Evaluation of Undiagnosed HIV Estimates Computed from the CD4 Depletion Model in a Rural, Medium-low HIV Prevalence State.

The CD4 depletion model estimates diagnosis delays by approximating infection date from CD4 T-cell count at diagnosis, and back-calculation can compute the proportion of undiagnosed PLWHA. The model assumes the immigration of PLWHA to the U.S. is negligible and counts as a transmission event, which may be impractical outside high prevalence states. Duration of U.S. residency among foreign-born PLWHA and diagnosis delays were compared. The impact on estimates of undiagnosed PLWHA was tested through simulation with different proportions of foreign-born people assumed to have acquired HIV abroad. In 67% of foreign-born people, the mean (SD) years of delay (9.9 (6.3)) exceeded the duration of U.S. residency (2.0 (1.9)). Additionally, inaccuracies in the estimates for proportions of undiagnosed PLWHA were pronounced when foreign-born people who acquired HIV abroad comprised 30% of diagnoses. The CD4 model inadvertently misclassified some diagnoses as in-state transmission events. Consequently, simulated results demonstrated inaccuracies and unstable calculations.

Mapping Lysine Acetyltransferase-Ligand Interactions by Activity-Based Capture.

Changes in reversible protein acetylation mediate many key aspects of genomic regulation and enzyme function. The catalysts for this posttranslational modification, lysine acetyltransferases (KATs), have been difficult targets for characterization due to their complex architecture and challenging reconstitution. To address this challenge, here we describe methods to profile endogenous KAT activities using activity-based probes. This method facilitates the targeted analysis of several cellular KATs and can be used to study their interactions with many different types of ligands, including acyl-CoA metabolites. This competitive activity-based capture approach provides a method to assess the selectivity of ligands for different KAT families in complex proteomic settings, and thus has the potential to offer substantial insights into the regulation of cellular KAT function.

Role of the human cytomegalovirus major immediate-early promoter's 19-base-pair-repeat cyclic AMP-response element in acutely infected cells.

Prior studies have suggested a role of the five copies of the 19-bp-repeat cyclic AMP (cAMP)-response element (CRE) in major immediate-early (MIE) promoter activation, the rate-limiting step in human cytomegalovirus (HCMV) replication. We used two different HCMV genome modification strategies to test this hypothesis in acutely infected cells. We report the following: (i) the CREs do not govern basal levels of MIE promoter activity at a high or low multiplicity of infection (MOI) in human foreskin fibroblast (HFF)- or NTera2-derived neuronal cells; (ii) serum and virion components markedly increase MIE promoter-dependent transcription at a low multiplicity of infection (MOI), but this increase is not mediated by the CREs; (iii) forskolin stimulation of the cAMP signaling pathway induces a two- to threefold increase in MIE RNA levels in a CRE-specific manner at a low MOI in both HFF- and NTera2-derived neuronal cells; and (iv) the CREs do not regulate basal levels of HCMV DNA replication at a high or low MOI in HFF. Their presence does impart a forskolin-induced increase in viral DNA replication at a low MOI but only when basal levels of MIE promoter activity are experimentally diminished. In conclusion, the 19-bp-repeat CREs add to the robust MIE promoter activity that occurs in the acutely infected stimulated cells, although the CREs' greater role may be in other settings.

Reactivation of the human cytomegalovirus major immediate-early regulatory region and viral replication in embryonal NTera2 cells: role of trichostatin A, retinoic acid, and deletion of the 21-base-pair repeats and modulator.

Inactivity of the human cytomegalovirus (HCMV) major immediate-early regulatory region (MIERR), which is composed of promoter, enhancer, unique region, and modulator, is linked to lack of HCMV replication in latently infected cells and in other nonpermissive cell types, including human embryonal NTera2 carcinoma (NT2) cells. I refined the embryonal NT2 cell model to enable characterization of the unknown mechanistic basis for silencing of HCMV MIERR-dependent transcription and viral replication in nonpermissive cells. These infected NT2 cells contain nonreplicating viral genomes with electrophoretic mobility equivalent to a supercoiled, bacterial artificial chromosome of comparable molecular weight. MIERR-dependent transcription is minimal to negligible. Increasing the availability of positive-acting transcription factors by retinoic acid (RA) treatment after infection is largely insufficient in reactivating the MIERR. In contrast, trichostatin A (TSA), a histone deacetylase inhibitor, reactivates MIERR-dependent transcription. Contrary to prior findings produced from transfected MIERR segments, deletion of the 21-bp repeats and modulator from the MIERR in the viral genome does not relieve MIERR silencing. To demonstrate that MIERR silencing likely results from enhancer inactivity, I examined an HCMV with a heterologous MIERR promoter that is enhancer dependent but exempt from IE2 p86-mediated negative autoregulation. This heterologous promoter, like its neighboring native MIERR promoter, exhibits immediate-early transcriptional kinetics in fibroblasts. In embryonal NT2 cells, the heterologous MIERR promoter is transcriptionally inactive. This silence is relieved by TSA but not by RA. Remarkably, TSA-induced reactivation of MIERR-dependent transcription from quiescent viral genomes is followed by release of infectious virus. I conclude that a mechanism of active repression imposes a block to MIERR-dependent transcription and viral replication in embryonal NT2 cells. Because TSA overcomes the block, viral gene silencing may involve histone deacetylase-based modification of viral chromatin, which might account for the covalently closed circular conformation of quiescent HCMV genomes.

