N-acetylaspartate from fat cells regulates postprandial body temperature

N-acetylaspartate (NAA), the brain's second most abundant metabolite, provides essential substrates for myelination through its hydrolysis. However, activities and physiological roles of NAA in other tissues remain unknown. Here, we show aspartoacylase (ASPA) expression in white adipose tissue (WAT) governs systemic NAA levels for postprandial body temperature regulation. Proteomics and mass spectrometry revealed NAA accumulation in WAT of Aspa knockout mice stimulated the pentose phosphate pathway and pyrimidine production. Stable isotope tracing confirmed higher incorporation of glucose-derived carbon into pyrimidine metabolites in Aspa knockout cells. Additionally, serum NAA positively correlates with the pyrimidine intermediate orotidine and this relationship predicted lower body mass index in humans. Using whole-body and tissue-specific knockout mouse models, we demonstrate that fat cells provided plasma NAA and suppressed postprandial body temperature elevation. Furthermore, exogenous NAA supplementation reduced body temperature. Our study unveils WAT-derived NAA as an endocrine regulator of postprandial body temperature and physiological homeostasis.

Burning questions: Current practices and critical gaps in evaluating removal of per- and polyfluoroalkyl substances (PFAS) during pyrolysis treatments of biosolids

Concerns surrounding potential health and environmental impacts of per- and polyfluoroalkyl substances (PFAS) are growing at tremendous rates because adverse health impacts are expected with trace-level exposures. Extreme measures are required to mitigate potential PFAS contamination and minimize exposures. Extensive PFAS use results in the release of diverse PFAS species from domestic, industrial, and municipal effluents to wastewater, which partition to biosolids throughout secondary treatment. Biosolids generated during municipal wastewater treatment are a major environmental source of PFAS due to prevailing disposal practices as fertilizers. Pyrolysis is emerging as a viable, scalable technology for PFAS removal from biosolids while retaining nutrients and generating renewable, raw materials for energy generation. Despite early successes of pyrolysis in PFAS removal, significant unknowns remain about PFAS and transformation product fates in pyrolysis products and emissions. Applicable PFAS sampling methods, analytical workflows, and removal assessments are currently limited to a subset of high-interest analytes and matrices. Further, analysis of exhaust gases, particulate matter, fly ashes, and other pyrolysis end-products remain largely unreported or limited due to cost and sampling limitations. This paper identifies critical knowledge gaps on the pyrolysis of biosolids that must be addressed to assess the effectiveness of PFAS removal during pyrolysis treatment.

Demonstration of a Modular Prototype End-to-End Simulator for Aquatic Remote Sensing Applications

This study introduces a prototype end-to-end Simulator software tool for simulating two-dimensional satellite multispectral imagery for a variety of satellite instrument models in aquatic environments. Using case studies, the impact of variable sensor configurations on the performance of value-added products for challenging applications, such as coral reefs and cyanobacterial algal blooms, is assessed. This demonstrates how decisions regarding satellite sensor design, driven by cost constraints, directly influence the quality of value-added remote sensing products. Furthermore, the Simulator is used to identify situations where retrieval algorithms require further parameterization before application to unsimulated satellite data, where error sources cannot always be identified or isolated. The application of the Simulator can verify whether a given instrument design meets the performance requirements of end-users before build and launch, critically allowing for the justification of the cost and specifications for planned and future sensors. It is hoped that the Simulator will enable engineers and scientists to understand important design trade-offs in phase 0/A studies easily, quickly, reliably, and accurately in future Earth observation satellites and systems.

Vitamin B2 enables regulation of fasting glucose availability

Flavin adenine dinucleotide (FAD) interacts with flavoproteins to mediate oxidation-reduction reactions required for cellular energy demands. Not surprisingly, mutations that alter FAD binding to flavoproteins cause rare inborn errors of metabolism (IEMs) that disrupt liver function and render fasting intolerance, hepatic steatosis, and lipodystrophy. In our study, depleting FAD pools in mice with a vitamin B2-deficient diet (B2D) caused phenotypes associated with organic acidemias and other IEMs, including reduced body weight, hypoglycemia, and fatty liver disease. Integrated discovery approaches revealed B2D tempered fasting activation of target genes for the nuclear receptor PPARα, including those required for gluconeogenesis. We also found PPARα knockdown in the liver recapitulated B2D effects on glucose excursion and fatty liver disease in mice. Finally, treatment with the PPARα agonist fenofibrate activated the integrated stress response and refilled amino acid substrates to rescue fasting glucose availability and overcome B2D phenotypes. These findings identify metabolic responses to FAD availability and nominate strategies for the management of organic acidemias and other rare IEMs.

Association of Preexisting Triple Fusion and Arthroscopic Ankle Arthrodesis nonunion

BACKGROUND

Arthroscopic ankle arthrodesis (AAA) is a successful treatment for end-stage ankle arthritis. A significant early complication of AAA is symptomatic nonunion. Published nonunion rates range from 8% to 13%. Longer term, there is concern that it predisposes to subtalar joint (STJ) fusion. To better understand these risks, we undertook a retrospective investigation of primary AAA.

METHODS

All adult AAA cases conducted at our institution over a 10-year period were reviewed. A total of 284 eligible AAA cases in 271 patients were analyzed. The primary outcome measure was radiographic union. Secondary outcome measures included reoperative rate, postoperative complications and subsequent STJ fusion. Univariate and multivariate logistic regression analysis was performed to identify nonunion risk factors.

RESULTS

The overall nonunion rate was 7.7%. Smoking (odds ratio [OR] 4.76 [1.67, 13.6], P = .004) and previous triple fusion (OR 40.29 [9.46, 171.62], P < .001) were independent risk factors on univariate analysis. Only prior triple fusion persisted as a major risk factor associated with nonunion on multivariate analysis (OR 18.3 [3.4, 99.7], P < .001). Seventy percent of patients with a previous triple fusion went on to develop nonunion compared to 5.5% of those without. Increasing age, obesity, surgical grade, diabetes, postoperative weightbearing plan, steroid use, and inflammatory arthropathy were not significant risk factors. The leading cause of reoperation was hardware removal (18%). There were 5 superficial (1.8%) and 4 deep (1.4%) infections. Eleven (4.2%) required subsequent STJ fusion. The "survivorship" of STJ post AAA was 98%, 85%, and 74% at 2, 5, and 9 years, respectively.

