Minimally invasive lateral plating for diaphyseal fractures with extension into the proximal humerus and its implications for the deltoid muscle and its distal insertion: functional analysis and MR-imaging

BACKGROUND

In minimally invasive lateral plate osteosynthesis of the humerus (MILPOH) the plate is introduced through a deltoid split proximally and advanced through the central portion of the deltoid insertion and between bone and brachial muscle to the distal aspect of the humerus. The fracture is then indirectly reduced and bridged by the plate. Whereas it has been shown that the strong anterior and posterior parts of the distal deltoid insertion remain intact with this maneuver, its impact on deltoid muscle strength and muscular morphology remains unclear. It was the aim of this study to evaluate deltoid muscle function and MR-morphology of the deltoid muscle and its distal insertion after MILPOH.

METHODS

Six patients (median age 63 years, range 52-69 years, f/m 5/1) who had undergone MILPOH for diaphyseal humeral fractures extending into the proximal metaphysis and head (AO 12B/C(i)) between 08/2017 and 08/2020 were included. Functional testing was performed for the injured and uninjured extremity including strength measurements for 30/60/90° shoulder abduction and flexion at least one year postoperatively. Constant-Murley-Score (CMS) including an age-and gender-adjusted version, were obtained and compared to the uninjured side. Oxford Shoulder Score (OSS) and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire were acquired for the affected extremity. Quality of life was measured using the EQ visual analogue scale (EQ-5D-5 L VAS). MR imaging was performed for both shoulders accordingly at the time of follow-up to assess the integrity of the distal insertion, muscle mass and fatty degeneration of the deltoid muscle. Muscle mass was determined by measuring the area of the deltoid muscle on the axial MR image at the height of the center of the humeral head.

RESULTS

Median follow-up was 29 months (range 12-48 months). Median difference of abduction strength after MILPOH was + 13% for 30°, 0% for 60° and - 22% for 90°. For flexion, the difference to the uninjured side was measured 5% for 30°, -7% for 60° and - 12% for 90°. Median CMS was 75 (66-82) for the operated extremity compared to 82 (77-90) for the uninjured side. Age- and gender-adapted CMS was calculated 88 (79-99) vs. 96 (89-107). Median OSS was 47 (40-48). DASH was 26 (15-36). EQ-5D-5 L VAS ranged from 81 to 95 with a median of 90. The median difference of the deltoid muscle area on MRI was 2% (-21% to + 53%) compared to the uninjured side. No fatty degeneration of the deltoid muscle was observed. The weaker central part of the distal deltoid insertion was exclusively perforated by the plate, leaving the strong anterior and posterior parts of the insertion intact in all patients.

CONCLUSIONS

MILPOH was associated with good functional and subjective outcome. Minor impairment of abduction strength was observed with increasing abduction angles. The reason for this impairment is unclear since MILPOH did not affect the structural quality of the deltoid muscle and the integrity of the strong anterior and posterior parts of its insertion remained intact.

TRIAL REGISTRATION

26/05/2023: ISRCTN51786146.

Fever Therapy With Intravenously Applied Mistletoe Extracts for Cancer Patients: A Retrospective Study

Purpose. So-called spontaneous remissions in cancer often seem to occur after febrile events. Mistletoe preparations (MPs) are used off-label intravenously to induce fever within concepts of integrative oncology. We wanted to investigate the frequency of febrile reactions and safety related to intravenously applied MPs (IAMPs). Methods. This was a retrospective analysis of data from consecutive cancer patients who were treated in 2 anthroposophic hospitals with IAMPs. The main outcome parameter was the rate of core temperature increase to ≥38.5°C within 24 hours after IAMPs. Secondary outcome parameters were Common Toxicity Criteria for Adverse Events (CTCAE; version 4.0). Results. 59 patients, with in total 567 IAMPs, were analyzed; 45 patients (76%, 95% CI = 65%-87%) had an increase of core temperature to ≥38.5°C after at least 1 treatment. Mean increase in temperature was 1.5°C ± 0.8°C. Adverse events were mostly fever-related symptoms (headache, joint pain, shivering). Grade 1 allergic reactions were documented in 0.6% of treatments. CTCAEs grade 3 to 5 did not occur; 38/59 patients had advanced and/or metastatic disease. Conclusion. IAMPs resulted in febrile reactions to >38.5°C in the majority of patients and can be considered as safe. Adverse events were mostly related to fever and were not severe.

