The Impact of Imaging on Negative Appendectomies for Early Appendicitis in Children.

OBJECTIVES: The rate of negative appendectomy in children is 7%. The value of imaging depends on the institution. In addition, imaging errors can lead to an appendectomy in children who do not have appendicitis. It is the hypothesis that children with short onset of symptoms who undergo negative appendectomy often have erroneous imaging findings. METHODS: A retrospective study of patients' records over a 30-month period was carried out. A search by histologic diagnosis in the department of pathology was used to identify the cases of all patients who did not have a diseased appendix with the preoperative diagnosis of appendicitis. In addition, the imaging report was reviewed for the radiologic diagnosis of each patient, and the operative note was reviewed to document the clinical indication for surgery. RESULTS: A total of 1377 patients who underwent appendectomy with the preoperative diagnosis of appendicitis were reviewed. Sixty-eight of these children did not have an abnormal pathologic diagnosis; hence, there was a negative appendectomy rate of 4.8%. All 68 had imaging before surgery consistent with appendicitis. Thirty-six of these patients had symptoms less than 3 days. In 30 (84%) of these 36 patients, the note identifies imaging as the indication for surgery. CONCLUSIONS: Children who had an appendectomy and found to have a normal appendix shared 2 characteristics. (1) Their symptoms were less than 3 days, and (2) the imaging was considered the indication by the surgical team. In the situation of an unclear diagnosis and a short onset of symptoms, observation or further evaluation should be considered.

Robust, 3-Dimensional Visualization of Human Colon Enteric Nervous System Without Tissue Sectioning.

BACKGROUND & AIMS: Small, 2-dimensional sections routinely used for human pathology analysis provide limited information about bowel innervation. We developed a technique to image human enteric nervous system (ENS) and other intramural cells in 3 dimensions. METHODS: Using mouse and human colon tissues, we developed a method that combines tissue clearing, immunohistochemistry, confocal microscopy, and quantitative analysis of full-thickness bowel without sectioning to quantify ENS and other intramural cells in 3 dimensions. RESULTS: We provided 280 adult human colon confocal Z-stacks from persons without known bowel motility disorders. Most of our images were of myenteric ganglia, captured using a 20× objective lens. Full-thickness colon images, viewed with a 10× objective lens, were as large as 4 × 5 mm2. Colon from 2 pediatric patients with Hirschsprung disease was used to show distal colon without enteric ganglia, as well as a transition zone and proximal pull-through resection margin where ENS was present. After testing a panel of antibodies with our method, we identified 16 antibodies that bind to molecules in neurons, glia, interstitial cells of Cajal, and muscularis macrophages. Quantitative analyses demonstrated myenteric plexus in 24.5% ± 2.4% of flattened colon Z-stack area. Myenteric ganglia occupied 34% ± 4% of myenteric plexus. Single myenteric ganglion volume averaged 3,527,678 ± 573,832 mm3 with 38,706 ± 5763 neuron/mm3 and 129,321 ± 25,356 glia/mm3. Images of large areas provided insight into why published values of ENS density vary up to 150-fold-ENS density varies greatly, across millimeters, so analyses of small numbers of thin sections from the same bowel region can produce varying results. Neuron subtype analysis revealed that approximately 56% of myenteric neurons stained with neuronal nitric oxide synthase antibody and approximately 33% of neurons produce and store acetylcholine. Transition zone regions from colon tissues of patients with Hirschsprung disease had ganglia in multiple layers and thick nerve fiber bundles without neurons. Submucosal neuron distribution varied among imaged colon regions. CONCLUSIONS: We developed a 3-dimensional imaging method for colon that provides more information about ENS structure than tissue sectioning. This approach could improve diagnosis for human bowel motility disorders and may be useful for other bowel diseases as well.

Pediatric laryngotracheal reconstruction with tissue-engineered cartilage in a rabbit model.

OBJECTIVES/HYPOTHESIS: To develop an effective rabbit model of in vitro- and in vivo-derived tissue-engineered cartilage for laryngotracheal reconstruction (LTR). STUDY DESIGN: 1) Determination of the optimal scaffold 1% hyaluronic acid (HA), 2% HA, and polyglycolic acid (PGA) and in vitro culture time course using a pilot study of 4 by 4-mm in vitro-derived constructs analyzed on a static culture versus zero-gravity bioreactor for 4, 8, and 12 weeks, with determination of compressive modulus and histology as outcome measures. 2) Three-stage survival rabbit experiment utilizing autologous auricular chondrocytes seeded in scaffolds, either 1% HA or PGA. The constructs were cultured for the determined in vitro time period and then cultured in vivo for 12 weeks. Fifteen LTRs were performed using HA cartilage constructs, and one was performed with a PGA construct. All remaining specimens and the final reconstructed larynx underwent mechanical testing, histology, and glycosaminoglycan (GAG) content determination, and then were compared to cricoid control specimens (n = 13) and control LTR using autologous thyroid cartilage (n = 18). METHODS: 1) One rabbit underwent an auricular punch biopsy, and its chondrocytes were isolated and expanded and then encapsulated in eight 4 by 4-mm discs of 1% HA, 2% HA, PGA either in rotary bioreactor or static culture for 4, 8, and 12 weeks, respectively, with determination of compressive modulus, GAG content, and histology. 2) Sixteen rabbits underwent ear punch biopsy; chondrocytes were isolated and expanded. The cells were seeded in 13 by 5 by 2.25-mm UV photopolymerized 1% HA (w/w) or calcium alginate encapsulated synthetic PGA (13 × 5 × 2 mm); the constructs were then incubated in vitro for 12 weeks (the optimal time period determined above in paragraph 1) on a shaker. One HA and one PGA construct from each animal was tested mechanically and histologically, and the remaining eight (4 HA and 4 PGA) were implanted in the neck. After 12 weeks in vivo, the most optimal-appearing HA construct was used as a graft for LTR in 15 rabbits and PGA in one rabbit. The seven remaining specimens underwent hematoxylin and eosin, Safranin O, GAG content determination, and flexural modulus testing. At 12 weeks postoperative, the animals were euthanized and underwent endoscopy. The larynges underwent mechanical and histological testing. All animals that died underwent postmortem examination, including gross and microhistological analysis of the reconstructed airway. RESULTS: Thirteen of the 15 rabbits that underwent LTR with HA in vitro- and in vivo-derived tissue-engineered cartilage constructs survived. The 1% HA specimens had the highest modulus and GAG after 12 weeks in vitro. The HA constructs became well integrated in the airway, supported respiration for the 12 weeks, and were histologically and mechanically similar to autologous cartilage. CONCLUSIONS: The engineering of in vitro- and in vivo-derived cartilage with HA is a novel approach for laryngotracheal reconstruction. The data suggests that the in vitro- and in vivo-derived tissue-engineered approaches may offer a promising alternative to current strategies used in pediatric airway reconstruction, as well as other head and neck applications. LEVEL OF EVIDENCE: NA. Laryngoscope, 126:S5-S21, 2016.

