Animal and translational models of SARS-CoV-2 infection and COVID-19

COVID-19 is causing a major once-in-a-century global pandemic. The scientific and clinical community is in a race to define and develop effective preventions and treatments. The major features of disease are described but clinical trials have been hampered by competing interests, small scale, lack of defined patient cohorts and defined readouts. What is needed now is head-to-head comparison of existing drugs, testing of safety including in the background of predisposing chronic diseases, and the development of new and targeted preventions and treatments. This is most efficiently achieved using representative animal models of primary infection including in the background of chronic disease with validation of findings in primary human cells and tissues. We explore and discuss the diverse animal, cell and tissue models that are being used and developed and collectively recapitulate many critical aspects of disease manifestation in humans to develop and test new preventions and treatments.

Clinical assessment of acellular dermal matrix (AlloDerm©) as an option in the replacement of the temporomandibular joint disc: A pilot study

BACKGROUND

There is limited data available in the literature describing the utility of acellular dermal matrix (AlloDerm©) in the replacement of the temporomandibular joint disc. Few reports of clinicians using implantable AlloDerm to replace the disc do exist, however, this has been described for reconstruction after surgical resection of the entire temporomandibular joint complex to treat pathology, as opposed to isolated articular disc disorders. Moreover, there is a lack of description in the literature regarding associated perioperative outcomes after such a procedure. We sought to assess the immediate perioperative outcomes in the form of a pilot study, to determine whether this technique warrants further investigation in the form of prospective clinical studies.

METHODS

The study team conducted a retrospective review of medical records for patients who underwent temporomandibular joint discectomy and replacement with AlloDerm© at a single tertiary care center, from 2011 to 2016. Perioperative outcomes of interest including pain levels and range of motion were recorded and descriptive statistics were utilized for statistical analysis.

RESULTS

15 patients met the inclusion criteria, of which 87% were females and 13% males. The mean age was 47.27±15.93 years. Preoperatively, 74% of the patients reported severe pain (VAS scores of 7-10); in contrast, 73% of the patients reported only mild pain (VAS scores of 1-3) during the postoperative visits, suggesting an overall reduction in pain intensity. Range of motion also improved from an average of 27.73±13.04mm, to an average of 38.60±6.08mm (P<0.01).

CONCLUSIONS

Based on our preliminary data, patients with advanced TMJ articular disc disorders showed clinical improvement from discectomy and replacement with acellular dermal matrix (AlloDerm©). Further longitudinal studies evaluating long-term outcomes need to be conducted to validate this technique, in the form of larger sample sizes with a control group, as well as radiographic assessment of long-term clinical outcomes.

Effective therapeutic strategy for massive retroperitoneal hematoma after conization: arterial embolization and pigtail catheter insertion

The loop electrosurgical excision procedure (LEEP) is commonly used to remove cervical intraepithelial neoplasia (CIN) because of its safety profile and likelihood of fewer complications. The authors report a rare case of massive retroperitoneal bleeding combined with hypovolemic shock after LEEP conization. Vessel injury was detected by angiographic computed tomography (CT) and embolization of the uterine artery was successfully performed to achieve hemostasis by an intervention radiologist. A pigtail catheter was subsequently inserted for the drainage of the large retroperitoneal hematoma. The patient did not show any further hemorrhage and recovered safely from hypovolemic shock. Th present case demonstrates a successful multidisciplinary and minimal invasive approach to manage retroperitoneal bleeding with uterine artery embolization. Thus, it should be considered a potential treatment option for hemostasis.

Biochemical indicators of implantation success of tissue-engineered oral mucosa

Real-time (RT) determination of the health of in vitro tissue-engineered constructs prior to grafting is essential for prediction of success of the implanted tissue-engineered graft. In addition, the US Food and Drug Administration requires specific release criteria in RT prior to the release of tissue-engineered devices for human use. In principle, assessing the viability and functionality of the cellular component can be achieved by quantifying the secretion of growth factors and chemokines of tissue-engineered constructs. Ex vivo-produced oral mucosa equivalents (EVPOMEs) were fabricated under thermally stressed conditions at 43 °C for 24 h to create a functionally compromised EVPOME. We used microchannel enzyme-linked immunosorbent assay to evaluate the functionality of the cellular component, oral keratinocytes, of stressed and unstressed EVPOMEs by measuring the release of vascular endothelial growth factor (VEGF), interleukin-8 (IL-8), human β-defensin 1 (hBD-1), and tissue inhibitor of metalloproteinase 1 and 2 (TIMP-1 and -2) into the spent medium, which was collected on the same day prior to graft implantation into severe combined immunodeficiency mice. Implanted EVPOMEs' histology on the seventh postimplantation day was used to correlate outcomes of grafting to secreted amounts of IL-8, hBD-1, VEGF, TIMP-1, and TIMP-2 from corresponding EVPOMEs. Our findings showed that significantly higher levels of IL-8, hBD-1, and TIMP-2 were secreted from controls than from thermally stressed EVPOMEs. We also found a direct correlation between secreted VEGF and IL-8 and blood vessel counts of implanted EVPOMEs. We concluded that measuring the constitutive release of these factors can be used as noninvasive predictors of healthy tissue-engineered EVPOMEs in RT, prior to their implantation.

Evaluation of a large-scale donation of Lifebox pulse oximeters to non-physician anaesthetists in Uganda

Pulse oximetry is widely accepted as essential monitoring for safe anaesthesia, yet is frequently unavailable in resource-limited settings. The Lifebox pulse oximeter, and associated management training programme, was delivered to 79 non-physician anaesthetists attending the 2011 Uganda Society of Anaesthesia Annual Conference. Using a standardised assessment, recipients were tested for their knowledge of oximetry use and hypoxia management before, immediately following and 3–5 months after the training. Before the course, the median (IQR [range]) test score for the anaesthetists was 36 (34–39 [26–44]) out of a maximum of 50 points. Immediately following the course, the test score increased to 41 (38–43 [25–47]); p < 0.0001 and at the follow-up visit at 3–5 months it was 41 (39–44 [33–49]); p = 0.001 compared with immediate post-training test scores, and 75/79 (95%) oximeters were in routine clinical use. This method of introduction resulted in a high rate of uptake of oximeters into clinical practice and a demonstrable retention of knowledge in a resource-limited setting.

