A RelA(p65) Thr505 phospho-site mutation reveals an important mechanism regulating NF-κB-dependent liver regeneration and cancer.

Post-translational modifications of nuclear factor (NF)-κB subunits provide a mechanism to differentially regulate their activity in response to the many stimuli that induce this pathway. However, the physiological significance of these modifications is largely unknown, and it remains unclear if these have a critical role in the normal and pathological functions of NF-κB in vivo. Among these, phosphorylation of the RelA(p65) Thr505 residue has been described as an important regulator of NF-κB activity in cell lines, but its physiological significance was not known. Therefore, to learn more about the role of this pathway in vivo, we generated a knockin mouse with a RelA T505A mutation. Unlike RelA knockout mice, the RelA T505A mice develop normally but exhibit aberrant hepatocyte proliferation following liver partial hepatectomy or damage resulting from carbon tetrachloride (CCl4) treatment. Consistent with these effects, RelA T505A mice exhibit earlier onset of cancer in the N-nitrosodiethylamine model of hepatocellular carcinoma. These data reveal a critical pathway controlling NF-κB function in the liver that acts to suppress the tumour-promoting activities of RelA.

The NF-κB subunit c-Rel regulates Bach2 tumour suppressor expression in B-cell lymphoma.

The REL gene, encoding the NF-κB subunit c-Rel, is frequently amplified in B-cell lymphoma and functions as a tumour-promoting transcription factor. Here we report the surprising result that c-rel-/- mice display significantly earlier lymphomagenesis in the c-Myc driven, Eµ-Myc model of B-cell lymphoma. c-Rel loss also led to earlier onset of disease in a separate TCL1-Tg-driven lymphoma model. Tumour reimplantation experiments indicated that this is an effect intrinsic to the Eµ-Myc lymphoma cells but, counterintuitively, c-rel-/- Eµ-Myc lymphoma cells were more sensitive to apoptotic stimuli. To learn more about why loss of c-Rel led to earlier onset of disease, microarray gene expression analysis was performed on B cells from 4-week-old, wild-type and c-rel-/- Eµ-Myc mice. Extensive changes in gene expression were not seen at this age, but among those transcripts significantly downregulated by the loss of c-Rel was the B-cell tumour suppressor BTB and CNC homology 2 (Bach2). Quantitative PCR and western blot analysis confirmed loss of Bach2 in c-Rel mutant Eµ-Myc tumours at both 4 weeks and the terminal stages of disease. Moreover, Bach2 expression was also downregulated in c-rel-/- TCL1-Tg mice and RelA Thr505Ala mutant Eµ-Myc mice. Analysis of wild-type Eµ-Myc mice demonstrated that the population expressing low levels of Bach2 exhibited the earlier onset of lymphoma seen in c-rel-/- mice. Confirming the relevance of these findings to human disease, analysis of chromatin immunoprecipitation sequencing data revealed that Bach2 is a c-Rel and NF-κB target gene in transformed human B cells, whereas treatment of Burkitt's lymphoma cells with inhibitors of the NF-κB/IκB kinase pathway or deletion of c-Rel or RelA resulted in loss of Bach2 expression. These data reveal a surprising tumour suppressor role for c-Rel in lymphoma development explained by regulation of Bach2 expression, underlining the context-dependent complexity of NF-κB signalling in cancer.

Evolution from the TUG to PAP flap for breast reconstruction: Comparison and refinements of technique.

BACKGROUND: Limitations of the transverse upper gracilis (TUG) flap for autologous breast reconstruction include: short pedicle, modest volume, muscle sacrifice and a problematic donor site. The Profunda Artery Perforator (PAP) flap utilises large perforators posterior to the gracilis muscle. We describe our preliminary experience of its use and compare it to our large series of TUG flaps. METHOD: Our technique has evolved from frog-leg to lithotomy position, and from an anterio-posterior to cranio-caudal raise. This allows either the descending branch of the inferior gluteal artery perforators (IGAP) or the TUG flap as alternatives should PAP perforators be unsuitable intra-operatively. A prospective database was utilised to compare TUG and PAP flaps undertaken 2010-2013. RESULTS: 54 TUG and 22 PAP flaps were performed. 4 PAP flaps were converted to IGAP flaps and 1 to TUG intra-operatively. 97% of all flaps were successful. Mean flap weight was 295 g (TUG) and 242 g (PAP). Donor site complications for both series included seroma (4 TUG, 1 PAP) sensory disturbance (2 TUG, 1 PAP) and scar revision (3 TUG, 1 PAP). CONCLUSION: Our preliminary experience of the PAP flap has not been universally favourable compared to the TUG flap. It is a more challenging flap to raise, which carries with it a learning curve, especially if raised in the supine position; we present our learning points for safer flap harvest, allowing the TUG as a bail out option. The benefits of the PAP include a longer pedicle, without the need to sacrifice muscle; the perforators should have a more defined and larger perfusion zone. The scar is better hidden, but we have not yet proven significant improvements to the donor site compared to the TUG flap. LEVEL OF EVIDENCE: III.

