Evaluation of bone healing in femurs lengthened via the gradual distraction method

BACKGROUND: Treatment of leg length inequality via lengthening of the shorter extremity is an infrequent orthopedic procedure due to the requirement of special distraction devices and possible serious complications. Essential qualitative changes in operative technique development are associated with the name of G. A. Ilizarov, who paved the way for the autoregenerate gradual distraction method in the 1950s. MATERIAL AND METHODS: In the years 1990 through 2006 a total of 57 patients underwent femur lengthening via gradual distraction using various types of external fixators at the Department of Pediatric Surgery, Orthopedics, and Traumatology, Faculty Hospital in Brno. The quality of bone healing was monitored and a number of parameters followed and statistically evaluated using regularly scheduled X-ray examinations. RESULTS: In 11 cases we had to remove the external fixator following the distraction phase, perform an osteosynthesis via a splint and fill the distraction gap via spongioplasty. The bone healing was satisfactory in the remaining 46 patients and the lengthened bone required no other fixation method. The analysis showed statistically significant deceleration in bone healing following distraction in female patients over 12 years of age, and in boys over 14 years of age. Lack of periosteal callus five weeks after surgery always signified serious problems in further healing. Severe complications were recorded in 11 cases during the distraction phase, and in 9 cases after the removal of the distraction apparatus. CONCLUSIONS: The aim of this report was to present the results of our study of distraction gap bone healing using the gradual lengthening approach.     

Intra-arterial chemotherapy and its significance in the treatment of oropharyngeal carcinoma

BACKGROUND: In complex therapeutic algorithms for cancer, regional intra-arterial chemotherapy is usually used as an adjuvant and placed in the beginning of treatment. Clinical experience however shows that the achieved remission of malignant tumour illness after non-adjuvant chemotherapy is only temporary and short-lived. The illness progresses relatively quickly if the patient receives no further treatment and most clinical studies have not found any significant increase in life expectancy in oncological patients treated with this method. The question remains to what extent the poor results are due to the treatment method and its position in the therapeutic algorithm, and to what extent they are due to imperfect knowledge of molecular tumour genetics or inappropriate choice of the neoadjuvant intra-arterial chemotherapy METHODS: We compared preliminary results of immunohistochemical examinations (detection and analysis of expression of proteins Ku 70, STAT 1,3,5 which take part in the regulation of cell cycle apoptosis and repair of damaged DNA, carried out before and after chemotherapy, suggest that depending on the effects of neoadjuvant intra-arterial chemotherapy and patient's survivance. RESULTS AND CONCLUSION: An overview of intra-arterial neoadjuvant chemotherapy of head and neck is presented. Knowledge of cell cycle processes, especially apoptosis and repair of damaged DNA, could significantly influence the choice of the therapeutic algorithm and therapeutical effect.     

Early onset pauciarticular arthritis is the major risk factor for naproxen-induced pseudoporphyria in juvenile idiopathic arthritis

Pseudoporphyria (PP) is characterized by skin fragility, blistering and scarring in sun-exposed skin areas without abnormalities in porphyrin metabolism. The phenylpropionic acid derivative group of nonsteroidal anti-inflammatory drugs, especially naproxen, is known to cause PP. Naproxen is currently one of the most prescribed drugs in the therapy of juvenile idiopathic arthritis (JIA). The prevalence of PP was determined in a 9-year retrospective study of children with JIA and associated diseases. In addition, we prospectively studied the incidence of PP in 196 patients (127 girls and 69 boys) with JIA and associated diseases treated with naproxen from July 2001 to March 2002. We compared these data with those from a matched control group with JIA and associated diseases not treated with naproxen in order to identify risk factors for development of PP. The incidence of PP in the group of children taking naproxen was 11.4%. PP was particularly frequent in children with the early-onset pauciarticular subtype of JIA (mean age 4.5 years). PP was associated with signs of disease activity, such as reduced haemoglobin (<11.75 g/dl), and increased leucocyte counts (>10,400/μl) and erythocyte sedimentation rate (>26 mm/hour). Comedications, especially chloroquine intake, appeared to be additional risk factors. The mean duration of naproxen therapy before the onset of PP was 18.1 months, and most children with PP developed their lesions within the first 2 years of naproxen treatment. JIA disease activity seems to be a confounding factor for PP. In particular, patients with early-onset pauciarticular JIA patients who have significant inflammation appear to be prone to developing PP upon treatment with naproxen.     

