Slicing through silos: Development and evaluation of a hospital-based telehealth hepatitis C virus treatment program.

BACKGROUND: There exist many barriers to hepatitis C virus (HCV) treatment for those with substance use disorder (SUD) or who lack access to routine medical care. A hospital-based telehealth program was developed to provide treatment opportunities for hospitalized patients living with HCV. METHODS: This single site prospective cohort study conducted from July 2022 to March 2023 aimed to measure linkage to care with an HCV clinician and initiation of HCV treatment in hospitalized patients. Patients were assessed in-person by a social worker then seen via telehealth by a clinician who prescribed either glecaprevir/pibrentasvir or sofosbuvir/velpatasvir. Treatment was initiated with pharmacist assistance. The team conducted in-person and/or telephonic outreach during and after hospitalization. Cure was confirmed by sustained virologic response at 12 weeks (SVR12) post-treatment. RESULTS: A total of 25 patients were enrolled and completed telehealth visits. All patients had a history of SUD and 18 (72 %) were unstably housed. Nineteen patients (76 %) initiated treatment, and 14 (56 %) successfully completed treatment. Twelve patients (48 %) completed post-treatment labs, including two who prematurely discontinued treatment. Eleven patients (44 %) achieved confirmed cure with SVR12. CONCLUSION: A hospital-based, multidisciplinary telehealth program can be an innovative care model to successfully treat HCV in a difficult-to-treat patient populations.

Clinical experience with single-nucleotide polymorphism-based non-invasive prenatal screening for 22q11.2 deletion syndrome.

OBJECTIVES: To evaluate the performance of a single-nucleotide polymorphism (SNP)-based non-invasive prenatal test (NIPT) for the detection of fetal 22q11.2 deletion syndrome in clinical practice, assess clinical follow-up and review patient choices for women with high-risk results. METHODS: In this study, 21 948 samples were submitted for screening for 22q11.2 deletion syndrome using a SNP-based NIPT and subsequently evaluated. Follow-up was conducted for all cases with a high-risk result. RESULTS: Ninety-five cases were reported as high risk for fetal 22q11.2 deletion. Diagnostic testing results were available for 61 (64.2%) cases, which confirmed 11 (18.0%) true positives and identified 50 (82.0%) false positives, resulting in a positive predictive value (PPV) of 18.0%. Information regarding invasive testing was available for 84 (88.4%) high-risk cases: 57.1% (48/84) had invasive testing and 42.9% (36/84) did not. Ultrasound anomalies were present in 81.8% of true-positive and 18.0% of false-positive cases. Two additional cases were high risk for a maternal 22q11.2 deletion; one was confirmed by diagnostic testing and one had a positive family history. There were three pregnancy terminations related to screening results of 22q11.2 deletion, two of which were confirmed as true positive by invasive testing. CONCLUSIONS: Clinical experience with this SNP-based non-invasive screening test for 22q11.2 deletion syndrome indicates that these deletions have a frequency of approximately 1 in 1000 in the referral population with most identifiable through this test. Use of this screening method requires the availability of counseling and other management resources for high-risk pregnancies.

Use of human stem cell derived cardiomyocytes to examine sunitinib mediated cardiotoxicity and electrophysiological alterations.

Sunitinib, an oral tyrosine kinase inhibitor approved to treat advanced renal cell carcinoma and gastrointestinal stroma tumor, is associated with clinical cardiac toxicity. Although the precise mechanism of sunitinib cardiotoxicity is not known, both the key metabolic energy regulator, AMP-activated protein kinase (AMPK), and ribosomal S 6 kinase (RSK) have been hypothesized as causative, albeit based on rodent models. To study the mechanism of sunitinib-mediated cardiotoxicity in a human model, induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) having electrophysiological and contractile properties of native cardiac tissue were investigated. Sunitinib was cardiotoxic in a dose-dependent manner with an IC50 in the low micromolar range, observed by a loss of cellular ATP, an increase in oxidized glutathione, and induction of apoptosis in iPSC-CMs. Pretreatment of iPSC-CMs with AMPK activators AICAR or metformin, increased the phosphorylation of pAMPK-T172 and pACC-S79, but only marginally attenuated sunitinib mediated cell death. Furthermore, additional inhibitors of AMPK were not directly cytotoxic to iPSC-CMs up to 250 µM concentrations. Inhibition of RSK with a highly specific, irreversible, small molecule inhibitor (RSK-FMK-MEA) did not induce cytotoxicity in iPSC-CMs below 250 µM. Extensive electrophysiological analysis of sunitinib and RSK-FMK-MEA mediated conduction effects were performed. Taken together, these findings suggest that inhibition of AMPK and RSK are not a major component of sunitinib-induced cardiotoxicity. Although the exact mechanism of cardiotoxicity of sunitinib is not known, it is likely due to inhibition of multiple kinases simultaneously. These data highlight the utility of human iPSC-CMs in investigating the potential molecular mechanisms underlying drug-induced cardiotoxicity.

