The Ubiquitin System and A20: Implications in Health and Disease.

Inflammation is triggered by stimulation of innate sensors that recognize pathogens, chemical and physical irritants, and damaged cells subsequently initiating a well-orchestrated adaptive immune response. Immune cell activation is a strictly regulated and self-resolving process supported by an array of negative feedback mechanisms to sustain tissue homeostasis. The disruption of these regulatory pathways forms the basis of chronic inflammatory diseases, including periodontitis. Ubiquitination, a covalent posttranslational modification of target proteins with ubiquitin, has a profound effect on the stability and activity of its substrates, thereby regulating the immune system at molecular and cellular levels. Through the cooperative actions of E3 ubiquitin ligases and deubiquitinases, ubiquitin modifications are implicated in several biological processes, including proteasomal degradation, transcriptional regulation, regulation of protein-protein interactions, endocytosis, autophagy, DNA repair, and cell cycle regulation. A20 (tumor necrosis factor α-induced protein 3 or TNFAIP3) is a ubiquitin-editing enzyme that mainly functions as an endogenous regulator of inflammation through termination of nuclear factor (NF)-κB activation as part of a negative feedback loop. A20 interacts with substrates that reside downstream of immune sensors, including Toll-like receptors, nucleotide-binding oligomerization domain-containing receptors, lymphocyte receptors, and cytokine receptors. Due to its pleiotropic functions as a ubiquitin binding protein, deubiquitinase and ubiquitin ligase, and its versatile role in various signaling pathways, aberrant A20 levels are associated with numerous conditions such as rheumatoid arthritis, diabetes, systemic lupus erythematosus, inflammatory bowel disease, psoriasis, Sjögren syndrome, coronary artery disease, multiple sclerosis, cystic fibrosis, asthma, cancer, neurological disorders, and aging-related sequelae. Similarly, A20 has recently been implicated as an essential regulator of inflammation in the oral cavity. This review presents information on the ubiquitin system and regulation of NF-κB by ubiquitination using A20 as a representative molecule and highlights how the dysregulation of this system can lead to several immune pathologies, including oral cavity-related disorders mainly focusing on periodontitis.

Dysregulation of the interleukin-17A pathway in endometrial tissue from women with unexplained infertility affects pregnancy outcome following assisted reproductive treatment.

STUDY QUESTION: Which transcriptomic alterations in mid-luteal endometrial scratch biopsies, taken prior to the assisted reproductive treatment (ART) treatment cycle are associated with unsuccessful pregnancy? SUMMARY ANSWER: Dysregulated interleukin-17 (IL-17) pathway components are demonstrated in women who fail to become pregnant after ART. WHAT IS KNOWN ALREADY: Implantation failure is now recognised as a critical factor in unexplained infertility and may be an important component of failed ART. STUDY DESIGN, SIZE, DURATION: Using a prospective longitudinal study design, 29 nulliparous women with unexplained infertility undergoing ART were recruited between October 2016 and February 2018. Mid-luteal stage endometrium and matched serum samples were collected, and patients underwent a single embryo transfer in the subsequent cycle. RNA-seq analysis of endometrial biopsies was performed on the discovery cohort (n = 20). PARTICIPANTS/MATERIALS, SETTING, METHODS: Gene set enrichment analysis of the differentially expressed genes (DEGs) was performed. Endometrium and serum were then prepared for IL-17A analysis by ELISA. MAIN RESULTS AND THE ROLE OF CHANCE: There were 204 differentially expressed protein-coding genes identified in tissue from women who became pregnant (n = 9) compared with tissue from women who failed to become pregnant (n = 11) (false discovery rate; P < 0.05). Of the 204 DEGs, 166 were decreased while 38 were increased in the pregnant compared to the non-pregnant groups. Gene set enrichment analysis of the DEGs identified an over-representation of IL-17 and Pl3K-Akt signalling pathways. All the DEGs within the IL-17 signalling pathway (MMP3, MMP1, IL1ß, LCN2, S100A9 and FOSL1) demonstrated decreased expression in the pregnant group. Serum IL-17 protein levels were increased in the non-pregnant discovery cohort (n = 11) and these findings were confirmed a validation cohort (n = 9). LIMITATIONS, REASONS FOR CAUTION: Limitations of our study include the cohort size and the lack of aneuploidy data for the embryos; however, all embryos transferred were single good or top-quality blastocysts. WIDER IMPLICATIONS OF THE FINDINGS: These findings demonstrate dysregulated IL-17 pathway components in women who fail to become pregnant after ART. Elevated serum levels of the pro-inflammatory cytokine IL-17 may predict failure of ART in women with unexplained infertility. Future trials of anti-IL-17 therapies in this cohort warrant further investigation. STUDY FUNDING/COMPETING INTEREST(S): Funding from the UCD Wellcome Institutional Strategic Support Fund, which was financed jointly by University College Dublin and the SFI-HRB-Wellcome Biomedical Research Partnership (ref 204844/Z/16/Z), is acknowledged. The authors have no competing interests. TRIAL REGISTRATION NUMBER: NA.

