SSV has been found in all green plants with conserved sequences and gene structures. Our phylogenetic analysis based on 780 base pairs has suggested that SSIV and SSV resulted from a gene duplication event, which may have occurred before the algae formation. An expression profile analysis of SSV in maize has indicated that ZmSSV is mainly transcribed in the kernel and ear leaf during the grain filling stage, which is partly similar to other SS isoforms. Therefore, it is likely that SSV may play an important role in starch biosynthesis. Subsequent analysis of SSV function may facilitate understanding the mechanism of starch granules formation, number and structure.Starch is an important reserve of carbon and energy in plants, providing the majority of calories in the human diet and animal feed. Its synthesis is orchestrated by several key enzymes, and the amount and structure of starch, affecting crop yield and quality, are determined mainly by starch synthase (SS) activity. To date, five SS isoforms, including SSI-IV and Granule Bound Starch Synthase (GBSS) have been identified and their physiological functions have been well characterized. Here, we report the identification of a new SS isoform in maize, designated SSV. By searching sequenced genomes,  Starch, a polymer of glucose, is an important reserve of carbon and energy in plants . In photStarch consists of two classes of α-1,4-glucan polymers, amylose and amylopectin. Amylose is a small linear polymer with few branches, while amylopectin is large and contains frequent α-1,6-branch linkages . In planSS transgenic and mutant lines reveals some redundant function among isoforms , SSI, SSII, SSIII, and SSIV have been reported . Each suisoforms . For exa1 . According to the maize genome annotation, ZmSSV has two extra long introns, which are intron 4 with a length of 7,398 bp and intron 17 with a length of 54,336 bp. To confirm whether ZmSSV could be normally transcribed or is just as a pseudogene, and whether there exist SSV homologs in other plants, we have isolated this SS-like gene, which is different from other SS gene subfamilies in maize. Furthermore, the orthologs in some monocots, eudicots, moss and algae have been identified by genome sequence searches. In this paper, the gene structure, expression patterns and evolution of ZmSSV are investigated and discussed.Five reported subfamilies of SS are well characterized chemically and genetically. Are there any other enzymes involved in plant SBP? What is the characteristic of expression and phylogeny for these novel genes? We have searched sequenced plant genomes to identify novel genes encoding SSs. Interestingly, a putative gene encoding a new SS, named 2 and stored at -80°C until use  were grown in the field at Sichuan Agricultural University Farm in Wenjiang, Sichuan, in April 2014, according to the local standard for high yield maize production. Roots, stems and leaves were taken from 5-leaf-stage seedlings. Silks were harvested before rolling out of the husk, and anthers were harvested during flowering. Developing kernels from self-pollinated ears were collected at 10 DAP, kernels used to separate pericarp, embryo and endosperm were collected at 15 DAP, and ear leaves also collected at 15 DAP. All samples were collected between 9:00 and 10:00 am, and frozen in liquid Nntil use . The sam2). Reverse transcription was carried out by using PrimeScriptTM RT reagent Kit  , removing contaminating genomic DNA. The forward and reverse primers for the ZmSSV full cDNA (∼2.1 kb) isolation were AGGTACGGCGCGCATAGCTAAC and TGTGCTTCTCTAGCAGATGCCCAG, respectively. The PCR was performed using high efficient and fidelity PCR enzyme  and under the following conditions: 94°C 2 min, 35 cycles of 98°C for 10 s, 60°C for 30 s, 68°C for 150 s, and a final extension at 68°C for 7 min. Amplified PCR products were visualized on a 1% agarose gel and amplicons purified with QIAquick Gel Extraction Kit.Total RNA was extracted from various tissues of maize by Trizol reagent according to the manufacturer’s instructions  and TCAGGACGATGAAGCTTACGG (reverse), which were specially designed for the length about 200 bp and across an intron. Actin (accession number: NM_001154731.1) was used as the internal control, and its primers were TCACTACGACTGCCGAGCGAG (forward) and GAGCCACCACTGAGGACAACATTAC (reverse). The real-time qRT-PCR was conducted with SYBR Premix Ex TaqTM (Takara) in the Biorad system, according to the manufacturer’s protocols.3 and the maize reference genome4. In order to retrieve their orthologous sequences in other plants and bacteria, we used all maize sequences as queries against TAIR5, NCBI3, Phytozome6 and Gramene7 by performing BLASTP, BLASTN, and TBLASTN programs with E-value less than 10-5. All the sequences used in the paper were listed in Additional File 1 (Supplementary Table S1).All full-length DNA and amino acid sequences of maize SSs were downloaded from databases of NCBI8, and the signal peptide cleavage sites were predicted with TargetP 1.19. The protein conserved domain prediction was performed using SMART10 and CD-search service11. Motif analysis was performed by MEME12 with the following parameters: repetitions per sequence = zero or one per sequence; maximum number of motifs found = 12; and an ideal motif size between 6 and 300 amino acids .4, we designed primers and isolated the 2190 bp full-length cDNA of ZmSSV in maize elite inbred 18–599 (GenBank accession number: KP192927). The amino acid sequence deduced from the open reading frame (ORF) contains 701 residues with a predicted molecular mass of about 78.6 kDa. Our sequencing result is identical to the ZmSSV ORF from genome annotation of inbred B73  . Besides the GT5 and GT1 domains, there is a coiled coli domain between amino acids 117 and 147 in the ZmSSV N-terminus, similar to the coiled coli domain of ZmSSIV but absent from other SS subfamilies. Moreover, the sequence identity of the coiled coil domain between ZmSSV and ZmSSIV is significantly higher than that of the surrounding region, and there are some conserved sites . We infer that the two domains may perform similar or identical functions. With these conserved domains, ZmSSV is identified as a SS.The putative amino acid sequence of ZmSSV is most closely related to ZmSSIV. Sequence alignment shows 35% identity, with consensus sequences not only in the conserved C-terminus including starch catalytic and glycosyltransferase domains, but also in the unique N-terminus. The GT5 domain is more conservative than GT1 in plant SSs . In ZmSSZmSSV is about 70.9 kb in the B73 reference genome  (EU621837) and Solanum tuberosum (EU661369), then aligned to the corresponding genome sequences to calculate exon lengths and determine the introns according to the “GT(C)-AG” rule . We found no full length Arabidopsis SSV CDS in GenBank, and were not successful in aligning the homologous SSV CDS of other eudicots with the Arabidopsis genome, so could not get the complete AtSSV ORFs.Although AG” rule . SimilarSSV is generally conserved in land plants (Table 1), suggesting ancient common ancestry of these genes. Of the 20 exons in monocots, 18 are equal in length, only the first and fourth varying slightly. In eudicots, SSV of Glycine max (soybean) and potato have 20 exons, and Populus trichocarpa has 18. Arabidopsis SSV has only 13 exons and 460 putative amino acids, suggesting that the genome annotation of AtSSV is not complete. Between soybean and potato, 14 of 20 exons are equal in length, 11 of these also being equal to poplar exons, and five to Arabidopsis exons (despite the incomplete annotation of AtSSV). Between monocots and dicots (excluding Arabidopsis), nine SSV exons are equal in length, also being equal to those of moss (Physcomitrella patens). SSV structure in algae (Chlamydomonas reinhardtii) is substantially different from land plants, suggesting rapid evolution of the gene in algae after divergence from a common ancestor shared with land plants.The exon and intron structure of SSV varies widely among species, due to lineage specific events. In maize, for example, a transposable element (TE) belonging to the long terminal repeat retrotransposon copia class with length of 7204 bp locates in intron 4, and a number of variable repeat sequences locate in intron 17 . Using LTR_FINDER  have affected them.The length of introns in R_FINDER , we founProchlorococcus marinus AS9601 and Synechoccus sp. CC9311). The topologies of phylogenetic trees, constructed by multiple methods, mostly agree with one another. The six SS classes cluster into two groups, each including three clades . For ease of description, we have designated GBSSI, SSI and SSII as group A, and SSIII, SSIV and SSV as group B. Within Group B, SSV of all plants except algae forms a new clade, separate from SSIII and SSIV. The phylogenetic relationship between SSIV and SSV is closest, perhaps suggesting that they result from an ancient gene duplication, consistent with the generation of other SS subfamilies. The phylogenetic relationships among GBSS and SSI-IV are consistent with previous reports  and GSs from two bacteria . For the C-terminus composed of the conserved starch catalytic (GT5) and glycosyltransferase-1 (GT1) domains, we aligned SSV not only with SSIV, but also with the glycogen synthase of A. tumefaciens and Escherichia coli, and rice GBSSI and barley SSI, for which the crystal structures have been determined . The consensus lines, last line of the alignment, composing of asterisks (*) and dots/colons (./:), have revealed identical and conserved residues of SSIV and SSV. Overall sequence identity is high, especially in the GT5 domain, with that of the GT1 domain slightly lower. One of the possibilities for lower sequence identity in the GT1 region between SSIV and SSV, is the rapid evolution accompanying functional divergence of SSV after gene duplication. Another possibility is that some members of SSIV, such as OsSSIVa and OsSSIVb, accumulate more deletion mutations. As the incomplete sequence of SSV in Arabidopsis, AtSSV is not involved in the alignment of GT1 region.SSV should share with other SSs features responsible for the conserved functions of SSs, and have unique features responsible for its specific functions. To further investigate SSV features, we aligned the SSIV and SSV protein sequences of monocots and eudicots. In the variable N-terminus, both the coiled coil domain and the other conservative region adjoining the GT5 domain had multiple identical and conserved amino acid sites  are noted