Patterns of injury and treatment for distal radius fractures at a major trauma centre.

AIMS: Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population. METHODS: We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission. RESULTS: Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180). CONCLUSION: The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were treated nonoperatively, locked anterior-plate fixation remains the predominant method of fixation for fractures of the distal radius; this is despite questions and continued debate about the best method of surgical fixation for these injuries.Cite this article: Bone Jt Open 2022;3(8):623-627.

Brunner's Gland Hamartomas: Two Cases of This (Sometimes) Distinctive Lesion.

Brunner's gland hamartomas (BGHs) are rare, benign, primary duodenal tumors. The clinical presentations can vary, and confirming a diagnosis can be challenging because of the submucosal nature of the lesions. We report two cases of BGHs with different clinical presentations. The diagnoses were not determined initially, despite utilizing endoscopy, mucosal biopsies, endoscopic ultrasound, and, in one case, fine-needle aspiration. Confirmation of BGHs was subsequently made following endoscopic or surgical resection.

Computed tomographic coronary angiography in risk stratification prior to non-cardiac surgery: a systematic review and meta-analysis.

OBJECTIVES: Utility of CT coronary angiography (CTA) and coronary artery calcium (CAC) scoring in risk stratification prior to non-cardiac surgery is unclear. Although current guidelines recommend stress testing in intermediate-high risk individuals, over one-third of perioperative major adverse cardiovascular events (MACE) occur in patients with a negative study. This systematic review and meta-analysis evaluates the value of CTA and CAC score in preoperative risk prognostication prior to non-cardiac surgery. METHODS: MEDLINE, PubMed and EMBASE databases were searched for articles published up to June 2018. Summary ORs for degree of coronary artery disease (CAD) and perioperative MACE were pooled using a random-effects model. RESULTS: Eleven studies were included. Two hundred and fifty-two (7.2%) MACE occurred in 3480 patients. Risk of perioperative MACE rose with the severity and extent of CAD on CTA (no CAD 2.0%; non-obstructive 4.1%; obstructive single-vessel 7.1%; obstructive multivessel 23.1%, p<0.001). Multivessel disease (MVD) demonstrated the greatest risk (OR 8.9, 95% CI 5.1 to 15.3, p<0.001). Increasing CAC score was associated with higher perioperative MACE (CAC score: ≥100 OR 5.1, ≥1000 OR 10.4, both p<0.01). In a cohort deemed high risk by established clinical indices, absence of MVD on CTA demonstrated a negative predictive value of 96% (95% CI 92.8 to 98.4) for predicting freedom from MACE. CONCLUSIONS: Severity and extent of CAD on CTA conferred incremental risk for perioperative MACE in patients undergoing non-cardiac surgery. The 'rule-out' capability of CTA is comparable to other non-invasive imaging modalities and offers a viable alternative for risk stratification of patients undergoing non-cardiac surgery. TRIAL REGISTRATION NUMBER: CRD42018100883.

Screw-type device diameter and orthodontic loading influence adjacent bone remodeling.

OBJECTIVE: To evaluate the effect of diameter and orthodontic loading of a screw-type implantable device on bone remodeling. MATERIALS AND METHODS: Screw-shaped devices of four distinct diameters, 1.6, 2, 3, and 3.75 mm, were placed into edentulous sites in five skeletally mature beagle dogs (n = 14/dog) following premolar extraction. Using a split-mouth design, devices on one side were loaded using calibrated 2N coil springs. Epifluorescent bone labels were administered intravenous prior to sacrifice. Bone-implant sections (∼ 70 µm) were evaluated to quantify bone formation rate (BFR), and other histomorphometric variables were assessed in the implant supporting bone. RESULTS: The mean BFR ranged from 10.93 percent per year to 38.91 percent per year. BFR in the bone adjacent to the device was lower for the loaded 1.6-mm screws when compared with the nonloaded 1.6-mm screws (P < .01) and the loaded 2.0-, 3.0-, and 3.75-mm diameter screws (P < .01). No significant differences in BFR were noted, regardless of loading condition, between the 2.0-, 3.0-, and 3.75-mm diameter screws. CONCLUSIONS: We detected a dramatic reduction in bone remodeling. Although orthodontic loading of 2N did not alter bone remodeling associated with screws with a 2.0-mm diameter or larger, it did decrease bone remodeling adjacent to a loaded 1.6-mm screw. The long-term effect of this diminished remodeling should be further investigated.

