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Constitutive internalization of murine MHC class I molecules.

The total number of cell surface glycoprotein molecules at the plasma membrane results from a balance between their constitutive internalization and their egress to the cell surface from intracellular pools and/or biosynthetic pathway. Constitutive internalization is net result of constitutive endocytosis and endocytic recycling. In this study we have compared spontaneous internalization of murine major histocompatibility complex (MHC) class I molecules (K(d), D(d), full L(d), and empty L(d)) after depletion of their egress to the cell surface (Cycloheximide [CHX], brefeldin A [BFA]) and internalization after external binding of monoclonal antibody (mAb). MHC class I alleles differ regarding their cell surface stability, kinetics, and in the way of internalization and degradation. K(d) and D(d) molecules are more stable at the cell surface than L(d) molecules and, thus, constitutively internalized more slowly. Although the binding of mAbs to cell surface MHC class I molecules results in faster internalization than depletion of their egress, it is still slow and, thereby, can serve as a model for tracking of MHC class I endocytosis. Internalization of fully conformed MHC class I molecules (K(d), D(d), and L(d)) was neither inhibited by chlorpromazine (CP) (inhibitor of clathrin endocytosis), nor with filipin (inhibitor of lipid raft dependent endocytosis), indicating that fully conformed MHC class I molecules are internalized via the bulk pathway. In contrast, internalization of empty L(d) molecules was inhibited by filipin, indicating that non-conformed MHC class I molecules require intact cholesterol-rich membrane microdomains for their constitutive internalization. Thus, conformed and non-conformed MHC class I molecules use different endocytic pathways for constitutive internalization.

Animals↗

Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian Colorectal Surgical Trials Group.

PURPOSE: This was a multicenter, randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure. METHODS: Patients with symptomatic chronic anal fissures were randomly assigned to 0.25 percent nitroglycerin tid or internal sphincterotomy. Both groups received stool softeners and fiber supplements and were assessed at six weeks and six months. RESULTS: Ninety patients were accrued, but 8 were excluded from the analysis because they refused internal sphincterotomy after randomization (6), the fissure healed before surgery (1), or a fissure was not observed at surgery (1). There were 38 patients in the internal sphincterotomy group (22 males; mean age, 40.3 years) and 44 patients in the nitroglycerin group (15 males; mean age, 38.7 years). At six weeks 34 patients (89.5 percent) in the internal sphincterotomy group compared with 13 patients (29.5 percent) in the nitroglycerin group had complete healing of the fissure (P = 5x10(-8)). Five of the 13 patients in the nitroglycerin group relapsed, whereas none in the internal sphincterotomy group did. At six months fissures in 35 (92.1 percent) patients in the internal sphincterotomy group compared with 12 (27.2 percent) patients in the nitroglycerin group had healed (P = 3x10(-9)). One (2.6 percent) patient in the internal sphincterotomy group required further surgery for a superficial fistula compared with 20 (45.4 percent) patients in the nitroglycerin group who required an internal sphincterotomy (P = 9x10(-6)). Eleven (28.9 percent) patients in the internal sphincterotomy group developed side effects compared with 37 (84 percent) patients in the nitroglycerin group (P<0.0001). Nine (20.5 percent) patients discontinued the nitroglycerin because of headaches (8) or a severe syncopal attack (1). CONCLUSIONS: Internal sphincterotomy is superior to topical nitroglycerin 0.25 percent in the treatment of chronic anal fissure, with a high rate of healing, few side effects, and low risk of early incontinence. Thus, internal sphincterotomy remains the treatment of choice for chronic anal fissure.

Administration, Topical↗

Evaluation of an internal thoracic artery as a coronary artery bypass graft by intercostal duplex scanning ultrasonography.

