Circulating Nucleated Red Blood Cells: An Updated Reference Interval.

CONTEXT.­: Nucleated red blood cells (nRBCs) are not identified in the peripheral blood in healthy individuals beyond the neonatal period. Their presence in children and adults is traditionally considered pathologic. Contemporary hematology analyzers measure nRBCs at very low levels compared to traditional manual morphometric methods. The original launch of the Sysmex XN analyzer in this study's clinical laboratory verified the previously used nRBC reference interval of 0.00 to 0.01 × 106/µL. However, nRBC results from apparently healthy patients were flagged as abnormal (high), subsequently causing patient anxiety and increased subspecialty referrals. OBJECTIVE.­: To determine whether current reference intervals (RIs) for nRBCs were clinically relevant. DESIGN.­: We performed a prospective analysis of 405 300 specimens from nonhospitalized individuals who received a complete blood count. Applying inclusion/exclusion criteria produced a total specimen pool of 66 498. RESULTS.­: Of the 66 498 samples with otherwise normal complete blood count results from healthy, nonhospitalized individuals, 338 showed results outside the previously established RI; 336 of 66 498 (0.5%) had nRBC results greater than 0.01 × 106/µL. Two samples had nRBC values greater than 0.10 ×106/µL. CONCLUSIONS.­: Based on statistical analysis of our results, we concluded that the upper limit of the RI could be updated from 0.01 × 106/µL to 0.10 × 106/µL. Increasing the upper limit of normal for the nRBC RI should decrease patient consternation from an abnormal laboratory value and significantly decrease costs through reducing unnecessary follow up care, and without causing patient harm.

Venetoclax and azacitidine compared with induction chemotherapy for newly diagnosed patients with acute myeloid leukemia.

Venetoclax (ven) plus azacitidine (aza) is the standard of care for patients with newly diagnosed acute myeloid leukemia (AML) who are not candidates for intensive chemotherapy (IC). Some patients who are IC candidates instead receive ven/aza. We retrospectively analyzed patients with newly diagnosed AML who received ven/aza (n = 143) or IC (n = 149) to compare outcomes, seek variables that could predict response to 1 therapy or the other, and ascertain whether treatment recommendations could be refined. The response rates were 76.9% for ven/aza and 70.5% for IC. The median overall survival (OS) was 884 days for IC compared with 483 days for ven/aza (P = .0020). A propensity-matched cohort was used to compare outcomes in the setting of equivalent baseline variables, and when matched for age, biological risk, and transplantation, the median OS was 705 days for IC compared with not reached for ven/aza (P = .0667). Variables that favored response to ven/aza over IC included older age, secondary AML, and RUNX1 mutations. AML M5 favored response to IC over ven/aza. In the propensity-matched cohort analyzing OS, older age, adverse risk, and RUNX1 mutations favored ven/aza over IC, whereas intermediate risk favored IC over ven/aza. In conclusion, patients receiving IC have improved OS compared with those receiving ven/aza. However, in a propensity-matched cohort of patients with equivalent baseline factors, there was a trend toward favorable OS for ven/aza. Specific variables, such as RUNX1 mutations, reported here for the first time, can be identified that favor ven/aza or IC, helping to guide treatment decisions for patients who may be eligible candidates for either therapy.

Monitoring the neurotransmitter release of human midbrain organoids using a redox cycling microsensor as a novel tool for personalized Parkinson's disease modelling and drug screening.

In this study, we have aimed at developing a novel electrochemical sensing approach capable of detecting dopamine, the main biomarker in Parkinson's disease, within the highly complex cell culture matrix of human midbrain organoids in a non-invasive and label-free manner. With its ability to generate organotypic structures in vitro, induced pluripotent stem cell technology has provided the basis for the development of advanced patient-derived disease models. These include models of the human midbrain, the affected region in the neurodegenerative disorder Parkinson's disease. Up to now, however, the analysis of so-called human midbrain organoids has relied on time-consuming and invasive strategies, incapable of monitoring organoid development. Using a redox-cycling approach in combination with a 3-mercaptopropionic acid self-assembled monolayer modification enabled the increase of sensor selectivity and sensitivity towards dopamine, while simultaneously reducing matrix-mediated interferences. In this work, we demonstrate the ability to detect and monitor even small differences in dopamine release between healthy and Parkinson`s disease-specific midbrain organoids over prolonged cultivation periods, which was additionally verified using liquid chromatography-multiple reaction monitoring mass spectrometry. Furthermore, the detection of a phenotypic rescue in midbrain organoids carrying a pathogenic mutation in leucine-rich repeat kinase 2, upon treatment with the leucine-rich repeat kinase 2 inhibitor II underlines the practical implementability of our sensing approach for drug screening applications as well as personalized disease modelling.

