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Chimeric antigen receptor (CAR)-T-cell therapy is a promising approach for the treatment of childhood cancers, particularly high-risk tumors that fail to respond to standard therapies. CAR-T cells have been highly successful in treating some types of hematological malignancies. However, CAR-T cells targeting solid cancers have had limited success so far for multiple reasons, including their poor long-term persistence and proliferation. Evidence is emerging to show that maintaining CAR-T cells in an early, less-differentiated state in vitro results in superior persistence, proliferation, and antitumor effects in vivo. Children are ideal candidates for receiving less-differentiated CAR-T cells, because their peripheral T-cell pool primarily comprises naïve cells that could readily be harvested in large numbers to generate early-phenotype CAR-T cells. Although several studies have reported different approaches to successfully generate early CAR-T cells, there are only a few clinical trials testing these in adult patients. No trials are currently testing early CAR-T cells in children. Here, we summarize the different strategies used to maintain CAR-T cells in an early phenotypic stage and present evidence suggesting that this approach may be particularly relevant to treating childhood cancers., Competing Interests: Disclosures DSZ received consultant fees from Amgen, Bayer, and DayOne. PJN received research funding from BMS, Roche Genentech, Compugen, and Allergan. PKD declares research funding from Myeloid Therapeutics, Prescient Therapeutics, and Juno Therapeutics. All other authors have declared no conflicts of interest., (Copyright © 2021 European Society for Medical Oncology. Published by Elsevier Ltd. All rights reserved.)

Background: Postoperative ileus is a common complication of abdominal surgery, leading to prolonged hospital stay and associated costs. Gum chewing may be a safe, cheap intervention to reduce postoperative ileus., Methods: The aim was to investigate the effect of gum chewing on postoperative ileus in open colorectal surgery patients. A literature search was conducted between December 2018 and March 2019 on CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews, MEDLINE, Academic Search Complete, PubMed, Scopus and Google Scholar. The keywords used included 'ileus', 'chewing gum', 'mastication' and 'sham feeding'. Papers had to include adults undergoing open colorectal surgery. The studies were appraised using Critical Appraisal Skills Programme tools and the results summarised using a narrative review., Results: A total of three systematic reviews and three randomised controlled trials were included in the study. The studies show a significant to highly significant effect of gum chewing on postoperative ileus-related outcomes. The trials however in general utilised a weak design., Conclusions: Gum chewing decreases postoperative ileus following colorectal surgery. More robust trials are required to confirm these findings. Due to the low risk of harm and cost of using gum chewing, its use is recommended even in the interim.

Background: Many nursing students participate in study abroad opportunities; yet, few studies explore their experiences. Given the increasing emphasis on evaluating the quality of higher education internationalization, this study explored the motivations for, and outcomes of, Maltese nursing students' Erasmus+ exchanges against the program's intended outcomes., Method: Sixty-five Erasmus+ mobility participants completed an online questionnaire (response rate = 44.8%), and 16 participated in a 2-hour focus group., Results: Participants overwhelmingly agreed that intended outcomes of the Erasmus+ program were achieved. Thematic analysis revealed five themes: Enhanced Employability as a Nurse; Exposure to Nursing Beyond the National Shores; Personal Growth; Context-Sensitivity of Nursing Care Delivery; Language and Citizenship., Conclusion: These positive experiences confirm that nurse educators should continue encouraging and facilitating study abroad experiences, and that such opportunities should be offered to even more students. However, more research is required to explore any negative outcomes of student mobility and whether the participants' perceptions change over time. [J Nurs Educ. 2020;59(9):501-505.]., (Copyright 2020, SLACK Incorporated.)

Background: Rapid response systems were created to improve recognition of and response to deterioration of general ward patients., Aim: This literature review aimed to evaluate the evidence on whether rapid response systems decrease in-hospital mortality and non-intensive care unit cardiac arrests., Method: Six databases (MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature, SCOPUS, Web of Science and PubMed) were systematically searched for primary studies published between 1st January 2014 and 31st October 2017, recruiting general ward patients, where the intervention involved introducing/maintaining a rapid response system, the comparison referred to a hospital setting without a rapid response system and the outcomes included mortality and cardiac arrests., Results: Fifteen studies met eligibility criteria: one stepped wedge cluster randomised controlled trial, one concurrent cohort controlled study and thirteen historically controlled studies. Thirteen studies investigated mortality of which seven reported statistically significant findings in favour of rapid response systems. Thirteen studies investigated cardiac arrests, of which eight reported statistically significant findings in favour of rapid response systems., Conclusion: Evidence suggests that when the process of introducing/maintaining a rapid response system is successful and under certain favourable conditions, rapid response systems significantly decrease mortality and cardiac arrests., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: To describe elementary school outcomes for children who experienced a traumatic brain injury (TBI) before age 6 years compared with a control group of children with orthopedic injuries., Participants: Children ages 6 to 9 years recruited from community and trauma registries in a large southeastern state., Design: Descriptive findings from the first year of a 3-year longitudinal study., Main Measures: Child assessment and parent report measures were administered to capture cognitive, language, reading, and behavior outcomes. Medical record review confirmed injuries and injury severity., Results: The TBI group (n = 39) had a mean age of 7.55 years (standard deviation = 1.29) and was 5.15 (standard deviation = 1.56) years postinjury. The TBI group had primarily classified as mild complicated TBI (63%). On average, children in both groups performed within normal limits on most cognitive, language, and reading measures. Group differences were identified in verbal IQ, receptive language, and reading comprehension, with robust performance differences in pragmatic language, story retell and word fluency, and parent report of executive functions., Conclusions: Findings indicate the importance of in-depth follow-up specialist assessments (eg, neuropsychologist and speech and language pathologists) to identify potential nuanced difficulties in children with mild complicated TBI that may be missed by general evaluations.