Fluoroanalogues of anti-cytomegalovirus agent cyclopropavir: synthesis and antiviral activity of (E)- and (Z)-9-{[2,2-bis(hydroxymethyl)-3-fluorocyclopropylidene]methyl}-adenines and guanines

Synthesis of fluorinated cyclopropavir analogues 13a, 13b, 14a, and 14b is described starting from alkene 15. Addition of carbene derived from dibromofluoromethane gave bromofluoro cyclopropane 16. Reduction (compound 17) followed by desilylation gave intermediate 18, which was transformed to 2-nitrophenylselenenyl derivative 19. Oxidation to selenoxide 20 was followed by beta-elimination to afford methylenecyclopropane 21. Addition of bromine provided compound 22 for alkylation-elimination of adenine and 2-amino-6-chloropurine. The resultant E,Z isomeric mixtures of methylenecyclopropanes 23a + 24a and 23c + 24c were resolved and the individual isomers were deprotected to give adenine analogues 13a and 14a as well as compounds 13c and 14c. Hydrolytic dechlorination of 13c and 14c furnished guanine analogues 13b and 14b. The only significant antiviral effects were observed with analogue 13a against HCMV and 14a against VZV in cytopathic inhibition assays.     

Overaccumulation of γ-Glutamylcysteine in a Jasmonate-Hypersensitive Arabidopsis Mutant Causes Jasmonate-Dependent Growth Inhibition

Glutathione (GSH) is essential for many aspects of plant biology and is associated with jasmonate signaling in stress responses. We characterized an Arabidopsis (Arabidopsis thaliana) jasmonate-hypersensitive mutant (jah2) with seedling root growth 100-fold more sensitive to inhibition by the hormone jasmonyl-isoleucine than the wild type. Genetic mapping and genome sequencing determined that the mutation is in intron 6 of GLUTATHIONE SYNTHETASE2, encoding the enzyme that converts γ-glutamylcysteine (γ-EC) to GSH. The level of GSH in jah2 was 71% of the wild type, while the phytoalexin-deficient2-1 (pad2-1) mutant, defective in GSH1 and having only 27% of wild-type GSH level, was not jasmonate hypersensitive. Growth defects for jah2, but not pad2, were also seen in plants grown to maturity. Surprisingly, all phenotypes in the jah2 pad2-1 double mutant were weaker than in jah2. Quantification of γ-EC indicated these defects result from hyperaccumulation of this GSH precursor by 294- and 65-fold in jah2 and the double mutant, respectively. γ-EC reportedly partially substitutes for loss of GSH, but growth inhibition seen here was likely not due to an excess of total glutathione plus γ-EC because their sum in jah2 pad2-1 was only 16% greater than in the wild type. Further, the jah2 phenotypes were lost in a jasmonic acid biosynthesis mutant background, indicating the effect of γ-EC is mediated through jasmonate signaling and not as a direct result of perturbed redox status.Glutathione (GSH) is an essential thiol of most higher organisms, including plants. Primarily found in the reduced form, its roles in maintaining a reduced intracellular state are numerous and well characterized (Foyer and Noctor, 2011; Noctor et al., 2011). Additionally, GSH is involved in detoxifying reactive oxygen species, heavy metal detoxification through phytochelatins, elimination of xenobiotics, and signaling of plant development and stress responses (Rouhier et al., 2008).GSH is synthesized in two steps. The first links Cys to the γ-carboxyl group of Glu through an amide bond catalyzed by γ-glutamylcysteine (γ-EC) synthetase, encoded by the single gene GSH1 in Arabidopsis (Arabidopsis thaliana). Gly is then added by GSH synthetase (GSH-S), also encoded by a single gene (GSH2). GSH is typically present at millimolar levels in plants, and although γ-EC is normally present at only a few percent of this amount, there is evidence that γ-EC has redox activities in Arabidopsis (Pasternak et al., 2008).Insertional knockouts of GSH1 are embryo lethal, and rootmeristemless1, with only 5% of wild-type GSH level, lacks a root apical meristem due to cell cycle arrest (Vernoux et al., 2000; Cairns et al., 2006). Other mutants producing 25% to 50% of wild-type GSH levels grow normally but exhibit defects under various stress conditions. For example, phytoalexin-deficient2-1 (pad2-1) and cadmium sensitive2 mutants are susceptible to pathogens and hypersensitive to Cd, respectively, while regulator of axillary meristems1 causes elevated expression of ASCORBATE PEROXIDASE2 under non-photooxidative-stress conditions (Glazebrook and Ausubel, 1994; Cobbett et al., 1998; Ball et al., 2004).GSH2 null alleles (gsh2-1 and gsh2-2) are also lethal, although plants survive to the early seedling stage (Pasternak et al., 2008). Survival past the embryo stage was attributed to partial complementation of GSH activity by γ-EC, which accumulates to excessive levels in gsh2-1, and the mutant is partially rescued by GSH supplementation. Missense and nonsense GSH2 alleles of membrane trafficking mutants (gsh2-3–gsh2-5) disrupt endoplasmic reticulum (ER) organization and also arrest growth in early seedling development, while a weaker allele (gsh2-6) reached maturity but was smaller than the wild type (Au et al., 2012). A screen for reduced response to Cd also yielded a viable missense mutant of GSH2 (nonresponse or reduced response to Cd2) with approximately 75% of the wild-type GSH level (Jobe et al., 2012).Plant oxidative stress responses involve both redox signaling through GSH and jasmonate hormonal signaling, and gene expression studies have clearly linked these two signaling systems. GSH biosynthesis and metabolism genes are induced by jasmonate, while manipulating GSH level or redox status in various mutants alters expression of genes for jasmonate biosynthesis and signaling (Xiang and Oliver, 1998; Mhamdi et al., 2010; Han et al., 2013). GSH and jasmonate are also associated with protective glucosinolate production in response to insect feeding (Noctor et al., 2011). For example, pad2-1 is deficient in glucosinolates and more susceptible to insects, while several studies have shown jasmonate induces glucosinolates (Brader et al., 2001; Mikkelsen et al., 2003; Sasaki-Sekimoto et al., 2005; Schlaeppi et al., 2008). Liu et al. (2010) isolated jasmonic acid hypersensitive1 (jah1), an Arabidopsis mutant with greater inhibition of root growth than the wild type in the presence of jasmonic acid (JA). The affected gene encodes a cytochrome P450 (CYP82C3) involved in indole glucosinolate production, and this mutant was more susceptible to Botrytis cinerea.The basic mechanism of jasmonate signal transduction and some of the downstream responses emanating from it are now well understood (Browse, 2009; Wasternack and Hause, 2013). However, the mechanisms by which jasmonate and GSH coordinate their activities to mediate oxidative stress and other responses are not known. This study characterized, to our knowledge, a new jasmonate-hypersensitive mutant that accumulates excess γ-EC due to a defect in GSH2, but GSH is only modestly reduced. Results show that elevated γ-EC is deleterious to plant growth through a jasmonate-dependent mechanism.     