OBJECTIVES: Although angiography is often used to determine whether the internal thoracic artery is appropriate as a coronary bypass graft, but use of duplex scanning ultrasonography for this purpose is not yet widespread. METHODS: The internal diameter and flow of the internal thoracic artery were measured using intercostal duplex scanning in 100 patients during April 1995. The ultrasonographic device (sonos 2000, Hewlett Packard) used had a linear probe delivering a frequency of 7.5 MHz. Bilateral internal thoracic arteries and their blood flow were imaged clearly in all subjects. Diameter was compared by angiography and duplex scanning ultrasonography in 20 patients. RESULTS: The average internal diameter of internal thoracic artery was 2.19 +/- 0.46 mm (right) or 2.13 +/- 0.32 mm (left) in men and 2.05 +/- 0.44 mm (right) or 2.09 +/- 0.42 mm (left) in women. The gender difference was statistically significant (p = 0.05). The maximum systolic blood flow velocity through the internal thoracic artery was 0.85 +/- 0.34 m/s (right) or 0.84 +/- 0.36 m/s (left) in men and 0.87 +/- 0.28 m/s (right) or 0.82 +/- 0.28 m/s (left) in women. The average internal thoracic arterial blood flow (F) was 54.6 +/- 29.0 ml/min (right) or 50.9 +/- 28.8 ml/min (left) in men and 56.8 +/- 38.2 ml/min (right) or 58.2 +/- 33.4 ml/min (left) in women. Duplex scanning ultrasonography using an intercostal approach enables easy imaging of bilateral internal thoracic arteries and visualizes entire internal thoracic artery structure by simply changing the probe position. CONCLUSION: Intercostal duplex scanning ultrasonography is thus recommended for reliable evaluation of the internal diameter and blood flow of the internal thoracic artery.

Aged↗

Clinical relevance of sentinel lymph nodes in the internal mammary chain in breast cancer patients.

PURPOSE: Despite the widespread use of sentinel lymph node (SLN) biopsy in breast cancer patients, some controversy exists about the correct management of extra-axillary nodes, especially those located in the internal mammary chain. The aim of this study was to evaluate the incidence of SLNs in this region, calculate the lymphoscintigraphic and surgical detection rates and evaluate the clinical impact on staging and therapeutic decisions. METHODS: The study involved 383 consecutive women diagnosed with early breast cancer with T1 or T2 tumours. Eight patients had a bilateral tumour, which brought the total to 391 lesions. Lymphoscintigraphy was performed on the day before surgery by injection of (99m)Tc-labelled nanocolloid. The injection site was subdermal (68 patients), peritumoural (107 patients) or intratumoural (216 patients). During surgery a gamma probe was used to guide the surgeon and the SLNs were removed. SLNs were analysed by a conventional pathological study and processed for H&E examination and immunohistochemistry. RESULTS: Lymphoscintigraphy detected at least one SLN in 369 out of the 391 procedures (94.4%). SLNs were found in the axillary chain in 367 cases and in the internal mammary chain in 55. In two of these 55 cases (3.6%), the SLN was the only one detected. There was no drainage to the internal mammary chain in any case of subdermal injection but such drainage was found in 15.9% of cases with peritumoural injection and 17.6% of those with intratumoural injection. Compared with tumours located in the outer quadrants, a higher percentage of tumours located in the inner quadrants showed drainage to the internal mammary chain (p<0.001). A total of 42 SLNs in the internal mammary chain could be removed in 32 patients without appreciable morbidity. In 20 cases both axillary and internal mammary SLNs were negative, in four both were positive, and in five axillary SLNs were positive and internal mammary SLNs were negative. More interestingly, in the remaining patient with both axillary and internal mammary SLNs, the axillary SLN was negative while malignant cells were found in the internal mammary region. In the evaluation of the clinical impact of internal mammary SLN biopsy, we found that staging was modified from pN1a to pN1c in four patients and, more importantly, from pN0 to pN0(i+) in one patient. The change in stage led to a modification of the postoperative treatment plan with respect to radiotherapy and systemic therapy. CONCLUSION: Evaluation of the SLNs in the internal mammary chain provides more accurate staging of breast cancer patients. If internal mammary sampling is not performed, patients can be understaged. This technique can offer a better indication of those patients who will benefit from selective treatment options like radiotherapy to this region or systemic therapy.

