Selection of appropriate non-clinical animal models to ensure translatability of novel AAV-gene therapies to the clinic.

Gene Therapy Medicinal Products consist of a recombinant nucleic acid intended for the modulation or manipulation of a genetic sequence. A single administration of a novel gene therapy has the potential to be curative, with a durable long-term benefit to patients. Adeno-associated viral vectors have become the viral vector of choice for in vivo delivery of therapeutic transgenes as they are mildly immunogenic, can effectively transduce a variety of human tissues and cells, and have low levels of genomic integration. Central to the effective translation of data generated in discovery studies to the clinic is the selection of appropriate animal species for pivotal non-clinical studies. This review aims to support the selection of appropriate animal models for non-clinical studies to advance the development of novel adeno-associated virus gene therapies.

Submental island flap - should we be worried about lymph node transfer? An anatomical and histological study.

The submental island flap has been increasing in popularity for both oncological and non-oncological reconstruction of the head and neck. However, the original description of this flap left it with the unfortunate designation as a lymph node flap. There has thus been significant debate on the oncological safety of the flap. In this cadaveric study the perforator system suppling the skin island is delineated and the lymph node yield of the skeletonised flap is analysed histologically. A safe and consistent approach to raising the perforator flap modification is described and the pertinent anatomy, and an oncological discussion with regards to the submental island perforator flap histological lymph node yield discussed. Ethical approval was received from Hull York Medical School for the anatomical dissection of 15 sides of cadavers. 6 x 4cm submental island flaps were raised following a vascular infusion of a 50/50 mix of acrylic paint. The flap size mimics the T1/T2 tumour defects these flaps would usually be used to reconstruct.The submental vascular anatomy, including length, diameter, venous drainage patterns, and the skin perforator system was documented. The dissected submental flaps were then histologically examined for the presence of lymph nodes by a head and neck pathologist at Hull University Hospitals Trust department of histology. The total length of the submental island arterial system, the distance from where the facial artery branches off from the carotid to the submental artery perforator entering the anterior belly of digastric or skin, averaged 91.1mm with anaverage facial artery length of 33.1mm and submental artery of 58mm. Vessel diameter for microvascular reconstruction was 1.63mm for the submental artery and 3mm for the facial artery. The most common venous anatomy drainage pattern was the submental island venaecomitantes draining to the retromandibular system then to the internal jugular vein. Almost half the specimens had a dominant superficial submental perforator allowing the ability to raise this as a skin only system. There were generally 2-4 perforators passing through the anterior belly of digastric to supply the skin paddle.73.3% (11/15) of the skeletonised flaps contained no lymph nodes on histological examination. The perforator version of the submental island flap can be safely and consistently raised with inclusion of the anterior belly of digastric. In approximately half the cases a dominant superficial branch allows for a skin only paddle. Due to the vessel diameter, free tissue transfer is predictable.Venous anatomy is variable and care needs to be taken when raising this flap. The skeletonised version of the perforator flap is largely devoid of nodal yield and on oncological review a 16.3% recurrence rate is equivalent to current standard treatment.

Triaging algorithm for head & neck oncology follow-up patients in COVID-19 climate.

The current climate is one of uncertainty and immeasurable tragedy for people afflicted by the pandemic of SARS-CoV-2 virus infection. As professionals, we have a duty of care towards all patients especially the vulnerable and those suffering with life-threatening illnesses such as oral cancer. We present a safe & objective triaging method for afflicted with this disease in the prevailing morbid situation.

Correction: Prioritization of Free-Text Clinical Documents: A Novel Use of a Bayesian Classifier.

[This corrects the article DOI: 10.2196/medinform.3793.].

Transoral Marsupialization of a Large Dermoid Cyst.

True dermoid cysts are rare congenital entities with a predilection for periorbital, floor-of-mouth, and submental areas in the head and neck region. They are usually asymptomatic unless they substantially enlarge, causing pain or difficulty in swallowing, breathing, speech, or vision, depending on their location. Conventionally, complete excision is the treatment of choice. The authors describe a transoral approach to marsupialize a large dermoid cyst, with a successful outcome and minimal complications. Using this technique, it is hoped that surgeons can minimize the risk of damaging vital structures, shorten operating time, and provide an esthetically better result with a comparable outcome.