Neuronal cell adhesion molecule deletion induces a cognitive and behavioral phenotype reflective of impulsivity.

Cell adhesion molecules, such as neuronal cell adhesion molecule (Nr-CAM), mediate cell-cell interactions in both the developing and mature nervous system. Neuronal cell adhesion molecule is believed to play a critical role in cell adhesion and migration, axonal growth, guidance, target recognition and synapse formation. Here, wild-type, heterozygous and Nr-CAM null mice were assessed on a battery of five learning tasks (Lashley maze, odor discrimination, passive avoidance, spatial water maze and fear conditioning) previously developed to characterize the general learning abilities of laboratory mice. Additionally, all animals were tested on 10 measures of sensory/motor function, emotionality and stress reactivity. We report that the Nr-CAM deletion had no impact on four of the learning tasks (fear conditioning, spatial water maze, Lashley maze and odor discrimination). However, Nr-CAM null mice exhibited impaired performance on a task that required animals to suppress movement (passive avoidance). Although Nr-CAM mutants expressed normal levels of general activity and body weights, they did exhibit an increased propensity to enter stressful areas of novel environments (the center of an open field and the lighted side of a dark/light box), exhibited higher sensitivity to pain (hot plate) and were more sensitive to the aversive effects of foot shock (shock-induced freezing). This behavioral phenotype suggests that Nr-CAM does not play a central role in the regulation of general cognitive abilities but may have a critical function in regulating impulsivity and possibly an animal's susceptibility to drug abuse and addiction.

Expression of the Bacillus subtilis trpEDCFBA operon is influenced by translational coupling and Rho termination factor.

The trp RNA-binding attenuation protein (TRAP) regulates expression of the Bacillus subtilis trpEDCFBA operon by transcription attenuation and translational control mechanisms. Both mechanisms require binding of tryptophan-activated TRAP to 11 (G/U)AG repeats in the trp leader transcript. trpE translational control involves formation of a TRAP-dependent RNA structure that sequesters the trpE Shine-Dalgarno (SD) sequence (the SD blocking hairpin). By comparing expression levels from trpE'-'lacZ translational fusions controlled by the wild-type leader or by a leader that cannot form the SD blocking hairpin, we found that translational control requires a tryptophan concentration higher than that required for transcription attenuation. We also found that inhibition of trpE translation by the SD blocking hairpin does not alter the stability of the downstream message. Since the coding sequences for trpE and trpD overlap by 29 nucleotides, we examined expression levels from trpED'-'lacZ translational fusions to determine if these two genes are translationally coupled. We found that introduction of a UAA stop codon in trpE resulted in a substantial reduction in expression. Since expression was partially restored in the presence of a tRNA suppressor, our results indicate that trpE and trpD are translationally coupled. We determined that the coupling mechanism is TRAP independent and that formation of the SD blocking hairpin regulates trpD translation via translational coupling. We also constructed a rho mutation to investigate the role of Rho-dependent termination in trp operon expression. We found that TRAP-dependent formation of the SD blocking hairpin allows Rho access to the nascent transcript, causing transcriptional polarity.

Overlapping functions of the cell adhesion molecules Nr-CAM and L1 in cerebellar granule cell development.

The structurally related cell adhesion molecules L1 and Nr-CAM have overlapping expression patterns in cerebellar granule cells. Here we analyzed their involvement in granule cell development using mutant mice. Nr-CAM-deficient cerebellar granule cells failed to extend neurites in vitro on contactin, a known ligand for Nr-CAM expressed in the cerebellum, confirming that these mice are functionally null for Nr-CAM. In vivo, Nr-CAM-null cerebella did not exhibit obvious histological defects, although a mild size reduction of several lobes was observed, most notably lobes IV and V in the vermis. Mice deficient for both L1 and Nr-CAM exhibited severe cerebellar folial defects and a reduction in the thickness of the inner granule cell layer. Additionally, anti-L1 antibodies specifically disrupted survival and maintenance of Nr-CAM-deficient granule cells in cerebellar cultures treated with antibodies. The combined results indicate that Nr-CAM and L1 play a role in cerebellar granule cell development, and suggest that closely related molecules in the L1 family have overlapping functions.

Three ways to be a saber-toothed cat.

Saber-toothed carnivores, until now, have been divided into two groups: scimitar-toothed cats with shorter, coarsely serrated canines coupled with long legs for fast running, and dirk-toothed cats with more elongate, finely serrated canines coupled to short legs built for power rather than speed. In the Pleistocene of North America, as in Europe, the scimitar-cat was Homotherium; the North American dirk-tooth was Smilodon. We now describe a new sabercat from the Early Pleistocene of Florida, combining the scimitar-tooth canine with the short, massive limbs of a dirk-tooth predator. This presents a third way to construct a saber-toothed carnivore.