Biopsy Results Are Not Sufficient to Exclude Breast Implant-associated Anaplastic Large Cell Lymphoma: A Case Mistaken for Disseminated Silicosis.

We present a case report of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) that was mistaken as disseminated silicosis after multiple percutaneous biopsies. The correct diagnosis of BIA-ALCL was confirmed only after a pathologic examination of the capsulectomy specimens. A review of the literature of percutaneous biopsies of ALCL showed a diagnostic yield of only 63%. Although percutaneous biopsies may be facile to obtain and may be diagnostic, in our case, biopsies were not sufficient to exclude the diagnosis of BIA-ALCL.

Real-world experience of venetoclax with azacitidine for untreated patients with acute myeloid leukemia.

Venetoclax is approved for older untreated acute myeloid leukemia (AML) patients. Venetoclax was available prior to approval off-label. We assessed our single-institution off-label experience with venetoclax/azacitidine, comparing outcomes with a clinical trial cohort that administered this regimen at the same institution. Thirty-three untreated AML patients unfit or unwilling to receive induction chemotherapy and prescribed venetoclax/azacitidine off-trial were retrospectively analyzed and compared with 33 patients who received the same therapy on trial. Outcomes were compared, and comparisons were made to a theoretical scenario in which off-trial patients received induction. Digital droplet polymerase chain reaction evaluated measurable residual disease (MRD). Off-trial venetoclax was attainable in nearly all patients for whom this was desired. The complete remission (CR)/CR with incomplete blood count recovery rate was 63.3% for off-trial patients who received treatment and 84.9% for trial patients (P = .081). The median overall survival for off-trial patients who received treatment was 381 days (95% confidence interval [CI], 174, not reached) vs 880 days (95% CI, 384, not reached) for trial patients (P = .041). Prior exposure to hypomethylating agents was associated with worse outcomes. Response rates with venetoclax/azacitidine were not inferior to a theoretical scenario in which patients received induction, and early death rates were less than expected with induction. MRD negativity was achievable. Newly diagnosed AML patients treated in a "real-world" scenario with off-trial venetoclax/azacitidine had inferior outcomes compared with patients treated in the setting of a clinical trial. Additionally, this therapy may be as effective, and less toxic, when compared with induction chemotherapy.

Diverse clinical and histopathologic features of cutaneous post-transplant lymphoproliferative disorders: A presentation of two cases.

Heterogeneous lymphoproliferative disorders occurring in the post-transplant setting are considered together as post-transplant lymphoproliferative disorders and can rarely present as primary cutaneous lesions. These disorders are often Epstein-Barr virus-driven and in some cases need only be treated with reduction in immune suppressive medications. We present two cases of monomorphic post-transplant lymphoproliferative disorder, a plasmablastic lymphoma and a diffuse large B-cell lymphoma, and summarise common reported clinical and histopathological features.

Co-culture of osteochondral explants and synovial membrane as in vitro model for osteoarthritis.

