Heart transplantation is the reference standard treatment for advanced acute and chronic heart failure, although limited by the scarcity of donor hearts. Careful selection of transplant candidates is therefore essential in combination with optimal donor recipient matching. In the current era, most surgeons use the bicaval heart transplant technique. Approximately half of the patients receiving a heart transplant are on mechanical circulatory support. Allograft rejection is clinically categorized according to its temporal occurrence (hyper-acute, acute, and chronic) and by the underlying mechanism (cellular, antibody-mediated, and mixed). The calcineurin inhibitors ciclosporin and tacrolimus are the cornerstones of current maintenance immunosuppression regimens and are used in combination with an anti-proliferative agent and corticosteroids to prevent rejection. The target of rapamycin inhibitors offer an alternative to chronic anti-rejection treatment. Despite the increasing complexity of heart transplant recipients, survival is improving progressively.

Heart transplantation is the reference standard treatment for advanced acute and chronic heart failure, although limited by the scarcity of donor hearts. Careful selection of transplant candidates is therefore essential in combination with optimal donor recipient matching. In the current era, most surgeons use the bicaval heart transplant technique. Approximately half of the patients receiving a heart transplant are on mechanical circulatory support. Allograft rejection is clinically categorized according to its temporal occurrence (hyper-acute, acute, and chronic) and by the underlying mechanism (cellular, antibody-mediated, and mixed). The calcineurin inhibitors ciclosporin and tacrolimus are the cornerstones of current maintenance immunosuppression regimens and are used in combination with an anti-proliferative agent and corticosteroids to prevent rejection. The target of rapamycin inhibitors offer an alternative to chronic anti-rejection treatment. Despite the increasing complexity of heart transplant recipients, survival is improving progressively.

Background: Duchenne muscular dystrophy (DMD), which afflicts 1 in 3500 boys, is one of the most common genetic disorders of children. This fatal degenerative condition is caused by an absence or deficiency of dystrophin in striated muscle. Most affected patients have inherited or spontaneous deletions in the dystrophin gene that disrupt the reading frame resulting in unstable truncated products. For these patients, restoration of the reading frame via antisense oligonucleotide-mediated exon skipping is a promising therapeutic approach. The major DMD deletion ‘‘hot spot’’ is found between exons 45 and 53, and skipping exon 51 in particular is predicted to ameliorate the dystrophic phenotype in the greatest number of patients. Currently the mdx mouse is the most widely used animal model of DMD, although its mild phenotype limits its suitability in clinical trials. The Golden Retriever muscular dystrophy (GRMD) model has a severe phenotype, but due to its large size, is expensive to use. Both these models have mutations in regions of the dystrophin gene distant from the commonly mutated DMD ‘‘hot spot’’. Methodology/Principal Findings: Here we describe the severe phenotype, histopathological findings, and molecular analysis of Cavalier King Charles Spaniels with dystrophin-deficient muscular dystrophy (CKCS-MD). The dogs harbour a missense mutation in the 59 donor splice site of exon 50 that results in deletion of exon 50 in mRNA transcripts and a predicted premature truncation of the translated protein. Antisense oligonucleotide-mediated skipping of exon 51 in cultured myoblasts from an affected dog restored the reading frame and protein expression. Conclusions/Significance: Given the small size of the breed, the amiable temperament and the nature of the mutation, we propose that CKCS-MD is a valuable new model for clinical trials of antisense oligonucleotide-induced exon skipping and other therapeutic approaches for DMD. Citation: Walmsley GL, Arechavala-Gomeza V, Fernandez-Fuente M, Burke MM, Nagel N, et al. (2010) A Duchenne Muscular Dystrophy Gene Hot Spot Mutation in Dystrophin-Deficient Cavalier King Charles Spaniels Is Amenable to Exon 51 Skipping. PLoS ONE 5(1): e8647. doi:10.1371/journal.pone.0008647 Editor: Mel B. Feany, Brigham and Women’s Hospital/Harvard Medical School, United States of America Received November 23, 2009; Accepted December 10, 2009; Published January 13, 2010 Copyright: 2010 Walmsley et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The Muscular Dystrophy Association (USA) funds canine studies in the laboratory of one of the authors (GDS). Prof. Muntoni acknowledges the financial support from the Medical Research Coucil (Award G0502130) for antisense oligonucleotide studies and for funding the Biobank of the University College London Medical Research Council Neuromuscular translational research centre. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: rpiercy@rvc.ac.uk

