Prevalence and correlates of cervico-vaginal clinical syndromes among women attending a health camp in Lalitpur district of Nepal.

BACKGROUND: Sexual and reproductive health of women is a major public health problem in Nepal. Screening of cervico-vaginal clinical syndromes could potentially provide insights to the prevalence of sexually transmitted infections (STIs), which is not known. OBJECTIVE: To investigate the prevalence and factors associated with cervico-vaginal clinical syndromes in the socio-behavioral, medical, and public health context of Nepal. METHODS: Married women attending a clinical health camp held by the Nepal Fertility Care Centerin Khokana of Lalitpur district were recruited to the study. Seventy-three participants completed face-to-face questionnaires on basic socio-demographic, behavioral and reproductive health factors and underwent pelvic screening including clinical diagnosis of cervicitis and vaginitis. An univariate analysis was performed to determine if any of the self-reported variables were associated with abnormal pelvic examination (cervicitis and/or vaginitis). RESULTS: Vaginitis was diagnosed in three (4.4%) participants, while cervicitis was detected in 16 (23.5%) women. None of the participants reported any high risk sexual behavior. However, 28% of the participants reported having had STI diagnosis in the past and was associated (P<0.008) with abnormal pelvic results. Additionally, women with lower education were associated (p<0.02) with abnormal pelvic results. CONCLUSIONS: The high occurrence of cervicitis in our exploratory could indicate the high prevalence of STIs. However, while there could potentially be an unknown epidemic of STIs related to the clinical syndromes, point of care testing practice might help to understand the true prevalence of STIs in Nepali women and also reduce the health burden and consequences of over treatment based on the current symptomatic diagnosis.

Tetrasomy is induced by human papillomavirus type 18 E7 gene expression in keratinocyte raft cultures.

We have demonstrated previously that oncogenic human papillomaviruses (HPVs) induce basal cell tetrasomy in low-grade squamous intraepithelial lesions of the cervix. To identify HPV genes and growth conditions involved in this process, we analyzed: (a) organotypic raft cultures of primary human keratinocytes transfected with whole HPV-18 genomes; and (b) organotypic raft cultures acutely infected with recombinant retroviruses expressing the HPV-18 E6, E7, or E6/E7 genes from the differentiation-dependent HPV-18 enhancer-promoter. Cultures were examined for HPV DNA by in situ hybridization and for karyotype by interphase cytogenetics. Tetrasomy occurred in the suprabasal strata of raft cultures expressing E7 and E6/E7 but not in those expressing E6 alone or in a control culture. These data indicate that suprabasal tetrasomy occurs in association with expression of the E7 gene alone. Basal cell tetrasomy was additionally observed in the raft culture transfected with whole HPV-18 genomes, consistent with observations in low-grade squamous intraepithelial lesions. The distribution of tetrasomic cells in these raft cultures may reflect the involvement of additional viral genes or possibly differences in the pattern of viral oncogene and host gene expression.

Expression of high-affinity laminin receptor mRNA correlates with cell proliferation rather than invasion in human papillomavirus-associated cervical neoplasms.

Induction of the expression of the Mr 67,000 high-affinity laminin receptor gene has been postulated as playing a role in the progression of human tumors to invasive cancers. We tested this hypothesis by examining histopathological sections of a large number of epithelial lesions of the genital tract associated with human papillomaviruses. In situ hybridization was performed with a riboprobe generated from a laminin receptor complementary DNA. Laminin receptor mRNA was expressed primarily in the less differentiated cells in normal squamous tissues and in a spectrum of squamous neoplasms. There was no net induction of mRNA per cell in intraepithelial or invasive squamous neoplasms relative to normal tissue. In contrast, laminin receptor mRNA was not expressed at a detectable level in normal glands of the uterine cervix but was dramatically induced in morphologically abnormal, human papillomavirus-positive glands, irrespective of the genotype of human papillomaviruses present. The induction occurred before any evidence of invasion, and there was no further increase during the transition from adenocarcinoma in situ to invasive carcinoma. We conclude that induction of high-affinity laminin receptor gene expression is associated with the development of malignancies of cervical glandular epithelia, but the increased expression appears to correlate with the proliferative rather than the invasive properties of these cells.

Post-transcriptional induction of p21cip1 protein by human papillomavirus E7 inhibits unscheduled DNA synthesis reactivated in differentiated keratinocytes.