Insect GDNF:TTC fusion protein improves delivery of GDNF to mouse CNS.

With a view toward improving delivery of exogenous glial cell line-derived neurotrophic factor (GDNF) to CNS motor neurons in vivo, we evaluated the bioavailability and pharmacological activity of a recombinant GDNF:tetanus toxin C-fragment fusion protein in mouse CNS. Following intramuscular injection, GDNF:TTC but not recombinant GDNF (rGDNF) produced strong GDNF immunostaining within ventral horn cells of the spinal cord. Intrathecal infusion of GDNF:TTC resulted in tissue concentrations of GDNF in lumbar spinal cord that were at least 150-fold higher than those in mice treated with rGDNF. While levels of immunoreactive choline acetyltransferase and GFRalpha-1 in lumbar cord were not altered significantly by intrathecal infusion of rGNDF, GDNF:TTC, or TTC, only rGDNF and GDNF:TTC caused significant weight loss following intracerebroventricular infusion. These studies indicate that insect cell-derived GDNF:TTC retains its bi-functional activity in mammalian CNS in vivo and improves delivery of GDNF to spinal cord following intramuscular- or intrathecal administration.

IGF-1:tetanus toxin fragment C fusion protein improves delivery of IGF-1 to spinal cord but fails to prolong survival of ALS mice.

To improve delivery of human insulin-like growth factor-1 (hIGF-1) to brain and spinal cord, we generated a soluble IGF-1:tetanus toxin fragment C fusion protein (IGF-1:TTC) as a secreted product from insect cells. IGF-1:TTC exhibited IGF-1 and TTC activity in vitro; it increased levels of immunoreactive phosphoAkt in treated MCF-7 cells and bound to immobilized ganglioside GT1b. In mice, the fusion protein underwent retrograde transport by spinal cord motor neurons following intramuscular injection, and exhibited both TTC- and IGF-1 activity in the CNS following intrathecal infusion. Analogous to the case with TTC, intrathecal infusion of the fusion protein resulted in substantial levels of IGF-1:TTC in spinal cord tissue extracts. Tissue concentrations of hIGF-1 in lumbar spinal cords of mice infused with IGF-1:TTC were estimated to be approximately 500-fold higher than those in mice treated with unmodified recombinant hIGF-1 (rhIGF-1). Like rhIGF-1, infusion of IGF-1:TTC reduced levels of IGF-1 receptor immunoreactivity in the same extracts. Despite raising levels of exogenous hIGF-1 in spinal cord, intramuscular- or intrathecal administration of IGF-1:TTC had no significant effect on disease progression or survival of high-expressing SOD1(G93A) transgenic mice. IGF-1:TTC may prove to be neuroprotective in other animal models of CNS disease or injury known to be responsive to unmodified IGF-1.

Recombinant GDNF: tetanus toxin fragment C fusion protein produced from insect cells.

Glial cell line-derived neurotrophic factor (GDNF) has potent survival-promoting effects on CNS motor neurons in experimental animals. Its therapeutic efficacy in humans, however, may have been limited by poor bioavailability to the brain and spinal cord. With a view toward improving delivery of GDNF to CNS motor neurons in vivo, we generated a recombinant fusion protein comprised of rat GDNF linked to the non-toxic, neuron-binding fragment of tetanus toxin. Recombinant GDNF:TTC produced from insect cells was a soluble homodimer like wild-type GDNF and was bi-functional with respect to GDNF and TTC activity. Like recombinant rat GDNF, the fusion protein increased levels of immunoreactive phosphoAkt in treated NB41A3-hGFRalpha-1 neuroblastoma cells. Like TTC, GDNF:TTC bound to immobilized ganglioside GT1b in vitro with high affinity and selectivity. These results support further testing of recombinant GDNF:TTC as a non-viral vector to improve delivery of GDNF to brain and spinal cord in vivo.

