Simulation technology for health care professional skills training and assessment

Changes in medical practice that limit instruction time and patient availability, the expanding options for diagnosis and management, and advances in technology are contributing to greater use of simulation technology in medical education. Four areas of high-technology simulations currently being used are laparoscopic techniques, which provide surgeons with an opportunity to enhance their motor skills without risk to patients; a cardiovascular disease simulator, which can be used to simulate cardiac conditions; multimedia computer systems, which includes patient-centered, case-based programs that constitute a generalist curriculum in cardiology; and anesthesia simulators, which have controlled responses that vary according to numerous possible scenarios. Some benefits of simulation technology include improvements in certain surgical technical skills, in cardiovascular examination skills, and in acquisition and retention of knowledge compared with traditional lectures. These systems help to address the problem of poor skills training and proficiency and may provide a method for physicians to become self-directed lifelong learners.

Identification by differential display of a protein phosphatase-2A regulatory subunit preferentially expressed in malignant melanoma cells

We described the occurrence of 4 transcripts differentially displayed between syngeneic murine B16F10 (metastatic melanoma) and Melan-a (immortalised melanocytes) cell lines. We now report that one such transcript, which is B16F10-specific, represents a protein phosphatase-2A B' regulatory subunit. No expression of this transcript was detected in the weakly metastatic B16F1 by Northern blotting. Moreover, the transcript was not expressed by spontaneously immortalised, non-tumorigenic, melanocytes (Melan-Ab and Melan-a2), nor was it expressed by ras-transformed, tumourigenic melanocytes (Melan-Ab-LTR-ras). Cloning of the 5'-end region of this transcript (termed band 8A) from B16F10 cells revealed an intracisternal A-particle insertion, including the long terminal repeat region, which could account for the observed high expression in B16F10 cells. Single cell clones of B16F10 manifested an experimental metastasis capacity, which correlated with band 8A expression with the lowest expressors being least metastatic. The human homologue of the B' regulatory subunit, B56gamma, is expressed preferentially at the mRNA level in human melanoma cell lines compared with normal epidermal melanocytes. In situ hybridisation studies on human clinical samples detected high expression of this gene in a number of malignant melanomas. Our results imply strongly that this protein phosphatase-2A regulatory subunit may have a role in melanoma tumour progression.

BEME Guide No. 1: Best Evidence Medical Education

There is a need to move from opinion-based education to evidence-based education. Best evidence medical education (BEME) is the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. It involves a professional judgement by the teacher about his/her teaching taking into account a number of factors-the QUESTS dimensions. The Quality of the research evidence available-how reliable is the evidence? the Utility of the evidence-can the methods be transferred and adopted without modification, the Extent of the evidence, the Strength of the evidence, the Target or outcomes measured-how valid is the evidence? and the Setting or context-how relevant is the evidence? The evidence available can be graded on each of the six dimensions. In the ideal situation the evidence is high on all six dimensions, but this is rarely found. Usually the evidence may be good in some respects, but poor in others.The teacher has to balance the different dimensions and come to a decision on a course of action based on his or her professional judgement.The QUESTS dimensions highlight a number of tensions with regard to the evidence in medical education: quality vs. relevance; quality vs. validity; and utility vs. the setting or context. The different dimensions reflect the nature of research and innovation. Best Evidence Medical Education encourages a culture or ethos in which decision making takes place in this context.

BEME Guide No. 1: Best Evidence Medical Education

There is a need to move from opinion-based education to evidence-based education. Best evidence medical education (BEME) is the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. It involves a professional judgement by the teacher about his/her teaching taking into account a number of factors-the QUESTS dimensions. The Quality of the research evidence available-how reliable is the evidence? the Utility of the evidence-can the methods be transferred and adopted without modification, the Extent of the evidence, the Strength of the evidence, the Target or outcomes measured-how valid is the evidence? and the Setting or context-how relevant is the evidence? The evidence available can be graded on each of the six dimensions. In the ideal situation the evidence is high on all six dimensions, but this is rarely found. Usually the evidence may be good in some respects, but poor in others.The teacher has to balance the different dimensions and come to a decision on a course of action based on his or her professional judgement.The QUESTS dimensions highlight a number of tensions with regard to the evidence in medical education: quality vs. relevance; quality vs. validity; and utility vs. the setting or context. The different dimensions reflect the nature of research and innovation. Best Evidence Medical Education encourages a culture or ethos in which decision making takes place in this context.