The human cytomegalovirus major immediate-early distal enhancer region is required for efficient viral replication and immediate-early gene expression.

The human cytomegalovirus (HCMV) major immediate-early (MIE) genes, encoding IE1 p72 and IE2 p86, are activated by a complex enhancer region (base positions -65 to -550) that operates in a cell type- and differentiation-dependent manner. The expression of MIE genes is required for HCMV replication. Previous studies analyzing functions of MIE promoter-enhancer segments suggest that the distal enhancer region variably modifies MIE promoter activity, depending on cell type, stimuli, or state of differentiation. To further understand the mechanism by which the MIE promoter is regulated, we constructed and analyzed several different recombinant HCMVs that lack the distal enhancer region (-300 to -582, -640, or -1108). In human fibroblasts, the HCMVs without the distal enhancer replicate normally at high multiplicity of infection (MOI) but replicate poorly at low MOI in comparison to wild-type virus (WT) or HCMVs that lack the neighboring upstream unique region and modulator (-582 or -640 to -1108). The growth aberrancy was normalized after restoring the distal enhancer in a virus lacking this region. For HCMVs without a distal enhancer, the impairment in replication at low MOI corresponds to a deficiency in production of MIE RNAs compared to WT or virus lacking the unique region and modulator. An underproduction of viral US3 RNA was also evident at low MOI. Whether lower production of IE1 p72 and IE2 p86 causes a reduction in expression of the immediate-early (IE) class US3 gene remains to be determined. We conclude that the MIE distal enhancer region possesses a mechanism for augmenting viral IE gene expression and genome replication at low MOI, but this regulatory function is unnecessary at high MOI.

A strong negative transcriptional regulatory region between the human cytomegalovirus UL127 gene and the major immediate-early enhancer.

The region of the human cytomegalovirus (CMV) genome between the UL127 open reading frame and the major immediate-early (MIE) enhancer is referred to as the unique region. DNase I protection analysis with human cell nuclear extracts demonstrated multiple protein binding sites in this region of the viral genome (P. Ghazal, H. Lubon, C. Reynolds-Kohler, L. Hennighausen, and J. A. Nelson, Virology 174:18-25, 1990). However, the function of this region in the context of the viral genome is not known. In wild-type human CMV-infected human fibroblasts, cells permissive for viral replication, there is little to no transcription from UL127. We determined that the unique region prevented transcription from the UL127 promoter but had no effect on the divergent MIE promoter. In transient-transfection assays, the basal level of expression from the UL127 promoter increased significantly when the wild-type unique sequences were mutated. In recombinant viruses with similar mutations in the unique region, expression from the UL127 promoter occurred only after de novo viral protein synthesis, typical of an early viral promoter. A 111-bp deletion-substitution of the unique sequence caused approximately a 20-fold increase in the steady-state level of RNA from the UL127 promoter and a 245-fold increase in the expression of a downstream indicator gene. This viral negative regulatory region was also mutated at approximately 50-bp regions proximal and distal to the UL127 promoter. Although some repressive effects were detected in the distal region, mutations of the region proximal to the UL127 promoter had the most significant effects on transcription. Within the proximal and distal regions, there are potential cis sites for known eucaryotic transcriptional repressor proteins. This region may also bind unknown viral proteins. We propose that the unique region upstream of the UL127 promoter and the MIE enhancer negatively regulates the expression from the UL127 promoter in permissive human fibroblast cells. This region may be a regulatory boundary preventing the effects of the very strong MIE enhancer on this promoter.

Effect of a modulator deletion on transcription of the human cytomegalovirus major immediate-early genes in infected undifferentiated and differentiated cells.