Expression of matrix-degrading enzymes in pulmonary vascular remodeling in the rat.

Exposure of rats to hypoxia causes pulmonary arterial remodeling, which is partly reversible after return to air. We hypothesized that degradation of excess collagen in remodeled pulmonary arteries in the posthypoxic period is mediated by endogenous matrix metalloproteinases (MMPs). Total proteolytic, collagenolytic, and gelatinolytic activities, levels of stromelysin-1 and tissue inhibitor of metalloprotease-1 (TIMP-1), and immunolocalization of stromelysin-1 in main pulmonary arteries were determined after exposure of rats to 10% O2 for 10 days followed by normoxia. We observed transient increases in total proteolytic, collagenolytic, and gelatinolytic activities and expression of approximately 72-, 68-, and 60-kDa gelatinases by zymography within 3 days of cessation of hypoxic exposure. The level of TIMP-1 increased as the stromelysin-1 level increased. Immunoreactive stromelysin-1 was localized predominantly in the luminal region of normal and hypertensive pulmonary arteries. These results are consistent with the notion that endogenous MMPs may mediate the breakdown of excess collagen in remodeled pulmonary arteries during the early posthypoxic period.

Computed axial tomography pancreatitis: an atypical asymptomatic postoperative disease without serum or urinary enzyme evaluation.

A case report of atypical postoperative pancreatitis following radical prostatectomy without any clinical symptoms is presented. The patient was asymptomatic in the postoperative period with regards to pancreas disease. Serum lipase, serum amylase and urinary amylase were normal. There was no history of alcoholism or biliary disease. The diagnosis was made by a CAT scan performed for an unrelated indication. The patient was followed for 17 months postoperatively. The pancreas CAT scan appearance returned to normal. No definitive treatment was given.

Malignant teratoma of the testicle: diagnosis suggested by preoperative ultrasonography.

A 22-year-old white man was found to have malignant teratoma of the testicle (nonseminomatous germ cell testicular tumor), which had been suggested by ultrasonography. Modified template retroperitoneal lymphadenectomy with nerve sparing showed no microscopic metastatic tumor.

Collagen changes in rat cervix in pregnancy--polarized light microscopic and electron microscopic studies.

The structural arrangement of collagen fibers in cervical ripening was studied in normal pregnant rats by picrosirius red staining and polarized light microscopy. The macromolecular arrangement of collagen fibers in the cervices of nonpregnant controls and in firm and rigid cervices of rats in early pregnancy (1-10 days of gestation) were optically anisotropic and had birefringence and a positive sign of elongation when examined by polarized light microscopy. The findings indicated that the structure of these collagen fibers was assembled from well-packed parallel collagen molecules. The direction of fibrous formation was arranged with regularity. In contrast, most of the collagen fibers in the soft cervices were optically isotropic. The fibers were fragmented and had a structure with discontinuous birefringence. Disarray and disorientation of the collagen fibers was found in the soft cervices. These collagen fibers changed their direction of formation. The disorganization of these collagen fibers might have a major impact on weakening the tensile strength of the cervix. Thus, we conclude that the processes of rearrangement of collagen fibers might be an important process in the cervical ripening. Electron microscopic studies suggest that in the focal hydrolytic processes of collagen and other matrix components degradation by lysosomal and phagosomal vesicles were associated with atrophic smooth muscle cells and fibroblasts of the cervices. Hydrolases released from lysosomes from these apoptotic cells may presumably be one of the processes in the remodeling of collagen structure.

Cervical cancer radiation injury to the urinary bladder and ureters: management by cecal augmentation to a previous ileal augmentation cystoplasty.

A case report of the management of severe post cervical carcinoma pelvic radiation injuries is presented. Management was accomplished by detubularized ileal augmentation cystoplasty followed by cecal augmentation to the detubularized ileal augmentation 4 years later when bilateral ureteral obstruction developed. The development of a vesicouterine fistula required the creation of a large bowel cecal conduit for cutaneous urinary diversion utilizing the cecal augmentation antireflux segment.

Genitourinary problems in the elderly patient.

Dramatic advances across several fronts have provided a marked improvement in the quality of life for the elderly urologic patient. Radical surgery for cancer is much safer than in the past, and our focus is on preservation of function or complete functional reconstruction. In other areas we strive to continue to deliver excellent treatment while minimizing patient morbidity. This is seen most dramatically in the treatment of urinary stone disease. Ongoing work in patients with BPH promises to provide similar benefits to this population in the coming years. At the same time, we must remember that our abundance of therapeutic options imposes a responsibility to individualize treatment so as to best serve each patient.

Clinicopathologic significance of cathepsin B immunostaining in transitional neoplasia.

