Cytosolic replication in epithelial cells fuels intestinal expansion and chronic fecal shedding of Salmonella Typhimurium

Persistent and intermittent fecal shedding, hallmarks of Salmonella infections, are important for fecal-oral transmission. In the intestine, Salmonella enterica serovar Typhimurium (STm) actively invades intestinal epithelial cells (IECs) and survives in the Salmonella-containing vacuole (SCV) and the cell cytosol. Cytosolic STm replicate rapidly, express invasion factors, and induce extrusion of infected epithelial cells into the intestinal lumen. Here, we engineered STm that self-destruct in the cytosol (STm^CytoKill), but replicates normally in the SCV, to examine the role of cytosolic STm in infection. Intestinal expansion and fecal shedding of STm^CytoKill are impaired in mouse models of infection. We propose a model whereby repeated rounds of invasion, cytosolic replication, and release of invasive STm from extruded IECs fuels the high luminal density required for fecal shedding.

Regulatory protein HilD stimulates Salmonella Typhimurium invasiveness by promoting smooth swimming via the methyl-accepting chemotaxis protein McpC

In the enteric pathogen Salmonella enterica serovar Typhimurium, invasion and motility are coordinated by the master regulator HilD, which induces expression of the type III secretion system 1 (T3SS1) and motility genes. Methyl-accepting chemotaxis proteins (MCPs) detect specific ligands and control the direction of the flagellar motor, promoting tumbling and changes in direction (if a repellent is detected) or smooth swimming (in the presence of an attractant). Here, we show that HilD induces smooth swimming by upregulating an uncharacterized MCP (McpC), and this is important for invasion of epithelial cells. Remarkably, in vitro assays show that McpC can suppress tumbling and increase smooth swimming in the absence of exogenous ligands. Expression of mcpC is repressed by the universal regulator H-NS, which can be displaced by HilD. Our results highlight the importance of smooth swimming for Salmonella Typhimurium invasiveness and indicate that McpC can act via a ligand-independent mechanism when incorporated into the chemotactic receptor array.

Risk of melanoma in women with endometriosis: A Scottish national cohort study

OBJECTIVE

To explore the risk of melanoma in women with endometriosis.

STUDY DESIGN

A retrospective cohort study using Scottish national population-based data was conducted. The study comprised 281,937 women with nearly 5 million person years (4,923,628) of follow up from 1981 to 2010. 17,834 women with a new surgical diagnosis of endometriosis were compared with 83,303 women with no evidence of endometriosis at laparoscopy, 162,966 women who underwent laparoscopic sterilisation and 17,834 age-matched women from the general population to determine the risk of melanoma. Cox proportional hazards regression was used to calculate crude and adjusted Hazards ratios with 95 % Confidence Intervals.

RESULTS

Women with endometriosis had a significantly higher risk of melanoma when compared to women with no evidence of endometriosis at laparoscopy (HR 1.59, 95 % CI 1.19-2.13), women who had undergone laparoscopic sterilisation (HR 1.82, 95 % CI 1.39-2.40) and age-matched women from the general population (HR 1.63, 95 % CI 1.08-2.45).

CONCLUSION

A diagnosis of endometriosis was associated with an increased risk of developing melanoma compared to those without endometriosis. These findings highlight the need for further research to explore shared pathways in the pathogenesis of the two conditions. It is important to acknowledge that the absolute increase in the risk of melanoma in women with endometriosis remains low, which should be considered when counselling women.

Mesh inlay, mesh kit or native tissue repair for women having repeat anterior or posterior prolapse surgery: randomised controlled trial (PROSPECT)

OBJECTIVE

To compare standard (native tissue) repair with synthetic mesh inlays or mesh kits.

DESIGN

Randomised controlled trial.

SETTING

Thirty-three UK hospitals.

POPULATION

Women having surgery for recurrent prolapse.

METHODS

Women recruited using remote randomisation.

MAIN OUTCOME MEASURES

Prolapse symptoms, condition-specific quality-of-life and serious adverse effects.

RESULTS

A Mean Pelvic Organ Prolapse Symptom Score at 1 year was similar for each comparison (standard 6.6 versus mesh inlay 6.1, mean difference [MD] -0.41, 95% CI -2.92 to 2.11: standard 6.6 versus mesh kit 5.9, MD -1.21 , 95% CI -4.13 to 1.72) but the confidence intervals did not exclude a minimally important clinical difference. There was no evidence of difference in any other outcome measure at 1 or 2 years. Serious adverse events, excluding mesh exposure, were similar at 1 year (standard 7/55 [13%] versus mesh inlay 5/52 [10%], risk ratio [RR] 1.05 [0.66-1.68]: standard 3/25 [12%] versus mesh kit 3/46 [7%], RR 0.49 [0.11-2.16]). Cumulative mesh exposure rates over 2 years were 7/52 (13%) in the mesh inlay arm, of whom four women required surgical revision; and 4/46 in the mesh kit arm (9%), of whom two required surgical revision.

CONCLUSIONS

We did not find evidence of a difference in terms of prolapse symptoms from the use of mesh inlays or mesh kits in women undergoing repeat prolapse surgery. Although the sample size was too small to be conclusive, the results provide a substantive contribution to future meta-analysis.

