Idhaliz Flores

Quantification of the impact of endometriosis symptoms on health-related quality of life and work productivity

OBJECTIVE To quantify the impact of endometriosis-related symptoms on physical and mental health status, health-related quality of life, and work-related aspects (absenteeism, presenteeism, work productivity, and activity impairment). DESIGN Cross-sectional quantitative study. SETTING Academic and research institution. PATIENT(S) Women (n = 193) with self-reported surgically diagnosed endometriosis from the Endometriosis Patient Registry at Ponce School of Medicine and Health Sciences (PSMHS). INTERVENTION(S) Anonymous questionnaire divided into three sections consisting of questions from the Patient Health Survey (SF-12), the Endometriosis Health Profile (EHP-5), and the Work Productivity and Activity Impairment Survey (WPAI). MAIN OUTCOME MEASURE(S) Quantification of impact of endometriosis symptoms on physical and mental health status, health-related quality of life, absenteeism, presenteeism, work productivity, and activity impairment. RESULT(S) Patients had SF-12 scores denoting statistically significant disability in the physical and mental health components. They also reported an average of 7.41 hours (approximately one working day) of work time lost during the week when the symptoms are worse. In addition, the WPAI scores showed a high impact on work-related domains: 13% of average loss in work time (absenteeism), 65% of work impaired (presenteeism), 64% of loss in efficiency levels (work productivity loss), and 60% of daily activities perturbed (activity impairment). CONCLUSION(S) Endometriosis symptoms such as chronic, incapacitating pelvic pain and infertility negatively and substantially impact the physical and mental health status, health-related quality of life, and productivity at work of women.

Patients’ report on how endometriosis affects health, work, and daily life

The objective of this study was to assess the burden of endometriosis by obtaining patient-reported outcome data describing the experience of living with this disease. Survey data from 107 women with self-reported, surgically diagnosed endometriosis showed that living with this disease may be characterized by physical limitations that disrupt health, work, and daily life.

Basal and Steroid Hormone-Regulated Expression of CXCR4 in Human Endometrium and Endometriosis

Endometriosis is associated with activation of local and systemic inflammatory mechanisms, including increased levels of chemokines and other proinflammatory cytokines. We have previously reported increased gene expression of chemokine receptor 4 (CXCR4), the receptor for CXCL12, in lesions of the rat model of endometriosis. The CXCR4-CXCL12 axis has been shown to have both immune (HIV infection, lymphocyte chemotaxis) and nonimmune functions, including roles in tissue repair, angiogenesis, invasion, and migration. There is evidence indicating that these mechanisms are also at play in endometriosis; therefore, we hypothesized that activation of the CXCR4-CXCL12 axis could be responsible, at least in part, for the survival and establishment of endometrial cells ectopically. Immunohistochemistry (IHC) showed that CXCR4 protein levels were significantly higher in endometriotic lesions compared to the endometrium of controls. Next, we determined basal gene and protein expression of CXCR4 and CXCL12 and regulation by estradiol (E2) and/or progesterone (P4) in endometrial cell lines using quantitative polymerase chain reaction (qPCR), and Western blots. Basal CXCR4 gene expression levels were higher in epithelial versus stromal cells; conversely, CXCL12 was expressed at higher levels in stromal vs epithelial cells. CXCR4 gene expression was significantly downregulated by ovarian steroid hormones in endometrial epithelial. These data suggest that steroid modulation of CXCR4 is defective in endometriosis, although the specific mechanism involved remains to be elucidated. These findings have implications for future therapeutic strategies specifically targeting the inflammatory component in endometriosis.

Molecular profiling of a rat model of colitis: Validation of known inflammatory genes and identification of novel disease-associated targets

Background: Inflammatory bowel disease (IBD) is a disease of unknown etiology characterized by acute and chronic relapsing inflammation. The most suitable animal model for studying this disease is still under debate. Microarray transcript profiling has the potential to illuminate the molecular processes that are involved in both the human condition and animal models. Aim: To identify differentially expressed genes in the 2,4,6‐trinitrobenzene sulfonic acid (TNBS) model of experimental colitis and compare gene expression profiles with that reported in patients. Methods: Colitis was induced by TNBS administration (30 mg in 50% ethanol) in female Sprague‐Dawley rats. Controls received the vehicle. Seventy‐two hours later, the animals were killed, the colons were removed and scored for damage, and total RNA was isolated. Gene expression levels were analyzed after hybridizing experimental and control cDNA to PIQOR Toxicology Rat Microarrays containing 1,252 genes. Genes with 2‐fold or more higher or 0.5‐fold or less lower expression levels were selected as significantly differentially expressed. Results were validated using real‐time reverse‐transcription polymerase chain reaction (RT‐PCR). Results: We observed increased expression of genes that have previously been shown to be up‐regulated in IBD patients, including chemokines/cytokines, extracellular matrix/remodeling genes, transcription factors and tumor necrosis factor family members. Using real‐time RT‐PCR, we validated 9 of 10 critical genes identified by DNA microarray. Fibulin 2 and lysyl oxidase are among some of the novel genes not previously associated with IBD that could potentially be related to the pathogenesis of this condition. Conclusion: We provide evidence supporting the TNBS colitis model as an appropriate tool to study the pathology of IBD and identify molecular targets with clinical relevance.

