Differentiation-Dependent KLF4 Expression Promotes Lytic Epstein-Barr Virus Infection in Epithelial Cells

Epstein-Barr virus (EBV) is a human herpesvirus associated with B-cell and epithelial cell malignancies. EBV lytically infects normal differentiated oral epithelial cells, where it causes a tongue lesion known as oral hairy leukoplakia (OHL) in immunosuppressed patients. However, the cellular mechanism(s) that enable EBV to establish exclusively lytic infection in normal differentiated oral epithelial cells are not currently understood. Here we show that a cellular transcription factor known to promote epithelial cell differentiation, KLF4, induces differentiation-dependent lytic EBV infection by binding to and activating the two EBV immediate-early gene (BZLF1 and BRLF1) promoters. We demonstrate that latently EBV-infected, telomerase-immortalized normal oral keratinocyte (NOKs) cells undergo lytic viral reactivation confined to the more differentiated cell layers in organotypic raft culture. Furthermore, we show that endogenous KLF4 expression is required for efficient lytic viral reactivation in response to phorbol ester and sodium butyrate treatment in several different EBV-infected epithelial cell lines, and that the combination of KLF4 and another differentiation-dependent cellular transcription factor, BLIMP1, is highly synergistic for inducing lytic EBV infection. We confirm that both KLF4 and BLIMP1 are expressed in differentiated, but not undifferentiated, epithelial cells in normal tongue tissue, and show that KLF4 and BLIMP1 are both expressed in a patient-derived OHL lesion. In contrast, KLF4 protein is not detectably expressed in B cells, where EBV normally enters latent infection, although KLF4 over-expression is sufficient to induce lytic EBV reactivation in Burkitt lymphoma cells. Thus, KLF4, together with BLIMP1, plays a critical role in mediating lytic EBV reactivation in epithelial cells.

Lytic EBV infection of differentiated oral epithelial cells results in the release of infectious viral particles and is required for efficient transmission of EBV from host to host. Lytic infection also causes a tongue lesion known as oral hairy leukoplakia (OHL). However, surprisingly little is known in regard to how EBV gene expression is regulated in epithelial cells. Using a stably EBV- infected, telomerase-immortalized normal oral keratinocyte cell line, we show here that undifferentiated basal epithelial cells support latent EBV infection, while differentiation of epithelial cells promotes lytic reactivation. Furthermore, we demonstrate that the KLF4 cellular transcription factor, which is required for normal epithelial cell differentiation and is expressed in differentiated, but not undifferentiated, normal epithelial cells, induces lytic EBV reactivation by activating transcription from the two EBV immediate-early gene promoters. We also show that the combination of KLF4 and another differentiation-dependent cellular transcription factor, BLIMP1, synergistically activates lytic gene expression in epithelial cells. We confirm that KLF4 and BLIMP1 expression in normal tongue epithelium is confined to differentiated cells, and that KLF4 and BLIMP1 are expressed in a patient-derived OHL tongue lesion. These results suggest that differentiation-dependent expression of KLF4 and BLIMP1 in epithelial cells promotes lytic EBV infection.

A cancer-associated Epstein-Barr virus BZLF1 promoter variant enhances lytic infection

Latent Epstein-Barr virus (EBV) infection contributes to both B-cell and epithelial-cell malignancies. However, whether lytic EBV infection also contributes to tumors is unclear, although the association between malaria infection and Burkitt lymphomas (BLs) may involve excessive lytic EBV replication. A particular variant of the viral promoter (Zp) that controls lytic EBV reactivation is over-represented, relative to its frequency in non-malignant tissue, in EBV-positive nasopharyngeal carcinomas and AIDS-related lymphomas. To date, no functional differences between the prototype Zp (Zp-P) and the cancer-associated variant (Zp-V3) have been identified. Here we show that a single nucleotide difference between the Zp-V3 and Zp-P promoters creates a binding site for the cellular transcription factor, NFATc1, in the Zp-V3 (but not Zp-P) variant, and greatly enhances Zp activity and lytic viral reactivation in response to NFATc1-inducing stimuli such as B-cell receptor activation and ionomycin. Furthermore, we demonstrate that restoring this NFATc1-motif to the Zp-P variant in the context of the intact EBV B95.8 strain genome greatly enhances lytic viral reactivation in response to the NFATc1-activating agent, ionomycin, and this effect is blocked by the NFAT inhibitory agent, cyclosporine, as well as NFATc1 siRNA. We also show that the Zp-V3 variant is over-represented in EBV-positive BLs and gastric cancers, and in EBV-transformed B-cell lines derived from EBV-infected breast milk of Kenyan mothers that had malaria during pregnancy. These results demonstrate that the Zp-V3 enhances EBV lytic reactivation to physiologically-relevant stimuli, and suggest that increased lytic infection may contribute to the increased prevalence of this variant in EBV-associated malignancies.