by pink squares. We have listed the important functional residues (Table 2) to directly bind and catalyze the substrate in AgtGS, EcGS, OsGBSSI, and HvSSI as reported previously  locate in this region. Likewise, in the adjoining region of the GT1 end, there are several identical and conserved residues  in all GSs and SSs, excepting the OsSSIVa end with great divergence. Comparing the conserved functional sites in SSV with other plant SSs and bacterial GSs (Table 2), more amino acid variants are found in SSV. For example, K15 in AgtGS is replaced by S237 in ZmSSV, and H163 in AgtGS is replaced by Q387, both substitutions from basic residues to uncharged amino acids, which would likely affect the functional properties of the enzymes. SSV may have significant functional divergence from other SSs.Because of the distant phylogenetic relationship between GSs and SSs in plant, we just showed partial alignment of conserved regions between AgtGS, EcGS, OsGBSSI, and HvSSI, and SSIV–V in eviously , and ideFigure 4) have been predicted using the Jpred program. The greatest divergence of secondary structure between ZmSSIV and ZmSSV is in the GT5 domain. One α-helix and two β-strands are absent in ZmSSV, and one α-helix of ZmSSIV changes to β-strand in the corresponding region of ZmSSV. In the starting region of GT1, one α-helix of ZmSSIV also changes to β-strand in ZmSSV. Two additional β-strands, located in GT1, and at the end of the C-terminus, respectively, are found only in ZmSSV. Outside of these regions, the secondary structure of the two proteins is quite conservative.To identify the specific structural features of SSV, the secondary structures of ZmSSIV and ZmSSV . Five motifs  are found in all members. Motif 9 and 10 are only found in monocots, and motif 11 is only in eudicots. Motifs in PpSSV and CrSSV are different from those of angiosperm, lacking motifs 3, 10, and 11 but with a unique motif (12). The results of motif investigation are consistent with the SSV gene phylogeny, indicating that each branch of SSV has unique functional regions and sites.The alignment also indicates some amino acid residues that vary within the SSV subfamily. To further reveal the potential functional regions or divergent sites in SSV, we have analyzed conserved motifs of SSV members by the MEME program, finding that there exist different motifs in SSV from algae to monocots . The level of ZmSSV transcription in anther is higher than that of silk. The highest expression level is in 15 DAP embryo and endosperm, followed by 15 DAP pericarp. Furthermore, because the 10 DAP kernel is too small to effectively partition the pericarp, endosperm and embryo, we tested the whole kernel, finding strong ZmSSV expression that was obviously higher than in vegetable tissues, but lower than in the 15 DAP kernel. The ear leaf, one of the vegetative tissues, is an important site of sucrose synthesis and supply to grain filling. ZmSSV is expressed highly in the ear leaf at the grain filling stage of 15 DAP, and its level is significantly higher than in seedling leaves.Quantitative RT-PCR analysis has been performed to study the expression profiles of transcripts encoded by ZmSSIV is compared to that of ZmSSV, because of the close phylogenetic relationship between the two isoforms . The highest ZmSSIV expression is also in the embryo, endosperm and pericarp at 15 DAP, and then in ear leaf, anther and silk. The ZmSSIV expression level is not high in 10 DAP kernels, and the lowest level is in the seedling root, stem and leaf. So the expression profiles across tissues of ZmSSIV and ZmSSV are similar. In addition, similar expression profiles have been found in homologues of ZmGBSSI, ZmSSI, OsSSIII-2 and OsSSIV-1 and others , the Rhodophyceae , and the Glaucophyta (glaucophytes) . Starch Synechocystis PCC 6803, and found that SpGS2 was closely related to the GBSSs, while SpGS1 was more similar to SSIV. They suggested that the Group A and Group B SSs evolved directly from the two independent GS types, the SSIV group evolved from SpGS1, and subsequent gene duplication events might lead to the evolution of SSIIIs. The exact origin of the ancestor of Group B SSs has not been determined, and further investigation is needed. The duplication leading to the evolution of SSIII must have been earlier than the duplication that we infer to have produced closely related SSIV and SSV, the latter perhaps occurring before or during the green plant lineage divergence.In this paper, phylogenetic analysis has suggested that SS isoforms of GBSS and SSI-V are present in all green plants . We infer that these isoforms have originated from early gene duplications, which may have occurred in the Archaeplastida ancestor or during the process of SBP redirection to the chloroplast . In Grou14. Just as is found in the structures of HvSSI, OsGBSSI and two GSs, the two Rossmann-fold like α-β-α domains are apparent in ZmSSIV and ZmSSV, and the large cleft separating both domains makes up the substrate-binding and catalytic center. Two classes of functional sites exist in the large cleft. One class is the ADP-binding pocket, which consists of the C-terminal domain wall and the conserved N-terminal KTGGL loop motif. The exact amino acid residues of the ADP-binding pocket in AtgGS include KTGGL(15–19), R299, Y354, E376 and T381 , several amino acid replacements with different characteristics have been found in SSV, such as K15/S, G18/P, R299/D and T381/I. The other class of functional sites are the acceptor  binding and catalyzing sites, including E9, Y96, DWQ(138–140) in AtgGS, and others. Some of the maltooligosaccharide-binding sites are conserved, but parts are flexible. Changes of non-conservative amino acids could affect enzyme properties. For example, Figure 4; Table 2), suggesting that these sites in SSs were flexible in different plant species. Collectively, substitutions in key amino acid residues and differences in secondary structure near or at the active/binding sites may lead to different spatio-conformational outcomes and possibly change interaction of protein with substrate. In this paper, we have found amino acids in substrate-binding and catalytic centers that are distinct between SS isoforms, which may partially explain important functional differences of each SS isoform. The significant difference of key amino acid residues between SSV and other isoforms has suggested that SSV may play roles in starch synthesis, that are distinct from the known isoforms of GBSS and SSI–SSIV.To further investigate the structure-function relationship of SSs, we have built a homology model for the C-terminus of ZmSSIV and ZmSSV (data not shown) based on the HvSSI structure using Swiss-modeland T381 . CompariArabidopsis display a severe growth defect, and the number of starch granules per plastid is dramatically decreased, leading to a single large particle per plastid, but the starch content and structure is near that of wild-type plants  by aligning to genome sequences. Conserved sequences and gene structures of SSV orthologs indicate that SSV in plants must be derived from the same ancestor. SSV is most related to the known SSIV, and they are produced by a gene duplication occurring in the early stages of the evolution of green plants. Although molecular evolution has conferred functional divergence of the duplicated gene pairs, their expression profiles remain similar.In summary, we have cloned the full CDS of YH, HL, and HZ conceived and designed the experiments. YL contributed plant materials. HL, BW, and GY contributed to data analysis. GY, YH, JZ, YW, and GY performed the experiments. HL wrote the manuscript. All authors discussed the results and commented on the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


For chronic subtypes, survival periods were of 213 months for 3 VA+ patients and of 33 months for 11 VA− patients (p = 0.023). For lymphoma subtypes, survival periods were of 144 months for 2 VA+ patients versus 6 months for 49 VA− patients (p = 0.0046). ATL cases with skin lesions, particularly lymphoma subtypes, had a longer survival (13.96 months) compared to those without skin lesions . Eight out of the 10 patients presenting with long survival had skin lesions.We describe the clinical and biological features of ten patients with a survival superior to ten years , out of 175 patients diagnosed with Adult T-cell Leukemia/Lymphoma (ATL) in Martinique (1983–2013). There were 5 lymphoma and 5 chronic subtypes. Five of them  had been treated with valproic acid (VA) for neurological disorders developed before or after ATL diagnosis, suggesting a beneficial role for VA as a histone deacetylase inhibitor (HDI) in ATL treatment. Total duration of uninterrupted VA treatment ranged from 8 to 37 years. Overall, the 175 incident ATL cases presented with a median survival of 5.43 months. The five VA-treated (VA The human T-lymphotropic virus 1 (HTLV-1) is the causative agent of ATL (Adult T-cell Leukemia/Lymphoma)  and of Hlow CD4+ CD7− phenotype, expresses the IL2 alpha receptor  and presents activation of NF-kappa B in a constitutive manner. Structural and numeric karyotypic abnormalities are frequent [The ATL cell, mainly of the T-CD3frequent . In our Two contradictory clinical trials focusing on VA treatment in HAM/TSP patients , 9 have  in vivo and in vitro studies have described the efficiency of VA and of other HDIs. As a result, different types of HDIs were successfully incorporated into several treatment protocols for other cutaneous T-cell lymphoma unrelated to HTLV-1 [ in vitro by various broad spectrum and specific HDIs [In the field of human lymphoid malignancies, severalo HTLV-1 –18. One fic HDIs , 19–21. fic HDIs , serum Ific HDIs , 19, andThe objective of this study was to compare the group of ATL patients presenting a survival superior to ten years  with all ATL patients identified over 30 years in Martinique (1983–2013). We also aim to discuss the rationale of VA use in the treatment of ATL on the basis of current knowledge about the natural history of the integrated HTLV-1 provirus and its tumoral resultant, ATL.This retrospective analysis concerns all ATL patients identified by the Martinique Registry of hematological malignancies and diagnosed between 1st January 1983 and 31st March 2013. Identification of patients, treated with VA, was the combined resultant of the retrospective analysis of patients diagnosed before year 2000 and of the prospective monitoring of patients as from year 2000. All study subjects presented a typical clinical