Background: Preparing nursing students to perform competently in complex emergency situations, such as during rapid patient deterioration, is challenging. Students' active engagement in such scenarios cannot be ensured, due to the unexpected nature of such infrequent events. Many students may consequently not experience and integrate the management of patient deterioration into their knowledge and practical competency by the end of their studies, making them unprepared to manage such situations as practicing nurses. This study investigated the effectiveness of virtual simulation in improving performance during rapid patient deterioration., Objective: To investigate the effectiveness of virtual simulation in improving student nurses' knowledge and performance during rapid patient deterioration., Design: A pre- and post-test design was used., Setting: Nursing students at a university in Malta were invited to participate in a virtual simulation program named FIRST 2 ACTWeb™, using their own computer devices., Participants: A total of 166 (response rate=50%) second and third year diploma and degree nursing students participated in the study., Methods: The simulation included three scenarios (Cardiac-Shock-Respiratory) portraying deteriorating patients. Performance feedback was provided at the end of each scenario. Students completed pre- and post-scenario knowledge tests and performance during each scenario was recorded automatically on a database., Results: Findings showed a significant improvement in the students' post-scenario knowledge (z=-6.506, p<0.001). Highest mean performance scores were obtained in the last scenario (M=19.7, median: 20.0, s.d. 3.41) indicating a learning effect. Knowledge was not a predictor of students' performance in the scenarios., Conclusions: This study supports virtual simulation as an effective learning tool for pre-registration nursing students in different programs. Simulation improves both knowledge about and performance during patient deterioration. Virtual simulation of rare events should be a key component of undergraduate nurse education, to prepare students to manage complex situations as practicing nurses., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Many dinoflagellate microalgae of the genus Symbiodinium form successful symbioses with a large group of metazoans and selected protists. Yet knowledge of growth kinetics of these endosymbionts and their ecological and evolutionary implications is limited. We used a Bayesian biphasic generalized logistic model to estimate key parameters of the growth of five strains of cultured Symbiodinium, S. microadriaticum (cp-type A194; strain 04-503), S. microadriaticum (cp-type A194; strain CassKB8), S. minutum (cp-type B184; strain Mf 1.05b.01.SCI.01), S. psygmophilum (cp-type B224; strain Mf 11.05b.01) and S. trenchii (cp-type D206; strain Mf 2.2b), grown in four different combinations of temperature and light. Growth kinetics varied among Symbiodinium strains and across treatments. Biphasic growth was especially evident for S. minutum and S. psygmophilum across all treatments. Monophasic growth was more common when final asymptotic densities were relatively low (~ 200 million cells ml-1). All species tended to grow faster and / or reached a higher asymptote at 26°C than at 18°C. The fastest growth was exhibited by S. minutum, with an approximate four-fold increase in estimated cell density after 60 days. The strongest effect of light was seen in S. trenchii, in which increasing light levels resulted in a decrease in initial growth rate, and an increase in asymptotic density, time when growth rate was at its maximum, final growth rate, and maximum growth rate. Results suggest that Symbiodinium species have different photokinetic and thermal optima, which may affect their growth-related nutritional physiology and allow them to modify their response to environmental changes.

Aim: To explore critical care nurses' decisions to seek help from doctors., Background: Despite their well-documented role in improving critically ill patients' outcomes, research indicates that nurses rarely take decisions about patients' treatment modalities on their own and constantly need to seek advice or authorization for their clinical decisions, even for protocol-guided actions. However, research around the factors related to, and the actual process of, such referrals is limited., Design: A grounded theory study, underpinned by a symbolic interactionist perspective., Methods: Data collection took place in a general intensive care unit between 2010 - 2012 and involved: 20 hours of non-participant and 50 hours of participant observation; ten informal and ten formal interviews; and two focus groups with ten nurses, selected by purposive and theoretical sampling. Data analysis was guided by the dimensional analysis approach to generating grounded theory., Findings: Nurses' decisions to seek help from doctors involve weighing up several occasionally conflicting motivators. A central consideration is that of balancing their moral obligation to safeguard patients' interests with their duty to respect doctors' authority. Subsequently, nurses end up in a position of dual agency as they need to concurrently act as an agent to medical practitioners and patients., Conclusion: Nurses' dual agency relationship with patients and doctors may deter their moral obligation of keeping patients' interest as their utmost concern. Nurse leaders and educators should, therefore, enhance nurses' assertiveness, courage and skills to place patients' interest at the forefront of all their actions and interactions., (© 2016 John Wiley & Sons Ltd.)