Perspective: tumour spread--the problems of latency

Tumour latency, or dormancy, is a well-recognized clinical phenomenon and induction or maintenance of this state would appear to offer a novel therapeutic approach to limiting the effects of neoplastic disease. Current interest has focused on the role that neovascularization plays in this process and the consequences of shifts in the balance between angiogenic and anti-angiogenic peptides. Targeting tumour vasculature by the administration or induction of such anti-angiogenic peptides is close to clinical evaluation.

Fibronectin is chemotactic for CT 26 colon carcinoma cells: sub-lines selected for increased chemotaxis to fibronectin display decreased tumorigenicity and lung colonization

CT 26 murine colon carcinoma cells demonstrated directional migration (chemotaxis) in response to fibronectin (FN). Sub-lines were derived by positive and negative selection to FN across Transwell filters of 8 microm pore size. The FL6 sub-line (positively selected) demonstrated a significantly increased chemotactic response (P<0.01) to FN compared with parental CT 26 cells, while the FU7 sub-line (negatively selected) showed a reduced chemotactic response to FN (P<0.01). Comparable levels of alpha4, alpha5, alphav and beta1 integrins, which mediate FN attachment, were expressed on positively and negatively selected sub-lines and parental CT 26 cells. Activation of integrins with Mn2+ suggested that the integrins expressed on FL6 cells were in the fully activated state; in contrast FU7 cells displayed only partially activated integrins. Cell attachment and integrin activation status of the sub-lines correlated with their chemotactic response to FN. In vivo FL6 cells showed a significantly reduced tumour growth rate s.c. and a reduction in the number of lung colonies formed following i.v. injection compared with parental CT 26 and FU7 cells. In contrast FU7 cells displayed a significant increase in s.c. tumour growth and the number of lung colonies when compared with the parental line and FL6 sub-line. The results indicate that interaction between integrin receptors expressed on cancer cells and FN plays a central role in the chemotactic response of CT 26 colon carcinoma cells, and that in this model cells selected for chemotaxis to FN displayed a reduced malignant potential.

Expression of B7 co-stimulatory molecules by B16 melanoma results in a natural killer cell-dependent local anti-tumour response, but induces T-cell-dependent systemic immunity only against B7-expressing tumours

In an attempt to enhance the anti-tumour immune response, the co-stimulatory molecules B7-1 or B7-2 were expressed on the surface of B16 melanoma cells. B7-expressing tumours grew more slowly in both syngeneic immunocompetent mice and athymic T cell-immunodeficient nude mice. The delay in growth of B7-expressing tumours was dependent on natural killer (NK) cells, as reductions in tumour growth rates were minimized in mice depleted of NK cells. Systemic immunity to B16 melanoma was examined by vaccination with irradiated tumour cells. Inoculation with irradiated B16 B7-1 cells failed to protect against a subsequent challenge with live parental B16 cells, but conferred partial protection against challenge with live B16 B7-1 cells. In contrast to the local anti-tumour reaction, this protective response was dependent on T cells. The results presented here reveal some of the mechanisms involved in the in vivo response to a poorly immunogenic tumour modified to express co-stimulatory molecules.

Rapid adenoviral transduction of freshly resected tumour explants with therapeutically useful genes provides a rationale for genetic immunotherapy for colorectal cancer

To develop protocols for the molecular immunotherapy of colorectal cancer, we compared the efficacy of three separate classes of therapeutic genes to induce antitumour responses in a murine colorectal cell model. Thus, the effects of two cytokines (IL-2 and GM-CSF) were compared with those of a costimulatory gene (B7.1) and a suicide gene (HSVtk). The rank order of efficacy against primary tumour growth was HSVtk[GCV], B7.1 > puro, IL-2 > GM-CSF, neo whereas the order of efficacy in inducing antitumour immunity was GM-CSF, IL-2, > B7.1, HSVtk[GCV] > puro, neo in a prophylactic vaccination model. To exploit these data in a clinically relevant and realistic way, we also demonstrated that colorectal tumours can reproducibly be explanted and established in short-term culture. Finally, a rapid transduction protocol has been developed by which, using adenoviral vectors, as many as 90% of the cells in these fresh tumour explants can be engineered to express high levels of the clinically relevant genes (GM-CSF or IL-2) within 1-2 weeks of surgery. Adenovirus-mediated gene delivery was reproducibly and significantly more efficient than retroviral transduction using the MFG-beta-Gal retroviral vector over the time-frame of importance for vaccination. Hence, combination of the animal model data with the ex vivo modification protocol suggests that vaccination of colorectal patients of the appropriate stage will be possible and effective.