Productive infection by human papillomaviruses (HPVs) occurs only in differentiated squamous epithelial cells in papillomas, condylomata, and low grade intraepithelial neoplasias. Host DNA replication is reactivated in a fraction of terminally differentiated keratinocytes in benign human lesions and in organotypic raft cultures of primary human keratinocytes (PHKs) transduced with retroviruses expressing HPV-18 E7 oncogene from its native upstream regulatory region (URR). Thus the natural function of E7 protein, which inactivates pRB family proteins, is to induce host genes essential to support viral DNA replication in post-mitotic cells. Using this raft culture model system, we show that HPV-18 URR-E7 induces the universal cyclin-dependent kinase inhibitor p21cip1 protein in a fraction of differentiated PHKs. Induction is mediated by posttranscriptional mechanisms independent of p53. Double immunofluorescence studies demonstrate that, in raft cultures and in laryngeal papillomas, p21cip1 induction and reactivated host DNA synthesis take place in a mutually exclusive manner in PCNA-positive, differentiated keratinocytes. We suggest that p21cip1 induction effectively blocks unscheduled DNA synthesis reactivated by E7. These results begin to explain the inverse relationship between p21cip1 induction and HPV activities previously observed in a spectrum of benign lesions regardless of HPV types present.

Recombinant retroviruses encoding human papillomavirus type 18 E6 and E7 genes stimulate proliferation and delay differentiation of human keratinocytes early after infection.

Human papillomavirus (HPV) DNAs are detected in most genital dysplasias and cancers, suggesting that these viruses perturb epithelial growth and differentiation. The E6 and E7 genes of HPV type 18 induce immortality in keratinocytes cultured from genital tract epithelia, and the immortal cell lines display aberrant squamous differentiation. To examine whether the E6 and E7 proteins directly alter keratinocyte growth and differentiation, high-titer recombinant retroviruses were constructed for efficient transfer and expression of HPV-18 genes E6, E6* and E7 in cultures of normal human keratinocytes. Infection with retroviruses encoding E6 and E7 stimulated cell proliferation, reduced the requirement for bovine pituitary extract and induced immortality. E6 and E7 also delayed but did not prevent the onset of terminal squamous differentiation. The magnitude of effects on growth and differentiation of cultured cells was directly related to levels of E7 protein expression. Thus, expression of the HPV-18 E6 and E7 genes stimulates cell proliferation and delays differentiation of keratinocytes in vitro.

Transition of human papillomavirus type 16 and 18 transfected human foreskin keratinocytes towards immortality: activation of telomerase and allele losses at 3p, 10p, 11q and/or 18q.

This study aimed at resolving cellular genetic alterations in the process of in vitro immortalization of human keratinocytes by human papillomavirus (HPV) types 16 and 18. Four cell lines of primary human foreskin keratinocytes transfected with HPV 16 and HPV 18, respectively, were analysed during the transition from the mortal to immortal state. All cell lines showed strong telomerase activity at the immortal state, whereas no or only weak telomerase activity was detected in mortal precursor cells. This was consistent with telomere stabilization or restoration only observed in immortal cells. HPV physical state and copy number appeared constant during immortalization and HPV E6/E7 transcripts were present throughout. Immortalization was associated with clonal allele losses at 3p combined with either 11q or 18q or at 10p, dependent on the cell line. Moreover, a correlation was evident between the onset of telomerase activity and allele loss at 3p or 10p. All immortalized cells retained the capability to differentiate after growth in the presence of physiological calcium and serum. Moreover, one of the immortal cell lines displayed terminal differentiation after organotypic culturing on collagen rafts. The data suggest that (a) several pathways exist for HPV mediated immortalization that may involve genes residing at 3p, 10p, 11q and/or 18q; (b) 3p and 10p may encode genes involved in telomerase regulation; and (c) immortalization in vitro can be correlated with a spectrum of morphological changes varying from mild to severe dysplasia.

High-efficiency transfection of primary human keratinocytes with positively charged lipopolyamine:DNA complexes.

The ability to introduce DNA into mammalian cells has provided a powerful means to examine the regulation of gene expression and the function of gene products. However, the most commonly used techniques for DNA transfection are not always suitable for primary cells. Primary human keratinocytes are particularly stringent in their growth requirements and are also very refractory to transfection, rendering transient gene expression studies difficult. We have investigated the ability of several polycationic lipids to promote DNA uptake into human epidermal keratinocytes, as monitored with the bacterial beta-galactosidase reporter gene. We report that the cationic lipopolyamine dipalmitoyl phosphatidylethanolamine spermine as well as another procedure using Polybrene can achieve a 20% to 30% transfection efficiency, superior to any other agent tested on these cells. Gene transfer was accomplished by a 3-h exposure of monolayer cells to DNA complexes formed with either reagent by simple mixing in a serum-free medium, followed by a brief osmotic shock with glycerol. Neither DNA carrier showed any toxicity at the effective concentrations nor interfered with cell attachment, growth or differentiation. The use of a fully biodegradable lipopolyamine as DNA carrier should make it possible to extend this transfection method to gene transfer for in vivo therapeutic applications.