Tumor necrosis factor-related apoptosis-inducing ligand translates neonatal respiratory infection into chronic lung disease

Respiratory infections in early life can lead to chronic respiratory disease. Chlamydia infections are common causes of respiratory disease, particularly pneumonia in neonates, and are linked to permanent reductions in pulmonary function and the induction of asthma. However, the immune responses that protect against early-life infection and the mechanisms that lead to chronic lung disease are incompletely understood. Here we identify novel roles for tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) in promoting Chlamydia respiratory infection-induced pathology in early life, and subsequent chronic lung disease. By infecting TRAIL-deficient neonatal mice and using neutralizing antibodies against this factor and its receptors in wild-type mice, we demonstrate that TRAIL is critical in promoting infection-induced histopathology, inflammation, and mucus hypersecretion, as well as subsequent alveolar enlargement and impaired lung function. This suggests that therapeutic agents that target TRAIL or its receptors may be effective treatments for early-life respiratory infections and associated chronic lung disease.

Neonatal respiratory infection and adult re-infection: effect on glucocorticoid and mineralocorticoid receptors in the hippocampus in BALB/c mice

Stressful events during the perinatal period in both humans and animals have long-term consequences for the development and function of physiological systems and susceptibility to disease in adulthood. One form of stress commonly experienced in the neonatal period is exposure to bacterial and viral infections. The current study investigated the effects of live Chlamydia muridarum bacterial infection at birth followed by re-infection in adulthood on hippocampal glucocorticoid receptors (GR) and mineralocorticoid receptors (MR) and stress response outcomes. Within 24 h of birth, neonatal mice were infected intranasally with C. muridarum (400 inclusion-forming units [ifu]) or vehicle. At 42 days, mice were re-infected (100 ifu) and euthanized 10 days later. In males, infection in adulthood alone had the most impact on the parameters measured with significant increases in GR protein compared to adult infection alone; and significant increases MR protein and circulating corticosterone compared to other treatment groups. Neonatal infection alone induced the largest alterations in the females with results showing reciprocal patterns for GR protein and TH protein. Perinatal infection resulted in a blunted response following adult infection for both males and females across all parameters. The present study demonstrates for the first time that males and females respond differently to infection based on the timing of the initial insult and that there is considerable sex differences in the hippocampal phenotypes that emerge in adulthood after neonatal infection.

Efficacy and rectal toxicity of hypofractionated radiation therapy with daily image guidance

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Background: To assess the biochemical control rates and long-term rectal side effect profile of hypofractionated image guided radiation therapy for prostate cancer. We hypothesize that daily CT-based image guidance will allow a higher dose per fraction to be safely administered, shortening the overall treatment time from 8 weeks to 4-5.5 weeks.

Methods: 160 patients were treated with image guided radiation therapy with or without adjuvant hormonal ablation between 2005 and 2009 for patients <= T3a N0 M0. Patients were classified into risk groups with 51 patients defined as low risk, 67 as intermediate risk, and 43 as high risk. Mean age was 70.2 years. All patients were treated with 60/67.6/70/70.2 Gy to the prostate divided into 20/26/28/27 fractions. 57% of patients received hormone therapy. Daily CT or fiducial-based image guidance was performed prior to each fraction. The median follow up was 34 months. Biochemical control was defined by the Phoenix definition. Rectal toxicity was graded by the CTCAE 4.0 scale. In general patients with rectal bleeding more than once per week were started on rectal steroids.

Results: 12/160 (7.5%) of patients had late grade 2 or worse rectal toxicity after radiation treatment. The Kaplan-Meier estimate for grade 2 rectal toxicity at 2 years was 6.9%. The crude rate of biochemical no evidence of disease was 96.3%. Kaplan Meier estimates for biochemical no evidence of disease at 3 and 5 years are 0.98/0.84, 0.97/0.97, and 1.0/0.67 for low, medium, and high-risk patients respectively. Log-rank analysis showed no statistically significant difference among the dosing regimens for toxicity-free survival (p=0.24).

Conclusions: With daily image guidance hypofractionated radiation therapy is clinically safe with moderate late rectal toxicity. Early follow-up suggests high efficacy. Ongoing and future randomized trials such as RTOG 0415 will be required to confirm these findings.

No significant financial relationships to disclose.

Which MR imaging sequences are necessary in determining the need for radiation therapy for cord compression? A prospective study

BACKGROUND AND PURPOSE

To determine which MR imaging sequences are necessary to assess for spinal metastases.

METHODS

Hypothetical MR imaging interpretations and management plans were made prospectively for consecutive adult cases acquired retrospectively. Standardized MR imaging protocols were independently interpreted by 2 neuroradiologists. MR imaging protocol types varied: 1) T1-weighted images only; 2) T1-weighted and T2-weighted images; 3) T1-weighted and postcontrast T1-weighted images; and 4) T1- and T2-weighted images and postcontrast T1-weighted images. Hypothetical management plans were created by 2 radiation oncologists. Logit model was used to investigate the effect of MR imaging protocol type on the probability of recommending radiation therapy (RT). Mixed effect models were used to investigate whether median spinal level or total number of spinal levels of planned RT was associated with MR imaging protocol type.

RESULTS

Thirty-one subjects were evaluated, each with multiple scan interpretations. Logit model showed that neither MR imaging protocol type nor neuroradiologist reader affected the probability that the oncologist would recommend RT (all P > .50). Mixed models showed that neither ML nor NL was affected by MR imaging protocol type or by neuroradiologist reader (all P > .12).

CONCLUSION

Although MR imaging is known to be the most useful diagnostic test in suspected spinal cord compression, which particular MR images are necessary remain unclear. Compared with T1-weighted images alone, the additional use of T2-weighted and/or postcontrast T1-weighted sequences did not significantly affect the probability that RT would be recommended or the levels that would be chosen for RT in our study. Our data suggest that unenhanced T1-weighted images may be sufficient for evaluation of possible cord compression.

Surgical removal of subfoveal choroidal neovascularization without removal of posterior hyaloid: a consecutive series in younger patients

PURPOSE

Subfoveal choroidal neovascularization (CNV) remains a common and important cause of visual loss. Previous studies have suggested that submacular surgery may improve or maintain visual acuity, particularly in younger patients. The majority of reported cases included removal of the posterior hyaloid during vitrectomy. The authors present a consecutive series of patients age 55 or younger with subfoveal CNV removal without posterior hyaloid removal.

