An Evaluation of an Advanced Practice Provider Led Weight Intervention in Liver Disease (WILD) Pathway.

Within the scope of their practice, advanced practice providers provide similar patient care as physicians, but in some cases have outperformed physicians in terms of health outcomes, satisfaction, and cost-effectiveness. At an academic medical center, hepatology trained advanced practice providers, who were also certified in obesity management, led an interprofessional team to develop the Weight Intervention in Liver Disease pathway. In September 2018, patients who were seen in the hepatology practice and met criteria for enrollment were referred to the Weight Intervention in Liver Disease program for comprehensive care of obesity and related metabolic disorders. A program evaluation was conducted in 2021 to identify whether the effectiveness of the advanced practice provider-led structure and process, and the Weight Intervention in Liver Disease pathway, supported weight loss goals as well as improvement in alanine aminotransferase levels, patient satisfaction, and provider satisfaction. Results found that the structure of the pathway and the implementation are resulting in positive outcomes of 100% patient satisfaction, 80% provider satisfaction, and a total average sustained weight loss of 5.05% ( SD = 7.98, p < .01). A weight loss pathway led by trained advanced practice providers proves successful in long-term weight loss goals.

Should NS5A inhibitors serve as the scaffold for all-oral anti-HCV combination therapies?

Chronic hepatitis C virus (HCV) infection represents a global health problem that affects up to 130-150 million people worldwide. The HCV treatment landscape has been transformed recently by the introduction of direct-acting antiviral (DAA) agents that target viral proteins, including the NS3 protease, the NS5B polymerase, and the NS5A protein. Treatment with multiple DAAs in combination has been shown to result in high rates of sustained virologic response, without the need for pegylated interferon, and a shorter duration of therapy compared with interferon-based regimens; however, the optimal combination of DAAs has yet to be determined. The class of NS5A inhibitors has picomolar potency with pangenotypic activity, and recent clinical studies have shown these inhibitors to be an important component of DAA combination regimens. This review discusses the rational design of an optimal anti-HCV DAA cocktail, with a focus on the role of NS5A in the HCV life cycle, the attributes of the NS5A class of inhibitors, and the potential for NS5A inhibitors to act as a scaffold for DAA-only treatment regimens.

Primary murine CD4+ T cells fail to acquire the ability to produce effector cytokines when active Ras is present during Th1/Th2 differentiation.

Constitutive Ras signaling has been shown to augment IL-2 production, reverse anergy, and functionally replace many aspects of CD28 co-stimulation in CD4+ T cells. These data raise the possibility that introduction of active Ras into primary T cells might result in improved functionality in pathologic situations of T cell dysfunction, such as cancer or chronic viral infection. To test the biologic effects of active Ras in primary T cells, CD4+ T cells from Coxsackie-Adenovirus Receptor Transgenic mice were transduced with an adenovirus encoding active Ras. As expected, active Ras augmented IL-2 production in naive CD4+ T cells. However, when cells were cultured for 4 days under conditions to promote effector cell differentiation, active Ras inhibited the ability of CD4+ T cells to acquire a Th1 or Th2 effector cytokine profile. This differentiation defect was not due to deficient STAT4 or STAT6 activation by IL-12 or IL-4, respectively, nor was it associated with deficient induction of T-bet and GATA-3 expression. Impaired effector cytokine production in active Ras-transduced cells was associated with deficient demethylation of the IL-4 gene locus. Our results indicate that, despite augmenting acute activation of naïve T cells, constitutive Ras signaling inhibits the ability of CD4+ T cells to properly differentiate into Th1/Th2 effector cytokine-producing cells, in part by interfering with epigenetic modification of effector gene loci. Alternative strategies to potentiate Ras pathway signaling in T cells in a more regulated fashion should be considered as a therapeutic approach to improve immune responses in vivo.

Broad ligament fibroid mimicking as ovarian tumor on ultrasonography and computed tomography scan.

