Evolving Practice Patterns Over Two Decades (1993-2013) in the Management of Desmoid-type Fibromatosis in British Columbia.

AIMS: Due to the rarity and varied natural history of desmoid-type fibromatosis, evidence-based treatment standards for this disease remain lacking. This study evaluated outcomes in patients with desmoid-type fibromatosis managed at a Canadian institution over two decades. MATERIALS AND METHODS: Records of 227 patients with desmoid-type fibromatosis referred from 1990 to 2013 were retrospectively reviewed to investigate management strategies including active surveillance, surgery, radiation therapy, cryoablation, and systemic therapy, including tamoxifen and chemotherapy. RESULTS: Thirty-two per cent of cases were men, median age 40 years, median tumour size 5.4 cm. Initial treatments were surgery (79%), tamoxifen (13%), radiation therapy (5.0%), chemotherapy (1.8%) and cryoablation (1.2%). Active surveillance was used upfront in 26% of cases, most after 2005. At a median follow-up of 77 months, one patient died of disease, 13 died of unrelated causes and the remainder were alive with no evidence of disease (56%), stable/responding disease (33%) or progressive disease (4%). The recurrence rate was 25% after upfront surgery. Response rates and disease control rates were 40% and 76% for active surveillance; 68% and 96% for radiation therapy; 31% and 67% for tamoxifen; and 53% and 80% for chemotherapy. On univariable analysis, factors associated with a higher recurrence after initial surgery were young age (P = 0.012), male gender (P = 0.012) and extremity location (P = 0.005). On multivariable analysis, only young age was significantly associated with recurrence risk (P = 0.010). CONCLUSIONS: Active surveillance was associated with spontaneous regression and long-term disease control consistent with other studies. Primary radiation therapy appeared to provide a similar response and disease control compared with systemic treatments and may be a viable option for patients who are not candidates for surgery or active surveillance.

Absence of ocular malignant transformation after sub-retinal delivery of rAAV2/2 or integrating lentiviral vectors in p53-deficient mice.

Insertional mutagenesis following gene therapy with gammaretroviral vectors can cause the development of lymphoproliferation in children with X-linked severe combined immunodeficiency. In experimental studies, recombinant adeno-associated virus (rAAV) vectors have also been reported to increase susceptibility to carcinogenesis. The possibility of vector-induced transformation in quiescent ocular cells is probably significantly lower than in mitotically active cells, but given the increasing number of clinical applications of rAAV and lentiviral vectors for ocular disease, a specific assessment of their oncogenic potential in the eye is important. In this study, we investigated the effect of rAAV2/2 and integrating HIV-1 vectors upon the incidence of ocular neoplasia in p53 tumour-suppressor gene-knockout (p53(-/-)) mice, which are highly susceptible to intraocular malignant transformation. Subretinal injections of high titre rAAV2/2 or integrating HIV-1 vectors induced no tumours in p53(-/-) or p53(+/-) animals, nor significantly affected their natural longevity. We conclude that any insertional events arising from subretinal delivery of these vectors appear insufficient to cause intraocular malignancy, even in highly susceptible animals. These findings support the continued development of these vectors for ocular applications.

Diagnosis of bovine-associated parapoxvirus infections in humans: molecular and epidemiological evidence.

Orf virus, pseudocowpox virus and bovine papular stomatitis virus, are parapoxviruses, associated with domestic ruminants, which are capable of causing cutaneous infections in humans. Owing to virtually identical appearances in humans, clinical differentiation of these viruses is difficult. We discuss three recent occurrences of parapoxvirus infection, involving contact with domestic bovine and use a combination of molecular and epidemiological data in the diagnosis. These cases underscore the utility of modern diagnostic tools, along with species-specific contact information in acquiring a definitive diagnosis, in the case of suspected parapoxvirus infection.

Isolation and characterisation of neural progenitor cells from the adult Chx10(orJ/orJ) central neural retina.