Differentiation-dependent expression of the human cytomegalovirus (HCMV) major immediate-early (MIE) genes, encoding IE1 and IE2, may partly govern virus replication in monocytic THP-1 and embryonal carcinoma (Tera-2) cells. The modulator of the MIE promoter was shown previously in transient transfection assays to repress transcription from promoter segments in undifferentiated THP-1 and Tera-2 cells but not in differentiated cells. To determine the biological importance of these findings, we constructed a recombinant HCMV (r delta MSVgpt) without a modulator. In comparison to wild-type (WT) virus, r delta MSVgpt exhibits a slight delay in growth in human fibroblasts, but there is no appreciable change in IE1 and IE2 transcription. Moreover, there is no appreciable change in the early/late kinetics of transcription of RNAs colinear with the predicted UL128 coding region, which is adjacent to the modulator, although the size distribution and abundance of these RNAs are altered. In infected undifferentiated THP-1 and Tera-2 cells, WT and r alpha MSVgpt viruses produce minimal but comparable amounts of IE1 RNAs. The genomes of both viruses are detectable in similar amounts within these undifferentiated cells. Induction of cellular differentiation before infection overcomes the block in MIE gene transcription. WT and r alpha MSVgpt infections of differentiated THP-1 cells produce similar levels of IE1 and IE2 RNAs. Thus, differentiation-dependent control of MIE gene transcription involves regulatory mechanisms other than the modulator. Possible alternative functions of the modulator are discussed.

Regulation of human cytomegalovirus immediate-early gene expression.

The positive and negative cis-acting elements that affect transcription from the human cytomegalovirus major immediate-early (MIE) promoter and the viral and cellular proteins that bind to these elements are discussed. The data obtained using in vitro transcription and transient transfection assays are reviewed and compared to recent data using recombinant viruses with cis-acting elements deleted. The effects of cell type and cellular differentiation on activation of transcription from the MIE promoter are compared with the effects of mitogens and virion-associated tegument proteins that directly or indirectly activate protein kinase pathways. The repressor and enhancer regions upstream of the MIE promoter in the large unique component of the viral genome are compared to the elements upstream of the more simplified IEUS3 promoter in the short unique component of the viral genome.

Interactions between varicella-zoster virus IE62 and cellular transcription factor USF in the coordinate activation of genes 28 and 29.

Varicella-zoster virus (VZV) gene 28 encodes the viral DNA polymerase, while 29 encodes the major DNA-binding protein. Because of the central importance of these proteins to productive replication of VZV and because, of these, only gene 29 seems to be expressed in latency, we sought to understand how their expression is controlled. We recently reported that the divergent gene 28 and gene 29 transcripts are coordinately upregulated by IE62. Deletions in the 221-bp promoter domain shared by genes 28 and 29 comparably diminish the expression of both genes. By a variety of transient expression, competition gel shift, and super-shift assays, we now show that cellular transcription factor USF binds to a palindromic recognition sequence lying equidistant from transcription start sites for both genes 28 and 29. In the presence of IE62, USF fully activates transcription of genes 28 and 29. Site-specific mutation of three bases in the USF core binding hexamer abrogates activation of the gene 28 and 29 promoters by IE62. USF is important for expression of genes 28 and 29 in productive VZV infection.

Mycobacterial and fungal infections of bone and joints.

The number of cases of tuberculous bone or joint infection reported annually in the United States has been rising, but it decreased slightly in 1993. Management of skeletal tuberculosis is a complex and evolving issue that requires knowledge of the treatment of drug-resistant organisms. Nontuberculous mycobacteria also may cause skeletal infections, which are often located in tenosynovium or osteoarticular components of the hand or wrist but may occur at other skeletal sites, particularly when there is underlying immunosuppression. Identification of the organism and determination of its drug sensitivities are crucial for providing optimal therapy. Fungal infections of bone or joint can be difficult to treat, but the availability of fluconazole and itraconazole has extended our therapeutic options for some mycoses.

Stereolithography in oral and maxillofacial operation planning.

Stereolithography (STL) is a method of organ-model-production based on computed tomography scans which enables the representation of complex 3-dimensional anatomical structures. Surfaces and internal structures of organs can be produced by polymerization of UV-sensitive liquid resin using a laserbeam. In oral and maxillofacial surgery this technique is advantageous for reconstruction of severe skull defects because a more accurate preoperative planning is possible. Using recently developed software we are able to reconstruct unilateral bony defects by virtual mirror imaging of the contralateral side and production of a STL mirror model as well as the reconstruction of non-mirrorable defects by superposition. Advantages of STL are the representation of complex anatomical structures, high precision and accuracy, and the option to sterilize the models for intraoperative use. More accurate planning using this method improves postoperative results, decreases risks and shortens treatment time.