During sensory transduction, external physical stimuli are translated into an internal biological signal. In vertebrates, hair cells are specialized mechanosensory receptors that transduce sound, gravitational forces, and head movements into electrical signals that are transmitted with remarkable precision and efficiency to afferent neurons. Hair cells have a conserved structure between species and are also found in the lateral line system of fish, including zebrafish, which serve as an ideal animal model to study sensory transmission in vivo. In this chapter, we describe the methods required to investigate the biophysical properties underlying mechanosensation in the lateral line of the zebrafish in vivo from microphonic potentials and single hair cell patch-clamp recordings to single afferent neuron recordings. These techniques provide real-time measurements of hair-cell transduction and transmission following delivery of controlled and defined stimuli and their combined use on the intact zebrafish provides a powerful platform to investigate sensory encoding in vivo., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a genetic disease predominantly caused by desmosomal gene mutations that account for only ~50% of cases. Ryanodine receptor 2 (RYR2) gene mutations usually cause catecholaminergic polymorphic ventricular tachycardia but have been associated with a peculiar phenotype named ARVC2., Objective: We aimed to determine the prevalence and phenotype associated with RYR2 mutations in a large ARVC/D population., Methods: We analyzed the whole RYR2 coding sequence by Sanger sequencing in 64 ARVC/D probands without desmosomal gene mutations., Results: We have identified 6 rare missense variants: p.P1583S, p.A2213S, p.G2367R, p.Y2932H, p.V3219M, and p.L4670V. It corresponds to a 9% prevalence of rare RYR2 variants in the ARVC/D population (6 of 64 probands), which is significantly higher than the estimated frequency of rare RYR2 variants in controls (Fisher exact test, P = .03). Phenotypes associated with RYR2 variants were similar to desmosome-related ARVC/D, associating typical electrocardiographic abnormalities at rest, frequent monomorphic ventricular tachycardia, right ventricular dilatation, wall motion abnormalities, and fibrofatty replacement when histopathological examination was available., Conclusion: In this first systematic screening of the whole coding region of the RYR2 gene in a large ARVC/D cohort without mutation in desmosomal genes, we show that putative RYR2 mutations are frequent (9% of ARVC/D probands) and are associated with a conventional phenotype of ARVC/D, which is in contrast with previous findings. The results support the role of the RYR2 gene in conventional ARVC/D., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

The late Quaternary Kibish Formation of the Omo Valley, southwestern Ethiopia, preserves environments reflecting a history of fluctuations in the level of nearby Lake Turkana over the past 200,000 years. The Kibish Formation has yielded a diverse mammalian fauna (as well as birds and crocodiles), stone tools, and the oldest anatomically modern Homo sapiens. Fish, the most common vertebrate fossils in this unit, are reported in this study. Catfish (especially clariids and Synodontis) and Nile perch (Lates niloticus) predominate, but the gymnarchid Gymnarchus, a cyprinid (Barbus), tigerfish (Hydrocynus), pufferfish (Tetraodon), and other catfish are also present. In total, nine teleost genera are found in the Kibish Formation, representing a subset of the 37 genera that constitute the modern Omo-Turkana ichthyofauna. Several taxa present in the modern fauna, including Polypterus and members of the family Cichlidae, are not found in the Kibish deposits. Most specimens are preserved as disarticulated or broken skeletal elements, but some preservation of articulated elements (e.g., sets of vertebrae, crania with lower jaws or cleithra) also occurs. Many of the catfish and Nile perch specimens are larger than the largest reported from the modern river or lake. Faunas of Kibish Members I and III closely resemble one another; the fauna from Member IV contains only the three most common taxa (Clarias, Synodontis, Lates), though this may result from insufficient sampling. Barbed bone points have been collected from the upper part of the formation, indicating a long association between the human inhabitants and the fish fauna of the Omo Valley.