METHODS

Seventeen patients without age-related macular degeneration (ARMD), with subfoveal CNV from choroiditis, presumed ocular histoplasmosis syndrome, myopia, or idiopathic causes, underwent a small retinotomy technique to extract the membranes after vitrectomy without posterior hyaloid removal.

RESULTS

Median improvement in visual acuity was from 20/320 to 20/50. Eleven patients (65%) experienced an improvement of three or more lines of Snellen acuity (average 7.5), 4 (23%) were within two lines of preoperative acuity, and 2 (12%) had decreased acuity, with an average follow-up of 12 months (range 3-31). Choroidal neovascularization recurred in six patients (35%). Postoperative retinal detachment, epiretinal proliferation, or macular hole did not occur.

CONCLUSIONS

In this series of younger patients with subfoveal CNV not from ARMD, visual acuity was improved in the majority after submacular membrane removal. Omission of removal of the posterior hyaloid did not adversely affect outcome.

Long-term follow-up of RTOG 92-10: cervical cancer with positive para-aortic lymph nodes

PURPOSE

The purpose of this study was to evaluate the late toxicity and efficacy of twice-daily external irradiation to the pelvis and lumbar para-aortic region with brachytherapy and concurrent chemotherapy for carcinoma of the cervix with positive para-aortic lymph nodes.

PATIENTS AND METHODS

This study was designed to administer twice-daily radiation doses of 1.2 Gy to the pelvis and lumbar para-aortic lymph nodes (simultaneously) at 4-6-h intervals, 5 days per week. The total external radiation doses were 24-48 Gy to the whole pelvis, 12-36 Gy parametrial boost, and 48 Gy to the lumbar para-aortic region with an additional boost to a total dose 54-58 Gy to the positive para-aortic lymph node(s). One or two intracavitary implants were performed to deliver a minimum total dose of 85 Gy to point A. Cisplatin (75 mg/m(2); Days 1, 22, and 43) and 5-fluorouracil (1,000 mg/m(2)/24 h x 4 consecutive days, beginning on Days 1, 22, and 43) were given for two or three cycles.

RESULTS

Thirty patients with clinical Stages I-IV carcinoma of the cervix with biopsy-proven para-aortic lymph node metastases were enrolled in this study. Hyperfractionated external irradiation was completed in 87% (26 of 30). Brachytherapy was given in two implants to 47% (14 of 30) and in one implant to 33% (10 of 30); 13% (4 of 30) did not receive brachytherapy, 1 patient had three implants, and 1 had five high-dose-rate implants. Radiotherapy was completed per protocol in 70%. Three cycles of chemotherapy were given to 23% (7 of 30); 73% (22 of 30) received two cycles, and 1 patient did not receive chemotherapy. The acute toxicity from chemotherapy was Grade 1 in 3%, Grade 2 in 17%, Grade 3 in 48%, and Grade 4 in 28%. Acute toxicity from radiotherapy was Grade 1 in 7%, Grade 2 in 34%, Grade 3 in 21%, and Grade 4 in 28%. Late toxicity was Grade 1 in 10%, Grade 2 in 17%, Grade 3 in 7%, and Grade 4 in 17%. Grade 5 toxicity occurred in 1 patient during the course of therapy, but none had a late Grade 5 toxicity. The median follow-up time for the 7 patients alive at the time of last follow-up was 57 months. The overall survival estimates were 46% at 2 years and 29% at 4 years. The probability of local-regional failure was 40% at 1 year and 50% at 2 and 3 years. The probability of disease failure at any site was 46% at 1 year, 60% at 2 years, and 63% at 3 years.

CONCLUSION

The results suggest that twice-daily external irradiation to the pelvis and lumbar para-aortic region with brachytherapy and concurrent chemotherapy resulted in an unacceptably high rate (17%, 5 of 29) of Grade 4 late toxicity. One patient died of acute complications of therapy. The survival estimates seem no better than standard fractionation irradiation without chemotherapy.

Welfare reform and "ineligibles": issue of constitutionality and recent court rulings

In 1996 welfare legislation made lawful immigrants, with a few exemptions, categorically ineligible for most forms of public assistance. This legislation has led affected immigrants and their advocacy groups to file lawsuits to challenge the constitutionality of the Personal Responsibility and Work Opportunity Reconciliation Act. This article reviews recent court rulings that have upheld the act and examines court decisions in light of two constitutional principles (the Equal Protection and Supremacy clauses), which traditionally have been applied to the issue of aliens' eligibility for welfare benefits. The author finds inconsistent outcomes between federal and state legislation in the judicial review process. To resolve this inconsistency, the author suggests several policy changes in the distribution of welfare benefits concerning eligibility of lawful immigrants. The implications for social work practice are discussed.

Bmp6 and Bmp7 are required for cushion formation and septation in the developing mouse heart

The mature heart valves and septa are derived from the cardiac cushions which initially form as local outgrowths of mesenchymal cells within the outflow tract and atrioventricular regions. Endocardial cells respond to signals from the overlying myocardium and undergo an epithelial-to-mesenchymal transformation to invade the intervening extracellular matrix. The molecules that can induce and maintain these cell populations are not known, but many candidates, including several TGFbetas and BMPs, have been proposed based on their expression patterns and activities in other systems. In the present study, we describe the expression of Bmp6 and Bmp7 in overlapping and adjacent sites, including the cardiac cushions during mouse embryonic development. Previous analyses demonstrate that neither of these BMPs is required during cardiogenesis, but analysis of Bmp6;Bmp7 double mutants uncovers a marked delay in the formation of the outflow tract endocardial cushions. A proportion of Bmp6;Bmp7 mutants also display defects in valve morphogenesis and chamber septation, and the embryos die between 10.5 and 15.5 dpc due to cardiac insufficiency. These data provide the first genetic evidence that BMPs are involved in the formation of the cardiac cushions.

Tumor shrinkage before intracavitary brachytherapy for cancer of the cervix: radiotherapy alone versus concurrent chemoradiotherapy

PURPOSE

The purpose of this study was to compare the tumor shrinkage between radiotherapy alone and concurrent chemoradiotherapy before intracavitary brachytherapy (ICBT).

MATERIALS AND METHODS

Nineteen consecutive patients (three stage IB2, nine stage IIB, seven stage IIIB) were selected for measurement of tumor regression. Ten patients underwent radiotherapy alone, and nine patients underwent concurrent cisplatin-based chemoradiotherapy. The average dose of pelvic radiation was given at 45 Gy over a 5-week period in both groups. Computed tomography-based tumor measurement before treatment was compared with measurement after treatment but before intracavitary brachytherapy. The largest width and thickness of the cervical mass were measured from the axial computed tomographic images.

