Polygenic architecture of flowering time and its relationship with local environments in the grass Brachypodium distachyon

Synchronizing the timing of reproduction with the environment is crucial in the wild. Among the multiple mechanisms, annual plants evolved to sense their environment, the requirement of cold-mediated vernalization is a major process that prevents individuals from flowering during winter. In many annual plants including crops, both a long and short vernalization requirement can be observed within species, resulting in so-called early-(spring) and late-(winter) flowering genotypes. Here, using the grass model Brachypodium distachyon, we explored the link between flowering-time-related traits (vernalization requirement and flowering time), environmental variation, and diversity at flowering-time genes by combining measurements under greenhouse and outdoor conditions. These experiments confirmed that B. distachyon natural accessions display large differences regarding vernalization requirements and ultimately flowering time. We underline significant, albeit quantitative effects of current environmental conditions on flowering-time-related traits. While disentangling the confounding effects of population structure on flowering-time-related traits remains challenging, population genomics analyses indicate that well-characterized flowering-time genes may contribute significantly to flowering-time variation and display signs of polygenic selection. Flowering-time genes, however, do not colocalize with genome-wide association peaks obtained with outdoor measurements, suggesting that additional genetic factors contribute to flowering-time variation in the wild. Altogether, our study fosters our understanding of the polygenic architecture of flowering time in a natural grass system and opens new avenues of research to investigate the gene-by-environment interaction at play for this trait.

Transposition of HOPPLA in siRNA-deficient plants suggests a limited effect of the environment on retrotransposon mobility in Brachypodium distachyon

Long terminal repeat retrotransposons (LTR-RTs) are powerful mutagens regarded as a major source of genetic novelty and important drivers of evolution. Yet, the uncontrolled and potentially selfish proliferation of LTR-RTs can lead to deleterious mutations and genome instability, with large fitness costs for their host. While population genomics data suggest that an ongoing LTR-RT mobility is common in many species, the understanding of their dual role in evolution is limited. Here, we harness the genetic diversity of 320 sequenced natural accessions of the Mediterranean grass Brachypodium distachyon to characterize how genetic and environmental factors influence plant LTR-RT dynamics in the wild. When combining a coverage-based approach to estimate global LTR-RT copy number variations with mobilome-sequencing of nine accessions exposed to eight different stresses, we find little evidence for a major role of environmental factors in LTR-RT accumulations in B. distachyon natural accessions. Instead, we show that loss of RNA polymerase IV (Pol IV), which mediates RNA-directed DNA methylation in plants, results in high transcriptional and transpositional activities of RLC_BdisC024 (HOPPLA) LTR-RT family elements, and that these effects are not stress-specific. This work supports findings indicating an ongoing mobility in B. distachyon and reveals that host RNA-directed DNA methylation rather than environmental factors controls their mobility in this wild grass model.

Course of ankle-brachial-index 12 months after intravascular lithotripsy in calcified peripheral lesions

Background

Intravascular lithotripsy (IVL) is a relatively novel treatment option for calcified lesions in peripheral artery disease. Little is known about the mid to long-term functional status of the patients and target lesion revascularization rate (TLR) after IVL only procedure.

Purpose

To evaluate the course of ankle-brachial-index (ABI) and to assess the rate of revascularization 1 year after intravascular lithotripsy performed on calcified peripheral lesions.

Methods

Between December 2018 and January 2021 IVL was performed on 61 limbs of 51 patients presenting with Rutherford classes 2–5. Ankle-brachial-index (ABI) was documented before the procedure as well as 1 day, 6 months and 1 year after the procedure within a single center real-life registry. Further endpoint was revascularization with PTA or peripheral bypass surgery. The vast majority of cases were done as IVL only procedure (58%) All procedures were done in upper leg/pelvic stenosis.

Results

ABI measurement after 12 months was done in 42 of 51 patients (82%). Three pts were missed due to media sclerosis. Due to loss of follow-up, ABI after 6 months could not be performed on 4/61 patients (7,8%) and 12-month-ABI in another 8/51 cases (15,6%). Initial baseline ABI of 0.6±0.26 before the procedure increased to 0.8±0.25 (p<0.0001) one day afterward. After 6 months, the ABI of 0.8±0.27 (n=49; p<0.0001) was still significantly improved compared to baseline. After 1 year, ABI with 0.7±0.22 was still improved, however not significantly different from baseline (Figure 1). Target lesion revascularization was needed in 7 patients (13%), 4 with subsequent IVL, 3 with PTA and 2 with peripheral bypass surgery.