Stress Exacerbates Endometriosis Manifestations and Inflammatory Parameters in an Animal Model

Women with endometriosis have significant emotional distress; however, the contribution of stress to the pathophysiology of this disease is unclear. We used a rat model of endometriosis to examine the effects of stress on the development of this condition and its influence on inflammatory parameters. Female Sprague-Dawley rats were subjected to swim stress for 10 consecutive days prior to the surgical induction of endometriosis by suturing uterine horn implants next to the intestinal mesentery (endo-stress). Sham-stress animals had sutures only, and an endo-no stress group was not subjected to the stress protocol. At the time of sacrifice on day 60, endometriotic vesicles were measured and colons assessed for macroscopic and microscopic damage. Colonic tissue and peritoneal fluid were collected for inflammatory cell analysis. Endometriosis, regardless of stress, produced a decrease in central corticotropin-releasing factor immunoreactivity, specifically in the CA3 subregion of the hippocampus. Prior exposure to stress increased both the number and severity of vesicles found in animals with endometriosis. Stress also increased colonic inflammation, motility, myeloperoxidase levels, and numbers of mast cells. In summary, prior stress may contribute to the development and severity of endometriosis in this animal model through mechanisms involving cell recruitment (eg, mast cells), release of inflammatory mediators, and deregulation of hypothalamic–pituitary axis responses in the hippocampus.

HDAC1 and HDAC2 are Differentially Expressed in Endometriosis

Epigenetic mechanisms have been ascribed important roles in endometriosis. Covalent histone modifications at lysine residues have been shown to regulate gene expression and thus contribute to pathological states in many diseases. In endometriosis, histone deacetylase inhibition (HDACi) resulted in reactivation of E-cadherin, attenuation of invasion, decreased proliferation of endometriotic cells, and caused lesion regression in an animal model. This study was conducted to assess basal and hormone-regulated gene expression levels of HDAC1 and HDAC2 (HDAC1/2) in cell lines and protein expression levels in tissues. Basal and steroid hormone-regulated HDAC1/2 gene expression levels were determined by quantitative polymerase chain reaction in cell lines and tissues. Protein levels were measured by immunohistochemistry (IHC) in tissues on an endometriosis tissue microarray (TMA). Basal HDAC1/2 gene expression levels were significantly higher in endometriotic versus endometrial stromal cells, which was confirmed by Western blot analysis. Estradiol (E2) and progesterone (P4) significantly downregulated HDAC1 expression in endometrial epithelial cells. Levels of HDAC2 were upregulated by E2 and downregulated by E2 + P4 in endometrial stromal cells. Hormone modulation of HDAC1/2 gene expression was lost in the endometriotic cell line. Immunohistochemistry showed that HDAC1/2 proteins were expressed in a substantial proportion of lesions and endometrium from patients, and their expression levels varied according to lesion localization. The highest proportion of strong HDAC1 immunostaining was seen in ovarian, skin, and gastrointestinal lesions, and of HDAC2 in skin lesions and endometrium from patients with endometriosis. These studies suggest that endometriosis etiology may be partially explained by epigenetic regulation of gene expression due to dysregulations in the expression of HDACs.

Endometriosis is characterized by a distinct pattern of histone 3 and histone 4 lysine modifications.