Adult↗

Robotic skeletonizing of the internal thoracic artery: is it safe?

BACKGROUND: The advantages of internal thoracic artery skeletonization include early high blood flow, a longer conduit, and less bleeding than pedicle internal thoracic artery grafts. Longer conduits are needed for complete endoscopic arterial revascularization. Therefore this study was designed to determine the feasibility and safety of internal thoracic artery skeletonization using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA). METHODS: Nine dogs underwent bilateral robotic internal thoracic artery harvesting through three ports placed in the left chest. One internal thoracic artery was harvested as a pedicle in each dog, and the other was skeletonized. Internal thoracic artery blood flow was measured in each graft, and comparative endothelial histologic studies were performed. Data are mean +/- the standard error of the mean. RESULTS: All 18 internal thoracic arteries were harvested successfully. Skeletonized internal thoracic artery harvests required more time (48.0 minutes +/- 1.8) than pedicle internal thoracic artery harvests (39.0 minutes +/- 1.4; p < 0.05). Internal thoracic artery flows during the final intervals were similar (skeletonized = 30.0 mL/min +/- 2.4 vs pedicle = 31.5 mL/min +/- 1.8; p = 0.9). Free internal thoracic artery bleeding flow was similar in both groups (skeletonized = 162.0 mL/min +/- 3.0 vs pedicle = 189.0 mL/min +/- 2.4; p = 0.4). Histologically, both groups were similar with minimal endothelial damage. CONCLUSIONS: Robotically skeletonized harvesting is safe, but it requires more time (48.0 minutes +/- 1.8) than pedicle internal thoracic artery harvesting. Despite muted tactile feedback with robotics, neither technique was associated with histologic or functional damage. These encouraging results may represent an advantage for complete arterial revascularization in robotic coronary bypass patients.

Animals↗

Internalization and recycling of human mu opioid receptors expressed in Sf9 insect cells.

Internalization and recycling of G protein-coupled receptors (GPCRs), such as the mu-opioid receptor, largely depend on agonist stimulation. Agonist-promoted internalization of some GPCRs has been shown to mediate receptor desensitization, resensitization, and down-regulation. In this study, we investigated whether different mu opioid agonists displayed different effects in receptor internalization and recycling, the potential mechanisms involved in ohmefentanyl-induced internalization process. In transfected Sf9 insect cells expressing 6His-tagged wild type mu opioid receptor, exposure to 100 nM ohmefentanyl caused a maximum internalization of the receptor at 30 min and receptors seemed to reappear at the cell membrane after 60 min as determined by radioligand binding assay. Ohmefentanyl-induced human mu opioid receptor internalization was concentration-dependent, with about 40% of the receptors internalized following a 30-min exposure to 1 microM ohmefentanyl. 10 microM morphine and 1 microM DAMGO could also induce about 40% internalization. The antagonist naloxone and pretreatment with pertussis toxin both blocked ohmefentanyl-induced internalization without affecting internalization themselves. Incubation with sucrose 0.45 M significantly inhibited ohmefentanyl-induced internalization of the mu receptor. The removal of agonists ohmefentanyl and morphine resulted in the receptors gradually returning to the cell surface over a 60 min period, while the removal of agonist DAMGO only partly resulted in the receptor recycling. The results of this study suggest that ohmefentanyl-induced internalization of human mu opioid receptor in Sf9 insect cells occurs via Gi/o protein-dependent process that likely involves clathrin-coated pits. In addition, the recycling process displays the differential modes of action of different agonists.

Analgesics, Opioid↗

Ligand internalization and recycling by human recombinant somatostatin type 4 (h sst(4)) receptors expressed in CHO-K1 cells.

