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Journal articleDavies A, Sabharwal S, Zamora Talaya B, et al., 2025,
Cost-effectiveness of total shoulder arthroplasty compared to hemiarthroplasty. A study using data from the National Joint Registry
, BMJ Open, Vol: 15, ISSN: 2044-6055Objectives The aim of this study was to compare the cost-effectiveness of total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) and explore variation by age and gender.Design Cost-effectiveness analysis using a lifetime cohort Markov model.Setting National population registry data.Participants Model parameters were informed by propensity score-matched comparisons of TSA and HA in patients with osteoarthritis and an intact rotator cuff using data from the National Joint Registry.Interventions TSA and HA.Primary outcome measures Quality-adjusted life years (QALYs) and healthcare costs for age and gender subgroups. A probabilistic sensitivity analysis was performed.Results In all subgroups, TSA was more cost-effective, with the probability of being cost-effective about 70% for TSA versus 30% for HA at any willingness-to-pay threshold above £1100 per QALY. TSA was dominant in young patients (≤60 years) with a mean cost saving of £463 in men and £658 in women, and a mean QALY gain of 2 in both men and women. In patients aged 61–75 years, there was a mean cost saving following HA of £395 in men and £181 in women, while QALYs remained superior following TSA with a 1.3 gain in men and 1.4 in women. In the older cohort (> 75 years), the cost difference was highest and the QALY difference was lowest; there was a cost-saving following HA of £905 in men and £966 in women. The mean QALY gain remained larger after TSA: 0.7 in men and 0.9 in women.Conclusion TSA was more cost-effective than HA in patients with osteoarthritis. QALYs were superior following TSA in all patient groups. Cost differences varied by age and TSA was dominant in young patients.
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Journal articleRistic M, Chappell KE, Lanz H, et al., 2025,
First in-vivo magic angle directional imaging using dedicated low-field MRI
, Magnetic Resonance in Medicine, Vol: 93, Pages: 1077-1089, ISSN: 0740-3194Purpose: To report the first in-vivo results from exploiting the magic angle effect, using a dedicated low-field MRI scanner that can be rotated about two axes. The Magic Angle Directional Imaging (MADI) method is used to depict collagen microstructures with 3D collagen tractography of knee ligaments and the meniscus. Methods: A novel low-field MRI system was developed, based on a transverse field open magnet, where the magnet can be rotated about two orthogonal. Sets of volume scans at various orientations were obtained in healthy volunteers. The experiments focused on the anterior cruciate ligament (ACL) and the meniscus of the knee. The images were co-registered, anatomical regions of interest (RoI) were selected and the collagen fiber orientations in each voxel were estimated from the observed image intensity variations. The 3D collagen tractography was superimposed on conventional volume images. Results: The MADI method was successfully employed for the first time producing in-vivo results comparable to those previously reported for excised animal specimens using conventional MRI. Tractography plots were generated for the ACL and the menisci. These results are consistent with the known microstructure of collagen fibers in these tissues. Conclusion: Images obtained using low-field MRI with 1 mm3 resolution were of sufficient quality for the MADI method, which was shown to produce high quality in-vivo information of collagen microstructures. This was achieved using a cost effective and sustainable low-field magnet making the technique potentially accessible and scalable, potentially changing the way we image injuries or disease in joints.
