How we achieve satisfaction in training - A German-wide survey on preferred training conditions among trainers and trainees for board certification in gastroenterology.

BACKGROUND: a majority of resident physicians in Germany are not satisfied with their training conditions. However, training satisfaction is important for physician retention and patient care. Although federal and state laws define the general training regulations and conditions, considerable variability still exists concerning their implementation in the healthcare units. Little is known about the expectations concerning training for gastroenterology board certification by trainers and trainees in Germany. This lack of data hinders discussion on and improvement of training in gastroenterology in Germany. AIM: assessment of preferred training conditions among trainers and trainees for board certification in gastroenterology in Germany. METHODS: an anonymous, voluntary survey consisting of single- and multiple-choice questions utilizing the Likert scale and fill-in responses was circulated to all members of the German Society for Digestive and Metabolic Diseases (DGVS - Deutsche Gesellschaft für Gastroenterologie, Verdauungs und Stoffwechselerkrankungen), as well as through the student council mailing lists of all German medical schools. The survey aimed to assess the consent regarding the ideal implementation of training regulations for gastroenterology board certification. Department heads, senior physicians, board-certified physicians, and outpatient-care physicians were classified as trainers and residents and students as trainees. Subgroups defined by place of work, age, gender, professional position, employment status, and parental status were investigated. RESULTS: 958 responses were included in the final analysis. We found a broad consensus among trainers and trainees on most aspects of our survey. Considerable differences were seen in items on part-time work, overtime, protected time for research, and advanced endoscopy training. CONCLUSION: the broad consensus seen in this survey is indicative of a shared vision for training conditions among trainers and trainees. However, the areas of dissent identified in this survey may assist trainers to better understand the expectations of trainees. Furthermore, this survey creates a sound basis upon which training conditions for board certification in gastroenterology in Germany can be discussed and improved.

Importance of interdisciplinarity in modern oncology: results of a national intergroup survey of the Young Oncologists United (YOU).

PURPOSE: Modern, personalized treatment concepts in oncology require an interdisciplinary and multiprofessional collaboration. In addition to its relevance in patient care, interdisciplinary collaboration is also becoming increasingly important in clinical research as well as medical education and resident training in oncology. METHODS: Between November 2021 and March 2022, an online survey was conducted among German early career research groups, represented by Young Oncologists United (YOU). The aim was to identify the status and need for interdisciplinarity at clinic, educational, and research levels. RESULTS: A total of 294 participants completed the questionnaire in full. 90.7% of the respondents fully or predominantly agreed with the statement that interdisciplinary work plays a major role in their daily clinical work. 78.9% wished for more interdisciplinary collaboration. Of the 49.7% of participants who have never participated in an interdisciplinary research project, 80.1% said they would like to participate in such a study project in the future. Lack of time resources, too much organizational effort, and possible political conflicts between institutions were identified as factors that make practical implementation difficult. 74.1% declared their willingness to become active in an oncology early career research group. CONCLUSION: Interdisciplinary collaboration has become increasingly important in oncology. Networks that span different disciplines could help to promote interdisciplinary research projects among young scientists and improve exchange in professional practice and education with the implication of improved patient care.

Author Correction: Increased stiffness of the tumor microenvironment in colon cancer stimulates cancer associated fibroblast-mediated prometastatic activin A signaling.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Increased stiffness of the tumor microenvironment in colon cancer stimulates cancer associated fibroblast-mediated prometastatic activin A signaling.

Colorectal cancer (CRC) is the second deadliest cancer in the US due to its propensity to metastasize. Stromal cells and especially cancer-associated fibroblasts (CAF) play a critical biophysical role in cancer progression, but the precise pro-metastatic mechanisms are not clear. Activin A, a TGF-ß family member, is a strong pro-metastatic cytokine in the context of CRC. Here, we assessed the link between biophysical forces and pro-metastatic signaling by testing the hypothesis that CAF-generated mechanical forces lead to activin A release and associated downstream effects. Consistent with our hypothesis, we first determined that stromal activin A secretion increased with increasing substrate stiffness. Then we found that stromally-secreted activin A induced ligand-dependent CRC epithelial cell migration and epithelial to mesenchymal transition (EMT). In addition, serum activin A levels are significantly increased in metastatic (stage IV) CRC patients (1.558 ng/ml versus 0.4179 ng/ml, p < 0.05). We propose that increased tumor microenvironment stiffness leads to stromal cell-mediated TGF-ß family signaling relying on the induction and utilization of activin A signaling.

