Invasive cervical carcinoma: role of MR imaging in pretreatment work-up--cost minimization and diagnostic efficacy analysis

PURPOSE

To examine the cost and efficacy of diagnostic work-up in patients with invasive cervical cancer.

MATERIALS AND METHODS

In 246 patients with invasive cervical cancer, all diagnostic tests performed before treatment were recorded. Patients were divided into two groups: those who underwent magnetic resonance (MR) imaging as the initial study (n = 105) and those who did not (n = 141). A list of 1995 Medicare global payments was used to measure cost. Bayesian analysis (likelihood ratios derived from a literature search) was performed for bladder, rectal, parameterial, and nodal involvement in stage Ib disease.

RESULTS

Significantly fewer procedures and fewer invasive studies were performed in the MR imaging group. Net cost savings for the MR imaging group was $401 for all patients and $449 for patients with stage Ib disease. For stage Ib disease, the 0% pretest probability of bladder or rectal invasion does not justify the routine use of barium enema examination, cystoscopy, or proctoscopy. The increase in predictive values for parameterial and nodal disease was highest for MR imaging when tumor size was at least 2 cm.

CONCLUSION

Guidelines for the pretreatment work-up of clinical stage Ib cervical cancer need revision. MR imaging should be used as an adjunct to clinical evaluation.

Pseudomonas syringae type III effector HopAF1 suppresses plant immunity by targeting methionine recycling to block ethylene induction

HopAF1 is a type III effector protein of unknown function encoded in the genomes of several strains of Pseudomonas syringae and other plant pathogens. Structural modeling predicted that HopAF1 is closely related to deamidase proteins. Deamidation is the irreversible substitution of an amide group with a carboxylate group. Several bacterial virulence factors are deamidases that manipulate the activity of specific host protein substrates. We identified Arabidopsis methylthioadenosine nucleosidase proteins MTN1 and MTN2 as putative targets of HopAF1 deamidation. MTNs are enzymes in the Yang cycle, which is essential for the high levels of ethylene biosynthesis in Arabidopsis We hypothesized that HopAF1 inhibits the host defense response by manipulating MTN activity and consequently ethylene levels. We determined that bacterially delivered HopAF1 inhibits ethylene biosynthesis induced by pathogen-associated molecular patterns and that Arabidopsis mtn1 mtn2 mutant plants phenocopy the effect of HopAF1. Furthermore, we identified two conserved asparagines in MTN1 and MTN2 from Arabidopsis that confer loss of function phenotypes when deamidated via site-specific mutation. These residues are potential targets of HopAF1 deamidation. HopAF1-mediated manipulation of Yang cycle MTN proteins is likely an evolutionarily conserved mechanism whereby HopAF1 orthologs from multiple plant pathogens contribute to disease in a large variety of plant hosts.

The Salmonella Secreted Effector SarA/SteE Mimics Cytokine Receptor Signaling to Activate STAT3

Bacteria masterfully co-opt and subvert host signal transduction. As a paradigmatic example, Salmonella uses two type-3 secretion systems to inject effector proteins that facilitate Salmonella entry, establishment of an intracellular niche, and modulation of immune responses. We previously demonstrated that the Salmonella anti-inflammatory response activator SarA (Stm2585, GogC, PagJ, SteE) activates the host transcription factor STAT3 to drive expression of immunomodulatory STAT3-targets. Here, we demonstrate-by sequence, function, and biochemical measurement-that SarA mimics the cytoplasmic domain of glycoprotein 130 (gp130, IL6ST). SarA is phosphorylated at a YxxQ motif, facilitating binding to STAT3 with greater affinity than gp130. Departing from canonical gp130 signaling, SarA function is JAK-independent but requires GSK-3, a key regulator of metabolism and development. Our results reveal that SarA undergoes host phosphorylation to recruit a STAT3-activating complex, circumventing cytokine receptor activation. Effector mimicry of gp130 suggests GSK-3 can regulate normal cytokine signaling, potentially enabling metabolic and immune crosstalk.

