Janet I. Andrews

Computed tomography in endometrial carcinoma

Objective To determine the value of computed tomography (CT) scans for preoperatively detecting extrauterine-nodal disease and postoperative recurrent disease in patients with endometrial cancer. Methods We reviewed records of 702 women with primary endometrial carcinoma that was diagnosed between 1979 and 1993. Preoperative CT findings were compared with pathologic findings to assess nodal disease. The yield of postoperative CT was reviewed in clinically suspicious and routine settings. Results Among 492 women eligible for analysis, 178 (36%) had a total 326 CT scans. Among 56 women who had preoperative CT scans and lymph node samplings, positive and negative predictive values for nodal involvement were 50% and 94%, respectively, and sensitivity and specificity were 57% and 92%, respectively. Preoperative CT findings altered treatment plans in only six patients (8%). Forty-five asymptomatic women had 73 routine CT scans, and recurrence was diagnosed by CT in only two (4.4%). Thirty-seven women had CT scans for suspicion of recurrence, which was confirmed in 17 (46%). Kaplan-Meyer analysis showed no survival advantage in women with subclinical recurrences diagnosed by CT scan. Conclusion Routine preoperative CT scanning rarely alters treatment and is a poor predictor of nodal disease. Computed tomography in the postoperative period might be helpful for detection and follow-up of recurrent disease, but there was no difference in survival when subclinical recurrence was found by CT. Thus, CT scanning of any woman with endometrial cancer should be discouraged unless it is to evaluate symptoms.

Obesity and prognosis in endometrial cancer.

OBJECTIVE We tested the null hypothesis that morbid obesity as measured by the Quetelet index has no influence on survival in endometrial cancer. STUDY DESIGN A retrospective study of 492 women with endometrial carcinoma was performed. Age, height, weight, Quetelet index, stage, cell type, grade, node status, peritoneal cytologic findings, and depth of myometrial invasion were analyzed for influence on survival. RESULTS Mean Quetelet index was 34 (range 16 to 89). Quetelet index was < 30 in 45% of patients, 30 to 40 in 33%, and > 40 in 22%. Five percent of those with a Quetelet index > 40 had positive nodes, but 64% of patients with a Quetelet index > 40 did not have lymph node sampling done. Lack of sampling of lymph nodes in the entire group had no adverse effect on survival. In a proportional hazards regression model for time from diagnosis to death from disease, grade, node status, myometrial invasion, and stage had highly significant effects. When Quetelet index was analyzed as a continuous variable, as Quetelet index increased, time to recurrence was significantly increased (p = 0.0136), and significance was approached for survival (p = 0.0645). Quetelet index was strongly related to grade (p = 0.013), depth of myometrial invasion (p = 0.031), negative cytologic findings (p = 0.004), and stage (p = 0.011) with obese patients having better differentiated, less invasive tumors of lower stage with negative washings. CONCLUSIONS Morbid obesity positively affects survival in endometrial carcinoma. This effect is accounted for by the association of obesity with less aggressive disease. Morbid obesity is not associated with increased death from other causes. Lack of sampling of negative lymph nodes does not adversely affect survival.

Intronic polyadenylation signal sequences and alternate splicing generate human soluble Flt1 variants and regulate the abundance of soluble Flt1 in the placenta

The gene FLT1 produces at least two transcripts from a common transcription start site: full‐length Flt1 contains 30 exons encoding a membrane‐bound VEGF receptor;soluble Flt1 (sFlt1) shares the first 13 exons but utilizes poly(A) signal sequences within intron 13 to create a transcript that lacks downstream exons. To address the mechanisms that regulate human sFlt1, we mapped the 3′ end of sFlt1 mRNA and defined the full extent of its 3′ untranslated region (UTR). We identified a 3.2 Kb sFlt1 transcript that is cleaved within an alternatively spliced exon downstream of exon 14 and is predicted to encode a C‐terminal variant of sFlt1 with an unusual polyserine tail. sFlt1 mRNA cleavage sites within intron 13 were identified in human placenta and in vascular endothe‐lium by ribonuclease protection assay (RPA). A proximal and two distal mRNA cleavage sites were identified by RPA downstream of consensus polyadenylation signals that create variant transcripts with a 3′ UTR ranging from 30 bases to ~4 Kb. Northern blot analysis and 3′ rapid amplification of cDNA ends (RACE) in placenta confirmed the existence of distal intronic sFlt1 cleavage sites that give rise to a sFlt1 transcript of ~7 Kb. The identity of the distal signal sequences were then confirmed by mutagenesis of putative signal elements in a polyadenylation reporter assay. We demonstrate the heterogeneity of human sFlt1 that arises from alternate splicing and from alternative polyadenylation directed by strong intronic poly(A) signal sequences leading to C‐terminal variants and to an sFlt1 transcript with a large 3′ UTR containing several AU rich elements and poly(U) regions that may regulate mRNA stability.— Thomas, C. P., Andrews, J. I., Liu, K. Z. Intronic polyadenylation signal sequences and alternate splicing generate human soluble Flt1 variants and regulate the abundance of soluble Flt1 in the placenta. FASEB J. 21, 3885–3895 (2007)

A recently evolved novel trophoblast-enriched secreted form of fms-like tyrosine kinase-1 variant is up-regulated in hypoxia and preeclampsia.