Using body temperature, food and water consumption as biomarkers of disease progression in mice with Eµ-myc lymphoma.

BACKGROUND: Non-invasive biomarkers of disease progression in mice with cancer are lacking making it challenging to implement appropriate humane end points. We investigated whether body temperature, food and water consumption could be used to predict tumour burden. METHODS: Thirty-six male, wild-type C57Bl/6 mice were implanted with subcutaneous RFID temperature sensors and inoculated with Eµ-myc tumours that infiltrate lymphoid tissue. RESULTS: Decrease in body temperature over the course of the study positively predicted post-mortem lymph node tumour burden (R(2)=0.68, F(1,22)=44.8, P<0.001). At experimental and humane end points, all mice that had a mean decrease in body temperature of 0.7 °C or greater had lymph nodes heavier than 0.5 g (100% sensitivity), whereas a mean decrease in body temperature <0.7 °C always predicted lymph nodes lighter than 0.5 g (100% specificity). The mean decrease in food consumption in each cage also predicted mean post-mortem lymph node tumour burden at 3 weeks (R(2)=0.89, F(1,3)=23.2, P=0.017). CONCLUSION: Temperature, food and water consumption were useful biomarkers of disease progression in mice with lymphoma and could potentially be used more widely to monitor mice with other forms of cancer.

Genetic load is associated with hypothalamic-pituitary-adrenal axis dysregulation in macaques.

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis pathway is associated with several neuropsychiatric disorders, including post-traumatic stress disorder (PTSD), major depressive disorder (MDD), schizophrenia and alcohol abuse. Studies have demonstrated an association between HPA axis dysfunction and gene variants within the cortisol, serotonin and opioid signaling pathways. We characterized polymorphisms in genes linked to these three neurotransmitter pathways and tested their potential interactions with HPA axis activity, as measured by dexamethasone (DEX) suppression response. We determined the percent DEX suppression of adrenocorticotropic hormone (ACTH) and cortisol in 62 unrelated, male rhesus macaques. While DEX suppression of cortisol was robust amongst 87% of the subjects, ACTH suppression levels were broadly distributed from -21% to 66%. Thirty-seven monkeys from the high and low ends of the ACTH suppression distribution (18 'high' and 19 'low' animals) were genotyped at selected polymorphisms in five unlinked genes (rhCRH, rhTPH2, rhMAOA, rhSLC6A4 and rhOPRM). Associations were identified between three variants (rhCRH-2610C>T, rhTPH2 2051A>C and rh5-HTTLPR) and level of DEX suppression of ACTH. In addition, a significant additive effect of the 'risk' genotypes from these three loci was detected, with an increasing number of 'risk' genotypes associated with a blunted ACTH response (P = 0.0009). These findings suggest that assessment of multiple risk alleles in serotonin and cortisol signaling pathway genes may better predict risk for HPA axis dysregulation and associated psychiatric disorders than the evaluation of single gene variants alone.

NF-κB mediates radio-sensitization by the PARP-1 inhibitor, AG-014699.