Freeman-Sheldon (whistling face) syndrome. Anaesthetic and airway management

We describe the anaesthetic management of Freeman-Sheldon syndrome in a two-and-a-half year old undergoing club foot correction. Following an inhalational induction using halothane, tracheal intubation by direct laryngoscopy proved impossible. A laryngeal mask airway was inserted and intubation with a 4.5 tracheal tube was successfully achieved using a fibreoptic bronchoscope passed through the LMA. The child had an uneventful anaesthetic course. A caudal epidural was used for postoperative analgesia and the child was discharged home on day two. The anaesthetic and airway management options of this syndrome are outlined.

XopR, a type III effector secreted by Xanthomonas oryzae pv. oryzae, suppresses microbe-associated molecular pattern-triggered immunity in Arabidopsis thaliana

Xanthomonas oryzae pv. oryzae is the causal agent of bacterial blight of rice. The XopR protein, secreted into plant cells through the type III secretion apparatus, is widely conserved in xanthomonads and is predicted to play important roles in bacterial pathogenicity. Here, we examined the function of XopR by constructing transgenic Arabidopsis thaliana plants expressing it under control of the dexamethasone (DEX)-inducible promoter. In the transgenic plants treated with DEX, slightly delayed growth and variegation on leaves were observed. Induction of four microbe-associated molecular pattern (MAMP)-specific early-defense genes by a nonpathogenic X. campestris pv. campestris hrcC deletion mutant were strongly suppressed in the XopR-expressing plants. XopR expression also reduced the deposition of callose, an immune response induced by flg22. When transiently expressed in Nicotiana benthamiana, a XopR::Citrine fusion gene product localized to the plasma membrane. The deletion of XopR in X. oryzae pv. oryzae resulted in reduced pathogenicity on host rice plants. Collectively, these results suggest that XopR inhibits basal defense responses in plants rapidly after MAMP recognition.

Risk factors for invasive cervical cancer in Latino women

Most invasive cervical cancer research in the United States has been conducted on non-Latino-White (NLW) and African-American women. Incidence, mortality, stage at diagnosis and survival indicators for invasive cervical cancer in Latino women in California are compared to NLW and African-American women. A model is presented which depicts structural, behavioral, genetic and biological risk factors for invasive cervical cancer. A literature review of risk factors and their association with invasive cervical cancer was conducted using MEDLINE and PsychINFO databases to determine if ethnic differences in risk factors explain observed differences in morbidity and mortality. Latino women experience a significantly higher incidence and mortality associated with invasive cervical cancer than NLW women. The review of risk factors found that rate differences of cervical cancer screening, early detection and human papilloma virus (HPV) type-specific infection explain much of the disparity in disease burden. Further research must clarify if ethnic differences exist in risk factors associated with ethnic variation in HPV-type prevalence in both cases and their sexual partners, in host immune responses, and multiparity.

Single-cell genome-wide association reveals that a nonsynonymous variant in ERAP1 confers increased susceptibility to influenza virus

During pandemics, individuals exhibit differences in risk and clinical outcomes. Here, we developed single-cell high-throughput human in vitro susceptibility testing (scHi-HOST), a method for rapidly identifying genetic variants that confer resistance and susceptibility. We applied this method to influenza A virus (IAV), the cause of four pandemics since the start of the 20th century. scHi-HOST leverages single-cell RNA sequencing (scRNA-seq) to simultaneously assign genetic identity to cells in mixed infections of cell lines of European, African, and Asian origin, reveal associated genetic variants for viral burden, and identify expression quantitative trait loci. Integration of scHi-HOST with human challenge and experimental validation demonstrated that a missense variant in endoplasmic reticulum aminopeptidase 1 (ERAP1; rs27895) increased IAV burden in cells and human volunteers. rs27895 exhibits population differentiation, likely contributing to greater permissivity of cells from African populations to IAV. scHi-HOST is a broadly applicable method and resource for decoding infectious-disease genetics.

