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During their annual migration, avian migrants alternate stopover periods, for refuelling, with migratory flight bouts. We hypothesise that European Nightjars (Caprimulgus europaeus) adapt their daily migration tactics in association with biomes. We tracked the autumn migration of 24 European Nightjars, from breeding populations in Mongolia, Belgium and UK, using GPS-loggers and multi-sensor data loggers. We quantified crepuscular and nocturnal migration and foraging probabilities, as well as daily travel speed and flight altitude during active migration in response to biomes. Nightjars adopt a rush tactic, reflected in high daily travel speed, flight altitude and high migration probabilities at dusk and at night, when travelling through ecological barriers. Migration is slower in semi-open, hospitable biomes. This is reflected in high foraging probabilities at dusk, lower daily travel speed and lower migration probabilities at dusk. Our study shows how nightjars switch migration tactics during autumn migration, and suggest nightjars alternate between feeding and short migratory flight bouts within the same night when travelling through suitable habitats. How this may affect individuals’ fuel stores and whether different biomes provide refuelling opportunities en route remains to be investigated, to understand how future land-use change may affect migration patterns and survival probabilities.

To systematically review all studies that developed or validated a vaginal birth after cesarean (VBAC) prediction model.MEDLINE, EMBASE, CINAHL, Cochrane Library, and ClinicalTrials.gov were searched from inception until February 2022.We included observational studies that developed or validated a multivariable VBAC prediction model in women with a singleton pregnancy and one previous lower segment cesarean delivery. A total of 3,758 articles were identified and screened.For 57 included studies, data were extracted in duplicate using a CHARMS (Critical Appraisal and Data Extraction for Systematic Review of Prediction Modelling Studies) checklist-based tool and included participants' characteristics, sample size, predictors, timing of application, and performance. PROBAST (Prediction model Risk of Bias Assessment Tool) and TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis) were used to assess risk of bias and transparency of reporting. Several studies developed or validated more than one model. There were 38 unique prediction models, 42 external validations of 10 existing prediction models, and six modifications of existing models. Of the 38 unique models, only 19 (19/38, 50%) were internally validated in the initial study. No studies externally validated their model in the initial study. Age, previous vaginal birth, and previous cesarean delivery for labor dystocia were the commonest predictors. The area under the curve in included studies ranged from 0.61 to 0.95. Models used close to delivery generally outperformed those used earlier in pregnancy. Most studies demonstrated a high risk of bias (45/57, 79%), the remainder were unclear (7/57, 12%) and low (5/57, 9%). Median TRIPOD checklist adherence was 70% (range 32-93%).Several prediction models for VBAC success exist, but many lack external validation and are at high risk of bias. Models used close to delivery outperformed those used earlier in pregnancy; however, their generalizability and applicability remain unclear. High-quality external validation and effect studies are required to guide clinical use.PROSPERO, CRD42020190930.

Background The association between mode of delivery and postnatal depression is uncertain. Mental health history may modify the association. Objectives The objective of this study was to determine whether the association between caesarean and postnatal psychological distress (PPD) differs according to long-standing depression/anxiety. Methods Analysis of the UK-based Millennium Cohort Study of women who gave birth 2000-2002 was carried out. The outcomes were PPD at 9 months by Rutter Malaise Inventory and actively treated physician-diagnosed depression/severe anxiety at 3 years. The exposure was mode of delivery. Adjusted relative risks were estimated using Poisson regression. Effect modification according to long-standing depression/anxiety was investigated multiplicatively and additively. Results We included 15,936 women, of whom 2346 (13.4%, weighted) reported PPD. Women with long-standing depression/anxiety were at 34% lower risk of PPD following elective caesarean, compared with vaginal birth: relative risk (RR) 4.36 (95% confidence interval [CI] 3.76, 5.05), RR 3.25 (95% CI 2.23, 4.75) and RR 4.92 (95% CI 3.67, 6.59) for vaginal, elective and emergency caesarean births, respectively, with relative excess risk due to interaction (RERI) -1.28 (95% CI -2.73, 0.16), ratio of RRs 0.66 (95% CI 0.42, 1.05). Women with long-standing depression/anxiety were at greatest risk of later treatment following emergency caesarean, with RR 4.95 (95% CI 3.86, 6.34), RR 4.09 (95% CI 2.51, 6.65) and RR 6.74 (95% CI 4.87, 9.32), for vaginal, elective and emergency caesarean births, respectively; RERI 1.79 (95% CI -0.13, 3.71), ratio of RRs 1.36 (95% CI 0.94, 1.99); all RRs with reference to vaginal birth in the absence of long-standing depression/anxiety. There was no evidence of a similar association between emergency caesarean and PPD nor elective caesarean and later treatment. Conclusions Women with long-standing depression or anxiety who had elective caesarean had a lower risk of postnatal distress. When this group had emergency caesarean, there was greater risk of actively treated depression/anxiety at 3 years. These associations were not observed in women without long-standing depression/anxiety.

