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Ackland GL, Patel A, Abbott TEF, Begum S, Dias P, Crane DR, Somanath S, Middleditch A, Cleland S, Gutierrez del Arroyo A, Brealey D, Pearse RM. Discontinuation vs. continuation of renin-angiotensin system inhibition before non-cardiac surgery: the SPACE trial. Eur Heart J 2024; 45:1146-1155. [PMID: 37935833 PMCID: PMC10984566 DOI: 10.1093/eurheartj/ehad716] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/07/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND AND AIMS Haemodynamic instability is associated with peri-operative myocardial injury, particularly in patients receiving renin-angiotensin system (RAS) inhibitors (angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers). Whether stopping RAS inhibitors to minimise hypotension, or continuing RAS inhibitors to avoid hypertension, reduces peri-operative myocardial injury remains unclear. METHODS From 31 July 2017 to 1 October 2021, patients aged ≥60 years undergoing elective non-cardiac surgery were randomly assigned to either discontinue or continue RAS inhibitors prescribed for existing medical conditions in six UK centres. Renin-angiotensin system inhibitors were withheld for different durations (2-3 days) before surgery, according to their pharmacokinetic profile. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury [plasma high-sensitivity troponin-T (hs-TnT) ≥ 15 ng/L within 48 h after surgery, or ≥5 ng/L increase when pre-operative hs-TnT ≥15 ng/L]. Pre-specified adverse haemodynamic events occurring within 48 h of surgery included acute hypertension (>180 mmHg) and hypotension requiring vasoactive therapy. RESULTS Two hundred and sixty-two participants were randomized to continue (n = 132) or stop (n = 130) RAS inhibitors. Myocardial injury occurred in 58 (48.3%) patients randomized to discontinue, compared with 50 (41.3%) patients who continued, RAS inhibitors [odds ratio (for continuing): 0.77; 95% confidence interval (CI) 0.45-1.31]. Hypertensive adverse events were more frequent when RAS inhibitors were stopped [16 (12.4%)], compared with 7 (5.3%) who continued RAS inhibitors [odds ratio (for continuing): 0.4; 95% CI 0.16-1.00]. Hypotension rates were similar when RAS inhibitors were stopped [12 (9.3%)] or continued [11 (8.4%)]. CONCLUSIONS Discontinuing RAS inhibitors before non-cardiac surgery did not reduce myocardial injury, and could increase the risk of clinically significant acute hypertension. These findings require confirmation in future studies.
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Affiliation(s)
- Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Akshaykumar Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Salma Begum
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - David R Crane
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Sameer Somanath
- County Durham and Darlington NHS Foundation Trust, Darlington, UK
| | | | | | - Ana Gutierrez del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
- UCL Hospitals NHS Foundation Trust, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Rupert M Pearse
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
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Ackland GL, Martin T, Joseph M, Dias P, Hameed R, Gutierrez del Arroyo A, Hewson R, Abbott TEF, Spooner O, Bhogal P. Transauricular nerve stimulation in acute ischaemic stroke requiring mechanical thrombectomy: Protocol for a phase 2A, proof-of-concept, sham-controlled randomised trial. PLoS One 2023; 18:e0289719. [PMID: 38134136 PMCID: PMC10745208 DOI: 10.1371/journal.pone.0289719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/07/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Labile blood pressure after acute ischaemic stroke requiring mechanical thrombectomy is independently associated with poor patient outcomes. OBJECTIVES This study protocol describes is designed to determine whether transauricular nerve stimulation, improves baroreflex sensitivity, reduces blood pressure variability in the first 24 hours after acute ischaemic stroke requiring mechanical thrombectomy. DESIGN: PHASE 2A, PROOF-OF-CONCEPT, SHAM-CONTROLLED RANDOMISED TRIAL Methods and Analysis: 36 individuals undergoing mechanical thrombectomy for acute ischaemic stroke with established hypertension aged >18 years will be randomly allocated to receive bilateral active or sham transauricular nerve stimulation for the duration of the mechanical thrombectomy procedure (AffeX-CT/001 investigational device). The intervention will be repeated for 1h the morning following the mechanical thrombectomy. Non-invasive blood pressure will be measured ≥2h for 24h after mechanical thrombectomy. Holter electrocardiographic monitoring will be recorded during transauricular nerve stimulation. Participants, clinicians and investigators will be masked to treatment allocations. The primary outcome will be the coefficient of variation of systolic blood pressure. Secondary outcomes include additional estimates of blood pressure variability and time/frequency-domain measures of autonomic cardiac modulation An adjusted sample size of 36 patients is required to have a 90% chance of detecting, as significant at the 5% level, a difference in the coefficient of variation in systolic blood pressure of 5±4mmHg between sham and active stimulation [assuming 5% non-compliance rate in each group]. Ethics: confirmed on 16 March 2023 by HRA and Health and Care Research Wales ethics committee (reference 23/WA/0013). DISCUSSION This study will provide proof-of-concept data that examines whether non-invasive autonomic neuromodulation can be used to favourably modify blood pressure and autonomic control after acute ischaemic stroke requiring mechanical thrombectomy. TRIAL REGISTRATION Trial registration number: NCT05417009.