Extracellular polysaccharide is required for wild-type virulence of Pseudomonas solanacearum

Several Pseudomonas solanacearum strains which produced no detectable extracellular polysaccharide (EPS) in planta had been reported to remain highly virulent when tested at high inoculum concentrations (P. Xu, M. Iwata, S. Leong, and L. Sequeira, J. Bacteriol. 172:3946-3951, 1990; P. Xu, S. Leong, and L. Sequeira, J. Bacteriol. 170:617-622, 1988). Two of these mutants, KD700 and KD710, have now been molecularly and genetically mapped to the EPSI gene cluster described by Denny and Baek (Mol. Plant-Microbe Interact. 4:198-206, 1991). When a range of inoculum concentrations was used, these two mutants and all other EPS-defective mutants tested were found to be reduced in virulence to eggplants and tobacco relative to the wild-type strain. Thus, EPS consistently is required for the wild-type level of virulence in P. solanacearum.

The cellular ataxia telangiectasia-mutated kinase promotes epstein-barr virus lytic reactivation in response to multiple different types of lytic reactivation-inducing stimuli

The Epstein-Barr virus (EBV) latent-to-lytic switch is mediated by the viral proteins BZLF1 (Z), BRLF1 (R), and BRRF1 (Na). Since we previously showed that DNA-damaging agents (including chemotherapy and irradiation) can induce EBV lytic reactivation and recently demonstrated that wild-type p53 contributes to lytic reactivation, we investigated the role of the ATM kinase during EBV reactivation. ATM phosphorylates and activates p53, as well as numerous other substrates involved in the cellular DNA damage response. Using an ATM inhibitor (KU55933), we found that ATM activity is required for efficient induction of EBV lytic gene expression by a variety of different stimuli, including a histone deacetylase (HDAC) inhibitor, the transforming growth factor β (TGF-β) cytokine, a demethylating agent (5-azacytidine), B cell receptor engagement with anti-IgG antibody, hydrogen peroxide, and the proteosome inhibitor bortezomib. In EBV-infected AGS (gastric) cells, knockdown of ATM, or p53, expression inhibits EBV reactivation. Conversely, treatment of these cells with nutlin-3 (which activates p53 and ATM) robustly induces lytic reactivation in a p53- and ATM-dependent manner. The ability of the EBV R and Na proteins to induce lytic reactivation in EBV-infected AGS cells is ATM dependent. However, overexpression of Z induces lytic gene expression in the presence or absence of ATM activity. Our results suggest that ATM enhances Z promoter activity in the context of the intact EBV genome and that p53 contributes to the ATM effect. Nevertheless, since we found that ATM inhibitors also reduce lytic reactivation in Burkitt lymphoma cells that have no p53, additional ATM substrates must also contribute to the ATM effect.

Leflunomide/teriflunomide inhibit Epstein-Barr virus (EBV)- induced lymphoproliferative disease and lytic viral replication

