The patellofemoral joint alignment in patients with symptomatic accessory navicular bone

Quadriceps angle (Q angle) provides useful information about the alignment of the patellofemoral joint. The aim of the present study was to assess a possible link between malalignment of the patellofemoral joint and symptomatic accessory navicular (AN) bone as an underlying cause in early adolescence using Q angle measurements. This study was performed on patients presenting to the Foot and Ankle Clinic at the Jordanian Royal Medical Services because of pain on the medial side of the foot that worsened with activities or shoe wearing, with no history of knee pain, between September 2013 and April 2015. The Q angle was measured using a goniometer in 27 early adolescents aged 10-18 years diagnosed clinically and radiologically with symptomatic AN bone, only seven patients had associated pes planus deformity; the data were compared with age appropriate normal arched feet without AN. Navicular drop test (NDT) was used to assess the amount of foot pronation. The mean Q angle value among male and female patients with symptomatic AN with/without pes planus was significantly higher than in controls with normal arched feet without AN (p<0.05). Symptomatic AN feet were also associated with higher NDT values (p<0.001). The present findings suggest an early change in patellofemoral joint alignment in patients with symptomatic AN bone with/without arch collapse. Therefore, it is recommended that Q angle assessment should be an essential component of the examination in patients with symptomatic AN bone

Putative interaction of TLR signaling and local regulation of cortisol in the human cornea.

<p>(A) Under physiological conditions, autocrine synthesis of cortisol in corneal epithelial cells contributes to the immunoprotection of the ocular surface mucosa. During induction of ocular surface TLRs cytokines are released in a ligand and cell specific manner. (B) On TLR3 ligation such as chronic immune -mediated disease e.g. SJS-TEN, synthesis of a diverse spectrum of cytokines primarily from the corneal epithelial cells, induces <u>weak</u> monocyte chemotaxis and differentiation to M1 macrophages. These cytokines <u>potently attenuate</u> M1 cortisol biosynthesis leading to a net reduction of ocular surface cortisol levels, promoting recruitment of inflammatory cells necessary for resolving the initial trigger. By contrast, on TLR4 ligation (C) activation of keratocytes to a fibroblast phenotype, form the first line of defense producing chemokines that <u>potently</u> induce monocyte migration to the site of infection for rapid eradication of bacterial invasion. Attenuation of M1 cortisol production is less pronounced and this facilitates resolution of the inflammatory response, limiting tissue damage thereby preserving optical clarity (and sight).</p

Macrophage infiltration in human keratitis.

<p>(A) Immunohistochemistry of the normal human central corneal epithelium showed no evidence of CD68 positive resident macrophages or basal TLR4 expression, although there was some basal TLR3 expression. Corneal stromal infiltration of CD68 positive cells is seen in both herpetic and gram negative keratitis associated with increased TLR3 and TLR4 expression in the corneal epithelium, respectively. (B–E) Migration assay showing culture supernatants of corneal cells having chemotactic potential on monocytes. Cell supernatants from PHCEC/PHKF stimulated with TLR3 (poly I∶C) or TLR4 (LPS) ligands for 16 h were tested for the ability to induce monocyte migration. ‘S’ denotes culture supernatants from PHCEC/PHKF cultures generated from 3 corneal donors, tested on a single allogenic PBMC donor. ‘D’ denotes 3 different PBMC donors subjected to culture supernatant from a single donor derived PHCEC/PHKF treated with TLR3 and TLR4 ligands. Data show that both LPS and Poly I∶C stimulation of corneal cells induce monocyte migration but LPS stimulation of PHKF has the greatest chemotactic potential. (Panels D and E). (F) Culture supernatants from experiments A–D (TLR3 and TLR4 induction of PHCEC/PHKF for 16 h) downregulates M1 macrophage 11β-HSD1 activity. Statistical analysis was carried using one-way ANOVA and comparisons were drawn with untreated control cells vs. TLR3/TLR4 treated cells.</p

Regulation of cytokine production with Cortisol/Dexamethasone on TLR3 or TLR4 stimulated Primary Human Corneal Fibroblasts (PHKF).

<p>Both cortisol (▪, black square) and dexamethasone (▪, gray square) reduced cytokines: VEGF, CCL5, IFN-γ, CXCL-10, IL-8 and GCSF (B) after either or both TLR 3 and 4 stimulation of PHKF. (Values =  Mean+SE, normalising to No Cortisol/Dexamethasone (□, white square) for each treatment n = 3; Statistical analysis 2-way ANOVA with Bonferroni post-test; *p<0.05, **p<0.01, ***p<0.001).</p

Ocular surface glucocorticoid bioavailability in health and disease.

