Prognostic impact and implications of extracapsular lymph node involvement in colorectal cancer: a systematic review with meta-analysis.

BACKGROUND: The extranodal extension (ENE) of nodal metastasis (i.e. the extension of tumor cells through the nodal capsule into the perinodal adipose tissue) has recently emerged as an important prognostic factor in different types of malignancies. However, the tumor-node-metastasis (TNM) staging system for colorectal cancer does not consider it as a prognostic parameter. Therefore, we conducted a systematic review and meta-analysis to determine the prognostic role of ENE in patients with lymph node-positive colorectal cancer. MATERIALS AND METHODS: Two independent authors searched PubMed and SCOPUS until 7 January 2015 without language restrictions. Prospective studies reporting data on prognostic parameters in subjects with colorectal cancer, comparing participants with the presence of ENE (ENE+) versus only intranodal extension (ENE-) were eligible. Data were summarized using risk ratios (RRs) for the number of deaths/recurrences and hazard ratios (HRs) together with 95% confidence intervals (CIs) for time-dependent risk related to ENE+, adjusted for potential confounders. RESULTS: Thirteen studies including 1336 patients were identified with a median follow-up of 4.7 years. ENE was associated with a higher T stage and tumor grading. In addition, ENE was associated with a significantly increased risk of all-cause mortality (RR = 1.75; 95% CI 1.42-2.16, P < 0.0001, I(2) = 60%; HR = 1.69, 95% CI 1.32-2.17, P < 0.0001, I(2) = 46%) and of recurrence of disease (RR = 2.07, 95% CI 1.65-2.61, P < 0.0001, I(2) = 47%; HR = 2.31, 95% CI 1.54-3.44, P < 0.0001, I(2) = 48%). CONCLUSIONS: Based of these results, in colorectal cancer, ENE should be considered from the gross sampling to the pathology report, as well as in future oncologic staging systems.

Characterization of ataxia telangiectasia fibroblasts with extended life-span through telomerase expression.

Ataxia-telangiectasia (A-T) is an autosomal recessive disease characterized by progressive cerebellar degeneration, immunodeficiencies, genomic instability and gonadal atrophy. A-T patients are hypersensitive to ionizing radiation and have an elevated cancer risk. Cells derived from A-T patients require higher levels of serum factors, exhibit cytoskeletal defects and undergo premature senescence in culture. We show here that expression of the catalytic subunit of telomerase (hTERT) in primary A-T patient fibroblasts can rescue the premature senescence phenotype. Ectopic expression of hTERT does not rescue the radiosensitivity or the telomere fusions in A-T fibroblasts. The hTERT+AT cells also retain the characteristic defects in cell-cycle checkpoints, and show increased chromosome damage before and after ionizing radiation. Although A-T patients have an increased susceptibility to cancer, the expression of hTERT in A-T fibroblasts does not stimulate malignant transformation. These immortalized A-T cells provide a more stable cell system to investigate the molecular mechanisms underlying the cellular phenotypes of Ataxia-telangiectasia.

Induction of terminal differentiation by constitutive activation of p38 MAP kinase in human rhabdomyosarcoma cells.

MyoD inhibits cell proliferation and promotes muscle differentiation. A paradoxical feature of rhabdomyosarcoma (RMS), a tumor arising from muscle precursors, is the block of the differentiation program and the deregulated proliferation despite MyoD expression. A deficiency in RMS of a factor required for MyoD activity has been implicated by previous studies. We report here that p38 MAP kinase (MAPK) activation, which is essential for muscle differentiation, is deficient in RMS cells. Enforced induction of p38 MAPK by an activated MAPK kinase 6 (MKK6EE) restored MyoD function and enhanced MEF2 activity in RMS deficient for p38 MAPK activation, leading to growth arrest and terminal differentiation. Stress and cytokines could activate the p38 MAPK in RMS cells, however, these stimuli did not promote differentiation, possibly because they activated p38 MAPK only transiently and they also activated JNK, which could antagonize differentiation. Thus, the selective and sustained p38 MAPK activation, which is distinct from the stress-activated response, is required for differentiation and can be disrupted in human tumors.

Volume recruitment and oxygenation in pulmonary edema: a comparison between HFOV and CMV.