presentation of the ATL disease  and had a positive serology for the HTLV-1 virus. Clinical subtypes were classified according to the LSG criteria [t-test. Categorical variables, such as gender, tumor syndrome , calcium and LDH values, eosinophilia status, and Strongyloides stercoralis (Ss) infection status, are presented as counts and percentages and were compared with the Fisher exact test. Survival curves were generated by the Kaplan-Meier method, and intergroup survival  was compared with the log-rank test. For all survival analyses, patients were considered at risk until date of death or date of last contact. Patients lost to follow-up were considered at risk until the date of last contact, at which point they were censored. Probability was significant at a level of 0.05 and all statistical tests were 2-tailed. Statistical analysis was performed with the use of the SAS 9.2 software .Continuous variables (age at diagnosis) are shown as mean ± SD and were compared by Student's unpaired During the study period, 175 new cases of ATL were identified. Clinical data are summarized in p = 0.002)  .p = 0.017) and presented with a higher frequency of skin lesions (p = 0.016) when compared to the rest of the patient sample.In our study, 10 patients (4 men and 6 women) presented with a long survival (superior to 10 years) . The medTwo patients were described with hypercalcemia and four patients presented with elevated LDH values while four other patients had eosinophilia . A monoc+) patients presented with longer survival compared to VA treatment-free patients (VA−). For chronic subtypes, survival periods were of 213 months for 3 VA+ patients versus 33 months for 11 VA− patients (p = 0.023). For lymphoma subtypes, survival periods were of 144 months for 2 VA+ patients and of 6 months for 49 VA− patients (p = 0.0046). For 2 of these 5 patients, other family members also developed an ATL condition with survival spanning from 3 days to 2 years. These family members did not receive any VA treatment. It is to be noted that no other patient from our series, apart from the five identified ones, received VA.Patient medical history and treatment course are presented in ATL is of very poor prognosis and the current urgency is finding treatments prolonging survival. Recently, an international meta-analysis revealed the efficacy of associating IFN with zidovudine in leukemia and chronic subtypes . This fiDuring the diagnosis period of patients with long survival, high LDH (4 patients) or high serum calcium rates (2 patients) showed that these prognostic tumoral markers were not barriers against an indolent evolution. The same could apply to eosinophilia , 28 and Furthermore, in the patient group with long survival, the high proportion of patients with skin lesions and early age at diagnosis suggests that skin tissue could be a primary, precocious, and privileged location for the ATL cell. Infiltration of other tissues would therefore be secondary, delayed, and metastatic in nature. Several facts underlie this hypothesis as follows: (i) the existence of a rare form of exclusively cutaneous ATL  as preseAs described by their medical history, one patient of our series received immunosuppressants such as antilymphocyte serum, cyclosporine, and corticosteroids due to kidney transplant during the 5 years preceding ATL disease while another received IFN, with antiviral and antiproliferative effects, for hepatitis C treatment. These treatments, especially antilymphocyte serum, cyclosporine, and IFN, could alter the integrity of the ATL cell, inducing apoptosis or repressing tumor extension through their anti-inflammatory effects and thus contributing to a slow evolutionary process . In two It is to be noted that, due to the small patient sample treated with VA, their longer survival periods (as compared to untreated patients) must be considered with care. Moreover, the introductory modalities of VA in these 5 patients were not homogeneous: two patients received VA for more than 15 years before ATL diagnosis while the remaining three only received VA, three years after ATL diagnosis, thus pointing towards the fact that VA administration before ATL treatment might not be necessary for its probable beneficial role. All 5 patients (patients 1 to 5) continued VA treatment without interruption and parallel to ATL treatment for time periods varying between 8 and 37 years. This observation might emphasize the importance of continuous VA administration over long time periods. The necessity for uninterrupted VA treatment was further underlined in a test on an ATL/NOD-SCID mouse model treated by another HDI, AR-42 , and in  TAX and HTLV-1 bZIP gene (HBZ). The HBZ protein might inhibit transactivation controlled by the TAX protein, which is itself under control of the 5′LTR [ TAX [However, these previous studies are not informative about VA's action on the integrated HTLV-1 provirus. The provirus, integrated in the host cell's genome, is flanked by two repeating units, the “long terminal repeat” (LTR), that is, the viral promoters (5′LTR and 3′LTR) which control the expression of viral genes, includinghe 5′LTR , 34. Thehe 5′LTR . VA and TR [ TAX . This reTR [ TAX , 13, 19,The two LTRs are virtually identical in terms of DNA sequence. At their level, they present an almost equal distribution of activators and coactivators, suggesting a common functionality . However NDRG2 (N-myc downstream-regulated gene 2) on ATL cells [Moreover, the entire cellular genome has a histone environment. Therefore, HDIs, such as VA, could restore the expression of many switched-off genes, particularly those that encode CD3/TCR protein complex. It could also be the case for the CD7 protein which is operatively associated with the CD3/TCR complex and which has a defective expression in ATL cells –42. In tTL cells , is an e HBZ with proliferative potential [Furthermore, the high frequency of aberrantly hypermethylated cellular genes in the ATL cell, involved in cell growth or apoptosis , suggestotential , 45, 46,otential , 47 or iotential  observedotential . in vitro with HTLV-1 cells in culture and in transgenic animal models for TAX [Moreover, in healthy carriers, HDI-induced TAX overexpression, due to its mutagenic effects, could favor early immortalization of HTLV-1 clones. This has been observed for TAX , 51. On  for TAX . In cont for TAX . Interes for TAX .It is reasonable to think that, to be active, HDIs require intact provirus and its histone environment. However, ATL patients and healthy carriers frequently have genetic or epigenetic abnormalities at the 5′LTR level , 47, 48.The long survival of ATL patients, recipients of long-term uninterrupted VA treatment, is an incentive to consider HDIs as potentially effective agents in ATL treatment, for induction or as a maintenance therapy either alone or in combination with other molecules. As such, HDIs are not curator agents but are stabilizing agents in indolent ATL forms. The asymmetric risk, resulting from the differential effects of HDIs at the level of the 2 LTRs, prompts to seek HDIs with specific action on each LTR. The use of HDIs also requires thought about the correct choice of associated molecules, with the objective of creating synergy without viral spread and for determining the administration sequence of those associated molecules. The selection of high risk candidates, such as ATL patient relatives, healthy carriers, or Ss-infected persons, is also a point to focus on. Furthermore, in the patient group with long survival, the high proportion of patients with skin lesions suggests that skin tissue could be a primary, precocious location for the ATL cell and that their early treatment in indolent ATL forms could limit evolution towards aggressive forms.


Our results on selected candidate genes in conferring oxidative stress and autoimmunity suggest that HLA-A*33:01, HLA-A*02:01,HLA-B*44:03, HLA-DRB1*07:01 and a few studied polymorphisms in IL4, CTLA4, SOD2, SOD3, GPX1, NALP1, MYG1, TNFA, TNFB, IFNG and IL10 genes are strongly associated with vitiligo susceptibility, whereas a few studied polymorphisms in PTPN22, MBL2, ACE, CAT, G6PD and SOD1 genes are not found to be significantly associated with Gujarat vitiligo patients. Gene expression studies of the IL4, CTLA4, SOD2, SOD3, NALP1, MYG1, TNFA, TNFB, IFNG, IL10 and ICAM1 genes suggest that these genes are strongly associated with vitiligo susceptibility. We are also addressing the role of immune-regulatory genes with respect to their expression in skin along with the effect of selected cytokines on in vitro cultured melanocytes derived from healthy and vitiliginous human skin to have an insight towards vitiligo pathogenesis. We are also exploring the potential microRNAs involved in pathogenesis of vitiligo. This integrated study will provide a better understanding of the role played by oxidative stress and autoimmunity in the pathogenesis of vitiligo in Gujarat population and also to develop selective therapy and the genetic marker/s for vitiligo.Vitiligo is an acquired, circumscribed hypomelanotic skin disorder, characterized by milky white patches due to loss of functional melanocytes from the epidermis. Prevalence of vitiligo is found to be very high in Gujarat i.e., ~8.8%. Vitiligo is a multifactorial polygenic disorder with a complex pathogenesis, linked with both genetic and non-genetic factors. Several theories have been proposed to explain the etiopathogenesis of vitiligo, but none of the hypotheses explains the entire spectrum of this disorder. We are addressing this complex disease in our Gujarat population with various approaches. Our study mainly deals with the evaluation of oxidative stress, autoimmune, genetic and neurochemical hypotheses in Gujarat vitiligo patients. We have shown that our vitiligo patients exhibit significant oxidative stress and thus, systemic oxidative stress could play a pathophysiological role in precipitation of vitiligo in Gujarat population. Our studies revealed that presence of increased antimelanocyte antibodies and the imbalance of T-cell  levels and antimelanocyte antibody titer decide the selective therapy for our vitiligo patients. The pathogenesis of vitiligo though partially understood still remains complex and enigmatic to a greater extent. Though the condition may be precipitated by multiple etiologies, the interaction of oxidative stress and immune system clearly appears to be the key convergent pathway that initiates and/or amplifies the enigmatic loss of melanocytes in vitiligo.