Intravenous vitamin K1 normalises prothrombin time in 1 hour in dogs with anticoagulant rodenticide toxicosis.

Four dogs with anticoagulant rodenticide toxicosis were treated with intravenous vitamin K1 in lieu of plasma transfusion due to client cost constraints. Two dogs experienced a suspected anaphylactoid reaction, necessitating cessation of the treatment in one dog. Prothrombin time was rechecked 1 h after treatment in the remaining three dogs and all results were within the normal reference range. All four dogs were discharged from hospital within 48 h of presentation. Intravenous vitamin K1 rapidly reverses the coagulopathic state in dogs with anticoagulant rodenticide toxicosis. It is a viable alternative therapy to plasma transfusion if circumstances preclude its use; however, patients must be monitored for anaphylactoid reactions.

Hypoventilation, cardiac dysrhythmia, and cardiac arrest following acute Brunfelsia species (Yesterday, today, tomorrow) intoxication in a dog.

BACKGROUND: Intoxication following ingestion of the popular garden shrub 'Yesterday, today, tomorrow' (Brunfelsia sp.) is known to result in gastrointestinal and central nervous system clinical signs in dogs. CASE REPORT: A 2-year-old dog developed acute-onset vomiting, profuse diarrhoea and ptyalism after unsupervised access to an enclosed backyard that contained a Brunfelsia sp. shrub. During initial assessment the watery diarrhoea contained plant material and the dog appeared painful on abdominal palpation. Soon after admission, severe neurological abnormalities developed. Decontamination was undertaken by gastric and colonic lavage under general anaesthesia, but on recovery the patient had generalised seizures that were unresponsive to benzodiazepines. Following treatment with multiple antiepileptic medications and endotracheal intubation for loss of gag reflex, the patient developed respiratory failure requiring mechanical ventilation. Four days after initial presentation, the patient developed cardiac dysrhythmia leading to fatal cardiac arrest. Plant material recovered from the shrub and the patient's gastrointestinal tract were identified as Brunfelsia spp. CONCLUSION: This is the first report of hypoventilation, severe cardiac dysrhythmia and cardiac arrest associated with Brunfelsia sp. intoxication in a dog. Previous reports described clinical signs of gastrointestinal disease and mild cardiac dysrhythmia progressing to seizure activity and opisthotonus. Electrocardiography should form part of patient monitoring and mechanical ventilation considered for patients that develop respiratory failure, especially if massive ingestion is suspected.

Cutaneous melanoma in Iceland: changing Breslow's tumour thickness.

