A chromosomal event resulting in possession and expression of multiple HLA-B and Cw genes in a renal patient

Routine HLA typing of a renal patient for purposes of registration for transplantation revealed an unusual human leucocyte antigen (HLA)-B and Cw genotype, with three specificities detected. Results were confirmed in a second sample, and in a second laboratory. The possibility of these results reflecting a chimaeric state was rejected following short tandem repeat (STR) analysis. Although cytogenetic analysis has failed to detect a chromosomal abnormality, these findings support the view that the aberrant expression of HLA in this patient resulted from an unequal crossover event, occurring during meiosis in a previous generation.

Adult xanthogranulomatous disease of the orbit and ocular adnexa: new immunohistochemical findings and clinical review

BACKGROUND/AIMS

Adult xanthogranulomatous disease involving the ocular tissues is rare and poorly understood. Adult onset xanthogranuloma (AOX), adult onset asthma and periocular xanthogranuloma (AAPOX), necrobiotic xanthogranuloma (NBX), and Erdheim-Chester disease (ECD) are the four syndromes within this disorder, which is diagnosed by characteristic histopathology. Experience with eight cases prompted a multi-institutional effort to study the histopathology, immunohistochemistry, clinical findings, and systemic associations in this disorder.

METHODS

22 cases, including histopathological slides, were compiled. Published reports were identified by an English language Medline search (1966-2005) and review of reference citations. Each case in this series and the literature was classified as one of four syndromes and then analysed for age onset, sex, skin xanthoma, orbital location, immune dysfunction, internal organ and bone lesions, treatment, and outcome. The histopathology in each of these cases was reviewed by two pathologists. Immunhistochemical stains (CD3, CD4, CD8, L26) were performed in 14 cases where unstained slides were available.

RESULTS

137 cases were compiled. There was no sex or age difference between syndromes. AOX, AAPOX, NBX affect the anterior orbit, ECD tends to be diffuse and intraconal. Skin lesions are found in all the syndromes. Immune dysfunction was noted in all cases of AAPOX and NBX; 11% of NBX and all ECD patients had internal organ disease. Treatment included surgery, corticosteroids, other chemotherapeutic agents, radiotherapy, and combinations of these. No AOX or AAPOX deaths occurred; 66% of ECD patients died. All 22 cases had xanthoma cells; most had Touton giant cells. Lymphocytes were present in all cases and occurred as aggregates (mostly in AAPOX) or diffuse populations mixed with fibroblasts (mostly in ECD). Immunohistochemistry revealed the majority of these to be CD8+. Necrosis was most marked in NBX.

CONCLUSION

Adult xanthogranuloma of the orbit is rare, making prospective evaluation or meta-analysis impossible. The best treatment is unknown but seems to be with multiagent chemotherapy guided by histopathological, immunohistochemical, and systemic findings.

Hepatic angiosarcoma and liver transplantation: case report and literature review

Hepatic angiosarcoma is a rare malignant vascular tumor that accounts for up to 2% of all primary liver tumors. Accurate diagnosis of this tumor is difficult, especially if the patient has no history of exposure to specific carcinogens including thorotrast, arsenicals, and vinyl chloride monomer. Diagnosis of diffuse angiosarcoma by means of liver biopsy has been reported as treacherous and nondiagnostic. Herein, we present a case of a 61-year-old Caucasian male with history of cryptogenic cirrhosis, normal alpha-fetoprotein, and pretransplant abnormal liver MRI who underwent nondiagnostic liver biopsies followed by liver transplantation. High grade diffuse angiosarcoma was diagnosed in the explanted liver. The patient developed bone metastases at 8 months and is alive 1 year posttransplantation. Diffuse liver tissue infiltration seen pretransplant on CT scan or MRI, suggesting the possibility of diffuse liver lesions (HCC, angiosarcoma, etc) must be fully investigated with all techniques available including multiple open liver biopsies to avoid the sacrifice of a liver allograft in these patients.

Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow-up study

BACKGROUND

Breast-cancer-related lymphoedema is a chronic condition with estimates of incidence ranging from 6 to 83%. Lymphoedema has been associated with a variety of risk factors. However, this evidence has suffered from methodological weaknesses, and so has had little impact upon clinical practice.

AIM

To examine incidence and risk factors [hospital skin puncture, surgical procedure, Body Mass Index (BMI), age, axillary node status, number of axillary nodes removed, radiotherapy and surgery on dominant side] for breast cancer-related arm lymphoedema.

DESIGN

Prospective observational study, with measurement of limbs pre-operatively and at regular intervals post-operatively.

METHODS

We recruited 251 women who had surgical treatment for breast cancer that involved sampling, excision or biopsy of axillary nodes, aged > or = 18 years, and free of advanced disease and psychological co-morbidities. Of these, 188 (74.9%) were available for 3-year follow-up.