Activin in acute pancreatitis: Potential risk-stratifying marker and novel therapeutic target.

Acute Pancreatitis is a substantial health care challenge with increasing incidence. Patients who develop severe disease have considerable mortality. Currently, no reliable predictive marker to identify patients at risk for severe disease exists. Treatment is limited to rehydration and supporting care suggesting an urgent need to develop novel approaches to improve standard care. Activin is a critical modulator of inflammatory responses, but has not been assessed in pancreatitis. Here, we demonstrate that serum activin is elevated and strongly correlates with disease severity in two established murine models of acute pancreatitis induced by either cerulein or IL-12 + IL-18. Furthermore, in mice, inhibition of activin conveys survival benefits in pancreatitis. In addition, serum activin levels were measured from a retrospective clinical cohort of pancreatitis patients and high activin levels in patients at admission are predictive of worse outcomes, indicated by longer overall hospital and intensive care unit stays. Taken together, activin is a novel candidate as a clinical marker to identify those acute pancreatitis patients with severe disease who would benefit from aggressive treatment and activin may be a therapeutic target in severe acute pancreatitis.

Increased Frequency of KRAS Mutations in African Americans Compared with Caucasians in Sporadic Colorectal Cancer.

OBJECTIVES: The basis for over-representation of colorectal cancer (CRC) in African-American (AA) populations compared with Caucasians are multifactorial and complex. Understanding the mechanisms for this racial disparity is critical for delivery of better care. Several studies have investigated sporadic CRC for differences in somatic mutations between AAs and Caucasians, but owing to small study sizes and conflicting results to date, no definitive conclusions have been reached. METHODS: Here, we present the first systematic literature review and meta-analysis investigating the mutational differences in sporadic CRC between AAs and Caucasians focused on frequent driver mutations (APC,TP53, KRAS,PI3CA, FBXW7,SMAD4, and BRAF). Publication inclusion criteria comprised sporadic CRC, human subjects, English language, information on ethnicity (AA, Caucasian, or both), total subject number >20, and information on mutation frequencies. RESULTS: We identified 6,234 publications. Meta-analysis for APC, TP54, FBXW7, or SMAD4 was not possible owing to paucity of data. KRAS mutations were statistically less frequent in non-Hispanic Whites when compared with AAs (odds ratio, 0.640; 95% confidence interval (CI): 0.5342-0.7666; P=0.0001), while the mutational differences observed in BRAF and PI3CA did not reach statistical significance. CONCLUSIONS: Here, we report the mutational patterns for KRAS, BRAF, and PI3CA in sporadic CRC of AAs and Caucasians in a systematic meta-analysis of previously published data. We identified an increase in KRAS mutations in sporadic CRC in AAs, which may contribute to worse prognosis and increased mortality of CRC in AAs. Future studies investigating health-care disparities in CRC in AAs should control for KRAS mutational frequency.

Activin signaling is an essential component of the TGF-ß induced pro-metastatic phenotype in colorectal cancer.

Advanced colorectal cancer (CRC) remains a critical health care challenge worldwide. Various TGF-ß superfamily members are important in colorectal cancer metastasis, but their signaling effects and predictive value have only been assessed in isolation. Here, we examine cross-regulation and combined functions of the two most prominent TGF-ß superfamily members activin and TGF-ß in advanced colorectal cancer. In two clinical cohorts we observed by immune-based assay that combined serum and tissue activin and TGF-ß ligand levels predicts outcome in CRC patients and is superior to single ligand assessment. While TGF-ß growth suppression is independent of activin, TGF-ß treatment leads to increased activin secretion in colon cancer cells and TGF-ß induced cellular migration is dependent on activin, indicating pathway cross-regulation and functional interaction in vitro. mRNA expression of activin and TGF-ß pathway members were queried in silico using the TCGA data set. Coordinated ligand and receptor expression is common in solid tumors for activin and TGF-ß pathway members. In conclusion, activin and TGF-ß are strongly connected signaling pathways that are important in advanced CRC. Assessing activin and TGF-ß signaling as a unit yields important insights applicable to future diagnostic and therapeutic interventions.

Multiorgan Failure Predicts Mortality in Emphysematous Pancreatitis: A Case Report and Systematic Analysis of the Literature.