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Journal articleWoodbridge HR, Alexander CM, Brett SJ, et al., 2025,
Investigating the safety of physical rehabilitation with critically ill patients receiving vasoactive drugs: an exploratory observational feasibility study
, PLoS One, Vol: 20, ISSN: 1932-6203BackgroundPhysical rehabilitation of critically ill patients may improve physical outcomes; however, the relative benefits and risks with patients requiring vasoactive drugs is currently unknown. A feasibility study is needed to inform the design of a future trial required to address this issue.MethodsA two-phase exploratory observational feasibility study was carried out:A retrospective study to clarify the current practice of rehabilitation with patients receiving vasoactive drugs to inform future trial interventions and design.A prospective study exploring recruitment and outcome measurement. Intensive care patients receiving vasoactive drugs were recruited and asked about the acceptability of a future trial. The feasibility of using an adverse event tool was measured during rehabilitation. Patients were followed up after 60 days to describe the feasibility of measuring outcomes for a future trial.ResultsRetrospective study (n = 78): Twenty-one percent of patients took part in physical rehabilitation whilst receiving vasoactive drugs. Of 321 days with vasoactive drugs administered, physical rehabilitation occurred on 27 days (8%).Prospective study (n = 40): Eighty-one percent of participants indicated acceptability of being recruited into a future trial (n = 37). Eighty-eight percent of clinicians found it acceptable to randomise patients into either early rehabilitation or standard care. The adverse event tool was implemented by researchers with 2% loss of information. Finally, a 100% follow-up rate at day 60 was achieved for mortality outcomes. Follow-up rates were 70% for the EQ-5D (5 level), 65% for the World Health Organisation’s Disability Assessment Schedule 2.0 and RAND 36-item Health Survey 1.0 and 26% for the 6-minute walk test.ConclusionsThis study found a low frequency of physical rehabilitation occurring with intensive care patients receiving vasoactive drugs. A high proportion of clinicians and patients found a future RCT within this patient g
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Journal articleSzepietowski O, Ertman H, Chiou S-Y, et al., 2025,
Measurement of voluntary activation of abdominal flexors using transcranial magnetic stimulation
, Journal of Electromyography and Kinesiology, Vol: 80, ISSN: 1050-6411BackgroundTranscranial magnetic stimulation (TMS) has been used to assess voluntary activation (VA) of limb and back muscles, however its ability to assess abdominal muscle VA is unknown. The assessment of abdominal muscle VA using TMS could be applied to patients with trunk dysfunction to enable further understanding of the neurophysiology of trunk control, inform practice and enable the development and monitoring of rehabilitation programmes.AimThe aim of this study was to investigate use of TMS and the twitch interpolation technique to measure voluntary activation of abdominal muscles.MethodsTwenty healthy participants performed sets of isometric abdominal contractions of varying levels, during which TMS was applied to the primary motor cortex. The evoked twitches were measured as torque, while simultaneous surface electromyographic (EMG) activity was recorded bilaterally from rectus abdominis, erector spinae, tensor fasciae latae, and rectus femoris. VA was calculated as: (1 – superimposed twitch amplitude/estimated resting twitch amplitude) x 100. Estimated resting twitch amplitude was calculated by extrapolation using linear regression of superimposed twitch amplitude against torque for contraction strengths 50–100 % maximum voluntary contraction (MVC).ResultsThere was a strong linear relationship between voluntary torque of 50–100 % MVC and TMS-evoked twitch amplitude (r2 = 0.994, p = 0.035), and voluntary torque between 50–100 % MVC and VA (r2 = 0.997, p = 0.025). VA at a target torque of 100 % MVC was less than 100 % (86.20 ± 2.29 %).ConclusionsVA of abdominal muscles can be assessed with twitch interpolation using TMS. VA has been shown to be submaximal during maximum voluntary contractions, and it has been demonstrated that superimposed twitch amplitude decreases in a linear fashion with increasing contraction intensity. Using this technique to explore trunk muscle function could help to improve understanding of the neurophy
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Journal articleZhou T, Kirby-Ginns S, Salman D, et al., 2025,
Using co-design workshops to develop a conceptual framework for a mobile health app targeting chronic low back pain self-management
, BMJ Open, Vol: 15, ISSN: 2044-6055Objectives The aim of this study was to gather insights from a diverse group of stakeholders, identify existing challenges and explore associated solutions to develop a conceptual framework that assists in the development of a chronic low back pain (CLBP) self-management app.Design Codesign workshop methodology.Setting The study was conducted online, allowing for the participation of a diverse group of stakeholders.Participants Participants were recruited through social media platforms and professional networks, including individuals with LBP for at least 3 months, healthcare professionals experienced in CLBP management and app developers with a background in digital health applications.Interventions The study used codesign workshops focused on brainstorming, communication and reflection exercises designed to foster collaboration and gather insights from stakeholders.Outcome measures Identification of key challenges and potential solutions for mobile health (mHealth) apps targeting CLBP.Results Nine stakeholders identified four primary challenges in current back pain apps: belief and trust, motivation, safety and usability. The group also collaboratively developed and proposed practical solutions to these challenges.Conclusions This study illustrated the utility of the codesign workshop approach in generating critical insights for the development of a mHealth solution for CLBP. The insights gathered from these workshops can be used to inform future app development, potentially improving user engagement.