The stress-inducible transcription factor, nuclear factor (NF)-κB induces genes involved in proliferation and apoptosis. Aberrant NF-κB activity is common in cancer and contributes to therapeutic-resistance. Poly(ADP-ribose) polymerase-1 (PARP-1) is activated during DNA strand break repair and is a known transcriptional co-regulator. Here, we investigated the role of PARP-1 function during NF-κB activation using p65 small interfering RNA (siRNA), PARP siRNA or the potent PARP-1 inhibitor, AG-014699. Survival and apoptosis assays showed that NF-κB p65(-/-) cells were more sensitive to ionizing radiation (IR) than p65(+/+) cells. Co-incubation with p65 siRNA, PARP siRNA or AG-014699 radio-sensitized p65(+/+), but not p65(-/-) cells, demonstrating that PARP-1 mediates its effects on survival via NF-κB. Single-strand break (SSB) repair kinetics, and the effect SSB repair inhibition by AG-014699 were similar in p65(+/+) and p65(-/-) cells. As preventing SSB repair did not radio-sensitize p65(-/-) cells, we conclude that radio-sensitization by AG-014699 is due to downstream inhibition of NF-κB activation, and independent of SSB repair inhibition. PARP-1 catalytic activity was essential for IR-induced p65 DNA binding and NF-κB-dependent gene transcription, whereas for tumor necrosis factor (TNF)-α-treated cells, PARP-1 protein alone was sufficient. We hypothesize that this stimulus-dependent differential is mediated via stimulation of the poly(ADP-ribose) polymer, which was induced following IR, not TNF-α. Targeting DNA damage-activated NF-κB using AG-014699 may therefore overcome toxicity observed with classical NF-κB inhibitors without compromising other vital inflammatory functions. These data highlight the potential of PARP-1 inhibitors to overcome NF-κB-mediated therapeutic resistance and widens the spectrum of cancers in which these agents may be utilized.

Co-occurring diagnoses among FMR1 premutation allele carriers.

Following the discovery of two disorders associated with premutation alleles of the fragile X mental retardation gene (FMR1), primary ovarian insufficiency [fragile X-associated primary ovarian insufficiency (FXPOI)] and a tremor/ataxia syndrome [fragile X-associated tremor/ataxia disorder (FXTAS)], numerous studies have examined other potential co-morbid conditions, including neuropsychological deficits. Here, the frequency of self-reported diagnoses obtained through medical history interviews from FMR1 premutation carriers and non-carriers aged 18-50 were analyzed. Study subjects included 537 women, 334 of whom carry the premutation and 151 men, 37 of whom carry the premutation. Men with the premutation did not report any medical conditions at higher rates compared with non-carriers, controlling for age, ethnicity/race, and household income. Women with the premutation reported mental health disorders [i.e. attention deficit hyperactivity disorder (ADHD), anxiety, depression] significantly more often than non-carriers. However, after adjusting for covariates, these increased rates were not statistically significant. Additional follow-up analyses examined the consequence of ovarian dysfunction as a cause of co-occurring conditions. Women with an indication of ovarian insufficiency (i.e. irregular cycles) reported higher rates of thyroid problems and depression/anxiety. Because only women, not men, reported these conditions more often, the relationship between FXPOI and hormone irregularities in women should be explored for a potential link with the increase in the reported medical conditions.

Demand management in plastic surgery for low priority procedures: the Welsh experience.

INTRODUCTION: Health Commission Wales (Specialist Services) [HCW] are responsible for resource allocation and demand management in plastic surgery for the population of Wales (2.9 M). Since 2004, all low priority plastic surgery referrals have been screened by a single HCW Case Officer against clinical inclusion criteria before the referral is passed to the provider. Only patients fulfilling these criteria proceed to an outpatient appointment, although there is an appeals procedure. Revised guidelines were introduced in 2006. Our aim was to investigate the effectiveness of the process and the impact of the revised criteria. METHODS: The Case Officer's database was used to determine numbers of index procedures referred and those disallowed before and after the policy change. RESULTS: Since 2004 9,654 referrals have been screened. In 2005-6, 32.5% failed to meet the inclusion criteria and were disallowed. In the year after the policy revision fewer low priority patients were referred (1720 vs. 2013) and more (46.6%) were declined. Body contouring / abdominoplasty were particularly affected with 73.2% not compliant with funding criteria. CONCLUSION: The Welsh model is an efficient, effective and equitable system for demand management, which amounts to thousands of requests per year. After 2006, tighter guidelines have resulted in a higher proportion of patients not meeting the criteria for funding, particularly for body contouring / abdominoplasty procedures. Difficulties remain however in determining reproducible and clinically appropriate criteria for patients seeking plastic surgery following massive weight-loss. Whilst this process streamlines the provision of NHS plastic surgery for the people of Wales, there is a potential impact on specialist training.