Obesity is a global issue and it has been suggested that an addiction to certain foods could be a factor contributing to overeating and subsequent obesity. Only one tool, the Yale Food Addiction Scale (YFAS) has been developed to specifically assess food addiction. This review aimed to determine the prevalence of food addiction diagnosis and symptom scores, as assessed by the YFAS. Published studies to July 2014 were included if they reported the YFAS diagnosis or symptom score and were published in the English language. Twenty-five studies were identified including a total of 196,211 predominantly female, overweight/obese participants (60%). Using meta-analysis, the weighted mean prevalence of YFAS food addiction diagnosis was 19.9%. Food addiction (FA) diagnosis was found to be higher in adults aged >35 years, females, and overweight/obese participants. Additionally, YFAS diagnosis and symptom score was higher in clinical samples compared to non-clinical counterparts. YFAS outcomes were related to a range of other eating behavior measures and anthropometrics. Further research is required to explore YFAS outcomes across a broader spectrum of ages, other types of eating disorders and in conjunction with weight loss interventions to confirm the efficacy of the tool to assess for the presence of FA. Obesity has been described as a global epidemic with 36.9% males and 38.0% females worldwide classified as overweight or obese . This isThe term “food addiction” has been used in combination with specific eating behaviors to describe an abnormal pattern of excessive consumption ,8,9. WhiDespite an increase in the number of publications regarding FA , with a A tool specifically designed to assess FA, the Yale Food Addiction Scale (YFAS) , was devTo the authors’ knowledge, only one study to date has provided an overview of how the YFAS has been used to measure FA . No reviA systematic literature review was undertaken to identify published studies that used the YFAS to assess FA diagnosis or symptom score from the year of tool development, 2009, to July 2014.Electronic databases were searched to identify relevant publications. These included: MEDLINE, The Cochrane Library, EMBASE (Excerpta Medica Database), CINAHL , Informit Health Collection, Proquest, Web of Science, Scopus and PsycINFO. Keywords were informed by preliminary literature searches and were searched including: Yale Food Addiction Scale, YFAS, questionnaire; food addiction, behavioral addiction, eating behavior, obesity, food, eat, feeding behavior, food preferences, food habits, body mass index, overeat, hyperphagia, substance related disorders, binge eating, hedonic eating. Both the English and American spellings of behavior/behaviour were searched. Database searches were supplemented by cited reference checks and systematic checking of reference lists of identified articles for additional relevant publications. The search strategy was registered with PROSPERO .To determine eligibility for inclusion in the review, titles and abstracts of identified studies were assessed by two independent reviewers using a predetermined inclusion criterion. Studies were included if they used the YFAS or a modified form of the YFAS to assess FA, reported either the YFAS diagnosis or symptom score, reported the population demographics in detail and were published in the English language. The articles for all studies meeting the inclusion criteria were retrieved. If a study’s eligibility for inclusion was unclear, the article was retrieved for further clarification.Quality of retrieved studies was assessed by two independent reviewers using a standardized 9-item tool . The qua2, or classified as overweight/obese if mean BMI ≥25 kg/m2. Participants were classified as children and adolescents (<18 years), young adults (18–35 years), and older adults (>35 years) to control for possible age related differences related to life stage  as well as dietary patterns and nutrient intakes [Studies were tabulated in chronological order. Results are reported based on scoring options used including: diagnosis of FA, YFAS symptom score and studies that reported high and low FA scores. Studies were grouped by BMI, age and gender for comparison in the systematic review and meta-analysis. As only two studies reported the prevalence of FA diagnosis of a sample with a mean BMI in the overweight category, studies of overweight or obese participants were grouped in a single category for meta-analysis. Participants were classified as healthy weight if mean BMI <25 kg/m intakes . Where Bvs. non-clinical population) was also undertaken if there were enough studies to conduct separate meta-analyses. As only one study reported FA prevalence for children, this study was not included in the meta-analysis. Meta-analyses were conducted using Comprehensive Meta-Analysis Professional version 2 . If details were not reported, authors were contacted in an attempt to gain the information required.Results were pooled using meta-analysis if the study reported the proportion of individuals with a diagnosis or mean symptom score as well as the number of participants. Due to the limited number of studies and lack of standardized definition for studies reporting high and low FA groups, only diagnosis and symptom score were included in the meta-analysis. Heterogeneity was tested during meta-analysis and if significant heterogeneity was present, the random effects model was used for statistical analysis. Sub-analysis by sex , weight status , age group (young adults 18–35 years or older adults >35 years) and clinical status  [n = 15) [A total of 1148 articles were initially identified using the search strategy. Following the removal of duplicate references and assessment of articles using the predefined inclusion criterion, 28 relevant articles describing 25 studies were identified  11,26,2,55,56,57n = 18) ,50,51 an[n = 15) ,48,49,50[n = 15) ,44,52, a[n = 15) . Eight s[n = 15) ,45,47,49[n = 15) ,56. Four[n = 15) ,32,36,49[n = 15) ,44,45,52[n = 15) .Critical appraisal of the quality of included studies is described in 2) [2) [2 [et al. [2 [A total of 196,211 participants were examined across reviewed studies ranging from one to 134,175 participants. Participants were predominantly female, with six studies investigating females exclusively ,42,50,522) ,41,42,432) [2) ,36,51, a) [2) [2 ,49,56,57) [2) [2 ,48,50,52 [et al.  investigt al. [2 .The standard YFAS comprised of 25 self-report questions was used in 23 studies. Two studies used the modified YFAS (m-YFAS) which consisted of nine core questions including one item for each symptom plus two items for clinical impairment and distress ,50. The Twenty-three studies reported the prevalence of FA diagnosis. As shown in The weighted mean prevalence of FA across all studies was 19.9% a 26,27,,53,56,57When categorized by disordered eating status the mean prevalence of FA was 57.6% in four samples with a clinically diagnosed eating disorder ,36,40,49the persistent desire or unsuccessful attempts to cut down foods” [Sixteen studies reported the total number or specific symptoms endorsed by participants. Eight studies reported the mean number of symptoms for the whole study sample and were meta-analyzed ,43,49,56n foods” ,48,49,56Across the reviewed studies, YFAS diagnosis and symptom score were associated with a variety of anthropometric measures. Specifically, higher BMI’s were related to higher rates of FA diagnosis ,36,50,51In support of the results of the pooled meta-analysis, prevalence of FA diagnosis and number of symptoms reported decreased with increasing age ,39 and fp = 0.04) and protein  compared to individuals with no FA diagnosis [Three studies examined relationships between the YFAS and foods or nutrients. Only one of these used a standardized dietary assessment method . Individiagnosis  as measuiagnosis . A case iagnosis . In addiiagnosis . Interesiagnosis . One stuiagnosis .The YFAS was commonly assessed in combination with other tools including the Binge Eating Scale (six studies) ,37,45,46No standardized definition for “high” and “low” FA scores were used in the two studies describing YFAS outcomes using this approach. In one of these studies, 35.8% were classified as “high” FA if they endorsed ≥3 symptoms and 28.2% as “low” FA if they endorsed ≤1 symptom, with individuals with moderate FA scores excluded . The secpersistent desire or unsuccessful attempts to cut down food intake”. When meta-analyzed by clinical status, clinical populations endorsed more than double the number of symptoms compared to non-clinical populations (4.0 and 1.7 symptoms respectively). However, it should be noted that the population samples in the included studies were predominantly comprised of overweight/obese females recruited from clinical settings. Hence, the prevalence of YFAS FA diagnosis and the average symptom scores are likely higher compared to a nationally representative general population sample due to the characteristics of included participants.This review aimed to systematically appraise studies that have used the YFAS to assess the presence of FA diagnosis or FA symptoms in a specified population. Using meta-analysis, the weighted mean prevalence of FA diagnosis in adult population samples was 19.9%. Meta-analysis indicated that FA prevalence was double that in overweight/obese population samples compared to those of a healthy BMI (24.9% and 11.1% respectively) and in females compared to males (12.2% and 6.4% respectively). FA prevalence was also higher in adults older than 35 years compared to adults younger than 35 years (22.2% and 17.0% respectively). Additionally, in populations with disordered eating, mean prevalence of FA was 57.6%, which was higher than that of individuals with no clinical diagnosis of disordered eating at 16.2%. The mean number of symptoms reported across studies was three out of a possible seven symptoms and the most common symptom reported in 70% of studies was “et al., females aged over 62 years had a lower prevalence of FA diagnosis than a group of middle aged females 42–64 years [It has been suggested that an addiction to food could act in a similar way to other substance addictions, with repeated exposures to pleasurable food diminishing the dopamine brain response ,61. This64 years . A simil64 years . It has Overconsumption and subsequent weight gain related to a blunted dopaminergic response could also provide a rationale for the finding that FA prevalence was higher in overweight/obese individuals. Of note, while YFAS diagnosis and symptom scores were positively related to anthropometric variables associated with adiposity in numerous studies reviewed, including a range of weight categories ,36,51, oMeta-analysis also identified that females had a higher prevalence of FA compared to males, which may be attributable to gender related differences in hormonal profiles and/or dietary patterns ,65. VeryThe majority of reviewed studies were cross sectional in design, assessing FA via the YFAS at one time point only. This precludes interpretation of cause and effect among variables. Only one study included in the review was classified as positive quality , which mIn contrast, studies of behavioral weight loss interventions reported disparate findings in the relationship between weight loss and YFAS outcomes. While one study found that YFAS scores at baseline predicted weight loss, a second longer term study found no relationship between FA status and weight loss success ,45. AlthIndividuals with diagnosed eating disorders including BED and bulimia nervosa were shown to have a higher prevalence of FA ,36,40,49Two recently published studies have investigated relationships between the YFAS and bulimia nervosa. In one of these studies, individuals with bulimia nervosa were found to have a higher prevalence of FA diagnosis compared to individuals with BED . In a seOnly three studies assessed FA in combination with specific foods or nutrients ,51,52. IOnly one study used a quantitative measure to assess FA using fMRI to assess whether FA scores correspond with brain activity . Individi.e., ≥6 symptoms) compared to a lower symptom score but satisfying the criteria for diagnosis  is yet to be investigated in detail. That is, although the diagnostic criteria have been modelled from the criteria to diagnose substance dependence, potentially the symptom score could provide comparable or more valuable information regarding FA, particularly in terms of developing future treatment approaches. The most meaningful method of scoring the YFAS should be more comprehensively investigated to further standardize the reporting FA characteristics. Two studies classified as high and low FA based on YFAS scores [The majority of studies reported YFAS outcomes using both the diagnosis and symptom score. The mean number of symptoms reported across studies was three out of seven, which is the diagnostic cut-off for FA in combination with clinical impairment or distress. This indicates that FA characteristics derived from the application of the DSM-IV criteria to food behaviors are quite highly endorsed across populations studied to date. However, when analyzed by clinical status, it was found that the mean symptom score of studies conducted in clinical settings was more than double that of non-clinical samples, which would likely have inflated the total mean symptom score. The significance of the differences between a high symptom score without clinical impairment or distress (S scores ,41,42 anS scores . ImportaSince the development of the original YFAS in 2009, modifications have been made to this tool for use in different populations. Five of the studies administered the YFAS via an online survey demonstrating the acceptability of the questionnaire completed online, which aids in reducing researcher and participant burden and highlights the movement towards use of technology in health assessment. Reducing the number of overall questions and subsequently reducing participant burden in the development of the m-YFAS has allowed for assessment of FA in large scale epidemiological surveys ,50 and cThe results of this review should be interpreted with caution due to the inherent limitations of the YFAS tool, including use of self-reported measures and lack of accepted definition for FA. However, the YFAS does not specifically refer to the term “food addiction” thus minimizing potential bias arising from self-report. The reviewed articles were predominantly cross-sectional precluding inferences about cause and effect. A limited number and spectrum of disordered eating studies were included in meta-analysis and findings should be interpreted accordingly. This review was further constrained by the limited number of studies reporting YFAS outcomes for older adults and children exclusively, which prevented meta-analysis in these age groups. Additionally, study populations were predominantly female and obese, limiting the generalizability of findings. Prevalence of FA identified through meta-analysis is likely higher than that seen in the general population as the majority of studies were conducted in clinical settings of overweight/obese individuals. A nationally representative sample is required to provide a better estimate of addictive like-eating in the general population.This study systematically reviewed all studies that used the YFAS to assess FA. Meta-analysis indicated that overweight/obese females aged over 35 years may be more predisposed to FA, as assessed by the YFAS. Additionally, participants with disordered eating had a much higher prevalence of FA, as assessed by the YFAS compared to their non-clinical counterparts. Notably, populations included in the reviewed studies were predominantly female, overweight/obese and adults aged over 35 years, and may not be representative of the general population. Further research is required to explore YFAS outcomes across a broader spectrum of ages, particularly children and adults aged >65 years, other types of eating disorders and in conjunction with weight loss interventions to confirm the efficacy of the tool to assess for the presence of FA. Additionally, future studies should investigate whether YFAS scores can be validated using a quantitative measure. This will provide further evidence to confirm or refute existence of FA and potentially help to develop appropriate treatment approaches to target FA specifically.