PURPOSE: In acute lung injury, edema floods alveoli decreasing mean lung volume (MLV) and increasing pulmonary venous admixture (Ova/Qt). We reasoned that a ventilatory strategy that uses large tidal volumes (VT) might recruit volume differently than a strategy that uses very small VT (high-frequency oscillatory ventilation, HFOV) which may require an inflation maneuver to total lung capacity (TLC) for full recruitment. MATERIALS AND METHODS: We studied six dogs with pulmonary edema induced by oleic acid injury and compared HFOV with conventional mechanical ventilation (CMV). Increasing mean airway opening pressure (Pao) from 6 to 14 cm H2O raised MLV from 932+/-162 to 1,550+/-210 mL and from 872+/-145 to 1,242+/-192 mL during CMV and HFOV, respectively, whereas Qva/Qt decreased from 24.1+/-8.5 to 9.3+/-4.3% and from 42.2+/-6.8 to 30.4+/-9.3%. We repeated our measurements at a Pao of 14 cm H2O after an inflation maneuver to TLC. RESULTS: Intlation to TLC recruited additional lung volume and decreased Qva/Qt further only during HFOV. After an inflation to TLC, we observed a rapid isobaric volume loss from the deflation limb of the pressure-volume curve during both CMV and HFOV. CONCLUSIONS: We conclude that after oleic acid injury in dogs pressure-volume hysteresis has two components: a recruitable portion associated with gas exchange improvement and a nonrecruitable portion. At the level of PEEP used in this study (8.5 cm H2O), full lung recruitment during HFOV required inflation to TLC, whereas during CMV it was accomplished by the relatively large VT.

Ataxia telangiectasia mutant protein activates c-Abl tyrosine kinase in response to ionizing radiation.

Ataxia telangiectasia (AT) is a rare human autosomal recessive disorder with pleiotropic phenotypes, including neuronal degeneration, immune dysfunction, premature ageing and increased cancer risk. The gene mutated in AT, ATM, encodes a putative lipid or protein kinase. Most of the human AT patient phenotypes are recapitulated in Atm-deficient mice. Cells derived from Atm-/- mice, like those from AT patients, exhibit abnormal response to ionizing radiation. One of the known responses to ionizing radiation is the activation of a nuclear tyrosine kinase encoded by the c-abl proto-oncogene. Ionizing radiation does not activate c-Abl in cells from AT patients or in thymocytes or fibroblasts from the Atm-deficient mice. Ectopic expression of a functional ATM kinase domain corrects this defect, as it phosphorylates the c-Abl tyrosine kinase in vitro at Ser 465, leading to the activation of c-Abl. A mutant c-Abl with Ser 465 changed to Ala 465 is not activated by ionizing radiation or ATM kinase in vivo. These findings identify the c-Abl tyrosine kinase as a downstream target of phosphorylation and activation by the ATM kinase in the cellular response to ionizing radiation.

Identification and characterization of an MGSA/GRO pseudogene.

Three linked genes for the CXC-chemokine melanoma growth stimulatory activity/growth related protein (MGSA/GRO) have been previously characterized and mapped to chromosome 4q12-q13. We have isolated and characterized a pseudogene, MGSA/GRO delta, which is 83% similar to the MGSA/GRO alpha gene in the region spanning the 5' UTR, first and second exons, and the first intron. The 5' upstream sequence for the MGSA/GRO delta gene, which is also very similar to the MGSA/GRO alpha, beta, gamma genes, contains a conserved NF-kappa B motif, a TATA box, and a transcription initiation site. However, the sequence becomes markedly divergent after the second exon and hybridization studies indicate that sequences similar to the third and forth exons of other MGSA/GRO genes are not present in this gene. Additional sequence differences include alteration of the MGSA/GRO delta translation initiation codon and a one base insertion resulting in an apparent frame shift and early termination within exon 2. Multiple mutations such as these are characteristic of pseudogenes.

Three distinct signalling responses by murine fibroblasts to genotoxic stress.