Conclusions

In our large single center registry, IVL performed mainly as a stand-alone procedure was safe and effective even after a mid-term follow up. TLR was necessary in 13%, which is lower than in previous published IVL data (20,7% as in DISRUPT-PAD-II) [1]. ABI after 12 months improved but did maintain statistical significance, compared with other procedure like scoring balloon [2].

Funding Acknowledgement

Type of funding sources: None.

Experimentally heat-induced transposition increases drought tolerance in Arabidopsis thaliana

Eukaryotic genomes contain a vast diversity of transposable elements (TEs). Formerly often described as selfish and parasitic DNA sequences, TEs are now recognised as a source of genetic diversity and powerful drivers of evolution. However, because their mobility is tightly controlled by the host, studies experimentally assessing how fast TEs may mediate the emergence of adaptive traits are scarce. We exposed Arabidopsis thaliana high-copy TE lines (hcLines) with up to c. eight-fold increased copy numbers of the heat-responsive ONSEN TE to drought as a straightforward and ecologically highly relevant selection pressure. We provide evidence for increased drought tolerance in five out of the 23 tested hcLines and further pinpoint one of the causative mutations to an exonic insertion of ONSEN in the ribose-5-phosphate-isomerase 2 gene. The resulting loss-of-function mutation caused a decreased rate of photosynthesis, plant size and water consumption. Overall, we show that the heat-induced transposition of a low-copy TE increases phenotypic diversity and leads to the emergence of drought-tolerant individuals in A. thaliana. This is one of the rare empirical examples substantiating the adaptive potential of mobilised stress-responsive TEs in eukaryotes. Our work demonstrates the potential of TE-mediated loss-of-function mutations in stress adaptation.

Intravascular lithotripsy in calcified peripheral lesions: the real-world single-center JEN-experience

Objective

Peripheral vascular disease (PVD) is a major cause of morbidity and mortality with increasing need for interventional therapies. Vascular calcification increases risk of complications and may impair the effect of antiproliferative therapy. Intravascular lithotripsy (IVL) using pulsatile sonic pressure waves to modify intimal and medial calcium is a promising approach for those patients to overcome the drawbacks of vascular calcification.

Purpose

A single-center, prospective registry of patients undergoing peripheral lithotripsy was established. Periprocedural safety events as well as short and long term follow-up clinical data were evaluated.

Methods

A prospective review of cases using IVL was performed for the period from December 2018 to January 2021 at our center. Angiographic images were quantified by using the QVA 8.0 module, Medis Suite Version 3.2.60.4 developed by Medis Imaging Systems.

Results

61 cases of IVL were performed in 51 patients with Rutherford class 3. Mean age was 71 years with 78% (28) of the patients being men. Diabetes was present in 80% and renal insufficiency in 47% of the cases. The median calcified lesion length treated was 82 mm (10; 390 mm) with a PACCS sore of 3 (1; 3), indicating a highly calcified status. In 41% (n=25), predilation was necessary. We treated 8 iliac-, 19 common femoral-, 52 superficial femoral-, 5 deep femoral-, 29 popliteal- and 2 crural- lesions with balloon sizes ranging from 4.0 to 7.0 mm. In 35 (57%) cases IVL was used as a stand-alone therapy, in the remaining 26 an adjunctive therapy (DCB and/or stent) was used. We were able to reach an acute luminal gain of 2.5 mm. A ballon rupture occurred in 6 (10%) cases. There were no other complications. Mean ABI improved from 0.6 to 0.8 (p<0.0001) immediate after the intervention. Follow-up after 6 months again demonstrated an improved ABI of 0.8 (p<0.0001 vs. baseline).

Conclusion

This first real-world data of IVL reports compelling safety of IVL in a complex, difficult-to-treat patient cohort. For the first time, clinical follow-up data were presented and demonstrated a sustained improved ABI after 6 months. This innovative approach will gain more interest in the future, especially since long term effects of paclitaxel eluting devices are controversially discussed.