RESULTS

Tumor regression before intracavitary brachytherapy varied widely, ranging from 15% to 65%. However, the tumor regression in patients who underwent chemoradiotherapy was higher, ranging from 41% to 65% (mean, 55%), compared with radiotherapy alone, which ranged from 15% to 52% (mean, 38%).

CONCLUSION

Our results show that significant tumor shrinkage occurs with concurrent chemoradiotherapy compared with radiotherapy alone. This finding supports the results of recent clinical trials demonstrating improvement of pelvic control and survival with concurrent chemoradiotherapy for advanced cancer of the cervix.

Recent developments in chemoradiotherapy for locally advanced cancer of the cervix

Patients with locally advanced cervical cancer comprise a significant proportion of the total population with cervical cancer, particularly in developing countries. The inability to control pelvic tumors is still a significant concern. Although neoadjuvant chemotherapy is associated with a high response rate, data from randomized trials clearly do not support the use of neoadjuvant chemotherapy prior to definitive irradiation. However, the results of concurrent cisplatin (Platinol)-based chemotherapy and radiotherapy are highly promising for locally advanced cancer of the cervix and should be considered as a treatment option. To decrease the risk of distant metastasis and improve survival, more effective drugs or drug combinations need to be developed.

A prospective evaluation of the timing of postoperative radiotherapy for preventing heterotopic ossification following traumatic acetabular fractures

PURPOSE

Preoperative and immediate postoperative irradiation of traumatic acetabular fractures (TAF), although known to reduce heterotopic ossification (HO), can cause significant organizational and logistic difficulties. We sought to determine an acceptable time interval between surgery and radiation without compromising control, as well as to update our large experience and to further validate our treatment philosophy.

METHODS AND MATERIALS

Beginning in June 1995, we began a prospective study, irradiating 152 patients on postoperative days 1, 2, or 3. There were also 17 patients delayed further secondary to medical difficulties.

RESULTS

All patients treated since June 1995 received 700 cGy/1 fx. Fifty-eight patients received radiation within 24 hours of surgery, 41 within 2 days, 53 within 3 days, 13 within 4 days, and 4 were delayed further. Delaying irradiation for up to 4 days postoperatively caused no statistical increase in HO (p = 0.625). Of 263 patients in our retrospective cohort, HO occurred in 5.3% of patients who received irradiation versus 60% of patients who did not.

CONCLUSION

In our prospective study, we noted no perceptible increase in HO with up to a 3-day interval between surgery and radiotherapy. This allows a more structured treatment schedule and allows the patient more time to heal and recover. Updated results from our overall series continue to demonstrate that adjuvant radiation decreases the incidence and severity of HO after TAF.

Effects of pelvic rotation and needle angle on pubic arch interference during transperineal prostate implants

PURPOSE

Pubic arch interference due to an enlarged prostate gland or a narrow pubic arch is often a limiting factor in adequate prostate coverage during transperineal brachytherapy. The purpose of this study was to evaluate the effects of both pelvic rotation and needle angles on pubic arch interference using CT-based 3-D information.

METHODS AND MATERIALS

Seven patients had CT imaging in both supine and lithotomy positions and 3-D treatment planning was performed with three needle angles (20 downward, 0, 20 upward). The pubic arch interference was then measured and comparisons were made for each needle trajectory and pelvic position.

RESULTS

Increasing pelvic rotation from supine to lithotomy position shows less pubic arch interference. Directing the needle tip upward shows less pubic arch interference in both supine and lithotomy positions when compared to needle tips directed downward.

CONCLUSIONS

Both pelvic position and needle angles are important factors influencing pubic arch interference. Preplanning CT-based 3-D information may assist for individualized treatment planning in patients with a significant bony interference, thus avoiding pubic arch interference during implantation.

Radiation response of Rosai-Dorfman disease presenting with involvement of the orbits

The purpose of this study was to review an interesting case of recurrent orbital sinus histiocytosis. The patient initially failed surgery, chemotherapy, and steroid therapy, only to have a durable response to low-dose radiation therapy of the orbits, lasting 6 and 11 years, respectively. Because there are few documented responses to radiotherapy, we present a case report in conjunction with the clinical, radiographic, and histopathologic information as well as a literature review of similar cases.

Tuberculous neuroretinitis

OBJECTIVES

To describe a patient with tuberculous neuroretinitis.

MATERIALS AND METHODS

Retrospective case report.

RESULTS

We describe a 43-year-old otherwise asymptomatic woman with a known exposure to tuberculosis who had unilateral optic disc edema and a partial macular star (neuroretinitis). This was followed approximately 1 year later by the development of an exudative retinal detachment in the setting of bilateral multifocal choroiditis. Laboratory testing revealed a marked positive cutaneous reaction to purified protein derivative (PPD). Treatment with antituberculosis medicine alone resulted in prompt resolution of the choroidal infiltrates and complete flattening of the exudative detachment.

CONCLUSIONS

Tuberculosis should be considered in the differential diagnosis for patients with neuroretinitis.

Primary lymphoma of the breast: breast mass as an initial symptom

Seven patients with lymphoma presenting as a breast mass are described. Four of them fulfilled the criteria for primary lymphoma of the breast, and three had evidence of secondary lymphoma of the breast. Two patients were diagnosed with stage IAE disease, and both did well with local treatment with or without chemotherapy. Two patients were diagnosed with stage IIAE disease; both had distant failure without systemic chemotherapy. Although local treatment is curative in a subset of stage IAE disease, combination chemotherapy followed by local radiation is a safer approach. For stage IIAE disease, combination chemotherapy and local radiation therapy should be considered.

Stereotactic Irradiation: potential new treatment method for brain metastases resulting from ovarian cancer

Stereotactic irradiation (radiosurgery) is a method of precisely focusing well-defined beams of radiation at small intracranial targets. The technique has been applied to the treatment of brain lesions that are benign (e.g., arteriovenous malformations, meningiomas, pituitary adenomas) and malignant (e.g., gliomas, metastases). This paper introduces preliminary data suggesting the possible value of radiosurgery in the management of ovarian cancer metastatic to the brain. Among 32 women with ovarian cancer metastatic to the brain treated with whole brain irradiation, nine (29%) experienced a complete radiographic response, compared with two of the five patients (40%) treated with radiosurgery. The 2-year survival rate was 60% among those treated with radiosurgery and 15% among those who received whole brain irradiation without radiosurgical boost. Stereotactic irradiation may be of clinical benefit to select patients with brain metastases resulting from ovarian cancer. A prospective randomized trial has been implemented by the Radiation Therapy Oncology Group (RTOG 95-08) to determine whether such observations are reproducible on a national scale.