Gestational hypertension may confer risk of atopic disease in offspring through a direct biological mechanism, but another possibility is that risk is mediated through complications of pregnancy. To explore these associations, we conducted an analysis of a nationally representative birth cohort based in the UK involving children born 2000–2002. We included 12,450 mother-child pairs. We used logistic regression to estimate the association between hypertensive disease and asthma, hay fever, or eczema by age 5, and parentally reported early wheeze and severe wheeze. Mediation by gestation at delivery and caesarean delivery was explored using causal mediation analysis. Odds ratios (95% CI) for gestational hypertension and childhood asthma, hay fever, and eczema were 1.32 (1.09, 1.59), 1.22 (0.97, 1.55), and 1.12 (0.96, 1.32) respectively, adjusted for confounding. The population attributable fractions were 2.4% (1.0–3.8%), 0.9% (−0.3% to 2.1%), and 1.8% (0.0–3.7%), respectively. Accounting for mediation by gestational age and caesarean delivery, odds ratios (95% CI) for the potential direct effects of gestational hypertension were 1.21 (0.97, 1.50), 1.17 (0.91, 1.49), and 1.11 (0.94, 1.31) for the same.Conclusion: Gestational hypertension was weakly positively associated with asthma and this was partly mediated by earlier delivery. Only a small proportion of early childhood asthma was attributable to gestational hypertensive disease in this representative UK-based birth cohort. What is known:• Gestational hypertension has been shown to be an inconsistent risk factor for the atopic diseases.• The in utero immune environment may modify the risk of atopy in offspring; alternatively, complications of pregnancy including caesarean delivery and prematurity may explain an association between hypertensive disease and atopy. What is new:• Self-reported gestational hypertension was a weak risk factor for asthma and wheeze in the Millennium Cohort Study.• Part of the association between gestational hypertensive disease and asthma was explained by earlier delivery.

Objective: To determine the value of uterine CD138+ cells, as a marker of chronic endometritis, in predicting subsequent reproductive outcome in women with history of recurrent pregnancy loss.\ud Design: A prospective longitudinal study.\ud Setting: Tertiary specialised clinic.\ud Patients: Women with history of recurrent pregnancy loss or implantation failure over a 12-months follow-up period. \ud Intervention: We quantified the CD138+ cells/high powered field (hpf) using immunohistochemistry and image analysis of endometrial biopsies obtained during the secretory stage post ovulation. \ud Main Outcome Measures: live birth and subsequent pregnancy loss. We calculated the receiver operator curve for predicting subsequent pregnancy loss and reported using relative risk (RR) and 95% confidence intervals (CI).\ud Results: We enrolled 344 women of whom eighty-eight became pregnant (88/344, 25.5%). Half of them had a subsequent live birth (47/88, 53%) and the rest lost their pregnancy (41/88, 46%). The median CD138+ score was significantly lower in the live birth group (p

Objectives\ud In bladder drainage, an essential part of post-hysterectomy care, the optimal timing for removing the urinary catheter is unclear. Our objective was to evaluate the risks and benefits of early (6 h) catheter removal post-hysterectomy.\ud Study design\ud A systematic review searching MEDLINE, EMBASE and Cochrane CENTRAL from inception till May 2019 for randomised trials of women undergoing hysterectomy. We reported on urinary retention, positive urine culture, urinary tract infection (UTI) (defined by symptoms and/or antibiotic use), post-operative pyrexia, time to ambulation, and length of hospital stay. We assessed risk of bias in included trials and used a random-effect model to generate risk ratios (RR) for dichotomous outcomes and weighted mean differences (WMD) for continuous outcomes, with 95 % confidence intervals (CI).\ud Results\ud Of 1020 potentially relevant citations, we included 10 randomised trials (1120 women). Four trials had low risk of bias for randomisation and allocation concealment while five had low risk for outcome assessment and selective reporting. Compared to delayed removal, women in the early catheter removal group had a higher risk of urinary retention and needing re-catheterisation (10 RCTs, RR 3.61, 95 %CI 1.21–9.21, I 2 = 56 %). There was some reduction in the risk of post-operative UTI (6 RCTs, RR 0.42, 95 %CI 0.18 to 0.96, I 2 = 0 %), but we did not find a significant difference in post-operative pyrexia (6 RCTs, RR 0.73, 95 %CI 0.43–1.24, I 2 = 18 %) or positive urine cultures (6 RCTs, RR of 0.56, 95 %CI 0.27–1.12, I 2 = 55 %). There was no significant difference in the average time to ambulation (3RCTs, WMD −4.6, 95 %CI −9.16 to −0.18, I 2 = 98 %) and length of hospital stay (3RCTs, WMD −1.05, 95 %CI −2.42 to 0.31, I 2 = 98 %). Our meta-regression on the provision of prophylactic antibiotics did not show a significant effect on the reported outcomes. Our analysis was limited by our inability to adjust for potential effect modifiers such as the surgical route.\ud Conclusions\ud Early removal of the urinary catheter

Cathepsin S inhibitors attenuate mechanical allodynia in preclinical neuropathic pain models. The current study evaluated the effects when combining the selective cathepsin S inhibitor MIV-247 with gabapentin or pregabalin in a mouse model of neuropathic pain. Mice were rendered neuropathic by partial sciatic nerve ligation. MIV-247, gabapentin, or pregabalin were administered alone or in combination via oral gavage. Mechanical allodynia was assessed using von Frey hairs. Neurobehavioral side effects were evaluated by assessing beam walking. MIV-247, gabapentin, and pregabalin concentrations in various tissues were measured. Oral administration of MIV-247 (100-200 µmol/kg) dose-dependently attenuated mechanical allodynia by up to approximately 50% reversal when given as a single dose or when given twice daily for 5 days. No behavioral deficits were observed at any dose of MIV-247 tested. Gabapentin (58-350 µmol/kg) and pregabalin (63-377 µmol/kg) also inhibited mechanical allodynia with virtually complete reversal at the highest doses tested. The minimum effective dose of MIV-247 (100 µmol/kg) in combination with the minimum effective dose of pregabalin (75 µmol/kg) or gabapentin (146 µmol/kg) resulted in enhanced antiallodynic efficacy without augmenting side effects. A subeffective dose of MIV-247 (50 µmol/kg) in combination with a subeffective dose of pregabalin (38 µmol/kg) or gabapentin (73 µmol/kg) also resulted in substantial efficacy. Plasma levels of MIV-247, gabapentin, and pregabalin were similar when given in combination as to when given alone. Cathepsin S inhibition with MIV-247 exerts significant antiallodynic efficacy alone, and also enhances the effect of gabapentin and pregabalin without increasing side effects or inducing pharmacokinetic interactions.

