Rural Disparities in Lung Cancer-directed Surgery: A Medicare Cohort Study.

OBJECTIVE: The primary objective of this study was to determine the influence of rural residence on access to and outcomes of lung cancer-directed surgery for Medicare beneficiaries. SUMMARY OF BACKGROUND DATA: Lung cancer is the leading cause of cancerrelated death in the United States and rural patients have 20% higher mortality. Drivers of rural disparities along the continuum of lung cancercare delivery are poorly understood. METHODS: Medicare claims (2015-2018) were used to identify 126,352 older adults with an incident diagnosis of nonmetastatic lung cancer. Rural Urban Commuting Area codes were used to define metropolitan, micropolitan, small town, and rural site of residence. Multivariable logistic regression models evaluated influence of place of residence on 1) receipt of cancer-directed surgery, 2) time from diagnosis to surgery, and 3) postoperative outcomes. RESULTS: Metropolitan beneficiaries had higher rate of cancer-directed surgery (22.1%) than micropolitan (18.7%), small town (17.5%), and isolated rural (17.8%) (P < 0.001). Compared to patients from metropolitan areas, there were longer times from diagnosis to surgery for patients living in micropolitan, small, and rural communities. Multivariable models found nonmetropolitan residence to be associated with lower odds of receiving cancer-directed surgery and MIS. Nonmetropolitan residence was associated with higher odds of having postoperative emergency department visits. CONCLUSIONS: Residence in nonmetropolitan areas is associated with lower probability of cancer-directed surgery, increased time to surgery, decreased use of MIS, and increased postoperative ED visits. Attention to timely access to surgery and coordination of postoperative care for nonmetropolitan patients could improve care delivery.

Cobalt ion interaction with TMEM16A calcium-activated chloride channel: Inhibition and potentiation.

TMEM16A, a Ca2+-sensitive Cl- channel, plays key roles in many physiological functions related to Cl- transport across lipid membranes. Activation of this channel is mediated via binding intracellular Ca2+ to the channel with a relatively high apparent affinity, roughly in the sub-µM to low µM concentration range. Recently available high-resolution structures of TMEM16 molecules reveal that the high-affinity Ca2+ activation sites are formed by several acidic amino acids, using their negatively charged sidechain carboxylates to coordinate the bound Ca2+. In this study, we examine the interaction of TMEM16A with a divalent cation, Co2+, which by itself cannot activate current in TMEM16A. This divalent cation, however, has two effects when applied intracellularly. It inhibits the Ca2+-induced TMEM16A current by competing with Ca2+ for the aforementioned high-affinity activation sites. In addition, Co2+ also potentiates the Ca2+-induced current with a low affinity. This potentiation effect requires high concentration (mM) of Co2+, similar to our previous findings that high concentrations (mM) of intracellular Ca2+ ([Ca2+]i) can induce more TMEM16A current after the Ca2+-activation sites are saturated by tens of µM [Ca2+]i. The degrees of potentiation by Co2+ and Ca2+ also roughly correlate with each other. Interestingly, mutating a pore residue of TMEM16A, Y589, alters the degree of potentiation in that the smaller the sidechain of the replaced residue, the larger the potentiation induced by divalent cations. We suggest that the Co2+ potentiation and the Ca2+ potentiation share a similar mechanism by increasing Cl- flux through the channel pore, perhaps due to an increase of positive pore potential after the binding of divalent cations to phospholipids in the pore. A smaller sidechain of a pore residue may allow the pore to accommodate more phospholipids, thus enhancing the current potentiation caused by high concentrations of divalent cations.

Comparison of ion transport determinants between a TMEM16 chloride channel and phospholipid scramblase.

Two TMEM16 family members, TMEM16A and TMEM16F, have different ion transport properties. Upon activation by intracellular Ca2+, TMEM16A-a Ca2+-activated Cl- channel-is more selective for anions than cations, whereas TMEM16F-a phospholipid scramblase-appears to transport both cations and anions. Under saturating Ca2+ conditions, the current-voltage (I-V) relationships of these two proteins also differ; the I-V curve of TMEM16A is linear, while that of TMEM16F is outwardly rectifying. We previously found that mutating a positively charged lysine residue (K584) in the ion transport pathway to glutamine converted the linear I-V curve of TMEM16A to an outwardly rectifying curve. Interestingly, the corresponding residue in the outwardly rectifying TMEM16F is also a glutamine (Q559). Here, we examine the ion transport functions of TMEM16 molecules and compare the roles of K584 of TMEM16A and Q559 of TMEM16F in controlling the rectification of their respective I-V curves. We find that rectification of TMEM16A is regulated electrostatically by the side-chain charge on the residue at position 584, whereas the charge on residue 559 in TMEM16F has little effect. Unexpectedly, mutation of Q559 to aromatic amino acid residues significantly alters outward rectification in TMEM16F. These same mutants show reduced Ca2+-induced current rundown (or desensitization) compared with wild-type TMEM16F. A mutant that removes the rundown of TMEM16F could facilitate the study of ion transport mechanisms in this phospholipid scramblase in the same way that a CLC-0 mutant in which inactivation (or closure of the slow gate) is suppressed was used in our previous studies.