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Affiliation(s)
- Gareth L. Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Tim Martin
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Mareena Joseph
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Rizwan Hameed
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Ana Gutierrez del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Russ Hewson
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Tom E. F. Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Oliver Spooner
- Department of Stroke Medicine, London, Royal London Hospital, London, Barts Health NHS Trust, London, United Kingdom
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, London, Barts Health NHS Trust, London, United Kingdom
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Kopach O, Sylantyev S, Bard L, Michaluk P, Heller JP, Gutierrez del Arroyo A, Ackland GL, Gourine AV, Rusakov DA. Human neutrophils communicate remotely via calcium-dependent glutamate-induced glutamate release. iScience 2023; 26:107236. [PMID: 37496680 PMCID: PMC10366500 DOI: 10.1016/j.isci.2023.107236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/25/2023] [Accepted: 06/23/2023] [Indexed: 07/28/2023] Open
Abstract
Neutrophils are white blood cells that are critical to acute inflammatory and adaptive immune responses. Their swarming-pattern behavior is controlled by multiple cellular cascades involving calcium-dependent release of various signaling molecules. Previous studies have reported that neutrophils express glutamate receptors and can release glutamate but evidence of direct neutrophil-neutrophil communication has been elusive. Here, we hold semi-suspended cultured human neutrophils in patch-clamp whole-cell mode to find that calcium mobilization induced by stimulating one neutrophil can trigger an N-methyl-D-aspartate (NMDA) receptor-driven membrane current and calcium signal in neighboring neutrophils. We employ an enzymatic-based imaging assay to image, in real time, glutamate release from neutrophils induced by glutamate released from their neighbors. These observations provide direct evidence for a positive-feedback inter-neutrophil communication that could contribute to mechanisms regulating communal neutrophil behavior.
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Affiliation(s)
- Olga Kopach
- Queen Square Institute of Neurology, University College London, Queen Square, London WC1N 3BG, UK
| | - Sergyi Sylantyev
- Queen Square Institute of Neurology, University College London, Queen Square, London WC1N 3BG, UK
- Rowett Institute, University of Aberdeen, Ashgrove Road West, Aberdeen AB25 2ZD, UK
| | - Lucie Bard
- Queen Square Institute of Neurology, University College London, Queen Square, London WC1N 3BG, UK
| | - Piotr Michaluk
- Queen Square Institute of Neurology, University College London, Queen Square, London WC1N 3BG, UK
- BRAINCITY, Laboratory of Neurobiology, Nencki Institute of Experimental Biology PAS, 3 Pasteur Street, 02-093 Warsaw, Poland
| | - Janosch P. Heller
- Queen Square Institute of Neurology, University College London, Queen Square, London WC1N 3BG, UK
- School of Biotechnology, Dublin City University, Dublin 9, Ireland
| | - Ana Gutierrez del Arroyo
- Translational Medicine and Therapeutics, Queen Mary University of London, Mile End Road, London E1 4NS, UK
| | - Gareth L. Ackland
- Translational Medicine and Therapeutics, Queen Mary University of London, Mile End Road, London E1 4NS, UK
| | - Alexander V. Gourine
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London WC1E 6BT, UK
| | - Dmitri A. Rusakov
- Queen Square Institute of Neurology, University College London, Queen Square, London WC1N 3BG, UK