Transduction of the E6 and E7 genes of epidermodysplasia-verruciformis-associated human papillomaviruses alters human keratinocyte growth and differentiation in organotypic cultures.

Epidermodysplasia-verruciformis-associated human papilloma virus DNA has been detected in skin cancers, in premalignant and benign skin lesions, and in plucked hairs from immunocompetent and immunosuppressed patients. The role of epidermodysplasia-verruciformis-associated human papilloma virus in the pathogenesis of nonmelanoma skin cancer is still enigmatic. In organotypic cultures we investigated the effects of retroviral transduction of the E6 and E7 genes of epidermodysplasia-verruciformis-associated human papilloma virus types 5, 12, 15, 17, 20, and 38 on the growth and differentiation of human keratinocytes. Differentiation was disturbed to different degrees as revealed by histology and by the expression patterns of differentiation markers keratin 10 and small proline rich protein 2. Conversely, proliferating cell nuclear antigen was induced in some of the suprabasal, differentiated cells to varying extent. No unscheduled DNA synthesis was detected in these cells, however, as probed by 5'-bromo-2'-deoxyuridine incorporation. Most intriguingly, when the E6 and E7 genes of epidermodysplasia-verruciformis-associated human papilloma virus types 15 and 17 were transduced, a broadening layer of basal cells and an accelerated differentiation were observed. In addition, "papilla-like structures" comprising basal-like keratinocytes arose from the basal layer into the differentiated layers. These cells did not express the differentiation markers keratin 10 and small proline rich protein 2, but did actively replicate DNA. These observations warrant further research by using this system to elucidate the replication strategy of epidermodysplasia-verruciformis-associated human papilloma virus types in keratinocytes and to shed light on the role of these human papilloma virus types in the pathogenesis of skin cancer.

Sequences of human adenovirus Ad3 and Ad7 DNAs encoding the promoter and first leader segment of late RNAs.

DNA segments containing the major promoter at coordinate 16.5 for rightward transcription from human adenovirus serotypes 3 and 7 (Ad3 and Ad7), two closely related class B viruses, have been sequenced and found virtually identical. Furthermore, over 80% of the nucleotides of Ad3 and Ad7 in this entire region are homologous to their counterparts in the DNA of the more distantly related class C serotype Ad2. There are the same number of nucleotide pairs among these serotypes within the region compared. Most changes are transitions or transversions and the several single-base deletions are always compensated by nearby insertions. These few changes nonetheless result in 24 differences between Ad7 (or Ad3) and Ad2 in a total of 32 cleavage sites. The promoter for the rightward-transcribed RNAs and the first segment of the consanguinous tripartite leader found at the 5'-ends of all the later mRNAs derived from that promoter have been identified by analogy to the nucleotide sequences of Ad2. In particular, the "Hogness box" or RNA polymerase staging site for the major rightward transcription unit is completely homologous to that of Ad2. There are only six bp changes in the first late leader segment despite previous evidence suggesting that they might be quite heterologous. A prominent dyad axis of symmetry exists just upstream from the presumed 5'-end of the late RNA. However, unlike the stem-loop structure proposed for Ad2 by Ziff and Evans (1978), the base changes relative to Ad2 mandate a different potential stemloop structure in the single strand of Ad3 and Ad7 DNAs. This hairpin places the "Hogness box" immediately next to the 5'-end of the RNA at the base of stem. An analogous dyad axis of symmetry or stemloop structure can be found in a number of eukaryotic systems, including the major rightward transcription unit of Ad2. This feature may be of relevance to the positioning of RNA polymerase II on the DNA and to the promotion of transcription.

In situ hybridization detection of human papillomavirus DNAs and messenger RNAs in genital condylomas and a cervical carcinoma.