Retinal stem cells have been isolated from the ciliary epithelium (CE) of the mammalian retina. However, the central neural retina (CNR) lacks the capability to regenerate, a phenomenon retained by lower vertebrates. Mutations in the Chx10 homeobox gene cause reduced proliferation of retinal progenitor cells during development, leading to microphthalmia. Recently, we showed that in Chx10(orJ/orJ) mice, dividing cells persist in the adult CNR, suggesting the existence of a dormant progenitor population. Here, we show that these cells are proliferative and give rise to neurospheres in vitro, a characteristic of neural stem cells. However, these adult-derived CNR progenitors differ from those of the wildtype CE, leading to de-pigmented, larger and more numerous neurospheres expressing Müller glial cell markers. Our results suggest that lack of Chx10 leads to maintenance of a dormant neural progenitor population in the adult CNR. Furthermore, Chx10 is not required for in vitro proliferation of these progenitors.

Retinal repair by transplantation of photoreceptor precursors.

Photoreceptor loss causes irreversible blindness in many retinal diseases. Repair of such damage by cell transplantation is one of the most feasible types of central nervous system repair; photoreceptor degeneration initially leaves the inner retinal circuitry intact and new photoreceptors need only make single, short synaptic connections to contribute to the retinotopic map. So far, brain- and retina-derived stem cells transplanted into adult retina have shown little evidence of being able to integrate into the outer nuclear layer and differentiate into new photoreceptors. Furthermore, there has been no demonstration that transplanted cells form functional synaptic connections with other neurons in the recipient retina or restore visual function. This might be because the mature mammalian retina lacks the ability to accept and incorporate stem cells or to promote photoreceptor differentiation. We hypothesized that committed progenitor or precursor cells at later ontogenetic stages might have a higher probability of success upon transplantation. Here we show that donor cells can integrate into the adult or degenerating retina if they are taken from the developing retina at a time coincident with the peak of rod genesis. These transplanted cells integrate, differentiate into rod photoreceptors, form synaptic connections and improve visual function. Furthermore, we use genetically tagged post-mitotic rod precursors expressing the transcription factor Nrl (ref. 6) (neural retina leucine zipper) to show that successfully integrated rod photoreceptors are derived only from immature post-mitotic rod precursors and not from proliferating progenitor or stem cells. These findings define the ontogenetic stage of donor cells for successful rod photoreceptor transplantation.

Burkitt's lymphoma in Kenya: geographical, age, gender and ethnic distribution.

OBJECTIVE: To show the geographical (Provincial), age, gender and ethnic distribution of Burkitt's lymphoma in patients in Kenya. DESIGN: A retrospective review of patients' records for the years 1988-1992 and a prospective evaluation of patients with BL between 1993 and 1997. These were descriptive and hospitals based studies. SETTING: Kenyatta National Hospital; Kenya's main referral and teaching hospital and seven provincial hospitals. MAIN OUTCOME MEASURES: For each tissue proven Burkitt's lymphoma case the following were required; province of birth and residence, tribe, age, sex, chief complains, physical examination findings, investigation results and tissues result confirming the diagnosis of BL. STATISTICAL METHOD: Mainly proportions were used to compare variables, however Pearson's liner correlation was used to assess the time trends. RESULTS: This study registered 1005 patients; 961 (95.6%) children and 44 (4.4%) adults. 0-14 years the age standardized incidence rate (ASR) of 0.83. Variations documented in the provinces' BL ASR range; 1.8 Coast to 0.23 Rift Valley and increasing yearly trend for both children and adults. The major tribes in Kenya consisted; Luo 29.5%. Luhya (24.1%) and Coastal (16.5%). No patient of Asian or European or Arab extraction was recorded in the study. The age distribution showed no case below two years, a rapid rise from three year 3 (5.6%), and peak at 6 (19.5%) for children and at 17 years (13.6%) years for the adult. Age group 5-9 years had the highest ASR. The male to female (M:F) ratios were; 1.5:1 and 1:1 in children and adults respectively, provincial ratios range; 2.6:1 in Nairobi to 1.2:1 in Nyanza, the tribes range; 3.5:1 in Somali to 1:1 in other tribes between 2 and 14 years old when also males were more than females. Peak time of presentation of symptoms was 4 weeks. Tumour sites were in children; jaw 51.6%, abdomen (25%), combined jaw and abdomen 13.8% and others 9.6% and adults; jaw (4.5%), abdomen (43.2%), combined jaw and abdomen (25%) and other sites (27.3%) 67.6% males and 42.4% female adults had HIV infection and disseminated BL disease. CONCLUSION: The study demonstrates that Burkitt's lymphoma is a childhood disease. The disease distribution is consistent with intermediate risk Burkitt's lymphoma level. Furthermore the distribution varied by province, tribe, age and gender. The variations could be due to environmental factors.