Background Peer-assisted learning provides a means through which individuals can learn from one another through a reciprocal process. Radiographic image interpretation skills are fundamental to both diagnostic radiography students and medical students due to their shared role in preliminary evaluation of conventional radiographic images. Medical students on graduation, may not be well prepared to carry out image interpretation, since evidence suggests that they perform less well than radiographers in e.g. Accident and Emergency situations. Method A review of literature was conducted exploring the application of peer-assisted learning within diagnostic radiography and health education more widely as well as the practice of initial image interpretation. An extensive and systematic search strategy was developed which provided a range of material related to the areas. Findings An overview was obtained of the effectiveness of peer-assisted learning and the issues associated with development of image interpretation skills and a degree of discrepancy was identified between the two cohorts regarding their interpretative competence and confidence. This inconsistency may create an opportunity to apply peer-assisted learning, better preparing both disciplines for the practical application of image interpretation skills. Conclusion The review identified the lack of a substantial evidence base relating to peer-assisted learning in radiography. Peer-assisted learning is not widely embraced in an interprofessional context. Multiple positive factors of such an intervention are identified which outweigh perceived negative issues. Student teacher and learner may benefit as should the clinical service from enhanced practitioner performance. The findings justify further research to develop the evidence base.

Background Recent evidence has suggested an association between postoperative non-steroidal anti-inflammatory drugs (NSAIDs) and increased operation-specific complications. This study aimed to determine the safety profile following gastrointestinal surgery across a multicentre setting in the UK. Methods This multicentre study was carried out during a 2-week interval in September–October 2013. Consecutive adults undergoing elective or emergency gastrointestinal resection were included. The study was powered to detect a 10 per cent increase in major complications (grade III–V according to the Dindo–Clavien classification). The effect of administration of NSAIDs on the day of surgery or the following 2 days was risk-adjusted using propensity score matching and multivariable logistic regression to produce adjusted odds ratios (ORs). The type of NSAID and the dose were registered. Results Across 109 centres, early postoperative NSAIDs were administered to 242 (16·1 per cent) of 1503 patients. Complications occurred in 981 patients (65·3 per cent), which were major in 257 (17·1 per cent) and minor (Dindo–Clavien grade I–II) in 724 (48·2 per cent). Propensity score matching created well balanced groups. Treatment with NSAIDs was associated with a reduction in overall complications (OR 0·72, 95 per cent confidence interval 0·52 to 0·99; P = 0·041). This effect predominately comprised a reduction in minor complications with high-dose NSAIDs (OR 0·57, 0·39 to 0·89; P = 0·009). Conclusion Early use of NSAIDs is associated with a reduction in postoperative adverse events following major gastrointestinal surgery.

Development of allosteric inhibitors into efficient drugs is hampered by their indirect mode-of-action and complex structure-kinetic relationships. To enable the design of efficient allosteric drugs targeting the polymerase of hepatitis C virus (NS5B), the interaction characteristics of three non-nucleoside compounds (filibuvir, VX-222, and tegobuvir) inhibiting HCV replication via NS5B have been analyzed. Since there was no logical correlation between the anti-HCV replicative and enzyme inhibitory effects of the compounds, surface plasmon resonance biosensor technology was used to resolve the mechanistic, kinetic, thermodynamic and chemodynamic features of their interactions with their target and their effect on its interaction with RNA. Tegobuvir could not be seen to interact with NS5B at all while filibuvir interacted in a single reversible step (except at low temperatures) and VX-222 in two serial steps, interpreted as an induced fit mechanism. Both filibuvir and VX-222 interfered with the interaction between NS5B and RNA. They competed for binding to the enzyme, suggesting that they had a common inhibition mechanism and identical or overlapping binding sites. The greater anti-HCV replicative activity of VX-222 over filibuvir is hypothesized to be due to a greater allosteric conformational effect, resulting in the formation of a less catalytically competent complex. In addition, the induced fit mechanism of VX-222 gives it a kinetic advantage over filibuvir, exhibited as a longer residence time. These insights have important consequences for the selection and optimization of new allosteric NS5B inhibitors.