EBV infection causes mononucleosis and is associated with specific subsets of B cell lymphomas. Immunosuppressed patients such as organ transplant recipients are particularly susceptible to EBV-induced lymphoproliferative disease (LPD), which can be fatal. Leflunomide (a drug used to treat rheumatoid arthritis) and its active metabolite teriflunomide (used to treat multiple sclerosis) inhibit de novo pyrimidine synthesis by targeting the cellular dihydroorotate dehydrogenase, thereby decreasing T cell proliferation. Leflunomide also inhibits the replication of cytomegalovirus and BK virus via both "on target" and "off target" mechanisms and is increasingly used to treat these viruses in organ transplant recipients. However, whether leflunomide/teriflunomide block EBV replication or inhibit EBV-mediated B cell transformation is currently unknown. We show that teriflunomide inhibits cellular proliferation, and promotes apoptosis, in EBV-transformed B cells in vitro at a clinically relevant dose. In addition, teriflunomide prevents the development of EBV-induced lymphomas in both a humanized mouse model and a xenograft model. Furthermore, teriflunomide inhibits lytic EBV infection in vitro both by preventing the initial steps of lytic viral reactivation, and by blocking lytic viral DNA replication. Leflunomide/teriflunomide might therefore be clinically useful for preventing EBV-induced LPD in patients who have high EBV loads yet require continued immunosuppression.

Roles of lytic viral infection and IL-6 in early versus late passage lymphoblastoid cell lines and EBV-associated lymphoproliferative disease

Lytically infected EBV-positive lymphoblastoid cells enhance the growth of early-passage, but not late-passage, EBV-immortalized lymphoblastoid cell lines (LCLs) in SCID mice and have enhanced IL-6 secretion. Here, we have examined the importance of IL-6 for the growth of early-passage LCLs (EPL) in SCID mice, identified lytic EBV proteins that activate IL-6 production and compared viral and cellular differences between early versus late passage LCLs (LPL). IL-6 was required for efficient growth of EPL in SCID mice. The EBV immediate-early (IE) proteins, BRLF1 and BZLF1, each induced IL-6 secretion when transfected into 293 and BJAB cells. Interestingly, the combination of BZLF1 and the latent EBV protein, LMP-1, induced much more IL-6 expression in both 293 and BJAB cells than either protein alone. Both BZLF1 and BRLF1 also enhanced IL-10 production in 293 cells. In comparison to the EPL, LPL had much reduced expression of early lytic viral proteins and cellular IL-6. In contrast, expression of cellular IL-10 was similar in EPL versus LPL, while VEGF secretion was increased in late-passage LCLs. These results suggest that both BRLF1 and BZLF1 contribute to IL-6 secretion in lytically infected cells and that lytically infected cells may promote early lymphoproliferative disease in patients through enhanced IL-6 production.

Repigmentation of vitiliginous skin by cultured cells

Epidermal cells from pigmented areas of a patient with vitiligo were cultured in MCDB-153 medium, which supports the clonal growth of undifferentiated keratinocytes and melanocytes. The cells were grown on collagen-coated substrata. After the cells reached semiconfluence, the composite of substratum and cells was emplaced onto dermabraded vitiliginous areas as a graft. Re-epithelialization of the grafted areas was complete after 2 weeks. Repigmentation was evident after 1 month and continued over the observation period of several months. There was complete and normal differentiation of the graft, including a normal distribution of melanocytes in the basal layer. Ultrastructural studies showed a normal distribution of melanosomes in the melanocytes and showed keratinocytes that were indistinguishable from the uninvolved skin.

Glycoproteins modulate adhesion in terminally differentiated keratinocytes

The stratum corneum can be dissociated into single squames by homogenization in ether. We have reaggregated the free corneocytes into a multilayered lamellar structure resembling an intact stratum corneum. The reconstituted stratum corneum reacts with fluorescein-conjugated lectins, unlike the intact tissue. We infer that the lack of binding in the intact tissue is due to masking of saccharide sites by lipids (which are extracted by the ether). In an extension of the procedure, the ether is removed and replaced by acetone. This system permits us to modulate corneocyte reaggregation by the addition of appropriate agents. We have used this system to corroborate our hypothesis that a 40 kD cell-surface glycoprotein (an endogenous lectin specific for amino sugars), which we have isolated from the stratum corneum, is instrumental in adhesion of corneocytes by cross-linking with amino sugar sites on adjacent cells. The reaggregation is inhibited by the antibody to the 40 kD glycoprotein. It is also inhibited by either the addition of amino sugars which bind to the endogenous lectin, or the addition of exogenous lectins specific for amino sugars which bind to the ligand.

Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline

Objective: To develop an evidence-based clinical practice guideline (CPG) through a broad-based consensus process on best practices for chiropractic management of patients with chronic musculoskeletal (MSK) pain. Design: CPG based on evidence-based recommendations of a panel of experts in chronic MSK pain management. Methods: Using systematic reviews identified in an initial literature search, a steering committee of experts in research and management of patients with chronic MSK pain drafted a set of recommendations. Additional supportive literature was identified to supplement gaps in the evidence base. A multidisciplinary panel of experienced practitioners and educators rated the recommendations through a formal Delphi consensus process using the RAND Corporation/University of California, Los Angeles, methodology. Results: The Delphi process was conducted January-February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions: low-back pain (LBP), neck pain, tension headache, osteoarthritis (knee and hip), and fibromyalgia. Recommendations were made for nonpharmacological treatments, including acupuncture, spinal manipulation/mobilization, and other manual therapy; modalities such as low-level laser and interferential current; exercise, including yoga; mind-body interventions, including mindfulness meditation and cognitive behavior therapy; and lifestyle modifications such as diet and tobacco cessation. Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized. Conclusions: These evidence-based recommendations for a variety of conservative treatment approaches to the management of common chronic MSK pain conditions may advance consistency of care, foster collaboration between provider groups, and thereby improve patient outcomes.

B cells infected with Type 2 Epstein-Barr virus (EBV) have increased NFATc1/NFATc2 activity and enhanced lytic gene expression in comparison to Type 1 EBV infection

Humans are infected with two distinct strains (Type 1 (T1) and Type 2 (T2)) of Epstein-Barr virus (EBV) that differ substantially in their EBNA2 and EBNA 3A/B/C latency genes and the ability to transform B cells in vitro. While most T1 EBV strains contain the "prototype" form of the BZLF1 immediate-early promoter ("Zp-P"), all T2 strains contain the "Zp-V3" variant, which contains an NFAT binding motif and is activated much more strongly by B-cell receptor signalling. Whether B cells infected with T2 EBV are more lytic than cells infected with T1 EBV is unknown. Here we show that B cells infected with T2 EBV strains (AG876 and BL5) have much more lytic protein expression compared to B cells infected with T1 EBV strains (M81, Akata, and Mutu) in both a cord blood-humanized (CBH) mouse model and EBV-transformed lymphoblastoid cell lines (LCLs). Although T2 LCLs grow more slowly than T1 LCLs, both EBV types induce B-cell lymphomas in CBH mice. T1 EBV strains (M81 and Akata) containing Zp-V3 are less lytic than T2 EBV strains, suggesting that Zp-V3 is not sufficient to confer a lytic phenotype. Instead, we find that T2 LCLs express much higher levels of activated NFATc1 and NFATc2, and that cyclosporine (an NFAT inhibitor) and knockdown of NFATc2 attenuate constitutive lytic infection in T2 LCLs. Both NFATc1 and NFATc2 induce lytic EBV gene expression when combined with activated CAMKIV (which is activated by calcium signaling and activates MEF2D) in Burkitt Akata cells. Together, these results suggest that B cells infected with T2 EBV are more lytic due to increased activity of the cellular NFATc1/c2 transcription factors in addition to the universal presence of the Zp-V3 form of BZLF1 promoter.

Kawasaki disease associated with streptococcal infection within a family

OBJECTIVE

To describe the illness occurring in four members of a family, which had clinical and laboratory features of Kawasaki disease and streptococcal infection.

METHODOLOGY

A retrospective report of three siblings and an adult male living in one household. The children had serology, blood counts, cultures and echocardiography performed and were treated with antibiotics and gammaglobulin infusions.

RESULTS

The patients developed clinical, and exhibited laboratory, features suggesting streptococcal infection and 4/5 criteria suggesting the diagnosis of Kawasaki disease. All made a good clinical recovery but the youngest developed a coronary artery aneurysm.

CONCLUSIONS

It may be difficult to distinguish streptococcal infection and Kawasaki disease. It is possible that some cases of Kawasaki disease are precipitated by streptococcal infection.

