Natural gene therapy by reverse mosaicism leads to improved hematology in Fanconi anemia patients.

Fanconi anemia (FA) is characterized by chromosome fragility, bone marrow failure (BMF) and predisposition to cancer. As reverse genetic mosaicism has been described as "natural gene therapy" in patients with FA, we sought to evaluate the clinical course of a cohort of FA mosaic patients followed at referral centers in Spain over a 30-year period. This cohort includes patients with a majority of T cells without chromosomal aberrations in the DEB-chromosomal breakage test. Relative to non-mosaic FA patients, we observed a higher proportion of adult patients in the cohort of mosaics, with a later age of hematologic onset and a milder evolution of (BMF). Consequently, the requirement for hematopoietic stem cell transplant (HSCT) was also lower. Additional studies allowed us to identify a sub-cohort of mosaic FA patients in whom the reversion was present in bone marrow (BM) progenitor cells leading to multilineage mosaicism. These multilineage mosaic patients are older, have a lower percentage of aberrant cells, have more stable hematology and none of them developed leukemia or myelodysplastic syndrome when compared to non-mosaics. In conclusion, our data indicate that reverse mosaicism is a good prognostic factor in FA and is associated with more favorable long-term clinical outcomes.

A case of Endometrioid endometrial adenocarcinoma with synchronous low-grade Appendiceal mucinous neoplasm and Pseudomyxoma peritonei.

Pseudomyxoma peritonei (PMP) is a rare condition usually associated with ruptured low-grade mucinous neoplasm of the appendix. Rarely, PMP can originate from mucinous adenocarcinoma of the ovary. However, the coexistence of adenocarcinoma of the endometrium and appendiceal mucinous neoplasm has not been reported. We present the case of a post-menopausal woman with endometrioid endometrial adenocarcinoma with unexpected low-grade appendiceal mucinous neoplasm and PMP.

Mosaicism in Fanconi anemia: concise review and evaluation of published cases with focus on clinical course of blood count normalization.

Fanconi anemia (FA) is a DNA repair disorder resulting from mutations in genes encoding for FA DNA repair complex components and is characterized by variable congenital abnormalities, bone marrow failure (BMF), and high incidences of malignancies. FA mosaicism arises from reversion or other compensatory mutations in hematopoietic cells and may be associated with BMF reversal and decreased blood cell sensitivity to DNA-damaging agents (clastogens); this sensitivity is a phenotypic and diagnostic hallmark of FA. Uncertainty regarding the clinical significance of FA mosaicism persists; in some cases, patients have survived multiple decades without BMF or hematologic malignancy, and in others hematologic failure occurred despite the presence of clastogen-resistant cell populations. Assessment of mosaicism is further complicated because clinical evaluation is frequently based on clastogen resistance in lymphocytes, which may arise from reversion events both in lymphoid-specific lineages and in more pluripotent hematopoietic stem/progenitor cells (HSPCs). In this review, we describe diagnostic methods and outcomes in published mosaicism series, including the substantial intervals (1-6 years) over which blood counts normalized, and the relatively favorable clinical course in cases where clastogen resistance was demonstrated in bone marrow progenitors. We also analyzed published FA mosaic cases with emphasis on long-term clinical outcomes when blood count normalization was identified. Blood count normalization in FA mosaicism likely arises from reversion events in long-term primitive HSPCs and is associated with low incidences of BMF or hematologic malignancy. These observations have ramifications for current investigational therapeutic programs in FA intended to enable gene correction in long-term repopulating HSPCs.

A Retrospective Comparative Analysis of 2D Versus 3D Laparoscopy in Total Laparoscopic Hysterectomy for Large Uteri (≥ 500g).