Activation of the Epstein-Barr virus lytic cycle by the latex of the plant Euphorbia tirucalli.

Exposure to the plant Euphorbia tirucalli has been proposed to be a cofactor in the genesis of endemic Burkitt's lymphoma (eBL). The purpose of this study was to examine the effects of unpurified E. tirucalli latex on Epstein-Barr virus (EBV) gene expression. A Burkitt lymphoma cell line was treated with varying dilutions of the latex and the effects on EBV gene expression were measured. We observed that the latex was capable of reactivating the EBV lytic cycle in a dose-dependent manner and at dilutions as low as 10(-6). Simultaneous treatment of cells with E. tirucalli latex and the protein kinase C inhibitor 1-(5-isoquinolinesulphonyl)-2-methylpiperazine dihydrochloride blocked lytic cycle activation. These data suggest that environmental exposure to the latex of E. tirucalli could directly activate the EBV lytic cycle and provide further evidence of a role for E. tirucalli in the aetiology of eBL.

Intraocular gene delivery of ciliary neurotrophic factor results in significant loss of retinal function in normal mice and in the Prph2Rd2/Rd2 model of retinal degeneration.

Intraocular delivery of a variety of neurotrophic factors has been widely investigated as a potential treatment for retinal dystrophy (RD). The most commonly studied factor, ciliary neurotrophic factor (CNTF), has been shown to preserve retinal morphology and to promote cell survival in a variety of models of RD. In order to evaluate CNTF as a potential treatment for RD, we used the Prph2(Rd2/Rd2) mouse. CNTF was expressed intraocularly using AAV-mediated gene delivery either by itself or, in a second treatment group, combined with AAV-mediated gene replacement therapy of peripherin2, which we have previously shown to improve photoreceptor structure and function. We confirmed in both groups of animals that CNTF reduces the loss of photoreceptor cells. Visual function, however, as assessed over a time course by electroretinography (ERG), was significantly reduced compared with untreated controls. Furthermore, CNTF gene expression negated the effects on function of gene replacement therapy. In order to test whether this deleterious effect is only seen when degenerating retina is treated, we recorded ERGs from wild-type mice following intraocular injection of AAV expressing CNTF. Here a marked deleterious effect was noted, in which the b-wave amplitude was reduced by at least 50%. Our results demonstrate that intraocular CNTF gene delivery may have a deleterious effect on the retina and caution against its application in clinical trials.

Perforin-deficient CD8+ T cells: in vivo priming and antigen-specific immunity against Listeria monocytogenes.

CD8+ T cells require perforin to mediate immunity against some, but not all, intracellular pathogens. Previous studies with H-2b MHC perforin gene knockout (PO) mice revealed both perforin-dependent and perforin-independent pathways of CD8+ T cell-mediated immunity to Listeria monocytogenes (LM). In this study, we address two previously unresolved issues regarding the requirement for perforin in antilisterial immunity: 1) Is CD8+ T cell-mediated, perforin-independent immunity specific for a single Ag or generalizable to multiple Ags? 2) Is there a deficiency in the priming of the CD8+ T cell compartment of PO mice following an immunizing challenge with LM? We used H-2d MHC PO mice to generate CD8+ T cell lines individually specific for three known Ags expressed by a recombinant strain of virulent LM. Adoptive transfer experiments into BALB/c host mice revealed that immunity can be mediated by PO CD8+ T cells specific for all Ags examined, indicating that perforin-independent immunity is not limited to CD8+ T cells that recognize listeriolysin O. Analysis of epitope-specific CD8+ T cell expansion by MHC class I tetramer staining and ELISPOT revealed no deficiency in either the primary or secondary response to LM infection in PO mice. These results demonstrate that the perforin-independent pathway of antilisterial resistance mediated by CD8+ T cells is generalizable to multiple epitopes. Furthermore, the results show that reduced antilisterial resistance observed with polyclonal PO CD8+ T cells is a consequence of a deficiency in effector function and not a result of suboptimal CD8+ T cell priming.