BACKGROUND: The incidence of cutaneous melanoma increased dramatically in Iceland during the last two decades of the 20th century. OBJECTIVE: The aim of this study was to investigate the trend in Breslow's tumour thickness during the years 1980-2009. METHODS: The population-based Icelandic Cancer Registry provided information on all cutaneous melanomas diagnosed in the country during the study period, a total of 854 cases. Incidence rates were stratified according to gender, age at diagnosis, year of diagnosis and Breslow's tumour thickness. RESULTS: When stratified by gender and age, the incidence of thin (≤1.0 mm) melanomas increased dramatically in all subgroups. The increase in thin (≤1.0 mm) melanomas was more apparent in women or 2.6 per 100,000 in 1980-1989 to 13.3 in 2000-2009 and especially in young (<50 years) women or from 1.6 to 12.2 per 100,000 during the same period compared to an increase from 0.2 to 3.4 per 100,000 for young (<50 years) men (P < 0.05). In intermediate thickness (1.01-4.0 mm) tumours, the incidence increased only in men over the age of 50 from 2.1 in 1980-1989 to 11.3 per 100,000 in 2000-2009 (P < 0.05). The incidence of thick melanomas (>4 mm) did not increase. The median Breslow's thickness declined from 2.15 mm in 1980-1989 to 0.9 mm in 2000-2009 in males and from 1.0 to 0.6 mm in females for the same period (P < 0.001). CONCLUSION: The rise in melanoma incidence in individuals under 50 years and in women over 50 years was confined to thin tumours. However, among older males there was also an increased incidence of tumours of an intermediate thickness. This could indicate that future melanoma educational campaigns in Iceland should be directed at older individuals, and that older men may need special attention regarding suspicious nevi.

Placental pathology associated with small for gestational age infants.

Infants with intrauterine growth restriction (IUGR) are at an increased risk of perinatal disease, including death. Many, but not all small for gestational age infants (SGA) have IUGR. Placental disease is an important cause of IUGR, and gross and microscopic examination is critical in explaining such cases. Reports of placentas from infants with a birth weight < 2SD from the mean (approx 3rd centile) born between Jan 2004-Dec 2011 were evaluated. The principal pathology was determined in each case. Where two or more pathologic findings were present, they were ranked as principal and co-existing in terms of severity. There were 69,493 deliveries over the study period. 461 SGA cases were identified. No placenta was available in 44 cases, and 21 cases of known anomalies were excluded, leaving a study group of 396 cases. Pathology potentially causing or contributing to SGA and/or IUGR was identified in 84.1% of cases. Significant co-existing pathology was seen in 88 cases (22%). Placental examination provides key information in understanding abnormal fetal growth.

Apparent improvement in survival for carcinoma of the cervix following the introduction of chemoradiation--a Will Rogers phenomenon.

The improved survival for bulky cervical cancers (> 4cm) reported with combination platinum based chemoradiation (1999) prompted a move away from surgery as these cases frequently received adjuvant radiotherapy and were exposed to the morbidity of multimodality treatment. The period pre-1999 (Group 1) was compared with post-1999 (Group 2) when chemoradiation was the preferred treatment for bulky operable cervical cancer. Significantly more cases were treated surgically among Group 1 compared with Group 2 (79% vs. 62%; P < 0.001). Switching from surgery to radiotherapy improved survival in both treatment categories (73% vs. 78% and 37% vs. 44%, respectively) but with no improvement in overall survival (70%/ov.s 70%). Survival (86%) was similar in both groups among surgically treated women with tumors < 4 cm, but significantly more in Group 2 with negative nodes received postoperative adjuvant chemoradiotherapy (Groups 1 vs. 2; 16% vs.37.5%: P < 0.001) and overall the surgically treated patients received more not less multimodality treatment (46.5% vs. 59%; P = 0.7).

Leukaemia cutis in chronic lymphocytic leukaemia following varicella zoster virus reactivation.

We report a case of a 75-year-old male with indolent chronic lymphocytic leukaemia (CLL) for 8 years, who presented with a 6-month history of a painful, zosteriform eruption in a T3-4 distribution that evolved into an unusual crop of papular nodules. Upon biopsy and immunostaining of these lesions CLL was proven consistent with leukaemia cutis related to varicella-zoster virus reactivation. In the absence of other treatment indices, he was commenced on chlorambucil with successful resolution of both his pain and the lesions.

Diagnostic and therapeutic dilemma associated with atypical glandular cells on liquid-based cervical cytology.