The cellular transcription factor USF cooperates with varicella-zoster virus immediate-early protein 62 to symmetrically activate a bidirectional viral promoter.

The mechanisms governing the function of cellular USF and herpesvirus immediate-early transcription factors are subjects of considerable interest. In this regard, we identified a novel form of coordinate gene regulation involving a cooperative interplay between cellular USF and the varicella-zoster virus immediate-early protein 62 (IE 62). A single USF-binding site defines the potential level of IE 62-dependent activation of a bidirectional viral early promoter of the DNA polymerase and major DNA-binding protein genes. We also report a dominant negative USF-2 mutant lacking the DNA-binding domain that permits the delineation of the biological role of both USF-1 and USF-2 in this activation process. The symmetrical stimulation of the bidirectional viral promoter by IE 62 is achieved at concentrations of USF-1 (43 kDa) or USF-2 (44 kDa) already existing in cells. Our observations support the notion that cellular USF can intervene in and possibly target promoters for activation by a herpesvirus immediate-early protein.

Mycobacterial and fungal infections of bone and joints.

The incidence of tuberculosis of the bone or joint is increasing. The number of Mycobacterium tuberculosis isolates that are resistant to multiple antibiotics is also on the rise. In response to the changing epidemiology, the approach to treatment of tuberculosis has been considerably modified. Laboratory methodology is improving to facilitate diagnosis and management of this disease. A variety of nontuberculous mycobacteria may also cause disease of skeletal structures. Mycobacterium haemophilum is an emerging pathogen in immunosuppressed patients with a proclivity for infecting bones and joints. The availability of the triazoles has substantially altered the therapeutic approach to fungal infections of bone or joint. Itraconazole can now be considered as therapy of blastomycosis, coccidioidosis, histoplasmosis, or sporotrichosis. Fluconazole is useful in cryptococcal infection, but its role in candida osteoarticular infection remains to be defined.

Placebo-controlled trial of vaccination with recombinant glycoprotein D of herpes simplex virus type 2 for immunotherapy of genital herpes.

Immunotherapy of chronic viral diseases with vaccines is an important but unproven concept. We investigated the effect of a vaccine containing recombinant glycoprotein D (gD2) of herpes simplex virus type 2 (HSV-2) on the frequency of symptomatic outbreaks in patients with genital herpes. 98 patients with documented genital herpes who reported 4-14 recurrences per year were enrolled in a double-blind, placebo-controlled trial. Subjects received injections of either 100 micrograms gD2 in alum or alum alone (placebo) at 0 and 2 months, and recurrences were documented for 1 year. The vaccine was well tolerated. gD2 recipients reported fewer recurrences per month than placebo recipients (mean 0.42 [SE 0.05] vs 0.55 [0.05]; p = 0.055), had fewer virologically confirmed recurrences per month (0.18 [0.03] vs 0.28 [0.03]; p = 0.019), and had a lower median number of recurrences for the study year (4 [range 0-17] vs 6 [0-15]; p = 0.039). Neither genital recurrence nor the placebo vaccine had any discernible effect on HSV-2-specific antibody responses, but gD2 vaccine boosted neutralising antibodies to HSV-2 fourfold and gD2-specific titres sevenfold over baseline levels. These results inspire optimism about the potential use of vaccine for the treatment of chronic, recurring viral diseases.

Varicella-zoster virus DNA polymerase and major DNA-binding protein genes have overlapping divergent promoters.

A detailed analysis of the transcriptionally divergent promoters of varicella-zoster virus (VZV) open reading frames (ORFs) 28 and 29, encoding the DNA polymerase and major DNA-binding proteins, respectively, was performed. We found that the 221-bp ORF 28-29 intergenic domain contains overlapping divergent promoters; these promoters have TATA boxes and cap sites arranged closely back-to-back, have highly concordant patterns of responsiveness to transactivation by VZV ORFs 4 and/or 62, and could not be separated without abolishing the effects that VZV trans activators imparted to them. Mutation of the ORF 28 TATA box rendered this promoter unresponsive to ORF 62 and the combination of ORFs 4 and 62 without altering ORF 29 promoter activity. Mutations of all potential ORF 29 TATA boxes collectively failed to abolish this promoter's responsiveness to either ORF 4 or ORF 62, suggesting a mechanism of gene regulation for ORF 29 that differs from that of ORF 28. These findings are concordant with the observation that both genes are expressed in productive infection, but only ORF 29 expression has been identified in latency.

Induction and enhancement of immune responses to herpes simplex virus type 2 in humans by use of a recombinant glycoprotein D vaccine.