The purpose of the current study was to establish an in vitro model for osteoarthritis (OA) by co-culture of osteochondral and synovial membrane explants. Osteochondral explants were cultured alone (control-1) or in co-culture with synovial membrane explants (control-2) in standard culture medium or with interleukin-1ß (IL1ß) and tumor necrosis factor (TNFα) added to the culture medium (OA-model-1 = osteochondral explant; OA-model-2 = osteochondroal-synovial explant). In addition, in OA-model groups a 2-mm partial-thickness defect was created in the centre of the cartilage explant. Changes in the expression of extracellular matrix (ECM) genes (collagen type-1 (Col1), Col2, Col10 and aggrecan) as well as presence and quantity of inflammatory marker genes (IL6, matrix metalloproteinase-1 (MMP1), MMP3, MMP13, a disintegrin and metalloproteinase with-thrombospondin-motif-5 (ADAMTS5) were analysed by immunohistochemistry, qPCR and ELISA. To monitor the activity of classically-activated pro-inflammatory (M1) versus alternatively-activated anti-inflammatory/repair (M2) synovial macrophages, the nitric oxide/urea ratio in the supernatant of osteochondral-synovial explant co-cultures was determined. In both OA-model groups immunohistochemistry and qPCR showed a significantly increased expression of MMPs and IL6 compared to their respective control group. ELISA results confirmed a statistically significant increase in MMP1and MMP3 production over the culturing period. In the osteochondral-synovial explant co-culture OA-model the nitric oxide/urea ratio was increased compared to the control group, indicating a shift toward M1 synovial macrophages. In summary, chemical damage (TNFα, IL1ß) in combination with a partial-thickness cartilage defect elicits an inflammatory response similar to naturally occurring OA in osteochondral explants with and without osteochondral-synovial explant co-cultures and OA-model-2 showing a closer approximation of OA due to the additional shift of synovial macrophages toward the pro-inflammatory M1 phenotype.

Use of tube cystostomy in the surgical management of obstructive urolithiasis in a Bactrian camel.

CASE DESCRIPTION: A 6-year-old castrated male Bactrian camel was evaluated because of a 14hour history of oliguria and stranguria that progressed to anuria. CLINICAL FINDINGS: Perineal urethral pulsations and intermittent tail flagging with no accompanying urination were observed. Ultrasonography of the urethra revealed multiple hyperechoic foci with shadowing artifact indicative of calculi present in the penile urethra distal to the sigmoid flexure. Rectal palpation revealed a pulsating hard urethra and intact distended urinary bladder. Further clinical examination was not possible because of challenges associated with handling the camel. TREATMENT AND OUTCOME: Urethral catheterization through a perineal urethral incision failed to achieve urinary bladder decompression. Tube cystostomy was performed to prevent bladder rupture. Urethrocystography performed 3 days after surgery revealed a urethral rupture at the level of the prepuce. Five weeks after surgery, the camel could urinate a steady stream via the urethrotomy site. Seven weeks after surgery, the cystostomy tube was removed, and the urethrotomy site was modified to provide a permanent urethral opening via perineal urethrostomy. During 6 years of subsequent periodic follow-up by telephone, the owner reported that the camel continued to do well and urinate through the revised opening. CLINICAL RELEVANCE: To the authors' knowledge, this is the first detailed description of a tube cystostomy in an adult camel with obstructive urolithiasis that includes information on the patient's long-term outcome. This technique was a viable option in the surgical management of obstructive urolithiasis in this camel and may be useful for other large camelids as well.

Tomorrow today: organ-on-a-chip advances towards clinically relevant pharmaceutical and medical in vitro models.

Organ-on-a-chip technology offers the potential to recapitulate human physiology by keeping human cells in a precisely controlled and artificial tissue-like microenvironment. The current and potential advantages of organs-on-chips over conventional cell cultures systems and animal models have captured the attention of scientists, clinicians and policymakers as well as advocacy groups in the past few years. Recent advances in tissue engineering and stem cell research are also aiding the development of clinically relevant chip-based organ and diseases models with organ level physiology for drug screening, biomedical research and personalized medicine. Here, the latest advances in organ-on-a-chip technology are reviewed and future clinical applications discussed.

Fetal articular cartilage regeneration versus adult fibrocartilaginous repair: secretome proteomics unravels molecular mechanisms in an ovine model.