Background: The histone modification patterns in endometriosis have not been fully characterized. This gap in knowledge results in a poor understanding of the epigenetic mechanisms (and potential therapeutic targets) at play. We aimed to (1) assess global acetylation status of histone 3 (H3) and histone 4 (H4), (2) measure levels of H3 and H4 lysine (K) acetylation and methylation, and (3) to identify histone acetylation patterns in promoter regions of candidate genes in tissues from patients and controls. Methods: Global and K-specific acetylation/methylation levels of histones were measured in 24 lesions, 15 endometrium from patients, and 26 endometrium from controls. Chromatin immunoprecipitation (ChIP)–polymerase chain reaction was used to determine the histone acetylation status of the promoter regions of candidate genes in tissues. Results: The lesions were globally hypoacetylated at H3 (but not H4) compared to eutopic endometrium from controls. Lesions had significantly lower levels of H3K9ac and H4K16ac compared to eutopic endometrium from patients and controls. Tissues from patients were hypermethylated at H3K4, H3K9, and H3K27 compared to endometrium from controls. The ChIP analysis showed hypoacetylation of H3/H4 within promoter regions of candidate genes known to be downregulated in endometriosis (e.g., HOXA10, ESR1, CDH1, and p21 WAF1/Cip1 ) in lesions versus control endometrium. The stereoidogenic factor 1 (SF1) promoter region was enriched for acetylated H3 and H4 in lesions versus control tissues, correlating with its reported high expression in lesions. Conclusions: This study describes the histone code of lesions and endometrium from patients with endometriosis and provides support for a possible role of histone modification in modulation of gene expression in endometriosis.

Self-reported prevalence of endometriosis and its symptoms among Puerto Rican women

To determine the prevalence of endometriosis and its symptoms in a Puerto Rican cohort, and to describe the menstrual, obstetric, and clinical profiles of the women.

Cloning and Molecular Characterization of a cDNA from Blomia tropicalis Homologous to Dust Mite Group 3 Allergens (Trypsin-Like Proteases)

Background: Exposure to the house dust mite Blomia tropicalis is increasingly being implicated as a major risk factor for asthma exacerbations in sensitized individuals. The objective of this study is to clone and characterize B. tropicalis allergens in order to better define their role in allergic asthma. Methods: A λgt22A cDNA library was constructed from B. tropicalis mRNA and screened using specific DNA probes. A full-length cDNA (Bt2-3) was isolated, subcloned, and sequenced. Results: Sequence analysis showed that clone Bt2-3 encodes the full-length serine protease preproenzyme from B. tropicalis. The predicted Bt2-3 protein consists of a 15-amino-acid signal peptide, a 20-amino-acid propeptide and a mature protein of 231 amino residues. BLAST analysis of the deduced amino acid sequence showed high homology (48–54%) between clone Bt2-3 and serine proteases (group 3 allergens) from domestic dust mites. Both the serine active site (DACQGDSGGPVA; amino acids 214–225) and the histidine active site (LTAAHC; amino acids 71–76) of serine proteases were highly conserved. The estimated molecular weight of the preproenzyme is 27.5 kD and its theoretical pI is 8.7. The mature protein contains a putative tyrosine kinase phosphorylation site (amino acids 24–31) and several N-myristoylation sites. Sequence alignment shows that the serine protease active sites are highly conserved among the clinically important mite species, including B. tropicalis. Conclusion: We report the cloning and molecular characterization of a B. tropicalis cDNA clone encoding a trypsin-like protease, with a possible major role as an allergen. Expression and further characterization of the recombinant product will help determine the role of proteolytic enzymes in the pathophysiology of allergic asthma.

Experimental Intestinal Endometriosis Is Characterized by Increased Levels of Soluble TNFRSF1B and Downregulation of Tnfrsf1a and Tnfrsf1b Gene Expression

Abstract Endometriosis is commonly associated with symptoms similar to those of gastrointestinal diseases, such as inflammatory bowel disease (IBD), leading to erroneous diagnosis and inappropriate management. The role of tumor necrosis factor alpha (TNF) in IBD is well established, but its role in endometriosis—also characterized by the activation of inflammatory mechanisms—is still under study. Furthermore, little is known about the involvement of TNF receptors. Intestinal endometriosis was surgically induced in female Sprague-Dawley rats (n = 10). Control rats (n = 10) received sutures with no implants. Samples of tissue and fluids were collected 60 days after surgery. Endometriotic implants were classified in grades, and the gastrointestinal tract was examined for damage. A significant increase was observed in protein levels of TNF and soluble TNFRSF1B in the peritoneal fluid of experimental rats compared to controls. Expression of Tnf mRNA was significantly increased both in peritoneal leukocytes and in intestinal segments associated with implants in experimental animals. Bioactivity of TNF in tissues was confirmed by overexpression of Icam1, Sele, Vegfa, Flt1 and Kdr. Gene expression of Tnfrsf1a and Tnfrsf1b was downregulated in colon and small intestine of experimental animals, possibly as a mechanism of protection against TNF cytotoxicity. Significant overexpression of genes encoding TNF receptor-associated factors that have been linked to activation of antiapoptotic pathways also was observed. Overexpression of TNF and target genes, underexpression of TNF-receptor genes, and increased shedding of TNFRSF1B in this animal model provide further evidence for involvement of the TNF system in the pathogenesis of endometriosis.