Characterization of antibody against the N-terminus of RDS/peripherin

Mutations in the gene encoding RDS/peripherin cause a variety of retinal disorders. Attempts to model such disorders in vitro and in vivo have been hampered by the paucity of available immunological reagents. Moreover, available antibodies have been generated from undefined or C-terminal epitopes and therefore may not suitable for detecting all known RDS/peripherin mutants. We consequently generated affinity-purified rabbit antibody against a 14 amino acid peptide corresponding to the highly conserved N-terminus of human RDS/ peripherin. This new antibody, N-RDS, recognizes RDS/peripherin in the retina of man, macaque, and rat. N-RDS may prove useful in studying RDS/peripherin mutants, particularly those with abnormal C-terminal domains.

Twice-daily fractionation of external irradiation with brachytherapy and chemotherapy in carcinoma of the cervix with positive para-aortic lymph nodes: Phase II study of the Radiation Therapy Oncology Group 92-10

PURPOSE

The purpose of this study was to evaluate the toxicity and efficacy of twice-daily external irradiation to the pelvis and para-aortics with brachytherapy and concurrent chemotherapy for carcinoma of the cervix with positive para-aortic lymph nodes.

METHODS AND MATERIALS

This study was designed to administer twice-daily radiation doses of 1.2 Gy to the pelvis and para-aortics at 4- to 6-h intervals, 5 days per week. The total external radiation doses were 24 to 48 Gy to the whole pelvis, 12 to 36 Gy parametrial boost, and 48 Gy to the para-aortics with an additional boost to a total dose of 54 to 58 Gy to the known metastatic para-aortic site. One or two intracavitary applications were performed to deliver a total minimum dose of 85 Gy to point A. Cisplatin (75 mg/m2, days 1 and 22) and 5-FU (1000 mg/m2/24 h x 4 days; days 1 and 22) were given for two or three cycles.

RESULTS

Twenty-nine patients with clinical Stages I to IV carcinoma of the cervix with biopsy-proven para-aortic lymph nodes were enrolled in this study. Hyperfractionated external radiotherapy was completed in 86% (25 of 29). Brachytherapy was given in two applications to 48% (14 of 29), 31% (9 of 29) had one intracavitary application, 14% (4 of 29) had no brachytherapy, one had three applications, and one had five HDR applications. Radiotherapy was completed per protocol in 69%. Three courses of chemotherapy were given to 24% (7 of 29), 72% (21 of 29) received two courses, and one patient did not receive chemotherapy. The acute toxicity from chemotherapy was Grade 1 in 3%, Grade 2 in 17%, Grade 3 in 48%, and Grade 4 in 28%. Radiotherapy toxicity was Grade 1 in 7%, Grade 2 in 34%, Grade 3 in 21%, and Grade 4 in 28%. One Grade 5 toxicity occurred and the patient died from a myocardial infarction from chemotherapy and radiotherapy colitis during her course of therapy. The median follow-up time was 18.9 months. The overall survival estimates were 59% at 1 year and 47% at 2 years. The probability of local-regional failure was 38% at 1 year and 49% at 2 years. The probability of disease failure at any site was 45% at 1 year and 59% at 2 years.

CONCLUSION

The results suggest that twice-daily external irradiation to the pelvis and para-aortics with brachytherapy and concurrent chemotherapy resulted in an unacceptably high rate (31%, 9 of 29) of Grade 4 nonhematologic toxicity. One patient died from complications of therapy. Radiotherapy was completed per protocol in 69%. The survival estimates appear no better than standard fractionation radiotherapy without chemotherapy. Additional follow-up is necessary for long-term survival estimates.

Adenocarcinoma of the fallopian tube: results of a multi-institutional retrospective analysis of 72 patients

PURPOSE/OBJECTIVE

To determine the prognostic factors for predicting outcome of patients with adenocarcinoma of the fallopian tube and to evaluate the impact of treatment modalities in managing this uncommon disease.

MATERIALS AND METHODS

A retrospective analysis of the tumor registries from 6 major medical centers from January 1, 1960 up to March 31, 1995 yielded 72 patients with primary adenocarcinoma of the fallopian tube. The Dodson modification of the FIGO surgical staging as it applies to carcinoma of the fallopian tube was utilized. Endpoints for outcome included overall and disease-free survival. Univariate analysis of host, tumor, and treatment factors was performed to determine prognostic significance, and patterns of failure were reviewed.

RESULTS

The median age of the study cohort was 61 years (range 30-79 years). Stage distribution was 24 (33%) Stage I; 20 (28%) Stage II; 24 (33%) Stage III; and 4 (6%) Stage IV. Adjuvant chemotherapy was administered to 54 (75%) patients, and postoperative radiotherapy was employed in 22 (31%). In the latter treatment group, 14 (64%) had whole pelvic external beam irradiation, 5 (23%) whole abdominal radiotherapy, 2 (9%) P-32 instillation, and 1 (4%) vaginal brachytherapy alone. Chemotherapy was used in 67% of Stage I and in 79% of Stages II/III/IV disease (not significant); radiotherapy was more commonly employed in Stage I than in Stages II/III/IV (46% vs. 23%, p = 0.05). The 5-, 8-, 15-year overall and disease-free survival for the study patients were 44.7%, 23.8%, 18.8% and 27.3%, 17%, 14%, respectively. Significant prognostic factors of overall survival included Stage I vs. II/III/IV (p = 0.04) and age < or = 60 years vs. > 60 years at diagnosis (p = 0.03). Only Stage I vs. II/III/IV (p = 0.05) was predictive of disease-free survival. Patterns of failure included 18% pelvic, 36% upper abdominal, and 19% distant. For all patients, upper abdominal failures were more frequently found in Stages II/III/IV (29%) than in Stage I (7%) (p = 0.03). Relapses solely outside of what would be included in standard whole abdominal radiotherapy portals occurred for only 15% of patients (6 of 40) with failures. Furthermore, patients having any recurrence, including the upper abdomen, were more likely (p = 0.001) to die (45%) than those without any type of relapse (18%).