Genotoxic stress triggers signalling pathways that mediate either the protection or killing of affected cells. Whereas induction of p53 involves events in the cell nucleus, the activation of transcription factors AP-1 and NF-kappaB by ultraviolet radiation is mediated through membrane-associated signalling proteins, ruling out a nuclear signal. An early event in AP-1 induction by ultraviolet radiation is activation of Jun kinases (JNKs), which mediate the induction of the immediate-early genes c-jun and c-fos. The JNKs have also been proposed to mediate the apoptopic response to genotoxins. The non-receptor tyrosine kinase c-Abl is also activated by genotoxic stress. To understand the relationship between these events, we compared the activation of p53, JNK and c-Abl by several DNA-damaging agents in murine fibroblasts. We found that whereas p53 was induced by every genotoxic stimulus tested, c-Abl was activated by most stimuli except ultraviolet irradiation and JNK was strongly stimulated only by ultraviolet light and the alkylating agent methyl methanesulphonate. Activation of JNK by this alkylating agent was normal in c-Abl-null cells but was reduced in c-Src-null cells. Unlike p53 induction, c-Abl activation occurs in the S phase of the cell cycle and does not affect cell proliferation. These findings show that signals generated by genotoxins are transduced by multiple, independent pathways. Only p53 appears to be a universal sensor of genotoxic stress.

Constitutive and cytokine-induced expression of the melanoma growth stimulatory activity/GRO alpha gene requires both NF-kappa B and novel constitutive factors.

Melanoma growth stimulatory activity (MGSA)/growth regulated (GRO) and interleukin-8 (IL-8) are highly related chemokines that have a causal role in melanoma progression. Expression of these chemokines is similar in that both require the NF-kappa B element and additional regions such as the CAAT/enhancer binding protein (C/EBP) element of the IL-8 promoter. The constitutive and cytokine IL-1-induced promoter activity of the chemokine MGSA/GRO alpha in normal retinal pigment epithelial and the Hs294T melanoma cells is partially regulated through the NF-kappa B element, which binds both NF-kappa B p50 and RelA (NF-kappa B p65) homodimers and heterodimers. Mutational analysis of the MGSA/GRO alpha promoter reveals that, in addition to the NF-kappa B element, the immediate upstream region (IUR) is necessary for basal expression in retinal pigment epithelial and Hs294T cells. Gel mobility shift and UV cross-linking analyses demonstrate that several constitutive DNA binding proteins interact with the IUR. Although this region has sequence similarity to the several transcription factor elements including C/EBP, the IUR includes sequences that have no similarity to previously identified enhancer regions. Furthermore, RelA transactivates through either the NF-kappa B element or the IUR, suggesting a putative interaction between NF-kappa B and this novel complex.

HMGI(Y) and Sp1 in addition to NF-kappa B regulate transcription of the MGSA/GRO alpha gene.

Expression of the chemokine MGSA/GRO is upregulated as melanocytes progress to melanoma cells. We demonstrate that constitutive and cytokine induced MGSA/GRO alpha expression requires multiple DNA regulatory regions between positions -143 to -62. We have previously shown that the NF-kappa B element at -83 to -65 is essential for basal and cytokine induced MGSA/GRO alpha promoter activity in the Hs294T melanoma and normal retinal pigment epithelial (RPE) cells, respectively. Here, we have determined that the Sp1 binding element located approximately 42 base pairs upstream from the NF-kappa B element binds Sp1 and Sp3 constitutively and this element is necessary for basal MGSA/GRO alpha promoter activity. We demonstrate that the high mobility group proteins HMGI(Y) recognize the AT-rich motif nested within the NF-kappa B element in the MGSA/GRO alpha promoter. Loss of either NF-kappa B or HMGI(Y) complex binding by selected point mutations in the NF-kappa B element results in decreased basal and cytokine induced MGSA/GRO alpha promoter activity. Thus, these results indicate that transcriptional regulation of the chemokine MGSA/GRO alpha requires at least three transcription factors: Sp1, NF-kappa B and HMGI(Y).

Heliox improves pulsus paradoxus and peak expiratory flow in nonintubated patients with severe asthma.