There is controversy as to whether somatostatin sst(4) receptors internalize. In this study, CHO-K1 cells expressing human sst(4) receptor (CHOsst(4) cells) cells internalized [(125)I]-[(11)Tyr]-SRIF in a time-dependent manner, reaching a steady state at 60 min (1.4+/-0.1x10(4) molecules internalized per cell). Internalization was blocked by hypertonic sucrose (0.5 M), ATP depletion or by decreasing the temperature to 4 degrees C. Internalization of [(125)I]-[(11)Tyr]-SRIF was also inhibited (pIC(50) values) by increasing concentrations of SRIF (7.74), L-362855 (6.27) and NNC-296100 (6.50) with pIC(50) values approximately 10 fold lower than those obtained for inhibition of [(125)I]-[(11)Tyr]-SRIF binding to membrane homogenates. Internalized ligand recycled rapidly to the extracellular media (t(1/2) 3.9+/-0.7 min) with only 6.8+/-0.6% of internalized radioactivity remaining in the cell after 45 min. Confocal microscopy of permeabilized, HA-epitope tagged CHOsst(4) cells labelled with a Cy-3 conjugated antibody revealed little internal immunostaining after SRIF (1 microM) treatment, consistent with the small proportion of receptors (3.5%) estimated to be internalized by radioimmunoassay. In summary, CHOsst(4) cells internalized [(125)I]-[(11)Tyr]-SRIF in a clathrin- and ATP-dependent manner with subsequent rapid recycling to the extracellular medium. Rapid receptor recycling and the consequent low proportion of receptors internalized at any one time may explain the inability to visualize internalized receptors by confocal microscopy. It seems unlikely therefore that the marked receptor desensitization observed in CHOsst(4) cells following SRIF treatment can be accounted for by a decrease in cell surface receptor expression.

Adenosine Triphosphate↗

Agonist-induced internalization of the substance P (NK1) receptor expressed in epithelial cells.

Internalization of the NK1 receptor (NK1R) and substance P was observed in cells transfected with cDNA encoding the rat NK1R by using anti-receptor antibodies and cyanine 3-labelled substance P (cy3-substance P). After incubation at 4 degrees C, NK1R immunoreactivity and cy3-substance P were confined to the plasma membrane. Within 3 min of incubation at 37 degrees C, NK1R immunoreactivity and cy3-substance P were internalized into small intracellular vesicles located beneath the plasma membrane. Fluorescein isothiocyanate-labelled transferrin and cy3-substance P were internalized into the same vesicles, identifying them as early endosomes. After 60 min at 37 degrees C, NK1R immunoreactivity was detected in larger, perinuclear vesicles. Internalization of 125I-labelled substance P was studied by using an acid wash to dissociate cell-surface label from that which has been internalized. Binding reached equilibrium after incubation for 60 min at 4 degrees C with no detectable internalization. After 10 min incubation at 37 degrees C, 83.5 +/- 1.0% of specifically bound counts were internalized. Hyperosmolar sucrose and phenylarsine oxide, which are inhibitors of endocytosis, prevented internalization of 125I-labelled substance P and accumulation of NK1R immunoreactivity into endosomes. Acidotropic agents caused retention of 125I-labelled substance P within the cell and inhibited degradation of the internalized peptide. Continuous incubation of cells with substance P at 37 degrees C reduced 125I-substance P binding at the cell surface. Therefore, substance P and its receptor are internalized into early endosomes within minutes of binding, and internalized substance P is degraded. Internalization depletes NK1Rs from the cell surface and may down-regulate the response of a cell to substance P.

Amino Acid Sequence↗

Identification of three internalization sequences in the cytoplasmic tail of the 46 kDa mannose 6-phosphate receptor.

The cytoplasmic tail of the human 46 kDa mannose 6-phosphate receptor (MPR 46) is necessary for rapid internalization of the receptor and sufficient to mediate internalization of a resident plasma membrane protein. To localize the internalization sequences within the 67 amino acids of the cytoplasmic tail, the tail was progressively shortened from its C-terminus, internal deletions of between four and eight amino acids were introduced into the tail, and individual residues were substituted by alanine, glycine or serine. Three sequences were identified that contribute to the internalization of MPR 46. The first is located within the 23 juxtamembrane cytoplasmic residues of the tail. It contains four essential residues within a heptapeptide and does not resemble known internalization signals. The second sequence contains as a critical residue Tyr-45. The third region is located within the C-terminal seven residues and contains a di-leucine pair as essential residues. The first and third sequences were shown to function as autonomous internalization sequences. Substitution of critically important residues within a single internalization sequence was tolerated, with no or only a moderate decrease in the internalization rate. When essential residues from two or all three internalization sequences were substituted, however, the internalization rate was decreased by more than 60% and 90% respectively. This indicates that the autonomous internalization signals in the cytoplasmic tail of MPR 46 function in an additive manner, but are partly redundant.

