Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

P5985New aspects of management of patients with long-term persistent atrial fibrillation before extracardiac interventions

Surgery in patients with atrial fibrillation is always an additional risk of thromboembolic complications. In the modern era of direct oral anticoagulants, the risk of bleeding is much lower, due to the lack of need for a Bridge, but at the same time, there is no clear position on the strategy of management of patients with long-term current atrial fibrillation in the tactics of rhythm control or heart rate control.

In our clinic we examined 772 before surgical intervention high risk. Of these, atrial fibrillation was diagnosed in 366 patients. 121 patients had a persistent or long-persistant form of arrhythmia. To determine the tactics, we performed a transesophageal echocardiographic study to assess intracardiac hemorheology. 109 studies were performed. 35 patients received rivaroxaban, 29 dabigatran, 19 apixaban, 26 patients did not receive anticoagulant therapy. Disorders of intracardiac hemorheology that do not allow to perform a planned cardioversion, such as blood clots and spontaneous contrast 3–4 degrees, were detected in 78% of patients not receiving anticoagulant therapy, 56% of patients receiving dabigatran, 52% of patients receiving rivaroxaban and 38% of patients receiving apixaban. Among patients with disorders of intracardiac hemorheology, unreasonably reduced doses were taken by 78% of patients. Patients with thrombotic disorders proposed to enter the perioperative period in accordance with the strategy of heart rate control and correction doses of anticoagulant therapy.

Thus, based on our observations, we recommend transesophageal echocardiography before elective surgery in all patients with persistant AF to determine the feasibility of restoring the sinus rhythm before surgery.

Molecular Modeling and Functional Analysis of Exome Sequencing–Derived Variants of Unknown Significance Identify a Novel, Constitutively Active FGFR2 Mutant in Cholangiocarcinoma

Purpose

Genomic testing has increased the quantity of information available to oncologists. Unfortunately, many identified sequence alterations are variants of unknown significance (VUSs), which thus limit the clinician’s ability to use these findings to inform treatment. We applied a combination of in silico prediction and molecular modeling tools and laboratory techniques to rapidly define actionable VUSs.

Materials and Methods

Exome sequencing was conducted on 308 tumors from various origins. Most single nucleotide alterations within gene coding regions were VUSs. These VUSs were filtered to identify a subset of therapeutically targetable genes that were predicted with in silico tools to be altered in function by their variant sequence. A subset of receptor tyrosine kinase VUSs was characterized by laboratory comparison of each VUS versus its wild-type counterpart in terms of expression and signaling activity.

Results

The study identified 4,327 point mutations of which 3,833 were VUSs. Filtering for mutations in genes that were therapeutically targetable and predicted to affect protein function reduced these to 522 VUSs of interest, including a large number of kinases. Ten receptor tyrosine kinase VUSs were selected to explore in the laboratory. Of these, seven were found to be functionally altered. Three VUSs (FGFR2 F276C, FGFR4 R78H, and KDR G539R) showed increased basal or ligand-stimulated ERK phosphorylation compared with their wild-type counterparts, which suggests that they support transformation. Treatment of a patient who carried FGFR2 F276C with an FGFR inhibitor resulted in significant and sustained tumor response with clinical benefit.

Conclusion

The findings demonstrate the feasibility of rapid identification of the biologic relevance of somatic mutations, which thus advances clinicians’ ability to make informed treatment decisions.

Induction and analysis of epithelial to mesenchymal transition

Epithelial to mesenchymal transition (EMT) is essential for proper morphogenesis during development. Misregulation of this process has been implicated as a key event in fibrosis and the progression of carcinomas to a metastatic state. Understanding the processes that underlie EMT is imperative for the early diagnosis and clinical control of these disease states. Reliable induction of EMT in vitro is a useful tool for drug discovery as well as to identify common gene expression signatures for diagnostic purposes. Here we demonstrate a straightforward method for the induction of EMT in a variety of cell types. Methods for the analysis of cells pre- and post-EMT induction by immunocytochemistry are also included. Additionally, we demonstrate the effectiveness of this method through antibody-based array analysis and migration/invasion assays.