TWEETABLE ABSTRACT

There is not enough evidence to support use of synthetic mesh inlay or mesh kits for repeat prolapse surgery.

Salmonella Typhimurium Infection of Human Monocyte-Derived Macrophages

The successful infection of macrophages by non-typhoidal serovars of Salmonella enterica is likely essential to the establishment of the systemic disease they sometimes cause in susceptible human populations. However, the interactions between Salmonella and human macrophages are not widely studied, with mouse macrophages being a much more common model system. Fundamental differences between mouse and human macrophages make this less than ideal. Additionally, the inability of human macrophage-like cell lines to replicate some properties of primary macrophages makes the use of primary cells desirable. Here we present protocols to study the infection of human monocyte-derived macrophages with Salmonella Typhimurium. These include a method for differentiating monocyte-derived macrophages in vitro and protocols for infecting them with Salmonella Typhimurium, as well as assays to measure the extent of infection, replication, and death. These protocols are useful for the investigation of both bacterial and host factors that determine the outcome of infection. © 2018 by John Wiley & Sons, Inc.

Predictable, Tunable Protein Production in Salmonella for Studying Host-Pathogen Interactions

Here we describe the use of synthetic genetic elements to improve the predictability and tunability of episomal protein production in Salmonella. We used a multi-pronged approach, in which a series of variable-strength synthetic promoters were combined with a synthetic transcriptional terminator, and plasmid copy number variation. This yielded a series of plasmids that drive uniform production of fluorescent and endogenous proteins, over a wide dynamic range. We describe several examples where this system is used to fine-tune constitutive expression in Salmonella, providing an efficient means to titrate out toxic effects of protein production.

A second wave of Salmonella T3SS1 activity prolongs the lifespan of infected epithelial cells

Type III secretion system 1 (T3SS1) is used by the enteropathogen Salmonella enterica serovar Typhimurium to establish infection in the gut. Effector proteins translocated by this system across the plasma membrane facilitate invasion of intestinal epithelial cells. One such effector, the inositol phosphatase SopB, contributes to invasion and mediates activation of the pro-survival kinase Akt. Following internalization, some bacteria escape from the Salmonella-containing vacuole into the cytosol and there is evidence suggesting that T3SS1 is expressed in this subpopulation. Here, we investigated the post-invasion role of T3SS1, using SopB as a model effector. In cultured epithelial cells, SopB-dependent Akt phosphorylation was observed at two distinct stages of infection: during and immediately after invasion, and later during peak cytosolic replication. Single cell analysis revealed that cytosolic Salmonella deliver SopB via T3SS1. Although intracellular replication was unaffected in a SopB deletion mutant, cells infected with ΔsopB demonstrated a lack of Akt phosphorylation, earlier time to death, and increased lysis. When SopB expression was induced specifically in cytosolic Salmonella, these effects were restored to levels observed in WT infected cells, indicating that the second wave of SopB protects this infected population against cell death via Akt activation. Thus, T3SS1 has two, temporally distinct roles during epithelial cell colonization. Additionally, we found that delivery of SopB by cytosolic bacteria was translocon-independent, in contrast to canonical effector translocation across eukaryotic membranes, which requires formation of a translocon pore. This mechanism was also observed for another T3SS1 effector, SipA. These findings reveal the functional and mechanistic adaptability of a T3SS that can be harnessed in different microenvironments.

Microwave endometrial ablation versus thermal balloon endometrial ablation (MEATBall): 5-year follow up of a randomised controlled trial

OBJECTIVE

To compare long-term outcomes following microwave endometrial ablation (MEA™) and thermal balloon ablation (TBall).

DESIGN

Follow up of a prospective, double-blind randomised controlled trial at 5 years.

SETTING

A teaching hospital in the UK.

POPULATION

A total of 320 women eligible for and requesting endometrial ablation.

METHODS

Eligible women were randomised in a 1:1 ratio to undergo MEA or Tball. Postal questionnaires were sent to participants at a minimum of 5 years postoperatively to determine satisfaction with outcome, menstrual status, bleeding scores and quality of life measurement. Subsequent surgery was ascertained from the women and the hospital operative database.

MAIN OUTCOME MEASURES

The primary outcome measure was overall satisfaction with treatment. Secondary outcomes included evaluation of menstrual loss, change in quality of life scores and subsequent surgery.

RESULTS

Of the women originally randomised 217/314 (69.1%) returned questionnaires. Nonresponders were assumed to be treatment failures for data analysis. The primary outcome of satisfaction was similar in both groups (58% for MEA™ versus 53% for TBall, difference 5%; 95% CI -6 to 16%). Amenorrhoea rates were high following both techniques (51% versus 45%, difference 6%; 95% CI -5 to 17%). There was no significant difference in the hysterectomy rates between the two arms (9% versus 7%, difference 2%; 95% CI -5 to 9%).

CONCLUSIONS

At 5 years post-treatment there were no significant clinical differences in patient satisfaction, menstrual status, quality of life scores or hysterectomy rates between MEA™ and Thermachoice 3, thermal balloon ablation.

Hysterectomy, endometrial ablation and Mirena® for heavy menstrual bleeding: a systematic review of clinical effectiveness and cost-effectiveness analysis

OBJECTIVE

The aim of this project was to determine the clinical effectiveness and cost-effectiveness of hysterectomy, first- and second-generation endometrial ablation (EA), and Mirena® (Bayer Healthcare Pharmaceuticals, Pittsburgh, PA, USA) for the treatment of heavy menstrual bleeding.