CONCLUSION

As the largest study of AAA in the literature, our findings suggest prior triple fusion is a major independent risk factor for AAA nonunion. These patients should be counseled of this high risk and may benefit from alternative surgical options.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Structure of a HIV-1 IN-Allosteric inhibitor complex at 2.93 Å resolution: Routes to inhibitor optimization

HIV integrase (IN) inserts viral DNA into the host genome and is the target of the strand transfer inhibitors (STIs), a class of small molecules currently in clinical use. Another potent class of antivirals is the allosteric inhibitors of integrase, or ALLINIs. ALLINIs promote IN aggregation by stabilizing an interaction between the catalytic core domain (CCD) and carboxy-terminal domain (CTD) that undermines viral particle formation in late replication. Ongoing challenges with inhibitor potency, toxicity, and viral resistance motivate research to understand their mechanism. Here, we report a 2.93 Å X-ray crystal structure of the minimal ternary complex between CCD, CTD, and the ALLINI BI-224436. This structure reveals an asymmetric ternary complex with a prominent network of π-mediated interactions that suggest specific avenues for future ALLINI development and optimization.

The rheumatoid arthritis drug auranofin lowers leptin levels and exerts antidiabetic effects in obese mice

Low-grade, sustained inflammation in white adipose tissue (WAT) characterizes obesity and coincides with type 2 diabetes mellitus (T2DM). However, pharmacological targeting of inflammation lacks durable therapeutic effects in insulin-resistant conditions. Through a computational screen, we discovered that the FDA-approved rheumatoid arthritis drug auranofin improved insulin sensitivity and normalized obesity-associated abnormalities, including hepatic steatosis and hyperinsulinemia in mouse models of T2DM. We also discovered that auranofin accumulation in WAT depleted inflammatory responses to a high-fat diet without altering body composition in obese wild-type mice. Surprisingly, elevated leptin levels and blunted beta-adrenergic receptor activity achieved by leptin receptor deletion abolished the antidiabetic effects of auranofin. These experiments also revealed that the metabolic benefits of leptin reduction were superior to immune impacts of auranofin in WAT. Our studies uncover important metabolic properties of anti-inflammatory treatments and contribute to the notion that leptin reduction in the periphery can be accomplished to treat obesity and T2DM.

Presurgical Perspective and Postsurgical Evaluation of the Diabetic Foot

Management of the diabetic foot is complex and challenging, requiring a multidisciplinary approach. Imaging plays an important role in the decision-making process regarding surgery. This article discusses the presurgical perspective and postsurgical evaluation of the diabetic foot.

Single cell multi-omics characterise discrete human tendon cells populations that persist in vitro and on fibrous scaffolds

Chronic tendinopathy represents a growing healthcare burden in the ageing global population. Curative therapies remain elusive as the mechanisms that underlie chronic inflammation in tendon disease remain unclear. Identifying and isolating key pathogenic and reparative cells is essential in developing precision therapies and implantable materials for improved tendon healing. Multiple discrete human tendon cell populations have been previously described ex vivo. To determine if these populations persist in vitro, healthy human hamstring tenocytes were cultured for 8 d on either tissue culture plastic or aligned electrospun fibres of absorbable polydioxanone. Novel single-cell surface proteomics combined with unbiased single-cell transcriptomics (CITE-Seq) was used to identify discrete tenocyte populations. 6 cell populations were found, 4 of which shared key gene expression determinants with ex vivo human cell clusters: PTX3_PAPPA, POSTN_SCX, DCN_LUM and ITGA7_NES. Surface proteomics found that PTX3_PAPPA cells were CD10+CD26+CD54+. ITGA7_NES cells were CD146+ and POSTN_SCX cells were CD90+CD95+CD10+. Culture on the aligned electrospun fibres favoured 3 cell subtypes (DCN_LUM, POSTN_SCX and PTX3_ PAPPA), promoting high expression of tendon-matrix-associated genes and upregulating gene sets enriched for TNF-a and IL-6/STAT3 signalling. Discrete human tendon cell subpopulations persisted in in vitro culture and could be recognised by specific gene and surface-protein signatures. Aligned polydioxanone fibres promoted the survival of 3 clusters, including pro-inflammatory PTX3-expressing CD10+CD26+CD54+ cells found in chronic tendon disease. These results improved the understanding of preferred culture conditions for different tenocyte subpopulations and informed the development of in vitro models of tendon disease.

The Application and Patient-Reported Experience of Telephone Consultations in Elective Foot and Ankle Orthopaedic Surgery: 12-Month Follow-up

BACKGROUND

Telemedicine offers convenient and affordable health care, overcoming the logistical challenges of face-to-face encounters. Clinicians increasingly relied on telemedicine during the global pandemic. To assess the ongoing role for telemedicine in orthopaedics, we prospectively analyzed the failure rate, safety and patient-reported experience of telephone consultations for 12 months.

METHODS

265 telephone Foot/Ankle consultations were conducted in April 2020 and were prospectively analyzed over 12 months. The primary outcome measure was the rate of failed telephone consultations. A consultation was deemed unacceptable if the patient did not answer, if the clinician could not reach a conclusion or if any outcome changed over 12 months. Secondary outcome measures included patient-reported satisfaction and time saved by avoiding a face-to-face visit.

RESULTS

A clinical decision was reached in 84% of follow-up telephone consultations and 64% of new patient consultations (P = 0.001). Sixty-six percent were managed with nonoperative therapies, 16% were discharged, and 11% were added to the waiting list for surgery. The reasons for failing to achieve a clinical decision included failure to contact the patient (12.8%), inappropriate discharge with subsequent rereferral (1.9%), and insufficient clinical information (1.5%). Overall, 84.7% of patients reported that the telephone consultation was highly useful and 71.9% would recommend it to a friend or family member. Patients reported a mean time saving of 120 minutes.