A monoclonal antibody against the receptor for advanced glycation end products attenuates inflammatory and neuropathic pain in the mouse

BACKGROUND

The receptor for advanced glycation end products (RAGE) is a multi-ligand receptor in the immunoglobulin superfamily. RAGE is localized throughout ascending sensory pathways (skin, peripheral nerve, dorsal root ganglion, spinal cord), and in cell types interacting with sensory neurons (endothelial cells, smooth muscle cells, monocytes and macrophages). Neuronal RAGE expression increases in pathological pain states in humans and rodents, and soluble RAGE attenuates thermal hypoalgesia in diabetic mice. The objective of the present study was to investigate whether pharmacological modulation of RAGE could attenuate mechanical allodynia in rodent pain models.

METHODS

We developed an anti-RAGE monoclonal antibody (11E6) that binds to the C2 immunoglobulin domain of human RAGE, binds to mouse RAGE, and presumably to the same domain in mouse RAGE. The antinociceptive activity of 11E6 was investigated in mouse models of inflammatory (complete Freund's adjuvant) and neuropathic (chronic constriction injury of the sciatic nerve) pain. Mice were dosed intraperitoneally with 11E6 or IgG (negative control).

RESULTS

Increased mechanical thresholds were observed following a single dose of 11E6 in both inflammatory and neuropathic pain models. Similar treatment with IgG did not alter nociceptive sensitivity. Repeated dosing with 11E6 significantly attenuated established mechanical hypersensitivity in a neuropathic pain model in a dose-related fashion.

CONCLUSIONS

These data demonstrate that specific modulation of RAGE effectively attenuates nociceptive sensitivity associated with chronic inflammatory and neuropathic pain states.

Plasma C-peptide levels identify insulin-treated diabetic patients suitable for oral hypoglycaemic therapy

Plasma C-peptide levels were measured fasting and 2 h after an oral glucose load in 37 insulin-treated diabetic patients to assess their clinical value in identifying any noninsulin-dependent diabetic patients. All subjects were changed from insulin to oral hypoglycaemic therapy and followed for 3 months. Twenty patients (group A) completed the trial without requiring insulin and 17 (group B) required restabilization on insulin due to deteriorating metabolic control. Fasting and 2 h C-peptide levels were significantly higher in group A (0.11 +/- 0.09 and 0.17 +/- 0.12 nmol/l; mean +/- S.D.) compared with group B (0.02 +/- 0.03 and 0.02 +/- 0.03 nmol/l) (p less than 0.002 and p less than 0.002). The fasting C-peptide levels at 3 months (0.28 +/- 0.14 nmol/l) were also significantly higher than the fasting levels at the beginning of the study (p less than 0.002). Fasting and 2-h glucose levels were lower in group A (11.0 +/- 3.7 and 17.6 +/- 5.2 mmol/l) than in group B (14.4 +/- 6.2 and 23.1 +/- 5.9 mmol/l; p less than 0.05 and 0.02, respectively). The differences in glycosylated haemoglobin and fasting glucose levels at the start of the study and after 3 months of oral therapy were not statistically significant. Although C-peptide values overlapped in groups A and B, they were of greater value in identifying patients suitable for oral therapy than any single clinical criterion, and thus may help in identifying insulin-treated diabetic patients who may be treated with oral therapy without deterioration in metabolic control.

Use of a dual monoclonal solid phase and a polyclonal detector to create an immunoassay for the detection of human cardiac troponin I

OBJECTIVES

We report the development of a fully automated, random access, chemiluminescent immunoassay, for the detection of human cardiac Troponin I (cTnI) in serum and plasma for use on the ACS:180(R) System.

DESIGN AND METHODS

This assay format uses a combination of two monoclonal antibodies covalently coupled to paramagnetic (PMP) particles as a solid phase and an affinity purified polyclonal antibody, specific to the N-terminal domain of cTnI (peptide-3 region) labeled with a chemiluminescent compound as the detector antibody. The assay offers excellent low-end sensitivity and precision.

RESULTS

No interferences are observed from by blood components such as HAMA and drugs used in cardiac therapy. Patient samples tested on the ACS:180 cTnI assay showed good correlation with the Stratus cTnI assay (ACS: cTnI = 1. 02*Stratus + 0.05 g/L, r = 0.96, n = 1170).