New Protocol for the Enrichment of Untouched Human Dendritic Cells (144.14)

We have developed a new negative selection protocol for the enrichment of untouched human dendritic cells (DCs) from human blood. The protocol can be carried out in less than one hour, after PBMC enrichment, and is characterized as a two-step negative selection procedure, using two different cocktails of biotinylated antibodies that target non-DC lineage markers. DCs enriched with this protocol performed better in T cell proliferation assays, as compared to DCs enriched with a commercial kit. Flow cytometric analysis of the isolated cells show that 90% of the enriched cells are CD14-/CD19-/BDCA1+/BDCA2+/BDCA3+ (total DCs), as compared to less than 10% before cell enrichment. Within these isolated DCs 2-8% are plasmacytoid DCs (BDCA2+/CD45+) and 82-88% are myeloid DCs (20-40% BDCA1+/CD11c+, 20-40% BDCA3+/CD11c+, 15-20% CD16+/CD11c+ and 20-25% CD56+/MHCII+). On average 1 million DCs were isolated per 100 million PBMCs. The advantages of this protocol include: a) better performance in T cell proliferation assays, compared to DCs enriched with a commercially available kit, and b) higher myeloid DC heterogeneity in the enriched DC fraction. The above observations could be the result of the fact that the isolated DCs are not bound to antibodies that could initiate activation cascades, and that CD16+ and CD56+ DCs were absent from the cell population isolated with the commercial kit.

Novel sequential ChIP and simplified basic ChIP protocols for promoter co-occupancy and target gene identification in human embryonic stem cells

Background

The investigation of molecular mechanisms underlying transcriptional regulation, particularly in embryonic stem cells, has received increasing attention and involves the systematic identification of target genes and the analysis of promoter co-occupancy. High-throughput approaches based on chromatin immunoprecipitation (ChIP) have been widely used for this purpose. However, these approaches remain time-consuming, expensive, labor-intensive, involve multiple steps, and require complex statistical analysis. Advances in this field will greatly benefit from the development and use of simple, fast, sensitive and straightforward ChIP assay and analysis methodologies.

Results

We initially developed a simplified, basic ChIP protocol that combines simplicity, speed and sensitivity. ChIP analysis by real-time PCR was compared to analysis by densitometry with the ImageJ software. This protocol allowed the rapid identification of known target genes for SOX2, NANOG, OCT3/4, SOX17, KLF4, RUNX2, OLIG2, SMAD2/3, BMI-1, and c-MYC in a human embryonic stem cell line. We then developed a novel Sequential ChIP protocol to investigate in vivo promoter co-occupancy, which is basically characterized by the absence of antibody-antigen disruption during the assay. It combines centrifugation of agarose beads and magnetic separation. Using this Sequential ChIP protocol we found that c-MYC associates with the SOX2/NANOG/OCT3/4 complex and identified a novel RUNX2/BMI-1/SMAD2/3 complex in BG01V cells. These two TF complexes associate with two distinct sets of target genes. The RUNX2/BMI-1/SMAD2/3 complex is associated predominantly with genes not expressed in undifferentiated BG01V cells, consistent with the reported role of those TFs as transcriptional repressors.

Conclusion

These simplified basic ChIP and novel Sequential ChIP protocols were successfully tested with a variety of antibodies with human embryonic stem cells, generated a number of novel observations for future studies and might be useful for high-throughput ChIP-based assays.

Chronic intrauterine pulmonary hypertension selectively modifies pulmonary artery smooth muscle cell gene expression

Pulmonary artery smooth muscle cell (PASMC) relaxation at birth results from an increase in cytosolic cGMP, cGMP-dependent and kinase-mediated activation of the Ca2+-sensitive K+channel (KCa), and closure of voltage-operated Ca2+channels (VOCC). How chronic intrauterine pulmonary hypertension compromises perinatal pulmonary vasodilation remains unknown. We tested the hypothesis that chronic intrauterine pulmonary hypertension selectively modifies gene expression to mitigate perinatal pulmonary vasodilation mediated by the cGMP kinase-KCa-VOCC pathway. PASMC were isolated from late-gestation fetal lambs that had undergone either ligation of the ductus arteriosus (hypertensive) or sham operation (control) at 127 days of gestation and were maintained under either hypoxic (∼25 Torr) or normoxic (∼120 Torr) conditions in primary culture. We studied mRNA levels for cGMP kinase Iα (PKG-1α), the α-chain of VOCC (Cav1.2), and the α-subunit of the KCachannel. Compared with control PASMC, hypertensive PASMC had decreased VOCC, KCa, and PKG-1α expression. In response to sustained normoxia, expression of VOCC and KCachannel decreased and expression of PKG-1α increased. In contrast, sustained normoxia had no effect on PKG-1α levels and an attenuated effect on VOCC and KCachannel expression in hypertensive PASMC. Protein expression of PKG-1α was consistent with the mRNA data. We conclude that chronic intrauterine pulmonary hypertension decreases PKG expression and mitigates the genetic effects of sustained normoxia on pulmonary vasodilation, because gene expression remains compromised even after sustained exposure to normoxia.