The human hyaluronan receptor RHAMM is expressed as an intracellular protein in breast cancer cells

The receptor for hyaluronan mediated motility (RHAMM) has been reported to mediate migration, transformation, and metastatic spread of murine fibroblasts. Here we describe the expression of two human RHAMM isoforms, which are generated by alternative splicing of the primary gene transcript, by a series of human breast carcinoma cell lines. A polyclonal antibody, raised against a bacterially expressed RHAMM fusion protein, detected an 85–90 kDa protein by western blot analysis. No correlation between the level of RHAMM mRNA and protein expression with known metastatic/malignant potential of the tumour cell lines was observed. Interestingly, we found that the antibody did not stain the cell surface but the cytoplasm of breast cancer cells. The intracellular localisation of RHAMM was confirmed by subcellular fractionation studies. RHAMM proteins were capable of binding to hyaluronan, but not to heparin or chondroitin sulphate, in an vitro binding assay. We also provide evidence that a potential hyaluronan-binding motif in the N terminus of the protein is not involved in the interaction of RHAMM with hyaluronan. Our findings lead us to conclude that RHAMM does not function as a conventional motility receptor for HA in human breast cancer cells and we suggest the term RHAMM be substituted by ‘intracellular hyaluronic acid binding protein’ (IHABP).

Hypoxia facilitates tumour cell detachment by reducing expression of surface adhesion molecules and adhesion to extracellular matrices without loss of cell viability

The effects of acute hypoxia on integrin expression and adhesion to extracellular matrix proteins were investigated in two human melanoma cell lines, HMB-2 and DX3, and a human adenocarcinoma cell line, HT29. Exposure to hypoxia caused a significant down-regulation of cell surface integrins and an associated decrease in cell adhesion. Loss of cell adhesion and integrin expression were transient and levels returned to normal within 24 h of reoxygenation. Other cell adhesion molecules, such as CD44 and N-CAM, were also down-regulated after exposure of cells to hypoxia. Acute exposure to hypoxia of cells at confluence caused rapid cell detachment. Cell detachment preceded loss of viability. Detached HMB-2 and DX3 cells completely recovered upon reoxygenation, and floating cells re-attached and continued to grow irrespective of whether they were left in the original glass dishes or transferred to new culture vessels, while detached HT29 cells partly recovered upon reoxygenation. Cell detachment after decreased adhesion appears to be a stress response, which may be a factor enabling malignant cells to escape hypoxia in vivo, with the potential to form new foci of tumour growth.

Matrix metalloproteinases and metastatic cancer

The rationale for matrix metalloproteinase (MMP) inhibition as a means to treat disease progression in breast cancer stems from the apparent involvement of MMPs in the hydrolysis of basement membranes during tumour cell invasion and subsequent metastasis. MMP-mediated matrix remodelling also appears to promote the growth of tumour cells, possibly by facilitating the proliferation and migration of endothelial cells and the neovascularization of tumour tissue. We found that transfection of the C127 breast cancer cell line by MMP-2 (gelatinase A), but not by MMP-1 or MMP-3 (collagenase and stromelysin respectively), gave rise to an invasive and metastatic phenotype. We were surprised to find that this phenotype depended not only on the catalytic properties of MMP-2 but also on properties associated with the MMP-2 non-catalytic C-terminal domain. Experiments with a synthetic gelatinase inhibitor revealed that a single dose could prevent the lungs of nude mice being colonized by the MMP-2 transfectants, and that the inhibitor had to be administered during or shortly after injection of the cells, indicating that an early event, such as the extravasation of the cells into the lung, is gelatinase-dependent in this system. In other studies employing long-term treatment with CT1746, an orally active gelatinase inhibitor, we have previously demonstrated a reduction in primary tumour growth rates, localized spread, and spontaneous metastasis, even when the treatment was commenced several days after tumour implantation. Furthermore, additive effects were recorded when gelatinase inhibitor therapy was combined with cytotoxic drug treatment. Since the gelatinase inhibitors can also inhibit bone resorption in vitro, these observations point to their potential for delaying disease recurrence and reducing rates of bone loss following conventional therapeutic strategies, in metastatic breast cancer.