Giant fibroids are known to arise from the uterus, and very rarely from the broad ligament. Large fibroids often undergo hyaline, cystic, and at times, red degeneration. In the present case, cystic degeneration with intervening septations in an adnexal mass raised the suspicion of ovarian neoplasm as the ovaries were not seen as separate from the lesion. The ultrasonographic and contrast-enhanced computed tomographic findings of this case were characteristic of ovarian neoplasm. The differential diagnosis included rare possibility of giant fibroid with cystic degeneration. The diagnosis was confirmed on histopathological examination. The patient underwent excision of the broad ligament fibroid, hysterectomy, and bilateral salpingo-oophorectomy. Magnetic resonance imaging has a role in the diagnosis of such lesions.

Evidence implicating the Ras pathway in multiple CD28 costimulatory functions in CD4+ T cells.

CD28 costimulation is a critical event in the full activation of CD4(+) T cells that augments cytokine gene transcription, promotes cytokine mRNA stability, prevents induction of anergy, increases cellular metabolism, and increases cell survival. However, despite extensive biochemical analysis of the signaling events downstream of CD28, molecular pathways sufficient to functionally replace the diverse aspects of CD28-mediated costimulation in normal T cells have not been identified. Ras/MAPK signaling is a critical pathway downstream of T cell receptor stimulation, but its role in CD28-mediated costimulation has been controversial. We observed that physiologic CD28 costimulation caused a relocalization of the RasGEF RasGRP to the T cell-APC interface by confocal microscopy. In whole cell biochemical analysis, CD28 cross-linking with either anti-CD28 antibody or B7.1-Ig augmented TCR-induced Ras activation. To determine whether Ras signaling was sufficient to functionally mimic CD28 costimulation, we utilized an adenoviral vector encoding constitutively active H-Ras (61L) to transduce normal, Coxsackie-Adenovirus Receptor (CAR) transgenic CD4(+) T cells. Like costimulation via CD28, active Ras induced AKT, JNK and ERK phosphorylation. In addition, constitutive Ras signaling mimicked the ability of CD28 to costimulate IL-2 protein secretion, prevent anergy induction, increase glucose uptake, and promote cell survival. Importantly, we also found that active Ras mimicked the mechanism by which CD28 costimulates IL-2 production: by increasing IL-2 gene transcription, and promoting IL-2 mRNA stability. Finally, active Ras was able to induce IL-2 production when combined with ionomycin stimulation in a MEK-1-dependent fashion. Our results are consistent with a central role for Ras signaling in CD28-mediated costimulation.

T cell anergy is reversed by active Ras and is regulated by diacylglycerol kinase-alpha.

T cell anergy has been correlated with defective signaling by the GTPase Ras, but causal and mechanistic data linking defective Ras activity with T cell anergy are lacking. Here we used adenoviral transduction to genetically manipulate nonproliferating T cells and show that active Ras restored interleukin 2 production and mitogen-activated protein kinase signaling in T cells that were made anergic in vitro or in vivo. Diacylglycerol kinases (DGKs), which negatively regulate Ras activity, were upregulated in anergic T cells, and a DGK inhibitor restored interleukin 2 production in anergic T cells. Both anergy and DGK-alpha overexpression were associated with defective translocation of the Ras guanine nucleotide-exchange factor RasGRP1 to the plasma membrane. Our data support a causal function for excess DGK activity and defective Ras signaling in T cell anergy.

Differential Ras signaling via the antigen receptor and IL-2 receptor in primary T lymphocytes.

Ras can become activated via multiple distinct receptors in T lymphocytes. However, mechanistic studies of Ras signaling in normal T cells have been hampered by the lack of an efficient technology for gene transfer into resting post-thymic cells. We have overcome this limitation by utilizing adenoviral transduction of T cells from Coxsackie/adenovirus receptor transgenic mice. Unexpectedly, dominant negative Ras17N blocked activation of Ras and ERK in response to IL-2R engagement but not TCR/CD3 ligation. However, TCR-induced ERK activation was suppressed by inhibitors of PKC and PLC-gamma. This first biochemical study of DN Ras in normal quiescent T cells reveals a striking contrast in Ras signaling via two receptors, and suggests that the principal mechanism of TCR-induced Ras activation in normal T cells may be distinct from that utilized in T-lineage tumor cell lines.