The fossil record indicates that cypriniform fishes, a group including the zebrafish, lost oral teeth over 50 million years ago. Despite subsequent diversification of feeding modes, no cypriniform has regained oral teeth, suggesting the zebrafish as a model for studying the developmental genetic basis of evolutionary constraint. To investigate the mechanism of cypriniform tooth loss, we compared the oral expression of seven genes whose mammalian orthologs are involved in tooth initiation in the zebrafish and the Mexican tetra, Astyanax mexicanus, a related species retaining oral teeth. The most significant difference we found was an absence in zebrafish oral epithelium of expression of dlx2a and dlx2b, transcription factors that are expressed in early Astyanax odontogenic epithelium. Analysis of orthologous genes in the Japanese medaka (Oryzias latipes) and a catfish (Synodontis multipunctatus) suggests that expression was lost in cypriniforms, rather than gained in Astyanax. Treatment of Astyanax with an inhibitor of Fibroblast growth factor (Fgf) signaling produced a partial phenocopy of the zebrafish oral region, in that oral teeth, and expression of dlx2a and dlx2b, were lost, whereas shh and pitx2, genes whose expression is present in zebrafish oral epithelium, were unaffected. We hypothesize that a loss of Fgf signaling to oral epithelium was associated with cypriniform tooth loss.

Loss of Bid confers clonogenic survival to granzyme B-treated cells, however the exact role of Bid-induced mitochondrial damage--upstream or downstream of caspases--remains controversial. Here we show that direct cleavage of Bid by granzyme B, but not caspases, was required for granzyme B-induced apoptosis. Release of cytochrome c and SMAC, but not AIF or endonuclease G, occurred in the absence of caspase activity and correlated with the onset of apoptosis and loss of clonogenic potential. Loss of mitochondrial trans-membrane potential (DeltaPsim) was also caspase independent, however if caspase activity was blocked the mitochondria regenerated their DeltaPsim. Loss of DeltaPsim was not required for rapid granzyme B-induced apoptosis and regeneration of DeltaPsim following cytochrome c release did not confer clonogenic survival. This functional dissociation of cytochrome c and SMAC release from loss of DeltaPsim demonstrates the essential contribution of Bid upstream of caspase activation during granzyme B-induced apoptosis.

Dental polymorphism in teleost fishes often involves production of a robust dentition, or "molarization", in one morph. The lower pharyngeals of a sample of wild-caught individuals of the polymorphic Cuatro Cienegas cichlid, Cichlasoma minckleyi (Kornfield and Taylor) (Proc. Biol. Soc. Wash. 96 (1983) 253), were measured to investigate morphological changes associated with molarization. Principal components analysis demonstrates that dental variability in this species increases in larger fish, and that only the molariform morph contributes to this increase. Reduced major axis regression analyses between pairs of variables indicate that the papilliform morph increases both tooth measures and numbers, whereas the molariform morph maintains a relatively constant number of teeth as it produces teeth of progressively larger size. In the papilliform morph, negative allometric scaling between tooth size and dentigerous area is compensated for by addition of teeth. Tooth size variables are isometric in the molariform morph, and tooth numbers are nearly static. These results are consistent with those reported for other polymorphic cichlid species. Further study is required to elucidate the mechanisms whereby tooth form in polyphyodont species may respond to environmental factors (like food hardness), but possibilities include direct mechanical influences or transmission of signals via nerves to developing replacement teeth.

Objective: To determine if Reactive Attachment Disorder (RAD) can be reliably identified in maltreated toddlers in foster care, if the two types of RAD are independent, and to estimate the prevalence of RAD in these maltreated toddlers., Methods: Clinicians treating 94 maltreated toddlers in foster care were interviewed regarding signs of attachment disorder at intake in an intervention program., Results: Using categorical and continuous measures, both types of RAD can be reliably identified in maltreated toddlers. Both continuous scores and categorical diagnoses indicated that a substantial minority of maltreated young children do exhibit signs of attachment disorders sufficient to meet criteria in DSM-IV and ICD-10. The two types were moderately convergent and at times co-occurred in the same child. Prevalence of RAD in this high-risk sample was 38-40%. Indiscriminate/disinhibited RAD was identified in children with and without an attachment figure. Within this maltreated group, toddlers whose mothers had a history of psychiatric disturbance were more likely to be diagnosed with attachment disorders., Conclusions: RAD may be reliably identified in maltreated toddlers. Emotionally withdrawn/inhibited and indiscriminate/disinhibited types of RAD are not entirely independent.

IFI 16 is a member of the HIN-200 family of transcriptional regulators that suppress cell growth, modulate the cell cycle and have been linked to cellular differentiation. We hypothesized that the activity of IFI 16 depends on its level of expression and therefore studied the transcriptional activity of the IFI 16 promoter. A discrete sequence within the 5' untranslated region was required for constitutive activity of the promoter and the functional motif within this region was shown to be a consensus AP-1 site. Interestingly, this AP-1 site was also critical for IFN-induced activation of the promoter and consistent with these observations, treatment of cells with IFNgamma resulted in a rapid and robust induction of AP-1 activity that preceded expression of IFI 16. These experiments define the transcriptional mechanisms of IFI 16 gene regulation and provide evidence suggesting that AP-1 activation may be an important event in IFN signaling., (Copyright 2003 Wiley-Liss, Inc.)