BACKGROUND: In 2008, the management of women in Ireland with atypical glandular cells changed to immediate referral to colposcopy. The optimal management of these women is unclear. A balance between the detection of occult disease and overtreatment is required. METHODS: Our study aim was to document the experience of this policy at the National Maternity Hospital, Dublin. Information from the computerized data management system was analysed with the statistical package SPSS. RESULTS: In 2009, 156 women attended colposcopy following a single atypical glandular cell diagnosis on liquid-based cytology. The mean age was 41 years. Thirty (19.2%) women had abnormal vaginal bleeding, 31 (19.9%) were smokers and 34 (21.8%) had received previous treatment. The colposcopy was satisfactory in 125 (80.1%) and unsatisfactory in 31 (19.9%). Cervical histology was available for 146 (93.6%) women: 57 excisional procedures and 89 diagnostic biopsies. Abnormal histology was detected in 46 women (31.5%). Four women (2.7%) had invasive cancer, five (3.4%) had adenocarcinoma in situ, 21 (14.4%) had cervical intraepithelial neoplasia (CIN) grade 2 or 3 and 16 (11.0%) had CIN1. No abnormality was detected in 100 women (68.5%), including 35 (61.4%) of those who had undergone excisional procedures. The colposcopic impression in this group was unsatisfactory in 10 women (28.6%), glandular abnormalities in six (17.1%), high- and low-grade changes in 12 (34.2%) and six (17.1%) women, respectively, and normal in one (2.9%). The findings were essentially negative in the remaining 10 women: overall, 30 (19.2%) of the 156 women referred to colposcopy had at least CIN2. CONCLUSION: This study confirmed significant levels of high-grade disease in women referred to colposcopy with atypical glandular cells on cytology. Concerns about undetected endocervical disease resulted in high levels of negative excisional biopsies. Alternative strategies, including endometrial sampling, human papillomavirus testing and discussion at clinicopathological meeting, should be considered.

Population-specific responses to light influence herbivory in the understory shrub Lindera benzoin.

Plants display photosynthetic plasticity in response to variation in light environment, and the extent of this plasticity often varies with genotype, i.e., genotype x environment interaction. Herbivory may also covary with light environment as a result of light-induced changes in photosynthetic traits. For example, greater levels of photoprotective phenolic compounds in high-light environments may reduce host quality to herbivores. We investigated intraspecific variation in photosynthetic responses to light and its consequences for herbivory in the understory shrub, Lindera benzoin (Lauraceae). We transplanted five plants from eight populations (N = 240) into three replicate sun and shade common gardens. Two years after transplantation, we tested for population x light environment interactions in six photosynthesis-related responses: specific leaf area, water content, chlorophyll content, chlorophyll fluorescence (F(0)), maximum quantum yield (F(v)/F(m)), and total phenolics. We assessed seasonal herbivory and consumption by a specialist lepidopteran herbivore (Epimecis hortaria). This allowed us to test for (1) population-specific patterns of photosynthetic acclimation and photoinhibition, (2) population-specific production of phenolics in response to photoinhibition, and (3) population-specific photosynthetic responses that contribute to population x light environment interactions in herbivory. Population X light environment interactions were insignificant in leaf variables but statistically significant for herbivory measured as consumption by E. hortaria. We found similar trends for population x light environment interactions in seasonal herbivory. Total phenolics and minimum chlorophyll fluorescence (F(0)) were significant covariates with herbivory, but their effects depended on light environment and population of origin. High-light environments eliminated differences among populations in how these leaf variables affected herbivory, while population-specific relationships were apparent in the shade. Analysis of total phenolics revealed that they were likely induced by photoinhibition, but that this response varied among the populations we assessed. However, phenolics increased herbivory in L. benzoin, which would limit the fitness value of this protective response to light-induced photoinhibition. Our results suggest that herbivores could affect evolution of photosynthetic plasticity in L. benzoin.

Stereology of the placenta in type 1 and type 2 diabetes.