Oxygen tension modulates the expression of pulmonary vascular BKCa channel alpha- and beta-subunits

At birth, the lung environment changes from low to relatively high O(2) tension. Pulmonary blood flow increases and pulmonary artery pressure decreases. Recent data suggest that pulmonary vascular calcium-sensitive K(+) channel (BK(Ca)) activation mediates perinatal pulmonary vasodilation. Although BK(Ca) channel expression is developmentally regulated, the molecular mechanisms responsible for BK(Ca) expression remain unknown. We tested the hypothesis that the low-O(2) tension environment of the normal fetus modulates BK(Ca) channel expression. We analyzed BK(Ca) expression under conditions of hypoxia and normoxia both in vitro and in vivo. BK(Ca) alpha-subunit mRNA expression increased twofold in ovine pulmonary artery smooth muscle cell (PASMC) primary cultures maintained in hypoxia. In vivo, BK(Ca) expression was similarly affected by hypoxia. When adult Sprague-Dawley rats were placed in hypobaric hypoxic chambers for 3 wk, hypoxic animals showed an increase of threefold in the expression of BK(Ca) alpha- and more than twofold in the expression of BK(Ca) beta(1)-subunit mRNA. Immunochemical staining was consistent with the genetic data. To assess transcriptional activation of the beta-subunit of the BK(Ca), both BK(Ca) beta(1)- and beta(2)-subunit luciferase (K(Ca) beta:luc(+)) reporter genes were constructed. Hypoxia increased PASMC K(Ca) beta(1):luc(+) reporter expression by threefold and K(Ca) beta(2):luc(+) expression by 35%. Fetal PASMC treated with the hypoxia-inducible factor-1 mimetic deferoxamine showed a 63 and 41% increase in BK(Ca) channel alpha- and beta(1)-subunit expression, respectively. Together, these results suggest that oxygen tension modulates BK(Ca) channel subunit mRNA expression, and the regulation is, at least in part, at the transcriptional level.

Oxygen increases ductus arteriosus smooth muscle cytosolic calcium via release of calcium from inositol triphosphate-sensitive stores

In utero, blood shunts away from the lungs via the ductus arteriosus (DA) and the foramen ovale. After birth, the DA closes concomitant with increased oxygen tension. The present experimental series tests the hypothesis that oxygen directly increases DA smooth muscle cell (SMC) cytosolic calcium ([Ca(2+)](i)) through inactivation of a K(+) channel, membrane depolarization, and entry of extracellular calcium. To test the hypothesis, DA SMC were isolated from late-gestation fetal lambs and grown to subconfluence in primary culture in low oxygen tension (25 Torr). DA SMC were loaded with the calcium-sensitive fluorophore fura-2 under low oxygen tension conditions and studied using microfluorimetry while oxygen tension was acutely increased (120 Torr). An acute increase in oxygen tension progressively increased DA SMC [Ca(2+)](i) by 11.7 +/- 1.4% over 40 min. The effect of acute normoxia on DA SMC [Ca(2+)](i) was mimicked by pharmacological blockade of the voltage-sensitive K(+) channel. Neither removal of extracellular calcium nor voltage-operated calcium channel blockade prevented the initial increase in DA SMC [Ca(2+)](i). Manganese quenching experiments demonstrated that acute normoxia initially decreases the rate of extracellular calcium entry. Pharmacological blockade of inositol triphosphate-sensitive, but not ryanodine-sensitive, intracellular calcium stores prevented the oxygen-induced increase in [Ca(2+)](i). Endothelin increased [Ca(2+)](i) in acutely normoxic, but not hypoxic, DA SMC. Thus acute normoxia 1) increases DA SMC [Ca(2+)](i) via release of calcium from intracellular calcium stores, and subsequent entry of extracellular calcium, and 2) potentiates the effect of contractile agonists. Prolonged patency of the DA may result from disordered intracellular calcium homeostasis.