VEGF increases blood-brain barrier permeability to Evans blue dye and tetanus toxin fragment C but not adeno-associated virus in ALS mice.

Entry of most compounds into the CNS is impeded by the blood-brain barrier (BBB). Because vascular endothelial growth factor (VEGF) is important in the formation and maintenance of the BBB and is known to modulate BBB permeability in newborn rodents, we tested the hypothesis that VEGF may enhance BBB permeability in adult mice. We examined the effect of VEGF on the CNS distribution of three different agents: a small molecule (Evans blue dye) that is known to bind plasma proteins, an exogenous protein (tetanus toxin fragment C; TTC), and a viral vector (recombinant adeno-associated virus serotype 2/5 marked with lacZ; rAAV2/5-lacZ). Pretreatment with VEGF (20 mug; i.v.) increased permeability of the BBB to Evans blue dye and TTC as detected by augmented concentrations of these substances in the cerebrum, brainstem, and spinal cord. By contrast, VEGF did not alter BBB permeability to AAV2/5-lacZ, as defined by beta-galactosidase activity assay. These data demonstrate the potential utility of VEGF for pharmacological modulation of the BBB, and indicate that the increase in BBB permeability mediated by VEGF is limited by the size of the delivered substance.

A glial cell line-derived neurotrophic factor (GDNF):tetanus toxin fragment C protein conjugate improves delivery of GDNF to spinal cord motor neurons in mice.

Glial cell line-derived neurotrophic factor (GDNF) has shown robust neuroprotective and neuroreparative activities in various animal models of Parkinson's Disease or amyotrophic lateral sclerosis (ALS). The successful use of GDNF as a therapeutic in humans, however, appears to have been hindered by its poor bioavailability to target neurons in the central nervous system (CNS). To improve delivery of exogenous GDNF protein to CNS motor neurons, we employed chemical conjugation techniques to link recombinant human GDNF to the neuronal binding fragment of tetanus toxin (tetanus toxin fragment C, or TTC). The predominant species present in the purified conjugate sample, GDNF:TTC, had a molecular weight of approximately 80 kDa as determined by non-reducing SDS-PAGE. Like GDNF, addition of GDNF:TTC to culture media of neuroblastoma cells expressing GFRalpha-1/c-RET produced a dose-dependent increase in cellular phospho-c-RET levels. Treatment of cultured midbrain dopaminergic neurons with either GDNF or the conjugate similarly promoted both DA neuron survival and neurite outgrowth. However, in contrast to mice treated with GDNF by intramuscular injection, mice receiving GDNF:TTC revealed intense GDNF immunostaining associated with spinal cord motor neurons in fixed tissue sections. That GDNF:TTC provided neuroprotection of axotomized motor neurons in neonatal rats further revealed that the conjugate retained its GDNF activity in vivo. These results indicate that TTC can serve as a non-viral vehicle to substantially improve the delivery of functionally active growth factors to motor neurons in the mammalian CNS.

Tetanus toxin fragment C fusion facilitates protein delivery to CNS neurons from cerebrospinal fluid in mice.