Routinely processed formalin-fixed paraffin-embedded sections from anogenital condyloma acuminatum and an invasive squamous cell carcinoma of the cervix were examined by in situ hybridization for the detection of human papillomavirus (HPV) DNAs and messenger RNAs. Asymmetric, single-stranded, tritium-labeled RNA probes for both the coding and the nonsense strands of HPVs 6, 11, 16, 18, and 31 were hybridized and washed under stringent conditions and detected by autoradiography. Type-specific HPV DNAs were detected with specific nuclear localization, while HPV messenger RNAs gave much higher signals and had clear-cut cytoplasmic localization. Cross-hybridization was observed only with closely related viruses. The level of signal obtained seemed to be linked to the degree of cellular differentiation, with koilocytotic cells labeling the most heavily. However, messenger RNA could be detected in even relatively undifferentiated cells within areas of dysplasia and invasive carcinoma. In situ hybridization is a sensitive and specific method for investigation of the dynamic interplay of papillomavirus replication and gene expression, cellular differentiation, and neoplastic transformation.

Induction of proliferating cell nuclear antigen in differentiated keratinocytes of human papillomavirus-infected lesions.

The expression of proliferating cell nuclear antigen (PCNA) was studied in human papillomavirus (HPV)-infected, benign and malignant lesions of the genital tract and larynx using immunocytochemical staining of formalin-fixed clinical specimens. We observed the induction of PCNA in squamous carcinomas and adenocarcinomas, as has been demonstrated with other malignancies. In addition, the differentiated keratinocytes of the upper spinous cells and granulocytes in condylomata acuminata and low-grade intraepithelial neoplasias showed a consistent induction of PCNA compared with the normal squamous epithelium, in which only some of the parabasal and basal cells were positive. This reactivation of PCNA synthesis correlated with the presence of high copy numbers of HPV DNA and was independent of the oncogenic risk potential of the infecting HPV genotype. We postulate that HPV gene products induce the expression of PCNA and other components of the host DNA replication machinery in differentiated cells of squamous lesions to facilitate vegetative viral replication.

Human papillomavirus type 16 and 18 gene expression in cervical neoplasias.

Human papillomavirus (HPV) types 16 and 18 are strongly implicated in the generation of progressive cervical neoplasms. The viruses produce complex families of overlapping messenger RNAs that are linked to differentiation, making it necessary to analyze gene expression in the context of morphology. We have developed HPV type 16 and type 18 subgenomic clones from which 3H-labeled riboprobes specific to individual mRNA families can be generated in vitro. Using these probes for in situ hybridization, we examined serial sections of archival biopsy specimens of the spectrum of genital lesions. In low-grade squamous lesions, all viral open reading frames were expressed, and the most abundant transcription spanned the E4 and E5 open reading frames at the 3' end of the E region. L region transcription coding for the capsid proteins was restricted to terminally differentiated keratinocytes. As the grade of neoplasia increased, cellular differentiation and overall viral transcription decreased and, with few exceptions, the L2 and L1 transcripts ceased to exist. The E6-E7 transforming region was invariably derepressed. Interestingly, the patterns of HPV-16 gene expression suggested the coexistence of episomal and integrated viral DNAs. In contrast, in HPV-18 lesions, all the viral template DNA appeared to have integrated. Integration was deduced to have occurred near the boundary of the E1 and E2 open reading frames. Viral transcription patterns were similar in carcinomas in situ and in invasive carcinomas, regardless of the histologic cell types or the associated virus types, consistent with the notion that additional host gene alterations were necessary for progression. On the basis of viral gene expression in vivo and the E6 promoter regulation previously characterized in vitro, we discuss a molecular mechanism for HPV-associated carcinogenesis.

Identification of Alternatively Spliced mRNAs and Localization of 5' Ends by Polymerase Chain Reaction Amplification.

Messenger RNAs of higher eucaryotes are usually modified posttran-scriptionally to contain 5' caps and nucleotide methylation, 3' polyadenylation, and one or more internal splices to remove introns and join exon segments into the mature protein-coding sequences. With the abilities of retroviral reverse transcriptases to create complementary DNA (cDNA) copies of RNA and of thermostable DNA polymerases to amplify specific DNA segments by repeated cycles of denaturation of duplex templates, annealing of complementary oligonucleotide primers, and strand elongation, it is becoming increasingly popular to use this highly sensitive polymerase chain reaction (PCR) to isolate partial cDNA sequences for the purpose of identifying RNA splice sites and inferring the coding capacity. The splice junction information from the partial cDNAs, together with additional biophysical or biochemical information, can then be employed to map the 5' ends of the mRNAs and assign the AUG protein initiation codon and open reading frame to the message.

Structure and genetic expression of papillomaviruses.