STUDY OBJECTIVE: To evaluate the outcomes of total laparoscopic hysterectomy using 3D vision in comparison with 2D vision in women with large uteri (≥500g). DESIGN: Retrospective analytical study Design Classification: Canadian Task Force II-1 Setting: Tertiary referral center for advanced gynecological surgery. PATIENTS: Five hundred forty six women who underwent total laparoscopic hysterectomy over a period of 13 years were studied: 301 under 2D vision and 245 under 3D vision. INTERVENTIONS: Total laparoscopic hysterectomy Measurements: Surgical time, blood loss and complications were recorded for every case in both groups. MAIN RESULTS: The duration of surgery for hysterectomy in the 3D laparoscopy group (88.01?36.95 min) was significantly shorter than that in the 2D group (112.61?42.59 min, p=.0001). Blood loss in the 500-1000g group was significantly less in the 3D group (p=.005). The total complication rates for 3D surgery (3.37 %) and 2D surgery (6.64%) were comparable (p=.25). CONCLUSION: Three-dimensional laparoscopy provides stereoscopic vision and increases precision and safety. The availability of depth perception adds to the ease of surgery, especially in cases of large uteri, leading to reductions in both the duration of surgery and blood loss, which improves patient outcomes.

Three-dimensional laparoscopy: Principles and practice.

The largest challenge for laparoscopic surgeons is the eye-hand coordination within a three-dimensional (3D) scene observed on a 2D display. The 2D view on flat screen laparoscopy is cerebrally intensive. The loss of binocular vision on a 2D display causes visual misperceptions, mainly loss of depth perception and adds to the surgeon's fatigue. This compromises the safety of laparoscopy. The 3D high-definition view with great depth perception and tactile feedback makes laparoscopic surgery more acceptable, safe and cost-effective. It improves surgical precision and hand-eye coordination, conventional and all straight stick instruments can be used, capital expenditure is less and recurring cost and annual maintenance cost are less. In this article, we have discussed the physics of 3D laparoscopy, principles of depth perception, and the different kinds of 3D systems available for laparoscopy. We have also discussed our experience of using 3D laparoscopy in over 2000 surgeries in the last 4 years.

Preclinical safety and efficacy of lentiviral-mediated gene therapy for leukocyte adhesion deficiency type I.

Leukocyte adhesion deficiency type I (LAD-I) is a primary immunodeficiency caused by mutations in the ITGB2 gene, which encodes for the CD18 subunit of ß2-integrins. Deficient expression of ß2-integrins results in impaired neutrophil migration in response to bacterial and fungal infections. Using a lentiviral vector (LV) that mediates a preferential myeloid expression of human CD18 (Chim.hCD18-LV), we first demonstrated that gene therapy efficiently corrected the phenotype of mice with severe LAD-I. Next, we investigated if the ectopic hCD18 expression modified the phenotypic characteristics of human healthy donor hematopoietic stem cells and their progeny. Significantly, transduction of healthy CD34+ cells with the Chim.hCD18-LV did not modify the membrane expression of CD18 nor the adhesion of physiological ligands to transduced cells. Additionally, we observed that the repopulating properties of healthy CD34+ cells were preserved following transduction with the Chim.hCD18-LV, and that a safe polyclonal repopulation pattern was observed in transplanted immunodeficient NOD scid gamma (NSG) mice. In a final set of experiments, we demonstrated that transduction of CD34+ cells from a severe LAD-I patient with the Chim.hCD18-LV restores the expression of ß2-integrins in these cells. These results offer additional preclinical safety and efficacy evidence supporting the gene therapy of patients with severe LAD-I.

Comparison of urine albumin creatinine ratio with the pediatric index of mortality 2 score for prediction of pediatric intensive care unit outcomes.

BACKGROUND: Predicting morbidity and mortality in a pediatric intensive care unit (PICU) is of extreme importance to make precise decisions for better outcomes. AIM: We compared the urine albumin creatinine ratio (ACR) with the established PICU score, pediatric index of mortality 2 (PIM 2) for predicting PICU outcomes. METHODS: This cross-sectional study enrolled 67 patients admitted to PICU with systemic inflammatory response syndrome. Urine ACR was estimated on admission, and PIM 2 score was calculated. ACR was compared with PIM 2 for PICU outcome measures: the need for inotropes, development of multiple organ dysfunction syndrome (MODS), duration of PICU stay, and survival. RESULTS: Microalbuminuria was found in 77.6% of patients with a median ACR of 80 mg/g. ACR showed a significant association with the need for inotropes (p < 0.001), MODS (p = 0.001), and significant correlation to PICU stay (p 0.001, rho = 0.361). The area under the receiver operating characteristic curve for ACR (0.798) was comparable to that of PIM 2 (0.896). The cutoff value of ACR derived to predict mortality was 110 mg/g. The study subjects were divided into 2 groups: below cutoff and above the cutoff. Outcome variables, inotrope use, MODS, mortality, and PICU stay compared between these subgroups, were statistically significant. CONCLUSION: ACR is a good predictor of PICU outcomes and is comparable to PIM 2 for mortality prediction.