CONCLUSION

Based on our experience, we provide recommended criteria for the safe and practical use of telephone consultations and suggest versatile patient care pathways into which a telephone consultation can be incorporated.

LEVEL OF EVIDENCE

Level IV, prospective cohort series (noncomparative).

Assembly of higher-order SMN oligomers is essential for metazoan viability and requires an exposed structural motif present in the YG zipper dimer

Protein oligomerization is one mechanism by which homogenous solutions can separate into distinct liquid phases, enabling assembly of membraneless organelles. Survival Motor Neuron (SMN) is the eponymous component of a large macromolecular complex that chaperones biogenesis of eukaryotic ribonucleoproteins and localizes to distinct membraneless organelles in both the nucleus and cytoplasm. SMN forms the oligomeric core of this complex, and missense mutations within its YG box domain are known to cause Spinal Muscular Atrophy (SMA). The SMN YG box utilizes a unique variant of the glycine zipper motif to form dimers, but the mechanism of higher-order oligomerization remains unknown. Here, we use a combination of molecular genetic, phylogenetic, biophysical, biochemical and computational approaches to show that formation of higher-order SMN oligomers depends on a set of YG box residues that are not involved in dimerization. Mutation of key residues within this new structural motif restricts assembly of SMN to dimers and causes locomotor dysfunction and viability defects in animal models.

Dependence on Autophagy for Autoreactive Memory B Cells in the Development of Pristane-Induced Lupus

The production of autoantibodies by autoreactive B cells plays a major role in the pathogenesis of lupus. Increases in memory B cells have been observed in human lupus patients and autoimmune lpr mice. Autophagy is required for the maintenance of memory B cells against viral infections; however, whether autophagy regulates the persistence of autoantigen-specific memory B cells and the development of lupus remains to be determined. Here we show that memory B cells specific for autoantigens can be detected in autoimmune lpr mice and a pristane-induced lupus mouse model. Interestingly, B cell-specific deletion of Atg7 led to significant loss of autoreactive memory B cells and reduced autoantibody production in pristane-treated mice. Autophagy deficiency also attenuated the development of autoimmune glomerulonephritis and pulmonary inflammation after pristane treatment. Adoptive transfer of wild type autoreactive memory B cells restored autoantibody production in Atg7-deficient recipients. These data suggest that autophagy is important for the persistence of autoreactive memory B cells in mediating autoantibody responses. Our results suggest that autophagy could be targeted to suppress autoreactive memory B cells and ameliorate humoral autoimmunity.

Ube2i deletion in adipocytes causes lipoatrophy in mice

Objective

White adipose tissue (WAT) expansion regulates energy balance and overall metabolic homeostasis. The absence or loss of WAT occurring through lipodystrophy and lipoatrophy contributes to the development of hepatic steatosis and insulin resistance. We previously demonstrated that sole small ubiquitin-like modifier (SUMO) E2-conjugating enzyme Ube2i represses human adipocyte differentiation. The role of Ube2i during WAT development remains unknown.

Methods

To determine how Ube2i impacts body composition and energy balance, we generated adipocyte-specific Ube2i knockout mice (Ube2i^a-KO). CRISPR/Cas9 gene editing inserted loxP sites flanking exons 3 and 4 at the Ube2i locus. Subsequent genetic crosses to Adipoq-Cre transgenic mice allowed deletion of Ube2i in white and brown adipocytes. We measured multiple metabolic endpoints that describe energy balance and carbohydrate metabolism in Ube2i^a-KO and littermate controls during postnatal growth.

Results

Surprisingly, Ube2i^a-KO mice developed hyperinsulinemia and hepatic steatosis. Global energy balance defects emerged from dysfunctional WAT marked by pronounced local inflammation, loss of serum adipokines, hepatomegaly, and near absence of major adipose tissue depots. We observed progressive lipoatrophy that commences in the early adolescent period.

Conclusions

Our results demonstrate that Ube2i expression in mature adipocytes allows WAT expansion during postnatal growth. Deletion of Ube2i in fat cells compromises and diminishes adipocyte function that induces WAT inflammation and ectopic lipid accumulation in the liver. Our findings reveal an indispensable role for Ube2i during white adipocyte expansion and endocrine control of energy balance.

•

A new mouse model reveals that Ube2i loss in fat cells impacts body composition.

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Ube2i fat-specific knockout (Ube2i^a-KO) causes fatty liver and hyperinsulinemia.

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Ube2i^a-KO mice develop metabolic inflexibility and cold intolerance.

•

Inflammation and caspase activation of cell death occur in Ube2i^a-KO adipocytes.

Allosteric HIV Integrase Inhibitors Promote Formation of Inactive Branched Polymers via Homomeric Carboxy-Terminal Domain Interactions

The major effect of allosteric HIV integrase (IN) inhibitors (ALLINIs) is observed during virion maturation, where ALLINI treatment interrupts IN-RNA interactions via drug-induced IN aggregation, leading to the formation of aberrant virions. To understand the structural changes that accompany drug-induced aggregation, we determined the soft matter properties of ALLINI-induced IN aggregates. Using small-angle neutron scattering, SEM, and rheology, we have discovered that the higher-order aggregates induced by ALLINIs have the characteristics of weak three-dimensional gels with a fractal-like character. Their formation is inhibited by the host factor LEDGF/p75, as well as ex vivo resistance substitutions. Mutagenesis and biophysical analyses reveal that homomeric carboxy-terminal domain interactions are required to achieve the branched-polymer nature of the ALLINI-induced aggregates. These studies provide key insight into the mechanisms of ALLINI action and resistance in the context of the crowded virion environment where ALLINIs exert their effect.