This study provides a taphonomic analysis of prey accumulations of crowned hawk-eagles (Stephanoaetus coronatus) from Ngogo, Kibale National Park, Uganda, collected over 37 months from below nests of two eagle pairs. Crowned hawk-eagles are powerful predators capable of killing animals much larger than themselves, and are significant predators of cercopithecoid monkeys in forest habitats throughout sub-Saharan Africa. At Ngogo, 81% of the individuals in the kill sample are monkeys. Redtail monkeys (Cercopithecus ascanius) are particularly well represented in the sample, making up 66% of monkeys identified to species. Despite an impressive killing apparatus, crowned hawk-eagles are fastidious eaters that inflict far less damage to bone than mammalian predators. Examination of skeletal material from the Ngogo kill sample reveals that crania, hindlimb elements, and scapulae survive predation better than do other bones. Crania of adults are typically complete and accompanied by mandibles, while crania of young individuals are usually dissociated from mandibles and lack basicrania and faces. Long bones are often whole or show minimal damage. Thin bones, such as crania and innominates, are marked by numerous nicks, punctures, and "can-opener" perforations. Scapular blades are heavily raked and shattered. Along with the strong preference for cercopithecoids, these distinct patterns of bone survival and damage indicate the feasibility of recognizing specific taphonomic signatures of large raptors in fossil assemblages. Berger and Clarke (1995) hypothesized that crowned hawk-eagles or similar large raptors were principally responsible for the accumulation of the late Pliocene fossil fauna from Taung, South Africa, including the type infant skull of Australopithecus africanus. The results of our study suggest that the faunal composition and type of damage to the hominid skull and other bone from Taung are consistent with the predatory activities of large raptors. More rigorous assessment of their hypothesis will require sorting the Taung fauna by locality and further detailed analysis of species composition and bone damage and survivability patterns.

The induction of cell death by cytotoxic T-lymphocytes (CTL) or natural killer (NK) cells is one of the main ways by which higher organisms protect themselves from rogue cells, including those infected by a virus, or posing a risk of cancer. Considering the rapidity of viral replication and spread to uninfected cells, CTL and NK are extremely efficient killers. This is at least partly due to the variety of pathways that these cytolytic lymphocytes (CL) can use to ensure the death of a cell. Primarily, CL utilize two independently initiated pathways involving either ligation of death receptors or perforin mediated trafficking of granzyme B to the target cell cytosol to activate a family of death proteases (caspases) in the target cell. The caspases then orchestrate the orderly dismantling of that cell by cleavage of a set of critical substrates. If caspases are inactivated, due either to mutations in proteins that signal their activation or direct inhibition by a viral gene product, CL can utilize a caspase-independent pathway to ensure the death of the target cell. Here we will discuss the mechanisms by which these stellar killers achieve their goal.

Granzyme B (graB) plays a pivotal role in cytotoxic lymphocyte granule-mediated apoptosis through cleavage of intracellular proteins in target cells. Proteinase inhibitor-9 (PI-9) is a potent inhibitor of graB and is highly expressed in cytotoxic lymphocytes. Here, we show by immunohistochemistry that PI-9 is also abundantly expressed in human testicular Sertoli cells and placental syncytial trophoblasts. Postulating that PI-9 protects these tissues from graB-producing auto- or allo-reactive cytotoxic lymphocytes, we also stained sections for graB. Unexpectedly, graB was observed in non-cytotoxic cells in both tissues. In the adult human testis, graB was present in spermatogenic cells within the seminiferous tubule, and this was verified by in-situ hybridization and reverse transcription-polymerase chain reaction (RT-PCR). Immunohistochemical analysis of term placentae demonstrated graB in syncytial trophoblasts, and this was confirmed by RT-PCR on primary trophoblasts from term placenta. Perforin, which is co-produced with graB by activated cytotoxic lymphocytes and is required for graB release into the target cell, was not detected in either testis or placenta. We postulate that, in these organs, graB has a perforin-independent role, involving hydrolysis of extracellular matrix components. In the testis, graB may facilitate migration of developing germ cells, while in the placenta, it may contribute to extracellular matrix remodelling during parturition.

Interferons (IFNs) are an important part of immune responses and are believed to protect the host from viral and bacterial pathogens as well as having a role in rejection of malignancies. The well-known anti-viral and cytostatic properties of IFNs have led to the clinical use of these proteins to treat some cancers and viral infections. Extensive research has begun to unravel much of the molecular basis for the biological effects of IFNs, and this information could now be used as a foundation for the development of novel therapeutic strategies that avoid some of the acknowledged shortcomings of cytokine therapies. This review explains the current model of IFN action, during viral infections and the potential for well-established and emerging groups of IFN inducible genes as therapeutic targets is highlighted.