DESIGN

Individual patient data (IPD) meta-analysis of existing randomised controlled trials to determine the short- to medium-term effects of hysterectomy, EA and Mirena. A population-based retrospective cohort study based on record linkage to investigate the long-term effects of ablative techniques and hysterectomy in terms of failure rates and complications. Cost-effectiveness analysis of hysterectomy versus first- and second-generation ablative techniques and Mirena.

SETTING

Data from women treated for heavy menstrual bleeding were obtained from national and international trials. Scottish national data were obtained from the Scottish Information Services Division.

PARTICIPANTS

Women who were undergoing treatment for heavy menstrual bleeding were included.

INTERVENTIONS

Hysterectomy, first- and second-generation EA, and Mirena.

MAIN OUTCOME MEASURES

Satisfaction, recurrence of symptoms, further surgery and costs.

RESULTS

Data from randomised trials indicated that at 12 months more women were dissatisfied with first-generation EA than hysterectomy [odds ratio (OR): 2.46, 95% confidence interval (CI) 1.54 to 3.93; p = 0.0002), but hospital stay [WMD (weighted mean difference) 3.0 days, 95% CI 2.9 to 3.1 days; p < 0.00001] and time to resumption of normal activities (WMD 5.2 days, 95% CI 4.7 to 5.7 days; p < 0.00001) were longer for hysterectomy. Unsatisfactory outcomes associated with first- and second-generation techniques were comparable [12.2% (123/1006) vs 10.6% (110/1034); OR 1.20, 95% CI 0.88 to 1.62; p = 0.2). Rates of dissatisfaction with Mirena and second-generation EA were similar [18.1% (17/94) vs 22.5% (23/102); OR 0.76, 95% CI 0.38 to 1.53; p = 0.4]. Indirect estimates suggested that hysterectomy was also preferable to second-generation EA (OR 2.32, 95% CI 1.27 to 4.24; p = 0.006) in terms of patient dissatisfaction. The evidence to suggest that hysterectomy is preferable to Mirena was weaker (OR 2.22, 95% CI 0.94 to 5.29; p = 0.07). In women treated by EA or hysterectomy and followed up for a median [interquartile range (IQR)] duration of 6.2 (2.7-10.8) and 11.6 (7.9-14.8) years, respectively, 962/11,299 (8.5%) women originally treated by EA underwent further gynaecological surgery. While the risk of adnexal surgery was similar in both groups [adjusted hazards ratio 0.80 (95% CI 0.56 to 1.15)], women who had undergone ablation were less likely to need pelvic floor repair [adjusted hazards ratio 0.62 (95% CI 0.50 to 0.77)] and tension-free vaginal tape surgery for stress urinary incontinence [adjusted hazards ratio 0.55 (95% CI 0.41 to 0.74)]. Abdominal hysterectomy led to a lower chance of pelvic floor repair surgery [hazards ratio 0.54 (95% CI 0.45 to 0.64)] than vaginal hysterectomy. The incidence of endometrial cancer following EA was 0.02%. Hysterectomy was the most cost-effective treatment. It dominated first-generation EA and, although more expensive, produced more quality-adjusted life-years (QALYs) than second-generation EA and Mirena. The incremental cost-effectiveness ratios for hysterectomy compared with Mirena and hysterectomy compared with second-generation ablation were £1440 per additional QALY and £970 per additional QALY, respectively.

CONCLUSIONS

Despite longer hospital stay and time to resumption of normal activities, more women were satisfied after hysterectomy than after EA. The few data available suggest that Mirena is potentially cheaper and more effective than first-generation ablation techniques, with rates of satisfaction that are similar to second-generation techniques. Owing to a paucity of trials, there is limited evidence to suggest that hysterectomy is preferable to Mirena. The risk of pelvic floor surgery is higher in women treated by hysterectomy than by ablation. Although the most cost-effective strategy, hysterectomy may not be considered an initial option owing to its invasive nature and higher risk of complications. Future research should focus on evaluation of the clinical effectivesness and cost-effectiveness of the best second-generation EA technique under local anaesthetic versus Mirena and types of hysterectomy such as laparoscopic supracervical hysterectomy versus conventional hysterectomy and second-generation EA.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Activation of Akt by the bacterial inositol phosphatase, SopB, is wortmannin insensitive

Salmonella enterica uses effector proteins translocated by a Type III Secretion System to invade epithelial cells. One of the invasion-associated effectors, SopB, is an inositol phosphatase that mediates sustained activation of the pro-survival kinase Akt in infected cells. Canonical activation of Akt involves membrane translocation and phosphorylation and is dependent on phosphatidyl inositide 3 kinase (PI3K). Here we have investigated these two distinct processes in Salmonella infected HeLa cells. Firstly, we found that SopB-dependent membrane translocation and phosphorylation of Akt are insensitive to the PI3K inhibitor wortmannin. Similarly, depletion of the PI3K regulatory subunits p85α and p85ß by RNAi had no inhibitory effect on SopB-dependent Akt phosphorylation. Nevertheless, SopB-dependent phosphorylation does depend on the Akt kinases, PDK1 and rictor-mTOR. Membrane translocation assays revealed a dependence on SopB for Akt recruitment to Salmonella ruffles and suggest that this is mediated by phosphoinositide (3,4) P(2) rather than phosphoinositide (3,4,5) P(3). Altogether these data demonstrate that Salmonella activates Akt via a wortmannin insensitive mechanism that is likely a class I PI3K-independent process that incorporates some essential elements of the canonical pathway.