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Journal articleWang E, Strutton P, Alexander C, 2025,
Falls and balance impairment; what and how has this been measured in adults with joint hypermobility? A scoping review
, BMC Musculoskeletal Disorders, Vol: 26, ISSN: 1471-2474BackgroundPeople with joint hypermobility have excessive joint flexibility, which is more common in young women. The people with symptomatic hypermobility report poor balance and even falls. This scoping review aims to identify and map the available evidence related to balance and falling in adults with joint hypermobility to support research planning and ideas for treatment direction.MethodsA framework for the search was constructed using the Joanna Briggs Institute (JBI) approach. Electronic searches of primary evidence were performed using the following databases: Medline, Web of Science, CINAHL, Scopus and EMBASE. Papers written in English and published between 1946 and November 2023 were included. Titles, abstracts, and full papers were independently screened by two reviewers. Data extracted related to the population, the concept under investigation, the method of measurement, the level of evidence and the result.ResultsNineteen of 1,950 screened articles were included. In terms of the population, details related to ethnicity of the research participants was missing. The hypermobility classification criteria varied; it was not always clear if people who were hypermobile had symptoms. Concepts related to fear of falling, balance and adaptive strategies prompted by different postural tasks with and without vision were explored. Centre of pressure, muscle activity, kinematics and psychological factors were measured using force plates, electromyography (EMG), motion capture, patient and clinician reported outcome measures, focus groups and interviews. Most papers were low on the hierarchy of evidence (i.e. equal or lower than a case control study). The participants with joint hypermobility had increased sway, different muscle activity, and different kinematics compared to people without hypermobility. When surveyed, they commonly fell and had a fear of falling.ConclusionsIt is unclear whether the participants represent the population of people with hypermobility. D
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Journal articleAbdulhadi Alagha M, Cobb J, Liddle AD, et al., 2025,
Prediction of implant failure risk due to periprosthetic femoral fracture after primary elective total hip arthroplasty
, Bone & Joint Research, Vol: 14, Pages: 46-57<jats:sec><jats:title>Aims</jats:title><jats:p>While cementless fixation offers potential advantages over cemented fixation, such as a shorter operating time, concerns linger over its higher cost and increased risk of periprosthetic fractures. If the risk of fracture can be forecasted, it would aid the shared decision-making process related to cementless stems. Our study aimed to develop and validate predictive models of periprosthetic femoral fracture (PPFF) necessitating revision and reoperation after elective total hip arthroplasty (THA).</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We included 154,519 primary elective THAs from the Swedish Arthroplasty Register (SAR), encompassing 21 patient-, surgical-, and implant-specific features, for model derivation and validation in predicting 30-day, 60-day, 90-day, and one-year revision and reoperation due to PPFF. Model performance was tested using the area under the curve (AUC), and feature importance was identified in the best-performing algorithm.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>The Lasso regression excelled in predicting 30-day revisions (area under the receiver operating characteristic curve (AUC) = 0.85), while the Gradient Boosting Machine (GBM) model outperformed other models by a slight margin for all remaining endpoints (AUC range: 0.79 to 0.86). Predictive factors for revision and reoperation were identified, with patient features such as increasing age, higher American Society of Anesthesiologists grade (> III), and World Health Organization obesity classes II to III associated with elevated risks. A preoperative diagnosis of idiopathic necrosis increased revision risk. Concerning implant design, factors such as cementless femoral fixation, reverse-hybrid fixation, hip resurfacing, and small (< 35 mm) or large (> 52 mm) femoral head
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Journal articleAlagha MA, Cobb J, Liddle A, et al., 2025,
Prediction of implant failure risk due to periprosthetic femoral fracture after primary elective total hip arthroplasty: a simplified and validated model based on 154,519 total hip replacements from the Swedish Arthroplasty Register
, Bone & Joint Research, Vol: 14, Pages: 46-57, ISSN: 2046-3758Introduction While cementless fixation offers potential advantages, such as a shorter operative time, concerns linger over its higher cost and increased risk of periprosthetic fractures. If the risk of fracture can be forecasted, it would aid the shared decision-making process related to cementless stems. Our study aimed to develop and validate predictive models of periprosthetic femoral fracture(PPFF) necessitating revision and re-operation after elective THR.Methods We included 154,519 primary elective THRs from the Swedish Arthroplasty Register(SAR), encompassing twenty-one patient-,surgical-,and implant-specific features, for model derivation and validation in predicting 30-,60-,90-day and 1-year revision and re operation due to PPFF. Model performance was tested using the area under the curve(AUC), and features importance were identified in the best performing algorithm.Results The Lasso regression excelled in predicting 30-day revisions(AUC=0.85), while the Gradient Boosting Machine(GBM) model outperformed other models by a slight margin for all remaining endpoints(AUC range:0.79-0.86). Predictive factors for revision and re-operation were identified, with patient features such as increasing age, higher ASA grade(> 3), and obesity classes II-III were associated with elevated risks. A pre-operative diagnosis of idiopathic necrosis increased revision risk. Concerning implant design, factors such as cementless femoral fixation, reverse-hybrid fixation, hip resurfacing, and small(< 35 mm) or large(> 52 mm) femoral heads increased both revision and re-operation risks.Conclusion This is the first study to develop machine learning models to forecast the risk of periprosthetic femoral fracture necessitating re-do surgery. Future studies are required to externally validate our algorithm and assess its applicability in clinical practice.
