Insights into the cellular basis of skin inflammation in systemic autoimmune rheumatic diseases from single-cell technologies.

Cutaneous inflammation is a common feature of several systemic autoimmune rheumatic diseases (SARDs) including systemic lupus erythematosus (SLE), undifferentiated connective tissue disease (UCTD), mixed connective tissue disease (MCTD) and dermatomyositis (DM) but is less common in other SARDs such as primary Sjögren's syndrome (pSS). It is important to understand whether the pathophysiological processes underlying skin inflammation are different or shared between SARDs to develop targeted therapies. This review will discuss commonalities and differences between inflammatory skin disease in SARDs focusing on histopathology and describe newer insights obtained from single-cell technologies.

Measuring the predictability of life outcomes with a scientific mass collaboration.

How predictable are life trajectories? We investigated this question with a scientific mass collaboration using the common task method; 160 teams built predictive models for six life outcomes using data from the Fragile Families and Child Wellbeing Study, a high-quality birth cohort study. Despite using a rich dataset and applying machine-learning methods optimized for prediction, the best predictions were not very accurate and were only slightly better than those from a simple benchmark model. Within each outcome, prediction error was strongly associated with the family being predicted and weakly associated with the technique used to generate the prediction. Overall, these results suggest practical limits to the predictability of life outcomes in some settings and illustrate the value of mass collaborations in the social sciences.

Extramedullary Haematopoiesis in Axillary Lymph Nodes of Breast Carcinoma Patients Receiving Neoadjuvant Chemotherapy: A Potential Diagnostic Pitfall.

Extramedullary haematopoiesis (EMH) in the axillary lymph node of breast cancer patients is extremely rare but when encountered can represent a diagnostic challenge. We aim to highlight this incidental finding as a diagnostic pitfall which can be mistaken for metastatic carcinoma (particularly of the metaplastic type). We report the case of a 68-year-old Caucasian female with a family history of cancer. Core biopsy revealed that she had grade II oestrogen receptor-negative, Her2-positive invasive ductal carcinoma. She was offered neoadjuvant chemotherapy with Herceptin and subsequently underwent breast-conserving surgery. Microscopic examination of the post-treatment breast surgical specimen showed a partial pathological response with large areas of tumour regression. The sentinel lymph node showed frequent large single and multinucleate giant cells with hyperchromatic nuclei located predominantly within the subcapsular and medullary sinuses. The morphological differentials of metastatic carcinoma, sinus histiocytosis and extramedullary haematopoiesis were considered. A panel of immunohistochemistry showed these large cells to be negative for epithelial markers and CD68. They were strongly positive for CD42b (megakaryocyte marker). Smaller myeloperoxidase and factor VIII-positive cells were identified. The findings confirmed EMH. Sentinel nodes are often well scrutinised by pathologists for evidence of metastatic carcinoma as an important prognostic parameter both in the standard and neoadjuvant setting. Nodal megakaryocytes have been described in response to neoadjuvant chemotherapy particularly in association with Herceptin treatment. Pathologists' awareness of this finding in the neoadjuvant setting is crucial to avoid a mistaken diagnosis of malignancy. A relevant immunohistochemical panel together with careful attention to morphology should help establish the correct diagnosis.

Transtibial osseointegration following unilateral traumatic amputation: An observational study of patients with at least two years follow-up.