Repression of organizer genes in dorsal and ventral Xenopus cells mediated by maternal XTcf3

In the early Xenopus embryo, the dorsal axis is specified by a Wnt signal transduction pathway, involving the movement of β-catenin into dorsal cell nuclei and its functional association with the LEF-type transcription factor XTcf3. The subsequent function of XTcf3 is uncertain. Overexpression data has suggested that it can be both an activator and repressor of downstream genes. XTcf3 mRNA is synthesized during oogenesis in Xenopus and is stored in the egg. To identify its role in dorsal axis specification, we depleted this maternal store in full-grown oocytes using antisense deoxyoligonucleotides, and fertilized them. The developmental effects of XTcf3 depletion, both on morphogenesis and the expression of marker genes, show that primarily, XTcf3 is an inhibitor, preventing both dorsal and ventral cells of the late blastula from expressing dorsal genes. We also show that simple relief from the repression is not the only factor required for dorsal gene expression. To demonstrate this, we fertilized eggs that had been depleted of both XTcf3 and the maternal transcription factor VegT. Dorsal genes normally repressed by XTcf3 are not activated in these embryos. These data show that normal dorsal gene expression in the embryo requires the transcriptional activator VegT, whilst XTcf3 prevents their inappropriate expression on the ventral side of the embryo.

Circadian activity of the GABAergic system in the golden hamster retina

Daily changes in gamma-aminobutyric acid (GABA) turnover rate were studied in the golden hamster retina. This parameter showed significant variations throughout the light-dark cycle, with minimal values during the day. Retinal glutamic acid decarboxylase (GAD) activity was higher at midnight than at noon. Moreover, [3H]GABA binding significantly varied throughout the 24-h cycle, with maximal values during the day. Saturation studies performed at 12:00 and 24:00 h indicated that the maximal concentration of [3H]GABA binding sites (Bmax) was significantly higher at noon, whereas the dissociation constant (Kd) remained unchanged. High K+-induced GABA release was significantly higher at midnight than at midday. Daily variations in retinal GABA turnover rate, GABA release, and in its specific binding persisted in golden hamsters exposed to constant darkness. In summary, these results support the idea of a circadian clock-controlled GABAergic activity in the hamster retina.

Voltage-gated K(+)-channel activity in ovine pulmonary vasculature is developmentally regulated

To examine mechanisms underlying developmental changes in pulmonary vascular tone, we tested the hypotheses that 1) maturation-related changes in the ability of the pulmonary vasculature to respond to hypoxia are intrinsic to the pulmonary artery (PA) smooth muscle cells (SMCs); 2) voltage-gated K(+) (K(v))-channel activity increases with maturation; and 3) O(2)-sensitive Kv2.1 channel expression and message increase with maturation. To confirm that maturational differences are intrinsic to PASMCs, we used fluorescence microscopy to study the effect of acute hypoxia on cytosolic Ca(2+) concentration ([Ca(2+)](i)) in SMCs isolated from adult and fetal PAs. Although PASMCs from both fetal and adult circulations were able to sense an acute decrease in O(2) tension, acute hypoxia induced a more rapid and greater change in [Ca(2+)](i) in magnitude in PASMCs from adult compared with fetal PAs. To determine developmental changes in K(v)-channel activity, the effects of the K(+)-channel antagonist 4-aminopyridine (4-AP) were studied on fetal and adult PASMC [Ca(2+)](i). 4-AP (1 mM) caused PASMC [Ca(2+)](i) to increase by 94 +/- 22% in the fetus and 303 +/- 46% in the adult. K(v)-channel expression and mRNA levels in distal pulmonary arteries from fetal, neonatal, and adult sheep were determined through the use of immunoblotting and semiquantitative RT-PCR. Both Kv2.1-channel protein and mRNA expression in distal pulmonary vasculature increased with maturation. We conclude that there are maturation-dependent changes in PASMC O(2) sensing that may render the adult PASMCs more responsive to acute hypoxia.

Fulminant Clostridium difficile colitis associated with paclitaxel and carboplatin chemotherapy

Resnik E, LeFevre CA. Fulminant Clostridium difficile colitis associated with paclitaxel and carboplatin chemotherapy. Pseudomembranous colitis is commonly associated with the use of antibiotics. Some antineoplastic agents even without associated antibiotic use can predispose patients to developing infection with Clostridium difficile. The infection is usually mild; however, in rare cases severe forms of pseudomembranous colitis may be encountered. A 66 year-old female with stage IIIC suboptimally debulked epithelial ovarian cancer was treated with paclitaxel and carboplatin. the patient developed fulminant C. difficile colitis three weeks after the second cycle of chemotherapy. Severe symptoms began 24 h prior to admission; however, mild nausea and diarrhea had been present for a week despite self-treatment with over-the-counter Imodium and Pepto-Bismol. Her last antibiotic use was seven weeks previously. The patient was hospitalized immediately for aggressive treatment. Notwithstanding all the efforts, her condition continued to deteriorate and she expired. Severe C. difficile colitis can be life threatening. Patients undergoing chemotherapy who develop significant diarrhea should be evaluated for C. difficile. Prompt diagnosis and intervention prior to onset of severe symptoms can potentially improve the outcome.