Funding Acknowledgement

Type of funding sources: None. ABI initial follow-up

Genomic impact of stress-induced transposable element mobility in Arabidopsis

Transposable elements (TEs) have long been known to be major contributors to plant evolution, adaptation and crop domestication. Stress-induced TE mobilization is of particular interest because it may result in novel gene regulatory pathways responding to stresses and thereby contribute to stress adaptation. Here, we investigated the genomic impacts of stress induced TE mobilization in wild type Arabidopsis plants. We find that the heat-stress responsive ONSEN TE displays an insertion site preference that is associated with specific chromatin states, especially those rich in H2A.Z histone variant and H3K27me3 histone mark. In order to better understand how novel ONSEN insertions affect the plant's response to heat stress, we carried out an in-depth transcriptomic analysis. We find that in addition to simple gene knockouts, ONSEN can produce a plethora of gene expression changes such as: constitutive activation of gene expression, alternative splicing, acquisition of heat-responsiveness, exonisation and genesis of novel non-coding and antisense RNAs. This report shows how the mobilization of a single TE-family can lead to a rapid rise of its copy number increasing the host's genome size and contribute to a broad range of transcriptomic novelty on which natural selection can then act.

Identification of Active Transposable Elements in Plants: The Mobilome-Seq Approach

Transposable elements (TEs) are the main component of eukaryotic genomes. Besides their impact on genome size, TEs are also functionally important as they can alter gene expression and influence phenotypic variation. In plants, most top-down studies focus on extremely clear phenotypes such as the shape or the color of individuals and do not explore fully the role of TEs in evolution. Assessing the impact of TEs in a more systematic manner, however, requires identifying active TEs to further study their impact on phenotypes. In this chapter, we describe an in planta approach that consists in activating TEs by interfering with pathways involved in their silencing. It enables to directly investigate the functional impact of single TE families at low cost.

Molybdenum - A biodegradable implant material for structural applications?

Molybdenum as a potentially new biodegradable material was investigated. Degradation behavior of commercially high purity molybdenum was observed in simulated physiological salt solutions (Kokubo's SBF with/without TRIS-HCl, Cu²⁺ addition and 0.9% NaCl solution). Potentiodynamic polarization, immersion mass loss and ion concentration measurements paired with REM/EDX analysis reveal gradual dissolution of molybdenum in the proper order of magnitude for stent application, associated with formation of thin, non-passivating corrosion products. The underlying corrosion mechanism is discussed as well as a comparison to literature data. However, formation of calcium phosphates (CaP) in SBF significantly decreases corrosion rates. In-situ polarization was found to be a potential way for overcoming this problem and simultaneously enhancing corrosion above the benchmark for a degradable stent material. STATEMENT OF SIGNIFICANCE: Biodegradable metals have the potential to overcome severe complications common to orthopedic and cardio-vascular implants. However, the need for a material with moderate and predictable degradation, high strength and toughness as well as MRI suitability must be satisfied. Molybdenum as potential new biodegradable material may just fulfill these requirements. An overall positive picture of molybdenum as an interesting alternative to recently discussed metallic biodegradable materials can be concluded from the herein presented results and from literature data, showing directions for future research on the topic.

The NRPD1 N-terminus contains a Pol IV-specific motif that is critical for genome surveillance in Arabidopsis

RNA-guided surveillance systems constrain the activity of transposable elements (TEs) in host genomes. In plants, RNA polymerase IV (Pol IV) transcribes TEs into primary transcripts from which RDR2 synthesizes double-stranded RNA precursors for small interfering RNAs (siRNAs) that guide TE methylation and silencing. How the core subunits of Pol IV, homologs of RNA polymerase II subunits, diverged to support siRNA biogenesis in a TE-rich, repressive chromatin context is not well understood. Here we studied the N-terminus of Pol IV’s largest subunit, NRPD1. Arabidopsis lines harboring missense mutations in this N-terminus produce wild-type (WT) levels of NRPD1, which co-purifies with other Pol IV subunits and RDR2. Our in vitro transcription and genomic analyses reveal that the NRPD1 N-terminus is critical for robust Pol IV-dependent transcription, siRNA production and DNA methylation. However, residual RNA-directed DNA methylation observed in one mutant genotype indicates that Pol IV can operate uncoupled from the high siRNA levels typically observed in WT plants. This mutation disrupts a motif uniquely conserved in Pol IV, crippling the enzyme's ability to inhibit retrotransposon mobilization. We propose that the NRPD1 N-terminus motif evolved to regulate Pol IV function in genome surveillance.