Description and psychometric properties of a prototype to test tactile acuity in the neck

BACKGROUND

Clinical tools assessing tactile acuity in people with persistent pain have limitations. Therefore, a novel and semi-automated tool was developed: The Imprint Tactile Acuity Device (iTAD).

AIM

To describe the iTAD prototype and present the psychometric properties of its tactile acuity assessments: the localisation test, the orientation test and the overall score (mean of both tests).

METHOD

A test-retest design with fifty healthy participants was used to assess intra-rater reliability (ICC_(2.1)), internal consistency (ICC_(2.4)) and measurement error (SEM) of the three assessments (0-100% accuracy scores each) performed at the neck. Using a known-group comparison design, balanced by age and sex, scores of thirty individuals with persistent neck pain were compared to thirty healthy controls to determine construct validity.

RESULTS

The ICC_(2,1) and ICC_(2,4) were 0.60 and 0.78 for the localisation test, 0.66 and 0.77 for the orientation test, and 0.73 and 0.84 for the overall score. The SEMs were 9.0%, 8.1% and 6.0%, respectively. No fixed or proportional bias, or signs of heteroscedasticity were observed. Overall, no between group differences were observed (p = 0.49). In the male subgroup, however, the overall score was lower for people with neck pain than for healthy participants (mean difference (SE); 7.6% (2.5); p = 0.008).

DISCUSSION

The tactile acuity assessments of the iTAD demonstrate moderate reliability and good internal consistency. Measurement errors appear comparable to currently preferred methods. Clear construct validity was not established, but results may be biased by design issues of the prototype. Taken together, the iTAD shows promise but further fine-tuning is needed.

STAT1 Dissociates Adipose Tissue Inflammation From Insulin Sensitivity in Obesity

Obesity fosters low-grade inflammation in white adipose tissue (WAT) that may contribute to the insulin resistance that characterizes type 2 diabetes. However, the causal relationship of these events remains unclear. The established dominance of STAT1 function in the immune response suggests an obligate link between inflammation and the comorbidities of obesity. To this end, we sought to determine how STAT1 activity in white adipocytes affects insulin sensitivity. STAT1 expression in WAT inversely correlated with fasting plasma glucose in both obese mice and humans. Metabolomic and gene expression profiling established STAT1 deletion in adipocytes (STAT1 a-KO ) enhanced mitochondrial function and accelerated tricarboxylic acid cycle flux coupled with reduced fat cell size in subcutaneous WAT depots. STAT1 a-KO reduced WAT inflammation, but insulin resistance persisted in obese mice. Rather, elimination of type I cytokine interferon-γ activity enhanced insulin sensitivity in diet-induced obesity. Our findings reveal a permissive mechanism that bridges WAT inflammation to whole-body insulin sensitivity.

NIX-Mediated Mitophagy Promotes Effector Memory Formation in Antigen-Specific CD8+ T Cells

Autophagy plays a critical role in the maintenance of immunological memory. However, the molecular mechanisms involved in autophagy-regulated effector memory formation in CD8⁺ T cells remain unclear. Here we show that deficiency in NIX-dependent mitophagy leads to metabolic defects in effector memory T cells. Deletion of NIX caused HIF1α accumulation and altered cellular metabolism from long-chain fatty acid to short/branched-chain fatty acid oxidation, thereby compromising ATP synthesis during effector memory formation. Preventing HIF1α accumulation restored long-chain fatty acid metabolism and effector memory formation in antigen-specific CD8⁺ T cells. Our study suggests that NIX-mediated mitophagy is critical for effector memory formation in T cells.

Gupta et al. demonstrate that mitophagy mediated by NIX, a mitochondrial outer membrane protein, plays a critical role in CD8⁺ T cell effector memory formation by regulating mitochondrial superoxide-dependent HIF1α protein accumulation and fatty acid metabolism. These findings elucidate the molecular mechanisms regulating T cell effector memory formation against viruses.

Multi-omic single cell analysis resolves novel stromal cell populations in healthy and diseased human tendon

Tendinopathy accounts for over 30% of primary care consultations and represents a growing healthcare challenge in an active and increasingly ageing population. Recognising critical cells involved in tendinopathy is essential in developing therapeutics to meet this challenge. Tendon cells are heterogenous and sparsely distributed in a dense collagen matrix; limiting previous methods to investigate cell characteristics ex vivo. We applied next generation CITE-sequencing; combining surface proteomics with in-depth, unbiased gene expression analysis of > 6400 single cells ex vivo from 11 chronically tendinopathic and 8 healthy human tendons. Immunohistochemistry validated the single cell findings. For the first time we show that human tendon harbours at least five distinct COL1A1/2 expressing tenocyte populations in addition to endothelial cells, T-cells, and monocytes. These consist of KRT7/SCX+ cells expressing microfibril associated genes, PTX3+ cells co-expressing high levels of pro-inflammatory markers, APOD+ fibro–adipogenic progenitors, TPPP3/PRG4+ chondrogenic cells, and ITGA7+ smooth muscle-mesenchymal cells. Surface proteomic analysis identified markers by which these sub-classes could be isolated and targeted in future. Chronic tendinopathy was associated with increased expression of pro-inflammatory markers PTX3, CXCL1, CXCL6, CXCL8, and PDPN by microfibril associated tenocytes. Diseased endothelium had increased expression of chemokine and alarmin genes including IL33.