Comparative validity of microalbuminuria versus clinical mortality scores to predict pediatric intensive care unit outcomes.

BACKGROUND: Predicting the prognosis of patients admitted to the pediatric intensive care unit (PICU) is very important in determining further management and resource allocation. The prognostication of critically ill children can be challenging; hence, accurate methods for predicting outcomes are needed. PURPOSE: To evaluate the role of microalbuminuria at admission as a prognostic marker in comparison to standard Pediatric Risk of Mortality (PRISM) and Pediatric Logistic Organ Dysfunction (PELOD) mortality scores in children admitted to the PICU. METHODS: This cross-sectional study was conducted from January 2015 to October 2016. Eighty-four patients aged 1 month to 18 years admitted to the PICU of teaching hospitals for more than 24 hours were enrolled by convenience sampling method. Microalbuminuria was estimated by spot urinary albumin-creatinine ratio. PRISM and PELOD scores were calculated using an online calculator. Outcome measures were PICU length of stay, inotrope usage, multiorgan dysfunction, and survival. ACR was compared with mortality scores for predicting survival. RESULTS: Microalbuminuria was present in 79.8% with a median value of 85 mg/g (interquartile range, 41.5-254 mg/g). A positive correlation was found between albumin-creatinine ratio and PICU length of stay (P=0.013, r=0.271). Albumin-creatinine ratio was significantly associated with organ dysfunction (P=0.004) and need for inotropes (P=0.006). Eight deaths were observed in the PICU. The area under the curve for mortality for albumin-creatinine ratio (0.822) was comparable to that for PRISM (0.928) and PELOD (0.877). Albumin-creatinine ratio >109 mg/g predicted mortality with a sensitivity of 87.5% and specificity of 63.2%. CONCLUSION: Microalbuminuria is a good predictor of PICU outcomes comparable with mortality scores.

Precision Medicines' Impact on Orphan Drug Designation.

The incentives provided under the Orphan Drug Act (ODA) have been credited for catalyzing the marketing approval of drugs for the treatment of rare diseases by the US Food and Drug Administration. Orphan drug designation, the granting of special status to drugs or biologics ("drugs") for the treatment of rare diseases, one of the ODA's key incentive programs, has seen major increases in volume over recent years. The new era of precision medicine and the development of therapies directed toward smaller "orphan" subsets of common diseases have been suggested as being a major driver. We evaluated the basis for orphan drug designations and orphan subsets in relation to the impact of precision medicines. We found that the increasing numbers of orphan drug designation determinations were not driven by precision medicines separating common diseases into orphan subsets and that orphan subsets overall also represented a relatively small proportion of designations.

Children and Adults With Rare Diseases Need Innovative Medical Devices.

Rare diseases (RD) affect approximately 30 million Americans, half of whom are children. This study is the first to comprehensively evaluate their medical device needs via a survey of physicians. The study sought to identify and document the presumed unmet diagnostic and therapeutic device needs for RD management; clarify the magnitude of the potential unmet need; and generate meaningful data to inform medical device stakeholders. A cross-sectional nonprobability survey was conducted. The study population was drawn from the membership files of four groups: FDA Medical Devices Advisory Committee, Pediatric Advisory Committee, Pediatric Device Consortia, and National Institutes of Health (NIH) Rare Diseases Clinical Research Network. Only physician respondents with experience or knowledge regarding RD were eligible. Among eligible respondents, 90% confirmed the need for innovative devices to care for people with RD. Over 850 device needs were identified for 436 RD, with 74% of needs related to children. Pediatric physicians (OR = 2.11, 95% CI 1.01-4.39, P = 0.046) and physicians with more RD experience reflected greater dissatisfaction with existing devices (OR = 4.49, 95% CI 2.25-8.96, P < 0.0001). Creation of entirely new devices is the top recommendation for mitigating needs. This study demonstrates a major public health need for innovative medical devices to care for children and adults with RD. FDA and NIH support and seek opportunities to accelerate device development for these vulnerable patients.