Cytotoxic lymphocytes largely comprise CD8(+) cytotoxic T cells and natural killer cells and form the major defense of higher organisms against virus-infected and transformed cells. A key function of cytotoxic lymphocytes is to detect and eliminate potentially harmful cells by inducing them to undergo apoptosis. This is achieved through two principal pathways, both of which require direct but transient contact between the killer cell and its target. The first, involving ligation of TNF receptor-like molecules such as Fas/CD95 by their cognate ligands, results in mobilization of conventional, programmed cell-death pathways centered on activation of pro-apoptotic caspases. This review concentrates on the second pathway, in which the toxic contents of secretory vesicles of the cytotoxic lymphocyte are secreted toward the target cell, and some toxins penetrate into the target cell cytoplasm and nucleus. In addition to invoking a powerful stimulus to caspase activation, this "granule-exocytosis mechanism" provides a variety of additional strategies for overcoming inhibitors of the caspase cascade that may be elaborated by viruses. The key molecular players in this process are the pore-forming protein perforin and a family of granule-bound serine proteases or granzymes. The molecular functions of perforin and granzymes are under intense investigation in many laboratories including our own, and recent advances will be discussed. In addition, this review discusses the evidence pointing to the importance of perforin and granzyme function in pathophysiological situations as diverse as infection with intracellular pathogens, graft versus host disease, susceptibility to transplantable and spontaneous malignancies, lymphoid homeostasis, and the tendency to auto-immune diseases.

Despite major advances in our understanding of adaptive immunity and dendritic cells, consistent and durable responses to cancer vaccines remain elusive and active immunotherapy is still not an established treatment modality. The key to developing an effective anti-tumor response is understanding why, initially, the immune system is unable to detect transformed cells and is subsequently tolerant of tumor growth and metastasis. Ineffective antigen presentation limits the adaptive immune response; however, we are now learning that the host's innate immune system may first fail to recognize the tumor as posing a danger. Recent descriptions of stress-induced ligands on tumor cells recognized by innate effector cells, new subsets of T cells that regulate tumor tolerance and the development of spontaneous tumors in mice that lack immune effector molecules, beckon a reflection on our current perspectives on the interaction of transformed cells with the immune system and offer new hope of stimulating therapeutic immunity to cancer.

The structurally related TCR-zeta and Fc receptor for IgE (Fc epsilon RI)-gamma are critical signaling components of the TCR and Fc epsilon RI, respectively. Although chimeric Ab receptors containing zeta and gamma signaling chains have been used to redirect CTL to tumors, a direct comparison of their relative efficacy has not previously been undertaken. Here, in naive T lymphocytes, we compare the signaling capacities of the zeta and gamma subunits within single-chain variable domain (scFv) chimeric receptors recognizing the carcinoembryonic Ag (CEA). Using a very efficient retroviral gene delivery system, high and equivalent levels of scFv-zeta and scFv-gamma receptors were expressed in T cells. Despite similar levels of expression and Ag-specific binding to colon carcinoma target cells, ligation of scFv-anti-CEA-zeta chimeric receptors on T cells resulted in greater cytokine production and direct cytotoxicity than activation via scFv-anti-CEA-gamma receptors. T cells expressing scFv-zeta chimeric receptors had a greater capacity to control the growth of human colon carcinoma in scid/scid mice or mouse colon adenocarcinoma in syngeneic C57BL/6 mice. Overall, these data are the first to directly compare and definitively demonstrate the enhanced potency of T cells activated via the zeta signaling pathway.

Members of the interferon-induced class of nuclear factors possess a putative CcN motif, comparable with that within proteins such as the simian virus 40 large tumour antigen (T-ag), which confers phosphorylation-mediated regulation of nuclear-localization sequence (NLS)-dependent nuclear import. Here we examine the functionality of the interferon-induced factor 16 (IFI 16) CcN motif, demonstrating its ability to target a heterologous protein to the nucleus, and to be phosphorylated specifically by the CcN-motif-phosphorylating protein kinase CK2 (CK2). The IFI 16 NLS, however, has novel properties, conferring ATP-dependent nuclear import completely independent of cytosolic factors, as well as binding to nuclear components. The IFI 16 NLS is not recognized with high affinity by the NLS-binding importin heterodimer, and transport mediated by it is insensitive to non-hydrolysable GTP analogues. The IFI 16 NLS thus mediates nuclear import through a pathway completely distinct from that of conventional NLSs, such as that of T-ag, but intriguingly resembling that of the NLS of the HIV-1 transactivator protein Tat. Since the IFI 16 CK2 site enhances nuclear import through facilitating binding to nuclear components, this represents a novel mechanism by which the site regulates nuclear-protein import, and constitutes a difference between the IFI 16 and Tat NLSs that may be of importance in the immune response.