Expression of alphav integrins and vitronectin receptor identity in breast cancer cells

In the present study we have used fluorocytometry and immunoprecipitation to characterize the expression of alphav-containing integrins in a panel of eight human breast cancer cell lines and one normal human mammary epithelial line. We show that the classical vitronectin receptor alphavbeta3 is expressed in only one cell line (MDA-MB-231), whereas alphavbeta5 is expressed on all breast cancer cell lines and alphavbeta1 is expressed on the majority. Using adherence assays to purified ligands in the presence and absence of function-blocking monoclonal antibodies, we have demonstrated that alphavbeta5 mediates adhesion to vitronectin in the majority of these cells. In one cell line, ZR75-1, alphavbeta1 contributes significantly to adhesion to immobilized vitronectin. The formation of focal adhesions containing the alphav and beta1 subunits on vitronectin is also demonstrated by indirect immunofluorescence.

Tumour cell expression of B7 costimulatory molecules and interleukin-12 or granulocyte-macrophage colony-stimulating factor induces a local antitumour response and may generate systemic protective immunity

Previously, we showed that expression of B7-1 in CMT93 murine colorectal tumour cells inhibited their growth in immunocompetent animals. However, this did not result in any significant increase in systemic protective immunity, relative to that elicited by the parental tumour. To potentiate the effects of B7-1 on systemic immunity. Interleukin-12 (IL-12) or granulocyte-macrophage colony-stimulating factor (GM-CSF) was co-expressed with this molecule. These combinations of immunostimulatory molecules were effective in eliciting systemic immunity. We also show that expression of B7-2 led to a local antitumour response as well as significantly raised systemic immunity. In another tumour model. K1735 minutes melanoma, which is moderately immunogenic, tumours secreting GM-CSF alone were as effective as the parental tumours in generating protective immunity. Previously, we described the deleterious effect of B7-1 expression on protective immunity. Co-expression of GM-CSF did not counteract this consequence of B7-1 expression. Expression of IL-12 was extremely effective in causing rejection of inoculated tumour cells, but evoked only minimal protective systemic immunity. These results suggest that combing costimulatory molecules and cytokines may be a useful therapeutic approach in some, but not all, tumours.

Comparative analysis of integrins in vitro and in vivo in uveal and cutaneous melanomas

Changes in integrin expression have been shown to be important for the growth and metastatic capacity of melanoma cells. In this study, we have examined the expression of alphav integrins by three uveal and four cutaneous malanoma lines. No lines expressed alphavbeta6 and only TXM13, a cutaneous line, expressed alphavbeta8. All lines expressed alphavbeta5 and alphavbeta3 (four out of four cutaneous, two out of three uveal) or avpl (OM431, an uveal line). Thus, OM431 is the second uveal melanoma we have described that expresses alphavbeta1 and this, we report again, functions as an alternative vitronectin/fibronectin receptor. Subcutaneous growth of cell lines in athymic mice correlated with an alphavbeta3-positive, alphavbeta1 -negative phenotype. Analysis of clinical material from cutaneous melanoma showed that although alphav expression was increased in 88% of metastases, this could not all be explained by up-regulation of alphavbeta3, with only 2 out of eight skin metastases expressing this heterodimer. Using antibody SZ.21, which as we report here works in archival material, only 1 out of 15 uveal metastases expressed detectable beta3. Thus, acquisition of alphavbeta3 expression, which has been implicated in cutaneous melanoma progression, may not be required for development of metastases from uveal melanoma or indeed for skin, as distinct from lymph node, metastases of cutaneous melanoma.