To analyze quality of life in people with symptomatic spine osteoarthritis (OA) using the results of a cross-sectional, nationwide survey.This study used data from the Fifth Korean National Health and Nutrition Examination Survey . After excluding ineligible subjects, the total number of subjects in the study was 8,963, including 4,091 males and 4,872 females. All participants reported disabilities related to spine OA. Plain radiographs of the spine were taken for all participants.Age, sex, smoking, drinking, education, and income level were significantly related to spine OA morbidity (P<0.05). OA morbidity was significantly higher in female ex-smokers . Quality of life (EQ-5D: L1~5) was significantly compromised in the group with spine OA compared to the group without spine OA (P<0.05). Overall, LQ 1, 2, 3, 4, and 5 domain scores were significantly higher in the group with spine OA (P<0.05). In the group with spine OA, quality of life was reduced on more than three questions for 34.3% of the group (EQ-5D: grade≥2); on two questions, for 18.5% of the group; and on one question, for 11.1% of the group. Mental stress, melancholy, and suicidal thinking were also more common in the group with spine OA (P<0.05). The group with radiographic spine OA but without symptoms did not have compromised EQ-5D scores, whereas the group with radiographic OA and symptoms showed a significantly reduced quality of life.Quality of life was significantly reduced in the group with symptomatic spine OA in a large cross-sectional analysis. Physicians should consider quality of life in the treatment of patients with spine OA Spine osteoarthritis (OA) with or without nerve compression plays a significant role in the development of symptomatic spinal disease. Fifteen percent of the US population suffers from pain related to OA, and this figure is predicted to double by 2020.–3 Many OThis cross-sectional study used data from the Fifth KNHANES-V: 2010–2012. The KNHANES is a nationwide health and nutrition survey conducted by the Korea Centers for Disease Control and Prevention. A stratified, multistage probability sampling design was used, and sampling units were based on geographical area, age, and sex., 13, 14 Spine radiography was performed with a SD3000 Synchro Stand . Anteroposterior and lateral plain radiographs of the spine were taken. Radiographic changes in each joint were then independently assessed by two radiologists using the Kellgren/Lawrence (KL) grading system: Grade 0, visible features of OA are absent or doubtful, such as questionable osteophytes; Grade 1, minimal, with definitive small osteophytes; Grade 2, definitive moderate osteophytes or subchondral bone cysts and sclerosis with or without foraminal stenosis. The presDemographic variables included age, sex, income, marital status, current residence, education level, smoking status, alcohol consumption, and physical activity. Equivalized household income was calculated as the total monthly household income divided by the square root of the total number of household members. Average alcoholic beverage consumption was assessed with a self-reported questionnaire and then converted into the amount of pure alcohol consumed per day. Education level was classified as low, intermediate and high . Subjects who had smoked more than 100 cigarettes in their lives were classified as ever-smokers. Smoking status was further classified as non-, ex- and current smokers. Physical activity was assessed with the Korean version of the International Physical Activity Questionnaire short form.2) was calculated. Waist circumference was measured at the narrowest point, between the lower costal margin and the iliac crest. Systolic blood pressure and diastolic blood pressure were measured with a standard mercury sphygmomanometer . Hypertension was defined as blood pressure greater than 140/90 mmHg, or current use of antihypertensive medications.[Body weight and height were measured, and body mass index  in a manner that reflected sampling weights and provided nationally representative estimates. The characteristics of the subjects with spine OA were compared with those of subjects without spine OA (control group) using independent sample nificant.There were 25,534 subjects included in the health interview survey and health examination survey . We exclWe defined spine OA as “definite osteoarthritis on plain radiographs with related pain of the spine.” Age, sex, smoking, and drinking were significantly related to spine OA morbidity . Only feEQ-5D and EQ VAS scores were significantly compromised in the spine OA group. LQ 1, 2, 3, 4, and 5 scores were significantly higher in the spine OA group , P<0.05.The majority of the spine OA group had grade 2 disability, whereas the control group had grade 1. The calculated risk for compromised mobility was 6.19 (odd ratio) compared to the control group.The majority of the spine OA and control groups had grade 1 disability. However, the incidence of grade 2 or 3 disability was higher in the spine OA group. In particular, grade 3 disability was higher than other domains (2.3%) in the spine OA group. The calculated risk for compromised mobility was 4.34 compared to the control group.The majority of the spine OA and control groups had grade 1 disability. However, the incidence of grade 2 or 3 disability was higher in the spine OA group. The calculated risk for compromised mobility was 5.97 compared to the control group.The majority of the spine OA group had grade 2 disability, whereas the control group had grade 1. In particular, grade 3 disability was higher than other domains (16.5%) in the OA group. The calculated risk for compromised mobility was 6.32 compared to the control group.The majority of the spine OA and control groups had grade 1 disability. However, the incidence of grade 2 or 3 disability was higher in the spine OA group. The calculated risk for compromised mobility was 2.12 compared to the control group.Many physicians focus on the treatment of spinal disease, but spine OA itself can induce disability. Although we focused on stenosis and listhesis specifically, OA itself should be considered as a specific modality. Spine OA, a chronic condition of the elderly population, is related to several chronic diseases and socio-economic problems. In this study, we found that the group with spine OA showed a higher prevalence of being single, low income, and low education, which indicates that a compromised social life may increase the incidence of spine OA or vice versa. In addition, the group with spine OA was more likely to have DM, HTN, and metabolic syndrome than the group without spine OA, as reported in previous studies., 22–29 TThe group with spine OA showed many related risk factors and a higher incidence of other diseases, indicating that the impact of spine OA itself should be studied. However, physicians have tended to focus on the related medical problems and risk factors of spine OA, with few reports analyzing the quality of life or mental status of patients with spine OA. Geryk et al. reported that arthritis negatively impacts HRQOL; patients with OA perceived their condition as disabling, similar to that of patients with RA. They also reported that OA patients had poor physical and mental health. In the pThere are several limitations to the present study. The cross-sectional study design prevented us from determining an exact cause-and-effect relationship. Future prospective studies are required to better elucidate causal relationships. Furthermore, longitudinal studies are also necessary in order to take (time-constant) unobserved heterogeneity into account as discussed in AgeCoDe studies., 39 In aIn the present study, quality of life was significantly compromised in the population with symptomatic spine OA. LQ 1, 2, 3, 4, and 5 domain scores were significantly higher in the group with spine OA. Physicians should consider quality of life in the treatment of patients with spine OA. In addition, female ex-smokers had a high prevalence of OA, and smoking cessation appears to be an important prevention strategy for OA.All subjects provided written informed consent, and the Institutional Review Board of the Korea Centers for Disease Control and Prevention approved the study protocol .


A prospective study was conducted to compare criterion, predictive, and construct validities of 9 fracture/osteoporosis assessment tools, including calcaneal quantitative ultrasonography (QUS), Age Bulk One or Never Estrogens (ABONE), body weight criterion (BWC), Fracture Risk Assessment Tool (FRAX), Garvan fracture risk calculator (GARVAN), Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Index of Risk (OSIRIS), Osteoporosis Self-Assessment Tool for Asians (OSTA), and Simple Calculated Osteoporosis Risk Estimation (SCORE), among older men and women in Taiwan.Using the femoral neck dual-energy x-ray absorptiometry (DXA) T-score as an external criterion, the sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and the area under the receiver operating characteristic curve (AUC) for each tool were calculated. The ability of these tools to predict injurious falls was examined. A principal component analysis was applied to understand whether these tools were measuring the same underlying construct.The FRAX, BWC, ORAI, OSIRIS, OSTA, and SCORE had AUCs of ≥0.8 in men, while the GARVAN, OSIRIS, OSTA, and SCORE had AUCs of ≥0.8 in women. The sensitivity, negative predictive value, and likelihood ratio of the ABONE, BWC, ORAI, OSIRIS, OSTA, and SCORE tools in both men and women were 100%, ≥90%, and 0.0, respectively; the specificity and positive predictive value and likelihood ratio were far from satisfactory. The GARVAN displayed the best predictive ability of a fall in both men  and women , despite being smaller in women. The 9 screening tools and 2 central DXA measurements assessed 5 different factors, while the ABONE, BWC, ORAI, OSIRIS, OSTA, and SCORE measured the same one.Simple self-assessment tools can serve as initial screening instruments to rule out persons who have osteoporosis; however, these tools may measure a different construct other than fracture/osteoporosis risk. Distal DXA poorly predicts a fracture, and bone markers vary widely among individuals. QUS of the calcaneus reflects both bone density and bone quality, and it is portable, radiation-free, and relatively low-cost.4 Furthermore, according to clinical risk factors, some fracture/osteoporosis risk self-assessment tools, such as the Age Bulk One or Never Estrogens (ABONE),5 body weight criterion (BWC),6 Fracture Risk Assessment Tool (FRAX),7 Garvan fracture risk calculator (GARVAN),8 Osteoporosis Risk Assessment Instrument (ORAI),9 Osteoporosis Index of Risk (OSIRIS),10 Osteoporosis Self-Assessment Tool for Asians (OSTA),11 and Simple Calculated Osteoporosis Risk Estimation (SCORE),12 may be suitable for mass screening among community-dwelling older people. However, most of these tools have not been validated in older men, and whether they measure the same construct as central DXA has not been examined.Alternatively, distal DXA, biochemical markers of bone resorption and formation, and quantitative ultrasonography (QUS)In this study, clinimetric properties, such as the criterion, predictive, and construct validities of calcaneal QUS, ABONE, BWC, FRAX, GARVAN, ORAI, OSIRIS, OSTA, and SCORE among community-dwelling older men and women in Taiwan were investigated.During a 6-month period from July to December 2012, we recruited study participants at community centers in Tanzi District of Taichung City, west-central Taiwan. Persons aged ≥60 years who had a registered household in Tanzi District and who were able to ambulate independently were eligible for the study. Exclusion criteria were difficulty with verbal communications, severe physical restrictions , and severe cardiopulmonary diseases .In total, 553 community-dwelling older people, consisting of 186 men and 367 women, participated in the baseline assessment conducted at the Taichung branch of Tzu-Chi General Hospital. This research was approved by the Institutional Review Board of Taipei Medical University and Tzu-Chi General Hospital, and written consent was obtained from each participant.2), an ideal weight (18.5–23.9 kg/m2), overweight (24–26.9 kg/m2), or obese (≥27 kg/m2).The baseline assessment included physical measurements and personal interviews. Physical measurements consisted of height, weight, visual acuity, DXA, and QUS. According to the body mass index (BMI) as the weight (kg) divided by the square of the height (m), subjects were categorized as being underweight . The World Health Organization (WHO) quantitatively defines osteoporosis as a BMD of 2.5 standard deviation units or more below the mean value for young adults (T-score ≤ 2.5).2 In participants who had undergone a left hip replacement surgery, the right femoral neck was measured instead. The hydroxyapatite hip phantom and spine phantom with 4 semianthropomorphic hydroxyapatite vertebrae provided by the manufacturer were scanned weekly.The areal BMD at the left femoral neck and lumbar spine (anterior-posterior L1–L4), recorded as g/cm14 The heel-estimated BMD (or QUS T-score) was also calculated based on the same young adults as a reference population. The precision of calcaneal QUS was assessed by obtaining 3 measurements after repositioning 20 subjects. The coefficients of variation of SOS, BUA, and heel-estimated BMD were 0.24%, 3.15%, and 3.24%, respectively. Acoustic phantoms provided by the manufacturer were scanned weekly.QUS of the left heel was measured using a Lunar Achilles Insight device . Three types of parameters are assessed by the device: the speed of sound (SOS), broadband ultrasound attenuation (BUA), and a stiffness