Amino Acid Sequence↗

Carboxyl-terminal domains determine internalization and recycling characteristics of bombesin receptor chimeras.

To investigate the role of the carboxy terminus in the regulation of the bombesin (BN) receptor, we constructed two chimeric receptors with carboxyl termini transferred from either m3 muscarinic cholinergic (m3 ACh) (BMC) or cholecystokinin A (CCKA) (BCC) receptors and expressed them in Chinese hamster ovary cells. Previous studies showed that agonist treatment caused rapid internalization of CCKA but not m3 ACh receptors in these cells. In the current study we conducted separate analyses of ligand and receptor internalization and analyzed receptor recycling. Ligand internalization was assessed using acid washing. BN and CCKA receptors internalized ligand with 80 +/- 3 and 85 +/- 7% in an acid-resistant compartment at equilibrium. Ligand internalization of chimeric receptors generally assumed the properties of the donor receptors. Thus, BCC receptors internalized ligand to a similar extent as wild-type CCKA receptors (75 +/- 3%), whereas, BMC receptors showed reduced ligand internalization (38 +/- 1%). Receptor internalization was more directly assessed by determining agonist-induced loss of surface binding. BN and CCKA receptors were largely internalized (56 +/- 8 and 50 +/- 7%, respectively). BCC receptors were also extensively internalized (82 +/- 3%). In contrast, BMC receptors were minimally internalized (22 +/- 8%). Receptor recycling was assessed as recovery from agonist induced loss of binding. BN, CCKA, and BMC receptors showed rapid recycling. In contrast, BCC receptors did not recycle. These data indicate that carboxyl-terminal structures determine both internalization of ligand-receptor complexes and subsequent receptor recycling.

Amino Acid Sequence↗

CXCR1 and CXCR2 activation and regulation. Role of aspartate 199 of the second extracellular loop of CXCR2 in CXCL8-mediated rapid receptor internalization.

CXCL8 (interleukin-8) interacts with two receptors, CXCR1 and CXCR2, to activate leukocytes. Upon activation, CXCR2 internalizes very rapidly relative to CXCR1 ( approximately 90% versus approximately 10% after 5 min). The C termini of the receptors have been shown to be necessary for internalization but are not sufficient to explain the distinct kinetics of down-regulation. To determine the structural determinant(s) that modulate receptor internalization, various chimeric and point mutant receptors were generated by progressively exchanging specific domains or amino acids between CXCR1 and CXCR2. The receptors were stably expressed in rat basophilic leukemia 2H3 cells and characterized for receptor binding, intracellular Ca(2+) mobilization, phosphoinositide hydrolysis, phosphorylation, internalization, and MAPK activation. The data herein indicate that the second extracellular loop (2ECL) of the receptors is critical for the distinct rate of internalization. Replacing the 2ECL of CXCR2 with that of CXCR1 (B(2ECL)A) or Asp(199) with its CXCR1 valine counterpart (B(D199V)A) delayed CXCR2 internalization similarly to CXCR1. Replacing Asp(199) with Asn (B(D199N)) restored CXCR2 rapid internalization. Structure modeling of the 2ECL of the receptors also suggested that Asp(199) plays a critical role in stabilizing and modulating CXCR2 rapid internalization relative to CXCR1. B(D199N) internalized rapidly but migrated as a single phosphorylated form like CXCR1 ( approximately 75 kDa), whereas B(2ECL)A and B(D199V)A showed slow and fast migrating forms like CXCR2 ( approximately 45 and approximately 65 kDa, respectively) but internalized like CXCR1. These data further undermine the role of receptor oligomerization in CXCL8 receptor internalization. Like CXCR1, B(D199V)A also induced sustained ERK activation and cross-desensitized Ca(2+) mobilization to CCR5 relative to B(D199N) and CXCR2. Altogether, the data suggest that the 2ECL of the CXCL8 receptors is important in modulating their distinct rate of down-regulation and thereby signal length and post-internalization activities.