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Journal articleJones GG, Campi S, von Knoch F, et al., 2025,
Indications for the addition of a patellofemoral joint arthroplasty following a previous unicondylar knee arthroplasty- a literature review and Delphi consensus
, ARCHIVES OF ORTHOPAEDIC AND TRAUMA SURGERY, Vol: 145, ISSN: 0936-8051 -
Journal articleHall TAG, Jones GG, van Arkel RJ, 2024,
Femorotibial angle scan–rescan reproducibility: a high‐precision calculation on a large cohort
, Knee Surgery, Sports Traumatology, Arthroscopy, Vol: 32, Pages: 3133-3140, ISSN: 0942-2056PurposeFemorotibial angle (FTA) is a convenient measure of coronal knee alignment that can be extracted from a short knee radiograph, avoiding the additional radiation exposure and specialist equipment required for full-leg radiographs. While intra- and inter-reader reproducibility from the same image has been reported, the full scan–rescan reproducibility across images, as calculated in this study, has not.MethodsIn this study, 4589 FTA measurement pairs from 2586 subjects acquired a year apart were used to estimate FTA scan–rescan reproducibility using data from the Osteoarthritis Initiative. Subjects with radiographic progression of osteoarthritis or other conditions that may cause a change in coronal knee alignment were excluded. Measurement pairs were analysed using paired-samples mathematical equation tests to detect differences and compared to symptomatic changes in Western Ontario and McMaster Universities Arthritis Index scores for joint pain, stiffness and physical function to detect correlations.ResultsThe 95% limit of agreement and the paired-samples correlation were calculated with high precision to be [−1.76°, +1.78°] and 0.938, considerably worse than the corresponding figures for intra- and inter-reader reproducibility, without relation to symptomatic or radiographic changes in knee condition. This error will weakly attenuate mathematical equation and mathematical equation values from their true values in correlative studies involving FTA. The realistic maximum value for mathematical equation is 87% and for Pearson's mathematical equation is 93%.ConclusionThe scan–rescan reproducibility in FTA is almost double the intra- and inter-reader reliability from a single scan. At almost ±2° accuracy, FTA is inappropriate for surgical use, but it is sufficiently reproducible to produce good correlations in studies predicting disease incidence and progression.Level of EvidenceLevel II, retrospective study.
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Journal articleBicer M, Phillips ATM, Melis A, et al., 2024,
Generative adversarial networks to create synthetic motion capture datasets including subject and gait characteristics
, Journal of Biomechanics, Vol: 177, ISSN: 0021-9290Resource-intensive motion capture (mocap) systems challenge predictive deep learning applications, requiring large and diverse datasets. We tackled this by modifying generative adversarial networks (GANs) into conditional GANs (cGANs) that can generate diverse mocap data, including 15 marker trajectories, lower limb joint angles, and 3D ground reaction forces (GRFs), based on specified subject and gait characteristics. The cGAN comprised 1) an encoder compressing mocap data to a latent vector, 2) a decoder reconstructing the mocap data from the latent vector with specific conditions and 3) a discriminator distinguishing random vectors with conditions from encoded latent vectors with conditions. Single-conditional models were trained separately for age, sex, leg length, mass, and walking speed, while an additional model (Multi-cGAN) combined all conditions simultaneously to generate synthetic data. All models closely replicated the training dataset (<8.1 % of the gait cycle different between experimental and synthetic kinematics and GRFs), while a subset with narrow condition ranges was best replicated by the Multi-cGAN, producing similar kinematics (<1°) and GRFs (<0.02 body-weight) averaged by walking speeds. Multi-cGAN also generated synthetic datasets for three previous studies using reported mean and standard deviation of subject and gait characteristics. Additionally, unseen test data was best predicted by the walking speed-conditional, showcasing synthetic data diversity. The same model also matched the dynamical consistency of the experimental data (32 % average difference throughout the gait cycle), meaning that transforming the gait cycle data to the original time domain yielded accurate derivative calculations. Importantly, synthetic data poses no privacy concerns, potentially facilitating data sharing.