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Ackland GL, Van Duijvenboden S, Abbott TE, Gutierrez del Arroyo A, Wilson MJ, David AL. Interleukin-1 receptor antagonist, mode of analgesia and risk of Caesarean delivery after onset of labour: a Mendelian randomisation analysis. Br J Anaesth 2022; 128:89-97. [PMID: 34802694 PMCID: PMC8787778 DOI: 10.1016/j.bja.2021.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Lower circulating levels of the anti-inflammatory cytokine interleukin-1 receptor antagonist (IL-1ra) are associated with intrapartum inflammation and epidural analgesia-related maternal fever, both of which increase the rate of obstetric interventions. We hypothesised that genetic variants determining IL-1ra levels would be associated with Caesarean delivery rates after the onset of labour. METHODS We performed Mendelian randomisation analyses in parous women ≥16 yr old who received either non-neuraxial or neuraxial analgesia for their first two labours (UK Biobank). We used an established genetic score (calculated as 0-4, determined by the presence/absence of rs6743376 and rs1542176 alleles), in which the complete absence of both alleles causes the lowest IL-1ra levels. The primary outcome was Caesarean delivery after the onset of labour (odds ratio [OR]: 95% confidence intervals). RESULTS There were 7731 women (mean [standard deviation] age at first birth: 25 [5] yr) who had complete genetic scores and delivery data. For women who received non-neuraxial analgesia, Caesarean delivery rates were different across allele scores (χ2=12.4; P=0.015): 104/596 (17.4%) women with zero allele score underwent Caesarean delivery, compared with 654/5015 (13.0%) with allele score ≥1 (OR 1.41; 1.12-1.77). For women who had neuraxial analgesia, Caesarean delivery was not different across allele scores, ranging from 18.1% to 20.8% (χ2=0.29; P=0.99). Caesarean delivery was independent of type of analgesia for 818/7731 (10.6%) women with zero allele scores (OR 0.93; 0.63-1.39), but was higher in women receiving neuraxial analgesia with allele scores ≥1 (OR 1.55; 1.35-1.79; P<0.001). CONCLUSIONS Mendelian randomisation analysis suggests that higher IL-1ra levels are associated with reduced Caesarean delivery rate. Neuraxial analgesia appears to disrupt this link. CLINICAL TRIAL REGISTRATION UK Biobank study 62745.
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Affiliation(s)
- Gareth L. Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK,Corresponding author.
| | | | - Tom E.F. Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Ana Gutierrez del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Matthew J. Wilson
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anna L. David
- Elizabeth Garret Anderson Institute for Women's Health, University College London, London, UK
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Tyler EJ, Gutierrez del Arroyo A, Hughes BK, Wallis R, Garbe JC, Stampfer MR, Koh J, Lowe R, Philpott MP, Bishop CL. Early growth response 2 (EGR2) is a novel regulator of the senescence programme. Aging Cell 2021; 20:e13318. [PMID: 33547862 PMCID: PMC7963333 DOI: 10.1111/acel.13318] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/16/2020] [Accepted: 12/31/2020] [Indexed: 12/14/2022] Open
Abstract
Senescence, a state of stable growth arrest, plays an important role in ageing and age-related diseases in vivo. Although the INK4/ARF locus is known to be essential for senescence programmes, the key regulators driving p16 and ARF transcription remain largely underexplored. Using siRNA screening for modulators of the p16/pRB and ARF/p53/p21 pathways in deeply senescent human mammary epithelial cells (DS HMECs) and fibroblasts (DS HMFs), we identified EGR2 as a novel regulator of senescence. EGR2 expression is up-regulated during senescence, and its ablation by siRNA in DS HMECs and HMFs transiently reverses the senescent phenotype. We demonstrate that EGR2 activates the ARF and p16 promoters and directly binds to both the ARF and p16 promoters. Loss of EGR2 down-regulates p16 levels and increases the pool of p16- p21- 'reversed' cells in the population. Moreover, EGR2 overexpression is sufficient to induce senescence. Our data suggest that EGR2 is a direct transcriptional activator of the p16/pRB and ARF/p53/p21 pathways in senescence and a novel marker of senescence.