High quality and quantity Genome-wide germline genotypes from FFPE normal tissue

Background

Although collections of formalin fixed paraffin embedded (FFPE) samples exist, sometimes representing decades of stored samples, they have not typically been utilized to their full potential. Normal tissue from such samples would be extremely valuable for generation of genotype data for individuals who cannot otherwise provide a DNA sample.

Findings

We extracted DNA from normal tissue identified in FFPE tissue blocks from prostate surgery and obtained complete genome wide genotype data for over 500,000 SNP markers for these samples, and for DNA extracted from whole blood for 2 of the cases, for comparison.

Four of the five FFPE samples of varying age and amount of tissue had identifiable normal tissue. We obtained good quality genotype data for between 89 and 99% of all SNP markers for the 4 samples from FFPE. Concordance rates of over 99% were observed for the 2 samples with DNA from both FFPE and from whole blood.

Conclusions

DNA extracted from normal FFPE tissue provides excellent quality and quantity genome-wide genotyping data representing germline DNA, sufficient for both linkage and association analyses. This allows genetic analysis of informative individuals who are no longer available for sampling in genetic studies.

Hysterectomy, endometrial ablation, and levonorgestrel releasing intrauterine system (Mirena) for treatment of heavy menstrual bleeding: cost effectiveness analysis

OBJECTIVE

To undertake a cost effectiveness analysis comparing first and second generation endometrial ablative techniques, hysterectomy, and the levonorgestrel releasing intrauterine system (Mirena) for treating heavy menstrual bleeding.

DESIGN

Model based economic evaluation with data from an individual patient data meta-analysis supplemented with cost and outcome data from published sources taking an NHS (National Health Service) perspective. A state transition (Markov) model was developed, the structure being informed by the reviews of the trials and clinical input. A subgroup analysis, one way sensitivity analysis, and probabilistic sensitivity analysis were also carried out.

POPULATION

Four hypothetical cohorts of women with heavy menstrual bleeding.

INTERVENTIONS

One of four alternative strategies: Mirena, first or second generation endometrial ablation techniques, or hysterectomy.

MAIN OUTCOME MEASURES

Cost effectiveness based on incremental cost per quality adjusted life year (QALY).

RESULTS

Hysterectomy is the preferred strategy for the first intervention for heavy menstrual bleeding. Although hysterectomy is more expensive, it produces more QALYs relative to other remaining strategies and is likely to be considered cost effective. The incremental cost effectiveness ratio for hysterectomy compared with Mirena is £1440 (€1633, $2350) per additional QALY. The incremental cost effectiveness ratio for hysterectomy compared with second generation ablation is £970 per additional QALY.

CONCLUSION

In light of the acceptable thresholds used by the National Institute for Health and Clinical Excellence, hysterectomy would be considered the preferred strategy for the treatment of heavy menstrual bleeding. The results concur with those of other studies but are highly sensitive to utility values used in the analysis.

Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine system (Mirena) for heavy menstrual bleeding: systematic review and meta-analysis of data from individual patients

OBJECTIVE

To evaluate the relative effectiveness of hysterectomy, endometrial destruction (both "first generation" hysteroscopic and "second generation" non-hysteroscopic techniques), and the levonorgestrel releasing intrauterine system (Mirena) in the treatment of heavy menstrual bleeding.

DESIGN

Meta-analysis of data from individual patients, with direct and indirect comparisons made on the primary outcome measure of patients' dissatisfaction.

DATA SOURCES

Data were sought from the 30 randomised controlled trials identified after a comprehensive search of the Cochrane Library, Medline, Embase, and CINAHL databases, reference lists, and contact with experts. Raw data were available from 2814 women randomised into 17 trials (seven trials including 1359 women for first v second generation endometrial destruction; six trials including 1042 women for hysterectomy v first generation endometrial destruction; one trial including 236 women for hysterectomy v Mirena; three trials including 177 women for second generation endometrial destruction v Mirena). Eligibility criteria for selecting studies Randomised controlled trials comparing hysterectomy, first and second generation endometrial destruction, and Mirena for women with heavy menstrual bleeding unresponsive to other medical treatment.

RESULTS

At around 12 months, more women were dissatisfied with outcome with first generation hysteroscopic techniques than with hysterectomy (13% v 5%; odds ratio 2.46, 95% confidence interval 1.54 to 3.9, P<0.001), but hospital stay (weighted mean difference 3.0 days, 2.9 to 3.1 days, P<0.001) and time to resumption of normal activities (5.2 days, 4.7 to 5.7 days, P<0.001) were longer for hysterectomy. Unsatisfactory outcomes were comparable with first and second generation techniques (odds ratio 1.2, 0.9 to 1.6, P=0.2), although second generation techniques were quicker (weighted mean difference 14.5 minutes, 13.7 to 15.3 minutes, P<0.001) and women recovered sooner (0.48 days, 0.20 to 0.75 days, P<0.001), with fewer procedural complications. Indirect comparison suggested more unsatisfactory outcomes with second generation techniques than with hysterectomy (11% v 5%; odds ratio 2.3, 1.3 to 4.2, P=0.006). Similar estimates were seen when Mirena was indirectly compared with hysterectomy (17% v 5%; odds ratio 2.2, 0.9 to 5.3, P=0.07), although this comparison lacked power because of the limited amount of data available for analysis.