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Journal articleMusbahi O, Nurek M, Pouris K, et al., 2024,
Can ChatGPT make surgical decisions with confidence similar to experienced knee surgeons?
, Knee, Vol: 51, Pages: 120-129, ISSN: 0968-0160BACKGROUND: Unicompartmental knee replacements (UKRs) have become an increasingly attractive option for end-stage single-compartment knee osteoarthritis (OA). However, there remains controversy in patient selection. Natural language processing (NLP) is a form of artificial intelligence (AI). We aimed to determine whether general-purpose open-source natural language programs can make decisions regarding a patient's suitability for a total knee replacement (TKR) or a UKR and how confident AI NLP programs are in surgical decision making. METHODS: We conducted a case-based cohort study using data from a separate study, where participants (73 surgeons and AI NLP programs) were presented with 32 fictitious clinical case scenarios that simulated patients with predominantly medial knee OA who would require surgery. Using the overall UKR/TKR judgments of the 73 experienced knee surgeons as the gold standard reference, we calculated the sensitivity, specificity, and positive predictive value of AI NLP programs to identify whether a patient should undergo UKR. RESULTS: There was disagreement between the surgeons and ChatGPT in only five scenarios (15.6%). With the 73 surgeons' decision as the gold standard, the sensitivity of ChatGPT in determining whether a patient should undergo UKR was 0.91 (95% confidence interval (CI): 0.71 to 0.98). The positive predictive value for ChatGPT was 0.87 (95% CI: 0.72 to 0.94). ChatGPT was more confident in its UKR decision making (surgeon mean confidence = 1.7, ChatGPT mean confidence = 2.4). CONCLUSIONS: It has been demonstrated that ChatGPT can make surgical decisions, and exceeded the confidence of experienced knee surgeons with substantial inter-rater agreement when deciding whether a patient was most appropriate for a UKR.
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Journal articleGeorgiakakis ECT, Khan AM, Logishetty K, et al., 2024,
Artificial intelligence in planned orthopaedic care
, SICOT-J, Vol: 10, ISSN: 2426-8887 -
Journal articleCampi S, Jones G, von Knoch F, et al., 2024,
Bicompartmental Knee Arthroplasty: a systematic review and Delphi consensus from the European Knee Society
, ARCHIVES OF ORTHOPAEDIC AND TRAUMA SURGERY, Vol: 144, Pages: 4685-4696, ISSN: 0936-8051 -
Journal articleDavies AR, Sabharwal S, Liddle AD, et al., 2024,
Patient-reported outcomes following total shoulder arthroplasty and hemiarthroplasty: an analysis of data from the National Joint Registry
, JOURNAL OF SHOULDER AND ELBOW SURGERY, Vol: 33, Pages: 2411-2420, ISSN: 1058-2746 -
Journal articleBehan F, Bull A, Beck B, et al., 2024,
Developing an exercise intervention to minimise hip bone mineral density loss following traumatic lower limb amputation: a Delphi study
, British Journal of Sports Medicine, Vol: 58, ISSN: 0306-3674Objective To elicit expert opinion and gain consensus on specific exercise intervention parameters to minimise hip bone mineral density (BMD) loss following traumatic lower limb amputation.Methods In three Delphi rounds, statements were presented to a panel of 13 experts from six countries. Experts were identified through publications or clinical expertise. Round 1 involved participants rating their agreement with 22 exercise prescription statements regarding BMD loss post amputation using a 5-point Likert scale. Agreement was deemed as 3–4 on the scale (agree/strongly agree). Statements of <50% agreement were excluded. Round 2 repeated remaining statements alongside round 1 feedback. Round 3 allowed reflection on round 2 responses considering group findings and the chance to change or maintain the resp onse. Round 3 statements reaching ≥70% agreement were defined as consensus.Results All 13 experts completed rounds 1, 2 and 3 (100% completion). Round 1 excluded 12 statements and added 1 statement (11 statements for rounds 2–3). Round 3 reached consensus on nine statements to guide future exercise interventions. Experts agreed that exercise interventions should be performed at least 2 days per week for a minimum of 6 months, including at least three different resistance exercises at an intensity of 8–12 repetitions. Interventions should include weight-bearing and multiplanar exercises, involve high-impact activities and be supervised initially.Conclusion This expert Delphi process achieved consensus on nine items related to exercise prescription to minimise hip BMD loss following traumatic lower limb amputation. These recommendations should be tested in future interventional trials.
