Bringing social context into global biomedical HIV cure-related research: An urgent call to action

Advances in science have ushered in a wave of new potential curative and control strategies for HIV that could eliminate the current requirement for life-long antiretroviral therapy (ART) for people living with HIV (PLWH). In this article, we argue that it is critical to consider social contexts in the development of HIV cure trial protocols. The biological and behavioral risk factors for HIV acquisition by study participants are inseparable from the social context in which these participants live. The article discusses an example of a cohort established to further HIV cure research that included social context, called the FRESH Acute HIV study, which combines a sociostructural intervention while conducting HIV prevention, treatment and cure-related research in Durban, South Africa. We make an urgent call to action to include sociobehavioral components as instrumental in future HIV cure trials in global context.

Depletion of the Microbiome Alters the Recruitment of Neuronal Ensembles of Oxycodone Intoxication and Withdrawal

Substance use disorders have a complex etiology. Genetics, the environment, and behavior all play a role in the initiation, escalation, and relapse of drug use. Recently, opioid use disorder has become a national health crisis. One aspect of opioid addiction that has yet to be fully examined is the effects of alterations of the microbiome and gut-brain axis signaling on central nervous system activity during opioid intoxication and withdrawal. The effect of microbiome depletion on the activation of neuronal ensembles was measured by detecting Fos-positive (Fos+) neuron activation during intoxication and withdrawal using a rat model of oxycodone dependence. Daily oxycodone administration (2 mg/kg) increased pain thresholds and increased Fos+ neurons in the basolateral amygdala (BLA) during intoxication, with a decrease in pain thresholds and increase in Fos+ neurons in the periaqueductal gray (PAG), central nucleus of the amygdala (CeA), locus coeruleus (LC), paraventricular nucleus of the thalamus (PVT), agranular insular cortex (AI), bed nucleus of the stria terminalis (BNST), and lateral habenula medial parvocellular region during withdrawal. Microbiome depletion produced widespread but region- and state-specific changes in neuronal ensemble activation. Oxycodone intoxication and withdrawal also increased functional connectivity among brain regions. Microbiome depletion resulted in a decorrelation of this functional network. These data indicate that microbiome depletion by antibiotics produces widespread changes in the recruitment of neuronal ensembles that are activated by oxycodone intoxication and withdrawal, suggesting that the gut microbiome may play a role in opioid use and dependence. Future studies are needed to better understand the molecular, neurobiological, and behavioral effects of microbiome depletion on addiction-like behaviors.

Ultrasonic surgical aspiration for gynecologic disease

Ultrasonic Surgical Aspiration (USA) is a technique which employs a hand-held instrument that selectively fragments and aspirates tissues of high-water content. The selectivity of the device permits preservation of underlying vital structures while the aspiration provides a tissue specimen for histologic analysis. Application of this device to neoplastic disease of the lower genital tract has been reported to provide durable success rates of 78% for conyloma acuminata and vulvar intraepithelial neoplasia (VIN) and 81% for vaginal intraepithelial neoplasia (VAIN).Employment of USA in patients with advanced ovarian cancer has been shown to improve surgical cytoreduction without increasing blood loss or complication rates.

Employer attitudes, training, and return-to-work outcomes: a pilot study

This work was concerned with investigating and changing employer attitudes and practices that impede return to work and rehabilitation for injured workers. Prior studies have shown that employer responses to workers reporting work-related musculoskeletal discomfort have significant and independent effects on disability outcomes. Based on these findings, a pilot training program was developed by occupational rehabilitation specialists to improve the response of supervisors to employees reporting work-related injuries. The training was delivered to 108 supervisors at seven southeastern New Hampshire companies that volunteered to participate. A survey was developed and pilot-tested, then administered before the training. Survey participants were employees who had work-related injuries in the past year. The survey asked about types and onset of injury, specific supervisor responses, and overall impression of supervisor interaction at the time of injury. Employee responses before the intervention were compared with those collected from workers who reported injuries after the training. The postintervention results demonstrated significant decreases in supervisors (1) blaming employees for the injury, (2) not taking the condition seriously, and (3) discouraging the worker from filing a claim. Positive trends in confidentiality of discussions, access to medical care, and accommodation and work modifications were also noted. Although anecdotal reports from the companies indicated a consistent decrease in work-related lost time after the intervention, actual verification was not possible, and other components of the intervention may have accounted for this outcome. Small numbers of cases and possible lack of comparability of cases before and after the intervention are significant limitations. However, rehabilitation professionals may be able to improve disability management practices and accommodations through employer education, especially when training is directed toward front-line supervisors.