Nitrogen removal from water resource recovery facilities using partial nitrification, denitratation-anaerobic ammonia oxidation (PANDA)

Nitrogen removal from wastewater is an energy and chemical intensive process that is becoming increasingly more common around the world. To address the cost and complexity issues associated with biological nitrogen removal from wastewater, an alternative approach for achieving next generation nitrogen removal via partial nitrification, denitratation and anaerobic ammonia oxidation (PANDA) has been developed. The PANDA process relies on converting 50% of influent ammonia load to nitrate via aerobic ammonia (AerAOB) and nitrite oxidizing bacteria (NOB). The nitrate is reduced to nitrite (denitratation), followed by the removal of ammonia and nitrite by heterotrophic denitrifiers and anaerobic ammonia oxidizing biomass (AnAOB). Results from a pilot-scale sidestream PANDA demonstration at nitrogen loadings of 0.2-0.25 kg N/m³-day illustrated that up to 80% ammonia removal could be achieved. Testing in the mainstream process at initial ammonia concentrations of ~25 mg N/L indicated that 90% removal of total inorganic nitrogen could be achieved and that nitrogen removal was ultimately dependent on operating factors including aeration time, supplemental carbon dosing, hydraulic retention time and nitrate concentrations. Results cumulatively indicated that there was inherent resiliency within the PANDA systems when responding to variable environmental and operational conditions. This is hypothesized to be due to the fact that nitrogen removal is due to the combined synergistic activity of AerAOB, NOB, heterotrophic denitrifiers and AnAOB. Accordingly, utilization of PANDA based treatment processes may allow Water Resource Recovery Facilities (WRRFs) to achieve more sustainable and cost effective nitrogen removal in sidestream and mainstream processes without the need for NOB suppression and complex operational controls.

Medium Term Outcome For A Constrained Acetabular Component At A Single Institution: What Is Important For Success?

BACKGROUND

The use of constrained Total Hip Replacements (THR) is controversial due to lack of definite indications and potentially high failure rates because of mechanical loosening or component failure. A review was performed to assess a departmental use of a single constrained acetabular component over a ten years period.

METHODS

Patient demographics, operative indications, complications and patient follow-up were recorded. Post-operative Oxford Hip Scores (OHS) were obtained via a combination of New Zealand Joint Registry interrogation and telephonic questioning. Cup version and inclination angles were obtained from standardised anteroposterior radiographs using established techniques.

RESULTS

Forty-four constrained components (in 39 patients) were implanted between 2005 and 2014. The mean age was 78 years with mean ASA 2.7 and mean follow-up 37.2 months (range 13-116). The mean post-operative OHS was 36 (SD 9.25), and there were 4 failures (3 dislocations and 1 peri-prosthetic fracture). The 3 dislocations had either cup ante version (AV) or inclination angles (IA) outside the data set interquartile range (AV 13-24°, IA 40-50°). The cup inclination was significantly lower (p<0.01) in patients with pain on sitting. At post-operative follow-up, 14/39 patients had died from unrelated causes, with only 1 patient surviving beyond 6 years.

CONCLUSIONS

Constrained acetabular components offer a solution to hip instability in a difficult group of patients. This study has shown good medium-term outcomes of a single component type in a predominantly frail group of low demand patients. Despite constraint, correct cup placement (particularly inclination) remains important to prevent dislocation or poor reported outcome.

Cosmological Constraints from Multiple Probes in the Dark Energy Survey

The combination of multiple observational probes has long been advocated as a powerful technique to constrain cosmological parameters, in particular dark energy. The Dark Energy Survey has measured 207 spectroscopically confirmed type Ia supernova light curves, the baryon acoustic oscillation feature, weak gravitational lensing, and galaxy clustering. Here we present combined results from these probes, deriving constraints on the equation of state, w, of dark energy and its energy density in the Universe. Independently of other experiments, such as those that measure the cosmic microwave background, the probes from this single photometric survey rule out a Universe with no dark energy, finding w=-0.80_{-0.11}^{+0.09}. The geometry is shown to be consistent with a spatially flat Universe, and we obtain a constraint on the baryon density of Ω_{b}=0.069_{-0.012}^{+0.009} that is independent of early Universe measurements. These results demonstrate the potential power of large multiprobe photometric surveys and pave the way for order of magnitude advances in our constraints on properties of dark energy and cosmology over the next decade.

Serine Integrase attP Binding and Specificity

Serine integrases catalyze the site-specific insertion of viral DNA into a host's genome. The minimal requirements and irreversible nature of this integration reaction have led to the use of serine integrases in applications ranging from bacterial memory storage devices to gene therapy. Our understanding of how the integrase proteins recognize the viral (attP) and host (attB) attachment sites is limited, with structural data available for only a Listeria integrase C-terminal domain (CTD) bound to an attP half-site. Here we report quantitative binding and saturation mutagenesis analyses for the Listeria innocua prophage attP site and a new 2.8-Å crystal structure of the CTD•attP half site. We find that Int binds with high affinity to attP (6.9 nM), but the Int CTD binds to attP half-sites with only 7- to 10-fold lower affinity, supporting the idea that free energy is expended to open an Int dimer for attP binding. Despite the 50-bp Int-attP interaction surface, only 20 residues are sensitive to mutagenesis, and of these, only 6 require a specific residue for efficient Int binding and integration activity. One of the integrase DNA-binding domains, the recombinase domain, appears to be primarily non-specific. Several substitutions result in an improved attP site, indicating that higher-efficiency attachment sites can be obtained through site engineering. These findings advance our understanding of serine integrase function and provide important data for efforts towards engineering this family of enzymes for a variety of biotechnology applications.

Coiled-coil interactions mediate serine integrase directionality

Serine integrases are bacteriophage enzymes that carry out site-specific integration and excision of their viral genomes. The integration reaction is highly directional; recombination between the phage attachment site attP and the host attachment site attB to form the hybrid sites attL and attR is essentially irreversible. In a recent model, extended coiled-coil (CC) domains in the integrase subunits are proposed to interact in a way that favors the attPxattB reaction but inhibits the attLxattR reaction. Here, we show for the Listeria innocua integrase (LI Int) system that the CC domain promotes self-interaction in isolated Int and when Int is bound to attachment sites. Three independent crystal structures of the CC domain reveal the molecular nature of the CC dimer interface. Alanine substitutions of key residues in the interface support the functional significance of the structural model and indicate that the same interaction is responsible for promoting integration and for inhibiting excision. An updated model of a LI Int•attL complex that incorporates the high resolution CC dimer structure provides insights that help to explain the unusual CC dimer structure and potential sources of stability in Int•attL and Int•attR complexes. Together, the data provide a molecular basis for understanding serine integrase directionality.