BACKGROUND AND PURPOSE The chemokine receptor CXCR3 directs migration of T-cells in response to the ligands CXCL9/Mig, CXCL10/IP-10 and CXCL11/I-TAC. Both ligands and receptors are implicated in the pathogenesis of inflammatory disorders, including atherosclerosis and rheumatoid arthritis. Here, we describe the molecular mechanism by which two synthetic small molecule agonists activate CXCR3. EXPERIMENTAL APPROACH As both small molecules are basic, we hypothesized that they formed electrostatic interactions with acidic residues within CXCR3. Nine point mutants of CXCR3 were generated in which an acidic residue was mutated to its amide counterpart. Following transient expression, the ability of the constructs to bind and signal in response to natural and synthetic ligands was examined. KEY RESULTS The CXCR3 mutants D112N, D195N and E196Q were efficiently expressed and responsive in chemotaxis assays to CXCL11 but not to CXCL10 or to either of the synthetic agonists, confirmed with radioligand binding assays. Molecular modelling of both CXCL10 and CXCR3 suggests that the small molecule agonists mimic a region of the ‘30s loop’ (residues 30–40 of CXCL10) which interacts with the intrahelical CXCR3 residue D112, leading to receptor activation. D195 and E196 are located in the second extracellular loop and form putative intramolecular salt bridges required for a CXCR3 conformation that recognizes CXCL10. In contrast, CXCL11 recognition by CXCR3 is largely independent of these residues. CONCLUSION AND IMPLICATIONS We provide here a molecular basis for the observation that CXCL10 and CXCL11 are allosteric ligands of CXCR3. Such findings may have implications for the design of CXCR3 antagonists. LINKED ARTICLE This article is commented on by O'Boyle, pp. 895–897 of this issue. To view this commentary visit http://dx.doi.org/10.1111/j.1476-5381.2011.01759.x

The basis for efficacy of the recombinant botulinum vaccine, serotypes A and B (rBV A/B) is that neutralizing antibodies induced by vaccination bind to botulinum neurotoxin complex serotype A, subtype A1 (BoNT/A1) and serotype B, subtype B1 (BoNT/B1) and prevent their actions at cholinergic neurons. The protective capacity of BoNT/A1 and BoNT/B1 neutralizing antibodies derived from the serum of clinical volunteers vaccinated with rBV A/B was evaluated in a guinea pig passive transfer model and a mouse bioassay. Guinea pigs passively immunized to achieve circulating neutralizing antibody concentration (NAC) levels representing the lowest measurable concentrations for BoNT/A1 and BoNT/B1 were protected against an intramuscular (IM) challenge more than 10 times the guinea pig IM median lethal dosage for BoNT/A1 and BoNT/B1. The passively immunized guinea pigs were asymptomatic during the 14-day post-challenge observation period. Control guinea pigs died within 48 h after challenge. Calculation of neutralizing efficiency of antibodies using results from a mouse bioassay indicated that a simple linearly proportional relationship does not exist between NAC level and the amount of BoNT neutralized. Based on this finding, estimates of level of protection must consider variability in BoNT neutralizing efficiency at different NAC levels. The protective capacity of human BoNT/A1 and BoNT/B1 neutralizing antibodies induced by rBV A/B vaccination was verified in a guinea pig passive immunization model. Additionally, estimates of the neutralizing efficiency have been established for BoNT/A1 and BoNT/B1 neutralizing antibodies obtained from clinical volunteers vaccinated with the rBV A/B.

We identified a series of structurally novel SCD (Delta9 desaturase) inhibitors via high-throughput screening and follow-up SAR studies. Modification of the central bicyclic scaffold has proven key to our potency optimization effort. The most potent analog (8g) had IC(50) value of 50 pM in a HEPG2 SCD assay and has been shown to be metabolically stable and selective against Delta5 and Delta6 desaturases.

Highly potent and selective 4-amidofuran-3-one inhibitors of cathepsin S are described. The synthesis and structure-activity relationship of a series of inhibitors with a sulfonamide moiety in the P3 position is presented. Several members of the series show sub-nanomolar inhibition of the target enzyme as well as an excellent selectivity profile and good cellular potency. Molecular modeling of the most interesting inhibitors describes interactions in the extended S3 pocket and explains the observed selectivity towards cathepsin K.

Reported results for patellar ACI include a mixed population of patients having or not a concomitant correction of the extensor mechanism. No study has reported separate outcome for those two patellar ACI subgroups. Forty four patients were included in this study designed to compare the outcome of patellar ACI with extensor realignment (group A) to patellar ACI with normal patellofemoral tracking (group B). Group A (n=22) had a higher increase in average modified Cincinnati knee score (4.5 vs. 1.7 points), better function (1.7 vs. 2.5), better SF-36 physical component scores (70.9 vs. 55.4 points) and higher IKDC scores (85.2 vs. 60.6 points) when compared to group B (n=22) at an average follow-up of 2 years. Patellar ACI with concomitant extensor realignment has superior outcome than patellar ACI with normal patellofemoral tracking. An unloading osteotomy could be desirable in selected patients with normal patellofemoral biomechanics to improve the outcome in this population.

The identification and evaluation of aryl-[1,4]diazepane ureas as functional antagonists of the chemokine receptor CXCR3 are described. Specific examples exhibit IC(50) values of approximately 60 nM in a calcium mobilization functional assay, and dose-dependently inhibit CXCR3 functional response to CXCL11 (interferon-inducible T-cell alpha chemoattractant/I-TAC) as measured by T-cell chemotaxis, with a potency of approximately 100 nM.

Between October 2000 and December 2003, 252 autologous chondrocyte implants were performed in 183 patients. Eighty lesions showed overgrowth of the subchondral bone plate under the chondral lesion, this was termed a "bone boss." Thirty-seven were on the medial femoral condyle (MFC), 18 on the lateral femoral condyle (LFC), 21 in the trochlea and 4 on the patella. There was a statistically significant association between the LFC and "bone boss." The lesions showing this finding were of a larger area (3.4 cm2 and 2.8 cm2 respectively, p=0.006), and had more diffuse chondral changes than lesions without. The patients with a "bone boss" had a tendency to longer duration of symptoms (85.3 months and 64.3 months respectively, p=0.089). The "bone bosses" were resected back to the level of the surrounding subchondral bone prior to implantation. Radiological and clinical follow-up showed no statistical difference between the two groups. A discussion of the possible aetiology of the "bone boss" is made.

