Synchronous primary colorectal and liver metastasis: impact of operative approach on clinical outcomes and hospital charges.

OBJECTIVES: The management of patients with colorectal cancer (CRC) and synchronous colorectal liver metastasis (CLM) remains controversial. The present study was conducted in order to assess the clinical and economic impacts of managing synchronous CLM with a staged versus a simultaneous surgery approach. METHODS: A total of 224 patients treated for synchronous CLM during 1990-2012 were identified in the Johns Hopkins Hospital liver database. Data on clinicopathological features, perioperative outcomes and total hospital charges (inflation-adjusted) were collected and analysed. RESULTS: Overall, 113 (50.4%) patients underwent staged surgery and 111 (49.6%) were submitted to a simultaneous CRC and liver operation. At surgery, liver-directed therapy included hepatectomy (75.0%) or combined resection and ablation (25.0%). Perioperative morbidity (30.0%) and mortality (1.3%) did not differ between groups (both P > 0.05). Median total length of hospitalization was longer in the staged (13 days) than the simultaneous (7 days) surgery group (P < 0.001). Median total hospital charges were higher among patients undergoing staged surgery (US$61,938) than among those undergoing a simultaneous operation (US$34,114) (P < 0.01). Median (simultaneous, 32.4 months versus staged, 39.6 months; P = 0.65) and 5-year (simultaneous, 27% versus staged, 29%; P = 0.60) overall survival were similar between groups. CONCLUSIONS: Patients with synchronous CLM managed with either simultaneous or staged surgery have comparable perioperative and longterm outcomes. However, patients treated with simultaneous surgery spent an average of 6 days fewer in hospital, resulting in a reduction of median hospital charges of US$27,824 (55.1%). When appropriate and technically feasible, the simultaneous surgery approach to synchronous CLM should be preferred.

Distinct roles for two histamine receptors (hclA and hclB) at the Drosophila photoreceptor synapse.

Histamine (HA) is the photoreceptor neurotransmitter in arthropods, directly gating chloride channels on large monopolar cells (LMCs), postsynaptic to photoreceptors in the lamina. Two histamine-gated channel genes that could contribute to this channel in Drosophila are hclA (also known as ort) and hclB (also known as hisCl1), both encoding novel members of the Cys-loop receptor superfamily. Drosophila S2 cells transfected with these genes expressed both homomeric and heteromeric histamine-gated chloride channels. The electrophysiological properties of these channels were compared with those from isolated Drosophila LMCs. HCLA homomers had nearly identical HA sensitivity to the native receptors (EC(50) = 25 microM). Single-channel analysis revealed further close similarity in terms of single-channel kinetics and subconductance states ( approximately 25, 40, and 60 pS, the latter strongly voltage dependent). In contrast, HCLB homomers and heteromeric receptors were more sensitive to HA (EC(50) = 14 and 1.2 microM, respectively), with much smaller single-channel conductances ( approximately 4 pS). Null mutations of hclA (ort(US6096)) abolished the synaptic transients in the electroretinograms (ERGs). Surprisingly, the ERG "on" transients in hclB mutants transients were approximately twofold enhanced, whereas intracellular recordings from their LMCs revealed altered responses with slower kinetics. However, HCLB expression within the lamina, assessed by both a GFP (green fluorescent protein) reporter gene strategy and mRNA tagging, was exclusively localized to the glia cells, whereas HCLA expression was confirmed in the LMCs. Our results suggest that the native receptor at the LMC synapse is an HCLA homomer, whereas HCLB signaling via the lamina glia plays a previously unrecognized role in shaping the LMC postsynaptic response.

Phylogenetic shadowing of a histamine-gated chloride channel involved in insect vision.

A recently identified gene, hclA (synonym: ort), codes for an ionotrophic histamine receptor subunit in Drosophila melanogaster, and known hclA mutations lead to defects in the visual system, neurologic disorders and changed responsiveness to neurotoxins. To investigate whether this novel class of receptors is common across the Insecta, we analysed the genomes of 15 other insect species (Diptera, Hymenoptera, Coleoptera, Lepidoptera) and revealed orthologs of hclA in all of them. The predicted receptor domain of HCLA is extensively conserved (86-100% of identity) among the 16 proteins. Minor changes in the amino acid sequence that includes the putative transmembrane domains (TMs) 1-3 were found in non-drosophilid species only. Substantial amino acid variability was observed in the signal polypeptides, the intracellular loop domains and in TM4, in good accordance with known data on sequence variations in ligand-gated ion channels. Pairwise comparisons revealed three consensus sequences for N-glycosylation, conserved in HCLAs of all species studied, as well as a drosophilid-specific putative phosphorylation site. Real-time PCR analysis demonstrated that hclA-mRNA is abundant in heads of adult Drosophila. However, species- and sex-specific variations of the hclA expression levels were also observed.