CONCLUSION

This retrospective, multi-institutional study demonstrated the importance of FIGO stage in predicting the overall and disease-free survival of patients with carcinoma of the fallopian tube. Future investigations should consider exploring whole abdominal irradiation as adjunctive therapy, particularly in Stage II and higher.

Coats-type retinitis pigmentosa in a 4-year-old child

PURPOSE

To describe the occurrence of Coats-like exudative retinopathy secondary to underlying retinitis pigmentosa in a 4-year-old child.

METHOD

Case report.

RESULTS

A 4-year-old girl had bilateral exudative retinal telangiectasia requiring photocoagulation. She subsequently developed progressive nyctalopia, photophobia, and reduced peripheral vision. Electroretinography and dark adaptometry at age 8 years confirmed the diagnosis of retinitis pigmentosa.

CONCLUSIONS

Coats-like exudative retinopathy secondary to retinitis pigmentosa can manifest as early as age 4 years and can precede the diagnosis of the underlying retinal dystrophy.

Digital angiography of experimental choroidal melanomas using benzoporphyrin derivative

PURPOSE

To examine benzoporphyrin derivative angiography as a modality for studying photosensitizer biodistribution in experimental choroidal melanomas.

METHODS

A liposomal preparation of benzoporphyrin derivative was used in this study. Digital benzoporphyrin derivative angiograms were performed in 10 rabbits (six for experimental choroidal melanomas, two for normal choroids, and two for irides) using a Topcon ImageNet H1024 digital imaging system, a Kodak Megaplus video camera, and a Topcon TRC-50-VT fundus camera. Only one eye from each rabbit was used. Filters specifically designed for benzoporphyrin derivative (peak absorption at 580 nm and peak emission at 695 nm) were used. Benzoporphyrin derivative (1 mg/kg) was injected into an ear vein while images of tumor, normal choroid, or iris were being obtained. Follow-up images were obtained during the first 3 hours and at 24 hours after injection. Fluorescence microscopy was performed in all 10 rabbits using 1 mg/kg of benzoporphyrin derivative. Tumor-bearing eyes were enucleated at the same time points that angiograms were performed, and the two sets of results were compared for maximum dye accumulation.

RESULTS

Digital angiography demonstrated that maximal benzoporphyrin derivative fluorescence occurred in tumors 15 to 45 minutes after injection. Fluorescence photometry corroborated these results.

CONCLUSION

Photosensitizer angiography is a valid modality for determining the optimum treatment time for photodynamic therapy.

Retinal function abnormalities in membranoproliferative glomerulonephritis type II

PURPOSE

To characterize retinal electrophysiologic and psychophysical abnormalities associated with membranoproliferative glomerulonephritis type II.

METHODS

Three adults with membranoproliferative glomerulonephritis type II were studied. Retinal function was measured psychophysically (automated perimetry, Farnsworth D-15 color vision testing, and dark adaptometry) and electrophysiologically (full-field flash electroretinography and electro-oculography).

RESULTS

Two symptomatic individuals had prominent drusenlike deposits and retinal pigment epithelial disturbances, findings characteristic of membranoproliferative glomerulonephritis type II retinopathy. These individuals had mild visual field and color vision abnormalities, prolonged dark adaptation, and delayed electroretinographic dark-adapted dim and bright flash responses of normal amplitude. The electro-oculogram of the most severely affected individual was abnormal. The third individual who was asymptomatic had the mildest fundus abnormalities and exhibited normal psychophysical and electrophysiologic responses.

CONCLUSIONS

Membranoproliferative glomerulonephritis type II retinopathy may be associated with symptomatic and measurable psychophysical and electrophysiologic abnormalities of retinal function.

Dynamics of pear-shaped dimensions and volume of intracavitary brachytherapy in cancer of the cervix: a desirable pear shape in the era of three-dimensional treatment planning

PURPOSE

To evaluate the dynamics of pear-shaped dimensions and volume of the intracavitary brachytherapy, and to define a desirable pear-shape in the era of three-dimensional (3D) treatment planning.

METHODS AND MATERIALS

Since Point A has been used for the dose specification, the pear shape defined the surface enclosed by Point A. This study utilized a new method of evaluating pear-shaped dimensions and its configuration. The pear shape was artificially divided into tandem and colpostat portions for evaluation of its changes. Width, height, and thickness at the tandem portion (Wt, Ht, and Tt) and at the colpostat portion (Wc, Hc, and Tc) were defined, respectively, on the frontal and sagittal plane. To evaluate the dynamics of the pear-shape configuration, 12 variations of applicator geometry and source loading were applied to generate the pear-shape isodose line and dose-volume histogram.

RESULTS

When the source strengths in the colpostats were reduced for optimization with the same dose to Point A dose, Wc, Hc, and Tc were decreased, whereas Wt, Ht, and Tt were increased without a change in the overall pear-shaped volume. When the separation of the colpostats was increased without a change in the source strength, Wc was increased, whereas Hc and Tc were reduced without a change in Wt, Ht, Tt and overall pear-shape volume. When the separation of colpostats and distal tandem source were increased, these changes at the colpostat portion were magnified. However, when both colpostat separation and its source strength were increased proportionally, Wc, Hc, and Tc were increased proportionally as well as its volume.

CONCLUSION

The dose specification at Point A is less meaningful without a desirable pear shape encompassing the tumor around the cervix. In the era of 3D treatment planning, understanding the dynamics of the pear shape should improve the individualized dosimetry according to tumor size and location. The relationships between a desirable pear shape and its tumor coverage should establish a more reliable dose specification for cancer of the cervix.

Predictive factors for response to medical therapy in bacterial ulcerative keratitis

BACKGROUND

Fifty-four consecutive cases of culture-positive bacterial ulcerative keratitis presenting at a major university hospital were reviewed to identify factors predictive of response to medical therapy for bacterial ulcerative keratitis (BUK).

METHODS

Eleven patients (20%) failed medical therapy (defined as the need for surgical intervention or cyanoacrylate gluing). Using multivariate logistic regression, the following variables were evaluated: (1) predisposing ocular factors (e.g., contact lens wear), (2) pre-existing ocular diseases, (3) ulcer size, and (4) the number of topical ocular medications used at the time of presentation.