OBJECTIVE:To evaluate whether there is increased mother-to-child transmission of human immunodeficiency virus (HIV)-1 associated with deliveries at 40 weeks of estimated gestational age (EGA) or greater in pregnant women with HIV-1 viral loads of 1,000 copies/mL or less.METHODS:We performed a secondary analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development International Site Development Initiative Perinatal and Longitudinal Study in Latin American Countries and International Maternal Pediatric Adolescent AIDS Clinical Trials P1025 cohorts. We included pregnant women with HIV-1 with recent viral loads of 1,000 copies/mL or less at the time of delivery and compared delivery outcomes at between 38 and less than 40 weeks EGA with delivery outcomes at 40 weeks EGA or greater, the exposure of interest. Our primary outcome of interest was mother-to-child transmission, and secondary outcomes included indicators of maternal and neonatal morbidity. We examined the association between EGA and mother-to-child transmission using Poisson distribution. Associations between EGA and secondary outcomes were examined through bivariate analyses using Pearson χ and Fisher exact test or the nonparametric Mann-Whitney U test.RESULTS:Among the 2,250 eligible neonates, eight neonates were infected with HIV-1 (overall transmission rate 0.4%, 95% CI 0.2-8.1%, 40 weeks EGA or greater 0.5% [3/621, 95% CI 0.2-1.4%], less than 40 weeks EGA 0.3% [5/1,629, 95% CI 0.1-0.7%]); there was no significant difference in transmission by EGA (rate ratio 1.57, 95% CI 0.24-8.09, P=.77). There was no difference in maternal viral load between the two groups nor was there a difference in timing of transmission among neonates born with HIV-1.CONCLUSION:In pregnant women with well-controlled HIV-1, the risk of mother-to-child transmission did not differ significantly by EGA at delivery, although we were not powered to demonstrate equivalence of proportions of mother-to-child transmission between EGA groups.

Purpose To examine myocardial inflammatory (MI) burden and phenotype of intravascular (IV) cells in EMBs with pathologic (p)AMR (Berry JHLT2011;30:601); to correlate both with pAMR grade, capillary C4d deposition and DSA status. Methods and Materials HE grade 1: n=6) or no pAMR (n=31). EMBs also showing acute cellular rejection ≥ 2R were excluded. Sections were stained for CD68, CD3, CD20 and CD138. Positive IV and interstitial mononuclear cells (MI burden) were counted in 5 microscopic fields at X40 magnification (area: .225 mm 2 ) by 6 pathologists blinded to the diagnosis. Results were correlated with pAMR grade, C4d-positivity and DSA status. Results [Table 1] Conclusions Mean MI burden correlates with pAMR grade, C4d positivity, and DSA positivity. In pAMR equivalent numbers of IV T lymphocytes and macrophages were seen. CD68 antibody staining alone is not sufficient to characterize IV cells in pAMR. Total burden inflammatory cells Total IV inflammatory cells CD 68 IV cell CD3 IV cells CD20 IV cells CD 138 IV cell Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) pAMR neg(n=31) 83.0 (61.3)* 8.1 (9.1)* 3.3 (3.8)* 4.0 (6.3)* 0.3 (1.0)** 0.4 (1.2)*** pAMR-positive/ suspicious (n=34) 329.1 (187.1)* 83.8 (64.3)* 37.4 (44.9)* 41.2 (36.9)* 2.4 (4.3)** 3.1 (8.2)*** C4d-negative (n=36) 96.4 (71.9)° 17.1 (27.1)° 4.9 (8.3)° 11.4 (23.6)° 0.3 (1.0)°° 0.3 (1.1)°°° C4d-positive (n=29) 354.8 (188.6)° 85.7 (68.3)° 41.3 (47.1)° 38.3 (36.6)° 2.8 (4.5)°° 3.7 (8.8)°°° DSA-negative (n=30) 104.1 (108.6)^ 14.3 (26.6)^ 6.9 (11.7)^ 6.4 (15.6)^ 0.7 (2.1)^^ 0.2 (0.6)^^^ DSA-positive (n=35) 304.0 (192.7)^ 76.3 (66.3)^ 33.3 (45.6)^ 38.0 (36.5)^ 2.0 (4.0)^^ 3.1 (8.1)^^^ pAMR(-) vs pAMR(+) *p