Multiple Respiratory Syncytial Virus Introductions Into a Neonatal Intensive Care Unit

BACKGROUND

Outbreaks of respiratory syncytial virus (RSV) in neonatal intensive care units (NICUs) are of concern because of the risk of severe disease in young infants. We describe an outbreak of RSV in a NICU and use whole genome sequencing (WGS) to better understand the relatedness of viruses among patients.

METHODS

An investigation was conducted to identify patients and describe their clinical course. Infection control measures were implemented to prevent further spread. Respiratory specimens from outbreak-related patients and the community were tested using WGS. Phylogenetic trees were constructed to understand relatedness of the viruses.

RESULTS

Seven patients developed respiratory symptoms within an 11-day span in December 2017 and were diagnosed with RSV; 6 patients (86%) were preterm and 1 had chronic lung disease. Three patients required additional respiratory support after symptom onset, and none died. Six of 7 patients were part of the same cluster based on > 99.99% nucleotide agreement with each other and 3 unique single-nucleotide polymorphisms were identified in viruses sequenced from those patients. The seventh patient was admitted from the community with respiratory symptoms and had a genetically distinct virus that was not related to the other 6. Implementation of enhanced infection control measures likely limited the spread.

CONCLUSIONS

Using WGS, we found 2 distinct introductions of RSV into a NICU, highlighting the risk of healthcare-associated infections during RSV season. Early recognition and infection control measures likely limited spread, emphasizing the importance of considering RSV in the differential diagnosis of respiratory infections in healthcare settings.

Redox control of the deubiquitinating enzyme Ubp2 regulates translation during stress

Protein ubiquitination is essential to govern cells' ability to cope with harmful environments by regulating many aspects of protein dynamics from synthesis to degradation. As important as the ubiquitination process, the reversal of ubiquitin chains mediated by deubiquitinating enzymes (DUBs) is critical for proper recovery from stress and re-establishment of proteostasis. Although it is known that ribosomes are decorated with K63-linked polyubiquitin chains that control protein synthesis under stress, the mechanisms by which these ubiquitin chains are reversed and regulate proteostasis during stress recovery remain elusive. Here, we showed in budding yeast that the DUB Ubp2 is redox-regulated during oxidative stress in a reversible manner, which determines the levels of K63-linked polyubiquitin chains present on ribosomes. We also demonstrate that Ubp2 can cleave single ubiquitin moieties out of chains and its activity is modulated by a series of repeated domains and the formation of disulfide bonds. By combining cellular, biochemical, and proteomics analyses, we showed that Ubp2 is crucial for restoring translation after stress cessation, indicating an important role in determining the cellular response to oxidative stress. Our work demonstrates a novel role for Ubp2, revealing that a range of signaling pathways can be controlled by redox regulation of DUB activity in eukaryotes, which in turn will define cellular states of health and diseases.

Predictive value of human placental lactogen determinations in pregnancy

The relation of human placental lactogen (hPL) levels to pregnancy outcome was studied in normal and preeclamptic pregnancies, hPL determinations were performed between 38 and 44 weeks of gestation, and the results were compared with birthweight and Apgar scores in three groups. The results of hPL determinations permitted prediction of intrauterine growth retardation in all except 2 patients. The value of hPL measurement as a screening test in pregnancy is noted.

Lymphocyte subset-specific and tissue-specific lymphocyte-endothelial cell recognition mechanisms independently direct the recirculation of lymphocytes from blood to lymph in sheep

