Proteomics of REPLICANT perfusate detects changes in the metastatic lymph node microenvironment.

In breast cancer (BC), detecting low volumes of axillary lymph node (ALN) metastasis pre-operatively is difficult and novel biomarkers are needed. We recently showed that patient-derived ALNs can be sustained ex-vivo using normothermic perfusion. We now compare reactive (tumour-free; n = 5) and macrometastatic (containing tumour deposits >2 mm; n = 4) ALNs by combining whole section multiplex immunofluorescence with TMT-labelled LC-MS/MS of the circulating perfusate. Macrometastases contained significantly fewer B cells and T cells (CD4+/CD8+/regulatory) than reactive nodes (p = 0.02). Similarly, pathway analysis of the perfusate proteome (119/1453 proteins significantly differentially expressed) showed that immune function was diminished in macrometastases in favour of 'extracellular matrix degradation'; only 'neutrophil degranulation' was preserved. Qualitative comparison of the perfusate proteome to that of node-positive pancreatic and prostatic adenocarcinoma also highlighted 'neutrophil degranulation' as a contributing factor to nodal metastasis. Thus, metastasis-induced changes in the REPLICANT perfusate proteome are detectable, and could facilitate biomarker discovery.

Toward a culturally informed rehabilitation treatment model for American Indian/Alaska Native veterans.

American Indians and Alaska Natives (AI/AN) have a long tradition of military service, allying with Western forces in North America since the 1700s. It is hardly surprising, therefore, that AI/AN veterans experience higher rates of overall disability and service-related disability than veterans of other races and ethnicities. It is not clear, however, that AI/AN veterans with disabilities are receiving effective, culturally informed rehabilitation services. This article examines the incidence of disability among contemporary AI/AN veterans, considers barriers to effective treatment, and points out model programs tailored to the particular needs of this population, with attention to the historical and cultural context of AI/AN military service.

Endovascular papillary angioendothelioma (Dabska tumor): underrecognized malignant tumor in childhood.

Endovascular papillary angioendothelioma, or Dabska tumor, was first presented in 1969 by Maria Dabska where she presented cases occurring in 6 children. The tumor was described as being a low-grade angiosarcoma characterized by papillary endovascular proliferations of atypical endothelial cells and anastomosing vascular channels within the dermis. Since its original description, only 30 case reports have been written describing the varying presentation, clinical course, and histopathology of this tumor. This case report documents the presentation and management of endovascular papillary angioendothelioma in a young male and reviews the current literature. Because more cases of EPAs are reported, perhaps a more standard approach to accurate diagnosis and treatment with surgical intervention and pathologic recognition via microscopy and immunohistochemistry can be determined.

Propranolol restores the tumor necrosis factor-alpha response of circulating inflammatory monocytes and granulocytes after burn injury and sepsis.

