Labetalol-Induced Hepatotoxicity during Pregnancy: A Case Report.

Background Drug-induced liver injury is a common cause of transaminitis, occurring in up to 5% of patients who are hospitalized for liver failure. In pregnancy, transaminitis is seen in conditions which may require expedited delivery. Case A 39-year-old G2P0010 at 27 2/7 weeks' gestation with chronic hypertension on labetalol was found to have elevated transaminases. Evaluation for preeclampsia, acute fatty liver, nonalcoholic steatohepatitis, cholelithiasis, infections, and autoimmune conditions were all negative. Labetalol was then discontinued, and liver biopsy was performed. After discontinuation of labetalol, her hepatitis improved, and she was discharged on hospital day 12 and went on to deliver at term. Conclusion Labetalol-induced hepatitis should be considered in the differential for transaminitis during pregnancy to prevent iatrogenic preterm delivery.

Managing Malnourishment in Pregnancy after Bariatric Surgery.

BACKGROUND: Little information exists to guide monitoring and treatment of malnourishment during pregnancy after bariatric surgery. Here we present a case with severe deficiencies and recommendations for testing and treatment. CASE: Our patient underwent a duodenal switch procedure resulting in significant weight loss and numerous deficiencies. She then experienced a neonatal demise with multiple congenital abnormalities, including diaphragmatic hernia, possibly related to severe vitamin A deficiency. After high doses of oral and parenteral replacement, pancreatic enzymes, and total parenteral nutrition, she delivered an anatomically normal but growth-restricted neonate in a subsequent pregnancy. CONCLUSION: Bariatric procedures may result in nutritional deficiencies that affect pregnancy outcome. Women with severe deficiencies require pre-pregnancy counselling, monitoring, aggressive treatment, and a multidisciplinary approach to care.

Multiple human papillomavirus genes affect the adeno-associated virus life cycle.

The risk of cervical cancer, one of the most prevalent cancers in the world, is determined by two viruses. Human papillomavirus (HPV) is the main risk factor for developing cervical cancer. However, although little known, it is well substantiated that the human Parvovirus adeno-associated virus type 2 (AAV), and its encoded Rep78 protein, interacts with HPV and lowers the risk of cervical cancer. HPV also contributes to AAV inhibition by serving as a helper virus for AAV and stimulating higher AAV replication levels. Here we surveyed four HPV-16 early genes, E1, E2, E6 and E7, for their ability to increase/decrease the basal level of AAV replication in stratifying squamous epithelium (the epithelial raft culture system). It was found that the HPV-16 E1, E2 and E6 genes were able to help/enhance AAV-2 replication in epithelial raft cultures. Under these conditions, with all the HPV genes being expressed from the AAV p5 promoter, E1 appeared to have the strongest enhancing effect on AAV DNA replication (Southern blot), RNA expression (RT-PCR), protein expression (Western blot) and AAV virion production (2 plate-Southern blot). Further study of E1 mutants showed that the carboxy-half of E1, the putative helicase/ATPase domain, was the main contributor of helper activity. These data are important for understanding the HPV-AAV interaction and its effect on modifying cervical cancer risk. These data also suggest the possibility that the identified HPV helper genes may be useful in the generation of recombinant (r)AAV virions for gene therapy, as rAAV is increasing in popularity for such purposes.

An autoimmune domain-reduced HCV core gene remains effective in stimulating anti-core cytotoxic T lymphocyte activity.

Chronic hepatitis C virus (HCV) infection cases resistant to conventional therapies might be treated by immunotherapy as cytotoxic T lymphocytes (CTL) are the main mechanism through which viral infections are cleared. The HCV core gene, with the highest homology between HCV types, deleted of its autoimmune-stimulating regions (pseudo-GOR and pseudo-p450), may be an appropriate antigen for targeting HCV-infected cells. Two recombinant adeno-associated virus (rAAV) vectors, carrying either the full length (aa 1-190) or truncated (aa 49-180, deleted of the pseudo-GOR and pseudo-p450 sequences) versions of core, were generated. Both AAV/core (l-190) and AAV/core (49-180) were used to transduce/load dendritic cells (DC) at high levels (88-95%). These two genetically altered DC types then stimulated anti-core CTL. The DC and CTL were analyzed by FACS and for killing efficiency (percent target killing). The rAAV-altered DC displayed higher levels of CD80, CD83, CD86, and CD 1a than control DC. The truncated core (aa 49-180) gene stimulated equivalent and strong killing of synthetic core-positive autologous peripheral blood lymphocyte (PBL) targets to that stimulated by the full length core gene. However, the smaller core (49-180) antigen gene stimulated lower levels of killing of core-negative "self" PBL targets (GOR- and p450-positive) (p = 0.002). These AAV/core: DC-stimulated CTL displayed higher IFN-gamma expression, higher CD8:CD4 ratios, and lower CD56:CD8 ratios than controls. The rAAV-loading derived CD8+ T cells had more CD69+ cells and the CD4+ T populations had fewer CD25+ cells than controls. We conclude that the core (49-180) gene is an effect antigen, but has the advantage of stimulating less self-recognition. Thus, core (49-180) may be useful for further translational immunotherapy studies against HCV.

Racial differences in the overexpression of epidermal growth factor type II receptor (HER2/neu): a major prognostic indicator in uterine serous papillary cancer.