Tissue-specific and lymphocyte subset-specific lymphocyte recirculation patterns have been analysed simultaneously. Lymphocytes obtained from one lymph compartment were directly labelled with fluorochrome in vitro and returned to the blood of the same animal. Over the next 48-72 h, the recirculation of these cells into both the same lymph compartment and at least one different lymph compartment was monitored. The cells in all of these lymph collections, as well as an aliquot of the cells used for direct fluorescent labelling, were then phenotyped with monoclonal antibodies (mAb) which define the mutually exclusive small CD4+ and CD8+ T-lymphocyte subsets in sheep. All cell samples were analysed by flow cytometry and CD4/CD8 ratios were determined for the recirculated, fluorochrome-labelled population in each lymph collection. The mean CD4/CD8 ratio calculated for each lymph compartment was then compared with the CD4/CD8 ratio calculated for each lymph compartment was then compared with the CD4/CD8 ratio of the transfused, starting population. In one experiment employing efferent prescapular lymph cells, three experiments employing efferent intestinal lymph cells, and two experiments employing afferent intestinal lymph cells, tissue-specific recirculation was observed. In all of these experiments, the pattern of recirculation of small CD4+ and CD8+ T lymphocytes was non-random. Moreover, in each experiment, this non-randomness was completely unrelated to tissue-specific phenomena, since the mean CD4/CD8 ratio of the recirculated population was higher than the CD4/CD8 ratio of the transfused, starting population regardless of the lymph compartment examined. These data are therefore consistent with the hypothesis that tissue-specific and lymphocyte subset-specific lymphocyte-endothelial cell recognition mechanisms independently direct the recirculation of small lymphocytes from blood to lymph.

Structures of trehalose-6-phosphate synthase, Tps1, from the fungal pathogen Cryptococcus neoformans: A target for antifungals

Invasive fungal diseases are a major threat to human health, resulting in more than 1.5 million annual deaths worldwide. The arsenal of antifungal therapeutics remains limited and is in dire need of drugs that target additional biosynthetic pathways that are absent from humans. One such pathway involves the biosynthesis of trehalose. Trehalose is a disaccharide that is required for pathogenic fungi to survive in their human hosts. In the first step of trehalose biosynthesis, trehalose-6-phosphate synthase (Tps1) converts UDP-glucose and glucose-6-phosphate to trehalose-6-phosphate. Here, we report the structures of full-length Cryptococcus neoformans Tps1 (CnTps1) in unliganded form and in complex with uridine diphosphate and glucose-6-phosphate. Comparison of these two structures reveals significant movement toward the catalytic pocket by the N terminus upon ligand binding and identifies residues required for substrate binding, as well as residues that stabilize the tetramer. Intriguingly, an intrinsically disordered domain (IDD), which is conserved among Cryptococcal species and closely related basidiomycetes, extends from each subunit of the tetramer into the "solvent" but is not visible in density maps. We determined that the IDD is not required for C. neoformans Tps1-dependent thermotolerance and osmotic stress survival. Studies with UDP-galactose highlight the exquisite substrate specificity of CnTps1. In toto, these studies expand our knowledge of trehalose biosynthesis in Cryptococcus and highlight the potential of developing antifungal therapeutics that disrupt the synthesis of this disaccharide or the formation of a functional tetramer and the use of cryo-EM in the structural characterization of CnTps1-ligand/drug complexes.

A single amino acid in the Salmonella effector SarA/SteE triggers supraphysiological activation of STAT3 for anti-inflammatory gene expression

Salmonella causes ∼1 million cases of gastroenteritis annually in the United States. Critical to virulence are secreted effectors that reprogram host functions. We previously discovered the effector SarA facilitates phosphorylation of STAT3, inducing expression of the anti-inflammatory cytokine interleukin-10 (IL-10). This STAT3 activation requires a region of homology with the host cytokine receptor gp130. Here, we demonstrate that a single amino acid difference is critical for the anti-inflammatory bias of SarA-STAT3 signaling. An isoleucine at pY+1 of the YxxQ motif in SarA (which binds the STAT3 SH2 domain) causes increased STAT3 recruitment and phosphorylation, biasing toward anti-inflammatory targets. This isoleucine renders SarA a better substrate for tyrosine phosphorylation by GSK-3. GSK-3 is canonically a serine/threonine kinase that nonetheless undergoes tyrosine autophosphorylation at a motif with isoleucine at the pY+1 position. Our results provide a molecular basis for how a Salmonella effector achieves supraphysiological levels of STAT3 activation to control host genes.