B cell adaptor for PI3-kinase (BCAP) modulates CD8+ effector and memory T cell differentiation.

CD8+ T cells respond to signals via the T cell receptor (TCR), costimulatory molecules, and immunoregulatory cytokines by developing into diverse populations of effector and memory cells. The relative strength of phosphoinositide 3-kinase (PI3K) signaling early in the T cell response can dramatically influence downstream effector and memory T cell differentiation. We show that initial PI3K signaling during T cell activation results in up-regulation of the signaling scaffold B cell adaptor for PI3K (BCAP), which further potentiates PI3K signaling and promotes the accumulation of CD8+ T cells with a terminally differentiated effector phenotype. Accordingly, BCAP-deficient CD8+ T cells have attenuated clonal expansion and altered effector and memory T cell development following infection with Listeria monocytogenes Thus, induction of BCAP serves as a positive feedback circuit to enhance PI3K signaling in activated CD8+ T cells, thereby acting as a molecular checkpoint regulating effector and memory T cell development.

Bifidobacterium breve MRx0004 protects against airway inflammation in a severe asthma model by suppressing both neutrophil and eosinophil lung infiltration.

Asthma is a phenotypically heterogeneous disease. In severe asthma, airway inflammation can be predominantly eosinophilic, neutrophilic, or mixed. Only a limited number of drug candidates are in development to address this unmet clinical need. Live biotherapeutics derived from the gut microbiota are a promising new therapeutic area. MRx0004 is a commensal Bifidobacterium breve strain isolated from the microbiota of a healthy human. The strain was tested prophylactically and therapeutically by oral gavage in a house dust mite mouse model of severe asthma. A strong reduction of neutrophil and eosinophil infiltration was observed in lung bronchoalveolar lavage fluid following MRx0004 treatment. Peribronchiolar and perivascular immunopathology was also reduced. MRx0004 increased lung CD4+CD44+ cells and CD4+FoxP3+ cells and decreased activated CD11b+ dendritic cells. Cytokine analysis of lung tissue revealed reductions of pro-inflammatory cytokines and chemokines involved in neutrophil migration. In comparison, anti-IL-17 antibody treatment effectively reduced neutrophilic infiltration and increased CD4+FoxP3+ cells, but it induced lung eosinophilia and did not decrease histopathology scores. We have demonstrated that MRx0004, a microbiota-derived bacterial strain, can reduce both neutrophilic and eosinophilic infiltration in a mouse model of severe asthma. This novel therapeutic is a promising next-generation drug for management of severe asthma.

Microsurgical Reconstruction of the Jaws Using Vascularised Free Flap Technique in Patients with Medication-Related Osteonecrosis: A Systematic Review.

BACKGROUND: Osteonecrosis of the jaw (ONJ) has been reported to be associated with patients receiving primarily bisphosphonate (BP) therapies. However, lately it has been documented that other medications, such as RANK ligand inhibitor (denosumab) and antiangiogenic drug, can cause ONJ. Micro-osseous-vascular reconstruction of the jaws in patients affected by medication-related osteonecrosis of the jaw represents a viable option of treatment for patients affected by stage III of the disease. However, there are still considerable doubts about the success of this procedure in the short, medium, and long term. MATERIAL AND METHODS: A multidatabase (PubMed/MEDLINE, EMBASE, and CENTRAL) systematic search was performed. Any type of studies considering human patients treated with antiresorptive and antiangiogenic drugs was considered. The aim of the research is to primarily understand the success rate of micro-osseous-vascular reconstruction in the short, medium, and long period of time. This review has also the goal of better understanding any perioperative and postoperative complications resulting from the use of the reconstruction techniques. RESULTS: Eighteen studies resulted eligible for the study. Fibula free flap is the most commonly utilised vascularised free flap reconstruction technique (80.76%). Ten out of eighteen studies reported no complications. Recurrence of osteonecrosis was registered in five cases (6.41%) after free flap reconstruction. The overall free flap success rate was 96.16%. CONCLUSIONS: Based on the limited data available in literature (Level 4 of the Oxford Evidence-based medicine scale), micro-osseous-vascular reconstruction of the jaws represents a valid treatment in patients with bisphosphonate-related osteonecrosis at stage III of the disease. However, additional data based on a larger cohort of patients are necessary to justify this type of intervention in patient affected by MRONJ.