Predictive value of the MGMT promoter methylation status in metastatic melanoma patients receiving first-line temozolomide plus bevacizumab in the trial SAKK 50/07

The O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation status is a predictive parameter for the response of malignant gliomas to alkylating agents such as temozolomide. First clinical trials with temozolomide plus bevacizumab therapy in metastatic melanoma patients are ongoing, although the predictive value of the MGMT promoter methylation status in this setting remains unclear. We assessed MGMT promoter methylation in formalin-fixed, primary tumor tissue of metastatic melanoma patients treated with first-line temozolomide and bevacizumab from the trial SAKK 50/07 by methylation-specific polymerase chain reaction. In addition, the MGMT expression levels were also analyzed by MGMT immunohistochemistry. Eleven of 42 primary melanomas (26%) revealed a methylated MGMT promoter. Promoter methylation was significantly associated with response rates CR + PR versus SD + PD according to RECIST (response evaluation criteria in solid tumors) (p<0.05) with a trend to prolonged median progression-free survival (8.1 versus 3.4 months, p>0.05). Immunohistochemically different protein expression patterns with heterogeneous and homogeneous nuclear MGMT expression were identified. Negative MGMT expression levels were associated with overall disease stabilization CR+PR+SD versus PD (p=0.05). There was only a poor correlation between MGMT methylation and lack of MGMT expression. A significant proportion of melanomas have a methylated MGMT promoter. The MGMT promoter methylation status may be a promising predictive marker for temozolomide therapy in metastatic melanoma patients. Larger sample sizes may help to validate significant differences in survival type endpoints.

Influence of EARLI1-like genes on flowering time and lignin synthesis of Arabidopsis thaliana

EARLI1 encodes a 14.7 kDa protein in the cell wall, is a member of the PRP (proline-rich protein) family and has multiple functions, including resistance to low temperature and fungal infection. RNA gel blot analyses in the present work indicated that expression of EARLI1-like genes, EARLI1, At4G12470 and At4G12490, was down-regulated in Col-FRI-Sf2 RNAi plants derived from transformation with Agrobacterium strain ABI, which contains a construct encoding a double-strand RNA targeting 8CM of EARLI1. Phenotype analyses revealed that Col-FRI-Sf2 RNAi plants of EARLI1 flowered earlier than Col-FRI-Sf2 wild-type plants. The average bolting time of Col-FRI-Sf2 and Col-FRI-Sf2 RNAi plants was 39.7 and 19.4 days, respectively, under a long-day photoperiod. In addition, there were significant differences in main stem length, internode number and rosette leaf number between Col-FRI-Sf2 and Col-FRI-Sf2 RNAi plants. RT-PCR showed that EARLI1-like genes might delay flowering time through the autonomous and long-day photoperiod pathways by maintaining the abundance of FLC transcripts. In Col-FRI-Sf2 RNAi plants, transcription of FLC was repressed, while expression of SOC1 and FT was activated. Microscopy observations showed that EARLI1-like genes were also associated with morphogenesis of leaf cells in Arabidopsis. Using histochemical staining, EARLI1-like genes were found to be involved in regulation of lignin synthesis in inflorescence stems, and Col-FRI-Sf2 and Col-FRI-Sf2 RNAi plants had 9.67% and 8.76% dry weight lignin, respectively. Expression analysis revealed that cinnamoyl-CoA reductase, a key enzyme in lignin synthesis, was influenced by EARLI1-like genes. These data all suggest that EARLI1-like genes could control the flowering process and lignin synthesis in Arabidopsis.

Genetic and physiological analysis of biennialism in Hyoscyamus niger

A genetic and physiological study of biennialism in the diploid selfer Hyoscyamus niger (black henbane), an obligate long-day plant, is described. Three annual and two biennial accessions that were homozygous for their respective growth habits were selected. The early-flowering trait of two annual accessions was dominant over the late-flowering trait of the third annual accession. The late-flowering annual accession, but not the early-flowering ones, responded to vernalization. Two biennial accessions remained vegetative after more than 1 year in soil and thus had an obligate vernalization requirement. Crosses between annual and biennial accessions showed that biennialism was conferred through a single dominant gene. However, plants containing only one copy of this dominant gene were transformed from biennials into very late-flowering winter-annual plants that responded more rapidly to vernalization than biennials. Taken together, these results indicated that there were allelic differences in photoperiod-specific flowering time genes and that biennialism was a dose-dependent trait with incomplete dominance. Models for flowering time regulation in henbane involving photoperiod-, vernalization-, and most likely gibberellin-specific pathways are discussed.

First-line temozolomide combined with bevacizumab in metastatic melanoma: a multicentre phase II trial (SAKK 50/07)

BACKGROUND

Oral temozolomide has shown similar efficacy to dacarbazine in phase III trials with median progression-free survival (PFS) of 2.1 months. Bevacizumab has an inhibitory effect on the proliferation of melanoma and sprouting endothelial cells. We evaluated the addition of bevacizumab to temozolomide to improve efficacy in stage IV melanoma.