Exchange of viral promoter/enhancer elements with heterologous regulatory sequences generates targeted hybrid long terminal repeat vectors for gene therapy of melanoma

To generate transcriptionally targeted vectors, tissue-specific elements of the human tyrosinase promoter were exchanged with corresponding viral elements in the Moloney murine leukemia virus long terminal repeat (LTR). From these experiments, a vesicular stomatitis virus type G pseudotyped, hybrid LTR vector that contained three tyrosinase enhancer elements and gave high-level, tightly tissue-specific expression at high titers (3 x 10(7) CFU/ml) was constructed.

Mechanisms of metastasis

The metastatic spread of solid tumours is responsible directly or indirectly for most cancer-related deaths. Our understanding of the molecular genetic and biological events that contribute to tumor cell dissemination has increased considerably over the last decade. It is clear that close anatomic and temporal co-operation between cellular adhesion molecules, extracellular matrix (ECM)-degrading proteases and peptides inducing tumour vascularisation are essential components of the metastatic behaviour of cancer cells. Although this enhanced understanding may have little immediate impact on patient survival (about 50% of patients have established metastatic disease at first presentation), it has led to the development of novel anti-metastatic therapies targeting distinct molecules and steps in the metastatic cascade. Here we review the role of matrix-degrading enzymes, changes in cellular adhesive capacity and tumour angiogenesis during cancer spread, highlighting areas that are of emerging importance in the clinic.

A family of bicistronic vectors to enhance both local and systemic antitumor effects of HSVtk or cytokine expression in a murine melanoma model

The herpes simplex virus-thymidine kinase/ganciclovir (HSVtk/GCV) system produces both direct and immune-mediated tumor cell killing. Here, we compare the efficacy of HSVtk/GCV with cytokines, alone and in combination, on the tumorigenicity and immunogenicity of B16 cells. With respect to single gene modifications, only HSVtk/GCV, or high-level interleukin-2 (IL-2) secretion, completely prevented tumor growth, whereas granulocyte-macrophage colony-stimulating factor (GM-CSF) generated the best levels of long-term systemic protection. To augment both local killing and immune activation, we constructed bicistronic constructs that express HSVtk and a cytokine within the same cell. Co-expression of HSVtk with IL-2 or GM-CSF enhanced the local antitumor activity of any gene alone. In a tumor-prevention model, HSVtk killing, in an environment preprimed with GM-CSF, generated the best long-term immune protection. However, in a short-term therapy model, continued IL-2 expression was most effective against 3-day established tumors. This probably reflects differences in the activities of IL-2 and GM-CSF in generating short-term, nonspecific immune stimulation compared to long-term immunological memory, respectively. As a prelude to in vivo delivery experiments, we also demonstrated that these bicistronic cassettes can be packaged normally into retroviral (5 x 10(5) virus/ml from pooled populations) and adenoviral vectors (5 x 10(9) virus/ml) and function as predicted within virally infected cells. This family of bicistronic vectors can be used to stimulate synergy between suicide and cytokine genes, overcomes the problems of delivering two genes on separate vectors, and should allow easier preparation of vectors for the delivery of multiple genes to patients' tumor cells.

Activation status and function of the VLA-4 (alpha4beta1) integrin expressed on human melanoma cell lines

We have examined the functional status of the VLA-4/alpha4beta1 integrin in a panel of human melanoma cell lines, focusing on the ability of cells expressing alpha4beta1 to mediate adhesion to the alpha4-specific ligands CS-1 peptide and VCAM-1. All melanoma cells expressing alpha4pbeta1 (8 of 10 lines examined) were capable of adhering to these specific ligands in adhesion assays, whereas 2 cell lines (HMB2 and VUP) which lacked surface alpha4 were unable to do so. Adherence of different melanoma cell lines to VCAM-1 was relatively uniform and not susceptible to upregulation with known integrin-activating factors, such as manganese ions, phorbol ester and activating monoclonal antibody (mAb) TS2/16. Cell adhesion to CS-1 peptide, however, varied according to cell surface receptor density and, in some cases, could be up-regulated by integrin-activating factors. Adhesion of SK23 cells to CS-1 peptide was increased by all 3 activating stimuli, whereas for all other melanoma cells an increase was obtained only by the use of TS2/16 mAb. Our data indicate not only an unusually low activation state of alpha4beta1 in SK23 cells but also heterogeneity in the activating capacity of the various stimuli. Moreover, a protein kinase C-dependent role in alpha4beta1 activity was suggested by adhesion assays carried out in the presence of the protein kinase C inhibitor calphostin C, which considerably reduced adhesion to CS-1 peptide.