OBJECTIVE: To assess by stereology the placental structure in type 1 (T1DM) and type 2 (T2DM) diabetic pregnancies compared to normal non-diabetic (ND) controls. STUDY DESIGN: Prospective case control study. Placentae were sampled in a systematic random fashion. Stereological analysis was performed using a computerised stereology programme (Image Pro 6.2, Media Cybernetics, Inc, Silver Spring MD, USA). Participants were matched for gender of infant and mode of delivery. MAIN OUTCOME MEASURES: Volume, length and surface area of placental components; clinical outcome. RESULTS: Ten ND, eight T2DM and ten T1DM women consented to the study. There was no difference between the groups regarding maternal age, neonatal birth weight, or placental weight. On stereological examination, terminal villous volume was significantly increased in both diabetic groups compared to ND controls. Capillary volume and length was increased in T1DM pregnancies compared to ND and T2DM. Capillary length was increased in both diabetic groups compared to ND. When all diabetic groups were compared based on severity of glycaemia those with poor glycaemic control (HbA1c>7%) had higher placental capillary volume than those with good glycaemic control. CONCLUSIONS: This study demonstrates an association between maternal diabetes and increased terminal villous volume. Additionally capillary volume and length is increased in the placentae of normally grown infants of T1DM diabetic mothers compared to non-diabetic controls. Maternal glycaemia appears to influence capillary, but not stromal, development. This suggests that factors other than glycaemia have a role in placental development in pre-gestational diabetes.

Villitis of unknown aetiology: correlation of recurrence with clinical outcome.

Villitis of unknown aetiology (VUA) is associated with adverse pregnancy outcome. Consequently, an ability to predict recurrence could be clinically relevant. We examined placentas where villitis was diagnosed in a previous pregnancy to establish the risk of recurrence and outcome. A total of 304 cases of VUA were diagnosed in our laboratory over a 4-year period. Subsequently, 19 of this cohort had a second placenta examined histologically. Recurrence and clinical outcome were recorded. Villitis recurred in 7 of 19 cases (37%). There was a high level of adverse pregnancy outcome in this cohort overall, characterised by small for gestational age infants and stillbirth, particularly in cases with high-grade villitis. We identified recurrent villitis more frequently than previously reported. Our findings confirm an association between high-grade villitis and poor outcome. Adequately powered prospective studies are required to determine if enhanced surveillance of subsequent pregnancies is indicated following a diagnosis of villitis.

Lymphovascular space involvement in early stage well-differentiated endometrial cancer is associated with increased mortality.

OBJECTIVE: To study the relationship between lymphovascular space involvement (LVSI) in stage 1a or 1b well-differentiated endometrial cancer and survival. DESIGN: Retrospective study consisting of a search of an oncology database to identify women with endometrial cancer between January 1990 and December 2004. SETTING: Tertiary referral centre, Dublin, Ireland. SAMPLE: Women who had well-differentiated stage 1a or 1b endometrial cancer. METHODS: During the period 1990-2004, 226 patients with endometrial cancer were treated in the National Maternity Hospital, Dublin. We looked at all patients who had well-differentiated endometrioid adenocarcinoma of the endometrium with invasion of <50% thickness of the myometrium. Forty-one patients fulfilled these inclusion criteria. The presence or absence of LSVI was determined by review of haematoxylin and eosin sections. Patients were followed for 5 years or till death if earlier. Mortality was calculated. Statistical analysis was performed using Fisher's exact test. An odds ratio and 95% confidence interval was calculated using fixed effect Mantel-Haenszel model. MAIN OUTCOME MEASURES: Death from recurrence of endometrial cancer. RESULTS: Of the 41 patients, five (12%) were found to have (LVSI). Of the five patients with LVSI, three (60%) patients died of recurrence. All patients with recurrence died of disease and none of the patients without LVSI died (0 of 36). Overall, the survival rate was 92.7%. The presence of LVSI was a highly significant predictor of recurrence (P < 0.001). CONCLUSION: In patients with early stage well-differentiated adenocarcinoma of the endometrium, the presence of LVSI is associated with a high risk of death.

A qualitative investigation into the opinions of adolescent females regarding their body image concerns and dieting practices in the Republic of Ireland (ROI).

The aim of this study was to investigate the opinions of female adolescents living in the ROI on issues relating to body image and dietary practice. A qualitative study was selected to enable the issues to be explored in depth. Sixteen focus groups were executed with adolescent females (n=124) aged 15-16 years. Data collection took place during class time in both rural and urban schools in the ROI. Data were analysed using a qualitative thematic methodology, namely framework analysis. High levels of body dissatisfaction existed and dieting was found to be prevalent. The influence of media celebrities was significant. The girls not only aspired to be like them in terms of physique but also followed their alleged dieting regimes in detail. Peers also influenced body dissatisfaction and dieting practices. Consequently, eating habits were altered to accommodate this quest for thinness with a tendency to skip main meals as part of the dieting practice while maintaining an unhealthy snacking pattern. The results are of concern as the adolescent females were utilising unhealthy methods of weight control such as skipping meals and fasting in their quest to obtain a thin physique. A slim body image was deemed important for peer acceptance; hence 'crash' dieting was in existence. This mindset and the resultant dietary practices may have negative health consequences during both adolescence and later life. School interventions targeting adolescent females and focusing on healthy eating and body image are therefore urgently required.