Emphysematous pancreatitis (EP) is a subtype of acute necrotizing pancreatitis (ANP) characterized by the presence of gas in and around the pancreas. Although investigators have studied prognostic factors in ANP, less is known about EP. We aimed to determine predictors of mortality and identify changes in management strategies for EP. A PubMed search was performed to identify EP cases. Data were gathered about patient demographics, clinical findings, laboratory results, radiological studies, procedures, outcomes, and mortality. Data were analyzed using univariate and multivariate logistic regression analyses. Including a case from our institution, the study cohort included 64 subjects. The overall mortality rate was 32.8% (21/64). On univariate analysis, age (P = 0.019), hypotension (P = 0.007), gas outside the pancreas on computed tomography imaging (P = 0.003), initial surgical evacuation (P = 0.007), and the development of multiorgan failure (P = 0.008) were associated with mortality. On multivariate analysis, only the development of multiorgan failure was found to be an independent predictor of mortality (P = 0.039). The overall mortality rate of 32.8% for EP is similar to the mortality rates published for ANP. The development of multiorgan failure in EP is strongly associated with increased mortality. Percutaneous and endoscopic approaches have been replacing surgical interventions.

NFkB is essential for activin-induced colorectal cancer migration via upregulation of PI3K-MDM2 pathway.

Colorectal cancer (CRC) remains a common and deadly cancer due to metastatic disease. Activin and TGFB (TGFß) signaling are growth suppressive pathways that exert non-canonical pro-metastatic effects late in CRC carcinogenesis. We have recently shown that activin downregulates p21 via ubiquitination and degradation associated with enhanced cellular migration independent of SMADs. To investigate the mechanism of metastatic activin signaling, we examined activated NFkB signaling and activin ligand expression in CRC patient samples and found a strong correlation. We hypothesize that activation of the E3 ubiquitin ligase MDM2 by NFkB leads to p21 degradation in response to activin treatment. To dissect the link between activin and pro-carcinogenic NFkB signaling and downstream targets, we found that activin but not TGFB induced activation of NFkB leading to increased MDM2 ubiquitin ligase via PI3K. Further, overexpression of wild type p65 NFkB increased MDM2 expression while the NFkB inhibitors NEMO-binding domain (NBD) and Bay11-7082 blocked the activin-induced increase in MDM2. In conclusion, in colon cancer cell migration, activin utilizes NFkB to induce MDM2 activity leading to the degradation of p21 in a PI3K dependent mechanism. This provides new mechanistic knowledge linking activin and NFkB signaling in advanced colon cancer which is applicable to targeted therapeutic interventions.

The predictors of mortality and secular changes in management strategies in emphysematous gastritis.

BACKGROUND AND AIMS: Emphysematous gastritis (EG) is caused by invasion of the gastric wall by gas-producing organisms and carries mortality rate up to 60%. Our investigation aimed to determine the predictors of survival and the secular trends in survival rates of subjects with EG. METHODS: PubMed search was completed to identify previous cases of EG. In addition, we included a recent case from our center. Statistical analysis was completed with two-sided Chi2 tests for categorical data and t-tests for continuous variables using SPSS v. 22.0 (SPSS Inc, Chicago, IL). RESULTS: Study cohort included 59 adults. Mean age was 55.5 years; mean LOS was 28.6 days, and 44.1% of subjects were female. Subjects who had EG before 2000 had significantly higher rates of exploratory laparotomy compared to subjects who had EG after 2000 (62.5% vs. 22.2%, P=0.002). In contrast, subjects with EG after 2000 had significantly higher rates of EGD (55.6% vs. 18.8%, P=0.003) and lower rates of mortality (33.3% vs. 59.4%, P=0.046) compared to subjects with EG on or before 2000. In multivariate logistic regression analysis, the only independent predictor of mortality was length of stay (P=0.047). CONCLUSION: We showed that previously reported 60% mortality rate of EG has been reduced to 33.3% for cases reported after 2000. EGD has been utilized more often while surgical interventions are used only in carefully selected cases. Our data suggests that early endoscopic evaluation and optimal medical management can perhaps continue to improve survival in subjects with EG.

Transforming Growth Factor ß Superfamily Signaling in Development of Colorectal Cancer.

Transforming growth factor (TGF)-ß cytokines signal via a complex network of pathways to regulate proliferation, differentiation, adhesion, migration, and other functions in many cell types. A high percentage of colorectal tumors contain mutations that disrupt TGF-ß family member signaling. We review how TGF-ß family member signaling is altered during development of colorectal cancer, models of study, interaction of pathways, and potential therapeutic strategies.