To improve protein delivery to the CNS following intracerebroventricular administration, we compared the distribution of a human Cu/Zn superoxide dismutase:tetanus toxin fragment C fusion protein (SOD1:TTC) in mouse brain and spinal cord with that of tetanus toxin fragment C (TTC) or human SOD1 (hSOD1) alone, following continuous infusion into the lateral ventricle. Mice infused with TTC or SOD1:TTC showed intense anti-TTC or anti-hSOD1 labeling, respectively, throughout the CNS. In contrast, animals treated with hSOD1 revealed moderate staining in periventricular tissues. In spinal cord sections from animals infused with SOD1:TTC, the fusion protein was found in neuron nuclear antigen-positive (NeuN+) neurons and not glial fibrillary acidic protein-positive (GFAP+) astrocytes. The percentage of NeuN+ ventral horn cells that were co-labeled with hSOD1 antibody was greater in mice treated with SOD1:TTC (cervical cord = 73 +/- 8.5%; lumbar cord = 62 +/- 7.7%) than in mice treated with hSOD1 alone (cervical cord = 15 +/- 3.9%; lumbar cord = 27 +/-4.7%). Enzyme-linked immunosorbent assay for hSOD1 further demonstrated that SOD1:TTC-infused mice had higher levels of immunoreactive hSOD1 in CNS tissue extracts than hSOD1-infused mice. Following 24 h of drug washout, tissue extracts from SOD1:TTC-treated mice still contained substantial amounts of hSOD1, while extracts from hSOD1-treated mice lacked detectable hSOD1. Immunoprecipitation of SOD1:TTC from these extracts using anti-TTC antibody revealed that the recovered fusion protein was structurally intact and enzymatically active. These results indicate that TTC may serve as a useful prototype for development as a non-viral vehicle for improving delivery of therapeutic proteins to the CNS.

A survival motor neuron:tetanus toxin fragment C fusion protein for the targeted delivery of SMN protein to neurons.

Spinal muscular atrophy (SMA) is a degenerative disorder of spinal motor neurons caused by homozygous mutations in the survival motor neuron (SMN1) gene. Because increased tissue levels of human SMN protein (hSMN) in transgenic mice reduce the motor neuron loss caused by murine SMN knockout, we engineered a recombinant SMN fusion protein to deliver exogenous hSMN to the cytosolic compartment of motor neurons. The fusion protein, SDT, is comprised of hSMN linked to the catalytic and transmembrane domains of diphtheria toxin (DTx) followed by fragment C of tetanus toxin (TTC). Following overexpression in Escherichia coli, SDT possessed a subunit molecular weight of approximately 130 kDa as revealed by both SDS-PAGE and immunoblot analyses with anti-SMN, anti-DTx, and anti-TTC antibodies. Like wild-type SMN, purified SDT showed specific binding in vitro to an RG peptide derived from Ewing's sarcoma protein. The fusion protein also bound to cultured primary neurons in amounts similar to those achieved by TTC. Unlike the case with TTC, however, immunolabeling of SDT-treated neurons with anti-TTC and anti-SMN antibodies showed staining restricted to the cell surface. Results from cytotoxicity studies in which the DTx catalytic domain of SDT was used as a reporter protein for internalization and membrane translocation activity suggest that the SMN moiety of the fusion protein is interfering with one or both of these processes. While these studies indicate that SDT may not be useful for SMA therapy, the use of the TTC:DTx fusion construct to deliver other passenger proteins to the neuronal cytosol should not be ruled out.

The Ewing's sarcoma protein interacts with the Tudor domain of the survival motor neuron protein.

The survival motor neuron (SMN) gene is the spinal muscular atrophy (SMA) determining gene. Here we report that the SMN protein product interacts in vitro and in vivo with the arginine/glycine (RG)-rich RNA binding protein and transcription factor, Ewing's sarcoma (EWS). Recently, the SMN encoded Tudor domain (exon 3) and the YG-motifs (exon 6) have been shown to be involved in binding to RG-rich proteins. Here, we demonstrate that the Tudor domain encoded by SMN exon 3 is independently sufficient to mediate the interaction with EWS. Synthetic mutations within the Tudor domain, as well as a SMA patient-derived mutation within exon 3, reduced the levels of the SMN/EWS interaction. Carboxyl-terminal SMN mutations that prevent formation of SMN oligomers also indirectly reduced EWS binding. A role for arginine methylation has been observed in some RG-containing SMN-interacting proteins. Here we demonstrate that SMN interacts with non-methylated EWS and an EWS-derived RG-containing peptide. In contrast to previously reported results, symmetrical dimethylation of the EWS-derived RG-peptide results in a quantitative increase in the dissociation rate between SMN and the symmetrical dimethylated EWS RG-peptide. Consistent with the interaction data, endogenous and transiently expressed SMN co-localizes with endogenous EWS in a number of cultured cell lines, as well as rat primary neuron cultures. Anti-sense RNA experiments, however, demonstrate that EWS does not mediate the nuclear distribution of SMN or other Cajal body components.