Gestational trophoblastic disease

Gestational trophoblastic disease consists of a broad spectrum of conditions ranging from an uncomplicated partial hydatidiform molar pregnancy to stage IV choriocarcinoma with cerebral metastases. Fortunately, with the advent of combination chemotherapy, the patient with advanced-stage disease has a significant chance of achieving complete remission. In addition, several studies have demonstrated that patients with a history of gestational trophoblastic neoplasia do not experience an increased risk of complications with future pregnancies. Patients who have undergone chemotherapy do not seem to experience an increase in the risk for congenital anomalies in their offspring. Patients with a history of hydatidiform molar pregnancy should be advised that they are at increased risk of future molar pregnancies, with a risk of 1% in subsequent gestations after one molar pregnancy and a risk as high as 23% after two molar gestations. Although patients should be reassured regarding their reproductive future, they should be advised to seek prompt medical attention once gestation is suspected so that an early work-up can be initiated if pregnancy is confirmed.

Somatic mutation of PTEN in vulvar cancer

PTEN, a candidate tumor suppressor gene located at chromosome 10q23.3, has been shown to be mutated in approximately 40% of endometrial cancers. Such mutations have also been identified in endometrial hyperplasia, indicating that inactivation of the PTEN tumor suppressor gene is an early event in the genesis of some endometrial cancers. In this study, we have extended the analysis of PTEN in gynecological cancer to include adenocarcinoma of the cervix and vulvar carcinomas. Microdissected tissue (including normal tissues), preneoplastic, and neoplastic lesions were analyzed from 9 patients with cervical cancer and 10 patients with vulvar cancer. Only 1 cervical adenocarcinoma displayed a PTEN mutation. In contrast, five of eight vulvar carcinomas studied harbored PTEN mutations. Alterations were identified in carcinoma in situ as well as squamous cell carcinoma of the vulva. In two patients, PTEN mutations were identified in mucosal regions with mild or focal dysplasia. These results suggest that PTEN is frequently altered in vulvar carcinomas and can be found associated with early dysplastic changes in vulvar mucosa.

Prophylactic mastectomy and inherited predisposition to breast carcinoma

Relative to her risk of breast carcinoma, the woman with a BRCA1 or BRCA2 gene mutation can be managed either by intensive screening (with or without chemoprevention) or by prophylactic mastectomy. Although it would be preferable to avoid prophylactic surgery, the current level of screening technology and the rudimentary state of chemoprevention do not guarantee a good outcome with intensive surveillance. A review of the currently available data was undertaken to determine the efficacy of prophylactic surgery, intensive screening, and chemoprevention. An attempt then was made to extrapolate the efficacy of the various approaches to the management of women who carry BRCA1 or BRCA2 gene mutations. Intensive surveillance may not detect breast carcinoma at an early, curable stage in young women with BRCA1 or BRCA2 gene mutations because the growth rate of the tumors in these women most likely will be rapid and the density of the breast tissue may compromise detection. Chemoprevention is in its infancy, and its efficacy in this population is unknown. Conversely, prophylactic surgery may not be completely effective in preventing breast carcinoma. The authors are hopeful that sometime in the next decade advances in chemoprevention, screening technology, or breast carcinoma treatment will make mastectomy obsolete. However, for the time being prophylactic mastectomy has attributes that make it an alternative for this population that must be considered. Careful discussion of all options is essential in the management of these women.