Hemiballismus and brain metastases from squamous cell carcinoma of the cervix

BACKGROUND

Brain metastases from cervical carcinoma are rare. Accompanying symptoms depend on the location of the metastatic lesions. Hemiballismus refers to a rare movement disorder characterized by involuntary, large amplitude movements of the limbs of one side of the body. The area of the brain controlling the limb movement is in the subthalamic nucleus of the contralateral side. In contrast, the usual location of brain metastases from cervical cancer is in the frontal and parietal parenchyma. There have been reported cases of hemiballismus secondary to metastatic carcinoma of the breast, lung, and gall bladder. This is the first reported case of putative cervical cancer metastases associated with hemiballismus.

CASE

A 38-year-old Caucasian female was diagnosed with FIGO stage II-B poorly differentiated squamous cell carcinoma of the cervix. Para-aortic lymph nodes were positive for metastatic disease. The patient was treated by radiation with hydroxyurea chemosensitization. Four months after the initial diagnosis she presented with acute onset of hemiballismus. Magnetic resonance imaging of the head revealed a solitary lesion in the left cerebral peduncle extending into the inferior aspect of the left basal ganglia complex. The lesion was inaccessible to biopsy or excision. Palliative radiation therapy to the brain was unsuccessful and the patient expired 1 year following primary presentation.

CONCLUSION

Treatment of hemiballismus is directed to its underlying causes. Some brain metastases from cervical cancer may be palliated or even cured by surgical resection and radiation therapy. Although not conclusive, it appears that hemiballismus in a setting of metastatic cervical cancer has a poor prognosis and little benefit from irradiation.

Long-term survival and DNA ploidy in advanced epithelial ovarian cancer

BACKGROUND AND OBJECTIVES

The relationship of the tumor DNA content to survival of patients with advanced epithelial cancer has not yet been clarified. A large amount of contradictory data exists in the literature. This study analyzes the putative relationship between ploidy and advanced ovarian carcinoma.

METHODS

A retrospective analysis of tumor ploidy, DNA index, and the S-phase fraction from 35 patients with nonborderline epithelial ovarian carcinomas was determined by flow cytometry of paraffin-embedded tissue. All patients had FIGO stage III or IV disease. Those patients who survived > 5 years were assigned to Group A (10 patients). Group B consisted of 25 age-matched subjects who succumbed to their disease within 5 years of diagnosis.

RESULTS

Group A had not reached a median overall survival with a median follow-up of 114 months (range 67-226), whereas Group B had a median overall survival of 17 months (range 1-48). Two of the patients in Group A and all of the patients in group B had died of the disease. The two groups were similar in age, histologic type, and treatment. In Group A, three patients had grade 1 tumors, in contrast to group B where all the patients had either grade 2 or 3 disease (P = 0.018). However, the distribution of aneuploidy was similar in both groups. Also, the DNA indices were similar: 1.40 +/- 0.42 in Group A, and 1.36 +/- 0.44 in Group B. The median S-phase fraction was 14% (range 3-23%) in Group A, and 15% (range 2-23%) in Group B. The grade and type of tumor were not related to the ploidy or the DNA index. There was no significant correlation between ploidy or the DNA index and survival.

CONCLUSION

This study suggests that the DNA content of tumor as measured by flow cytometry is not a predictor of long-term survival in ovarian cancer patients with advanced disease.

Malignant uterine smooth muscle tumors: role of etoposide, cisplatin, and doxorubicin (EPA) chemotherapy

BACKGROUND

Nearly 80% of patients with malignant uterine smooth muscle tumor will suffer local relapse and/or distant metastases after initial surgical resection. There is no convincing evidence that the addition of pelvic radiation improves the outcome. However, adjuvant chemotherapy might be an appropriate therapeutic modality.