IMPORTANCE: Most patients use a traditional socket prosthesis (TSP) to ambulate independently following transtibial amputation. However, these patients generally require prosthesis repairs more than twice annually and an entirely new prosthesis every two years. Furthermore, transtibial amputation patients have four times the skin ulceration rate of transfemoral patients, prompting more frequent prosthesis refitting and diminished use. Trans-Tibial osseointegration (TTOI) is a promising technique to address the limitations of TSP, but remains understudied with only four cohorts totaling 41 total procedures reported previously. Continued concerns regarding the risk of infection and questions as to functional capacity postoperatively have slowed adoption of TTOI worldwide. OBJECTIVE: This study reports the changes in mobility, quality of life (QOL), and the safety profile of the largest described cohort of patients with unilateral TTOI following traumatic amputation. DESIGN: Retrospective observational cohort study. The cohort consisted of patients with data outcomes collected before and after osseointegration intervention. SETTING: A large, tertiary referral, major metropolitan center. PARTICIPANTS: Twenty-one skeletally mature adults who had failed socket prosthesis rehabilitation, with at least two years of post-osseointegration follow-up. MAIN OUTCOMES AND MEASURES: Mobility was evaluated by K-level, Timed Up and Go (TUG), and Six Minute Walk Test (6MWT). QOL was assessed by survey: daily prosthesis wear hours, prosthesis problem experience, general contentment with prosthesis, and Short Form 36 (SF36). Adverse events included any relevant unplanned surgery such as for infection, fracture, implant loosening, or implant failure. RESULTS: All patients demonstrated statistically significant improvement post osseointegration surgery with respect to K-level, TUG, 6MWT, prosthesis wear hours, prosthesis problem experience, general prosthesis contentment score, and SF36 Physical Component Score (p < 0.01 for all). Three patients had four unplanned surgeries: two soft tissue refashionings, and one soft tissue debridement followed eventually by implant removal. No deaths, postoperative systemic complications, more proximal amputations, or periprosthetic fractures occurred. CONCLUSIONS AND RELEVANCE: TTOI is likely to confer mobility and QOL improvements to patients dissatisfied with TSP rehabilitation following unilateral traumatic transtibial amputation. Adverse events are relatively infrequent and not further disabling. Judicious use of TTOI seems reasonable for properly selected patients. LEVEL OF EVIDENCE: 2 (Therapeutic investigation, Observational study with dramatic effect).

Rare skin appendage tumour on the right leg: a case of primary cutaneous cribriform carcinoma.

A woman in her 60s presented with a longstanding history of a purplish, fleshy and pedunculated nodule on the right shin on a background of bilateral lower limb lymphoedema. A shave biopsy with double curettage of the base of the lesion revealed a nodular tumour with hyperchromatic basaloid cells arranged in a cribriform pattern and encircling eosinophilic substance. Immunohistochemistry staining showed cells positive for pancytokeratin, low molecular weight keratin, BerEP4 and negative for cytokeratin 20. There were no clinical or radiological features of primary visceral malignancy. These histological and immunohistochemical features favour a diagnosis of primary cribriform carcinoma of the skin. This is a rare, indolent skin appendage tumour of presumed apocrine origin with no reported cases in the literature of metastasis or local recurrence after excision.

Amputation With Osseointegration for Patients With Intractable Complex Regional Pain Syndrome: A Report of 3 Cases.

CASES: Three patients with knee-level complex regional pain syndrome type 1 (CRPS1), recalcitrant to conservative interventions, elected for transfemoral amputation and osseointegration. Two patients gained independent ambulation; the third remains on crutches after a disrupted sciatic nerve targeted reinnervation. One uses no pain medication, one is weaning off, and one requires a reduced regimen after revision nerve innervation. CONCLUSION: Osseointegration seems suitable to optimize rehabilitation after amputation for CRPS1.

Pelvic Osseointegration for Unilateral Hip Disarticulation: A Case Report.

CASE: A 24-year-old man with right unilateral hip disarticulation, intolerant of a traditional socket-mounted prosthesis (TSP), underwent pelvic transcutaneous osseointegration and was fit with a prosthetic lower extremity 7 months later. Twenty-four months after osseointegration, he remains pain-free and complication-free, wears his prosthesis all waking hours, walks without assistive devices and can carry 2-handed objects, and works as a livestock farmer. CONCLUSION: Through 24 months, the world's first patient with pelvic osseointegration has no complications and better mobility than most patients with unilateral hip disarticulation using TSPs. Pelvic osseointegration seems reasonable to further consider in carefully selected patients.

Transtibial Osseointegration for Patients with Peripheral Vascular Disease: A Case Series of 6 Patients with Minimum 3-Year Follow-up.