Inhibition of RNA polymerase II allows controlled mobilisation of retrotransposons for plant breeding

Background

Retrotransposons play a central role in plant evolution and could be a powerful endogenous source of genetic and epigenetic variability for crop breeding. To ensure genome integrity several silencing mechanisms have evolved to repress retrotransposon mobility. Even though retrotransposons fully depend on transcriptional activity of the host RNA polymerase II (Pol II) for their mobility, it was so far unclear whether Pol II is directly involved in repressing their activity.

Results

Here we show that plants defective in Pol II activity lose DNA methylation at repeat sequences and produce more extrachromosomal retrotransposon DNA upon stress in Arabidopsis and rice. We demonstrate that combined inhibition of both DNA methylation and Pol II activity leads to a strong stress-dependent mobilization of the heat responsive ONSEN retrotransposon in Arabidopsis seedlings. The progenies of these treated plants contain up to 75 new ONSEN insertions in their genome which are stably inherited over three generations of selfing. Repeated application of heat stress in progeny plants containing increased numbers of ONSEN copies does not result in increased activation of this transposon compared to control lines. Progenies with additional ONSEN copies show a broad panel of environment-dependent phenotypic diversity.

Conclusions

We demonstrate that Pol II acts at the root of transposon silencing. This is important because it suggests that Pol II can regulate the speed of plant evolution by fine-tuning the amplitude of transposon mobility. Our findings show that it is now possible to study induced transposon bursts in plants and unlock their use to induce epigenetic and genetic diversity for crop breeding.

Electronic supplementary material

The online version of this article (doi:10.1186/s13059-017-1265-4) contains supplementary material, which is available to authorized users.

The effectiveness of the paclitaxel-coated Luminor® balloon catheter versus an uncoated balloon catheter in superficial femoral and popliteal arteries in preventing vessel restenosis or reocclusion: study protocol for a randomized controlled trial

BACKGROUND

The aim of this investigator-initiated trial is to evaluate the safety and efficacy of the novel Luminor® paclitaxel-coated drug-eluting balloon (DEB) catheter (iVascular, S.L.U., Barcelona, Spain) in inhibiting restenosis and in ensuring long-term vascular patency.

METHODS/DESIGN

This is a multicenter randomized controlled trial to evaluate the Luminor® paclitaxel-coated DEB catheter for stenotic or occlusive lesions (length ≤15 cm) in the superficial femoral artery (SFA) and the popliteal artery (PA) up to the P1 segment compared to the noncoated, plain old balloon angioplasty (POBA) catheter. In total 172 subjects will be treated with either the DEB catheter or the POBA catheter in 11 German study centers in a 1:1 randomization study design. The primary endpoint is late lumen loss (LLL) at 6 months. Secondary endpoints are patency rate, target lesion/vessel revascularization, quality of life (assessed with the Walking Impairment Questionnaire (WIQ) and the EQ-5D), change of Rutherford stage and ankle-brachial index, major and minor amputation rate at the index limb, number of dropouts and all-cause mortality.

DISCUSSION

EffPac represents a randomized controlled trial that will provide evidence on the effectiveness of the Luminor® paclitaxel-coated DEB catheter for the reduction of restenosis compared to the POBA catheter for the SFA and the PA. The results of EffPac will allow direct comparison to other already-completed RCTs applying paclitaxel-coated DEBs from different manufacturers with different coating technologies in the same target vessel.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02540018 , registered on 17 August 2015. Protocol version: CIP Version Final04, 11 February 2016. EUDAMED No: CIV-15-03-013204.

Chronic p38 mitogen-activated protein kinase inhibition improves vascular function and remodeling in angiotensin II-dependent hypertension

Introduction:

An excess of angiotensin II (Ang II) causes hypertension and vascular injury. Activation of mitogen-activated protein kinase p38 (p38-MAPK) plays a substantial role in Ang II-dependent organ damage. Recently, we showed that p38-MAPK activation regulates the pressor response to Ang II. This study evaluates the effect of chronic p38-MAPK inhibition in Ang II-dependent hypertension.