Insall proximal realignment for disorders of the patella

Proximal realignment with standard lateral retinacular release (Insall operation) was performed on 35 knees with a follow-up time of two to 11 years. The results for chondromalacia patellae were satisfactory to excellent results in 20 of 23 knees (87%) at two years and in eight of 15 knees (55%) at five to 11 years. Satisfactory to excellent results in 11 of 12 knees (92%) were noted for recurrent patellar dislocation. This procedure should be reserved for advanced chondromalacia patellae (Grades III and IV) and recurrent patellar dislocation. Anatomic studies suggest that the pain relief was most likely due to a combination of patellar denervation and restoration of patellar congruence.

Preventing and managing pelvic inflammatory disease: key questions, practices, and evidence

Clinicians play a pivotal role in protecting women from pelvic inflammatory disease (PID), one of the most prevalent and serious diseases affecting women of reproductive age. This article examines PID prevention and management by critically addressing five questions: (1) What are the key risk factors for PID? (2) What are the principal microorganisms involved in PID? (3) What are the appropriate diagnostic criteria for PID? (4) What are the best treatment regimens for PID? and (5) What are the effective strategies for preventing PID? In addressing each of these questions, the quality of available evidence and recommended practice is discussed and gaps in the evidence are highlighted.

Hospitalization for congestive heart failure. Explaining racial differences

OBJECTIVE

To determine whether the higher rate of hospitalization among African Americans for congestive heart failure (CHF) could be explained by racial differences in the prevalence of clinical risk factors for CHF.

DESIGN

Retrospective cohort study.

SETTING

A large health maintenance organization (HMO).

PATIENTS

A sample of 64,877 enrollees (27% African American and 73% white) of the Northern California Kaiser Permanente Medical Care Program who took at least one multiphasic health checkup (MHC) at or after the age of 40 years and were free of CHF at that time.

MAIN OUTCOME MEASURES

First hospitalization with a principal diagnosis of CHF.

RESULTS

Among cohort members younger than 60 years at baseline MHC, the age-adjusted risk ratio (RR) (African American/white) for CHF hospitalization was 2.14 for men and 2.73 for women, while for persons 60 years of age and older at MHC, the age-adjusted RR was 1.48 for both sexes. Cox proportional hazards models were used to adjust for risk factors and length of follow-up. In persons aged 60 years and older, the race difference was explained by greater prevalence of hypertension and diabetes in African Americans (RR = 1.12; 95% confidence interval [CI], 0.94 to 1.34 after adjustment for hypertension and diabetes). In those younger than 60 years, findings differed by sex. For men, African-American race was no longer a significant predictor of CHF after adjusting for hypertension, diabetes, left ventricular hypertrophy on electrocardiogram, and body mass index (adjusted RR = 1.16; 95% CI, 0.86 to 1.56). However, among younger women, African Americans continued at increased risk despite adjustment for these variables as well as smoking, plasma cholesterol, renal function, alcohol use, and myocardial infarction (adjusted RR = 1.49; 95% CI, 1.00 to 2.21).

CONCLUSIONS

In this HMO population, the race differences in first hospitalization for CHF are largely explained by known clinical and behavioral risk factors, although in younger women these risk factors do not completely explain the excess risk among African Americans. These findings highlight the role of hypertension and diabetes in the development of CHF, particularly among African Americans.

Development and validation of the pharmaceutical care satisfaction questionnaire

The development and validation of a survey instrument to assess consumer satisfaction with pharmacy services is discussed. The Pharmaceutical Care Satisfaction Questionnaire (PCSQ) is a 30-item instrument administered by someone other than the pharmacist that uses a Likert scale to score respondents' answers. The PCSQ is written approximately at a seventh grade reading level. Following initial development, the PCSQ was administered to 360 consumers in ambulatory pharmacies and to 311 patients in a multicenter hyperlipidemia outcomes study. The Cronbach coefficient alpha was .94 for the consumer data, with a 64.8% variance accounted for by the 4-factor solution. A coefficient alpha of .84 was found on all 30 items in the hyperlipidemia study, with a variance of 63.78% in control patients and 60.16% in treatment patients. The PCSQ is easy to administer and score, with minimal cost. Unlike other satisfaction surveys, the PCSQ contains patient evaluations regarding outcomes of care. A primary limitation of the PCSQ is that it is a newly developed instrument that needs to be used in more studies to strengthen its validity.