index. Sound waves pass faster through higher bone densities and better elasticity, and broadband signals are attenuated by higher bone densities and better bone structures. The stiffness index is a composite parameter, determined by the machine according to the formula of (0.67 × BUA + 0.28 × SOS) − 420.15Personal interviews collected information on age, gender, education level, marital status, cigarette smoking, alcohol consumption, regular exercise, chronic conditions, medication use, cognitive status, a history of falls and fractures, and other information for calculating risk scores for the 9 fracture/osteoporosis self-assessment tools. The cognitive status was measured using the Mini Mental State Examination with a score of ≤23 indicating impairment.Eight self-assessment screening tools, including the ABONE, BWC, FRAX, GARVAN, ORAI, OSIRIS, OSTA, and SCORE, calculate a risk score of fracture/osteoporosis for each individual. Self-reported variables were collected using personal interviews with structured questionnaires. Interview procedures and interviewer attitudes were standardized through participation in a 4-hour training course. Risk factors, including calculating the risk score, scoring algorithm, and recommended cutoff points of fracture/osteoporosis for these self-assessment tools, in addition to the QUS, are described in detail in Table The FRAX and GARVAN can be used with or without BMD to calculate the 5- and/or 10-year probability of a hip fracture and other osteoporotic or fragility fractures. For comparison with FRAX, only the 10-year probabilities of a hip fracture and any osteoporotic fracture for GARVAN were computed. Femoral neck DXA BMD data were not included in the calculation of the risk scores of the 2 tools, since this study emphasized screening, and femoral neck DXA BMD was treated as a standard for defining osteoporosis.17 and it could discriminate older Taiwanese people with lower-extremity fractures from those without; the areas under the receiver operating characteristic curve (AUC) for the discrimination were 0.821 in men and 0.734 in women.18The criterion validity detects how closely a QUS parameter or self-assessment tool is related to the femoral neck DXA BMD. Here, the femoral neck DXA T-score was used as an external criterion. The femoral neck DXA BMD is considered the best predictor of hip fracture and is comparable to other measurements for predicting fractures at other sites,19The sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and the AUC for each of the QUS parameters and self-assessment tools to discriminate individuals who had osteoporosis from those who did not were calculated. The positive predictive value was the proportion of persons with osteoporosis who had a positive result. The negative predictive value was the proportion of persons without osteoporosis who had a negative result. The positive likelihood ratio (sensitivity/(1 − specificity)) indicates how much more likely a positive screening tool result was obtained for low bone density  than for normal or subnormal bone density. The negative likelihood ratio ((1 − sensitivity)/specificity) indicates how much less likely a negative screening tool result was obtained for low bone density than for normal bone density. The AUC, which ranges from 0.5 for a noninformative instrument to 1.0 for perfect concurrence, represented a summary measure of the criterion validity.20 and predictors for fractures are similar to those for falls.21 Accordingly, we used injurious falls as a surrogate for fractures to examine the predictive ability of the fracture/osteoporosis screening tools.The predictive validity determines how well a QUS parameter or self-assessment tool predicted the occurrence of an injurious fall during a 12-month follow-up period. The occurrence of a fracture is a rare event; more than 90% of fractures result from falls; 22 The AUC was computed for each screening tool, with a larger AUC indicating a better predictive ability.The occurrence of falls was prospectively monitored and recorded daily using a diary mailed monthly to the study coordinator over the 12-month follow-up period. Participants who failed to return the diary or provided incomplete data were contacted by telephone. An injurious fall was defined as an unintentional loss of balance with the body hitting the floor or ground from a standing height or less that resulted in any outpatient or emergency room visit or hospital admission.r ≥ 0.4) among the 10 assessment tools. A Pearson correlation coefficient of <0.4 is considered low, one of ≥0.4 and <0.75 moderate, and one of ≥0.75 high.23The assessment tools that conceptually converge should be relatively strongly correlated, whereas those tools with less in common should show weaker correlations. We hypothesized moderate or higher correlations . The 2 DXA measures were included to check if these screening tools measured the same construct (BMD). Three criteria of factor eigenvalues (>1), the proportion of total variance (>5%), and a scree test indicate how many common factors should be adequate to represent these fracture/osteoporosis assessment tools.All data analyses were stratified by gender, and all statistical calculations were conducted using the SAS system  for Windows vers. 9.3.Distributions of demographic and medical characteristics of the 553 participants, consisting of 186 men and 367 women, are shown in Table Osteoporosis was defined by a femoral neck DXA BMD T-score of ≤−2.5, and values of the sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and AUC of the 9 fracture/osteoporosis screening tools are shown in Table In women, the AUCs of QUS parameters ranged 0.74 to 0.77; those of the FRAX ranged 0.71 to 0.75; and those of the GARVAN for hip fracture and osteoporotic fracture ranged 0.75 to 0.80. Of the remaining tools, the sensitivity, negative predictive value, likelihood ratio, and AUC were 100%, 90% to 92%, 0.0, and 0.70 to 0.83, respectively. As a whole, these tools performed better in men than women.During the 12-month follow-up, 15 men and 48 women experienced an injurious fall. The AUCs of the 9 screening tools used to predict the occurrence of a fall are shown in Table In women, the GARVAN for hip fracture and osteoporotic fracture had the greatest AUCs (0.567 and 0.560), followed by the QUS SOS (0.556) and SCORE (0.555).Results of Pearson correlation analysis among the 9 screening tools and 2 DXA measures are shown in Table Results of the principle components analysis for the construct validity among 9 screening tools and 2 DXA measures are shown in Table In summary, among the 9 fracture/osteoporosis screening tools, the FRAX, BWC, ORAI, OSIRIS, OSTA, and SCORE had AUC values of ≥0.8 in men, while the GARVAN, OSIRIS, OSTA, and SCORE had AUC values of ≥0.8 in women. The GARVAN displayed the greatest ability to predict a fall in both men and women, despite being smaller in women. The 9 screening tools and 2 central DXA measurements assessed 5 different constructs, and the ABONE, BWC, ORAI, OSIRIS, OSTA, and SCORE measured the same one.26 Second, on the basis of the high negative predictive value and likelihood ratio for the criterion validity and low prevalence of fractures, these simple tools are useful in identifying those individuals who do not need BMD testing, particularly among older men. Better results for men of the negative predictive value and likelihood ratio likely reflected their lower prevalence of osteoporosis. Third, unlike the FRAX and GARVAN that directly assess the absolute risk of fracture, all these tools were originally developed to identify osteoporosis risk, and the definition of low BMD may differ among the tools, with the ABONE, BWC, OSTA, and OSIRIS using a T-score of ≤−2.5 and the ORAI and SCORE using a T-score of ≤−2.0. However, this study defined T-scores of ≤−2.5 as osteoporosis for the ORAI and SCORE. Finally, of these 6 self-assessment tools, the OSTA was developed and validated in postmenopausal women in Asian countries, while the others were developed using Caucasian women. The OSTA was also the only tool that has been validated in men.27 Despite the overall clinimetric performance of some tools such as the OSIRIS being no less adequate than that of the OSTA, the OSTA displayed a higher AUC and specificity than the others, implying that the screening cutoff points in these tools may need to be validated in Asian populations.Several features of 6 simple self-assessment tools, including the ABONE, BWC, ORAI, OSIRIS, OSTA, and SCORE, were noted. First, the overall clinimetric performance of these simple assessment tools was not less adequate than the FRAX, GARVAN, and QUS parameters. A recent study even reported that simple tools had better performances than the FRAX with BMD for identifying women with an increased risk of a fracture.29 Nevertheless, a low bone density may also increase the risk of falling, particularly in older women.30 Furthermore, weak correlations were found for the FRAX and GARVAN with other fracture/osteoporosis assessment tools, possibly reflecting that the FRAX and GARVAN were developed to predict fracture risk, while other tools were developed to assess osteoporosis risk.The FRAX and GARVAN, compared to osteoporosis screening tools , had poorer criterion validities for DXA-determined osteoporosis but displayed better predictive ability of a fall. Despite a fracture most likely occurring in the osteoporotic range, the better prediction validities of the FRAX and GARVAN were partly accounted for by certain clinical risk factors  that are also risk factors for falls. This finding also revealed complicated interrelations among osteoporosis, fracture risk, and falls. Owing to a low correlation between osteoporosis and fracture occurrence and a high correlation between falls and fracture occurrence, several investigators advocated that fracture reduction in older people should shift from osteoporosis intervention to fall prevention.31 The reference ranges of QUS T-scores might be incomparable with a BMD classification by DXA T-scores, which could cause significant discrepancies in the classification of bone density;32 therefore, some investigators suggested a cutoff value of QUS T-scores of ≤−1.8 for osteoporosis33 versus ≤ −2.5 used in the study. The young reference populations for calculating T-scores between calcaneal QUS and femoral neck DXA were also not the same.Calcaneal QUS did not have a better performance for the criterion and prediction validities than did the other screening tools. The nature, precision, reference ranges, and bone site may have confounded the results of the criterion validity. Calcaneal QUS might not be a direct surrogate of femoral neck DXA BMD because it may measure the nature of the bone quality (including the bone strength and density) at the calcaneus, while central DXA is the standard measurement for diagnosing low bone density at the hip and spine. Also, variations in QUS reference ranges may exist across different devices, reference populations, and study populations.34 The high loadings (≥0.9) of QUS parameters onto the same factor in both men and women suggested that these parameters consistently measure the same acoustic properties of the calcaneus. On the other hand, it was intriguing that lumbar spine and femoral neck DXA BMDs had only modest loading scores  onto the same factor. This finding indicates that despite the 2 DXA measurements having measured a similar construct, some degree of discrepancy existed in the 2 DXA BMD measurements, compared to those simple screening tools with higher loadings (≥0.7) onto the underlying construct.Significant loadings of the 9 screening tools onto 4 factors in both men and women indicated that these tools did not measure the presumed construct . Different factors located by central DXA and calcaneal QUS measurements reflect that the 2 techniques may measure different bone natures and bone sites.Several limitations of our study should be noted. First, the results cannot be generalized to all older people because a spectrum effect could have occurred. In addition to a healthy volunteer effect that may have existed in the study participants recruited from advertising posters and flyers, the exclusion of those patients with severe spondylosis and joint arthritis of the lower limbs may also have reduced the prevalence of osteoporosis in the study population and thus underestimated the overall clinimetric performances of the self-assessment tools. Moreover, despite the study results being separately presented for men and women, the spectrum effect might have differed between men and women because more female than male participants might not only reflect their health status but also their awareness of bone health. Second, cutoff values of the assessment tools, such as the ABONE, BWC, ORAI, OSIRIS, and SCORE, were based on Caucasian postmenopausal women only, and their appropriateness for older men in Taiwan or Asia needs to be further validated. Finally, the use of injurious falls as a surrogate for fractures needs to be further validated in future studies. Interrelationships among risks of falls, osteoporosis, and fractures are not clearly understood, and some environmental factors associated with falls but not related to fracture occurrences may have confounded the prediction validity.Simple self-assessment tools can serve as initial screening tools to rule out individuals who do not need further BMD testing or have no risk of a fracture; however, these simple tools may measure different constructs from central DXA, calcaneal QUS, and the FRAX. Further research is needed to investigate whether these tools do measure the risk of fracture/osteoporosis and have similar clinical performances between older men and women.