High tibial osteotomy has been generally accepted as a useful treatment for unicompartment osteoarthritis of the knee to improve a patient's quality of life. Few studies have examined the outcome from the patient's perspective. A survival analysis of one to twenty-one years was conducted on 67 knees including analysis of the patients' satisfaction level with this procedure. Cumulative survival probability of 89.5% at 5 years, 74.7% at 10 years and 66.9 % for 15 and 20 years was reported. Ninety-one percent of patients had improvement in pain score and would choose to have this surgery again. Average patient satisfaction level was 75.5%. Forty-eight percent of patients were able to perform at a higher level of activity than before surgery, although none was able to perform at the level prior to the onset of knee pathology. It was concluded that this procedure was able to improve a patient's quality of life and achieved high satisfaction among patients. There is an increasing role of high tibial osteotomy as an adjunct to an autologous chondrocyte implantation procedure.

Background. Lateral epicondylitis resistant to conservative treatment is a rare yet disabling condition. When diagnosed, it should be treated surgically. The appropriate surgical treatment relies on a precise diagnosis, usually based on physical examination. Exclusion of other pathologies in the lateral elbow area is essential. Methods. We report on an outcome in a group of 19 consecutive patients treated by excision, release, reattachment and repair of the common extensor origin. These patients were followed clinically for at least 2 years. Results. Eighteen patients reported recovery from pain and a satisfactory subjective gaining of strength in their forearm on average 3 and 4 months after the surgery, respectively. Conclusions. The presented treatment method is highly effective in the treatment of resistant lateral epicondylitis.

The cysteinyl proteinase cathepsin S is implicated as a key enzyme in the processing of major histocompatability complex (MHC) class II molecules expressed on antigen presenting cells and thus is a potential therapeutic target for modulation in immune system-based disease. We have identified a form of rat cathepsin S, similar to a published mouse form with an eight-amino acid extended presequence relative to the human enzyme and the previously published rat enzyme. In addition, we have expressed these mouse and rat proteins in baculovirally infected Sf9 insect cells along with "humanized" forms truncated by eight residues at the amino-terminus. All forms of the rodent proteinases were overexpressed and milligram per litre amounts of functional enzyme could be isolated from the cells and/or the cell culture supernatant. Furthermore, addition of a carboxy-terminal hexahistidine purification tag had no effect on the kinetic characteristics of any of the enzyme forms against the Boc-Val-Leu-Lys-AMC peptide substrate (rat k(cat) s(-1) approximately 30; mouse k(cat) s(-1) approximately 65). Differences were seen in the potency of the generic cysteine proteinase inhibitor, E64, against the human, mouse, or rat form of the enzyme (13.3 x 10(4), 43.2 x 10(4), and 25 x 10(4) K(obe)/[I] M(-1) s(-1), respectively). Such data highlights the need for greater awareness of species variation in inhibitor potency. These reagents are vital for confirming inhibitor potency against the endogenous form of the enzyme prior to evaluation of drug candidates in rodent model systems.

Mobile bearing knee replacement has been designed to provide an effective prosthetic tool for improving long-term survivorship. Although, its potential long-term superiority has not been proven, an alarming possibility of its early mechanical failure has been previously reported. In the present study on 27 patients with 35 replaced knees due to osteoarthritis, 97.1% of a 5-year survivorship of LCS mobile bearing cementless total knee prosthesis is reported. This high survival rate, with a satisfactory functional outcome at middle term follow-up has been achieved by following an optimal technique of implantation. Therefore, in the middle term this mobile bearing design of total knee replacement is no less effective than the conventional fixed bearing designs.

We discovered a structurally novel SCD (Delta9 desaturase) inhibitor 4a (CVT-11,563) that has 119 nM potency in a human cell-based (HEPG2) SCD assay and selectivity against Delta5 and Delta6 desaturases. This compound has 90% oral bioavailability (rat) and excellent plasma exposure (dAUC 935 ng h/mL). Additionally, 4a shows moderately selective liver distribution (three times vs plasma and adipose tissue) and relatively low brain penetration. In a five-day study (high sucrose diet, rat) compound 4a significantly reduced SCD activity as determined by GC analysis of fatty acid composition in plasma and liver. We describe the discovery of 4a from HTS hit 1 followed by scaffold replacement and SAR studies focused on DMPK properties.

A series of trisubstituted purinones was synthesized and evaluated as A(2A) receptor antagonists. The A(2A) structure-activity relationships at the three substituted positions were studied and selectivity against the A(1) receptor was investigated. One antagonist 12o exhibits a K(i) of 9nM in an A(2A) binding assay, a K(b) of 18nM in an A(2A) cAMP functional assay, and is 220-fold selective over the A(1) receptor.

The discovery and synthesis of a series of 2-amino-5-benzoyl-4-(2-furyl)thiazoles as adenosine A2A receptor antagonists from a small-molecule combinatorial library using a high-throughput radioligand-binding assay is described. Antagonists were further characterized in the A2A binding assay and an A1 selectivity assay. Selected examples exhibited excellent affinity for A2A and good selectivity versus the A1 receptor.