CONCLUSION

Paired with the other ACS:180 cardiac assays, myoglobin and CKMBII, the ACS:180 system now offers an excellent panel of cardiac assay for use in rapid and accurate diagnosis of a myocardial event.

Relationship between viticultural climatic indices and grape maturity in Australia

Historical temperature data and maturity records were analyzed for 45 vineyard blocks in 15 winegrowing regions across Australia in order to evaluate the suitability of common viticultural indices to estimate date of grape maturity. Five temperature-based viticultural indices (mean January temperature, mean growing season temperature, growing degree days, biologically effective degree days, Huglin Index) along with four springtime temperature indices (mean and maximum temperature summations for September, October, and November; growing degree days and biologically effective degree days modified to include September) were compared to maturity data in order to investigate index relationship to observed maturity timing. Daily heat summations for the months of September, October, and November showed the best correlation to day of year of maturity, suggesting that springtime temperatures are important relative to the timing of grape maturity. Mean January temperature, a commonly used index, had the poorest correlation with day of year of maturity of all the indices included in this study. Indices that included the month of April had poorer correlation than indices that shifted the months included in the growing season to be from September to March inclusive. Calculated index values for the past 30 years for every region included in this study showed increasing temporal trends to various degrees, indicating that all regions studied are experiencing warming temperatures during the growing season. These results emphasize the need to reevaluate viticultural indices in the context of a changing climate.

Lithostratigraphic analysis of a new stromatolite-thrombolite reef from across the rise of atmospheric oxygen in the Paleoproterozoic Turee Creek Group, Western Australia

This study describes a previously undocumented dolomitic stromatolite-thrombolite reef complex deposited within the upper part (Kazput Formation) of the c. 2.4-2.3 Ga Turee Creek Group, Western Australia, across the rise of atmospheric oxygen. Confused by some as representing a faulted slice of the younger c. 1.8 Ga Duck Creek Dolomite, this study describes the setting and lithostratigraphy of the 350-m-thick complex and shows how it differs from its near neighbour. The Kazput reef complex is preserved along 15 km of continuous exposure on the east limb of a faulted, north-west-plunging syncline and consists of 5 recognisable facies associations (A-E), which form two part regressions and one transgression. The oldest facies association (A) is characterised by thinly bedded dololutite-dolarenite, with local domical stromatolites. Association B consists of interbedded columnar and stratiform stromatolites deposited under relatively shallow-water conditions. Association C comprises tightly packed columnar and club-shaped stromatolites deposited under continuously deepening conditions. Clotted (thrombolite-like) microbialite, in units up to 40 m thick, dominates Association D, whereas Association E contains bedded dololutite and dolarenite, and some thinly bedded ironstone, shale and black chert units. Carbon and oxygen isotope stratigraphy reveals a narrow range in both δ(13) Ccarb values, from -0.22 to 0.97‰ (VPDB: average = 0.68‰), and δ(18) O values, from -14.8 to -10.3‰ (VPDB), within the range of elevated fluid temperatures, likely reflecting some isotopic exchange. The Kazput Formation stromatolite-thrombolite reef complex contains features of younger Paleoproterozoic carbonate reefs, yet is 300-500 Ma older than previously described Proterozoic examples worldwide. Significantly, the microbial fabrics are clearly distinct from Archean stromatolitic marine carbonate reefs by way of containing the first appearance of clotted microbialite and large columnar stromatolites with complex branching arrangements. Such structures denote a more complex morphological expression of growth than previously recorded in the geological record and may link to the rise of atmospheric oxygen.

Purification of proteins from polyacrylamide gels, free of detergent or dye

A two step procedure recovers proteins from sodium dodecyl sulfate polyacrylamide gels. The proteins are eluted by electrophoretic dialysis. The eluent is then passed through an Amberlite CG-400 anion-exchange resin. The recovery of protein is nearly total. The recovered proteins have no detectable sodium dodecyl sulfate contamination. With gels that have been stained with Coomassie Brilliant Blue R, the procedure recovers the proteins free of the dye. We have used this procedure successfully during the purification of epidermal glycoproteins.