Long-term follow-up of stage I cervical adenocarcinoma treated by radical surgery

From 1972 to 1988 55 patients underwent radical abdominal hysterectomy, pelvic lymph node dissection for treatment of FIGO Stage I cervical adenocarcinoma. A minimum of 60 months follow-up was available on all surviving patients. A detailed retrospective analysis was conducted to determine the influence of radical surgery on survival and to identify prognostic factors for recurrence. A bilateral salpingo-oophorectomy was included as part of the primary surgery in 52 the patients. Histologic subtypes included endocervical adenocarcinoma (44), papillary carcinoma (5), clear cell carcinoma (3), and adenosquamous carcinoma (3). The 5- and 10-year disease-free survival was 85.5%. The median follow-up of the surviving patients was 78.5 months (range, 60 to 240 months). Eight patients recurred, all but 1 of whom died of disease. Median time to recurrence was 28 months (range, 6 to 47 months). Five patients recurred beyond 24 months. One patient recurred locally, 5 recurred regionally, and 2 developed distant recurrences. Lymph node metastases (P < 0.0001), histologic grade (P < 0.0001), depth of invasion (P = 0.0001), presence of paracervical disease (P = 0.0034), and size of the lesion (P = 0.0059) were shown to be significant determinants of recurrence. Two of the 3 patients with a single involved lymph node recurred. Age, parity, history of oral contraceptive use, histologic subtype, and lymph vascular space involvement were not statistically significant determinants of recurrence. Adjuvant whole pelvic radiotherapy did not influence regional recurrence or survival but may decrease local recurrence. Radical abdominal hysterectomy pelvic lymph node dissection is an appropriate treatment of patients with Stage I cervical adenocarcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Placental site trophoblastic tumor in a postmenopausal woman

Placental site trophoblastic tumor is a rare neoplasm that arises in the trophoblastic tissue of the placental bed. This case report is unusual because of the patient's advanced age at the time of diagnosis and the favorable response of the disease to chemotherapy. Although the clinical course is benign for most patients with placental site trophoblastic tumor, the malignant variant of the disease is characterized by recurrence, relative insensitivity to radiation and chemotherapy, and death. To the authors' knowledge, the 53-year-old woman reported is the oldest patient with histologically confirmed placental site trophoblastic tumor. Initially, surgery, radiation, and multiagent chemotherapy failed to control vaginal and pulmonary metastatic disease. After administration of four treatment cycles of a "second-line" chemotherapeutic regimen consisting of cyclophosphamide and cisplatin, complete clinical and radiologic remission was achieved. The patient's serum level of human chorionic gonadotropin has remained undetectable, and she has been without measurable evidence of disease for 16 months.

Investigation of ovarian neoplasia of low malignant potential for human papillomavirus

Recent in situ hybridization studies have suggested the presence of human papillomavirus type 6 (HPV-6) DNA in ovarian cancer cells. An association between HPV and ovarian neoplasia of low malignant potential (LMP) has not been previously identified. Paraffin-embedded tissue blocks from 24 patients with LMP ovarian tumors were screened for human papillomavirus DNA. The patients ranged in age from 18 to 73 years. Corresponding microscopic slides from each tissue block were reviewed to confirm the histopathologic diagnosis. For identification of HPV genome, deparaffinized sections were subjected to the polymerase chain reaction to achieve amplification of DNAs of HPV types 6, 11, 16, and 18. For each HPV type, a 120-base-pair region of the E6 gene was targeted for amplification. Human papillomaviral DNA was not detected in the tissue specimens subjected to polymerase chain reaction. These results suggest that HPV types 6, 11, 16, and 18 are not likely to play a role in LMP ovarian tumors. These results do not totally exclude possible contributions of other HPV types.

Pelvic inflammatory disease in the adolescent

We studied 171 women, 106 young adults, and 65 adolescents, with a clinical diagnosis of pelvic inflammatory disease (PID) to determine whether differences existed in the presentation in these two groups. The study population was an age-stratified, random sample obtained from 1162 women with this condition. Demographic characteristics, sexual history, physical findings, severity of illness, and laboratory findings were compared between the two groups. The most significant findings were that the adolescents sought health care later in the course of the illness (7.8 vs. 5.6 days; p less than 0.02) and were more commonly infected with the gonococcus (42% vs. 28%; p less than 0.05). No statistically significant differences were found in the other parameters evaluated. Implications of these findings regarding the health care for sexually transmitted diseases (STDs) and the education of adolescents are discussed.