During the last 25 years, antibody-mediated rejection of the cardiac allograft has evolved from a relatively obscure concept to a recognized clinical complication in the management of heart transplant patients. Herein we report the consensus findings from a series of meetings held between 2010-2012 to develop a Working Formulation for the pathologic diagnosis, grading, and reporting of cardiac antibody-mediated rejection. The diagnostic criteria for its morphologic and immunopathologic components are enumerated, illustrated, and described in detail. Numerous challenges and unresolved clinical, immunologic, and pathologic questions remain to which a Working Formulation may facilitate answers.

Gerald Berry, MD, Margaret Burke, FRCPath, Claus Andersen, MD, DMSc, Annalisa Angelini, MD, Patrick Bruneval, MD, Fiorella Calbrese, MD, Michael C. Fishbein, MD, Martin Goddard, FRCS, MRCPa, Ornella Leone, MD, Joseph Maleszewski, MD, Charles Marboe, MD, Dylan Miller, MD, Desley Neil, FRCPath, Robert Padera, MD, PhD, Doris Rassi, MBBS, MRCP, Monica Revello, MD, PhD, Alexandra Rice, FRCPath, Susan Stewart, FRCPath, and Samuel A Yousem, MD

Our series of 5 cases of histologically-proven Giant cell myocarditis with concurrent CMR shows a pattern of late gadolinium enhancement which tends to be widespread involving all layers of the myocardium.

Prospective national registry data on 98 patients were studied to determine the long-term outcome of immune related lymphoproliferative disease (LPD) and define prognostic factors. Seventy-three developed LPD following organ transplant (26 liver, 21 heart, 15 kidney, nine bone marrow [BM], two bowel). Twenty-five had non-transplant related immunosuppression. Age was 1.1-17 years (median 8.6). Fifty-eight patients had lymphomatous, 21 systemic and 17 lymphadenopathic disease. Sixty (73%) were disseminated and 22 (27%) localized. Thirty-three (54%) were monoclonal. Seventy-three (83%) were Epstein-Barr virus (EBV) positive. Median follow-up was 7.6 years. LPD developed earlier after liver and BM as compared to heart or kidney transplant. Five-year overall survival (OS) was 58%. Prognosis was best after liver and kidney transplant (OS >77%). Mortality was higher following heart (2.5 times) and BM transplant (5 times). Adverse prognostic factors were disseminated or lymphomatous disease and lack of reduction of immunosuppression. With appropriate reduction of immunosuppression, rituximab and low-dose chemotherapy, long-term survival is high.

