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Hyalgan

Hyaluronan (also called hyaluronic acid or hyaluronate) is a glycosaminoglycan distributed widely throughout connective, epithelial, and neural tissues. It is one of the chief components of the extracellular matrix, contributes significantly to cell proliferation and migration, and may also be involved in the progression of some malignant tumors. more...

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Functions

Until the late 1970s, hyaluronan was described as a "goo" molecule, a ubiquitous carbohydrate polymer that comprised the extracellular matrix. For example, hyaluronan is a major component of the extracellular matrix that constitutes synovial fluid. Along with lubricin, it is one of the fluid's main lubricating components. It helps protect joints by increasing the viscosity of the fluid and by making the cartilage between bones more elastic.

While it is found in large numbers in extracellular matrices, hyaluronan also contributes to tissue hydrodynamics, movement and proliferation of cells, and participates in a number of cell surface receptor interactions, notably those including its primary receptor in vivo, CD44. Upregulation of CD44 itself is widely accepted as a marker of cell activation in lymphocytes.

Hyaluronan's contribution to tumor growth may be due to its interaction with CD44. CD44, the chief in vivo hyaluronan receptor, participates in cell adhesion interactions required by tumor cells. Some of the enzymes that break down hyaluronan are known tumor suppressants; paradoxically, the gene for hyaluronidase-2 is an oncogene and promotes tumor growth.

Structure

The chemical structure of hyaluronan was determined in the 1950s in the laboratory of Karl Meyer. Hyaluronan is a polymer of disaccharides themselves composed of D-glucuronic acid and D-N-acetylglucosamine, linked together via alternating beta-1,4 and beta-1,3 glycosidic bonds. Polymers of hyaluronan can range in size from 102 to 104 kDa in vivo.

Hyaluronan is energetically stable in part because of the stereochemistry of its component disaccharides. Bulky groups on each sugar molecule are in sterically favored positions while the smaller hydrogens assume the less favorable axial positions.

Synthesis

Hyaluronan is synthesized by a class of integral membrane proteins called hyaluronan synthases, of which vertebrates have three types: HAS1, HAS2, and HAS3. These enzymes lengthen hyaluronan by repeatedly adding glucuronic acid and N-acetylglucosamine to the nascent polysaccharide.

Degradation

Hyaluronan is degraded by a family of enzymes called hyaluronidases. In humans, there are at least seven types of hyaluronidase-like enzymes, several of which are tumor suppressors. The degradation products of hyaluronan, the oligosaccharides and very low molecular weight hyaluronan, exhibit pro-angiogenic properties.

Medical applications

Hyaluronan is naturally found in many tissues of the body such as skin, cartilage, and the vitreous humor. It is therefore well suited to biomedical applications targeting these tissues. The first hyaluronan biomedical product, Healon, was developed in the 1970s and 1980s and is approved for use in ophthalmic surgery (i.e. corneal transplantation, cataract surgery, glaucoma surgery and retinal attachment surgery). Other biomedical companies also produce brands of hyaluronan for ophthalmic surgery .

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HPV testing may replace Pap smears for primary screening
From Journal of Family Practice, 4/1/04

Cuzick J, Szarewski A, Cubie H, et al. Management of women who test positive for high-risk types of human papillomavirus: the HART study. Lancet 2003; 362:1871-1876.

* CLINICAL QUESTION

Can human papillomavirus testing replace Papanicolaou tests as the primary means of screening for cervical cancer?

* BOTTOM LINE

Using human papillomavirus (HPV) testing is likely to replace Papanicolaou (Pap) testing for primary screening for cervical cancer for a variety of reasons--detection of the etiologic factor should predate the development of disease; urine testing for HPV may remove patient barriers to screening; and reduced interpretation error. This study can't really provide the kind of data to support this, however. It is even more likely that vaccination against HPV may render both these technologies obsolete. (LOE=2b)

* STUDY DESIGN

Randomized controlled trial (nonblinded)

* SETTING

Outpatient (primary care)

* SYNOPSIS

In this multicenter screening study, 11,085 women aged 30 to 60 years were recruited from 161 family practices in the United Kingdom. To be eligible, the women could not have had an abnormal Pap result in the preceding 3 years and could never have been treated for cervical intraepithelial neoplasia (CIN). Women had a standard Pap test using an extended-tip Ayre's spatula and a sample was placed into transport medium. Women with mild dyskaryosis or worse were referred for colposcopy.

A total of 825 women (8%) showed minimal abnormalities (borderline cytology, or positive high-risk HPV test results and negative cytology) and were randomized to immediate colposcopy or surveillance by HPV testing and cytology at 6 and 12 months. Women in the surveillance group were referred for colposcopy at 6 months if the cytology result progressed to mild dyskaryosis or worse. In all other cases the women were invited for colposcopy and repeat testing at 12 months. HPV testing was more sensitive than abnormal Pap results (97% vs 77%; P=.002) at detecting CIN 2 or worse, but it was less specific (93% vs 96%; P<.0001).

Among the 825 randomized women, immediate colposcopy and surveillance were comparable: 45% of the surveillance women tested positive for HPV at baseline, had negative cytology, and 35% with borderline cytology were HPV negative at 6 to 12 months. None had CIN 2 or worse.

Technically speaking, this is not a trial comparing screening modalities, but rather a trial of different modes of follow-up. Since we don't have outcomes data, and since cervical cancer is relatively rare and tends to be slow-growing, these data need confirmation in larger, longer, more rigorous trials.

COPYRIGHT 2004 Dowden Health Media, Inc.
COPYRIGHT 2004 Gale Group

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