Oligomeric Properties of Survival Motor Neuron·Gemin2 Complexes

The survival motor neuron (SMN) protein forms the oligomeric core of a multiprotein complex required for the assembly of spliceosomal small nuclear ribonucleoproteins. Deletions and mutations in the SMN1 gene are associated with spinal muscular atrophy (SMA), a devastating neurodegenerative disease that is the leading heritable cause of infant mortality. Oligomerization of SMN is required for its function, and some SMA patient mutations disrupt the ability of SMN to self-associate. Here, we investigate the oligomeric nature of the SMN·Gemin2 complexes from humans and fission yeast (hSMN·Gemin2 and ySMN·Gemin2). We find that hSMN·Gemin2 forms oligomers spanning the dimer to octamer range. The YG box oligomerization domain of SMN is both necessary and sufficient to form these oligomers. ySMN·Gemin2 exists as a dimer-tetramer equilibrium with Kd = 1.0 ± 0.9 μM. A 1.9 Å crystal structure of the ySMN YG box confirms a high level of structural conservation with the human ortholog in this important region of SMN. Disulfide cross-linking experiments indicate that SMN tetramers are formed by self-association of stable, non-dissociating dimers. Thus, SMN tetramers do not form symmetric helical bundles such as those found in glycine zipper transmembrane oligomers. The dimer-tetramer nature of SMN complexes and the dimer of dimers organization of the SMN tetramer provide an important foundation for ongoing studies to understand the mechanism of SMN-assisted small nuclear ribonucleoprotein assembly and the underlying causes of SMA.

Complications of minimally invasive calcaneal osteotomy versus open osteotomy

BACKGROUND

Calcaneal osteotomy is an established technique for correcting hindfoot deformity. Patients traditionally receive an osteotomy through the open lateral approach to the calcaneus. To reduce the rate of wound complications associated with a direct open lateral approach, a minimally invasive surgical (MIS) technique has been adopted. This uses a low-speed, high-torque burr to perform the same osteotomy under radiographic guidance. We hypothesized that the new MIS calcaneal osteotomy would be a safe alternative to open calcaneal osteotomy while obtaining the same displacement.

METHODS

The safety of the new MIS technique was investigated with a case controlled study on all patients who underwent displacement calcaneal osteotomy at the Nuffield Orthopaedic Centre from 2008 to 2014. The primary outcome measure was 30 day postoperative complication rate. Secondary outcome measures included operating time, duration of stay, fusion rates, and calcaneal displacement. Eighty-one patients underwent calcaneal osteotomy as part of their corrective surgery, 50 in the Open approach group and 31 in MIS group. The average age was 47.7 years (range 16-77) for the Open group and 50.1 (range 21-77) in the MIS group.

RESULTS

A mean calcaneal displacement of 9.4 mm (SD = 1.16, 8 to 11 mm) and 10.2 mm (SD = 1.06, 8 to 13 mm) was achieved through the MIS and Open approaches, respectively. There were significantly fewer wound complications in the MIS group (6.45%) compared to the Open group (28%, P = .022). The MIS group was associated with significantly lower rate of wound infection (3% versus 20%, P = .044). Three patients in the Open group experienced sural peripheral neuropathy. The average length of stay was 3.8 days following MIS and 4.3 days following open calcaneal osteotomy. Nonunion occurred in only 1 patient in the MIS group and none in the open group.

CONCLUSIONS

MIS calcaneal osteotomy was found to be a safe technique. It was technically as effective as calcaneal osteotomy performed through an open lateral approach but was associated with significantly fewer wound complications and fewer nerve complications.

LEVEL OF EVIDENCE

Level III, comparative study.

Arthroscopic ankle fusion for avascular necrosis of the talus

BACKGROUND

Avascular necrosis (AVN) of the talus is a painful condition leading to destruction of the ankle-hindfoot complex. Moderate outcomes and high complication rates are reported in small numbers of advanced disease treated with tibiotalocalcaneal fusion, which has the additional disadvantage of sacrificing both the ankle and subtalar joints. The blood supply of the talus is tenuous, and open procedures risk further talar collapse by disrupting extraosseous vessels. This article reports the outcome of arthroscopic ankle fusion for late-stage AVN of the talus. Our hypothesis was that arthroscopic ankle fusion would relieve symptoms of advanced talar AVN, prevent collapse of the talus, and preserve the subtalar joint.

METHODS

A cohort study was performed on 16 patients with talar AVN treated with arthroscopic ankle fusion. Our primary outcome was fusion rate. Secondary outcomes included perioperative complications, ongoing pain, and further operative intervention. All radiologic investigations were reported independently by a senior radiologist. The average age of the patients was 53.5 years. The presumed causes of talar AVN were steroids, trauma, hematologic disorders, and alcoholism. The etiology was unknown in 7 patients. One patient was lost to follow-up.

RESULTS

Clinical and radiologic fusion at the ankle joint was confirmed in 15 of 15 available patients. Thirteen patients reported resolution of pain at follow-up. Three patients had ongoing pain and underwent a subsequent successful subtalar fusion.

CONCLUSIONS

Arthroscopic ankle fusion was a safe and reliable treatment of symptomatic advanced talar AVN. It was a minimally invasive procedure with minimal complication rate, preserving the talus and sparing the subtalar joint.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Minimally important change was estimated for the Manchester-Oxford Foot Questionnaire after foot/ankle surgery

OBJECTIVES

To ascertain the smallest amounts of change for the three Manchester-Oxford Foot Questionnaire (MOXFQ) domains that are likely to be clinically meaningful and beyond measurement error for conditions affecting the foot/ankle. Estimates were compared with those from the Short-Form 36 (SF-36).

STUDY DESIGN AND SETTING

A prospective observational study of 671 consecutive patients undergoing foot or ankle surgery at an orthopedic hospital. Before and 9 months after surgery, patients completed the MOXFQ and SF-36; transition items (anchor) asked about perceived changes in foot/ankle pain or problems since the surgery.