Ectopic expression of RNF168 and 53BP1 increases mutagenic but not physiological non-homologous end joining

DNA double strand breaks (DSBs) formed during S phase are preferentially repaired by homologous recombination (HR), whereas G₁ DSBs, such as those occurring during immunoglobulin class switch recombination (CSR), are repaired by non-homologous end joining (NHEJ). The DNA damage response proteins 53BP1 and BRCA1 regulate the balance between NHEJ and HR. 53BP1 promotes CSR in part by mediating synapsis of distal DNA ends, and in addition, inhibits 5’ end resection. BRCA1 antagonizes 53BP1 dependent DNA end-blocking activity during S phase, which would otherwise promote mutagenic NHEJ and genome instability. Recently, it was shown that supra-physiological levels of the E3 ubiquitin ligase RNF168 results in the hyper-accumulation of 53BP1/BRCA1 which accelerates DSB repair. Here, we ask whether increased expression of RNF168 or 53BP1 impacts physiological versus mutagenic NHEJ. We find that the anti-resection activities of 53BP1 are rate-limiting for mutagenic NHEJ but not for physiological CSR. As heterogeneity in the expression of RNF168 and 53BP1 is found in human tumors, our results suggest that deregulation of the RNF168/53BP1 pathway could alter the chemosensitivity of BRCA1 deficient tumors.     