Functional consequences of mutations in the Drosophila histamine receptor HCLB.

The gene hclB encodes a histamine-gated chloride channel subunit in Drosophila melanogaster. Mutations in hclB lead to defects in the visual system and altered sensitivity to the action of ivermectin. To investigate whether this member of the Cys-loop receptors is common across the Insecta, we analysed the genomes of seven other insect species (Diptera, Hymenoptera, Coleoptera) and revealed orthologues of hclB in all of them. Sequence comparisons showed high identity levels between the orthologues, indicating similar constraints and conserved function between the species. Two D. melanogaster mutants, hclB(T1) (P293S) and hclB(T2) (W111*, a null mutation) were tested for the lapse into, and recovery from, paralysis induced by high temperature or the anaesthetic action of halothane. At 41 degrees C, the hclB(T2) flies lapsed into coma faster than wild-type or the hclB(T1) flies, while both mutants recovered more slowly. A substantially impaired recovery rate was also observed in hclB(T1) after anaesthesia with halothane. Enhanced synaptic signalling at low-intensity light stimuli was registered on electroretinograms recorded from the two mutant strains. Our results suggest that HCLB may play an essential and conserved role in insect neurophysiology.

Altered ivermectin pharmacology and defective visual system in Drosophila mutants for histamine receptor HCLB.

The Drosophila gene hclB encodes a histamine-gated chloride channel, which can be activated by the neurotoxin ivermectin when expressed in vitro. We have identified two novel hclB mutants, carrying either a missense mutation (P293S, allele hclB (T1)) or a putative null mutation (W111*, allele hclB (T2)), as well as a novel splice form of the gene. In survival studies, hclB (T1) mutants were more sensitive to ivermectin than wild-type, whereas hclB (T2) were more resistant. Electroretinogram recordings from the two mutants exhibited enlarged peak amplitudes of the transient components, indicating altered synaptic transmission between retinal photoneurons and their target cells. Ivermectin treatment severely affected or completely suppressed these transient components in an allele-specific manner. This suppression of synaptic signals by ivermectin was dose-dependent. These results identify HCLB as an important in vivo target for ivermectin in Drosophila melanogaster, and demonstrate the involvement of this protein in the visual pathway.

Altered drug resistance and recovery from paralysis in Drosophila melanogaster with a deficient histamine-gated chloride channel.

The recent identification and characterization of two genes, encoding histamine-gated chloride channel subunits from Drosophila melanogaster, has confirmed that histamine is a major neurotransmitter in the fruitfly. One of the cloned genes, hclA (synonyms: HisCl-alpha1; HisCl2), corresponds to ort (ora transientless), mutationsin which affect synaptic transmission in the Drosophila visual system. We identified a mutational change (a null mutation) in the genomic and RNA copies of hclA derived from mutants carrying the ort(1) allele. This correlates with new phenotypes observed in the mutant strain. We found hypersensitivity to the avermectin neurotoxins in both the ort(1) adult flies and third instar larvae compared to Oregon R wild-type animals. On the other hand, the mutation makes both male and female adult flies more resistant to treatment with diethyl ether, and the animals show substantially prolonged recovery from paralysis after diethylether anaesthesia, as well as from paralysis after mechanical shock, as revealed by the bang sensitivity test. Altogether, our data give direct evidence that in vivo a HCLA subunit-containing receptor has a distinct role in the neurotoxic action of the avermectins. They also provide new evidence for a function in the response to diethylether anaesthesia and, moreover, that HCLA function is not limited to the visual system.

The target of Drosophila photoreceptor synaptic transmission is a histamine-gated chloride channel encoded by ort (hclA).

By screening Drosophila mutants that are potentially defective in synaptic transmission between photoreceptors and their target laminar neurons, L1/L2, (lack of electroretinogram on/off transients), we identified ort as a candidate gene encoding a histamine receptor subunit on L1/L2. We provide evidence that the ort gene corresponds to CG7411 (referred to as hclA), identified in the Drosophila genome data base, by P-element-mediated germ line rescue of the ort phenotype using cloned hclA cDNA and by showing that several ort mutants exhibit alterations in hclA regulatory or coding sequences and/or allele-dependent reductions in hclA transcript levels. Other workers have shown that hclA, when expressed in Xenopus oocytes, forms histamine-sensitive chloride channels. However, the connection between these chloride channels and photoreceptor synaptic transmission was not established. We show unequivocally that hclA-encoded channels are the channels required in photoreceptor synaptic transmission by 1) establishing the identity between hclA and ort and 2) showing that ort mutants are defective in photoreceptor synaptic transmission. Moreover, the present work shows that this function of the HCLA (ORT) protein is its native function in vivo.