RESULTS

At follow-up, 39 (20.7%) had developed lymphoedema. Hospital skin puncture (vs. none) (RR 2.44, 95%CI 1.33-4.47), mastectomy (vs. wide local excision or lumpectomy) (RR 2.04, 95%CI 1.18-3.54), and BMI > or = 26 (vs. BMI 19-26) (RR 2.02, 95%CI 1.11-3.68) were the only significant risk factors.

DISCUSSION

Lymphoedema remains a significant clinical problem, with 1:5 women in this sample developing the condition following treatment for breast cancer. Risk factors are identified in the development of lymphoedema that should be taken into account in clinical practice.

The effect of pelvic osteotomy plate type on axial rotation of the acetabular segment in the triple pelvic osteotomy

OBJECTIVE

The purpose of this study is to evaluate the changes in structural anatomy of cadaver pelves, with specific emphasis on axial rotation, resulting from the application of TPO plates differing by type, angle and orientation.

SAMPLE POPULATION

Nine cadaver pelves procedure: The degree of axial rotation was determined for three different pelvic osteotomy plate types, four different plate angles and two different orientations of the same plate.

RESULTS

The observed degree of axial rotation was significantly different than the degree of axial rotation predicted by the plate angle for each group except the Rooks pelvic osteotomy plate.

CONCLUSIONS/CLINICAL RELEVANCE

In the triple pelvic osteotomy the final degree of axial rotation may be significantly different than the predetermined plate angle.

Influence of recipient and donor IL-1alpha, IL-4, and TNFalpha genotypes on the incidence of acute renal allograft rejection

AIMS

To determine whether polymorphisms of the genes encoding donor or recipient interleukin 1alpha (IL-1alpha), tumour necrosis factor alpha (TNFalpha), or IL-4 have any impact on the incidence of acute rejection after renal transplantation.

METHODS

All donors and recipients were genotyped for three polymorphisms in the three cytokine genes: IL1A -889, TNFA -308, and IL4 -590.

RESULTS

Statistical analysis of the data obtained revealed no association between the cytokine gene polymorphisms tested and the incidence of post-transplant acute rejection. After stratification for human leucocyte antigen (HLA) matching, it was found that kidneys from donors positive for the TNFA-A allele had a significantly increased incidence of acute rejection in HLA-DR mismatched transplants.

CONCLUSIONS

This finding argues for prospective TNFA genotyping of renal donors, with avoidance of allocation of kidneys from donors positive for the TNFA-A allele to HLA-DR mismatched recipients.

Improving tall fescue (Festuca arundinacea) for cool-season vigour

A highly winter-active cultivar of tall fescue, Melik, was compared with 3 commercial cultivars in a field experiment in South West Victoria. Winter production of Melik was superior to the widely used commercial cultivars (P<0.05). In a second experiment, a selection from a Melik nursery, designated Melik Select, was compared with the summer-active cultivars, Demeter and AU Triumph. Seed blends of Melik Select and Demeter (1:2 or 2:1 mix) were also evaluated and seasonal production was measured under grazing. Over 3 years, the cumulative yield of tall fescue per se was not different between cultivars, despite a 73% increase in winter for Melik Select compared with Demeter (P<0.001). Melik Select produced 55% of its annual yield in winter. For Demeter the winter proportion was 33%. Spring (P<0.01) and summer production (P<0.001) was superior from the summer-active cultivars, Demeter and AU Triumph, when compared with the yield from Melik Select. Melik Select plots were however, characterised by higher contributions from subterranean clover (Trifolium subterraneum L.). After 7 years of rotational grazing by sheep, the frequency of Melik Select plants (63%) was greater than that of Demeter (9%) and AU Triumph (8%) (P<0.01). Melik Select exhibited greater crown rust (Puccinia coronata) resistance than Demeter and AU Triumph (P<0.001) in autumn. The seed blend treatments, which included 66% Melik Select, did not increase winter production above that obtained from the summer-active cultivars (P>0.05). It was concluded that, while increased cool season production from tall fescue may be obtained by the use of highly winter-active cultivars sown alone, blends of the contrasting types of tall fescue may provide a more even distribution of growth throughout the year. To significantly increase winter growth in the Hamilton climate, however, the highly winter-active component may have to represent >66% of the blend. Options for using Mediterranean type tall fescue for their autumn–winter growth potential are discussed for districts with a shorter growing season. Melik Select was compared against 5 check cultivars, in a 3-year field experiment at Hamilton, to characterise the seasonal growth of 36 Neotyphodium endophyte infected accessions of tall fescue collected from the Mediterranean basin. These accessions contained endophyte variants differing from N. coenophialum, as found in continental winter-dormant types of tall fescue. Ratings confirmed the importance of Mediterranean material as a source of vigorous growth during the cool season. Melik Select was superior to other cultivars and accessions in both the cool and warm seasons. The use of Melik Select to develop and evaluate a new type of highly winter-active tall fescue for temperate Australia, since released as cultivar Fraydo, is discussed.