Considerable progress has been made in achieving consensus amongst pathologists and in refining the ISHLT 2005 working formulation criteria for the pathologic diagnosis of AMR (Box 1, Box 2). Several technical and interpretative issues have been raised. Although some were resolved and a new grading system proposed, further work is required to standardize and validate the consistency and reproducibility of a proposed scoring system for capillary C4d deposition in EMB specimens. Further additional inquiry is needed to address a number of unresolved and essential issues, such as the early histopathologic features of AMR. This can be achieved by establishing a central ISHLT-supported database for collection of digitized images and data of AMR cases to evaluate and clarify areas of uncertainty both in diagnosis and reproducibility.Box 1A. Consensus points reached during the conference on AMRConsensus #1: While debate continues about the make-up of the primary recommended panel for Paraffin IC, it is recommended that at a minimum, the panel should include C4d. Centers currently using CD68 or other macrophage markers in their IC panel will continue and other centers are encouraged to consider using a multi-antibody approach.Consensus #2: Agreement was reached to limit the panel of antibodies in the recommended primary panel for IF to C3d and C4d with HLA staining for capillaries as needed.Consensus #3: There was agreement that, for C4d staining, only the interstitial capillaries should be assessed in the evaluation of AMR.Consensus #4: The group recommended that immunostaining for C4d is avoided in the first 2 weeks after transplant, because there are a number of perioperative issues that may confound staining and interpretation.Consensus #5: the recommended surveillance protocol includes 2 biopsies in the first month (eg, at 2 and 4 weeks) and then according to the center's circulating antibody monitoring schedule (eg, at 1, 3, 6, and 12 months).Consensus #6: After a positive biopsy, the group recommended that subsequent biopsies should be studied by immunostaining until a negative result is achieved.Consensus #7: The group reached consensus that, for IF methodologies, the intensity of immunostaining of 2+ or 3+ staining was required for a positive result. For IC staining, 3 categories were enumerated: 0 = negative, 1 = faint positive, and 2 = strong positive. For both IF and IC, only multifocal or diffuse staining constitutes a positive result.B: PRELIMINARY nomenclature scheme advisedpAMR 0: Negative for Pathologic AMR: both histologic and immunopathologic studies are negative.pAMR 1 (H+): Histopathologic AMR Alone: histological findings present and immunopathological findings negative.pAMR1 (I+): Immunopathologic AMR Alone: histological findings negative and immunopathological findings positive.pAMR 2: Pathologic AMR: Both histologic and immunopathologic findings are present.pAMR 3: Severe Pathologic AMR: This category recognizes the rare cases of severe AMR with histopathologic findings of interstitial hemorrhage, capillary fragmentation, mixed inflammatory infiltrates, endothelial cell pyknosis and/or karyorrhexis and marked edema. The reported experience of the group was that these cases are associated with profound allograft dysfunction and poor clinical outcomes.Box 2Pathologic Diagnosis of Cardiac AMR: Future DirectionsProject #1: Using digital pathology slide technology, we will standardize and validate reproducibility of a scoring system for intensity and distribution of capillary C4d deposition in EMB specimens using IC protocols. The images can be manipulated online in real time, which will enable pathologists to score cases from their offices.Project #2: Using digital pathology slide technology as above, we will clarify, standardize, and validate reproducibility of early histopathologic features of AMR.Project #3: We will seek to establish a central ISHLT-supported database for collection of de-identified data on cases of AMR linked to digitized slides of their biopsy specimens. This will enable us to build on the above two projects by clarifying areas of uncertainty and improving concordance of diagnosis amongst pathologists through education and reproducibility studies.Project #4: We will seek to publish a comprehensive illustrated update to the ISHLT 2005 working formulation for biopsy diagnosis of cardiac AMR.

HistopathologyVolume 59, Issue 1 p. 152-156 Correspondence Tumour infiltrating plasmacytoid dendritic cells in B cell post-transplant lymphoproliferative disorders, human immunodeficiency virus-associated B cell lymphomas and immune competent diffuse large B cell lymphomas Hazem A H Ibrahim, Hazem A H Ibrahim Departments of Histopathology, Hammersmith Hospital and Imperial College, London, UK Deputed from Department of Histopathology, Faculty of Medicine, Mansoura University, Mansoura, EgyptSearch for more papers by this authorLia Menasce, Lia Menasce The Christie Hospital, ManchesterSearch for more papers by this authorSabine Pomplun, Sabine Pomplun Kings College, LondonSearch for more papers by this authorMargaret Burke, Margaret Burke Harefield Hospital, MiddlesexSearch for more papers by this authorMark Bower, Mark Bower Department of Oncology and HIV Medicine, Chelsea Westminster Hospital, London, UKSearch for more papers by this authorKikkeri N Naresh, Kikkeri N Naresh Departments of Histopathology, Hammersmith Hospital and Imperial College, London, UKSearch for more papers by this author Hazem A H Ibrahim, Hazem A H Ibrahim Departments of Histopathology, Hammersmith Hospital and Imperial College, London, UK Deputed from Department of Histopathology, Faculty of Medicine, Mansoura University, Mansoura, EgyptSearch for more papers by this authorLia Menasce, Lia Menasce The Christie Hospital, ManchesterSearch for more papers by this authorSabine Pomplun, Sabine Pomplun Kings College, LondonSearch for more papers by this authorMargaret Burke, Margaret Burke Harefield Hospital, MiddlesexSearch for more papers by this authorMark Bower, Mark Bower Department of Oncology and HIV Medicine, Chelsea Westminster Hospital, London, UKSearch for more papers by this authorKikkeri N Naresh, Kikkeri N Naresh Departments of Histopathology, Hammersmith Hospital and Imperial College, London, UKSearch for more papers by this author First published: 19 July 2011 https://doi.org/10.1111/j.1365-2559.2011.03872.xCitations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume59, Issue1July 2011Pages 152-156 RelatedInformation