Ionizing radiation-induced NF-kappaB activation requires PARP-1 function to confer radioresistance.

Recent reports implicate poly(ADP-ribose) polymerase-1 (PARP-1) in the activation of nuclear factor kappaB (NF-kappaB). We investigated the role of PARP-1 in the NF-kappaB signalling cascade induced by ionizing radiation (IR). AG14361, a potent PARP-1 inhibitor, was used in two breast cancer cell lines expressing different levels of constitutively activated NF-kappaB, as well as mouse embryonic fibroblasts (MEFs) proficient or deficient for PARP-1 or NF-kappaB p65. In the breast cancer cell lines, AG14361 had no effect on IR-induced degradation of IkappaBalpha or nuclear translocation of p50 or p65. However, AG14361 inhibited IR-induced NF-kappaB-dependent transcription of a luciferase reporter gene. Similarly, in PARP-1(-/-) MEFs, IR-induced nuclear translocation of p50 and p65 was normal, but kappaB binding and transcriptional activation did not occur. AG14361 sensitized both breast cancer cell lines to IR-induced cell killing, inhibited IR-induced XIAP expression and increased caspase-3 activity. However, AG14361 failed to increase IR-induced caspase activity when p65 was knocked down by siRNA. Consistent with this, AG14361 sensitized p65(+/+) but not p65(-/-) MEFs to IR. We conclude that PARP-1 activity is essential in the upstream regulation of IR-induced NF-kappaB activation. These data indicate that potentiation of IR-induced cytotoxicity by AG14361 is mediated solely by inhibition of NF-kappaB activation.

Sciatic neuroma presenting forty years after above-knee amputation.

We report a case of a sciatic neuroma presenting forty years after above knee amputation. Patients developing neuroma following a limb amputation can present with stump pain which is commonly resistant to medical intervention. The length of interval from the initial injury to presentation is widely variable. Diagnosis relies on clinical suspicion and accurate assessment, radiological imaging and, if indicated, surgical exploration. MRI provides a better soft tissue definition than CT and is more accurate in identifying small lesions than ultrasound. The aim of treatment for symptomatic neuroma is pain relief and improvement of function. This is often achieved by surgical excision.

Effects of early use of pioglitazone in combination with metformin in patients with newly diagnosed type 2 diabetes.

BACKGROUND: Type 2 diabetes is characterised by a progressive decline in HbA1c control over time. Early combination therapy, rather than sequential introduction of individual oral glucose-lowering agents, has been proposed to prevent this gradual rise in HbA1c. This observational study assessed the effect of early dual combination oral glucose-lowering therapies within 6 months of diagnosis in newly diagnosed, drug-naïve patients with type 2 diabetes. PATIENTS AND METHODS: This was an observational, open-label, non-randomised study in newly diagnosed patients with type 2 diabetes, aged 35-70 years, with HbA1c levels > 8.0% at diagnosis or > 7.0% at the 3-6-month follow-up. Patients were allocated to dietary management alone if the HbA1c level was 7.0-8.0% at diagnosis. Metformin combined with gliclazide, repaglinide, or pioglitazone was given at diagnosis if the HbA1c was > 8.0%. Similar treatments were introduced at 3-6 months if the HbA1c was > 7.0%. Over a 3-year period, HbA1c was measured at 3-monthly intervals. All patients underwent regular dietetic review. Target HbA1c was < or = 7.0%. RESULTS: 416 patients were considered eligible for inclusion, with a mean (+/- SD) age of 54.1 +/- 9.2 years, BMI of 33.5 +/- 6.1 kg/m2, and baseline HbA1c of 8.6 +/- 1.7%. A mixed model analysis of variance on the 178 patients who started with combination therapy, either immediately or after a 3-6 month period on diet, showed that metformin plus gliclazide, repaglinide, or pioglitazone was associated with a gradual increase in HbA1c values. Amongst those patients treated with the metformin/pioglitazone combination there was an estimated 0.1% increase in HbA1c/year. This was much less pronounced than the rises seen in HbA1c/year of 0.5% with the metformin/gliclazide and metformin/repaglinide combinations. CONCLUSIONS: This preliminary analysis of an observational, non-randomised, open-label ongoing study has shown that early use of combination therapy at time of diagnosis or within the first 3-6 months following diagnosis with metformin plus pioglitazone in newly diagnosed type 2 diabetes results in a slower deterioration in glycaemic control than that with metformin combined with either gliclazide or repaglinide. This may be due to the beta-cell protective properties of pioglitazone. These results need to be confirmed by further studies with a more robust design and methodology.