Varicella during pregnancy: the timing of effective treatment

Maternal varicella infections during pregnancy can be either benign or disastrous for the infant according to the timing of infection during gestation. We report a case of varicella occurring at term that was managed successfully. Appropriate management includes tocolysis, unless contraindicated, and varicella-zoster immune globulin (VZIG) administered to the mother within 72 hours of delivery, or to the neonate when the mother's rash appears within 48 hours after delivery. Treatment can markedly decrease the risk of mortality and severe morbidity in the relatively immunocompromised infant.

Peritoneal cytology in endometrial cancer: a review

Utilization of literature review to evaluate peritoneal cytology as a test for the detection of malignant cells in the peritoneal cavity is limited by the size of the study populations, varied use of preoperative radiation, the lack of consistent methodology for specimen retrieval and processing, and the inherent subjectivity of cytologic interpretation. A standardized methodology for retrieval and processing of peritoneal cytologic specimens should be developed to allow meaningful comparisons of future studies. However, certain conclusions are permitted from published data: 1. The incidence of positive peritoneal cytology is 11.4 per cent among 3091 patients with FIGO stage I endometrial cancer. 2. The depth of the uterus does not influence the incidence of positive peritoneal cytology. 3. Positive peritoneal cytology is predictive of other known prognostic factors including advanced histologic grade, depth of myometrial invasion, and pelvic/periaortic lymph node metastases. 4. The presence of malignant cells in the peritoneal washings from some patients with no myometrial invasion and the high incidence of lymph node metastases in other patients with positive peritoneal cytology suggest that malignant cells gain access to the peritoneal cavity in a variety of ways. It is unclear whether each of these modes of access result in viable tumor cells with the potential for viable metastasis. The high incidence of lymph node metastasis in such patients suggests that lymphatic dissemination of malignant cells plays a significant role in the development of positive peritoneal cytology. In this setting positive peritoneal cytology clearly identifies that individual at high risk for recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Ovarian carcinoma and paraneoplastic cerebellar degeneration

A case of paraneoplastic cerebellar degeneration complicating ovarian cancer is presented. This rare disorder is characterized by vertigo, nystagmus, diplopia, and ataxia. Neurologic sequelae are progressive, ultimately culminating in complete incapacitation and death. Symptoms of paraneoplastic cerebellar degeneration precede the diagnosis of malignancy in the majority of cases. Marked elevation in the anti-Purkinje cell antibody titer together with immunofluorescent staining techniques suggest that an autoimmune mechanism plays a role in the etiology of this disorder.

The clinical diagnosis of trichomoniasis

Two hundred twenty-six consecutive women attending an inner-city clinic for sexually transmitted diseases were evaluated. Problem-directed histories and physical examinations were conducted and vaginal specimens for wet preparation and Trichomonas vaginalis culture were obtained from each patient. One hundred patients were found to be infected. Patients with multiple sex partners were found to be at increased risk of trichomoniasis (P less than .05). Those with abnormal discharge noted on examination had a higher frequency of positive cultures for T vaginalis (P less than .001). Only 50% of patients with trichomoniasis had an abnormal discharge. Patients with greater than 10 white blood cells per high power field on wet preparation, regardless of whether trichomonads were visualized, had a higher incidence of trichomoniasis (P less than .01). Factors that were not associated with Trichomonas infection included patient age, frequency of coitus, date of most recent coitus, day of menstrual cycle on which patient was examined, recent antibiotic use, use of contraceptives or specific contraceptive methods, symptoms of discharge or pruritus, or the finding of Leptothrix on wet preparation. These data support the contention that the classic description of trichomoniasis cannot be uniformly relied upon for diagnosis, but that patients with multiple sex partners, abnormal vaginal discharge and/or greater than 10 white blood cells per high power field on wet preparation are at increased risk of infection by T vaginalis.