CONTEXT Recent published studies indicate a possible role for sFlt1 in the development of preeclampsia. OBJECTIVE The objective of the study was to investigate the expression and regulation of sFlt1-e15a, a recently described novel C-terminal variant isoform of sFlt1. DESIGN The studies included a computational comparative analysis of the genomic locus of sFlt1 across vertebrate species; an assessment of sFlt1 variants in human and rhesus cells and tissues; an analysis of sFlt1 variants transiently expressed in HeLa and COS-7 cells; an evaluation of the effect of hypoxia on sFlt1 expression in trophoblasts; and a comparison of placental sFlt1 expression between pregnancies complicated by preeclampsia and control pregnancies. RESULT AND CONCLUSIONS sFlt1-e15a emerged as an alternate transcript of Flt1 late in evolution with the insertion of an AluSq sequence into the primate genome after the emergence of the simian infraorder about 40 million years ago. sFlt1-e15a is particularly abundant in human placenta and trophoblasts and is also highly expressed in nonhuman primate placenta. The expressed protein has a C-terminal polyserine tail and, like reference sequence sFlt1 (sFlt1-i13), is glycosylated and secreted. Consistent with a role in placental pathophysiology, hypoxia stimulates sFlt1-e15a expression in isolated cytotrophoblasts and a trophoblast cell line, and differentiation into syncytiotrophoblasts further enhances the effect of hypoxia. Placental levels of sFlt1-e15a and sFlt1-i13 transcripts are significantly elevated in patients with preeclampsia compared with normal pregnancies. We speculate that sFlt1-e15a may contribute to the pathophysiology of preeclampsia.

Molecular Epidemiology of Macrolide Resistance in Neonatal Bloodstream Isolates of Group B Streptococci

ABSTRACT Pulsed-field gel electrophoresis (PFGE) was performed on 122 neonatal bloodstream isolates of group B streptococci (GBS) to further examine the relationship between macrolide resistance and serotype V GBS (GBS-V). Over one-third (35%) of macrolide-resistant GBS belonged to a single PFGE subtype of GBS-V, which was also the most common GBS-V subtype noted in previous Centers for Disease Control and Prevention surveillance studies. Erm methylase (ermA and ermB) was the most common resistance mechanism detected, present in 12 of 20 macrolide-resistant GBS.

Reversal of Human Cytomegalovirus Major Immediate-Early Enhancer/Promoter Silencing in Quiescently Infected Cells via the Cyclic AMP Signaling Pathway

ABSTRACT The human cytomegalovirus (HCMV) major immediate-early (MIE) enhancer contains five functional cyclic AMP (cAMP) response elements (CRE). Because the CRE in their native context do not contribute appreciably to MIE enhancer/promoter activity in lytically infected human fibroblasts and NTera2 (NT2)-derived neurons, we postulated that they might have a role in MIE enhancer/promoter reactivation in quiescently infected cells. Here, we show that stimulation of the cAMP signaling pathway by treatment with forskolin (FSK), an adenylyl cyclase activator, greatly alleviates MIE enhancer/promoter silencing in quiescently infected NT2 neuronal precursors. The effect is immediate, independent of de novo protein synthesis, associated with the phosphorylation of ATF-1 serine 63 and CREB serine 133, dependent on protein kinase A (PKA) and the enhancers CRE, and linked to viral-lytic-cycle advancement. Coupling of FSK treatment with the inhibition of either histone deacetylases or protein synthesis synergistically activates MIE gene expression in a manner suggesting that MIE enhancer/promoter silencing is optimally relieved by an interplay of multiple regulatory mechanisms. In contrast, MIE enhancer/promoter silence is not overcome by stimulation of the gamma interferon (IFN-γ) signaling pathway, despite the enhancer having two IFN-γ-activated-site-like elements. We conclude that stimulation of the cAMP/PKA signaling pathway drives CRE-dependent MIE enhancer/promoter activation in quiescently infected cells, thus exposing a potential mode of regulation in HCMV reactivation.

Spontaneous Pneumomediastinum presenting as jaw pain during labor

BACKGROUND Pneumomediastinum, or presence of free air within the mediastinum, is a rare complication of labor. Common symptoms of this condition include chest pain, dyspnea, and subcutaneous emphysema. CASE A woman complained of right jaw pain 90 minutes after the onset of her second stage of labor. On examination, she was found to have swelling and crepitus over her face, neck, and supraclavicular region. A chest radiograph demonstrated a pneumomediastinum, which resolved spontaneously. CONCLUSION Pneumomediastinum is associated with Valsalva maneuvers such as those seen during the second stage of labor. We report jaw pain as an unusual presenting symptom of this rare condition. Familiarity with the presenting symptoms of a pneumomediastinum is imperative for appropriate treatment and monitoring for significant complications.