Animals↗

Anatomical variations of internal jugular vein location: impact on central venous access.

OBJECTIVE: To evaluate whether underlying anatomical variations in the position of the internal jugular vein may account for difficulty in obtaining central venous access in individual patients. DESIGN: Consecutive series. SETTING: Cardiac catheterization laboratory, coronary care unit, and ICU. PATIENTS: Two hundred patients (52 +/- 7 yrs, 147 males) who were undergoing internal jugular vein cannulation for hemodynamic monitoring or endomyocardial biopsy. INTERVENTION: The internal jugular vein and carotid artery were visualized with two-dimensional ultrasound and their position was compared with their projected location from external landmarks. RESULTS: In 183 (92%) patients, the position of the internal jugular vein was lateral and anterior to the carotid artery and increased in diameter during a Valsalva maneuver. In five (2.5%) patients, the internal jugular vein was not visualized and was probably thrombosed, as the internal jugular vein was normal on the other side. In six (3%) patients, the internal jugular vein was unusually small and did not increase in diameter during the Valsalva maneuver. In two (1%) patients, the internal jugular vein was positioned greater than 1 cm lateral to the carotid artery. Four (2%) patients had a medially positioned internal jugular vein overlying the carotid artery. In 5.5% of the patients, the position of the internal jugular vein was outside the path that had been predicted by the external landmarks. CONCLUSIONS: These findings suggest that anatomical variation may partly account for the inability to cannulate the internal jugular vein in certain patients. In these cases, ultrasound examination quickly establishes the position of the internal jugular vein and may allow for easy and rapid access.

Carotid Arteries↗

Recipient vessels in free-flap breast reconstruction: a study of the internal mammary and thoracodorsal vessels.

The internal mammary vessels as recipient site for free flaps in breast reconstruction were investigated in this paper because of their ideal location for breast reconstruction. Comparisons were made with the thoracodorsal vessels in terms of external vessel diameter, vessel size discrepancy, flap loss and reexploration rates, and ease of flap placement. Eighty-one patients underwent 110 breast free-flap reconstructions (92 TRAM flaps and 18 superior gluteal flaps) between 1988 and 1994. Vessel size measurements were available on 75 flaps. The internal mammary artery diameter (2.36 +/- 0.50 mm, n = 51) was significantly larger than the thoracodorsal artery diameter (1.79 +/- 0.34 mm, n = 23; p < 0.001). There was no significant difference between the diameters of the internal mammary vein 2.6 +/- 0.58 mm, n = 52) and thoracodorsal vein (2.51 +/- 0.50 mm, n = 23; p = 0.93). The right internal mammary artery (2.52 +/- 0.51 mm) was significantly larger than the left internal mammary artery (2.30 +/- 0.55 mm; p = 0.046). The right internal mammary vein (2.89 +/- 0.56 mm) also was significantly larger than the left internal mammary vein (2.31 +/- 0.48 mm; p = 0.002). In terms of vessel size discrepancy, the internal mammary recipient artery tended to be greater in size than the TRAM flap donor artery (p = 0.003), while the thoracodorsal recipient artery tended to be smaller than the TRAM flap donor artery (p = 0.002). Flap failures and flap reexplorations occurred in the group using the thoracodorsal vessels but not in the internal mammary group. Correct flap placement using the internal mammary recipient site was achieved more easily for both unilateral and bilateral reconstructions because of the avoidance of lateral fullness and medial deficiency problems. The internal mammary recipient site is an important and at times superior alternative to the axillary recipient site because of its larger artery, especially when the axilla is scarred. For smaller free flaps such as a hemi-TRAM flap, as in bilateral TRAM flap reconstructions, the internal mammary site is invaluable because this recipient site allows exact placement of a smaller flap in the breast area.