BACKGROUND: The aim of this study was to assess, at the European level and using digital technology, the inter-pathologist reproducibility of the ISHLT 2004 system and to compare it with the 1990 system We also assessed the reproducibility of the morphologic criteria for diagnosis of antibody-mediated rejection detailed in the 2004 grading system.METHODS: The hematoxylin eosin-stained sections of 20 sets of endomyocardial biopsies were pre-selected and graded by two pathologists (A.A. and M.B.) and digitized using a telepathology digital pathology system (Aperio ImageScope System; for details refer to http://aperio.com/). Their diagnoses were considered the index diagnoses, which covered all grades of acute cellular rejection (ACR), early ischemic lesions, Quilty lesions, late ischemic lesions and (in the 2005 system) antibody-mediated rejection (AMR). Eighteen pathologists from 16 heart transplant centers in 7 European countries participated in the study. Inter-observer reproducibility was assessed using Fleiss's kappa and Krippendorff's alpha statistics.RESULTS: The combined kappa value of all grades diagnosed by all 18 pathologists was 0.31 for the 1990 grading system and 0.39 for the 2005 grading system, with alpha statistics at 0.57 and 0.55, respectively. Kappa values by grade for 1990/2005, respectively, were: 0 = 0.52/0.51; 1A/1R = 0.24/0.36; 1B = 0.15; 2 = 0.13; 3A/2R = 0.29/0.29; 3B/3R = 0.13/0.23; and 4 = 0.18. For the 2 cases of AMR, 6 of 18 pathologists correctly suspected AMR on the hematoxylin eosin slides, whereas, in each of 17 of the 18 AMR-negative cases a small percentage of pathologists (range 5% to 33%) overinterpreted the findings as suggestive for AMR.CONCLUSIONS: Reproducibility studies of cardiac biopsies by pathologists in different centers at the international level were feasible using digitized slides rather than conventional hi histology glass slides. There was a small improvement in interobserver agreement between pathologists of different European centers when moving from the 1990 ISHLT classification to the "new" 2005 ISHLT classification. Morphologic suspicion of AMR in the 2004 system on hematoxylin eosin-stained slides only was poor, highlighting the need for better standardization of morphologic criteria for AMR. Ongoing educational programs are needed to ensure standardization of diagnosis of both acute cellular and antibody-mediated rejection. J Heart Lung Transplant 2011;30:1214-20 (C) 2011 International Society for Heart and Lung Transplantation All rights reserved.

BACKGROUND:The problem of AMR remains unsolved because standardized schemes for diagnosis and treatment remains contentious. Therefore, a consensus conference was organized to discuss the current status of antibody-mediated rejection (AMR) in heart transplantation.METHODS:The conference included 83 participants (transplant cardiologists, surgeons, immunologists and pathologists) representing 67 heart transplant centers from North America, Europe, and Asia who all participated in smaller break-out sessions to discuss the various topics of AMR and attempt to achieve consensus.RESULTS:A tentative pathology diagnosis of AMR was established, however, the pathologist felt that further discussion was needed prior to a formal recommendation for AMR diagnosis. One of the most important outcomes of this conference was that a clinical definition for AMR (cardiac dysfunction and/or circulating donor-specific antibody) was no longer believed to be required due to recent publications demonstrating that asymptomatic (no cardiac dysfunction) biopsy-proven AMR is associated with subsequent greater mortality and greater development of cardiac allograft vasculopathy. It was also noted that donor-specific antibody is not always detected during AMR episodes as the antibody may be adhered to the donor heart. Finally, recommendations were made for the timing for specific staining of endomyocardial biopsy specimens and the frequency by which circulating antibodies should be assessed. Recommendations for management and future clinical trials were also provided.CONCLUSIONS:The AMR Consensus Conference brought together clinicians, pathologists and immunologists to further the understanding of AMR. Progress was made toward a pathology AMR grading scale and consensus was accomplished regarding several clinical issues.

The Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology have produced this position paper concerning the current role of endomyocardial biopsy (EMB) for the diagnosis of cardiac diseases and its contribution to patient management, focusing on pathological issues, with these aims: • Determining appropriate EMB use in the context of current diagnostic strategies for cardiac diseases and providing recommendations for its rational utilization • Providing standard criteria and guidance for appropriate tissue triage and pathological analysis • Promoting a team approach to EMB use, integrating the competences of pathologists, clinicians, and imagers.