Fifty Stage heterogeneous urinary bladder carcinomas were immunostained for cathepsin B, a lysosomal endoproteinase putatively associated with tumor invasion. Neoplastic cell CB immunoreactivity was strongly correlated to both grade (I/II--42% positive versus III--68% positive, P = 0.01) and invasion beyond the lamina propria (Ta/T1--42% positive versus T2/T3--68% positive, P = 0.02). Most low grade, papillary tumors displayed a granular cytoplasmic staining pattern, compatible with lysosomal distribution, in contrast to high grade tumors, in which diffuse staining was present in the cytoplasm. Staining was also accentuated at the advancing front of invading tumors and in angiolymphatic tumor emboli. Non-neoplastic mononuclear inflammatory cells, particularly those at the host-tumor interface, displayed variable, sometimes intense staining. Strong tumor-cell CB was more frequent among recurrent TCC than in patients who remain free of disease (55% versus 29%, n = 18, T2-3, cystectomy, 5-yr min. follow-up). We conclude these observed staining patterns and grade/stage associations are compatible with an important biological role for CB in facilitating host invasion in some bladder tumors. Levels and/or distribution of CB may also be of potential value in defining clinically aggressive tumor subsets.

Gastrocystoplasty without opening the stomach.

We describe a modification of gastrocystoplasty using the GIA stapler to harvest the segment for augmentation without opening the stomach. This simplification reduces operative time and blood loss without introducing complication specific to it and has been successfully used in our first 5 patients.

Comparison of DNA content in primary and lymph node metastases in prostate adenocarcinoma.

There is increasing evidence that nuclear DNA content has significant prognostic value for adenocarcinoma of the prostate. There also appear to be considerable differences in cellular DNA content between patient cohorts when primary tumor or pelvic lymph node metastases are measured. In addition, prostate adenocarcinoma is heterogeneous in DNA measurements; that adds confusion to studies incorporating fine needle aspiration biopsy samples. We compared cellular DNA content in 34 patients with available needle biopsies and pelvic lymph node metastases. Four groups of patients were identified: diploid-range primaries and metastases (8 patients), diploid-range primaries and aneuploid metastases (13), aneuploid primaries and metastases (10), and aneuploid primaries and diploid-range metastases (2). Patients with diploid-range primary tumors had a longer interval to progression and death than did patients with aneuploid primary tumors, although neither was significant in this small series. Patients with diploid-range lymph node metastasis had a longer interval to progression (P = .04) and survival (P = .09) than did individuals with aneuploid metastases. We conclude that the cellular DNA content of prostate cancer metastases in this series of stage D1 patients was more powerful in predicting time to progression and ultimate survival than evaluation of needle biopsy specimens of the primary cancer.

Collagen fibril assembly by corneal fibroblasts in three-dimensional collagen gel cultures: small-diameter heterotypic fibrils are deposited in the absence of keratan sulfate proteoglycan.

Extracellular matrix assembly is a multistep process and the various steps in collagen fibrillogenesis are thought to be influenced by a number of factors, including other noncollagenous matrix molecules. The synthesis and deposition of extracellular matrix by corneal fibroblasts grown within three-dimensional collagen gel cultures were examined to elucidate the factors important in the establishment of tissue-specific matrix architecture. Corneal fibroblasts in collagen gel cultures form layers and deposit small-diameter collagen fibrils (approximately 25 nm) typical of the mature corneal stroma. The matrix synthesized contains type VI collagen in a filamentous network and type I and type V collagen assembled as heterotypic fibrils. The amount of type V collagen synthesized is relatively high and comparable to that seen in the corneal stroma. This matrix is deposited between cell layers in a manner reminiscent of the secondary corneal stroma, but is not deposited as densely or as organized as would be found in situ. No keratan sulfate proteoglycan, a proteoglycan found only in the corneal stroma, was synthesized by the fibroblasts in the collagen gel cultures. The assembly and deposition of small-diameter fibrils with a collagen composition and structure identical to that seen in the corneal stroma in the absence of proteoglycans typical of the secondary corneal stroma imply that although proteoglycan-collagen interactions may function in the establishment of interfibrillar spacing and lamellar organization, collagen-collagen interactions are the major parameter in the regulation of fibril diameter.

Maximal androgen ablation: a review.

Primary management of advanced (stage D) adenocarcinoma of the prostate is androgen ablation. Since this principle was discovered in the early 1940s, therapeutic alternatives and "progress" have centered around different ways to obtain castrate levels of androgens. The role of adrenal androgens in supporting prostate or prostatic cancer growth has been debated for decades and until recently was believed to be minimal. In the 1980s the concept of maximum androgen suppression, involving both the testes and adrenal glands, was reintroduced with some investigators claiming exceptional results. We review studies that have examined this concept, with emphasis on the largest trial which was carried out by the National Cancer Institute.