The synthesis and identification of sulfonamido-aryl ethers as potent bradykinin B1 receptor antagonists from a approximately 60,000 member encoded combinatorial library are reported. Two distinct series of compounds exhibiting different structure-activity relationships were identified in a bradykinin B1 whole-cell receptor-binding assay. Specific examples exhibit K(i) values of approximately 10nM.

The discovery and synthesis of a series of (dimethoxyphenoxy)alkylamino acetamides as orexin-2 receptor antagonists from a small-molecule combinatorial library using a high-throughput calcium mobilization functional assay (HEK293-human OX2-R cell line) is described. Active compounds show a good correlation between high-throughput single concentration screening data and measured IC(50)s. Specific examples exhibit IC(50) values of approximately 20 nM using human orexin A as the peptide agonist for the orexin-2 receptor.

Angiopoietins and Tie2 receptor were recently identified as an endothelial cell-specific ligand-receptor system that is critical for vascular development and postnatal pathologic angiogenesis by mediating vascular integrity. In this study, we identified a series of small-molecule Tie2 inhibitors, which blocked Ang1-induced Tie2 autophosphorylation and downstream signaling with an IC 50 value at 0.3 μM. Further optimization yields improved selectivity, aqueous solubility, microsomal stability and cytochrome P450 profile for one of the compounds (compound 7 ). Both compound 1 and compound 7 inhibit endothelial cell tube formation. Furthermore, in a rat model of Matrigel-induced choroidal neovascularization, compound 7 significantly diminished aberrant vessel growth. Our findings demonstrate a potential clinical benefit by specifically targeting Tie2-mediated angiogenic disorders.

The discovery and evaluation of 5-(4-phenylbenzyl)oxazole-4-carboxamides as prostacyclin (IP) receptor antagonists is described. Analogs disclosed showed high affinity for the IP receptor in human platelet membranes with IC50 values of 0.05–0.50 μM, demonstrated functional antagonism by inhibiting cAMP production in HEL cells with IC50 values of 0.016–0.070 μM, and exhibited significant selectivity versus other prostanoid receptors.

Information regarding the quality of autologous chondrocyte implantation repair is needed to determine whether the current autologous chondrocyte implantation surgical technology and the subsequent biologic repair processes are capable of reliably forming durable hyaline or hyaline-like cartilage in vivo. We report and analyze the properties and qualities of autologous chondrocyte implantation repairs. We evaluated 66 autologous chondrocyte implantation repairs in 57 patients, 55 of whom had histology, indentometry, and International Cartilage Repair Society repair scoring at reoperation for mechanical symptoms or pain. International Knee Documentation Committee scores were used to address clinical outcome. Maximum stiffness, normalized stiffness, and International Cartilage Repair Society repair scoring were higher for hyaline articular cartilage repairs compared with fibrocartilage, with no difference in clinical outcome. Reoperations revealed 32 macroscopically abnormal repairs (Group B) and 23 knees with normal-looking repairs in which symptoms leading to arthroscopy were accounted for by other joint disorders (Group A). In Group A, 65% of repairs were either hyaline or hyaline-like cartilage compared with 28% in Group B. Autologous chondrocyte repairs composed of fibrocartilage showed more morphologic abnormalities and became symptomatic earlier than hyaline or hyaline-like cartilage repairs. The hyaline articular cartilage repairs had biomechanical properties comparable to surrounding cartilage and superior to those associated with fibrocartilage repairs.

In a high-throughput screen of four million compounds from combinatorial libraries for small-molecule modulators of the chemokine receptor CXCR3, two classes of receptor agonists, based on tetrahydroisoquinoline and piperidinyl diazepanone templates, were identified. Several of these compounds stimulated calcium flux in HEK293 cells expressing the recombinant human CXCR3 receptor with efficacies and kinetics similar to those of native ligand CXCL11/I-TAC and stimulated chemotaxis of activated human T-cells. The agonist small molecules also inhibited binding of another CXCR3 ligand, CXCL10/IP-10, to the receptor. The response to small-molecule agonists was inhibited by a CXCR3-specific small-molecule antagonist previously identified within the same combinatorial compound collection but structurally unrelated to the agonists. Remarkably, while other, non-amino acid substituents were present in the majority of the library compounds screened, the agonists from both classes contained a positively charged amino acid component, with preference for Arg>Lys, as well as a hydrophobic component.

The p38 mitogen-activated protein (MAP) kinases are a family of serine/threonine protein kinases that play important roles in cellular responses to inflammation and external stress. Inhibitors of the p38 MAP kinase have shown promise for potential treatment of inflammatory disorders such as rheumatoid arthritis, acute coronary syndrome, psoriasis, and Crohn's disease. We identified a novel class of p38 inhibitors via high-throughput screening. PS200981 [3-(4-(1,4-diazepan-1-yl)-6-(((1S,2R,5S)-6,6-dimethylbicyclo[3.1.1]heptan-2-yl)methylamino)-1,3,5-triazin-2-ylamino)-4-methylbenzamide], a representative compound identified from screening a collection of combinatorial libraries, amounting to 2.1 million compounds, inhibits p38alpha kinase and the lipopolysaccharide (LPS)-induced increase in tumor necrosis factor (TNF) alpha levels in cell media of human monocytes with IC50 values of 1 microM. The screening data revealed a preferred synthon, 3-amino-4-methyl benzamide, which is critical for the activity against p38. This synthon appeared almost exclusively in screening hits including PS200981, and slight variations of this synthon including 3-amino benzamide and 2-amino-4-methyl benzamide also contained in the library were inactive. PS200981 is equally potent against the alpha and beta forms of p38 but did not inhibit p38 gamma and is25-fold selective versus a panel of other kinases. PS200981 inhibited the LPS-induced increase in TNFalpha levels when administered at 30 mg/kg to mice. Selectivity and in vivo activity of this class of p38 inhibitors was further demonstrated by PS166276 [(R)-3-(4-(isobutyl(methyl)-amino)-6-(pyrrolidin-3-ylamino)-1,3,5-triazin-2-ylamino)-4-methylbenzamide], a highly structurally related but more potent and less cytotoxic inhibitor, in several intracellular signaling assays, and in LPS-challenged mice. Overall, this novel class of p38 inhibitors is potent, active in vitro and in vivo, and is highly selective.