Summary: Granzymes, a family of serine proteases, are expressed exclusively by cytotoxic T lymphocytes and natural killer (NK) cells, components of the immune system that protect higher organisms against viral infection and cellular transformation. Following receptor-mediated conjugate formation between a granzyme-containing cell and an infected or transformed target cell, granzymes enter the target cell via endocytosis and induce apoptosis. Granzyme B is the most powerful pro-apoptotic member of the granzyme family. Like caspases, cysteine proteases that play an important role in apoptosis, it can cleave proteins after acidic residues, especially aspartic acid. Other granzymes may serve additional functions, and some may not induce apoptosis. Granzymes have been well characterized only in human and rodents, and can be grouped into three subfamilies according to substrate specificity: members of the granzyme family that have enzymatic activity similar to the serine protease chymotrypsin are encoded by a gene cluster termed the 'chymase locus'; granzymes with trypsin-like specificities are encoded by the 'tryptase locus'; and a third subfamily cleaves after unbranched hydrophobic residues, especially methionine, and is encoded by the 'Met-ase locus'. All granzymes are synthesized as zymogens and, after clipping of the leader peptide, maximal enzymatic activity is achieved by removal of an amino-terminal dipeptide. They can all be blocked by serine protease inhibitors, and a new group of inhibitors has recently been identified - serpins, some of which are specific for granzymes. Future studies of serpins may bring insights into how cells that synthesize granzymes are protected from inadvertent cell suicide.

Recent studies have demonstrated that granzymes A and B make an important contribution to the clearance of the orthopoxvirus ectromelia, and in graft versus host disease. To test whether granzymes are generally necessary for lymphocyte-mediated cytotoxicity in vivo, we assessed the cytotoxic capacity of granzyme A and/or B-deficient lymphocytes in several perforin-dependent settings. Splenocytes and allogeneic CTL of granzyme A and/or B-deficient mice were defective for induction of DNA fragmentation, but induced significant membrane damage and target cell death. These results correlated well with the behavior of granzyme A/B-deficient CTL and NK cells in three different perforin-dependent tumor models. In a classical assay of NK cell-mediated rejection, granzyme A and/or B-deficient mice inoculated with RMA-S cells were as susceptible to tumor as wild-type mice. Perforin-deficient mice were also considerably more susceptible to tumor initiation by methylcholanthrene than granzyme A and/or B-deficient mice. Furthermore, rejection of the K1735-melanoma expressing MHC class I and II molecules was mediated by adoptively transferred H-2b anti-k CTL from immunized granzyme A and/or B-deficient mice. In summary, these data suggest that granzymes A and B are not critical for most anti-tumor effector functions of NK cells and CTL that are perforin mediated.

We used yeast two-hybrid screening to identify the cytoskeletal protein filamin as a ligand for the proapoptotic protease granzyme B, produced by cytotoxic T lymphocytes. Filamin was directly cleaved by granzyme B when target cells were exposed to granzyme B and the lytic protein perforin, but it was also cleaved in a caspase-dependent manner following the ligation of Fas receptors. A similar pattern of filamin cleavage to polypeptides of approximately 110 and 95 kDa was observed in Jurkat cells killed by either mechanism. However, filamin cleavage in response to granzyme B was not inhibited by the caspase inhibitor z-Val-Ala-Asp-fluoromethylketone at concentrations that abolished DNA fragmentation. Filamin staining was redistributed from the cell membrane into the cytoplasm of Jurkat cells exposed to granzyme B and perforin and following ligation of Fas receptors, coincident with the morphological changes of apoptosis. Filamin-deficient human melanoma cells were significantly (although not completely) protected from granzyme B-mediated death compared with isogenic filamin-expressing cells, both in clonogenic survival and (51)Cr release assays, whereas death from multiple other stimuli was not affected by filamin deficiency. Thus, filamin is a functionally important substrate for granzyme B, as its cleavage may account at least partly for caspase-independent cell death mediated by the granzyme.

Interferons are important in regulating cell growth and differentiation, immune function and initiating anti-viral responses. While the pleotrophic actions of interferons have been well documented, the molecular mechanisms underpinning their biological effects have not been fully characterized. IFI 16 is a member of the interferon-inducible HIN-200 family of nuclear proteins, which we have recently shown can function as a potent transcriptional repressor. A murine member of the HIN-200 family, p202, can indirectly interact with p53 via the p53 binding protein (p53bp) and inhibit p53-mediated transcriptional activation. The binding activity of p202 to p53bp was shown to require the conserved MFHATVAT motif present in all 200 amino acid repeat regions of HIN-200 proteins. Given that IFI 16 contains two MFHATVAT motifs, we sought to determine whether IFI 16 may form a complex with p53 and if so to ascertain the functional significance of this interaction. We demonstrate that IFI 16 can directly bind to the C-terminal region of p53 and augment p53-mediated transcriptional activation without altering the steady state levels of p53. Thus, in addition to its ability to directly regulate gene expression, IFI 16 can also modulate the transcription function of other cellular transcription factors. These findings demonstrate a possible link between gene induction following interferon stimulation and p53-mediated cellular events.