Tapia's Syndrome.

More than 100,000 general anesthetic procedures are conducted in United Kingdom every year for dental interventions, according to large survey of the National Health Services. 1 The risk of mortality has reduced considerably in the past few decades because of the use of safe and effective techniques. However, adverse effects still exist and are dependent on patient, environmental, and operator factors. We present an uncommon complication of intubation that merits due awareness.

Elevated ACKR2 expression is a common feature of inflammatory arthropathies.

Objectives: Chemokines are essential contributors to leucocyte accumulation at sites of inflammatory pathology. Interfering with chemokine or chemokine receptor function therefore represents a plausible therapeutic option. However, our currently limited understanding of chemokine orchestration of inflammatory responses means that such therapies have not yet been fully developed. We have a particular interest in the family of atypical chemokine receptors that fine-tune, or resolve, chemokine-driven responses. In particular we are interested in atypical chemokine receptor 2 (ACKR2), which is a scavenging receptor for inflammatory CC-chemokines and that therefore helps to resolve in vivo inflammatory responses. The objective of the current study was to examine ACKR2 expression in common arthropathies. Methods: ACKR2 expression was measured by a combination of qPCR and immuno-histochemistry. In addition, circulating cytokine and chemokine levels in patient plasma were assessed using multiplexing approaches. Results: Expression of ACKR2 was elevated on peripheral blood cells as well as on leucocytes and stromal cells in synovial tissue. Expression on peripheral blood leucocytes correlated with, and could be regulated by, circulating cytokines with particularly strong associations being seen with IL-6 and hepatocyte growth factor. In addition, expression within the synovium was coincident with aggregates of lymphocytes, potentially atopic follicles and sites of high inflammatory chemokine expression. Similarly increased levels of ACKR2 have been reported in psoriasis and SSc. Conclusion: Our data clearly show increased ACKR2 in a variety of arthropathies and taking into account our, and others', previous data we now propose that elevated ACKR2 expression is a common feature of inflammatory pathologies.

Spread of Psoriasiform Inflammation to Remote Tissues Is Restricted by the Atypical Chemokine Receptor ACKR2.

Elucidating the poorly defined mechanisms by which inflammatory lesions are spatially restricted in vivo is of critical importance in understanding skin disease. Chemokines are the principal regulators of leukocyte migration and are essential in the initiation and maintenance of inflammation. The membrane-bound psoriasis-associated atypical chemokine receptor 2 (ACKR2) binds, internalizes and degrades most proinflammatory CC-chemokines. Here we investigate the role of ACKR2 in limiting the spread of cutaneous psoriasiform inflammation to sites that are remote from the primary lesion. Circulating factors capable of regulating ACKR2 function at remote sites were identified and examined using a combination of clinical samples, relevant primary human cell cultures, in vitro migration assays, and the imiquimod-induced model of psoriasiform skin inflammation. Localized inflammation and IFN-γ together up-regulate ACKR2 in remote tissues, protecting them from the spread of inflammation. ACKR2 controls inflammatory T-cell chemotaxis and positioning within the skin, preventing an epidermal influx that is associated with lesion development. Our results have important implications for our understanding of how spatial restriction is imposed on the spread of inflammatory lesions and highlight systemic ACKR2 induction as a therapeutic strategy in the treatment and prevention of psoriasis and potentially a broad range of other immune-mediated diseases.

Use of a dermal regeneration template and full-thickness skin grafts to reconstruct exposed bone in the head and neck.

Soft tissue defects over bone are difficult to reconstruct and this is compounded when there is no periosteum. We present what is to our knowledge the first reported use of a dermal regeneration template (Integra®, Integra Life Sciences Corp, Plainsboro, NJ, USA) to assist in reconstruction over an exposed mandible.

Prioritization of free-text clinical documents: a novel use of a bayesian classifier.