Materials and methods:

C57Bl/6J mice were infused with Ang II for 14 days and either treated with the p38-MAPK inhibitor BIRB796 (50 mg/kg/day) or the vehicle as the control. We assessed vascular function in the aorta and isolated perfused kidneys.

Results:

Chronic p38-MAPK inhibition did not alter blood pressure at the baseline, but attenuated Ang II-induced hypertension significantly (baseline: 122 ± 2 versus 119 ± 4 mmHg; Ang II: 173 ± 3 versus 155 ± 3 mmHg; p < 0.001). In addition, BIRB796 treatment improved vascular remodeling by reducing the aortic media-to-lumen ratio and decreasing the expression of the membrane metalloproteinases (MMP) MMP-1 and MMP-9. Moreover, renal vascular dysfunction induced by chronic Ang II infusion was significantly ameliorated in the BIRP796-treated mice. Acute p38-MAPK inhibition also improved vascular function in the aorta and kidneys of Ang II-treated mice, highlighting the important role of p38-MAPK activation in the pathogenesis of vascular dysfunction.

Conclusions:

Our findings indicated there is an important role for p38-MAPK in regulating blood pressure and vascular injury, and highlighted its potential as a pharmaceutical target.

Analysis of plant Pb tolerance at realistic submicromolar concentrations demonstrates the role of phytochelatin synthesis for Pb detoxification

Lead (Pb) ranks first among metals with respect to tonnage produced and released into the environment. It is highly toxic and therefore an important pollutant of worldwide concern. Plant Pb uptake, accumulation, and detoxification mobilize Pb into food webs. Still, knowledge about the underlying mechanisms is very limited. This is largely due to serious experimental challenges with respect to Pb availability. In most studies, Pb(II) concentrations in the millimolar range have been used even though the toxicity threshold is in the nanomolar range. We therefore developed a low-phosphate, low-pH assay system that is more realistic with respect to soil solution conditions. In this system the growth of Arabidopsis thaliana seedlings was significantly affected by the addition of only 0.1 μM Pb(NO3)2. Involvement of phytochelatins in the detoxification of Pb(II) could be demonstrated by investigating phytochelatin synthase mutants. They showed a stronger inhibition of root growth and a lack of Pb-activated phytochelatin synthesis. In contrast, other putative Pb hypersensitive mutants were unaffected under these conditions, further supporting the essential role of phytochelatins for Pb detoxification. Our findings demonstrate the need to monitor plant Pb responses at realistic concentrations under controlled conditions and provide a strategy to achieve this.

Synchronization and resynchronization of inseminations in lactating dairy cows with the CIDR insert and the Ovsynch protocol

Pregnancy per artificial insemination (AI) was evaluated in dairy cows (Bos taurus) subjected to synchronization and resynchronization for timed AI (TAI). Cows (n=718) received prostaglandin F(2alpha) (PGF) on Days -38 and -24 (Days 39 and 53 postpartum), gonadotropin-releasing hormone (GnRH) on Day -10, PGF on Day -3, and GnRH and TAI on Day 0. Between Days -10 and -3, cows received a progesterone intravaginal insert (CIDR group) or no CIDR (Control group). Between Days 14 and 23, cows received a CIDR (Resynch CIDR group) or no CIDR (Resynch control group), GnRH on Day 23, with pregnancy diagnosis on Day 30. Cows in estrus (between Days 0 and 30) were re-inseminated at detected estrus (RIDE). Nonpregnant cows received PGF on Day 30 and GnRH and TAI on Day 33. Plasma progesterone was determined to be low or high on Days -24 and -10. Pregnancy rates were evaluated 30 and 55 d after AI. The CIDR insert included in the Presynch-Ovsynch protocol did not increase overall pregnancy per AI for first service (36.1% and 33.6% for CIDR; 34.1% and 28.8% for Control) but did decrease pregnancy loss (7.0% for CIDR and 15.6% for Control). The CIDR insert increased pregnancy per AI in cows with high progesterone at the time the CIDR insert was applied. Administration of a CIDR insert between Days 14 and 23 of the estrous cycle after first service did not increase overall pregnancy per AI to second service (24.7% and 22.7% for Resynch CIDR; 28.6% and 25.3% for Resynch control). For second service, RIDE cows had lower pregnancy rates in the Resynch CIDR group than in the Resynch control group. Cows with a CL (corpus luteum) at Day 30 had higher pregnancy rates in the Resynch CIDR group than those in the Resynch control group.