METHODS

Between 1986 and 1991, 13 consecutive patients with malignant uterine smooth muscle tumors were treated at Yale-New Haven Hospital with a combination chemotherapy containing etoposide 100 mg/M2 on days 1 and 2, cisplatin 50 mg/M2 on day 1, and doxorubicin 50 mg/M2 on day 1, repeated every 28 days. Six patients had Stage I disease, one patient had Stage III disease, and six patients had Stage IV disease. The number of cycles ranged from 2 to 9.

RESULTS

The median follow-up was 30 months (range 4-81). The mean overall survival for the group was 43.1 +/- 6.7 months, with the progression-free interval of 25.5 +/- 8.0 months. Of the seven patients with evaluable disease, one patient had complete response and one had partial response (total response rate of 28.6%). Of the six patients treated adjuvantly, three recurred at 9, 33, and 59 months (recurrence rate of 50%).

CONCLUSIONS

We conclude that this combination has only modest activity against malignant uterine smooth muscle tumors at the schedule and doses tested.

Neoadjuvant chemotherapy in uterine papillary serous carcinoma

Uterine papillary serous carcinoma (UPSC) is an aggressive variant of endometrial cancer that frequently imitates serous carcinoma of the ovary in its clinical presentation and histologic appearance. Unlike the ovarian lesion, however, it is known to be particularly resistant to chemotherapy. A patient with a putative diagnosis of unresectable Stage IV ovarian cancer was treated with three cycles of neoadjuvant chemotherapy containing paclitaxel and carboplatin. After a remarkable response, interval cytoreductive surgery was performed. A primary endometrial tumor with the pathologic features of UPSC was found. To our knowledge, the use of paclitaxel-containing chemotherapy in UPSC has not been reported. We suggest that this therapy might be useful in the treatment of patients with advanced uterine papillary serous carcinoma, as well as in an adjuvant setting.

Combination chemotherapy with etoposide, cisplatin, and doxorubicin in mixed müllerian tumors of the adnexa

Eleven patients with ovarian (9) or fallopian tube (2) mixed müllerian tumors who underwent primary surgery at Yale New Haven Medical Center between 1986 and 1994 were treated with etoposide, cisplatin, and doxorubicin. Responses were observed in three (60%) of five evaluable patients with two complete (40%) and one partial (20%) response. Median survival time was 17 months with an estimated 3-year survival of 18%. Survival may have been improved with earlier stage disease, but survival was not significantly improved with optimal surgical cytoreduction in patients with advanced disease. Four patients required dose reductions for myelosuppression and there was one treatment related death. Toxicity was comparable to other combination chemotherapy regimens. EPA has modest therapeutic activity in ovarian and fallopian tube MMT.

Integration host factor amplifies the induction of the aceBAK operon of Escherichia coli by relieving IclR repression

A binding site for integration host factor (IHF) was identified upstream of the aceBAK promoter. Under inducing conditions, IHF activates aceB::lacZ expression by opposing IclR repression. In contrast, IHF has little effect on aceB::lacZ expression under repressing conditions. The ability of IHF to relieve repression under inducing but not repressing conditions allows this protein to amplify the induction of aceBAK.

Syndrome of inappropriate antidiuretic hormone secretion in papillary serous surface carcinoma of the peritoneum

A case of syndrome of inappropriate antidiuretic hormone secretion (SIADH) in a patient with suboptimally cytoreduced stage III papillary serous surface carcinoma of the peritoneum is described. After the primary surgery, the patient refused further therapy. Within a month bilateral pleural effusions and abdominal ascites compelled the patient to accept treatment with carboplatin and cyclophosphamide. Ten days following the chemotherapy, she was admitted in a disoriented state with serum sodium of 117-mEq/L. During the evaluation, treatment, and subsequent follow-up, the diagnosis of SIADH was confirmed. Numerous disease processes have been associated with the development of SIADH; however, there have been few reports in gynecologic malignancies. Possible etiology and clinical management of this patient are briefly discussed.