OBJECTIVE: A difference in survival rates between black and white patients with cancer of the corpus uteri is well established. This study was conducted to determine whether the overexpression of HER2/neu oncogene is associated with poor outcome in uterine serous papillary endometrial cancer, which is a highly aggressive variant of endometrial cancer, and whether a racial difference in the frequency of HER2/neu overexpression may contribute to the disparity in endometrial cancer survival. STUDY DESIGN: Immunohistochemical evaluation was used to examine HER2/neu expression in paraffin blocks from 27 women with stage IA to IV uterine serous papillary endometrial cancer. Univariable analysis was performed and followed by multivariable analysis with Cox's proportional hazard model to evaluate whether HER2/neu expression was associated with poor outcome in uterine serous papillary endometrial cancer. RESULTS: Black patients tended to be younger (P = .02) and have higher HER2/neu expression than white patients (trend P = .02). Seven of 10 black patients (70%) showed heavy (3+) expression, compared with 4 of 17 white patients (24%; P = .04). The association of heavy HER2/neu expression with race persisted after age was controlled through stratification (P = .05). Earlier deaths from uterine serous papillary endometrial cancer were seen among heavy HER2/neu expressers (P = .002), black patients (P = .04), and patients < or = 65 years old (P = .04). However, multivariate Cox regression showed that short survival was associated significantly with heavy HER2/neu expression (P = .02) but not with age (P = .07) or race (P = .35), which indicates that HER2/neu expression accounted for much of the race disparity in survival in this patient population. CONCLUSION: Overexpression of HER2/neu in uterine serous papillary endometrial cancer is an independent variable that is associated with poor outcome, occurs more frequently in black women, and may contribute to racial disparity in survival. HER2/neu expression may guide clinical treatment of patients with uterine serous papillary endometrial cancer and may have implications for the implementation of novel treatment strategies.

Gene expression profiles of primary HPV16- and HPV18-infected early stage cervical cancers and normal cervical epithelium: identification of novel candidate molecular markers for cervical cancer diagnosis and therapy.

With the goal of identifying genes with a differential pattern of expression between invasive cervical carcinomas (CVX) and normal cervical keratinocytes (NCK), we used oligonucleotide microarrays to interrogate the expression of 14,500 known genes in 11 primary HPV16 and HPV18-infected stage IB-IIA cervical cancers and four primary normal cervical keratinocyte cultures. Hierarchical cluster analysis of gene expression data identified 240 and 265 genes that exhibited greater than twofold up-regulation and down-regulation, respectively, in primary CVX when compared to NCK. Cyclin-dependent kinase inhibitor 2A (CDKN2A/p16), mesoderm-specific transcript, forkhead box M1, v-myb myeloblastosis viral oncogene homolog (avian)-like2 (v-Myb), minichromosome maintenance proteins 2, 4, and 5, cyclin B1, prostaglandin E synthase (PTGES), topoisomerase II alpha (TOP2A), ubiquitin-conjugating enzyme E2C, CD97 antigen, E2F transcription factor 1, and dUTP pyrophosphatase were among the most highly overexpressed genes in CVX when compared to NCK. Down-regulated genes in CVX included transforming growth factor beta 1, transforming growth factor alpha, CFLAR, serine proteinase inhibitors (SERPING1 and SERPINF1), cadherin 13, protease inhibitor 3, keratin 16, and tissue factor pathway inhibitor-2 (TFPI-2). Differential expression of some of these genes including CDKN2A/p16, v-Myb, PTGES, and TOP2A was validated by quantitative real-time PCR. Flow cytometry on primary CVX and NCK and immunohistochemical staining of formalin fixed paraffin-embedded tumor specimens from which primary CVX cultures were derived as well as from a separate set of invasive cervical cancers confirmed differential expression of the CDKN2A/p16 and PTGES markers on CVX versus NCK. These results identify several genes that are coordinately disregulated in cervical cancer, likely representing common signaling pathways triggered by HPV transformation. Moreover, these data obtained with highly purified primary tumor cultures highlight novel molecular features of human cervical cancer and provide a foundation for the development of new type-specific diagnostic and therapeutic strategies for this disease.

Infection, replication, and cytopathology of human papillomavirus type 31 in trophoblasts.

Human papillomavirus (HPV) DNA is preferentially found in spontaneous abortions, specifically residing in trophoblasts, and transfected HPV-16 DNA replicates and produces progeny in 3A trophoblasts in culture. In this study 3A trophoblasts were shown to display both HPV receptors and infection by HPV-31b and HPV-6 virus resulted in de novo (increasing) HPV DNA replication in these cells (inhibited by neutralizing anti-HPV31b antibodies). Reverse transcription-polymerase chain reaction analysis revealed that E1;E4, E6, and L1 were significantly expressed at days 5 (early) and 10 (late), respectively, and in situ immunocytochemistry verified L1 protein expression. Perhaps most important, HPV 31b virus infection caused both a decrease in 3A trophoblast cell numbers in a dose-dependent manner and a low trophoblast-endometrial cell adhesion (both inhibited by neutralizing anti-HPV-31 antibodies). These data further support the hypothesis that HPVs are fully active in trophoblasts and may cause some spontaneous abortions.