BACKGROUND: The amount of incoming data into physicians' offices is increasing, thereby making it difficult to process information efficiently and accurately to maximize positive patient outcomes. Current manual processes of screening for individual terms within long free-text documents are tedious and error-prone. This paper explores the use of statistical methods and computer systems to assist clinical data management. OBJECTIVE: The objective of this study was to verify and validate the use of a naive Bayesian classifier as a means of properly prioritizing important clinical data, specifically that of free-text radiology reports. METHODS: There were one hundred reports that were first used to train the algorithm based on physicians' categorization of clinical reports as high-priority or low-priority. Then, the algorithm was used to evaluate 354 reports. Additional beautification procedures such as section extraction, text preprocessing, and negation detection were performed. RESULTS: The algorithm evaluated the 354 reports with discrimination between high-priority and low-priority reports, resulting in a bimodal probability distribution. In all scenarios tested, the false negative rates were below 1.1% and the recall rates ranged from 95.65% to 98.91%. In the case of 50% prior probability and 80% threshold probability, the accuracy of this Bayesian classifier was 93.50%, with a positive predictive value (precision) of 80.54%. It also showed a sensitivity (recall) of 98.91% and a F-measure of 88.78%. CONCLUSIONS: The results showed that the algorithm could be trained to detect abnormal radiology results by accurately screening clinical reports. Such a technique can potentially be used to enable automatic flagging of critical results. In addition to accuracy, the algorithm was able to minimize false negatives, which is important for clinical applications. We conclude that a Bayesian statistical classifier, by flagging reports with abnormal findings, can assist a physician in reviewing radiology reports more efficiently. This higher level of prioritization allows physicians to address important radiologic findings in a timelier manner and may also aid in minimizing errors of omission.

An analysis of the function and expression of D6 on lymphatic endothelial cells.

The mechanisms by which CC chemokine receptor (CCR)7 ligands are selectively presented on lymphatic endothelium in the presence of inflammatory chemokines are poorly understood. The chemokine-scavenging receptor D6 is expressed on lymphatic endothelial cells (LEC) and contributes to selective presentation of CCR7 ligands by suppressing inflammatory chemokine binding to LEC surfaces. As well as preventing inappropriate inflammatory cell attachment to LECs, D6 is specifically involved in regulating the ability of LEC to discriminate between mature and immature dendritic cells (DCs). D6 overexpression reduces immature DC (iDC) adhesion to LECs, whereas D6 knockdown increases adhesion of iDCs that displace mature DCs. LEC D6 expression is regulated by growth factors, cytokines, and tumor microenvironments. In particular, interleukin-6 and interferon-γ are potent inducers, indicating a preferential role for D6 in inflamed contexts. Expression of the viral interleukin-6 homolog from Kaposi sarcoma-associated herpesvirus is also sufficient to induce significant D6 upregulation both in vitro and in vivo, and Kaposi sarcoma and primary effusion lymphoma cells demonstrate high levels of D6 expression. We therefore propose that D6, which is upregulated in both inflammatory and tumor contexts, is an essential regulator of inflammatory leukocyte interactions with LECs and is required for immature/mature DC discrimination by LECs.

Elevated expression of the chemokine-scavenging receptor D6 is associated with impaired lesion development in psoriasis.

D6 is a scavenging-receptor for inflammatory CC chemokines that are essential for resolution of inflammatory responses in mice. Here, we demonstrate that D6 plays a central role in controlling cutaneous inflammation, and that D6 deficiency is associated with development of a psoriasis-like pathology in response to varied inflammatory stimuli in mice. Examination of D6 expression in human psoriatic skin revealed markedly elevated expression in both the epidermis and lymphatic endothelium in "uninvolved" psoriatic skin (ie, skin that was more than 8 cm distant from psoriatic plaques). Notably, this increased D6 expression is associated with elevated inflammatory chemokine expression, but an absence of plaque development, in uninvolved skin. Along with our previous observations of the ability of epidermally expressed transgenic D6 to impair cutaneous inflammatory responses, our data support a role for elevated D6 levels in suppressing inflammatory chemokine action and lesion development in uninvolved psoriatic skin. D6 expression consistently dropped in perilesional and lesional skin, coincident with development of psoriatic plaques. D6 expression in uninvolved skin also was reduced after trauma, indicative of a role for trauma-mediated reduction in D6 expression in triggering lesion development. Importantly, D6 is also elevated in peripheral blood leukocytes in psoriatic patients, indicating that upregulation may be a general protective response to inflammation. Together our data demonstrate a novel role for D6 as a regulator of the transition from uninvolved to lesional skin in psoriasis.