[Urinary ascites and perirenal urinoma - a renoprotective "Complication" of posterior urethral valves]

We report on a male newborn with urinary ascites and perirenal urinoma due to calyceal rupture caused by bladder outlet obstruction and posterior urethral valves. Despite the presence of left-sided high-grade reflux, the "pop-off" mechanism occurred in the non-refluxing right kidney. Impressive normalization of the upper urinary tract anomalies and renal function occurred after surgical treatment of the valves and removal of obstruction.

Interaction between dextran and human low density lipoproteins (LDL) observed using laser light scattering

Dextran infusions in humans lead to a reduction of low density lipoproteins (LDL) in the plasma compartment. The interaction of dextran with human LDL was investigated in vitro by static and dynamic light scattering. The experiments were performed with human LDL (apoB concentration 0.75 g l(-1)) and dextran (Mw = 40,000 and 70,000 g mol(-1)) at 25 degrees C. The dextran concentrations after mixing were 10 and 50 g l(-1). The hydrodynamic radius for native LDL was found to be RH = 12.9 nm. The addition of dextran induces the formation of LDL associates with a mean radius of RH approximately 200 nm. These findings show that even non-sulphated polysaccharides interact with LDL. The dextran-dependent formation of LDL associates detected in vitro could be the reason for the in vivo effect of dextran on the lipid metabolism.

Titanium powder sintering for preparation of a porous functionally graded material destined for orthopaedic implants

This work focuses on basic research into a P/M processed, porous-surfaced and functionally graded material (FGM) destined for a permanent skeletal replacement implant with improved structural compatibility. Based on a perpendicular gradient in porosity the Young's modulus of the material is adapted to the elastic properties of bone in order to prevent stress shielding effects and to provide better long-term performance of the implant-bone system. Using coarse Ti particle fractions the sintering process was accelerated by silicon-assisted liquid-phase sintering (LPS) resulting in a substantial improvement of the neck geometry. A novel evaluation for the strength of the sinter contacts was proposed. The Young's modulus of uniform non-graded stacks ranged from 5 to 80 GPa as determined by ultrasound velocity measurements. Thus, the typical range for cortical bone (10-29 GPa) was covered. The magnitude of the Poisson's ratio proved to be distinctly dependent on the porosity. Specimens with porosity gradients were successfully fabricated and characterized using quantitative description of the microstructural geometry and acoustic microscopy.

European whole body counter measurement intercomparison

In order to test the common quality standards for the performance of measurements of internal radioactivity, the European Commission funded a European intercomparison of whole body counters, which was organized and carried out by the Institut fuer Strahlenhygiene (part of the German Bundesamt fuer Strahlenschutz). Forty-four whole body counting facilities from forty-two institutions in nineteen countries (the fifteen member states of the European Union plus Hungary, the Czech Republic, Switzerland and Norway) took part in this intercomparison, which made it the most comprehensive ever carried out in Europe. For the study, the 70 kg tissue equivalent St Petersburg phantom was used with rods containing 40K, 57Co, 60Co, and 137Cs. The overall results of the whole body counter study were rather good.

Alterations in function and phenotype of monocytes from patients with septic disease--predictive value and new therapeutic strategies

Recently we described the predictive value of the proportion of HLA-DR+ peripheral blood monocytes for the clinical outcome of septic disease in immunosuppressed patients (allograft recipients) and surgical patients mostly with peritonitis as septic focus (following perforation of gastrointestinal tract). The experiments described here show that the loss of HLA-class II antigen expression and other phenotypical abnormalities of monocytes from septic patients with fatal outcome are associated with functional defects (antigen presentation, formation of reactive oxygen species, cytokine secretion). The picture of phenotypical and functional defects of monocytes was termed "immunoparalysis" (leading parameter: loss of HLA-DR antigen expression less than 20%). Interferon-gamma as well as GM-CSF normalized in vitro the surface antigen expression on monocytes derived from septic patients with "immunoparalysis". However, sera from patients with "immunoparalysis" prevented the cytokine-mediated effects on HLA-DR antigen expression. The inhibitory activity in septic sera was not dialysable. In order to remove such factors we started a plasmapheresis study in septic patients selected for "immunoparalysis". The preliminary data of this clinical trial suggest an improved survival rate.