CONCLUSIONS

More women are dissatisfied after endometrial destruction than after hysterectomy. Dissatisfaction rates are low after all treatments, and hysterectomy is associated with increased length of stay in hospital and a longer recovery period. Definitive evidence on effectiveness of Mirena compared with more invasive procedures is lacking.

Outpatient microwave endometrial ablation: 5-year follow-up of a randomised controlled trial without endometrial preparation versus standard day surgery with endometrial preparation

The objective was to compare long-term outcomes following outpatient microwave endometrial ablation in the postmenstrual phase with those following day surgery microwave endometrial ablation after standard drug-based endometrial preparation. Of the women originally recruited, 154/197 (78%) returned questionnaires. The primary outcome of satisfaction was high in both groups (71% postmenses versus 65% preparation) as were the amenorrhoea rates (84% versus 87%). There was no significant difference in the hysterectomy rates between the two arms. It can be concluded that microwave endometrial ablation outcomes are not affected in the long term by undertaking the procedure in the postmenstrual phase in an outpatient setting.

Clinical outcomes from a randomised comparison of Microwave Endometrial Ablation with Thermal Balloon endometrial ablation for the treatment of heavy menstrual bleeding

OBJECTIVE

To compare the clinical outcomes of microwave endometrial ablation and thermal balloon ablation for the treatment of heavy menstrual bleeding.

DESIGN

A double blind randomised controlled trial.

SETTING

A UK teaching hospital.

POPULATION

Three hundred and twenty women requesting endometrial ablation.

METHODS

Operative data collection and patient completed postal questionnaires were used to ascertain women's satisfaction with outcome, acceptability of each procedure, changes in menstrual symptoms and health related quality of life and additional treatments received.

MAIN OUTCOME MEASURES

Primary outcomes were satisfaction and menstrual scores 1 year. Secondary outcomes were operative differences, acceptability of treatment and changes in health related quality of life.

RESULTS

Both technologies achieved high levels of satisfaction (-1%, 95% CI (-11, 9)). Menstrual scores were also similar (4%, 95% CI (-7, 19)) Microwave had a significantly shorter operating time, reduced usage of antiemetics and opiate analgesia, increased discharge by 6 hours and fewer device failures.

CONCLUSIONS

Both treatments are acceptable to women, with high levels of satisfaction. Microwave is quicker to perform with faster hospital discharge.

A randomised comparison of microwave endometrial ablation with transcervical resection of the endometrium: follow up at a minimum of 10 years

OBJECTIVE

To compare outcomes and further operations at a minimum of 10 years following microwave endometrial ablation (MEA) or transcervical resection of the endometrium (TCRE).

DESIGN

Follow up of a randomised controlled trial using postal questionnaires and operative databank review.

SETTING

Gynaecology department of a large UK teaching hospital.

MAIN OUTCOME MEASURES

Women's satisfaction with treatment, menstrual symptoms, changes in health-related quality of life, and additional treatments received.

RESULTS

One-hundred and eighty-nine of the original 263 women returned questionnaires (72%) after a minimum of 10 years post-treatment. Those totally or generally satisfied with treatment numbered 77/129 (60%) in the microwave arm and 70/134 (52%) in the resection arm, the difference is not statistically significant. Bleeding and pain scores were highly significantly reduced and similar following both MEA and TCRE, achieving amenorrhoea rates of 83 and 88% respectively. The hysterectomy rate after 10 years was significantly different with 22 (17%) in the MEA and 38 (28%) in the TCRE arm (95% CI: -0.21, -0.13).

CONCLUSIONS

Both techniques achieve significant and comparable improvements in menstrual symptoms, health-related quality of life and high rates of satisfaction. With the known operative advantages, lower costs and fewer hysterectomies, it is clear that MEA is a more effective and efficient treatment for heavy menstrual loss than TCRE.

Histoplasma capsulatum encodes a dipeptidyl peptidase active against the mammalian immunoregulatory peptide, substance P

The pathogenic fungus Histoplasma capsulatum secretes dipeptidyl peptidase (Dpp) IV enzyme activity and has two putative DPPIV homologs (HcDPPIVA and HcDPPIVB). We previously showed that HcDPPIVB is the gene responsible for the majority of secreted DppIV activity in H. capsulatum culture supernatant, while we could not detect any functional contribution from HcDPPIVA. In order to determine whether HcDPPIVA encodes a functional DppIV enzyme, we expressed HcDPPIVA in Pichia pastoris and purified the recombinant protein. The recombinant enzyme cleaved synthetic DppIV substrates and had similar biochemical properties to other described DppIV enzymes, with temperature and pH optima of 42°C and 8, respectively. Recombinant HcDppIVA cleaved the host immunoregulatory peptide substance P, indicating the enzyme has the potential to affect the immune response during infection. Expression of HcDPPIVA under heterologous regulatory sequences in H. capsulatum resulted in increased secreted DppIV activity, indicating that the encoded protein can be expressed and secreted by its native organism. However, HcDPPIVA was not required for virulence in a murine model of histoplasmosis. This work reports a fungal enzyme that can function to cleave the immunomodulatory host peptide substance P.