The management of peripheral vascular disease (PVD) can require amputation. Osseointegration surgery is an emerging rehabilitation strategy for amputees. In this study, we report on 6 patients who had PVD requiring transtibial amputation (PVD-TTA) and either simultaneous or subsequent osseointegration (PVD-TTOI). METHODS: Six patients (aged 36 to 84 years) with transtibial amputation and preexisting PVD underwent osseointegration between 2014 and 2016 and were followed for 3 to 5 years. Pre- and postoperative clinical and functional outcomes (pain, prosthesis wear time, mobility, walking ability, and quality of life) and adverse events (infection, fracture, implant failure, revision surgery, additional amputation, and death) were prospectively recorded. RESULTS: All patients' mobility improved following osseointegration. Three patients initially had required the use of a wheelchair, precluding baseline walking tests; the other 3 were classified as K level 1 or 2, with mean baseline Timed Up and Go (TUG) test = 14.0 ± 2.2 s and 6-Minute Walk Test (6MWT) = 262 ± 75 m. At the time of the latest follow-up, all patients were K level 2 or 3; mean TUG = 12.7 ± 7.2 s and 6MWT = 353 ± 148 m. Four patients wore their prosthesis ≥16 hours daily. Three patients had superficial soft-tissue infections. One other patient experienced recurrent infections 2.8 years after osseointegration requiring debridements and transfemoral amputation; the patient died 2 days following surgery from myocardial infarction caused by coronary atherosclerosis. CONCLUSIONS: All 6 patients who underwent PVD-TTOI in this case series survived through 2 years. Patients who initially had used a wheelchair achieved and maintained independent, unaided ambulation until PVD-related impairments in the contralateral leg occurred in 1 patient. Patients previously using a traditional socket prosthesis reported improvement in mobility and quality of life. One patient's death underscores the importance of careful patient selection. However, marked improvement in the other 5 patients suggests cautious optimism that PVD-TTA is not an absolute osseointegration contraindication. Conscientious further investigation seems appropriate. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Dose-intensified treatment of Burkitt lymphoma and B-cell lymphoma unclassifiable, (with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma) in young adults (<50 years): a comparison of two adapted BFM protocols.

The chemotherapy dose-intensity in two adapted German BFM paediatric protocols (BFM 90 and NHL 86) was compared in contemporaneously treated adults <50 years with Burkitt lymphoma and B-cell lymphoma unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma (collectively referred to as BL). In BFM 90, primary prophylaxis with Granulocyte-colony-stimulating factor was used, postinduction treatment was started at granulocytes > or =0.5 x 10(9)/L (> or =1.0 x 10(9)/L in NHL 86) with a higher mean methotrexate dose (2.9 g/m(2)/cycle, n = 23; 1.6 g/m(2)/cycle in NHL 86, n = 22, P < 0.001). Intervals between consecutive treatment-cycles were shorter in BFM 90 (P < 0.001) with no additional toxicity. However, the two-year failure-free survival with BFM 90 (82%) was similar to that achieved with NHL 86 (72%, P = 0.33). We conclude that BFM 90 enables safe intensification of therapy in young adults with BL compared to NHL 86, but registry-based studies are required to further evaluate the antineoplastic effects and cost-effectiveness of the two therapeutic approaches.

Periprosthetic osseointegration fractures are infrequent and management is familiar.

AIMS: Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees. METHODS: A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed. RESULTS: There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312). CONCLUSION: The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential. Cite this article: Bone Joint J 2020;102-B(2):162-169.

Osseointegrated reconstruction and rehabilitation of transtibial amputees: the Osseointegration Group of Australia surgical technique and protocol for a prospective cohort study.