PATIENTS AND METHODS

Previously untreated metastatic melanoma patients with Eastern Cooperative Oncology Group performance status of two or more were treated with temozolomide 150 mg/m(2) days 1-7 orally and bevacizumab 10 mg/kg body weight i.v. day 1 every 2 weeks until disease progression or unacceptable toxicity. The primary end point was disease stabilisation rate [complete response (CR), partial response (PR) or stable disease (SD)] at week 12 (DSR12); secondary end points were best overall response, PFS, overall survival (OS) and adverse events.

RESULTS

Sixty-two patients (median age 59 years) enrolled at nine Swiss centres. DSR12 was 52% (PR: 10 patients and SD: 22 patients). Confirmed overall response rate was 16.1% (CR: 1 patient and PR: 9 patients). Median PFS and OS were 4.2 and 9.6 months. OS (12.0 versus 9.2 months; P = 0.014) was higher in BRAF V600E wild-type patients.

CONCLUSIONS

The primary end point was surpassed showing promising activity of this bevacizumab/temozolomide combination with a favourable toxicity profile. Response and OS were significantly higher in BRAF wild-type patients.

A gene expression screen identifies EARLI1 as a novel vernalization-responsive gene in Arabidopsis thaliana

Vernalization promotes early flowering in late ecotypes of Arabidopsis thaliana. The mechanisms of vernalization are poorly understood. A subtractive hybridization approach was used to isolate vernalization-responsive genes from a late-flowering ecotype of Arabidopsis thaliana based on the premise that transcript levels of such genes would increase with cold treatment and remain high even after removal of the vernalization stimulus. EARLI1 is the first Arabidopsis gene shown to be stably activated by vernalization. The abundance of its RNA is progressively elevated by vernalization and remains high for at least 20 days at room temperature. The basal level of EARLI1 RNA is higher in early-flowering ecotypes, but is increased also after vernalization. Vernalization and subsequent growth in long-day photoperiods have an additive or synergistic effect on EARLI1 activation. EARLI1 RNA levels are also transiently induced by brief exposures to cold, but not to abscisic acid. EARLI1 is thus a novel vernalization-responsive gene in Arabidopsis thaliana that can be used to investigate vernalization-specific transcriptional regulation.

Concerted formation of macromolecular Suppressor-mutator transposition complexes

Transposition of the maize Suppressor-mutator (Spm) transposon requires two element-encoded proteins, TnpA and TnpD. Although there are multiple TnpA binding sites near each element end, binding of TnpA to DNA is not cooperative, and the binding affinity is not markedly affected by the number of binding sites per DNA fragment. However, intermolecular complexes form cooperatively between DNA fragments with three or more TnpA binding sites. TnpD, itself not a sequence-specific DNA-binding protein, binds to TnpA and stabilizes the TnpA-DNA complex. The high redundancy of TnpA binding sites at both element ends and the protein-protein interactions between DNA-bound TnpA complexes and between these and TnpD imply a concerted transition of the element from a linear to a protein crosslinked transposition complex within a very narrow protein concentration range.

Epigenetic mechanisms in the regulation of the maize Suppressor-mutator transposon

Transcription and transposition of the maize Suppressor-mutator (Spm) transposon are epigenetically controlled. Methylation of specific element sequences prevents transcription and transposition in a heritable manner. Reactivation and demethylation occur in the presence of an active element, implying the existence of an element-encoded epigenetic activator. The methylation target sequences are the 0.2 kb promoter and an 0.35 kb GC-rich downstream sequence. Two Spm-encoded proteins, TnpA and TnpD, participate in transposition. In addition, TnpA has positive and negative regulatory activities. TnpA represses and activates the unmethylated and methylated Spm promoters, respectively, and it participates in the transient and heritable demethylation of the promoter and GC-rich region. There is evidence that TnpA-mediated repressor and epigenetic activator functions occur by different molecular mechanisms.

A highly sensitive plant hybrid protein assay system based on the Spm promoter and TnpA protein for detection and analysis of transcription activation domains

TnpA is a multifunctional DNA binding protein encoded by the maize Suppressor-mutator (Spm) transposable element. TnpA is required for transposition and is a repressor of the unmethylated Spm promoter. While analyzing protein domains using a yeast GAL4-based hybrid system in transiently transformed tobacco cells, we found that TnpA represses the > 10-fold transcriptional activation observed when the GAL4 DNA-binding domain is used alone. By contrast, compared to the backgroundless TnpA DNA-binding domain alone, 33- to 45-fold activation of the Spm promoter was observed when the VP16 activation domain was fused to it. TnpA-binding sites, but no TATA box, were required for transcription activation. Among the TnpA deletion derivatives tested, those retaining the coding sequences for the DNA-binding and protein dimerization domains gave the highest level of transcription activation when fused with the VP16 activation domain. The TnpA gene and TnpA-binding sites in the short Spm promoter therefore provide a novel, highly sensitive single-hybrid system for identifying and studying plant transcription activation domains in plant cells.