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Affiliation(s)
- Eleanor J. Tyler
- Blizard InstituteBarts and The London School of Medicine and Dentistry, Queen Mary University of LondonLondonUK
| | - Ana Gutierrez del Arroyo
- Translational Medicine & TherapeuticsWilliam Harvey Research InstituteBarts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Bethany K. Hughes
- Blizard InstituteBarts and The London School of Medicine and Dentistry, Queen Mary University of LondonLondonUK
| | - Ryan Wallis
- Blizard InstituteBarts and The London School of Medicine and Dentistry, Queen Mary University of LondonLondonUK
| | - James C. Garbe
- Biological Systems and Engineering DivisionLawrence Berkeley National LaboratoryBerkeleyCaliforniaUSA
| | - Martha R. Stampfer
- Biological Systems and Engineering DivisionLawrence Berkeley National LaboratoryBerkeleyCaliforniaUSA
| | - Jim Koh
- Division of General SurgeryDepartment of SurgeryUCSFSan FranciscoCaliforniaUSA
| | - Robert Lowe
- Blizard InstituteBarts and The London School of Medicine and Dentistry, Queen Mary University of LondonLondonUK
| | - Michael P. Philpott
- Blizard InstituteBarts and The London School of Medicine and Dentistry, Queen Mary University of LondonLondonUK
| | - Cleo L. Bishop
- Blizard InstituteBarts and The London School of Medicine and Dentistry, Queen Mary University of LondonLondonUK
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Gutierrez del Arroyo A, Cyrus T, Bahelil F, Bliss E, Heywood W, Mills K, Ackland GL. Serial proteomic characterisation of skin during the perioperative period. Br J Anaesth 2019. [DOI: 10.1016/j.bja.2019.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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del Arroyo AG, El Messaoudi S, Clark PA, James M, Stott F, Bracken A, Helin K, Peters G. E2F-Dependent Induction of p14ARF During Cell Cycle Re-entry in Human T Cells. Cell Cycle 2014; 6:2697-705. [PMID: 17912037 DOI: 10.4161/cc.6.21.4857] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The ARF protein, encoded by alternate exon usage within the CDKN2A locus, provides a link between the retinoblastoma (pRb) and p53 tumor suppressor pathways. Agents that disable pRb or otherwise impinge on the E2F family of transcription factors induce expression of ARF, resulting in stabilization of p53 and activation of p53-regulated genes. However, in some cell types ARF is not induced upon cell cycle re-entry, as expected of a conventional E2F target gene, leading to the suggestion that the ARF promoter only responds to supra-physiological or aberrant levels of E2F. These properties have recently been attributed to a variant E2F binding site but attempts to map specific response elements within the ARF promoter have generally yielded confusing answers. Here we show that in IL2-dependent T-lymphocytes, ARF expression is induced as cells progress from G(0) into S phase, in parallel with other bona fide E2F target genes. This is accompanied by increased association of E2F1 with the endogenous ARF promoter. Our findings suggest that the ability of ARF to register normal proliferative cues depends on the levels of E2F generated in different settings and argue against the idea that it reacts exclusively to oncogenic signals.
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del Fresno C, García-Rio F, Gómez-Piña V, Soares-Schanoski A, Fernández-Ruíz I, Jurado T, Kajiji T, Shu C, Marín E, Gutierrez del Arroyo A, Prados C, Arnalich F, Fuentes-Prior P, Biswas SK, López-Collazo E. Potent Phagocytic Activity with Impaired Antigen Presentation Identifying Lipopolysaccharide-Tolerant Human Monocytes: Demonstration in Isolated Monocytes from Cystic Fibrosis Patients. J Immunol 2009; 182:6494-507. [DOI: 10.4049/jimmunol.0803350] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Irelan JT, Gutierrez del Arroyo A, Gutierrez A, Peters G, Quon KC, Miraglia L, Chanda SK. A functional screen for regulators of CKDN2A reveals MEOX2 as a transcriptional activator of INK4a. PLoS One 2009; 4:e5067. [PMID: 19340300 PMCID: PMC2659797 DOI: 10.1371/journal.pone.0005067] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Accepted: 02/24/2009] [Indexed: 12/02/2022] Open
Abstract
The CDKN2A locus encodes two important tumor suppressors, INK4a and ARF, which respond to oncogenic stresses by inducing cellular senescence. We conducted a genome-scale cDNA overexpression screen using a reporter containing INK4a regulatory sequences to identify novel transcriptional activators of this locus. This screen revealed 285 cDNAs that putatively regulate the transcriptional activation of INK4a. Of these, 56 are annotated as transcription factors, including two previously reported activators of the locus, ETS2 and JUNB. Fourteen genes were further validated for activity and specificity, including several homeodomain proteins. We found that the transcription of one of these, the homeodomain protein MEOX2 (GAX) is enhanced in primary cells during the induction of senescence, and forced expression of this protein results in the induction of premature senescence. We further demonstrate that MEOX2-induced senescence is dependent upon INK4a activity, and chromatin immunoprecipitation studies indicate that MEOX2 directly binds the INK4a promoter. These results support a role for this homeodomain protein as a direct regulator of INK4a transcription and senescence in human cells.
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Affiliation(s)
- Jeffrey T. Irelan
- Genomics Institute of the Novartis Research Foundation, San Diego, California, United States of America
- * E-mail: (JTI); (SKC)
| | | | - Abel Gutierrez
- Genomics Institute of the Novartis Research Foundation, San Diego, California, United States of America
| | - Gordon Peters
- CRUK London Research Institute, London, United Kingdom
| | - Kim C. Quon
- Genomics Institute of the Novartis Research Foundation, San Diego, California, United States of America
| | - Loren Miraglia
- Genomics Institute of the Novartis Research Foundation, San Diego, California, United States of America
| | - Sumit K. Chanda
- Genomics Institute of the Novartis Research Foundation, San Diego, California, United States of America
- * E-mail: (JTI); (SKC)
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