Histoplasma capsulatum secreted gamma-glutamyltransferase reduces iron by generating an efficient ferric reductant

The intracellular fungal pathogen Histoplasma capsulatum (Hc) resides in mammalian macrophages and causes respiratory and systemic disease. Iron limitation is an important host antimicrobial defence, and iron acquisition is critical for microbial pathogenesis. Hc displays several iron acquisition mechanisms, including secreted glutathione-dependent ferric reductase activity (GSH-FeR). We purified this enzyme from culture supernatant and identified a novel extracellular iron reduction strategy involving gamma-glutamyltransferase (Ggt1) activity. The 320 kDa complex was composed of glycosylated protein subunits of about 50 and 37 kDa. The purified enzyme exhibited gamma-glutamyl transfer activity as well as iron reduction activity in the presence of glutathione. We cloned and manipulated expression of the encoding gene. Overexpression or RNAi silencing affected both GGT and GSH-FeR activities concurrently. Enzyme inhibition experiments showed that the activity is complex and involves two reactions. First, Ggt1 initiates enzymatic breakdown of GSH by cleavage of the gamma-glutamyl bond and release of cysteinylglycine. Second, the thiol group of the released dipeptide reduces ferric to ferrous iron. A combination of kinetic properties of both reactions resulted in efficient iron reduction over a broad pH range. Our findings provide novel insight into Hc iron acquisition strategies and reveal a unique aspect of Ggt1 function in this dimorphic mycopathogen.

A randomised trial comparing local versus general anaesthesia for microwave endometrial ablation

OBJECTIVE

To compare the acceptability of microwave endometrial ablation using a local anaesthesia/sedation regime or general anaesthesia. To compare recovery following treatment with each type of anaesthetic.

DESIGN

Prospective randomised controlled trial with follow up of women who declined randomisation.

SETTING

The gynaecology department of a large teaching hospital in the UK.

POPULATION

All women referred for microwave endometrial ablation at the Aberdeen Royal Infirmary between July 1999 and September 2000 without a medical reason to favour one or other type of anaesthetic.

METHODS

191 women were equally randomised to undergo microwave endometrial ablation under general or local anaesthesia. Details were also collected for women not randomised because of an anaesthetic preference. All procedures were undertaken in an operating theatre.

MAIN OUTCOME MEASURES

Data collected by questionnaire including the woman's view of treatment acceptability, operative details and post-operative recovery.

RESULTS

Sixty-nine percent of eligible women would consider treatment under local anaesthesia. Ninety-one percent of microwave endometrial ablation procedures that started under local anaesthesia were completed without conversion to general anaesthesia. Anaesthetic type and allocation by randomisation or preference made no significant difference to the proportion of women describing treatment as totally or generally acceptable at two weeks. Neither parity nor cavity size predicted acceptability. Women allocated general anaesthesia were more likely to describe the procedure as totally acceptable and to choose the same anaesthetic again. There was no significant difference between anaesthetic groups regarding post-operative pain, nausea or recovery time.

CONCLUSIONS

Microwave endometrial ablation under local anaesthesia was acceptable to the majority of women referred for treatment. There was no recovery advantage from local anaesthesia and almost 1 in 10 women who starting treatment under local anaesthesia needed a general anaesthetic because of discomfort. The incidence of post-operative pain and nausea means that treatment with this local anaesthetic/sedation regime remains a day case rather than an outpatient procedure.

Five-year follow up of women randomised to medical management or transcervical resection of the endometrium for heavy menstrual loss: clinical and quality of life outcomes

OBJECTIVE

To assess clinical status, changes in health related quality of life, and subsequent management five years after medical management or transcervical resection of the endometrium for treatment of heavy menstrual loss.

DESIGN

Five year follow up using postal questionnaires and operative databank review.

SETTING

Gynaecology department of a large UK teaching hospital.

POPULATION

Women referred to the gynaecologist for treatment of heavy menstrual loss.

METHODS

Eligible women, without a treatment preference, were randomised equally to either medical treatment or transcervical resection of the endometrium.

MAIN OUTCOME MEASURES

Women's satisfaction with treatment, menstrual status, changes in health related quality of life, and additional treatments received at five years.

RESULTS

One hundred and forty-four patients completed questionnaires, achieving 77% follow up (medical n = 71/94; transcervical resection of the endometrium n = 73/93). At five-year follow up, 7/71 (10%) of those randomised to the medical arm still used medical treatment, while 72/94 (77%) had undergone surgical treatment and 17/94 (18%) a hysterectomy. Twenty-five (27%) women allocated to transcervical resection of the endometrium had undergone further surgery, 18/93 (19%) a hysterectomy. At five years women initially randomised to medical treatment were significantly less likely to be totally satisfied (P < 0.01, difference 21%, 95% CI -37% to -4%), or to recommend their allocated treatment to a friend (P < 0.001, difference 59%, 95% CI -73% to -45%). Bleeding and pain scores were similar in both groups and highly significantly reduced. Significantly more women in the transcervical resection of the endometrium arm had no bleeding or very light bleeding (P < 0.02, difference -22%, CI -31% to -4%), and they had significantly less days heavy bleeding (P < 0.02). Short Form 36 health survey scores were significantly improved from baseline for all eight health scales in the transcervical resection of the endometrium arm, and four in the medical arm.