INTRODUCTION: Lower extremity amputation uniformly impairs a person's vocational, social and recreational capacity. Rehabilitation in traditional socket prostheses (TSP) is associated with a spectrum of complications involving the socket-residuum interface which lead to reduced prosthetic use and quality of life. Osseointegration has recently emerged as a novel concept to overcome these complications by eliminating this interface and anchoring the prosthesis directly to bone. Though the complications of TSPs affect both transfemoral and transtibial amputees, Osseointegration has been predominantly performed in transfemoral ones assuming a greater benefit/risk ratio. However, as the safety of the procedure has been established, we intend to extend the concept to transtibial amputees and document the outcomes. METHODS AND ANALYSIS: This is protocol for a prospective cohort study, with patient enrolment started in 2014 and expected to be completed by 2022. The inclusion criteria are age over 18 years, unilateral, bilateral and mixed transtibial amputation and experiencing socket-related problems. All patients receive osseointegrated implants, the type of which depend on the length of the residuum and quality of bone, which are press-fitted into the residual bone. Objective functional outcomes comprising 6-Minute Walk Test, Timed Up-and-Go test and K-level, subjective patient-reported-quality-of-life outcomes (Short Form Health Survey 36, daily prosthetic wear hours, prosthetic wear satisfaction) and adverse events are recorded preoperatively and at postoperative follow-up intervals of 3, 6, 12 months and yearly, and compared with the preoperative values using appropriate statistical tests. Multivariable multilevel logistic regression will be performed with a focus to identify factors associated with outcomes and adverse events, specifically infection, periprosthetic fracture, implant fracture and aseptic loosening. ETHICS AND DISSEMINATION: The Ethics approval for the study has been received from the University of Notre Dame, Sydney, Australia (014153S). The outcomes of this study will be disseminated by publications in peer-reviewed academic journals and scientific presentations at relevant orthopaedic conferences.

p27Kip1 and p130 cooperate to regulate hematopoietic cell proliferation in vivo.

To investigate the potential functional cooperation between p27Kip1 and p130 in vivo, we generated mice deficient for both p27Kip1 and p130. In p27Kip1-/-; p130-/- mice, the cellularity of the spleens but not the thymi is significantly increased compared with that of their p27Kip1-/- counterparts, affecting the lymphoid, erythroid, and myeloid compartments. In vivo cell proliferation is significantly augmented in the B and T cells, monocytes, macrophages, and erythroid progenitors in the spleens of p27Kip1-/-; p130-/- animals. Immunoprecipitation and immunodepletion studies indicate that p130 can compensate for the absence of p27Kip1 in binding to and repressing CDK2 and is the predominant CDK-inhibitor associated with the inactive CDK2 in the p27Kip1-/- splenocytes. The finding that the p27Kip1-/-; p130-/- splenic B cells are hypersensitive to mitogenic stimulations in vitro lends support to the concept that the hyperproliferation of splenocytes is not a result of the influence of their microenvironment. In summary, our findings provide genetic and molecular evidence to show that p130 is a bona fide cyclin-dependent kinase inhibitor and cooperates with p27Kip1 to regulate hematopoietic cell proliferation in vivo.

Bezafibrate and medroxyprogesterone acetate target resting and CD40L-stimulated primary marginal zone lymphoma and show promise in indolent B-cell non-Hodgkin lymphomas.

B cell non-Hodgkin lymphomas (B-NHLs) are the most common adult hematological cancers and many remain incurable. Development of chemotherapy regimens is confounded by the prevalence of B-NHL in older, frailer patients and the chemo-protective tumor microenvironment. Although biological therapies such as rituximab have significantly improved outcomes and selective kinase inhibitors are showing promise, the rate of new drug discovery remains disappointing, the treatments expensive and long-term benefits uncertain. An alternative strategy is redeployment of available, inexpensive and non-toxic drugs. Here, we demonstrate the antiproliferative and mitochondrial superoxide (MSO) driven pro-apoptotic activities of bezafibrate (BEZ) and medroxyprogesterone acetate (MPA) against B-NHL cells, with a bias toward MZL, in the presence and absence of the microenvironmental signal CD40L. Our study is the first to confirm the presence of CD40L within the lymph node of B-NHL and its capacity to drive B-NHL proliferation. These findings implicate BEZ + MPA as a potential therapeutic strategy in B-NHL.

Inflammatory cell distribution in primary merkel cell carcinoma.