A phase II study of etoposide, cisplatin, and doxorubicin chemotherapy in mixed müllerian tumors (MMT) of the uterus

Mixed Müllerian tumors (MMT) of the uterus are aggressive entities that result in a very poor prognosis even for patients in whom the disease is limited to the uterus. This phase II trial was undertaken in an attempt to improve overall survival as well as progression-free survival of these patients. Forty-two consecutive patients were treated with a combination chemotherapy containing etoposide 100 mg/m2 on Days 1 and 2, cisplatin 50 mg/m2 on Day 1, and doxorubicin 50 mg/m2 on Day 1, repeated every 28 days. There were 23 patients with early-stage disease (stages I and II) and 19 patients with advanced (stages III and IV) or recurrent disease. In the early-stage group, the number of cycles ranged from 2 to 9 (5.2 +/- 1.9). The median follow-up was 32 months (range 11-93). There were five recurrences: three patients died of disease at 11, 36, and 51 months, and two patients are still alive with disease at 12 and 19 months. Two-year overall survival was 92%. In the advanced disease group, the number of cycles ranged from 1 to 11 (5.9 +/- 2.4). The median follow-up for this group was 20 months (range 5-62). The median overall survival was 18 months. Two-year overall survival was 33%. Two-year progression-free survival was 20%. Four patients were evaluable for response. There were two complete responses (duration 15-33 months) and two partial responses (duration 6-10 months). The responders were patients whose adenocarcinoma component was of the papillary serous (UPSC) variety. The chemotherapy combination appears to be highly active in early-stage disease. In the advanced uterine MMT it has moderate activity, especially when associated with the UPSC component.

Engineering the quaternary structure of an enzyme: construction and analysis of a monomeric form of malate dehydrogenase from Escherichia coli

The citric acid cycle enzyme, malate dehydrogenase (MDH), is a dimer of identical subunits. In the crystal structures of 2 prokaryotic and 2 eukaryotic forms, the subunit interface is conformationally homologous. To determine whether or not the quaternary structure of MDH is linked to the catalytic activity, mutant forms of the enzyme from Escherichia coli have been constructed. Utilizing the high-resolution structure of E. coli MDH, the dimer interface was analyzed critically for side chains that were spatially constricted and needed for electrostatic interactions. Two such residues were found, D45 and S226. At their nearest point in the homodimer, they are in different subunits, hydrogen bond across the interface, and do not interact with any catalytic residues. Each residue was mutated to a tyrosine, which should disrupt the interface because of its large size. All mutants were cloned and purified to homogeneity from an mdh- E. coli strain (BHB111). Gel filtration of the mutants show that D45Y and D45Y/S226Y are both monomers, whereas the S226Y mutant remains a dimer. The monomeric D45Y and D45Y/S226Y mutants have 14,000- and 17,500-fold less specific activity, respectively, than the native enzyme. The dimeric S226Y has only 1.4-fold less specific activity. All forms crystallized, indicating they were not random coils. Data have been collected to 2.8 A resolution for the D45Y mutant. The mutant is not isomorphous with the native protein and work is underway to solve the structure by molecular replacement.

Early postpartum endometritis. Randomized comparison of ampicillin/sulbactam vs. ampicillin, gentamicin and clindamycin

Seventy-six parturients with a clinical diagnosis of early postpartum endometritis were randomized to be treated with either standard therapy--ampicillin, gentamicin and clindamycin--or a new regimen, ampicillin/sulbactam. We deliberately chose to administer 1.5 g of ampicillin/sulbactam rather than a 3-g dose every six hours in order to accentuate any differences that might occur between the regimens. Failure rates, days of therapy and cost of treatment were compared. There was no statistically significant difference (P > .9) in the failure or recovery rates: 4 of 42 (9.5%) patients failed standard therapy vs. 6 of 34 (17.6%) patients in the ampicillin/sulbactam group. The times to recovery were 3.6 +/- 1.8 SD and 3.3 +/- 1.3 days, respectively. There was no difference in side effects or drug toxicity between the two groups. The cost of standard therapy was $355.32 for 3.6 days, whereas ampicillin/sulbactam cost $139.49 for 3.3 days. Therapy with ampicillin/sulbactam may be an equally effective and efficient way to treat patients with early postpartum endometritis.

Advanced ovarian carcinoma: molecular evidence of unifocal origin

The clonal origin has sometimes been disputed in advanced epithelial cancers when multiple sites of peritoneal tumors were present because of the developmental similarity of the surface epithelium of the ovary and the peritoneal mesothelium. We have taken two independent approaches to study the clonality of advanced epithelial carcinoma. Tumor samples of both ovaries, and/or omentum, and/or peritoneum from nine patients were examined. The analysis of loss of heterozygosity (LOH) at 86 polymorphic chromosomal loci distributed on every chromosome revealed the loss of the same allele in every tumor of each patient when LOH was detected. In addition, we used a restriction-fragment-length polymorphism in an X-linked sequence (DXS255) to examine the pattern of X-chromosome inactivation based on the differential methylation of DXS255 in active and inactive X chromosomes. Inactivation of the same X chromosome in various tumors from the same patient was observed in each of the five informative patients. Our results strongly suggest that the advanced epithelial cancers are monoclonal in origin.