Epigenetic regulation of the maize Spm transposon

Expression and transposition of the Suppressor-mutator (Spm) transposon of maize are controlled by interacting epigenetic and autoregulatory mechanisms. Methylation of critical element sequences prevents both transcription and transposition, heritably inactivating the element. The promoter, comprising the terminal 0.2 kb of the element, and a 0.35-kb, highly GC-rich, downstream sequence are the methylation target sequences. The element encodes two proteins necessary for transposition, TnpA and TnpD. There are multiple TnpA binding sites, both in the 5' terminal promoter region and at the element's 3' end. In addition to its role in transposition, TnpA is both a positive and a negative regulator of transcription. TnpA represses the element's promoter when it is not methylated. When the element is inactive and its promoter methylated, TnpA activates the methylated promoter and facilitates both its transient and heritable demethylation.

Epigenetic regulation of the maize Spm transposable element: novel activation of a methylated promoter by TnpA

Spm is epigenetically inactivated by C-methylation near its transcription start site. We have investigated the interaction between TnpA, an autoregulatory protein that can reactivate a silent Spm, and the promoter of the element. The promoter undergoes rapid de novo methylation and inactivation in stably transformed plants, but only if it includes a GC-rich sequence down-stream of the promoter. TnpA activates the inactive, methylated promoter and leads to reduced methylation. By contrast, TnpA represses the active, unmethylated Spm promoter. Only the internal DNA-binding and dimerization domains of the protein are required for repression, while activation requires an additional C-terminal sequence. TnpA is therefore a unique regulatory protein with a conventional transcriptional repressor activity and a novel ability to activate a methylated, inactive promoter.

TnpA trans-activates methylated maize Suppressor-mutator transposable elements in transgenic tobacco

The maize Suppressor-mutator (Spm) transposable element is subject to epigenetic inactivation in transgenic tobacco, as it is in maize. Spm inactivation in tobacco is correlated with increased methylation of sequences near the element's transcription start site. To determine whether element-encoded gene products can promote the reactivation of an inactive element, we investigated the effects of introducing individual CaMV 35S promoter-driven cDNAs for tnpA, tnpB, tnpC and tnpD, the element's four known protein-coding sequences. Introduction of the tnpA cDNA promoted the reactivation of the inactive resident Spm element, as judged by the appearance of regenerants with very early excision events and transposed elements. By contrast, the tnpB, tnpC and tnpD cDNAs had no affect on the activity of the resident Spm element. Similar results were obtained when the element-encoded cDNAs were introduced either by Agrobacterium-mediated retransformation or by a genetic cross. Reactivation of an inactive Spm by the tnpA cDNA is accompanied by reduced methylation of several methylation-sensitive restriction sites near the element's transcription start site. Maintenance of the reactivated Spm element in an active state requires the continued presence of the tnpA cDNA. Elimination of the tnpA cDNA locus by genetic segregation generally results in decreased element activity, as judged by a low frequency of excision events, and is accompanied by increased methylation of the element's 5'-end. Exceptions resembling the phenomenon of "presetting" are also observed in which progeny plants that did not receive the tnpA cDNA locus after meiotic segregation maintain high excision activity and exhibit low methylation levels.

T-DNA transfer to maize cells: histochemical investigation of beta-glucuronidase activity in maize tissues

Agrobacterium tumefaciens is routinely used to engineer desirable genes into dicotyledonous plants. However, the economically important graminaceous plant maize is refractory to tumor induction by inoculation with virulent strains of A. tumefaciens. Currently, the only clearcut evidence for transferred DNA (T-DNA) transport from Agrobacterium to maize comes from agroinfection. To study T-DNA transfer from Agrobacterium to maize cells in a virus-free system, we used here the beta-glucuronidase (GUS; EC 3.2.1.31) gene as a marker. GUS expression was observed with high efficiency on shoots of young maize seedlings after cocultivation with Agrobacterium carrying the GUS gene. Agrobacterium virulence mutants, incapable of transferring T-DNA to dicot tissue, were shown to be deficient in eliciting GUS expression in maize. Hence, expression of the T-DNA-located GUS gene in maize cells is strictly dependent on Agrobacterium-mediated DNA transfer. Histochemical staining of maize shoots revealed GUS expression located mainly in the leaves and the coleoptile.