Refinements of the LeJour vertical mammaplasty skin pattern for skin-sparing mastectomy and immediate breast reconstruction.

BACKGROUND: Skin-sparing mastectomy (SSM) is a well-established technique for immediate breast reconstruction (IBR). When used for large and/or ptotic breasts, traditional SSM patterns produce long skin flaps prone to necrosis or 'T' junction breakdown. The authors have previously demonstrated the applicability of the LeJour-type vertical mammaplasty skin pattern to this group of patients. With further experience, indications for this procedure have been widened and the technique refined. RESULTS: Over five years, 26 immediate breast reconstructions were carried out in 19 patients using this technique: three expandable implants, seven LDs, three pedicled TRAMs, five free TRAMs, seven DIEPs and one SIEA flap. Fourteen patients (74%) had simultaneous contralateral balancing LeJour breast reductions or mastopexies. The remaining five patients had bilateral mastectomies and reconstructions using the vertical mammaplasty skin pattern for both breasts. All flaps were successful, but there were three cases of minor skin flap necrosis, three of delayed wound healing and two instances of significant post-operative bleeding. Cosmesis was suboptimal in the prosthetic reconstruction group, necessitating revisional surgery. DISCUSSION AND CONCLUSIONS: The vertical mammaplasty skin pattern was successfully used with a wide range of reconstructions. However, to avoid suboptimal cosmetic results and minimise wound healing problems this technique is not recommended in heavy smokers, very obese patients, those undergoing prosthetic reconstructions or neoadjuvant chemotherapy. The skin resection pattern should also be conservative. The LeJour-type vertical mammaplasty pattern is a viable alternative technique for SSM in selected patients, especially those requiring contralateral balancing surgery and undergoing autologous tissue reconstruction.

A comparison of Salmonella serotypes isolated from New Zealand sea lions and feral pigs on the Auckland Islands by pulsed-field gel electrophoresis.

The Salmonella serotypes S. Cerro and S. Newport were isolated from New Zealand sea lions (Phocarctos hookeri) and feral pigs on the Auckland Islands in the New Zealand subantarctic region. The isolates were typed by pulsed-field gel electrophoresis using Xba1 as the restriction enzyme. The isolates were indistinguishable, which suggests that Salmonella infection cycles between sea lions and pigs in this environment. Apart from a previous isolation from a single New Zealand fur seal (Arctocephalus forsteri), S. Newport has not been recorded in any animals from New Zealand, but it is associated with gastroenteritis in humans. Contamination of the marine environment by human waste is a possible source of infection for marine mammals and warrants further investigation.

Studies on effects of dietary fatty acids as related to their position on triglycerides.

This article reviews published literature on how the stereospecific structure of dietary triglycerides may affect lipid metabolism in humans. Animal studies have shown enhanced absorption of fatty acids in the sn-2 position of dietary triglycerides. Increasing the level of the saturated fatty acid palmitic acid in the sn-2 position (e.g., by interesterification of the fat to randomize the positions of the fatty acids along the glycerol backbone) has been shown in rabbits to increase the atherogenic potential of the fat without impacting levels of blood lipids and lipoproteins. In contrast, enhancing the level of stearic acid in the sn-2 position has not been found to affect either atherogenic potential or levels of blood lipids and lipoproteins in rabbits. Fatty acids other than palmitic and stearic have not been studied systematically with respect to possible positional effects. A limited number of human studies have shown no significant effects of interesterified fats on blood lipid parameters. However, it is unknown whether modifying the stereospecific structure of dietary triglycerides would affect atherogenicity or other long-term health conditions in humans. It is possible that incorporation of palmitic acid into the sn-2 position of milk fat is beneficial to the human infant (as a source of energy for growth and development) but not to human adults. Additional research is needed to determine whether processes like interesterification, which can be used to alter physical parameters of dietary fats (e.g., melting characteristics), may result in favorable or unfavorable long-term effects in humans.