Purpose: Our purposes were to report the clinical outcome of autologous chondrocyte implantation (ACI) patients with graft hypertrophy compared with that of unoperated ACI patients and to longitudinally assess the effects of graft hypertrophy debridement. Methods: We divided 170 knee ACI patients with a minimum of 2 years' follow-up into groups according to the need for reoperation after ACI and the findings at surgery. Group A (n = 73) comprised patients who did not undergo reoperation, group B (n = 61) comprised patients who underwent reoperation and had findings unrelated to the repair, and group C (n = 36) comprised patients who underwent reoperation and had isolated graft hypertrophy. The International Knee Documentation Committee, modified Cincinnati knee rating, and Short Form 36 physical component scores for the 3 groups were compared. Of the repairs debrided because of graft hypertrophy, 41 were longitudinally assessed with arthroscopy or magnetic resonance imaging. Results: The mean follow-up was 42.2 months. Patch-related problems were seen in 73.7% of cases undergoing reoperation less than 2 years after implantation, whereas cartilage-related problems were the dominant finding more than 2 years after implantation (70.2%). Group A patients fared significantly better than group B or C patients with regard to all 3 parameters measured, with no difference between groups B and C. Longitudinal assessment of 41 hypertrophied repairs revealed 18 with signs of pathology after graft debridement. Conclusions: This study shows that reoperation is frequent after ACI and is associated with a less satisfying outcome. Furthermore, debridement of a hypertrophied ACI graft appears to be detrimental as shown by longitudinal assessment of repairs. Level of Evidence: Level IV, therapeutic case series.

A novel class of 5-cyanopyrimidine-based inhibitors of p38alpha MAP kinase has been investigated. Analogues optimized through SAR iterations display low nanomolar enzymatic and cellular activity. The in vivo efficacy of this class of p38 inhibitors was demonstrated by 3a and 3b (>50% reduction in TNF levels when orally dosed at 5 mg/kg, 5 h prior to LPS administration in an acute murine model of inflammation). For 3a and 3b, the previously identified N-methoxybenzamide moiety (1) was replaced with N-(isoxazol-3-yl)benzamide, thereby providing increased metabolic stability. Cyanopyrimidine 3a demonstrated 100% oral bioavailability in mouse. High p38 kinase selectivity versus over 20 kinases was observed for analogue 3b. Direct hydrogen bonding of the cyano nitrogen of the 5-cyanopyrimidine core to the backbone NH of Met109 was confirmed by X-ray crystallographic analysis of 3a bound to p38alpha.

To determine the efficacy of autologous chondrocyte implantation (ACI) in treating focal chondral defects of the knee, we reviewed the 2-year treatment outcome of ACI in 53 patients (72 lesions) through clinical evaluation, MRI, second-look arthroscopy and biopsies obtained. Improvement in mean subjective score from preoperative (37.6) to 12 months (56.4) and 24 (60.1) months post-ACI were observed. Knee function levels also improved [86% International Cartilage Repair Society (ICRS) III/IV to 66.6% I/II] from preoperative period to 24 months postimplantation. Objective IKDC score of A or B were observed in 88% preoperatively. This decreased to 67.9% at 3 months before improving to 92.5% at 12 months and 94.4% at 24 months post implantation. Transient deterioration in all these clinical scores was observed at 3 months before progressive improvement became evident. MRI studies demonstrated 75.3% with at least 50% defect fill, 46.3% with near normal signal, 68.1% with mild/no effusion and also 66.7% with mild/no underlying bone marrow oedema at 3 months. These values improved to 94.2%, 86.9%, 91.3% and 88.4%, respectively, at 12 months. At 24 months, further improvements to 97%, 97%, 95.6% and 92.6%, respectively, were observed. Second-look arthroscopy carried out in 22 knees (32 lesions) demonstrated all grafts to be normal/nearly normal based on the International Cartilage Repair Society (ICRS) visual repair assessment while core biopsies from 20 lesions demonstrated 13 grafts to have hyaline/hyaline-like tissue. Improvement in clinical and MRI findings obtained from second-look arthroscopy and core biopsies evaluated indicate that, at 24 months post-ACI, the resurfaced focal chondral defects of the knee remained intact and continued to function well.

A new structural class of triaminotriazine aniline amides possessing potent p38 enzyme activity has been discovered. The initial hit (compound 1a) was identified through screening the Pharmacopeia ECLiPS compound collection. SAR modification led to the identification of a short acting triaminotriazine aniline methoxyamide (compound 1m) possessing in vitro and in vivo oral activity in animal models of acute and chronic inflammatory disease. An X-ray crystal structure of compound 1m in this class, cocrystallized with unactivated p38 alpha protein, indicates that these compounds bind to the ATP binding pocket and possess key H-bonding interactions within a deeper cleft. Hydrogen bonding between one of the triazine nitrogens and the backbone NH of the Met109 residue occurs through a water molecule. The methoxyamide NH and carbonyl oxygen are within H-bonding distance of Glu71 and Asp168.