Atypical fibroxanthoma--a retrospective immunohistochemical study of 42 cases.

PURPOSE: Atypical fibroxanthoma is a cutaneous dermal malignancy that presents on the sun-damaged skin of elderly people. It requires a definitive diagnosis, from a high-grade sarcoma to a nonmesenchymal neoplasm. The recommended treatment protocol differs from similar histologically related tumors; thus, a diagnosis of atypical fibroxanthoma should fulfill strict histologic and immunohistochemical stain criteria. The use of these standards will exclude other skin malignancies, including malignant fibrous histiocytoma, angiosarcoma, malignant melanoma, and squamous cell carcinoma. This study was performed with the aim of identifying key immunostains to develop diagnostic criteria. MATERIALS AND METHODS: Forty-two cases were studied retrospectively over a 10-year period using a panel of immunostains. RESULTS: The average age at presentation was 78 years, with a male predominance. The scalp was found to be the most common site of occurrence, although other investigators have found the forehead, cheeks, nose, and ears as the prevailing sites of presentation. CONCLUSIONS: An extensive panel of immunohistochemical stains can be used to prove a diagnosis of atypical fibroxanthoma.

An investigation of the inflammatory cytokine and chemokine network in systemic sclerosis.

OBJECTIVES: Systemic sclerosis (SSc) is characterised by vasculopathy, an aberrantly activated immune system and excessive extracellular matrix deposition. Inflammatory chemokines control migration of cells to sites of tissue damage; their removal from inflamed sites is essential for resolution of the inflammatory response. The atypical chemokine receptor D6 has a critical role in this physiological balance. To explore potential deregulation of this system in SSc, inflammatory chemokine and D6 expression were compared with that in healthy controls (HC). METHODS: Serum levels of inflammatory mediators were assessed by luminex analysis. Peripheral blood mononuclear cells (PBMCs) were used in molecular and immunocytochemical analysis. Platelet-rich plasma was collected and assessed by western blotting for D6 expression levels. Sex-matched HC were used for comparison. RESULTS: 72 patients with SSc and 30 HC were enrolled in the study. The chemokines MCP-1/CCL2, MIP-1α/CCL3, MIP-1ß/CCL4 and IL-8/CXCL8 were significantly increased in patients with SSc, regardless of disease subtype and phase. Quantitative PCR analysis revealed a significant 10-fold upregulation of D6 transcripts in patients with SSc compared with controls, and this was paralleled by increased D6 protein expression in the PBMCs of patients with SSc. Platelet lysates also showed strong D6 expression in patients with SSc but not in controls. Importantly, high levels of D6 expression correlated with reduced levels of its ligands in serum. CONCLUSIONS: Inflammatory chemokines and the regulatory receptor D6 are significantly upregulated in SSc and high D6 levels are associated with lower systemic chemokine levels, indicating that some patients control systemic chemokine levels using D6. These results suggest that chemokines may represent a therapeutic target in SSc.

Clinical negligence and duty of candour.

The Department of Health is considering imposing a legal duty of candour on health care providers to ensure that an apology and explanation are given to patients when errors occur during medical treatment. This aims to improve quality of care and reduce adverse events during medical treatment. We present the current system of clinical negligence and the future of medical ethics. We discuss relevant cases with regard to duty of candour, and highlight the existence of serious imbalances in which patients' rights and corresponding ethical duties of professionals predominate over the responsibilities of patients themselves. It is known that most adverse events arise because of multiple factors for which no individual should be blamed. To improve healthcare services there is a need for a system in which lessons can be learnt from mistakes, and services can be improved in the interest of patient safety, and for transparency in the broad principles on which the decisions are based within which clinical performance is supervised and monitored.