RESULTS

We noted certain factors to be potentially predictive of medical therapy outcome. The average size of the ulcer at the time of presentation was 4.4 +/- 2.4 mm in the failure group but only 2.5 +/- 1.9 mm for the success group (P = 0.027). In addition, patients in the medical failure group used more topical ocular medications at the time of presentation (P = 0.0075). Further analysis of the individual topical ocular medications revealed that the use of corticosteroids was higher in the failure group (56% vs 12%, P = 0.0005 by Fisher's exact test). Other factors such as patient age, the type of organism(s), and the time elapsed between the onset of symptoms and the beginning of definitive therapy were not statistically significant.

CONCLUSION

In this population, ulcer size at the onset of antibacterial treatment and the use of certain ocular medications, specifically corticosteroids, were significant predictive factors for failure of medical therapy for BUK.

Photodynamic therapy of pigmented choroidal melanomas of greater than 3-mm thickness

PURPOSE

The purpose of the study is to determine the effect of photodynamic therapy in the destruction of experimental pigmented choroidal melanomas > or = 3 mm in thickness using a liposomal preparation of benzoporphyrin derivative, verteporfin.

METHODS

Pigmented choroidal tumors were established in 32 New Zealand albino rabbit eyes. Animals were treated with daily injections of cyclosporine, and tumor growth was followed by serial fundus examinations and ultrasonography. When a tumor exceeded 3 mm in thickness (tumor height ranged from 3.1-4.6 mm), the authors administered benzoporphyrin derivative intravenously (1 mg/kg) and irradiated the tumor at 692-nm through an argon-pumped dye laser at different total light doses ranging from 60 to 120 J/cm2. Control animals were treated with light or benzoporphyrin derivative only. Each animal then was followed-up for 4 to 6 weeks by fundus photography, fluorescein angiography, and ultrasonography.

RESULTS

All animals treated with benzoporphyrin derivative and light at fluences of > or = 80 J/cm2 showed complete tumor arrest. In contrast, both control groups showed continuous tumor growth in all animals with tumors filling most of the vitreous cavity by 3 weeks. Histologic examination results of tumors treated with dye plus light immediately after treatment showed prominent vascular closure. No vascular changes were noted in the control eye treated with light or dye alone. Examination results of the eyes that showed tumor regression after a 4-week follow-up period showed tumor necrosis and extensive infiltration of mononuclear cells and pigment-laden macrophages at the tumor site.

CONCLUSIONS

These data suggest that photodynamic therapy may have a role in the management of pigmented choroidal melanomas.

Postsurgical recurrent carcinoma of the cervix: reassessment and results of radiation therapy options

PURPOSE

To evaluate outcome and reassess the radiation therapy options in pelvic recurrences of cervical cancer treated initially with surgery.

MATERIALS AND METHODS

In 30 patients, the prognostic factors analyzed for local control included site of recurrence (central, pelvic wall), tumor size, modality of radiation therapy, and radiation dose. Mean follow-up in survivors was 111.5 months.

RESULTS

Local control was attained in (a) nine of 20 patients with central recurrence and in two of 10 with pelvic wall recurrence (p = .25); (b) none of four who received less than 50 Gy, five of nine who received 50-60 Gy, and six of 17 who received greater than 60 Gy (p = .27); and (c) five of 11 with tumor smaller than 3 cm, five of nine with tumor size 3-6 cm, and one of 10 with tumor larger than 6 cm. Multivariate analysis revealed a significant benefit of local control on survival (P = .05). Median survival for patients with central recurrence was 14.5 months compared with 9 months for those with pelvic wall recurrence.

CONCLUSION

Local pelvic control depends on site and size of recurrence and radiation therapy modality and dose. Appropriate choice of brachytherapy modality is important. To improve local control and survival, more aggressive treatment is indicated, but attendant higher complications may be expected.

Reactive oxygen intermediates increase vascular endothelial growth factor expression in vitro and in vivo

Elevated vascular endothelial growth factor (VEGF) levels are required for ocular and tumor angiogenesis in animal models. Ischemic hypoxia is strongly correlated with increased VEGF expression in these systems and is considered a physiologically relevant stimulus. Because ischemic hypoxia is often followed by reperfusion and reactive oxygen intermediate (ROI) generation, we examined the potential role of ROI in the control of VEGF gene expression. Human retinal pigment epithelial cells exposed to superoxide or hydrogen peroxide rapidly increased VEGF mRNA levels. Superoxide-associated mRNA increases were dose dependent, blocked by antioxidants, and associated with elevated VEGF protein levels in conditioned media. Increases in VEGF mRNA levels were also observed in cultured human melanoma and rat glioblastoma cells with superoxide or hydrogen peroxide. Cycloheximide prevented the ROI-associated increases in VEGF mRNA. Transcriptional inhibition with actinomycin D revealed an inducible increase in VEGF mRNA half-life, but nuclear run-on experiments showed no increase in VEGF transcriptional rate. Reoxygenation of human retinal pigment epithelial cells in vitro and ocular reperfusion in vivo increased retinal VEGF mRNA levels. Antioxidants prevented the reperfusion-associated VEGF mRNA increases in retina. We conclude that ROIs increase VEGF gene expression in vitro and during the reperfusion of ischemic retina in vivo. The ROI-associated increases are mediated largely through increases in VEGF mRNA stability.

Photodynamic therapy of pigmented choroidal melanomas using a liposomal preparation of benzoporphyrin derivative

OBJECTIVE

To evaluate the effectiveness of photodynamic therapy of pigmented choroidal melanoma using a liposomal preparation of benzoporphyrin derivative monoacid (BPD), verteporfin.

DESIGN

Pigmented choroidal melanomas were established in 25 New Zealand albino rabbit eyes. The animals were treated with daily injections of cyclosporine, and tumor growth was monitored with funduscopic examination and ultrasonography. Fifteen minutes after intravenous injection of BPD (2 mg/kg), the tumors were irradiated at 692 nm through an argon-pumped dye laser with the delivered fluence ranging between 40 and 150 J/cm2. Control animals were treated with light only, photosensitizer only, or observation only. Tumor growth was monitored by indirect ophthalmoscopy, fundus photography, fluorescein angiography, and ultrasonography. Histologic examination was performed.

RESULTS

Eighteen tumor-bearing rabbits were treated with light and BPD; 16 were followed up for 1 month, and two were killed immediately for histologic examination. Tumors regressed in all eyes treated with 60 J/cm2 or more. With fluence of 40 J/cm2, tumor regrowth was observed in one animal within 10 days of treatment. In the three control groups, all animals showed continuous tumor growth. Histologic examination of the eyes treated with photosensitizer and light immediately after treatment showed prominent vascular occlusion throughout the full thickness of the tumor. One month after treatment, tumor necrosis and infiltration of mononuclear cells and pigment-laden macrophages were the predominant findings.