Osteoarthritis (OA), a degenerative joint disease characterized by progressive cartilage degeneration, is one of the leading causes of disability worldwide owing to the limited regenerative capacity of adult articular cartilage. Currently, there are no disease-modifying pharmacological or surgical therapies for OA. Fetal mammals, in contrast to adults, are capable of regenerating injured cartilage in the first two trimesters of gestation. A deeper understanding of the properties intrinsic to the response of fetal tissue to injury would allow us to modulate the way in which adult tissue responds to injury. In this study, we employed secretome proteomics to compare fetal and adult protein regulation in response to cartilage injury using an ovine cartilage defect model. The most relevant events comprised proteins associated with the immune response and inflammation, proteins specific for cartilage tissue and cartilage development, and proteins involved in cell growth and proliferation. Alarmins S100A8, S100A9 and S100A12 and coiled-coil domain containing 88A (CCDC88A), which are associated with inflammatory processes, were found to be significantly upregulated following injury in adult, but not in fetal animals. By contrast, cartilage-specific proteins like proteoglycan 4 were upregulated in response to injury only in fetal sheep postinjury. Our results demonstrate the power and relevance of the ovine fetal cartilage regeneration model presented here for the first time. The identification of previously unrecognized modulatory proteins that plausibly affect the healing process holds great promise for potential therapeutic interventions.

Metastatic Urothelial Carcinoma to the Uterine Cervix: A Case Report of a Rare Entity and Review of the Diagnostic Differential.

Urothelial carcinoma (UC) rarely metastasizes to the gynecologic tract, occurring in descending order of frequency, within the vagina, uterus, ovaries, and cervix. Significant morphologic overlap exists between primary gynecologic squamous lesions (both benign and malignant) and metastatic UC, thus potentially hindering a timely and accurate diagnosis. We present a case of UC metastatic to the uterine cervix in a 69-year-old female initially found to have noninvasive high-grade papillary UC of the bladder. Complaints of vaginal spotting lead to identification and biopsy of a mass in the uterine cervix. Histologic evaluation of the cervical mass showed a neoplastic proliferation of atypical epithelioid cells arranged in a papillary architecture. The differential in this case included primary uterine cervical tumors such as condyloma acuminatum, immature condyloma, verrucous carcinoma, warty/condylomatous carcinoma, and papillary squamotransitional cell carcinoma, as well as metastatic UC. A careful evaluation of histologic variances and a selective immunohistochemical panel allows differentiation of these tumors. We herein review the subtle, albeit significant, histologic and immunohistochemical differences of the aforementioned lesions.

Pelvic flexure enterotomy closure in the horse with a TA-90 stapling device: a retrospective clinical study of 84 cases (2001-2008).

Our objective was to compare survival and complication rates of horses undergoing pelvic flexure enterotomy closure with a TA-90 stapler to those with hand-sewn closure. Medical records of horses undergoing pelvic flexure enterotomy between 2001 and 2008 were reviewed. History, clinical signs, surgical findings, surgical techniques, and post-operative complications were recorded. Long-term outcome was established by telephone questionnaire. Of 84 pelvic flexure enterotomies performed, 70 were stapled and 14 were hand-sewn. Seventy-seven horses survived to discharge (91.7%). There were no significant associations between survival and closure technique (P = 0.69). Follow-up was available for 54 horses; 50 survived long-term (93.0%). No statistical significance was identified between long-term survival and closure method (P = 0.39). Forty horses went on to athletic performance (80.0%). TA-90 stapled closure of pelvic flexure enterotomies is a safe technique resulting in survival and complication rates equivalent to those of hand-sewn closure.

Comparison of single layer staple closure versus double layer hand-sewn closure for equine pelvic flexure enterotomy.

Our objective was to compare thoracoabdominal (TA Premium™ 90) stapled enterotomy closure to traditional hand-sewn closure, using time to perform the technique, luminal diameter, and bursting pressure in ex-vivo specimens. The pelvic flexures of 13 client-owned horses were harvested. Each pelvic flexure had 1 enterotomy performed; 6 were closed via staples, 7 closures were hand-sewn. Luminal diameter at the enterotomy site was assessed via contrast radiography performed pre-and post-enterotomy. Bursting pressure of the closure was assessed by continuous manometry during rapid infusion. Time to perform stapled closure was significantly shorter than hand-sewn closure (P < 0.0001). Percent reduction of luminal diameters was significantly decreased in stapled specimens (P = 0.034). There was no significant difference in bursting strength between closure techniques (P = 0.196). In conclusion, stapled enterotomy closure offers statistically significant reduction in closure time and better maintains pre-enterotomy luminal diameter without reducing biomechanical strength, compared to a double layer hand-sewn closure.