The Association of Surgeons in Training (ASiT) Consensus Statement on Major Trauma Training in the UK

INTRODUCTION

Since the establishment of the Major Trauma Networks in 2012, it is estimated that an extra 1,600 lives have been saved across England. Although the delivery of trauma care has improved significantly, the provision of trauma training has not and remains fragmented. The Association of Surgeons in Training (ASiT), an independent organisation run by trainees, is dedicated to excellence in surgical training within the United Kingdom (UK) and Republic of Ireland (ROI). The aim of this study was to develop a consensus statement representing the views of the ASiT on the future of trauma surgery training.

METHODS

A modified nominal group technique was used in five stages: 1, scoping exercise; 2, virtual consultation; 3, nominal group consensus meeting; 4, virtual feedback from stakeholders; and 5, virtual confirmation by the ASiT Council. The design and reporting of the consensus followed best practice methodology for consensus research.

RESULTS

Overall, 62 participants gave 90 statements across stages 1-3. Eleven key themes were identified, all of which met the consensus of the ASiT Council. The key findings were widespread support for increased exposure to trauma for medical students and early surgical trainees as well as an increased use of simulation methods and improved focus on non-technical skills within trauma surgery.

CONCLUSIONS

This study sets out the position of the ASiT on the future of trauma surgery training and how training in major trauma surgery in the UK and ROI could be improved.

Is quantification of lymphovascular space invasion useful in stage 1B2 cervical carcinomas?

The objective was to determine whether quantification of lymphovascular space invasion (LVSI) by simple techniques adds prognostic information above its mere identification in stage 1B2 cervical cancer. The method was to quantify LVSI by extent, density and distance from the advancing front in 88 consecutive stage 1B2 cervical cancers treated by radical hysterectomy and pelvic lymphadenectomy and to compare them with pelvic lymph node status and local and distant recurrence. The results were that LVSI involved more tumour blocks, was denser and extended a further distance in those with positive nodes. However, effective adjuvant therapy confounded the association between quantification of LVSI and local recurrence. Furthermore, pelvic lymph node status was a stronger predictor of distant recurrence than any degree of LVSI. In conclusion, quantifying LVSI in stage 1B2 cervical cancer is a good predictor of lymph node metastasis, but is not useful where the lymph node status is known.

Systematic review of survival following liver or lung metastasectomy for metastatic anal squamous cell carcinoma

INTRODUCTION

Metastatic anal squamous cell carcinoma (SCC) carries a poor prognosis and the evidence base for surgical resection of metastases remains limited. The aim of this study was to establish the survival outcomes for patients undergoing metastasectomy for anal SCC.

METHODS

A systematic review was performed using the MEDLINE®, Embase®, Cochrane and PubMed® databases. Studies were considered for inclusion in the review if they involved patients aged >18 years with a diagnosis of stage IV anal SCC who underwent metastasectomy for liver and/or lung metastases. The primary outcome measure was overall survival. Secondary outcome measures were disease free survival, early morbidity according to the Clavien-Dindo classification and quality of life, measured using a validated scoring tool. Risk of bias was assessed with the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool.

RESULTS

There were 10 studies with a total of 98 patients. There was heterogeneity in results reporting, with recurrence free survival the most reported outcome. For all studies reporting on liver metastasectomy, the one-year overall survival rate was 87%. In studies with adequate follow-up reported, the three and five-year overall survival rates were 53% and 38% respectively. Only one study reported on lung metastasectomy patients; the overall median survival was 24 months. None of the studies reported on quality of life measures. The ROBINS-I tool identified a critical risk of bias in six studies, a serious risk in one study and a moderate risk in three studies.

CONCLUSIONS

The evidence base for metastasectomy in metastatic anal SCC is limited. Further information is required to inform future treatment methods and use of a standardised outcomes reporting method is needed to support this.

Cohesive properties of terminally differentiated keratinocytes

The stratum corneum can be dissociated into single squames by several extraction methods: mechanically, with organic solvents, and with detergents. We have performed studied of reaggregation from single squames prepared by these methods. Mechanically dispersed corneocytes recombined into a lamellar-like structure closely resembling intact stratum corneum. Squames obtained by dissociation in ether formed a multilayered structure which differed from the intact tissue in the collapse of the bilayered lamellar structure into a single lucent band with osmiophilic deposits. Squames obtained after extraction with detergent failed to reaggregate.