RESULTS

Four hundred ninety-one patients completed pre- and postoperative questionnaires. Anchor-based minimal clinically important change (MCIC) values were ~13 points for each of the MOXFQ Walking/standing (W/S), Pain, and Social Interaction (S-I) domains [and greater than the standard error of measurement (SEM)]. MCIC values for all SF-36 domains fell within the SEM. Between-group MCIDs for the MOXFQ were W/S, 16.2; Pain, 9.9; S-I, 9.3. Distribution-based minimal detectable change (MDC90) values for the MOXFQ were ~11, ~12, and ~16 score points for the W/S, Pain, and S-I scales, respectively.

CONCLUSION

This article provides information for aiding the interpretability of MOXFQ outcomes data and for planning future studies. The SF-36 is not recommended as a primary outcome for foot/ankle surgery.

A theoretical and practical evaluation of struvite control and recovery

Struvite accumulation is a costly problem in many water resource recovery facilities (WRRFs) that use anaerobic digestion, causing significant labor and equipment costs and potentially impacting facility performance and permit compliance. A comprehensive study was undertaken to evaluate possible solutions to struvite control at two similar Miami-Dade County, Florida, WRRFs. Alternatives analyzed included periodic cleaning and repair of damaged piping and equipment; optimum ferric salt dosing, use of in situ scaling coupons; and engineered struvite precipitation. The effectiveness and cost of each alternative was evaluated using a newly constructed dynamic process model and a net present worth analysis. Results indicate that nutrient recovery was a potential benefit at both facilities. This study establishes a comprehensive process and specific testing protocols for evaluating struvite control alternatives.

Attachment site recognition and regulation of directionality by the serine integrases

Serine integrases catalyze the integration of bacteriophage DNA into a host genome by site-specific recombination between ‘attachment sites’ in the phage (attP) and the host (attB). The reaction is highly directional; the reverse excision reaction between the product attL and attR sites does not occur in the absence of a phage-encoded factor, nor does recombination occur between other pairings of attachment sites. A mechanistic understanding of how these enzymes achieve site-selectivity and directionality has been limited by a lack of structural models. Here, we report the structure of the C-terminal domains of a serine integrase bound to an attP DNA half-site. The structure leads directly to models for understanding how the integrase-bound attP and attB sites differ, why these enzymes preferentially form attP × attB synaptic complexes to initiate recombination, and how attL × attR recombination is prevented. In these models, different domain organizations on attP vs. attB half-sites allow attachment-site specific interactions to form between integrase subunits via an unusual protruding coiled-coil motif. These interactions are used to preferentially synapse integrase-bound attP and attB and inhibit synapsis of integrase-bound attL and attR. The results provide a structural framework for understanding, testing and engineering serine integrase function.

The Manchester-Oxford Foot Questionnaire (MOXFQ): Development and validation of a summary index score

Objectives

The Manchester–Oxford Foot Questionnaire (MOXFQ) is a validated 16-item, patient-reported outcome measure for evaluating outcomes of foot or ankle surgery. The original development of the instrument identified three domains. This present study examined whether the three domains could legitimately be summed to provide a single summary index score.

Methods

The MOXFQ and Short-Form (SF)-36 were administered to 671 patients before surgery of the foot or ankle. Data from the three domains of the MOXFQ (pain, walking/standing and social interaction) were subjected to higher order factor analysis. Reliability and validity of the summary index score was assessed.

Results

The mean age of the participants was 52.8 years (sd 15.68; 18 to 89). Higher order principle components factor analysis produced one factor, accounting for 74.7% of the variance. The newly derived single index score was found to be internally reliable (α = 0.93) and valid, achieving at least moderate correlations (r ≥ 0.5, p < 0.001) with related (pain/function) domains of the SF-36.

Conclusions

Analyses indicated that data from the MOXFQ can be presented in summary form. The MOXFQ summary index score (MOXFQ-Index) provides an overall indication of the outcomes of foot and ankle surgery. Furthermore, the single index reduces the number of statistical comparisons, and hence the role of chance, when exploring MOXFQ data.

The dangers of euthanasia and dementia: how Kantian thinking might be used to support non-voluntary euthanasia in cases of extreme dementia

Some writers have argued that a Kantian approach to ethics can be used to justify suicide in cases of extreme dementia, where a patient lacks the rationality required of Kantian moral agents. I worry that this line of thinking may lead to the more extreme claim that euthanasia is a proper Kantian response to severe dementia (and similar afflictions). Such morally treacherous thinking seems to be directly implied by the arguments that lead Dennis Cooley and similar writers to claim that Kant might support suicide. If rationality is the only factor in valuing a human life, then the loss of that rationality (however such loss might be defined) would allow us to use essentially utilitarian thinking in order to support non-voluntary euthanasia, since the patients themselves would no longer be moral agents that demand respect.

Responsiveness of the Manchester-Oxford Foot Questionnaire (MOXFQ) compared with AOFAS, SF-36 and EQ-5D assessments following foot or ankle surgery

The responsiveness of the Manchester-Oxford Foot Questionnaire (MOXFQ) was compared with foot/ankle-specific and generic outcome measures used to assess all surgery of the foot and ankle. We recruited 671 consecutive adult patients awaiting foot or ankle surgery, of whom 427 (63.6%) were female, with a mean age of 52.8 years (18 to 89). They independently completed the MOXFQ, Short-Form 36 (SF-36) and EuroQol (EQ-5D) questionnaires pre-operatively and at a mean of nine months (3.8 to 14.4) post-operatively. Foot/ankle surgeons assessed American Orthopaedic Foot and Ankle Society (AOFAS) scores corresponding to four foot/ankle regions. A transition item measured perceived changes in foot/ankle problems post-surgery. Of 628 eligible patients proceeding to surgery, 491 (78%) completed questionnaires and 262 (42%) received clinical assessments both pre- and post-operatively. The regions receiving surgery were: multiple/whole foot in eight (1.3%), ankle/hindfoot in 292 (46.5%), mid-foot in 21 (3.3%), hallux in 196 (31.2%), and lesser toes in 111 (17.7%). Foot/ankle-specific MOXFQ, AOFAS and EQ-5D domains produced larger effect sizes (> 0.8) than any SF-36 domains, suggesting superior responsiveness. In analyses that anchored change in scores and effect sizes to patients' responses to a transition item about their foot/ankle problems, the MOXFQ performed well. The SF-36 and EQ-5D performed poorly. Similar analyses, conducted within foot-region based sub-groups of patients, found that the responsiveness of the MOXFQ was good compared with the AOFAS. This evidence supports the MOXFQ's suitability for assessing all foot and ankle surgery.