The Canadian apheresis registry

Apheresis is a procedure in which a specific blood component is selectively removed from a patient using computerized machines. In Canada it is currently used to treat over 30 different diseases, and, in 2002 a total of 8600 plasma exchange procedures were performed at a cost of over 7 million Canadian dollars. The Canadian Apheresis Group (CAG) is a national, volunteer organization of physicians and nurses who have special interest in evaluating the appropriate application of therapeutic apheresis (TA). It was formed in 1980 under the auspices of the Department of National Health and Welfare with the goals of providing a forum for the exchange of information among apheresis practitioners in Canada and developing statistically sound, prospective clinical trials to test the efficacy of plasma exchange as treatment for various disorders. The group includes representatives from each of the major medical centres in Canada so that there is a liaison between the CAG and local medical communities across the country. Over the years the group has been funded by Health Canada, then the Canadian Blood Committee, the Canadian Blood Agency and, for the past 3 years, by the Canadian Blood Services and the Province of Quebec. The CAG was the first group to organize a national database and, since 1981, has collected data from 42 apheresis units throughout Canada and more than 140,000 plasma exchange procedures. In 1981 there were 4716 plasma exchanges done while in 2002 there were 8561. This total has been relatively stable at approximately 8500 for each of the last 4 years. However, 20 years ago exchanges for hematological and neurological disorders each constituted 30% of the total and 15 years ago the majority of procedures were performed for neurological disorders (50%). In 2002 the majority of procedures were performed for hematological disorders (55%) and neurological disorders had fallen to 40% of the total. We believe these changes have been of a controlled and appropriate nature as a result of the activities of the CAG. We have developed national practice guidelines and have directed studies in a number of diseases, the results of which have refined practice across the country. We have also monitored replacement fluids and have had a significant effect on the appropriate use of plasma or albumin. Over the past 22 years, the activities of the CAG have lead to a rational, cost effective, use of TA in our country, have promoted the dissemination of knowledge among apheresis practitioners and have fostered optimal patient care.

Bilateral microphthalmia with cyst, facial clefts, and limb anomalies: a new syndrome with features of Waardenburg syndrome, cerebro-oculo-nasal syndrome, and craniotelencephalic dysplasia

We report a patient with bilateral microphthalmia with cyst, limb anomalies, and multiple facial malformations. This patient has clinical features similar to Waardenburg ophthalmo-acromelic syndrome, cerebro-oculo-nasal syndrome, and craniotelencephalic dysplasia. Although all of these syndromes are characterized by microphthalmia, the presently reported patient does not have the complete pattern of any of these syndromes, It is possible that he has a previously undescribed syndrome, most closely related to the cerebro-oculo-nasal syndrome with malformations outside the craniofacial region. More case reports are needed to further delineate this possibly new syndrome.

Laboratory investigations following an unexpectedly positive crossmatch result in a patient awaiting renal transplantation

In the preparation of patients for renal transplantation tests of human leucocyte antigen (HLA) sensitisation are performed to detect "unacceptable" HLA antigens that, if present on donor cells, would be expected to result in a positive crossmatch. Individuals bearing such specificities may then be excluded from consideration as donors. Unexpected positive crossmatch results are sometimes obtained when a serum specificity has not been detected on screening. Failure to identify a donor relevant HLA antibody in a recipient at the time of crossmatch may result in hyperacute rejection of the graft. This report describes laboratory investigations performed after a positive crossmatch result in a live donor situation. The pattern of crossmatch results indicated that reactivity resulted from HLA class I antibody. Previously performed serum screening using a standard complement dependent cytotoxicity technique had failed to identify donor relevant antibody specificities in the recipient. Retrospective flow cytometric screening of the same serum samples identified an HLA-A24 specificity of donor relevance. The lower sensitivity of methods used for routine serum screening compared with those used for crossmatching accounts for the findings in this case. The laboratory has amended its serum screening protocol to include flow cytometric analysis.

Clinical, genetic and histopathologic findings in two siblings with muscle-eye-brain disease

PURPOSE

We present the clinical, genetic and histopathologic findings in two siblings with Muscle-Eye-Brain Disease (MEB-D), an autosomal recessive disease characterized by mental retardation, muscular dystrophy, retinal hypoplasia and brain abnormalities.

METHODS

Clinical, histopathologic and gene mapping studies of a family with two normal and two children with MEB-D.

RESULTS

Two siblings presented in the first few months of life with developmental delay, hypotonia, and strabismus. MRI of the brain showed colpocephaly, pontine and cerebellar atrophy, and diffuse white matter disease. Both patients were blind and had high myopia, strabismus, and retinal and optic nerve abnormalities. The older boy had glaucoma. Both children died from uncontrolled seizures. There was retinal, choroidal and RPE atrophy and optic nerve hypoplasia on ocular histopathology. Both patients shared the same parental haplotypes at the MEB locus on chromosome 1p, while an unaffected sibling did not, indicating possible linkage to the MEB locus.

CONCLUSIONS

Patients with MEB-D have severe visual impairment from retinal and optic nerve hypoplasia. High myopia appears to be a consistent finding. The ocular manifestations of MEB-D appear to be distinct from those of patients with Walker-Warburg syndrome.