Background: Simultaneous anterior and posterior ankle impingement has not been previously reported. We identified 62 patients with both anterior and posterior impingement and report the results of anterior arthroscopic and posterior open treatment. Methods: Between January, 1990, and December, 2003, 62 consecutive patients with symptoms and signs of both anterior and posterior impingement of the ankle were identified. Fifty-eight recorded a single injury or multiple ankle sprains. The most common mechanism of injury was inversion or plantarflexion. Initial conservative treatment failed in all patients and anterior arthroscopy and open posterior clearance were done. Followup averaged 11.4 months (up to 5 years). All patients showed posttraumatic synovitis at arthroscopy, and 48 had other arthroscopically-detected lesions, such as anterior tibial plafond lesions, ossicles, or soft-tissue impingement. The posterior arthrotomy revealed a bony cause for impingement in all but four patients, usually an os trigonum or a long posterior process of the talus. Results: Three patients had anterolateral tenderness after arthroscopy and three had tenderness of the posterior arthrotomy scar. There were no persistent neurologic complications. Fifty-eight patients were available for followup. Forty-seven (81%) had excellent or good outcomes, nine (15.5%) had fair outcomes, and two (3.5%) were graded as poor. Conclusion: Usually, anterior and posterior impingement occur separately; however, there are patients who have symptoms and signs of both anterior and posterior ankle impingement. A single inversion or plantarflexion mechanism of injury may be responsible for this syndrome, although it may also be caused by repetitive inversion injury. Combined anterior arthroscopic and posterior open treatment obtained good results with minimal complications and morbidity.

Patellofemoral pain remains one of the most common musculoskeletal disorders encountered in orthopaedic practice. In this retrospective clinical study, 108 knees in 98 patients with patellofemoral pain due to malalignment were treated using a combined proximal and distal realignment technique. The results were evaluated at an average of 29.2 (1–9.2 years) months postoperatively. At final evaluation using the modified Trillat grading scale, good or excellent results were obtained in 88 (81.4%) of the knees treated. Second-look arthroscopy performed in 65 (60.2%) knees demonstrated good patellar tracking and Grade II articular changes were noted in 16 (14.8%) of the patellofemoral joints examined. Complications noted included anterior compartment syndrome with foot drop in one case and arthrofibrosis in another. We conclude that extensor realignment surgery with a combined proximal and distal realignment procedure is a reliable technique for patellofemoral pain secondary to malalignment.

We have reviewed 22 patients from a total of 135 treated by autologous chondrocyte implantation (ACI) who had undergone further surgery for pain in the knee and mechanical symptoms after a mean of 10.5 months. There were 31 grafted lesions. At operation the findings included lifting (24/31) and detachment (3/31) of periosteal patches for which arthroscopic shaving was performed. Chondroplasty was undertaken on two new lesions, another required an ACI and a further patient required trimming of a meniscus. The mechanical symptoms resolved within two weeks. At the last review, two to 14 months from reoperation; 68% had improved, and 86% had normal or nearly normal IKDC scores. Of the 31 lesions, 30 (97%) had normal or nearly normal visual repair scores. Biopsy showed good integration with subchondral bone and the marginal interface in all specimens, most of which showed hyaline or hyaline-like cartilage (70%). Troublesome mechanical symptoms required surgery in 13% of ACI-treated patients and were attributed to periosteal extrusion. Simple arthroscopic debridement was curative.

Proteolytic processing of the amiloride-sensitive epithelial sodium channel (ENaC) by serine proteases is known to be important for channel activation. Inappropriate ENaC activation by proteases may contribute to the pathophysiology of cystic fibrosis and could be involved in sodium retention and the pathogenesis of arterial hypertension in the context of renal disease. We hypothesized that in addition to serine proteases, cathepsin proteases may activate ENaC. Cathepsin proteases belong to the group of cysteine proteases and play a pathophysiological role in inflammatory diseases. Under pathophysiological conditions, cathepsin-S (Cat-S) may reach ENaC in the apical membrane of epithelial cells. The aim of this study was to investigate the effect of purified Cat-S on human ENaC heterologously expressed in Xenopus laevis oocytes and on ENaC-mediated sodium transport in cultured M-1 mouse renal collecting duct cells. We demonstrated that Cat-S activates amiloride-sensitive whole-cell currents in ENaC-expressing oocytes. The stimulatory effect of Cat-S was preserved at pH 5. ENaC stimulation by Cat-S was associated with the appearance of a γENaC cleavage fragment at the plasma membrane indicating proteolytic channel activation. Mutating two valine residues (V182 and V193) in the critical region of γENaC prevented proteolytic activation of ENaC by Cat-S. Pre-incubation of the oocytes with the Cat-S inhibitor morpholinurea-leucine-homophenylalanine-vinylsulfone-phenyl (LHVS) prevented the stimulatory effect of Cat-S on ENaC. In contrast, LHVS had no effect on ENaC activation by the prototypical serine proteases trypsin and chymotrypsin. Cat-S also stimulated ENaC in differentiated renal epithelial cells. These findings demonstrate that the cysteine protease Cat-S can activate ENaC which may be relevant under pathophysiological conditions.