Analgesic effects of adrenal chromaffin allografts: contingent on special procedures or due to experimenter bias?

Many articles have reported that adrenal chromaffin cell transplants produce analgesic effects. Surprisingly, studies conducted in our laboratory failed to detect analgesic effects of adrenal chromaffin cell transplants. Although we have attempted to replicate the procedures reported to produce analgesic effects with adrenal chromaffin transplants, many of the different cell preparation procedures we have examined are fairly complex, and it is possible that our transplants were not sufficiently viable because of some subtle difference in our cell preparation procedures. In the present study we attempted to replicate as precisely as possible, and with very large groups to maximize statistical power, the simplest and most straightforward procedures previously reported to produce analgesic effects, adrenal allografts in the formalin test. The first experiment, conducted in our laboratories, failed to detect analgesic effects of intrathecal adrenal allografts in the formalin test. Another study conducted at a different research facility confirmed the absence of analgesic effects in the formalin test but verified that analgesic effects of morphine were detectable under the same blinded conditions. In addition, graft viability was verified histologically, but there was no correlation in either experiment between adrenal chromaffin cell number and pain behaviors. These results demonstrate more clearly than any of our previous reports that the analgesic effects of intrathecal adrenal transplants are not reliable and should not be accepted as valid until they can be produced reliably under rigorously blinded conditions.

Survival motor neuron protein in the nucleolus of mammalian neurons.

Spinal muscular atrophy (SMA) is an inherited motor neuron disease caused by mutations in the survival motor neuron gene (SMN1). While it has been shown that the SMN protein is involved in spliceosome biogenesis and pre-mRNA splicing, there is increasing evidence indicating that SMN may also perform important functions in the nucleolus. We demonstrate here through the use of a previously characterized polyclonal anti-SMN antibody, abSMN, that the SMN protein shows a striking colocalization with the nucleolar protein, fibrillarin, in both nucleoli and Cajal bodies/gems of primary neurons. Immunoblot analysis with antifibrillarin and two different anti-SMN antibodies reveals that SMN and fibrillarin also cofractionate in the insoluble protein fraction of cultured cell lysates. Immunoprecipitation experiments using whole cell extracts of HeLa cells and cultured neurons revealed that abSMN coprecipitated small amounts of the U3 small nucleolar RNA (snoRNA) previously shown to be associated with fibrillarin in vivo. These studies raise the possibility that SMN may serve a function in rRNA maturation/ribosome synthesis similar to its role in spliceosome biogenesis.

Numerous adrenal chromaffin cell preparations fail to produce analgesic effects in the formalin test or in tests of acute pain even with nicotine stimulation.

Previous studies have reported that intrathecal implants of a variety of adrenal chromaffin cell preparations all produce analgesic effects in rodents. The major objective of the present study was to determine if any adrenal chromaffin cell preparations produce more robust analgesic effects than other cell preparations. The present study included adult rat adrenal chromaffin tissue allografts, purified adult bovine chromaffin cells, and polymer-encapsulated calf adrenal chromaffin cells, all prepared according to previously published procedures, as well as purified calf adrenal chromaffin cells. Previous studies have also suggested that immunosuppression may play a role in graft survival, and potentially increase the magnitude of analgesic effects, so the present study included both immunosuppressed and non-immunosuppressed groups (cyclosporin A, 10 mg/kg per day). Behavioral tests included the formalin test; and a dorsal tail-flick, hot-plate, and paw-pinch test, conducted sequentially 2 min after systemic nicotine (0.1 mg/kg) to evoke release from the chromaffin cells, as previously reported. Analgesic effects related to morphine and nicotine were detected, and consistent differences in performance could be detected between individual animals. Surprisingly, no analgesic effects were detectable with any of the four chromaffin cell preparations, with or without immunosuppression, in the formalin test or with nicotine stimulation in tests of acute pain.