Analysis of diethyltoluamide (DEET) following intentional oral ingestion of Muscol.

N,N-Diethyl-m-toluamide (DEET) is an effective component of several insect repellent products. A 19-year-old woman was admitted to the emergency department following ingestion of 15-25 mL 95% diethyltoluamide (Muscol). Serum and urine toxicology screening tests were negative except for detection of DEET. DEET was qualitatively identified and quantitated by gas chromatography-mass spectrometry. Concentrations of DEET based on selected ion monitoring (ion at m/z 119) were 63.0, 17.2, 1.9, and less than 0.2 mg/L in serum specimens collected at 2, 5, 24, and 48 h following ingestion, respectively. Serial monitoring of DEET concentrations and the cardiac abnormalities observed in this case following oral ingestion were not reported previously.

Effects of crystalloid and colloid fluids on extravascular lung water in hypoproteinemic dogs.

We compared the effect of crystalloid to colloid fluid infusion on extravascular lung water (EVLW) in hypoproteinemic dogs. Plasmapheresis was used to decrease plasma colloid osmotic pressure (COP) to less than 40% of its base-line level. Five animals were then infused with 0.9% sodium chloride (saline), five with 5% human serum albumin (albumin), and five with 6% hydroxyethyl starch (hetastarch) to increase the pulmonary arterial occlusive pressure by 10 Torr in comparison to the postplasmapheresis level for a 5-h study interval. On completion of the procedure, the lungs were harvested and EVLW measured by the blood-free gravimetric technique. Three to six times the volume of saline compared with albumin or hetastarch (P less than 0.001) was infused. In the saline animals, COP was decreased to 3.3 +/- 1.3 Torr, whereas COP was increased to 18.1 +/- 1.4 Torr in albumin animals (P less than 0.001) and 20.1 +/- 1.6 Torr in the hetastarch group (P less than 0.001). The saline-treated dogs developed gross signs of systemic edema. The EVLW was 8.1 +/- 0.9 ml/kg in saline animals compared with 5.3 +/- 2.1 ml/kg in the albumin (P less than 0.05) and 4.1 +/- 1.4 ml/kg in the hetastarch (P less than 0.01) groups. These data indicate that crystalloid fluid infusion during hypoproteinemia is associated with the development of both systemic and pulmonary edema.

Evaluating Multimembership Classifiers: A Methodology and Application to the MEDAS Diagnostic System.

Performance evaluation measures for multimembership classifiers are presented and applied in a retrospective study on the diagnostic performance of the MEDAS (Medical Emergency Decision Assistance System) system. Admission and discharge diagnoses for 122 patients with one or more of 26 distinct disorders in five major disorder categories were gathered. The average number of disorders per patient was 2 with 36 (29.5 percent) patients having 3 or more disorders simultaneously. The features (symptoms, signs, and laboratory data) available at admission were entered into a multimembership Bayesian pattern recognition algorithm which permits for diagnosis of multiple disorders. When the top five computer-ranked diagnoses were considered, all of the correct diagnoses for 86.1 percent of the patients were displayed by the fifth position. In 71.6 percent of these cases, no false diagnosis preceded any correct diagnosis. In ten cases a discharge diagnosis which was suggested by the available findings was omitted by the admitting physician. In six of these ten cases, the overlooked diagnoses appeared at the computer ranked list above all false diagnoses. Considering the urgency of diagnosis in the Emergency Department, the high uncertainty involved due to the limited availability of data, and the high frequency with which multiple disorders coexist, this limited study encourages our confidence in the MEDAS knowledge base and algorithm as a useful diagnostic support tool.