This article reviews the physical structures, genetic organization, expression, and regulation of papillomaviruses. In view of the extensive characterization of cellular transformation and viral functions that have been achieved in experimentally infected animals and in transformed cell cultures, the bovine papillomavirus type 1 (BPV-1) and Shope cottontail rabbit papillomavirus (CRPV) are compared and contrasted with the human papillomaviruses.

Human papillomaviruses: A window into the mechanism and regulation of eucaryotic cellular DNA replication.

Papillomaviruses are ubiquitous pathogens of humans and other vertebrates. Productive infections lead to hyperproliferative lesions in squamous epithelia from diverse anatomic sites, both cutaneous and mucosal. The 7,900 bp double-stranded, circular DNA genome replicates as extrachromosomal plasmids in the nuclei of infected cells. The productive phase of the HPV infection takes place in differentiated, post-mitotic squamous keratinocytes. However, viral DNA replication requires the host cells to supply much of the replication machinery and substrates. Consequently, these viruses usurp the cellular control mechanisms via protein interactions and provide an excellent model system to investigate cellular processes. This paper summarize our investigations and insight into the virus-host interactions observed in productively infected patient lesions, in a model organotypic culture system of primary human keratinocytes transduced with viral genes, and in a cell-free viral DNA replication system with purified viral and host protein.

In situ analysis of the transcriptional activity of integrated viral DNA using tyramide-FISH.

Infection by the oncogenic human papillomavirus (HPV) types 16 and type 18 can progress to cancers. Two well studied cervical carcinoma cell lines, SiHa and CaSki, contain two to four copies, or several hundred copies of integrated HPV-16, respectively. To define the chromosomal loci from which HPV mRNAs are transcribed in these cells, we have simultaneously visualized chromosomal DNA territories, HPV DNA or nascent HPV RNA sequences by using a highly sensitive in situ hybridization (T-FISH) technique employing deposition of fluorescent tyramides. We found that, in SiHa cells, nascent HPV RNAs co-localized with both integrated HPV copies on chromosome 13. Surprisingly, in CaSki cells, nascent HPV RNA only co-localized with one minor HPV DNA-positive locus on chromosome 14. The DNA signal intensity of this locus was consistent with a single to a few HPV intergrants. The tyramide methodologies described here provide an in-depth molecular cytological analyses applicable to research and diagnosis.

Viral latency--the papillomavirus model.

To investigate the prevalence and the natural history of human papillomavirus infections, we monitored HPV DNA shedding as a consequence of immunosuppression, with the expectation that latent viral infections would reactivate and become detectable. The study populations consisted of women who were in end-stage renal failure, those who ultimately received kidney transplantations, and those who had HIV/AIDS with various degrees of immune depression at entry. For each woman, cervico-vaginal lavage to sample viral shedding from the lower genital tract was performed at approximately six month intervals, and the cohorts have been followed since 1996. Nested polymerase chain reaction amplification of papillomavirus DNA using novel pairs of primers was followed by diagnostic restriction endonuclease cleavage or by DNA sequencing. This strategy is particularly capable of identifying single and multiple infections and determining the genotypes of any viruses present. Of the 225 women in the HIV cohort, 177 (79%) were HPV-positive and 111 (49%) shed from two up to eight different HPV types over the course of the survey. Thirty-five different mucosotropic HPV types, virtually all that have ever been described worldwide, were isolated from these 225 women, and nine additional new (provisional) types were discovered. As is always the case, HPV-6 was very common. However, all the other frequently detected HPV types (45, 52, 53, 54, 58, 74) were more prevalent than the types typically reported forthe general population (HPV-11, 16, 18, 31, 33, 35). Notably, the 14 members of the A3 phylogenetic subgroup (HPV-61, 62, 72, 81, 83, 84, and all the new types) were by far the most frequently observed viral types in the AIDS cohort. The HPV prevalence in the cohorts of kidney transplantation candidates and recipients was only slightly lower than that in the AIDS cohort. We conclude that HPV infections are extraordinarily common and are normally held in a sub-clinical state by functional immune systems, but can be reactivated by immunosuppressive conditions. The question of how so many distinct types persist in the human population and can be repeatedly isolated from specimens collected around the world raises complex issues concerning the nature of viral transmission, reproduction, shedding, and mutational drift. These molecular epidemiological observations signal the likelihood that HPV is part of the commensal microflora of human epithelia. Their prevalence elicits a caution that latent HPV DNA may be present in primary human epithelial tissues.