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Journal articleYork TJ, Szyszka B, Brivio A, et al., 2024,
A radiographic artificial intelligence tool to identify candidates suitable for partial knee arthroplasty
, Archives of Orthopaedic and Trauma Surgery, Vol: 144, Pages: 4963-4968, ISSN: 0936-8051Introduction: Knee osteoarthritis is a prevalent condition frequently necessitating knee replacement surgery, with demand projected to rise substantially. Partial knee arthroplasty (PKA) offers advantages over total knee arthroplasty (TKA), yet its utilisation remains low despite guidance recommending consideration alongside TKA in shared decision making. Radiographic decision aids exist but are underutilised due to clinician time constraints.Materials and Methods: This research develops a novel radiographic artificial intelligence (AI) tool using a dataset of knee radiographs and a panel of expert orthopaedic surgeons' assessments. Six AI models were trained to identify PKA candidacy. Results: 4,967 labelled four-view radiograph series were included. Models achieved statistically significant accuracies above random assignment, with EfficientNet-ES demonstrating the highest performance (AUC 95%, F1 score 83% and accuracy 80%). Conclusions: The AI decision tool shows promise in identifying PKA candidates, potentially addressing underutilisation of this procedure. Its integration into clinical practice could enhance shared decision making and improve patient outcomes. Further validation and implementation studies are warranted to assess real-world utility and impact.
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Journal articleChang R, Campbell A, Kent P, et al., 2024,
Improvements in Forward Bending Are Related to Improvements in Pain and Disability During Cognitive Functional Therapy for People With Chronic Low Back Pain
, JOURNAL OF ORTHOPAEDIC & SPORTS PHYSICAL THERAPY, Vol: 54, Pages: 721-731, ISSN: 0190-6011 -
Journal articleZhao Y, Coppola A, Karamchandani U, et al., 2025,
Correction: Artificial intelligence applied to magnetic resonance imaging reliably detects the presence, but not the location, of meniscus tears: a systematic review and meta-analysis
, EUROPEAN RADIOLOGY, ISSN: 0938-7994 -
Journal articleRiley N, Kasza I, Hermsmeyer IDK, et al., 2024,
Dietary lipid is largely deposited in skin and rapidly affects insulating properties.
, Res SqSkin has been shown to be a regulatory hub for energy expenditure and metabolism: mutations of skin lipid metabolism enzymes can change the rate of thermogenesis and susceptibility to diet-induced obesity. However, little is known about the physiological basis for this function. Here we show that the thermal properties of skin are highly reactive to diet: within three days, a high fat diet reduces heat transfer through skin. In contrast, a dietary manipulation that prevents obesity accelerates energy loss through skins. We found that skin was the largest target in a mouse body for dietary fat delivery, and that dietary triglyceride was assimilated both by epidermis and by dermal white adipose tissue. Skin from mice calorie-restricted for 3 weeks did not take up circulating lipids and showed a highly depleted stratum corneum. Dietary triglyceride acyl groups persist in skin for weeks after feeding. Using multi-modal lipid profiling, we have implicated both keratinocytes and sebocytes in the altered lipids which correlate with thermal function. In response to high fat feeding, wax diesters and ceramides accumulate, and triglycerides become more saturated. In contrast, in response to the dramatic loss of adipose tissue that accompanies restriction of the branched chain amino acid isoleucine, skin becomes more heat-permeable, resisting changes induced by Western diet feeding, with a signature of depleted signaling lipids. We propose that skin should be routinely included in physiological studies of lipid metabolism, given the size of the skin lipid reservoir and its adaptable functionality.
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