Breast↗

Evidence for two independent pathways of insulin-receptor internalization in hepatocytes and hepatoma cells.

A study of insulin-receptor internalization and recycling was undertaken in primary cultures of rat hepatocytes and a human hepatoma cell line (HepG2). Receptors were quantitated by measuring 125I-insulin binding to partially purified soluble receptor preparations from untreated cells (total receptors) and trypsinized cells (intracellular receptors). In resting HepG2 cells, exposure to insulin results in internalization of insulin receptors, the rate and extent of which is dependent on the insulin concentration. However, receptors do not accumulate inside the cell in proportion to the higher rates of internalization at high concentrations of insulin. This lack of accumulation is explained by much higher recycling rates after exposure to high concentrations of insulin. Similar results were noted for primary cultures of rat hepatocytes. These results imply qualitatively different fates for receptors internalized after exposure to different concentrations of insulin. To further investigate the possibility of different pathways for insulin-receptor internalization and processing, cells in low (1 ng/ml) or high (100 ng/ml) concentrations of insulin were exposed to drugs or treatments known to affect receptor metabolism. Hypotonic shock and hypokalemia, which arrest coated-pit formation, blocked internalization of insulin and insulin receptors at low concentrations of insulin but allowed internalization in response to high concentrations of insulin. The lysosomotropic drugs monensin and chloroquine caused intracellular accumulation of insulin and its receptors internalized at low concentrations of insulin but had a relatively smaller effect on receptors internalized at high concentrations of insulin. All internalization is blocked by 2,4-dinitrophenol. We conclude that high doses of insulin lead to insulin-receptor internalization and recycling through a pathway that is functionally distinct from the pathway taken by receptors internalized by low (physiologic) concentrations of insulin. The pharmacologic experiments raise the possibility that the high-dose pathway, unlike the low-dose pathway, may proceed independently of coated pits and endosomal acidification.

2,4-Dinitrophenol↗

Internal mammary node drainage and its role in sentinel lymph node biopsy: the initial ALMANAC experience.

This study was designed to identify the frequency of internal mammary drainage in patients undergoing sentinel lymph node (SLN) lymphoscintigraphy in a controlled clinical trial. The practicability and relevance of internal mammary SLN biopsy as a method to improve nodal staging and treatment in breast cancer were investigated. A total of 707 evaluable patients with invasive breast cancer underwent SLN biopsy based on lymphoscintigraphy, intraoperative g probe detection, and blue dye mapping using technetium Tc 99m albumin colloid and Patent Blue V injected peritumorally. This was followed by standard axillary treatment in the same operation in all patients. Lymphoscintigraphy showed internal mammary sentinel nodes in 62 patients (9%), and internal mammary drainage was identified perioperatively in an additional 7 patients (1%) using g probe detection. Sampling of the internal mammary basin, based on the results of lymphoscintigraphy and g probe detection, was done in 31 of 69 patients (45%). One patient had a pneumothorax and 2 experienced bleeding during internal mammary sampling. Internal mammary metastases were detected in 4 of 31 patients (13%). In 2 of the patients (6%), internal mammary nodes (IMNs) showed metastatic involvement without accompanying axillary metastases. One of these 2 patients would have received adjuvant endocrine systemic therapy because of the characteristics of the tumor, but may not have been recommended to receive adjuvant chemotherapy. Sampling of the internal mammary basin led to a change of management in these 2 patients, ie, institution of adjuvant chemotherapy. Therefore, a change in management occurred in only 2 of the 69 patients in our series, but 38 patients with unbiopsied "hot" IMNs remained with unknown internal mammary status. Biopsy of IMNs alters staging in few patients, and the impact on indication for adjuvant treatment was low. Internal mammary SLN biopsy may be associated with some additional morbidity. Current evidence suggests that internal mammary SLN biopsy is still a research tool.

Adult↗

[Obstetrics, surgical gynecology, or medical gynecology: what type of practice interests today's interns?].