CONCLUSIONS

A policy of immediate transcervical resection of the endometrium for women referred to a gynaecologist for treatment of heavy menstrual loss achieves higher levels of satisfaction, better menstrual status, and greater improvements in health related quality of life than medical treatment. In addition, transcervical resection of the endometrium is safe and does not lead to an increase in the number of hysterectomies. An effective endometrial ablative technique should be offered to all eligible women seeking treatment of their heavy menses from a gynaecologist.

Comparison of microwave endometrial ablation and transcervical resection of the endometrium for treatment of heavy menstrual loss: a randomised trial

BACKGROUND

Various new endometrial ablation techniques have emerged for the treatment of menorrhagia. We undertook a randomised controlled trial comparing one new technique, microwave endometrial ablation (MEA), with a proven procedure, transcervical resection of the endometrium (TCRE), for women with heavy menstrual loss.

METHODS

263 eligible and consenting women, referred for endometrial ablative surgery, were randomly assigned MEA (Microsulis plc, Waterlooville, Hampshire, UK; n=129) or TCRE (n=134). 230 participants were needed to give 80% power of demonstrating a 15% difference in satisfaction with treatment. All procedures were done under general anaesthesia 5 weeks after endometrial thinning with goserelin 3.6 mg. Questionnaires were completed at recruitment and at 12 months' follow-up. The primary outcome measures were patients' satisfaction with and the acceptability of treatment. Analysis was by intention to treat among women followed up to 12 months (n=116 MEA, n=124 TCRE).

FINDINGS

At 12 months, 89 (77%) women in the MEA group and 93 (75%) in the TCRE group were totally or generally satisfied with their treatment (95% CI for difference -12 to 17) and 109 (94%) versus 112 (90%) found it acceptable (-11 to 35). Mean operating times were shorter for MEA than for TCRE (11.4 vs 15.0 min, p=0.001) and the postoperative stay slightly but not significantly shorter. One blunt perforation occurred in each study group resulting in one immediate hysterectomy (TCRE group). Of eight health-related quality of life dimensions, all were improved after MEA (six significantly) and seven were improved after TCRE (all significantly).

INTERPRETATION

Both techniques achieved high rates of satisfaction and acceptability and both improved quality of life after 1 year. However, we cannot exclude a difference in satisfaction between the groups of less than 15%. MEA seems a suitable alternative to TCRE.

Research priorities for nephrology nursing: American Nephrology Nurses' Association's Delphi Study

The purpose of this study was to identify and prioritize research topics of importance for nephrology nursing and the American Nephrology Nurses' Association (ANNA). This was an explorative survey design using the Delphi technique. Nephrology nurses who are members of ANNA participated in the study. In Round 1 participants included 90 members of the Advanced Practice Special Interest Group. Round 2 participants were 537 nephrology nurses who attended the 28th ANNA National Symposium. Participants in Round 3 were 491 ANNA members who had at least a master's degree in nursing or another field. A three-round Delphi technique was used to solicit, identify, and prioritize problems for nephrology nursing research. In Round 1, 90 nurses identified problems in response to an open-ended question. These responses were analyzed and categorized into a 21-item research survey that was used for subsequent rounds. Round 2 participants rated each research question/topic on the survey on a 1 to 5 scale for level of importance. In addition, they were asked to identify the top-ranked research priorities from the 21 questions. In Round 3, the participants were asked to do the same as in Round 2. In addition, they indicated whether the research priority was primarily a nursing responsibility or a collaborative effort with other health care personnel. Based on 3 rounds of the Delphi study and analysis of both level of importance and rated-research priority, the five areas that were identified as research priorities are (a) nursing interventions to prevent vascular access infections, (b) nursing interventions to maintain vascular access patency, (c) educational needs of patients and families, (d) levels of nursing competence and the effect on patient outcomes, and (e) validation of nursing interventions to achieve patient outcomes. These research priorities provide direction for nephrology nursing research and the ANNA. This Delphi study represents a significant step for ANNA in its commitment to research.

Two-year follow up of women randomised to medical management or transcervical resection of the endometrium for heavy menstrual loss: clinical and quality of life outcomes

OBJECTIVE

To assess clinical status and changes in health related quality of life after two years in women randomised to medical management or transcervical resection of the endometrium (TCRE) for treatment of heavy menstrual loss.

DESIGN

Two-year follow up using postal questionnaires and operative databank review.

SETTING

Gynaecology department of a large UK teaching hospital.

PARTICIPANTS

Women who had joined a randomised comparison of medical treatment with TCRE for heavy menstrual loss two years previously.

MAIN OUTCOME MEASURES

Women's satisfaction with treatment, gynaecological symptoms, changes in health related quality of life, and additional treatments received at two years.