Loss of TGFß signaling promotes colon cancer progression and tumor-associated inflammation.

TGFß has both tumor suppressive and tumor promoting effects in colon cancer. Also, TGFß can affect the extent and composition of inflammatory cells present in tumors, contextually promoting and inhibiting inflammation. While colon tumors display intratumoral inflammation, the contributions of TGFß to this process are poorly understood. In human patients, we found that epithelial loss of TGFß signaling was associated with increased inflammatory burden; yet overexpression of TGFß was also associated with increased inflammation. These findings were recapitulated in mutant APC models of murine tumorigenesis, where epithelial truncation of TGFBR2 led to lethal inflammatory disease and invasive colon cancer, mediated by IL8 and TGFß1. Interestingly, mutant APC mice with global suppression of TGFß signals displayed an intermediate phenotype, presenting with an overall increase in IL8-mediated inflammation and accelerated tumor formation, yet with a longer latency to the onset of disease observed in mice with epithelial TGFBR-deficiency. These results suggest that the loss of TGFß signaling, particularly in colon epithelial cells, elicits a strong inflammatory response and promotes tumor progression. This implies that treating colon cancer patients with TGFß inhibitors may result in a worse outcome by enhancing inflammatory responses.

Expression of an Oncogenic BARD1 Splice Variant Impairs Homologous Recombination and Predicts Response to PARP-1 Inhibitor Therapy in Colon Cancer.

BRCA1-associated RING domain protein 1 (BARD1) stabilizes BRCA1 protein by forming a heterodimeric RING-RING complex, and impacts function of BRCA1, including homologous recombination (HR) repair. Although colon cancer cells usually express wild type BRCA1, presence of an oncogenic BARD1 splice variant (SV) in select cancers may render BRCA1 dysfunctional and allow cells to become sensitive to HR targeting therapies. We previously reported association of loss of full-length (FL) BARD1 with poor prognosis in colon cancer as well as expression of various BARD1 SVs with unknown function. Here we show that loss of BARD1 function through the expression of a BARD1 SV, BARD1ß, results in a more malignant phenotype with decreased RAD51 foci formation, reduced BRCA1 E3 ubiquitin ligase activity, and decreased nuclear BRCA1 protein localization. BARD1ß sensitizes colon cancer cells to poly ADP ribose polymerase 1 (PARP-1) inhibition even in a FL BRCA1 background. These results suggest that expression of BARD1ß may serve as a future biomarker to assess suitability of colon cancers for HR targeting with PARP-1 inhibitors in treatment of advanced colon cancer.

Activin and TGFß use diverging mitogenic signaling in advanced colon cancer.

BACKGROUND: Understanding cell signaling pathways that contribute to metastatic colon cancer is critical to risk stratification in the era of personalized therapeutics. Here, we dissect the unique involvement of mitogenic pathways in a TGFß or activin-induced metastatic phenotype of colon cancer. METHOD: Mitogenic signaling/growth factor receptor status and p21 localization were correlated in primary colon cancers and intestinal tumors from either AOM/DSS treated ACVR2A (activin receptor 2) -/- or wild type mice. Colon cancer cell lines (+/- SMAD4) were interrogated for ligand-induced PI3K and MEK/ERK pathway activation and downstream protein/phospho-isoform expression/association after knockdown and pharmacologic inhibition of pathway members. EMT was assessed using epithelial/mesenchymal markers and migration assays. RESULTS: In primary colon cancers, loss of nuclear p21 correlated with upstream activation of activin/PI3K while nuclear p21 expression was associated with TGFß/MEK/ERK pathway activation. Activin, but not TGFß, led to PI3K activation via interaction of ACVR1B and p85 independent of SMAD4, resulting in p21 downregulation. In contrast, TGFß increased p21 via MEK/ERK pathway through a SMAD4-dependent mechanism. While activin induced EMT via PI3K, TGFß induced EMT via MEK/ERK activation. In vivo, loss of ACVR2A resulted in loss of pAkt, consistent with activin-dependent PI3K signaling. CONCLUSION: Although activin and TGFß share growth suppressive SMAD signaling in colon cancer, they diverge in their SMAD4-independent pro-migratory signaling utilizing distinct mitogenic signaling pathways that affect EMT. p21 localization in colon cancer may determine a dominant activin versus TGFß ligand signaling phenotype warranting further validation as a therapeutic biomarker prior to targeting TGFß family receptors.