Heliox is a blend of helium and oxygen with a gas density less than that of air that decreases airway resistance (Raw) in patients ventilated for status asthmaticus. We tested whether breathing an 80:20 mixture of helium:oxygen would reduce pulsus paradoxus (PP) and increase peak expiratory flow (PEF) in patients presenting to the emergency room with an exacerbation of asthma. After receiving 30 min of beta-agonist aerosols and intravenously administered methylprednisolone, 27 patients whose PP remained greater than 15 mm Hg and whose PEF remained less than 250 L/min consented to breathe heliox or room air for 15 min. PP decreased and PEF increased with time in control patients, indicating a time-related effect of routine bronchodilator therapy (p < 0.05). PP decreased in 15 of 16 patients during heliox, and the change with heliox was significantly greater than that during air breathing (p < 0.01). PEF measured with a Wright's peak flow meter calibrated for heliox increased in all patients breathing heliox. Again, the increase in PEF during heliox breathing was significantly greater than the corresponding change in control patients breathing air (p < 0.001). To the extent that PP reflects the inspiratory fall in pleural pressure, this reduction in PP indicates a substantial reduction in inspiratory Raw when the less dense gas is inspired through narrowed bronchi having turbulent flow regimes. The 35% increase in PEF while breathing heliox signals a similar reduction in expiratory Raw, which might diminish the hyperinflation often observed during an exacerbation of asthma.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of cooling on oxygen consumption in febrile critically ill patients.

Hyperthermic critically ill patients are commonly cooled to reduce their oxygen consumption (VO2). However, no previous studies in febrile humans have measured VO2 during cooling. We cooled 12 febrile, critically ill, mechanically ventilated patients while measuring VO2 and CO2 production (VCO2) by analysis of inspired and expired gases. All patients were mechanically ventilated for hypoxemic, hypercapneic, or shock-related respiratory failure and had a mean APACHE II score of 22.4 +/- 7.7. As temperature was reduced from 39.4 +/- 0.8 to 37.0 +/- 0.5 degrees C, VO2 decreased from 359.0 +/- 65.0 to 295.1 +/- 57.3 ml/min (p < 0.01) and VCO2 decreased from 303.6 +/- 43.6 to 243.5 +/- 37.3 ml/min (p < 0.01). The respiratory quotient (RQ) did not change significantly, and calculated energy expenditure decreased from 2,481 +/- 426 to 1,990 +/- 33 kcal/day (p < 0.01). In 7 patients with right heart catheters, cardiac output decreased from 8.4 +/- 3.2 to 6.5 +/- 1.8 L/min (p < 0.01) as the oxygen extraction fraction also tended to decrease from a mean of 28.2 +/- 6.8 to 23.4 +/- 4.7% (p = 0.12) during cooling. Accordingly, cooling the febrile patient unloads the cardiorespiratory system and, in situations of limited oxygen delivery or hypoxemic respiratory failure, may thus facilitate resuscitation and minimize the potential for hypoxic tissue injury.

The effect of mechanical ventilation on oxygen consumption in critically ill patients.

We measured oxygen consumption (VO2) during spontaneous breathing with continuous positive airway pressure (CPAP), assist control ventilation (AC), and control ventilation during muscle relaxation (AC-MR) in eight patients undergoing resuscitation from cardiopulmonary failure. VO2 decreased in all eight patients between CPAP and AC-MR; mean VO2 (255 +/- 92 ml/min) on CPAP exceeded that on AC-MR (209 +/- 79 ml/min) (p < 0.005). Compared with CPAP, AC without MR reduced VO2 in five of eight patients and mean VO2 (227 +/- 59 ml/min) tended to decrease (p = 0.14); clinical examination did not distinguish patients requiring MR to reduce VO2 further. If VO2 on CPAP approximates VO2 during spontaneous breathing, the difference between CPAP and AC-MR (VO2resp) represents the decrement of VO2 that can be obtained during muscle rest. Both VO2resp and the mechanical work performed by the ventilator on the respiratory system were increased to about five times the efficiencies reported for normal patients, but VO2resp did not correlate with the mechanical work because of a wide range of respiratory muscle efficiencies. These efficiencies are less than those reported in normal patients, which may reflect the effect of sepsis, acidemia, hypoxia, or other conditions in these patients. We conclude that mechanical ventilation with muscle relaxation reduces VO2 by more than 20%; beyond stabilizing pulmonary gas exchange, these interventions preserve limited O2 delivery (QO2) for other vital organs.