Modulation of human stromelysin 3 promoter activity and gene expression by human breast cancer cells

The matrix-degrading enzyme family of matrix-metalloproteinases (MMPs) has been implicated in the process of tumour metastasis. Cellular protein and RNA localisation techniques have been used to show that, whilst several MMP genes are expressed in both cancer and stromal cells, stromelysin 3 is expressed only in stromal fibroblasts adjacent to cancer cells. Immunohistochemical and in situ hybridisation evidence suggests that neoplastic cells can stimulate stromal cell MMP production either in a paracrine fashion or by a cell-cell contact mechanism. Using 2 different lengths of the human stromelysin 3 (ST3) gene 5' flanking sequence cloned upstream of luciferase and CAT reporter genes, we now show that human breast cancer cells can directly activate the ST3 promoter. The putative response element in the ST3 promoter, which lies between 0.46 and 3.4 kb upstream of the transcription start site, is able to effect a 2- to 3-fold increase in downstream gene expression. We further show that this transcriptional up-regulation definitely occurs via a paracrine, and possibly via a cell-cell contact, mechanism. Confirmation that this ST3 promoter activation results in ST3 gene induction of a similar magnitude was shown using Northern blotting of stimulated fibroblasts. Our data provide further evidence that cancer cells can induce fibroblast MMP expression and help to explain the in vivo expression pattern of ST3 in breast cancer.

Integrin alpha5beta1-mediated adenovirus infection is enhanced by the integrin-activating antibody TS2/16

Adenovirus internalization generally has been accepted to involve an interaction of the adenoviral penton base protein with alpha(v)beta3 and alpha(v)beta5 cell surface integrins. In this study we show that exposure of a panel of melanoma cells to the beta1-activating antibody TS2/16 rendered such cells more susceptible to adenovirus infection. This increase in adenoviral infectivity paralleled effects on cell adhesion, and both these characteristics were mediated, in part, by the alpha5beta1 integrin. These observations suggest that alpha5beta1 may act as an alternative adenovirus receptor and that integrin-activating strategies may improve the efficacy of recombinant adenoviruses as vectors for gene therapy.

Investigation of alternative prodrugs for use with E. coli nitroreductase in 'suicide gene' approaches to cancer therapy

The most commonly employed 'suicide' gene/prodrug system used in cancer gene therapy is the herpes simplex virus thymidine kinase (HSVtk)/ganciclovir system. We have examined the efficacy of an alternative approach utilising the E. coli nitroreductase B enzyme with CB1954 and a variety of other prodrugs. V79 cells transfected with a nitroreductase expression vector were up to 770-fold more sensitive to CB1954 than control non-expressing cells. In general other prodrugs which were found by HPLC to act as substrates for purified E. coli nitroreductase also exhibited increased cytotoxicity against the nitroreductase-expressing cells, although this correlation was not absolute. In particular nitrofurazone (97-fold) and additional aromatic nitro-compounds (nine- to 50-fold) showed a large differential whereas the quinones and the antimetabolite, B-FU, were less effective (< three-fold). The results support the possibility of using nitroreductase and CB1954 for 'suicide gene' therapy and in addition suggest that alternative prodrugs, such as nitrofurazone, warrant further investigation in this novel approach.

Biology of tumor micrometastasis

Metastasis is the major cause of death in cancer patients. Our understanding of the molecular genetic and biologic events that contribute to tumor cell dissemination has increased considerably over the last decade. It is clear that close anatomic and temporal cooperation between cellular adhesion molecules, extracellular matrix-degrading proteases, and tumor vascularization is an essential component of the metastatic behavior of cancer cells. With this improved understanding have come novel antimetastatic therapies targeting distinct molecules and steps in the metastatic cascade. Here, we review the role of matrix-degrading enzymes, changes in cellular adhesive capacity, and tumor angiogenesis during cancer spread.