Merkel cell carcinoma (MCC) is an aggressive poorly differentiated neuroendocrine cutaneous carcinoma associated with older age, immunodeficiency and Merkel cell polyomavirus (MCPyV) integrated within malignant cells. The presence of intra-tumoural CD8+ lymphocytes reportedly predicts better MCC-specific survival. In this study, the distribution of inflammatory cells and properties of CD8+ T lymphocytes within 20 primary MCC specimens were characterised using immunohistochemistry and multicolour immunofluorescent staining coupled to confocal microscopy. CD8+ cells and CD68+ macrophages were identified in 19/20 primary MCC. CD20+ B cells were present in 5/10, CD4+ cells in 10/10 and FoxP3+ cells in 7/10 specimens. Only two specimens had almost no inflammatory cells. Within specimens, inflammatory cells followed the same patchy distribution, focused at the edge of sheets and nodules and, in some cases, more intense in trabecular areas. CD8+ cells were outside vessels on the edge of tumour. Those few within malignant sheets typically lined up in fine septa not contacting MCC cells expressing MCPyV large T antigen. The homeostatic chemokine CXCL12 was expressed outside malignant nodules whereas its receptor CXCR4 was identified within tumour but not on CD8+ cells. CD8+ cells lacked CXCR3 and granzyme B expression irrespective of location within stroma versus malignant nodules or of the intensity of the intra-tumoural infiltrate. In summary, diverse inflammatory cells were organised around the margin of malignant deposits suggesting response to aberrant signaling, but were unable to penetrate the tumour microenvironment itself to enable an immune response against malignant cells or their polyomavirus.

A recombinant modified vaccinia ankara vaccine encoding Epstein-Barr Virus (EBV) target antigens: a phase I trial in UK patients with EBV-positive cancer.

PURPOSE: Epstein-Barr virus (EBV) is associated with several cancers in which the tumor cells express EBV antigens EBNA1 and LMP2. A therapeutic vaccine comprising a recombinant vaccinia virus, MVA-EL, was designed to boost immunity to these tumor antigens. A phase I trial was conducted to demonstrate the safety and immunogenicity of MVA-EL across a range of doses. EXPERIMENTAL DESIGN: Sixteen patients in the United Kingdom (UK) with EBV-positive nasopharyngeal carcinoma (NPC) received three intradermal vaccinations of MVA-EL at 3-weekly intervals at dose levels between 5 × 10(7) and 5 × 10(8) plaque-forming units (pfu). Blood samples were taken at screening, after each vaccine cycle, and during the post-vaccination period. T-cell responses were measured using IFNγ ELISpot assays with overlapping EBNA1/LMP2 peptide mixes or HLA-matched epitope peptides. Polychromatic flow cytometry was used to characterize functionally responsive T-cell populations. RESULTS: Vaccination was generally well tolerated. Immunity increased after vaccination to at least one antigen in 8 of 14 patients (7/14, EBNA1; 6/14, LMP2), including recognition of epitopes that vary between EBV strains associated with different ethnic groups. Immunophenotypic analysis revealed that vaccination induced differentiation and functional diversification of responsive T-cell populations specific for EBNA1 and LMP2 within the CD4 and CD8 compartments, respectively. CONCLUSIONS: MVA-EL is safe and immunogenic across diverse ethnicities and thus suitable for use in trials against different EBV-positive cancers globally as well as in South-East Asia where NPC is most common. The highest dose (5 × 10(8) pfu) is recommended for investigation in current phase IB and II trials.

Treatment of chronic lymphocytic leukemia requires targeting of the protective lymph node environment with novel therapeutic approaches.

Chronic lymphocytic leukemia (CLL) remains associated with low complete response rates and high relapse rates. This is in part due to poor understanding of CLL biology and thus inadequate targeting of therapy. For years CLL has been proposed as bi-compartmental: the quiescent tumor in the periphery and the proliferating cells within specific microenvironments. Historically the bone marrow was considered the major tissue of the CLL microenvironment. However, many recent innovative studies have categorically shown that peripheral CLL cells are derived from the lymph nodes (LN). Proliferation here is largely driven by helper T cells via CD40-CD40L engagement. Critically, in vitro studies have shown that such engagement additionally protects LN CLLs from apoptosis. Agents inducing apoptosis in non-CD40 engaged CLL cells are frequently ineffective against those continually engaged with CD40L. This emphasizes that, in order to improve responses and prevent relapse, novel therapies must be assessed against CD40L engaged CLL cells to show effective targeting against the LN. This review discusses the evidence supporting the superior involvement of the LN in CLL, how CD40L engaged CLL studies should be conducted, and the novel therapies studied in vitro and in vivo that have been proposed to be effective in this setting.