Pregnant women have increased incidence of IgE autoantibodies reactive with the skin and placental antigen BP180 (type XVII collagen).

BP180 (type XVII collagen) is a transmembrane protein expressed in a variety of cell types. It is also the target of autoantibodies in cutaneous autoimmune disease including bullous pemphigoid and pemphigoid gestationis, a disease unique to pregnancy. The purpose of this study was to determine the prevalence and specificity of cutaneous autoantibodies in a cohort of pregnant women. De-identified sera were collected from pregnant women (n=299) and from non-pregnant controls (n=134). Sera were analyzed by ELISA for the presence of IgG and IgE autoantibodies directed against several cutaneous autoantigens. IgE antibodies against the NC16A domain of BP180 were detected in 7.7% of pregnant women, compared to 2.2% of healthy controls (p=0.01). No increase in total or cutaneous autoantigen specific IgG was seen. Total serum IgE was within the normal range. Full-length BP180 was detected by western immunoblot in epidermal, keratinocyte, placental and cytotrophoblast (CTB) cell lysates. Furthermore, flow cytometry and indirect immunofluorescence confirmed the expression of BP180 on the surface of cultured CTBs. Finally, it was demonstrated that IgE antibodies in the pregnancy sera labeled not only cultured CTBs, but also the placental amnion and cutaneous basement membrane zone using indirect immunofluorescence. We conclude that some pregnant women develop antibodies specific for BP180, and that these autoantibodies are capable of binding both CTB and the placental amnion, potentially affecting placental function.

Nonmenstrual Toxic Shock Syndrome Due to Methicillin-Resistant Staphylococcus aureus

CASE: Four weeks after a cesarean delivery for breech presentation, a 20year-old parous woman was referred to a tertiary hospital with the suspected postpartum diagnosis of toxic shock syndrome. Earlier that day, she presented to her primary care facility with left breast tenderness, rash, fever to 38.4°C and chills. The physician judged her clinical examination consistent with mastitis. She was treated with ceftriaxone and prescribed oral trimethoprim-sulfamethoxazole. Later that night, she became confused and collapsed. On arrival to the local facility, she was significantly hypotensive, tachycardic, and tachypneic. She was treated with intravenous broad-spectrum antibiotics and respiratory and blood pressure support until transfer could be facilitated. On arrival at the intensive care unit, the patient was intubated but could follow commands. Pressors were weaned off. Intravenous antibiotics (clindamycin, piperacillin/tazobactam, and vancomycin) were continued. Her skin was diffusely erythematous over her extremities. Her left breast was erythematous and tender to palpation but without masses, fissures, or ulcers. Her abdomen was diffusely tender. The incision was dry and intact with no erythema, crepitation, or fluctuance. The uterus was slightly enlarged and not tender. Vaginal examination confirmed the absence of a tampon or foreign object. Breast and pelvic ultrasonograms and abdominal/pelvic computed tomography imaging showed no evidence for abscess. Given the normal pelvic examination and imaging studies, hysterectomy was not indicated. Chest X-ray was consistent with acute respiratory distress syndrome. Laboratory values indicated acute renal failure (creatinine 4.5 mg/dL), and she also had leukocytosis (white blood cells 30,100), thrombocytopenia (platelets 36,000), and elevated liver transaminases (aspartate aminotransferase 85 units/L) and creatine kinase (1,350 units/L). Other than the malpresentation, her pregnancy and initial postpartum course were uncomplicated. She began breast-feeding after delivery but stopped 1 week before admission after starting fluoxetine for depression. She had used tampons occasionally after delivery for postpartum bleeding. She had no postpartum infectious morbidity until presentation. Her clinical situation remained unchanged for 6 days despite normalization of her laboratory values. She remained intubated and febrile. Multiple cultures of nares, blood, urine, cervix, and stool were negative throughout her hospitalization. On hospital day 9, her left breast was erythematous and mildly tender, with a persistent 5x4 cm firm area, but no fluctuance. Therefore, the left breast ultrasonography was repeated, and this time showed a 5-mm fluid collection, which was aspirated. The breast fluid aspirate grew methicillin-resistant Staphylococcus aureus (MRSA). Vancomycin and clindamycin were continued to complete a 14-day course. The patient was successfully extubated on her ninth hospital day. She was weaned off oxygen, remained afebrile, and she was discharged 9 days later. After hospital discharge, the toxic shock syndrome toxin assay was reported positive for enterotoxin B, a known cause of nonmenstrual toxic shock syndrome. Admission testing revealed that the patient lacked antibodies to enterotoxin B. Further characterization of the MRSA isolate revealed it to be subtype USA1000, Panton-Valentine leukocidin–negative, and resistant to -lactam antibiotics, erythromycin, and clindamycin.

Prenatal testing for infectious disease

Prenatal testing for infectious diseases is performed frequently and for a variety of indications. The purpose of this article is to review the maternal and fetal infections that pose diagnostic concerns. Recent advances in diagnostic testing (such as avidity testing) is included. Testing issues focus on the diagnosis of maternal and fetal infection.