The essential upstream steps in granzyme B-mediated apoptosis remain undefined. Herein, we show that granzyme B triggers the mitochondrial apoptotic pathway through direct cleavage of Bid; however, cleavage of procaspases was stalled when mitochondrial disruption was blocked by Bcl-2. The sensitivity of granzyme B-resistant Bcl-2-overexpressing FDC-P1 cells was restored by coexpression of wild-type Bid, or Bid with a mutation of its caspase-8 cleavage site, and both types of Bid were cleaved. However, Bid with a mutated granzyme B cleavage site remained intact and did not restore apoptosis. Bid with a mutation preventing its interaction with Bcl-2 was cleaved but also failed to restore apoptosis. Rapid Bid cleavage by granzyme B (<2 min) was not delayed by Bcl-2 overexpression. These results clearly placed Bid cleavage upstream of mitochondrial Bcl-2. In granzyme B-treated Jurkat cells, endogenous Bid cleavage and loss of mitochondrial membrane depolarization occurred despite caspase inactivation with z-Val-Ala-Asp-fluoromethylketone or Asp-Glu-Val-Asp-fluoromethylketone. Initial partial processing of procaspase-3 and -8 was observed irrespective of Bcl-2 overexpression; however, later processing was completely abolished by Bcl-2. Overall, our results indicate that mitochondrial perturbation by Bid is necessary to achieve a lethal threshold of caspase activity and cell death due to granzyme B.

Destruction of tumor cells is a key function of lymphocytes, but the molecular processes driving it are unclear. Analysis of signal molecules indicated that mitogen-activated protein kinase (MAPK)/extracellular regulated kinase 2 critically controlled lytic function in human NK cells. We now have evidence to indicate that target ligation triggers a Ras-independent MAPK pathway that is required for lysis of the ligated tumor cell. Target engagement caused NK cells to rapidly activate MAPK within 5 min, and PD098059 effectively blocked both MAPK activation and tumoricidal function in NK cells. Target engagement also rapidly activated Ras, detected as active Ras-GTP bound to GST-Raf-RBD, a GST fusion protein linked to the Raf protein fragment containing the Ras-GTP binding domain. However, Ras inactivation by pharmacological disruption with the farnesyl transferase inhibitor, FTI-277, had no adverse effect on the ability of NK cells to lyse tumor cells or to express MAPK activation upon target conjugation. Notably, MAPK inactivation with PD098059, but not Ras inactivation with FTI-277, could interfere with perforin and granzyme B polarization within NK cells toward the contacted target cell. Using vaccinia delivery of N17 Ras into NK cells, we demonstrated that IL-2 activated a Ras-dependent MAPK pathway, while target ligation used a Ras-independent MAPK pathway to trigger lysis in NK cells.

The molecular pathways responsible for apoptosis in response to granzyme B have remained unresolved. Here we present data supporting the notion that granzyme B-mediated cell death is largely dependent on a pathway that is inhibitable by Bcl-2 or its viral analog BHRF1. We used a panel of stably transfected FDC-P1 mouse myeloid cell lines to show that overexpression of functional, wild-type Bcl-2 or BHRF1 rescued cells from granzyme B-mediated apoptosis, whereas mutated (Gly145-->Glu) Bcl-2, or wild-type Bcl-2 directed to the plasma membrane conferred no protection. Overexpression of Bcl-2 resulted in inhibition of multiple parameters of apoptosis in response to purified perforin and granzyme B, including DNA fragmentation, changes in light scatter profile indicating cell shrinkage and increased refractivity, loss of mitochondrial membrane potential and inhibited colony formation in clonogenic assays. Nevertheless, when exposed to cytotoxic lymphocytes, FDC-P1 and YAC-1 cells overexpressing Bcl-2 remained susceptible to death imparted by cytolytic granules, irrespective of whether the granules contained granzyme B. Thus, alternative granzyme B-independent pathways can be activated by intact lymphocytes to overcome Bcl-2-like inhibitors of apoptosis, enabling CTLs to overcome potential viral blocks to granzyme B-mediated cell death.

Immune surveillance by cytotoxic lymphocytes against cancer has been postulated for decades, but direct evidence for the role of cytotoxic lymphocytes in protecting against spontaneous malignancy has been lacking. As the rejection of many experimental cancers by cytotoxic T lymphocytes and natural killer cells is dependent on the pore-forming protein perforin (pfp), we examined pfp-deficient mice for increased cancer susceptibility. Here we show that pfp-deficient mice have a high incidence of malignancy in distinct lymphoid cell lineages (T, B, NKT), indicating a specific requirement for pfp in protection against lymphomagenesis. The susceptibility to lymphoma was accentuated by simultaneous lack of expression of the p53 gene, mutations in which also commonly predispose to human malignancies, including lymphoma. In contrast, the incidence and age of onset of sarcoma was unaffected in p53-deficient mice. Pfp-deficient mice were at least 1,000-fold more susceptible to these lymphomas when transplanted, compared with immunocompetent mice in which tumor rejection was controlled by CD8(+) T lymphocytes. This study is the first that implicates direct cytotoxicity by lymphocytes in regulating lymphomagenesis.