RESULTS

Women allocated medical treatment were significantly less likely to be totally or generally satisfied (57% vs 79%, difference -22%, 95% CI -36, -9%), to find their management acceptable (77% vs 93%, difference -16%, 95% CI -26, -4%), or to recommend their allocated treatment (24% vs 78%, difference -54%, 95% CI -61, -33%). In the medical cohort 59% of women had undergone TCRE, hysterectomy or both, whereas 17% in the TCRE cohort had undergone further surgery. Bleeding and pain scores were similar in the groups and highly significantly better than at recruitment. Short Form-36 health survey scores were significantly improved from baseline for five of the eight health scores in the medical arm, and seven in the TCRE arm.

CONCLUSIONS

The results at two years consolidate the findings and conclusions based on the four-month follow up data. A policy of early TCRE is effective and safe and does not result in an increase in hysterectomies. It should not be routinely withheld in an effort to try alternative medical therapies.

A randomised comparison of medical and hysteroscopic management in women consulting a gynaecologist for treatment of heavy menstrual loss

OBJECTIVES

To compare medical with hysteroscopic management in women referred to a gynaecologist complaining of heavy menstrual loss.

DESIGN

Single-centre randomised trial.

SETTING

A teaching hospital in the United Kingdom.

PARTICIPANTS

One hundred and ninety-seven women seeking specialist treatment of heavy menstrual loss for the first time and willing to accept either treatment.

INTERVENTIONS

1. Medical treatments not previously used by the women prescribed by experienced gynaecologists in standard doses and timings for a minimum of three cycles (n = 94), and 2. transcervical resection of the endometrium performed under general anaesthesia five weeks after goserelin preparation (n = 93).

MAIN OUTCOME MEASURES

Treatment satisfaction and acceptability, relief of symptoms, change in haemoglobin, and improvement in health related quality of life, all after four months.

RESULTS

Women allocated transcervical resection were more likely to be totally or generally satisfied (76% versus 27%, P < 0.001), to find the treatment acceptable (93% versus 36%, P < 0.001), and willing to have the treatment again (93% versus 31%, P < 0.001). Although pain and bleeding were significantly reduced by medical treatment this was modest in comparison with transcervical resection (P < 0.001). Haemoglobin levels were significantly increased only following transcervical resection. Short form 36 scores were also improved in both arms, although only transcervical resection returned them to normal values.

CONCLUSIONS

Medical treatment was less effective than transcervical resection of the endometrium, irrespective of previous treatment or type of medical management. Early hysteroscopic endometrial surgery should be considered by such woman with the choice made by the woman after a full discussion of the advantages and disadvantages of all the options.

The impact of using a partially randomised patient preference design when evaluating alternative managements for heavy menstrual bleeding

OBJECTIVE

To identify the advantages and disadvantages of using a partially randomised patient preference design rather than a conventional randomised controlled design when evaluating alternative managements for heavy menstrual bleeding.

DESIGN

Randomised controlled comparison of two clinical trial designs with subsequent follow up of the cohorts of women generated.

PARTICIPANTS

Women attending a general gynaecology clinic for the first time because of heavy menstrual bleeding.

INTERVENTIONS

Partially randomised patient preference clinical trial design and conventional randomised controlled design.

MAIN OUTCOME MEASURES

Overall participation; participation in randomised clinical trial of medical management compared with transcervical surgical resection of the endometrium; prognostic characteristics (socio-demographic and Short Form 36) of clinical trial groups; outcomes (clinical and Short Form 36) of clinical trial groups.

RESULTS

Overall, more women participated in the partially randomised patient preference design (130/135 vs 97/138; difference 27%, 95% CI 18% to 34%) but there was no difference in the numbers who agreed to be randomised (90/135 vs 97/138; difference-3%, 95% CI-15% to 7%). Women who chose medical management tended to have better general health, to be less restricted by their menstrual problems, with fewer having been previously treated by their general practitioner. Those who chose transcervical resection of the endometrium had all tried medical management and had higher bleeding scores. Follow up satisfactions and acceptability rates, and Short Form 36 scores were highest after transcervical resection of the endometrium, whether chosen or randomised. Acceptability and a desire to continue the same treatment was greater among those who chose medical management than those randomly allocated it.

CONCLUSIONS

Use of the partially randomised patient preference design did not affect recruitment to the randomised controlled trial suggesting that a conventionally designed trial would not be biased by motivational factors in this context. Data from the preference groups informed the generalisability of the results but did tend to confirm conclusions that anyway reasonably followed from the randomised controlled trial. The extra resource implications of using the partially randomised patient preference design were significant reflecting the additional 40% who participated and the extra analyses entailed.

Cerebral metastases from epithelial ovarian carcinoma treated with carboplatin

We describe three women with cerebral metastases who presented following treatment for ovarian cancer. In all three cases the primary tumor underwent complete remission following cytoreductive surgery and adjuvant platinum-based combination chemotherapy. Cerebral metastases occurred at 18, 19, and 25 months following initial diagnosis of ovarian carcinoma. These cerebral lesions were treated with carboplatin 400 mg/m2 as a single agent. In one case total resolution of a single cerebral metastasis was achieved. In the other two women a significant reduction in tumor mass occurred and one of these responded to repeat treatment on two occasions. Survival times from diagnosis of the cerebral lesions were 11, 16, and 25 months. The treatment afforded rapid subjective and objective relief, significantly improved survival times, and was associated with good quality of life. Carboplatin should be considered for the treatment of cerebral metastases for ovarian cancer.