The wear nanoparticles would be prone to binding with proteins to form protein-particle complexes, to interacting with visible components in the blood including erythrocytes, leukocytes, and platelets, and to being phagocytosed by macrophages or fibroblasts to deposit in the local tissue, leading to the formation of fibrous local pseudocapsules. These particles would also be translocated to and disseminated into the main organs such as the lung, liver and spleen via blood circulation. The inflammatory response, oxidative stress, and signaling pathway are elaborated to analyze the potential toxicological mechanism. Inhibition of the oxidative stress response and signaling transduction may be a new therapeutic strategy for wear debris–mediated osteolysis. Developing biomimetic materials with better biocompatibility is our goal for orthopedic implants.The adverse biological effect of nanoparticles is an unavoidable scientific problem because of their small size and high surface activity. In this review, we focus on nano-hydroxyapatite and TiO It is well known that the nanometer regime is the fundamental unit of length over which cells and molecules interact with biological environments. The molecular basic blocks of proteins, nucleic acids, and lipids are materials that possess unique properties at the nanoscale. For example, the width of a DNA strand is approximately 2 nm. The extracellular matrix, providing structural and biochemical support to surrounding cells, has a hierarchical structure with spatial and temporal levels from nanometer to centimeter scale. Now, inspired by the innate nanostructure of biological tissue and biomolecules, many researchers have attempted to fabricate some biomedical nanomaterials with nanoscale surface features to improve biological application in orthopedics [With the advent and rapid development of nanoscience and nanotechnology, every synthetic event occurs at the nanoscale . Especially the engineered nanoparticles (NPs) are massively produced and widely used in the fields of electronics, environment, agriculture, pharmacy, and medicine, hopedics ,4.2), HA, ceramics, and nanofibers of polymers. In this review, TiO2 and HA are selected as the representative nanomaterials used in orthopedics because they are generally studied as potential biomedical materials, as shown in the following.Bone is viewed as a nanofibrous composite with a hierarchical structure composed of organic compounds (mainly collagen) reinforced with inorganic hydroxyapatite (HA). HA crystals are approximately 2 nm thick by 25–50 nm wide, embedded in the holes within the collagen molecule structures and increasing the rigidity of bone. The organization of bone spans three or more orders of magnitude from large ~200 μm osteons with subunits of ~200 nm collagen fibrils to the 20 nm crystallized HA platelets. The specific structure of bone provides mechanical support, metabolic function and protects bone morrow with nutrients in the body. The fracture of bone often occurs because of high force impact and stress, and is also a result of certain medical conditions such as osteoporosis, bone cancer and osteogenesis imperfecta. The broken bone is a lot more than painful and inconvenient, and is sometimes a costly and permanent health problem. According to the National Institutes of Health, approximately 1.5 million hip fractures occur worldwide each year, and this number might increase to 2.6 million by 2025 and 4.5 million by 2050 [10(PO4)6(OH)2, being the main inorganic constituent of natural bone, has been widely used for biomedical applications owing to good biocompatibility and osteoconductivity [co-glycolic acid) (PLGA) NPs, aiming to develop an osteoconductive material with the ability of inhibiting osteosarcoma [HA with the chemical formula of Cauctivity . It is puctivity . Many stuctivity , polymeructivity . The n-Huctivity ,12. The uctivity . Recentlosarcoma .2 NPs, which have poor solubility and are chemically inert, are stable in the organism and have good biocompatibility and tissue compatibility. TiO2 is considered as a promising bone scaffolding material because it promotes osteoblast adhesion and induces bone formation [et al. fabricated TiO2 scaffolds by themselves and analyzed the bone ingrowth into the scaffold structure after implanting the scaffolds into surgically modified extraction sockets in miniature pigs [2 scaffolds. Webster et al. firstly reported that osteoblast cells showed a greater synthesis function of proliferation and osteogenic differentiation on nanophase TiO2, ceramics, and HA than conventional ceramics with grain sizes greater than 100 nm [2 NPs are also used to reinforce the porosity and mechanical properties of polymer scaffolds, aiming to increase bone-forming ability [2 nanotubes gain much attention in orthopedic implants due to the nanostructured surface stimulating the growth and mineralization of osteoblasts in vitro and inducing bone regeneration and osseointegration in vivo [2 nanotubes could significantly increase the bone-implant contact and the bone bonding strength [2 nanotube implant surface, but not on the Ti grit-blasted implant surface, indicating the strong osseointegration of TiO2 nanotubes [2 nanotubes increased the bone-implant contact by 55.46% ± 9.71%, and the fluorescent labels  in the surrounding bone of implants with TiO2 nanotubes were more obvious and continuous than those of machined implants [2 nanotubes [2 show superior characteristics for bone-related cell adhesion and proliferation due to their distinctive nanoscale features and novel physical properties. On the surface of the titanium disk coated with nanoscale anatase and rutile, human mesenchymal stem cells and osteoblasts are successfully grown and expanded. The bone-specific genes including OSX, ALP, OCN, and bone sialoprotein (BSP) are increased on all nanoscale features in vitro [2 nanotubes coated on a titanium surface could prevent bacterial colonization and bacterial biofilm formation on the implant surface [TiOormation ,16,17,18n 100 nm ,20. TiO2 ability ,22. In r in vivo ,24. The strength . The eneanotubes . At threin vitro . In addi surface ,28.2 NPs used as materials of bone implants, to clarify their possible negative effects on the organism and the correlated mechanism.However, nanoscale materials usually exhibit unique physical and chemical properties, including magnetic, catalytic, electrical, and mechanical features. Compared to bulk materials, nanomaterials behave very differently. They more easily enter the body and couple with biological entities such as protein, cells, and tissues. There is great concern about the health consequences of nanomaterials due to their extremely small size, high specific surface area, quantum and surface boundary effects, and increased surface activity. The nanostructured surfaces can stimulate cells through initial surface protein adsorption, and activate cell adhesion and proliferation. Evidently, engineered NPs can act as a double-edged sword, either as a platform for osseointegration or as a toxic agent, depending on the context. This has led to increased interest in obtaining an understanding of the biological response to NPs. The potential toxicity of engineered NPs on different cells and tissue has been explored for decades and continues to be investigated. Therefore, the goal of this paper is to analyze the biological data about n-HA and TiOetc. Nygren et al. [2 surface using immunofluorescence technology with short durations of exposure to capillary blood. They detected that serine proteases were the dominating protein adsorbed onto the annealed TiO2 and there was a high amount of fibrinogen on the acid-oxidized surface. Platelets could adhere and spread on the annealed surface within 5 s of blood-material contact. When the platelets adhere to the surface they start the signal cascade that eventually leads to cross-linking of fibrin and subsequently to blood clot formation. Using fresh non-anticoagulated human blood, Ekstrand-Hammarström et al. [2 NPs at 50 ng/mL induced strong activation of platelets in the contact system, which could lead to a thrombotic reaction and the generation of bradykinin. Ellingsen [2 and HA surface-adsorbed calcium ions. They identified that the surface of TiO2 and HA with calcium binding could selectively take up the albumin, prealbumin and IgG from human serum. The binding of TiO2 NPs with human serum albumin involves the van der Waals force and hydrogen bonding formation, and electrostatic interactions might be included [et al. [2 NPs with the highest affinity than albumin [2 nanorods evidently adsorb with immunoglobulins IgM and IgG, but TiO2 nanotubes mainly bind with fibrinogen. Albumin and apolipoprotein can be adsorbed both on the TiO2 nanorods and on the nanotubes [2 nanorods are the only factors that influence the amount of adsorbed fibrinogen [et al. [2 particles than those in the medium containing human serum albumin. While in the presence of fibrinogen, the particle uptake is lowered by fibroblast cells [NPs, when entered into the body, will interact initially with proteins present in biological fluids, such as blood. Protein adsorption onto NPs in biological medium has been taken into consideration as an important factor for the assessment of biological responses to NPs ,30,31. Bn et al.  exploredm et al.  detectedllingsen  examinedincluded . Sousa e [et al.  observed albumin ,40. The  albumin . TiO2 nabrinogen . Shen et [et al.  studied  [et al. , which a [et al. . The ads [et al. . In gene [et al. ,47. NP b [et al. . In protst cells . Fleischst cells  reportedet al. [2 both in vivo (rats) and in vitro (rabbit erythrocytes). The results showed that HA sol obviously prolonged the time of bleeding, clotting and prothrombin in rats after intravenous injection while TiO2 sol had no effect. In vitro, both NPs’ sol did not cause hemolysis but did induce the aggregation of rabbit red blood cells.It is generally reported that NPs can enter the vascular system intentionally. As a type of active particles, the interaction of NPs with blood cannot be neglected. The previous investigators demonstrated that NPs may have an effect on blood coagulation and hemolysis ,51,52. Cet al.  evaluatein vivo