Certolizumab pegol plus methotrexate 5-year results from the rheumatoid arthritis prevention of structural damage (RAPID) 2 randomized controlled trial and long-term extension in rheumatoid arthritis patients

IntroductionAs patients with rheumatoid arthritis (RA) receive treatment with anti-tumour necrosis factors over several years, it is important to evaluate their long-term safety and efficacy. The objective of this study was to examine the safety and benefits of certolizumab pegol (CZP)+methotrexate (MTX) treatment for almost 5 years in patients with RA.MethodsPatients who completed the 24-week Rheumatoid Arthritis Prevention of Structural Damage (RAPID) 2 randomized controlled trial (RCT; {"type":"clinical-trial","attrs":{"text":"NCT00160602","term_id":"NCT00160602"}}NCT00160602), or who were American College of Rheumatology (ACR) 20 non-responders at Week 16, entered the open-label extension (OLE; {"type":"clinical-trial","attrs":{"text":"NCT00160641","term_id":"NCT00160641"}}NCT00160641). After ≥6 months treatment with CZP 400 mg every two weeks (Q2W), dose was reduced to 200 mg Q2W, the approved maintenance dose. Safety data are presented from all patients who received ≥1 dose CZP (Safety population, n=612). Efficacy data are presented to Week 232 for the intent-to-treat (ITT, n=492) and Week 24 CZP RCT Completer (n=342) populations, and through 192 weeks of dose-reduction for the Dose-reduction population (patients whose CZP dose was reduced to 200 mg, n=369). Radiographic progression (modified total Sharp score change from RCT baseline >0.5) to Week 128 is reported for the Week 24 CZP Completers.ResultsIn the RCT, 619 patients were randomized to CZP+MTX (n=492) or placebo+MTX (n=127). Overall, 567 patients (91.6%) entered the OLE: 447 CZP and 120 placebo patients. Of all randomized patients, 358 (57.8%) were ongoing at Week 232. Annual drop-out rates during the first four years ranged from 8.4–15.0%. Event rates per 100 patient-years were 163.0 for adverse events (AEs) and 15.7 for serious AEs. Nineteen patients (3.1%) had fatal AEs (incidence rate=0.8). Clinical improvements in the RCT were maintained to Week 232 in the CZP Completers: mean Disease Activity Score 28 (Erythrocyte Sedimentation Rate) change from baseline was −3.4 and ACR20/50/70 responses 68.4%/47.1%/25.1% (non-responder imputation). Similar improvements observed in the ITT were maintained following dose-reduction. 73.2% of CZP Completers had no radiographic progression at Week 128.ConclusionsIn patients with active RA despite MTX therapy, CZP was well tolerated, with no new safety signals identified. CZP provided sustained improvements in clinical outcomes for almost 5 years.

Trial registration

ClinicalTrials.gov, {"type":"clinical-trial","attrs":{"text":"NCT00160602","term_id":"NCT00160602"}}NCT00160602 and {"type":"clinical-trial","attrs":{"text":"NCT00160641","term_id":"NCT00160641"}}NCT00160641. Registered 8 September 2005.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0767-2) contains supplementary material, which is available to authorized users.     

Serum calprotectin (S100A8/9): an independent predictor of ultrasound synovitis in patients with rheumatoid arthritis

IntroductionCalprotectin, a heterodimeric complex of S100A8/9 (MRP8/14), has been proposed as an important serum biomarker that reflects disease activity and structural joint damage in rheumatoid arthritis (RA). The objective of this cross-sectional study was to test the hypothesis that calprotectin is associated with clinical and ultrasound-determined disease activity in patients with RA.MethodsA total of 37 patients with RA (including 24 females, a mean disease duration of 20 months) underwent a clinical examination and 7-joint ultrasound score (German US-7) of the clinically dominant hand and foot to assess synovitis by grey-scale (GS) and synovial vascularity by power Doppler (PD) ultrasound using semiquantitative 0–3 grading. The levels of serum calprotectin and C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were determined at the time of the ultrasound assessment. We analysed the relationship between serum calprotectin level, traditional inflammatory markers, and ultrasound-determined synovitis.ResultsThe levels of serum calprotectin were significantly correlated with swollen joint count (r = 0.465, p < 0.005), DAS28-ESR (r = 0.430, p < 0.01), ESR (r = 0.370, p < 0.05) and, in particular, CRP (r = 0.629, p < 0.001). Calprotectin was significantly associated with GS (r = 0.359, p < 0.05) and PD synovitis scores (r = 0.497, p < 0.005). Using multivariate regression analysis, calprotectin, adjusted for age and sex, was a better predictor of PD synovitis score (R² = 0.765, p < 0.001) than CRP (R² = 0.496, p < 0.001).ConclusionsThe serum levels of calprotectin are significantly associated with clinical, laboratory and ultrasound assessments of RA disease activity. These results suggest that calprotectin might be superior to CRP for monitoring ultrasound-determined synovial inflammation in RA patients.