Vaginal haemangioendothelioma: an unusual tumour.

Vaginal tumours are uncommon and this is a particularly rare case of a vaginal haemangioendothelioma in a 38-year-old woman. Initial presentation consisted of symptoms similar to uterovaginal prolapse with "something coming down". Examination under anaesthesia demonstrated a necrotic anterior vaginal wall tumour. Histology of the lesion revealed a haemangioendothelioma which had some features of haemangiopericytoma. While the natural history of vaginal haemangioendothelioma is uncertain, as a group, they have a propensity for local recurrence. To our knowledge this is the third reported case of a vaginal haemangioendothelioma. Management of this tumour is challenging given the paucity of literature on this tumour. There is a need to add rare tumours to our "knowledge bank" to guide management of these unusual tumours.

Histological grading of epithelial ovarian carcinomas.

The grade of an ovarian epithelial neoplasm provides useful information. However, different approaches to grading exist and many ovarian cancers are not graded. We examined primary ovarian cancers from patients treated at our hospital and applied the 'universal' grading system. We found a significant association between grade and clinical stage, with a survival difference between grades for low-stage tumours. The application of grade is discussed in the light of developments in the grading of other gynaecological cancers.

The role of placental cytogenetic cultures in intrauterine and neonatal deaths.

Knowledge of chromosomal status is useful in helping to explain fetal and neonatal deaths, but maceration has been felt to compromise the success rate. As well as skin fibroblast culture, the placenta can be sampled and this may be useful where permission for autopsy is refused. We examined placental cytogenetic results from 250 cases over a 5-year period. There was a success rate of 84.4%, with neither weight (< or > 500 g) nor maceration status showing a significant impact. Placentas sampled within 1 day were significantly more likely to give a positive culture. The results suggested that placental cytogenetic cultures should be attempted in all perinatal deaths where such information is desired.

Notochord anomalies in the adriamycin rat model: A morphologic and molecular basis for the VACTERL association.

BACKGROUND/PURPOSE: The Adriamycin rat model (ARM) is a reliable model of the VACTERL association. The notochord is structurally abnormal in the region of the foregut, midgut, and hindgut in the ARM. The authors hypothesised that notochord anomalies allow ectopic expression of molecular signals in the developing embryo and thus lead to VACTERL malformations. This study was designed to investigate this hypothesis. METHODS: Adriamycin (1.75 mg/kg) was administered intraperitoneally to pregnant rats on days 7, 8, and 9 of gestation. Control animals were given saline. Embryos were recovered on gestational days 10.5 to 14 at (1/2)-day intervals and at full term. The first group of embryos were embedded in resin, and sagittal sections stained with Toluidine blue were studied for morphologic abnormalities. The second group of embryos were examined using in situ hybridization for the expression of Sonic Hedgehog (Shh), a patterning gene implicated in the etiology of the VACTERL association. RESULTS: Twenty-seven of the 28 (96.4%) full-term embryos showed VACTERL anomalies. Forty-five of the 50 (90%) experimental embryos (gestational days 10.5 to 14) showed notochord abnormalities. Abnormal ventral branches from the notochord toward the gut were a commonly observed abnormality. These were seen to impinge on the developing foregut, midgut, dorsal aorta, and kidney. In situ hybridization for Shh showed that these branches from the notochord expressed Shh in 66.6% of experimental embryos. This abnormal Shh expression was not seen in the control embryos. CONCLUSIONS: Adriamycin diffusely induces altered notochord morphology in the rat embryo. The abnormal notochord morphology may allow ectopic expression of Sonic Hedgehog, and, thus, contribute to the malformations found in the VACTERL association.