CONCLUSIONS

Photodynamic therapy with BPD may have a role in the treatment of pigmented choroidal melanomas.

Radiation oncology at the centennial

1995 marks the centennial year of the discovery of x-rays. The medical profession advanced rapidly following Roentgen's discovery of the x-ray. Every aspect of medicine came to rely on radiology in some way. The x-ray not only revolutionized diagnostic medicine, it transformed therapeutic medicine as well. Only months after its discovery, the x-ray was being used with therapeutic intent, thus began radiation therapy. We can examine the development of radiation oncology in several periods.

An experimental model of retinal pigment epithelial and neurosensory serous detachment

PURPOSE

The authors document an animal model of retinal pigment epithelial (RPE) detachments.

METHODS

N-ethylmaleimide (NEM) and sodium iodate (sulfhydryl-alkylating agents) were injected into the vitreous of Dutch pigmented rabbits. Subretinal fluid samples were withdrawn 0.5 and 3 hours after NEM injections and analyzed for albumin content by gel electrophoresis. Selected eyes were examined histologically.

RESULTS

Injections of 9.2 micrograms NEM caused wrinkling of the retina within 15 minutes, at which time fluorescein angiography revealed multifocal RPE detachments. At this stage, histologic sections showed moderate choroidal edema and RPE detachment. Elevated retinal detachments developed over the next 15 to 25 minutes. Histologic sections showed massive choroidal edema and RPE fragmentation. The albumin concentration of subretinal fluid rose from 60% of serum level at 30 minutes after NEM to 80% after 3 hours. Sodium iodate did not cause choroidal edema or RPE detachment.

CONCLUSION

In rabbits, intravitreal NEM causes the rapid appearance of choroidal edema and RPE detachment, followed by serous retinal detachment. The initial effect probably is caused by an alteration of choroidal vascular permeability. The relationship of these effects to sulfhydryl alkylation is unclear because sodium iodate failed to produce RPE detachments. N-ethylmaleimide effects may model aspects of clinical RPE and serous retinal detachments.

Giant retinal tear and retinal detachment with underlying retinitis pigmentosa and hearing loss

Few retinal detachments have been described in patients with retinitis pigmentosa and allied retinal disorders, with only two cases (both with hearing loss) reported in association with giant retinal tears. To further characterise clinical characteristics of giant retinal tear associated with retinitis pigmentosa, we reviewed the course of four eyes of three patients. Unexpectedly, all three individuals also suffered from congenital sensorineural hearing loss. One suffered from associated myopathy. Despite aggressive surgical management, three of the four eyes became blind. The diagnosis of retinal detachment preceded the diagnosis of photoreceptor dystrophy in two of the three patients. To date, giant retinal tears occurring with underlying retinitis pigmentosa have been described in five young individuals, all of whom had associated congenital sensorineural hearing loss.

The efficacy of cranial irradiation in ovarian cancer metastatic to the brain: analysis of 32 cases

OBJECTIVE

To determine the role of irradiation in the management of brain metastases from epithelial ovarian cancer.

METHODS

Tumor registries from five university cancer centers were searched to identify ovarian cancer patients with brain metastases. During a 30-year period (1965-1994), 4027 ovarian cancer patients were evaluated, 32 of whom were found to have cerebral metastases. Each received fractionated whole-brain irradiation (median dose 30 Gy, range 20-52.5). Five patients received concomitant chemotherapy with whole-brain irradiation.

RESULTS

The median survival time for the whole population was 4 months. For the entire series, symptomatic response (complete response and partial response) was achieved in 23, 16 of whom were palliated until death. Patients with higher Karnofsky performance status (70 or above versus below 70) were more likely to derive a palliative response and attained a statistically significant survival advantage. No other factor predicted the likelihood of deriving a palliative response or a survival advantage after treatment.

CONCLUSIONS

In this large review of patients with cerebral metastases from ovarian cancer, we found that most of those treated with whole-brain irradiation achieved palliation until death. Nearly all women with high performance status derived durable palliation from cerebral irradiation. Whole-brain irradiation was an effective means of palliating ovarian cancer metastatic to the brain and provided a favorable alternative to other means of management.

Twice-per-day fractionated high versus continuous low dose rate intracavitary therapy in the radical treatment of cervical cancer: a nonrandomized comparison of treatment results

PURPOSE

To compare the efficacy of two twice-per-day fractionated high dose rate (HDR) brachytherapies with a historical control group treated with low dose rate (LDR) brachytherapy for cervical cancer patients.

METHODS AND MATERIALS

From 1985 to 1988, 92 patients with cancer of the cervic were treated by remote-controlled, HDR brachytherapy, six fractions of 7 Gy per fraction (42 Gy) at point A (HDR-6). Fifty-seven patients were treated with four fractions of 8 Gy per fraction (32 Gy) at point A (HDR-4). A twice-per-day program was used for all HDR patients by two split courses. As a historical control, treatment results of 259 patients treated with LDR brachytherapy (40 Gy in two split courses) were compared with those of the two HDR regimens. All patients received whole pelvic external irradiation, 36-45 Gy (mostly 40 Gy) before brachytherapy.

RESULTS

Five-year local control rates were not significantly different for the three groups (HDR-6 = 82.0%, HDR-4 = 85.5%, and LDR = 89.5%, respectively). Five-year survival rates were also comparable (67.7%, 77.9%, and 74.1%, respectively). However, late complications were lower in HDR-4 than HDR-6 (11.0% vs. 25.6%).

CONCLUSIONS

Both 5-year local control and survival rates were comparable among the three groups. However, HDR-4, which was more biologically equivalent to our LDR regimen, showed fewer complications compared to HDR-6. In addition, our twice-per-day schedule shortened the hospital stay.

Recurrent acute multifocal placoid pigment epitheliopathy in two cousins

PURPOSE/METHODS

To test the hypothesis that there may be inherited predisposition in acute multifocal placoid pigment epitheliopathy, HLA typing was undertaken in two cousins with recurrent disease.

RESULTS/CONCLUSIONS

Both cousins were shown to have HLA antigens DR2 but not B7; both antigens have been associated with this disorder previously. This finding is compatible with the concept that DR2 may be associated with an increased risk of recurrent disease.