INTRODUCTION: Two major modifications have recently changed the training program of interns in obstetrics and gynecology in France. The first modification is an important increase in the number of interns in OBGYN, allowing more lower ranked medical students to enter this training. The second modification is the imposed subdivision of the pool of interns in two distinctive branches: obstetrics and gynecological surgery, and medical gynecology with a 2/1 ratio. These modifications were decided without consulting interns on the type of practice they intend to have later. This study tries to determine what type of practice French interns in OBGYN intend to have when they have finished their training. MATERIAL AND METHOD: We distributed surveys to all French interns in OBGYN. The survey included questions on the type of practice they intend to have, and questions on their opinions on how OBGYN show be taught. RESULTS: Two third of interns wanted to have a full practice in OBGYN. This proportion was the same considering only first year interns. Three quarters of interns wanted to have a future practice that includes at least medical gynecology, and only one intern wanted to do solely medical gynecology later. French interns in OBGYN wanted more medical gynecology teaching during their training CONCLUSION: Despite recent modifications in the training program, French interns in OBGYN intend to have a full practice later. This choice is not influenced by the 5 years of training.

Attitude of Health Personnel↗

The Y graft: myocardial revascularization with both internal thoracic arteries. Evaluation of eighty cases with coronary angiographic assessment.

The use of bilateral in situ internal thoracic arteries is restricted by the risk of sternal devascularization, the length of the pedicle, and the necessity to avoid crossing the midline. The aim of this study is to evaluate Y grafts achieved by anastomosing the proximal end of the free right internal thoracic artery to the side of the attached left internal thoracic artery. Y grafts were performed in 80 patients, aged 41 to 74 years (mean age 58.6 years) between May 1991 and September 1992. Two different techniques were used. Thirty-four patients were included in group 1 and 46 in group 2. Seventy-nine grafts were performed from the left internal thoracic artery to the left anterior descending artery. The right internal thoracic artery was anastomosed to the diagonal artery (5 times), the marginal branch (67 times), the circumflex artery (7 times) and the right coronary artery (2 times). Seventy-five complementary saphenous vein bypasses were performed in 58 patients. Operative mortality was 2.5%. Two patients had perioperative myocardial infarcts (2.5%) on nonbypassed sites. Three patients had sternal wound infections (3.7%). Sixty-two patients (80%) were reexamined by angiography at month 6-25 in group 1 and 37 in group 2. Sixty left internal thoracic artery bypass grafts (97%) were patent versus 39 right internal thoracic artery bypass grafts (63%). In group 1, 23 of 25 left internal thoracic artery bypass grafts were patient (92%) versus 12 right internal thoracic artery grafts (48%). In group 2, all 37 left internal thoracic artery bypass grafts were patent (100%) versus 27 right internal thoracic artery grafts (73%). With this procedure, particular attention must be paid to the length of the right internal thoracic artery, and extensive training is required.

Adult↗

Nursing education and international health in the United States, Latin America, and the Caribbean.

PURPOSE: To identify international health activities in United States, Latin American, and Caribbean schools of nursing. In the international community, nurses face challenges similar to those in related professions, but without the benefit of a long tradition. There is little research about how nursing education and associated activities prepare nurses to deal with international health, and little information about the extent of international health activities in U.S. schools of nursing. DESIGN: Descriptive. METHOD: Using a questionnaire with 16 items, a survey was conducted in 1995 on a random sample of representatives from 100 university schools of nursing in the United States plus 15 schools with known international activities (10 from the United States and 5 from Latin America and the Caribbean). FINDINGS: International health as a program topic was found in one-third of U.S. schools of nursing. However, nursing curriculums do not integrate international health with other subjects. Also, partnerships with foreign institutions are incipient and international health activities are usually individual initiatives with little institutional support. CONCLUSIONS: For nurses to become major contributors to international health, nursing curriculum content must shift from "international nursing" to "international health." Programs of nursing education should include study of social, economic, and political factors that affect health care systems. Schools should develop partnership agreements.

Curriculum↗