Cardiovascular physiology teaching: computer simulations vs. animal demonstrations.

The roots of physiology lie in laboratory observation, and physiology courses continue to rely on laboratory observation to provide students with practical information to correlate with their developing base of conceptual knowledge. To this end, animal laboratories provide a functioning example of interactions among organ systems and a source of data for student analysis. However, there are continuing objections to using animals for teaching, and animal labs are costly in time and effort. As an alternative laboratory tool, computer software can simulate the operation of multiple organ systems: responses to interventions illustrate intrinsic organ behavior and integrated systems physiology. Advantages of software over animal studies include alteration of variables that are not easily changed in vivo, repeated interventions, and cost-effective hands-on student access. Nevertheless, simulations miss intangible aspects of experimental physiology, and results depend critically on the assumptions of the model. We used both computer and animal demonstrations in teaching cardiovascular physiology to first-year medical students. The students rated both highly, but the computer-based session received a higher rating. We believe that both forms of teaching have educational merit. At the introductory level, the computer appears to provide an effective alternative.

Active sodium transport and alveolar epithelial Na-K-ATPase increase during subacute hyperoxia in rats.

Active Na+ transport and lung edema clearance were studied in a model of lung injury caused by sublethal oxygen exposure. Rats exposed to 85% O2 for 7 days were studied at 0, 7, 14, and 30 days after removal from the hyperoxic chamber and compared with room air controls. In the isolated-perfused, fluid-filled rat lung, albumin flux from the perfusate into the air spaces increased after oxygen exposure and returned to control values after 7 days of recovery. However, permeability to small solutes (Na+ and mannitol) normalized only after 30 days of recovery from hyperoxia. Active Na+ transport increased immediately after oxygen exposure and returned to control values 7 days after removal from hyperoxic chamber. Na-K-adenosinetriphosphatase (ATPase) activity, and protein expression in alveolar epithelial type II cells obtained at the end of the isolated lung experiments increased significantly after the oxygen exposure compared with controls in association with the increased active Na+ transport. We conclude that active Na+ transport and lung liquid clearance are increased in the subacute hyperoxic phase of lung injury in rats, due in part to the upregulation of alveolar epithelial Na-K-ATPases. Conceivably, this behavior protects against the effects of lung injury by allowing the injured lung to clear edema more effectively. Accordingly, this upregulation may be targeted as a strategy to diminish edema in patients with lung injury.

The effect of adrenergic agonists on the systemic response to hemorrhage.

PURPOSE: Systemic blood loss elicits a variety of reflex cardiovascular responses, which preserve cardiac output as possible and preserve arterial blood pressure when cardiac output decreases. When compensatory venoconstriction is exhausted, hemorrhage reduces oxygen delivery (QO2), and systemic vasoconstriction competes with local metabolic vasodilation to preserve tissue oxygen uptake (VO2). Through their effects on vascular tone and blood flow distribution, adrenergic agents might interfere with the physiological responses to reduced O2 delivery. This study was designed to determine the effects of dobutamine and norepinephrine on oxygen extraction and systemic vascular resistance during progressive hemorrhage. METHODS: We infused dobutamine or norepinephrine into anesthetized, ventilated dogs and measured the systemic vascular resistance, oxygen consumption, and oxygen extraction ratio as oxygen delivery (blood flow) was reduced by blood withdrawal. Four groups were compared: control (saline), dobutamine (10 micrograms/kg/min), high-dose norepinephrine (1.0 microgram/kg/min), and low-dose norepinephrine (0.1 microgram/kg/min). RESULTS: High-dose norepinephrine increased oxygen demand but did not alter extraction significantly at the critical point. Neither low-dose norepinephrine nor dobutamine affected oxygen extraction during hemorrhage. Dobutamine and norepinephrine both ablated the increase in systemic vascular resistance that accompanies hemorrhage. Low-dose norepinephrine was not different from control. CONCLUSIONS: Norepinephrine and dobutamine appear to block reflex vasoconstriction, and mechanistic explanations for this finding remain speculative. Despite inhibition of reflex vasoconstriction, neither dobutamine nor norepinephrine significantly impaired oxygen extraction during hemorrhage.