<p>Evaluation of tear film glucocorticoid profiles as surrogate readouts of net ocular surface glucocorticoid bioavailability, defines cortisol depletion (reduced cortisol∶cortisone (F∶E ratio, mean±SE) during active untreated pseudomonas keratitis (PSK) but not herpes simplex keratitis (HSK), and amplification during chronic clinically quiescent immune-mediated disease (MMP, mucous membrane pemphigoid; SJS/TEN, Stevens-Johnson Syndrome/Toxic-epidermal Necrolysis). Statistical analysis performed using t-test with two-tailed Mann Whitney post -test. * = P<0.05.</p

Pre-receptor regulation of glucocorticoids and TLR expression in human corneal cells.

<p>(A) RT-PCR of PHCEC, PHKF showing expression of the major genes for the pre-receptor regulation of glucocorticoids: 11β-HSD1, 11β-HSD2, H6PD and GR. Macrophages, M1 and M2, also express 11β-HSD1 but not 11β-HSD2. All cell types demonstrate 11β-HSD1 oxo-reductase activity (B), most marked in M1 macrophages. (C) TLR 1–9 induction did not alter 11β-HSD1 activity in either PHCEC or PHKF after stimulation for 16 h.</p

Human corneal cells respond to TLR stimulation by producing cytokines.

<p>Multiplex bead ELISA analysis (Plex-30) of cytokine production in response to TLR 1–9 stimulation for 16 hours is shown. Cytokines analysed included: IL-1β, IL-1Rα, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-9, IL-10, IL-12(p70), IL-13, IL-15, IL-17, Eotaxin, Basic FGF, G-CSF, GM-CSF, IFN-γ, CXCL-10, CCL2, CCL3, CCL4, PDGF-BB, CCL5, TNF-α, VEGF. Induction of a range of cytokines and chemokines was seen after TLR 3 challenge (CCL2, CCL3, CCL4, CCL5, CXCL10, IL1, IFNγ and IFNβ). Values =  Mean+SE, n = 3, Statistical analysis was carried using One-way ANOVA and comparisons were drawn with untreated control Vs TLR stimulated cells. * p<0.05, ** p<0.01, *** p<0.001.</p

Hormones detected in human ocular biofluids versus serum.

<p>A) Cortisone and (B) cortisol levels in the tear film and AqH. There was no gender dependency for any of the analyte (• black circle, Male and (▪ red square, Female)). There was a positive correlation between cortisol and cortisone in both ocular biofluids (C–D), but concentrations were largely independent of those found in serum (E–H). There was an association between AqH and Tear film cortisone (I) and cortisol (J), and cortisol∶cortisone (F∶E) ratios were consistently higher in AqH versus the tear film (K).</p

Cortisol Biosynthesis in the Human Ocular Surface Innate Immune Response

<div><p>Innate immune responses have a critical role in regulating sight-threatening ocular surface (OcS) inflammation. While glucocorticoids (GCs) are frequently used to limit tissue damage, the role of intracrine GC (cortisol) bioavailability via 11-beta-hydroxysteroid dehydrogenase type 1 (11β-HSD1) in OcS defense, remains unresolved. We found that primary human corneal epithelial cells (PHCEC), fibroblasts (PHKF) and allogeneic macrophages (M1, GM-CSF; M2, M-CSF) were capable of generating cortisol (M1>PHKF>M2>PHCEC) but in corneal cells, this was independent of Toll-like receptor (TLR) activation. While PolyI∶C induced maximal cytokine and chemokine production from both PHCEC (IFNγ, CCL2, CCL3, and (CCL4), IL6, CXCL10, CCL5, TNFα) and PHKF (CCL2, IL-6, CXCL10, CCL5), only PHKF cytokines were inhibited by GCs. Both Poly I∶C and LPS challenged-corneal cells induced M1 chemotaxis (greatest LPS-PHKF (250%), but down-regulated M1 11β-HSD1 activity (30 and 40% respectively). These data were supported by clinical studies demonstrating reduced human tear film cortisol∶cortisone ratios (a biomarker of local 11β-HSD1 activity) in pseudomonas keratitis (1∶2.9) versus healthy controls (1∶1.3; p<0.05). This contrasted with putative TLR3-mediated OcS disease (Stevens-Johnson Syndrome, Mucous membrane pemphigoid) where an increase in cortisol∶cortisone ratio was observed (113.8∶1; p<0.05). In summary, cortisol biosynthesis in human corneal cells is independent of TLR activation and is likely to afford immunoprotection under physiological conditions. Contribution to ocular mucosal innate responses is dependent on the aetiology of immunological challenge.</p></div