The MOXFQ patient-reported questionnaire: assessment of data quality, reliability and validity in relation to foot and ankle surgery

Previously validated for hallux valgus surgery, the Manchester-Oxford Foot Questionnaire (MOXFQ) is here evaluated for use with different regions of the foot and ankle. The study recruited 671 consecutive patients (87.8% of those eligible), mean age 52.8 years, 64% female, who completed the MOXFQ and SF-36 general health survey before foot or ankle surgery. Surgeons completed the American Orthopaedic Foot & Ankle Society (AOFAS) scales and indicated that the patients' main regions for surgery were: Hallux 210 (31.3%), Lesser toes 119 (17.7%), Mid foot 22 (3.3%), Ankle/hind foot 311 (46.3%), Multiple/whole foot 9 (1.3%). Individual MOXFQ items were assessed in terms of response rate and floor/ceiling effects, with the validity of the three MOXFQ scales (Walking/standing, Pain, and Social interaction) being assessed in terms of item-total correlations, internal and test-retest reliability, and construct validity. MOXFQ item response rates were high (all >98%). Cronbach's alphas of >0.7 confirmed internal consistency of all three scales. Test-retest ICCs were all ≥0.89. Correlations of >0.4 obtained with related SF-36 and AOFAS scales supported a priori hypotheses. Good measurement properties are confirmed for the MOXFQ in the context of baseline assessment of patients receiving surgery for a variety of foot or ankle problems.

Fate of organic nitrogen in four biological nutrient removal wastewater treatment plants

This study investigated the fate of nitrogen species, especially organic nitrogen, along the mainstream wastewater treatment processes in four biological nutrient removal (BNR) wastewater treatment plants (WWTPs). It was found that the dissolved organic nitrogen (DON) fraction was as high as 47% of soluble nitrogen (SN) in the low-SN effluent plant, which limited the plant's capability to remove nitrogen to very low levels. A lower DON fraction was observed in high-SN effluent plants. Effluent DON concentrations from the four plants ranged from 0.5 to 2 mg N/L and did not vary significantly, even though there was a large variation in the influent organic nitrogen concentrations. Size fractionation of organic nitrogen by serial filtration through 1.2-, 0.45-, and 0.22-microm pore-sized membrane filters and the flocculation-and-filtration with zinc sulfate (ZnSO4) method was investigated. The maximum colloidal organic nitrogen (CON) fractions found were 68 and 45% in the primary effluent and final effluent, respectively. The experimental results showed that effluents after filtration through the 0.45-microm pore-sized filter contain significant colloidal fractions; hence, the constituents, including organic nitrogen, are not truly dissolved. A high CON fraction was observed in wastewater influents and was less significant in effluents. The flocculation and filtration method removed the colloidal fraction; therefore, the true DON fraction can be determined.

Requirements for catalysis in the Cre recombinase active site

Members of the tyrosine recombinase (YR) family of site-specific recombinases catalyze DNA rearrangements using phosphoryl transfer chemistry that is identical to that used by the type IB topoisomerases (TopIBs). To better understand the requirements for YR catalysis and the relationship between the YRs and the TopIBs, we have analyzed the in vivo and in vitro recombination activities of all substitutions of the seven active site residues in Cre recombinase. We have also determined the structure of a vanadate transition state mimic for the Cre-loxP reaction that facilitates interpretation of mutant activities and allows for a comparison with similar structures from the related topoisomerases. We find that active site residues shared by the TopIBs are most sensitive to substitution. Only two, the tyrosine nucleophile and a conserved lysine residue that activates the 5'-hydroxyl leaving group, are strictly required to achieve >5% of wild-type activity. The two conserved arginine residues each tolerate one substitution that results in modest recombination activity and the remaining three active site positions can be substituted with several alternative amino acids while retaining a significant amount of activity. The results are discussed in the context of YR and TopIB structural models and data from related YR systems.

Conservatively treated massive prolapsed discs: a 7-year follow-up

INTRODUCTION

The natural history of a lumbar hernia of the nucleus pulposus (HNP) is not fully known and clear indications for operative intervention cannot be established from the literature. Several studies have shown that the largest discs appear to have the greatest tendency to resolve. The aim of this study was to investigate whether massive prolapsed discs can be safely managed conservatively once clinical improvement has occurred.

PATIENTS AND METHODS

Thirty-seven patients were studied by clinical assessments and serial magnetic resonance imaging (MRI) over 2 years. Patients had severe sciatica at first, but began to show clinical improvement despite the large disc herniations. Clinical assessment included the Lasegue test and neurological appraisal. The Oswestry Disability Index was used to measure function and changes in function. Serial MRI studies allowed measurement of volume changes of the herniated disc material over a period of time.

RESULTS

Initial follow-up at an average of 23.2 months revealed that 83% had a complete and sustained recovery at the initial follow-up. Only four patients required a discectomy. The average Oswestry disability index improved from 58% to 15%. Volumetric analysis of serial MRI scans found an average reduction of 64% in disc size. There was a poor correlation between clinical improvement and the extent of disc resolution.

CONCLUSIONS

A massive disc herniation can pursue a favourable clinical course. If early progress is shown, the long-term prognosis is very good and even massive disc herniations can be treated conservatively.