and in vitro. In a hamster model, Nemmar et al. [2 (20 nm) in vitro underwent abnormal sedimentation, hemagglutination and dose-dependent hemolysis, totally differing from those treated with micro-TiO2 (200 nm). The ghost cells were observed after exposure to nano-TiO2. Han et al. [2 NPs at 1–3 nm showed no cytotoxicity, no oxidative ability and no genotoxicity on human dermal microvascular endothelial cells (HMEC-1) [2 NPs caused mortality and malformations in the form of pericardial edema when injected. The anti-angiogenic effects were also detected both in HMEC-1 cells and in zebrafish embryos, accompanied by a decreased nitric oxide concentration [2 NPs on human umbilical vein endothelial cells (HUVECs) were reported by some scientists. Results showed that TiO2 NPs (about 25 nm) at 10, 20, and 40 μg/mL induced higher lactic dehydrogenase (LDH) and superoxide dismutase (SOD) activities in the culture medium (0 μg/mL). When HUVECs were exposed to nano-TiO2, IL-6 was significantly released in the medium at 20 and 40 μg/mL and tumor necrosis factor α (TNF-α) was highly released at 5 and 20 μg/mL [2 NPs internalized into HUVECs strongly inhibited cell proliferation and induced apoptosis by 20% and necrotic death by 60%, even at 5 μg/cm2. TiO2 NPs provoked the activation of HUVECs through an increase in U937 monocytic adhesion and in the expression of adhesion molecules , associated with increased reactive oxygen species (ROS) production and nuclear factor (NF)-κB pathway activation [The blood cell is dominated by erythrocytes (99%), with much fewer leukocytes and platelets (1%). The interaction of NPs with erythrocytes has been investigated both r et al.  reportedn et al.  investign et al. . However(HMEC-1) . In earlntration . For thentration . The tox20 μg/mL . The indtivation . A similtivation . The potet al. [2 NPs to simulate the release of wear NPs into the joint cavity, Wang et al. [2 NPs penetrated the synovial capillaries and were transported to the heart or lung tissues of rats with blood circulation, and the larger aggregated TiO2 particles were deposited in the knee joint, resulting in the injury of the local tissues. For the synovium, the intra-articular TiO2 NPs induced fibroblast-like synoviocyte proliferation, lymphocyte and plasma cell infiltration and synovium hypertrophy [Generally, there are two kinds of tissue responses to particles, the macrophage-mediated response and the lymphocyte-dominated response. In the periprosthetic tissue, Lohmann et al.  found mag et al.  revealedertrophy . The aseertrophy ,65. DHR 2 nanoparticles. The authors [2 NPs at post-exposure days 1, 7, 14, and 30 in a time-dependent manner using the contrast-enhanced high resolution micro-computed tomography. The decreased cartilage volume was detected too. The histopathological changes showed that the chondrocytes had edema with shrunken nuclei in the radial and calcified zone of the cartilage. The cartilage ultrastructure observed by transmission electron microscopy showed the degenerated chondrocytes with condensed chromatin, a dilated endoplasmic reticulum, and rich mitochondria [In the joint, the articular cartilage is avascular and alymphatic and is innervated. The chondrocyte is the only living element of the cartilage. The effect of wear debris on the articular cartilage is investigated through the intra-articular injection of TiO authors  detectedchondria .The wear NPs released from metal-on-metal and metal-on-polyethylene implants circulate in the organism both locally and systemically, penetrate the cell membrane, couple with cellular proteins, and mediate the inflammatory response and expression of cytokines . The macin vitro experiment [The activated macrophage exhibits a spectrum of polarization states, the classically activated M1 phonotype by pro-inflammatory signals  and the alternatively activated M2 state by anti-inflammatory signals . The proinflammatory signals stimulate the expression of nuclear factor kappa-B ligand (RANKL) on the surface of osteoblasts, and increase the RANKL/OPG (osteoprotegerin) ratio and ROS production by NADPH-oxidase. RANKL interacts with RANK to activate osteoclasts and regulate bone resorption ,70. It iperiment .2 NPs [et al. [in vivo and in vitro. By injecting Ti particles with different sizes into the spaces surrounding the Ti alloy pins, they demonstrated that the osteoblast function significantly attenuated with the increased expression of the receptor activator of RANKL, which was a dominant signal for osteoclast recruitment and depended on the size of the Ti particle. Therefore, the chronic proinflammatory response induced by wear particles has a negatively effect on osteoblast function, and decreases bone formation and osseointegration. This maybe a major factor in osteolysis and the subsequent aseptic loosening of arthroplasty implants [The inflammatory responses occur and the cytokines are produced including TNF-α, IL-1α, IL-1β, and IL-6. These cytokines stimulate osteoblasts to release soluble cytokines, such as granulocyte-macrophage colony-stimulating factor (GM-CSF), RANKL, IL-6 and prostaglandin E2 (PGE2), or they indirectly stimulate osteoclasts to activate osteolysis ,73,74. A2 NPs ,78. The  [et al.  determinimplants .et al. [et al. [The translocation and accumulation of NPs would occur in the body regardless of the entry routes. There is evidence that NPs can reach and accumulate in the second target organs across body membranes, such as the lung, heart, liver, spleen, and brain. NPs used for bone repair and reconstruction, without exception, would diffuse and redistribute with blood circulation and be entrapped by the reticuloendothelial system (RES). Urban et al.  firstly et al. . Using I [et al.  quantitaet al. [et al. [et al. [It is well known that the liver, spleen and kidney are the important metabolic and excretory organs. The special biochemical parameters in serum partially reflect the function of these organs, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST) for liver function, blood urea nitrogen (BUN) for kidney function and alkaline phosphatase (ALP) for liver function or bone formation–related diseases, and so on. Liu et al.  found thet al. . However [et al.  detected [et al.  reported2 NPs released from implants is investigated in rats by intra-articular injection [2 NPs can potentially affect major organs such as the heart, lung and liver, which indicated the circulation of intra-articular NPs from the joint cavity to the system [2 and the severe pathological impairment of major organs resulted in the rats after exposure to 2 and 20 mg/kg TiO2 suspensions. In the lung tissue, the particle-laden macrophages and the inflammatory cells, such as neutrophils, lymphocytes and eosinophils, are observed in the pulmonary alveoli with thickened alveolar walls. The fatty degeneration of hepatocytes and inflammatory cell infiltration of the portal area prove the injury of the liver. The difficult clearance of TiO2 NPs in the lung and liver results in the increased coefficients of organs and the significant upregulation of the serum AST/ALT level, especially in the 20 mg/kg group.The translocation of TiOnjection . The rese system . The sliOverall, regardless of whether the NPs were injected or were produced from the prosthesis, once they entered the body, they would circulate everywhere along with the blood circulation and deposit to interact with cells or tissues, leading to the injury of some organs.2 and HA NPs cause an elevated ROS level and expression of inflammatory transcripts in human oral epithelial cells [et al. [et al. [S-transferase (GST) and antioxidants and mediated the oxidative DNA and matrix protein modifications (DNA hydroxylation and protein nitrosylation). The over-production of ROS is implicated in the degeneration and necrosis of tissues in fibrous pesudocapsule tissues, and even in diseases. Ding [As stated above, wear debris particles can activate an inflammatory response locally and systemically. This is mediated by monocytes/macrophages, lymphocytes, synoviocytes, osteoblasts and fibroblasts to secret the products of the proinflammatory cytokines, such as PGE2, IL-6, IL-1β, IL-18, TNF-α ,87,88, aal cells . Oxidatial cells ,93. Kino [et al.  detected [et al.  analyzedes. Ding  revealedes. Ding ,98.2 NPs and its unusual physicochemical characteristics, including the size, shape, surface coating, and crystal phases. The ROS mechanism is also elucidated in the toxicity of TiO2 NPs. Nano-HA with rod-, spherical-, or needle-shaped crystals can inhibit the growth of primary rat osteoblasts in a dose-dependent manner and induce apoptosis via p53 and the cytochrome C-dependent mitochondrial pathways [et al. [Many reports state that the structural features of nanoparticles including physical and chemical properties, such as size, shape, crystal phases and surface coating, can exert cytotoxicity through oxidative stress ,99,100. pathways . Zhao et [et al.  demonstret al. [2 NPs [The overproduction of ROS is thought of as the best-developed paradigm for the toxicity of NPs ,93. Withet al.  found thet al. ,108. In et al. . The mic. [2 NPs , while t. [2 NPs .2 NPs are generously exploited to increase the repair and reconstruction of bone. However, because of their small size and high surface activity, the adverse biological effects of nanoparticles are an unavoidable scientific problem, which gains much attention from clinicians and scientists. The wear nanoparticles would be prone to adsorb blood proteins to form protein–particle complexes, and further to be phagocytosed by macrophages or fibroblasts and to deposit in the local tissue, leading to delayed hypersensitivity reactions. Meanwhile, the dissemination of nanoparticles into the main organs such as the lung, liver and spleen occurs in the blood circulation system. The inflammatory response, oxidative stress and signaling pathways are elaborated to analyze the toxicological mechanism. Inhibition of redox-related signaling transduction may be a new therapeutic strategy for wear debris–mediated osteolysis. Developing biomimetic materials with better biocompatibility is our goal for orthopedic implants.Depending on good biocompatibility and osteoconductivity, nano-HA and TiO