A vaccine for a chronic or recurrent viral infection should induce immune responses that protect against primary disease or that augment preexisting defenses sufficiently to diminish the likelihood of disease recurrence or progression. Such a vaccine was sought for genital herpes, a sexually transmitted infection of epidemic proportion. Vaccine containing recombinant herpes simplex virus type 2 glycoprotein D expressed in CHO cells was given repeatedly and safely to 24 human volunteers. In previously uninfected subjects, the vaccine induced primary antigen-specific and neutralizing antibody responses nearing or exceeding those seen at entry in subjects with genital herpes. Primary cellular immune responses were also evoked. Vaccination of previously seropositive subjects boosted antibody titers to levels that remained, for > or = 1 year, severalfold above those attained in recurrent genital herpes. Either the quantity or mode of presentation of antigen permitted this vaccine to exhibit previously unachieved immunogenicity, which may prove adequate for antiviral immunoprophylaxis or treatment of genital herpes.

Varicella-zoster virus transcription in human trigeminal ganglia.

Our laboratory previously reported in situ hybridization analyses showing varicella-zoster virus (VZV)-specific RNA transcripts in latently infected human trigeminal ganglia. These transcripts were found exclusively in non-neuronal cells and emanated from at least three separate regions of the VZV genome, those encompassing restriction fragments BamHI-EY, EcoRI-B, and BamHI-J. Extending these in situ studies, we now report that VZV RNAs colinear with open reading frames (ORFs) 29 and 62 are demonstrable in non-neuronal cells; however, neither VZV RNA colinear with ORF 28 nor antisense RNAs of ORFs 29 and 62 are detected. Northern hybridization analyses of poly(A)+ RNA from human trigeminal ganglion pools also reveal VZV-specific transcripts corresponding to ORFs 29 and 62, but not those of ORFs 28 or 61. The ORF 29- and 62-specific transcripts are similar to those expressed in productive infection, with regard to size and polyadenylation. The cumulative findings suggest that VZV latency is characterized by selected expression of multiple genes, which appear to include some but not all putative immediate-early and early genes.

The frozen shoulder: diagnosis and treatment. Prospective study of 50 cases of adhesive capsulitis.

A prospective study of randomized analysis treatment of 50 cases of frozen shoulder was carried out in 3 Swiss medical centres. Three separate aetiological groups were studied: post-traumatic (40%), neurological (14%) and idiopathic (46%). An increased radioisotope bone scan (99 mTc diphosphonate) was found in 96% of cases, regardless of aetiology. The so-called idiopathic frozen shoulder showed a scapulo-humeral increase in radioisotope uptake in several areas (in 82% of cases) without involvement of the ipsilateral carpus. Clinically, the neurological type was associated with a shoulder-hand syndrome with positive bone scan of the shoulder and the wrist in all cases. The post-traumatic type showed a diffuse (in 50% of the cases) or at several circumscribed areas (also in 50%) increase in radioisotope uptake in the shoulder. In 45% of the post-traumatic type, there was also a shoulder-hand syndrome with uptake in the wrist also. A physical treatment and early mobilization, associated with the administration of subcutaneous salmon calcitonin for 21 days (100 U Calcitonin Sandoz) had a statistically significant increased effect on pain compared to treatment with physiotherapy alone by patients with post-traumatic frozen shoulders (p < 0.02). There was no significant difference, however, in the speed of recovery of function between the two treatment groups. These observations strengthen the hypothesis that adhesive capsulitis behave like an algoneurodystrophic process.

Comparative biology of latent varicella-zoster virus and herpes simplex virus infections.

The clinicoepidemiologic features of varicella-zoster virus and herpes simplex virus latency are clearly distinctive. These differences indicate that each virus has evolved a unique strategy to ensure the establishment and maintenance of latency and to reactive therefrom. Indeed, current data reveal divergent pathogenetic and molecular biologic properties that may account for the clinicoepidemiologic characteristics that distinguish recurrent infections with these herpesviruses.

The effect of adding calcitonin to physical treatment on reflex sympathetic dystrophy.

The efficacy of intranasal salmon calcitonin was examined in a double-blind randomized study in reflex sympathetic dystrophy. Sixty-six patients were randomly divided in two groups receiving physiotherapy. In addition group I also received 3 x 100 U/day of salmon calcitonin by intranasal spray whereas group II received 3 sprays of placebo. The pain and the range of motion were improved by calcitonin administration. Similarly the patients' ability to work was also improved. The results confirmed that salmon calcitonin has an effect but that this effect was not equally observed on all parameters analyzed. It was most marked on pain (at rest and on movement) and on the ability to work.