Beta-adrenergic blockade ameliorates the hypermetabolism and catabolism in severe burn injury. Despite the salutary effects of beta-adrenergic blockade, the immunologic responses that accompany beta-blockade are not known. We have shown that burn sepsis is associated with increased sympathetic activation leading to altered monocytopoiesis and cytokine release in macrophages (MØ). Recent evidence suggests that murine MØ expressing F4/80+Gr1+ are the inflammatory phenotype. Here, we report that propranolol given after burn sepsis modulates the number and function of myeloid cells in circulation. B6D2F1 male mice were divided into sham (S), burn (B), and burn sepsis (BS) groups. Dorsal hair was shaved from S, B, and BS; B and BS received 15% scald burn; BS was inoculated with Pseudomonas Aeruginosa (PA 14, 4000-5000 colony-forming units) at the burn site. Mice from each group were then subjected to two different treatment regimens. One set received subcutaneous injections of propranolol (5 mg/kg body weight) at 24 and 48 hours after the injury while the control groups received saline. Blood was collected by cardiac puncture at 72 hours. The distribution of total F4/80+ monocyte population was determined by flow cytometry. Inflammatory monocyte subset was gated on Gr1+ expression in the F4/80+ fraction. Lipopolysaccharide-stimulated intracellular tumor necrosis factor (TNF)-alpha (ic-TNF) was also measured as an indicator of inflammatory response. The total F4/80+ monocyte fraction was significantly increased in BS (45 +/- 0.8%) vs S and B (10 +/- 0.8%; 9.5 +/- 0.6%). Propranolol treatment for 2 days reduced the number of circulating monocytes by 60% in BS. The mean fluorescent intensity (MFI) of ic-TNF produced per cell (F4/80+Gr1+ MØ) was significantly decreased in B and BS (S: 3043 +/- 213, B: 1638 +/- 343, BS: 1463 +/- 67). Of importance, propranolol treatment partially restored the MFI of ic-TNF (2177 +/- 114) and increased the percentage of inflammatory monocyte subset (F4/80+Gr1+) in BS by 70% compared with saline treatment. In contrast, beta-blockade after BS increased the percentage of granulocytes in circulation (28.4 +/- 3.6% in BS propranolol vs 15.4 +/- 0.3% in BS saline; P < .05) and augmented their TNF production (MFI = 903 +/- 102 in BS propranolol vs 644 +/- 5 in BS saline; P < .05). Propranolol reverses burn sepsis-induced monocytosis and simultaneously increases the number of granulocytes and enhances the inflammatory potential of the granulocytes and inflammatory monocyte subsets in circulation suggesting that monitoring MØ subsets and granulocytes in blood is a reliable biomarker to predict the efficacy of beta-blockade.

Teaching professionalism during anesthesiology training.

Recently, there has been a focus on the teaching of professionalism in postgraduate medical education. Many discussions and studies have been performed to help in teaching professionalism and in the evaluation of the effectiveness of this teaching process. Unfortunately, many anesthesiologists are unaware of the literature and the discussions that have taken place. This review article serves as a primer for those individuals faced with the task of instilling the concepts of professionalism, not only in trainees but also in anesthesiologists practicing today.

Bone marrow norepinephrine mediates development of functionally different macrophages after thermal injury and sepsis.

OBJECTIVE: We sought to determine the influence of thermal (burn) injury with sepsis and norepinephrine on the clonogenic potential and functional cytokine response to lipopolysaccharide (LPS) stimulation in nonmyeloid committed (CD117) and myeloid committed (ER-MP12) bone marrow progenitor cells. SUMMARY AND BACKGROUND DATA: We have previously demonstrated that norepinephrine stimulated myelopoiesis after burn injury and sepsis, but the site of this stimulation in monocyte development is unknown. In the present study the influence of norepinephrine on the developmental hierarchy of bone marrow cells after thermal injury and sepsis was determined by assessing the clonogenic potential and LPS-stimulated cytokine responses of mature macrophages derived from CD117 and ER-MP12 bone marrow progenitor cells. METHODS: Tissue and bone marrow norepinephrine content was ablated by chemical sympathectomy with 6-hydroxydopamine treatment. CD117 and ER-MP12 bone marrow cells were isolated using antibody-linked magnetic microbeads. Clonogenic potential in response to colony-stimulating factors was determined. Both progenitor cell types were differentiated to mature macrophages in vitro and tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 cytokine responses to LPS provocation were determined. RESULTS: The macrophage- and granulocyte-macrophage colony-stimulating factor responsive clonogenic potential was increased with burn sepsis, suggesting an expansion of both progenitor populations. Such increases were greatly reduced with prior depletion of norepinephrine. TNF-alpha and IL-6 cytokine responses to LPS were markedly influenced by the specific progenitor cells involved as well as the injury conditions and the status of norepinephrine prior to injury. In burn sepsis the depletion of norepinephrine resulted in a dramatic decrease in both IL-6 and TNF-alpha production by both progenitor-derived macrophages. CONCLUSIONS: Depletion of norepinephrine attenuated burn and burn sepsis-induced bone marrow progenitor clonal growth in response to macrophage- and granulocyte-macrophage colony-stimulating factor. Functional phenotypes of bone marrow progenitor-derived macrophages are greatly influenced by norepinephrine and the milieu created by thermal injury and sepsis.