Facilitating role of preprotachykinin-I gene in the integration of breast cancer cells within the stromal compartment of the bone marrow: a model of early cancer progression.

Despite early detection of breast cancer, patients' survival may be compromised if the breast cancer cells (BCCs) enter the bone marrow (BM). It is highly probable that BCCs enter the BM long before clinical detection. An in vitro coculture model with BM stroma and BCCs (cell lines; primary cells from stage III BC, n = 7, and stage M0, n = 3) mimicked early entry of BCCs into the BM. In coculture, BCCs exhibit contact inhibition and do not require otherwise needed growth supplements. Stromal growth rate was increased 2-fold in coculture. The inclusion of BCCs in stromal support of long-term culture-initiating cell assay frequencies show no difference (38 +/- 3 versus 36 +/- 6). Nontumorigenic breast cells (patients and cell lines) did not survive in coculture, suggesting that the model could select for malignant population in surgical breast tissues. Cocultures were able to select cells with 73 +/- 7% cloning efficiencies and with the ability to form cocultures with BM stroma. Preprotachykinin-I (PPT-I), a gene that is conserved by evolution, facilitates BCC integration as part of the stromal compartment. This was deduced as follows: (a) nontumorigenic breast cells (n = 4) genetically engineered to express PPT-I and led to anchorage-independent growth, foci formation, and formation of cocultures; and (b) suppression of PPT-I in BCCs (n = 5) with pPMSKH1-PPT-I small interfering RNA reverted the cells to nontumorigenic phenotypes and was undetectable in the BM nude mice. The evidence supports that the PPT-I gene facilitates the integration of BCCs in the stromal compartment during a period before clinical detection, without disrupting hematopoietic activity.

Laparoscopic myomectomy with uterine artery ligation: review article and comparative analysis.

Uterine leiomyomas are one of the most common benign smooth muscle tumors in women, with a prevalence of 20 to 40% in women over the age of 35 years. Although many women are asymptomatic, problems such as bleeding, pelvic pain, and infertility may necessitate treatment. Laparoscopic myomectomy is one of the treatment options for myomas. The major concern of myomectomy either by open method or by laparoscopy is the bleeding encountered during the procedure. Most studies have aimed at ways of reducing blood loss during myomectomy. There are various ways in which bleeding during laparoscopic myomectomy can be reduced, the most reliable of which is ligation of the uterine vessels bilaterally. In this review we propose to discuss the benefits and possible disadvantages of ligating the uterine arteries bilaterally before performing laparoscopic myomectomy.

Single-incision total laparoscopic hysterectomy.

Single-incision laparoscopic surgery is an alternative to conventional multiport laparoscopy. Single-access laparoscopy using a transumbilical port affords maximum cosmetic benefits because the surgical incision is hidden in the umbilicus. The advantages of single-access laparoscopic surgery may include less bleeding, infection, and hernia formation and better cosmetic outcome and less pain. The disadvantages and limitations include longer surgery time, difficulty in learning the technique, and the need for specialized instruments. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. We perform single-incision total laparoscopic hysterectomy using three ports in the single transumbilical incision.

Parasitic myoma after morcellation.

We report an interesting case of parasitic fibroid which developed from a morcellation remnant following laparoscopic myomectomy. The patient presented with incidental finding of pelvic mass in 2005. She underwent laparoscopic myomectomy for a myoma extending from the Pouch of Douglas to both sides of broad ligament. She subsequently presented with abdominal pain 3 years later in 2008. She underwent total laparoscopic hysterectomy with removal of broad ligament fibroids. During her hysterectomy, a right lumbar mass attached to the omentum was detected, which was excised laparoscopically. Histopathology of the mass confirmed it to be consistent with leiomyoma. This mass could probably be a morcellation remnant that has grown to this size taking blood supply from the omentum. We report this case to emphasize that all tissue pieces that are morcellated should be diligently removed. Even small bits displaced into the upper abdomen can result in parasitic fibroids. Thus, it can be concluded that parasitic myomas can arise from morcellated remnants and grow depending on the blood supply.