Relative expression of the products of glyoxylate bypass operon: contributions of transcription and translation

Although the genes of the aceBAK operon are expressed from the same promoter, the relative cellular levels of their products are approximately 0.3:1:0.003. Gene and operon fusions with lacZ were constructed to characterize this differential expression. The upshift in expression between aceB and aceA resulted from differences in translational efficiency. In contrast, inefficient translation and premature transcriptional termination contributed to the downshift in expression between aceA and aceK. Premature transcriptional termination occurred within aceK and appears to result from inefficient translation. Deletion of repetitive extragenic palindromic elements between aceA and aceK had little effect on the relative expression of these genes. Rather, the sequences responsible for inefficient expression of aceK lie within the aceK ribosome binding site.

Transvesical cesarean following bowel and urinary tract reconstructive surgery

Intentional transvesical cesarean was done for delivery in a woman born with an imperforate anus, ectopic intravaginal urethra, and vaginal and urethral strictures. She had undergone multiple reconstructive procedures that left her bladder completely covering the anterior uterine surface. The rest of the uterus, including the fundus and the broad ligaments, was obscured by multiple bowel adhesions. Cesarean delivery was necessary because of pelvic bone and soft-tissue deformity. Anterior and posterior vertical cystotomies resulted in exposure of the anterior uterine wall, and the fetus was delivered through a vertical uterine incision. The woman recovered and 6 months later has no genitourinary complaints.

Inhibition of interferon gamma production by peripheral blood mononuclear leukocytes of patients with sarcoidosis. Pathogenic implications

Interferon gamma (IFN-gamma) production by stimulated peripheral mononuclear leukocytes of 30 patients with sarcoidosis was studied. A significant inhibition (64 percent, 5 to 330 IU/ml vs normal individuals = 1,000 +/- 250 IU/ml) in the IFN-gamma synthesis was found. The inhibition is due to a defect in the circulating monocytes and not in the peripheral T lymphocytes of these patients. This defect in the peripheral IFN-gamma production could be involved in the pathogenesis of this disease.

Introduction of single-copy sequences into the chromosome of Escherichia coli: application to gene and operon fusions

We have developed a general method for the introduction of any cloned sequence into the chromosome of Escherichia coli. This method employs an Hfr strain which carries a fragment of bla (the pBR322 gene imparting ampicillin resistance) between lacI and lacZ. Plasmid-borne inserts which are flanked by sequences from bla and lacZ can be introduced at this locus by homologous recombination. The isolation of recombinants is enhanced by selection for transfer of an integrated copy of the plasmid during conjugation. Once introduced into the chromosome, the inserted sequences can be transferred to other strains by conventional methods such as P1 transduction or conjugation. This method is suitable for the transfer of any cloned sequence to the chromosome and is particularly well suited to the construction of chromosomal gene and operon fusions with lacZ.

Placenta previa percreta involving the urinary bladder: a report of two cases and review of the literature

The incidences of both placenta previa and placenta accreta are increased in patients with scarred uteri, and patients with uterine scars and placenta previa are at increased risk for also having placenta accreta. Two cases are presented of placenta previa percreta with involvement of the urinary bladder necessitating cesarean hysterectomy, partial cystectomy, and, in one case, bilateral ureteral reimplantation. Both patients had two previous cesarean deliveries. Serious hemorrhage is common in patients with placenta percreta. The primary goal of surgical management must be to control bleeding, which usually requires resection of all tissue involved by the infiltrating placenta. After hemorrhage is controlled, the surgeon must reestablish the integrity of the urinary system and reconstruct the pelvis as necessary.

Clear cell adenocarcinoma of the cervix and vagina in a woman with mixed gonadal dysgenesis. A case report

Clear cell adenocarcinoma of the cervix and vagina occurred in a woman with 45,X/46,XY gonadal dysgenesis. The patient had no known exposure to synthetic estrogen prenatally and did not receive exogenous estrogen at any time.

Angiographic embolization in the management of late postpartum hemorrhage. A case report

Bilateral selective embolization of the internal iliac arteries was utilized to control late recurrent post-partum hemorrhage. Angiographic embolization appears to be safe and effective, and giving consideration to its use in patients in similar situations is recommended.