Single-stage versus multi-stage pull-through for Hirschsprung's disease: practice trends and outcomes in infants.

PURPOSE: The aim of this study was to evaluate surgical treatments and outcomes in a multi-institutional cohort of neonates with Hirschsprung's disease (HD). METHODS: Using the Pediatric Health Information System (PHIS) from 1999 to 2009, neonates diagnosed with HD were identified and classified as having a single stage pull-through (SSPT) or multi-stage pull-through (MSPT). Diagnosis and classification algorithms and clinical variables and outcomes were validated by multi-institutional chart review. Groups were compared using logistic regression modeling and propensity-score matched analysis to account for baseline differences between groups. RESULTS: 1555 neonates with HD were identified; 77.2% underwent SSPT and 22.8% underwent MSPT. Misclassification of disease or surgical treatment was <2%. Rates of SSPT increased over time (p=0.03). Compared to SSPT, patients undergoing MSPT had significantly lower birth weights and higher rates of prematurity, non-HD gastrointestinal anomalies, enterocolitis, and preoperative mechanical ventilation. Patients undergoing MSPT had significantly higher rates of readmissions (58.5 vs. 37.9%) and additional operations (38.7 vs. 26%). Results were consistent in the propensity-score matched analysis. CONCLUSION: Most neonates with HD undergo SSPT. In patients with similar observed baseline characteristics, MSPT was associated with worse outcomes suggesting that some infants currently selected to undergo MSPT may have better outcomes with SSPT. However, there remains a subgroup of MSPT patients who were too ill to be adequately compared to SSPT patients; for this subgroup of severely ill infants with HD, MSPT may be the best option.

Rotary bioreactor culture can discern specific behavior phenotypes in Trk-null and Trk-expressing neuroblastoma cell lines.

Neuroblastoma is characterized by biological and genetic heterogeneity that leads to diverse, often unpredictable, clinical behavior. Differential expression of the Trk family of neurotrophin receptors strongly correlates with clinical behavior; TrkA expression is associated with favorable outcome, whereas TrkB with unfavorable outcome. Neuroblastoma cells cultured in a microgravity rotary bioreactor spontaneously aggregate into tumor-like structures, called organoids. We wanted to determine if the clinical heterogeneity of TrkA- or TrkB-expressing neuroblastomas was reflected in aggregation kinetics and organoid morphology. Trk-null SY5Y cells were stably transfected to express either TrkA or TrkB. Short-term aggregation kinetics were determined by counting the number of single (non-aggregated) viable cells in the supernatant over time. Organoids were harvested after 8 d of bioreactor culture, stained, and analyzed morphometrically. SY5Y-TrkA cells aggregated significantly slower than SY5Y and SY5Y-TrkB cells, as quantified by several measures of aggregation. SY5Y and TrkB cell lines formed irregularly shaped organoids, featuring stellate projections. In contrast, TrkA cells formed smooth (non-stellate) organoids. SY5Y organoids were slightly smaller on average, but had significantly larger average perimeter than TrkA or TrkB organoids. TrkA expression alone is sufficient to dramatically alter the behavior of neuroblastoma cells in three-dimensional, in vitro rotary bioreactor culture. This pattern is consistent with both clinical behavior and in vivo tumorigenicity, in that SY5Y-TrkA represents a more differentiated, less aggressive phenotype. The microgravity bioreactor is a useful in vitro tool to rapidly investigate the biological characteristics of neuroblastoma and potentially to assess the effect of cytotoxic as well as biologically targeted drugs.

Microgravity assay of neuroblastoma: in vitro aggregation kinetics and organoid morphology correlate with MYCN expression.

Neuroblastoma, the most common and deadly solid pediatric tumor, features genetic and biologic heterogeneity that defies simple risk assessments, drives diverse clinical behavior, and demands more extensive characterization. This research served to investigate the utility of a microgravity assay-rotary bioreactor culture-to evaluate and characterize the cell-specific, in vitro behavior of neuroblastoma cell lines: aggregation kinetics of single cells and the morphology of the formed structures, called organoids. Specifically, we examined the effect of amplification of the oncogene MYCN, a genetic factor that is strongly associated with poor clinical outcome. Three human neuroblastoma cell lines with varied MYCN expression (CHP-212 (unamplified), SK-N-AS (unamplified), IMR-32 (amplified)) were cultured in the microgravity rotary bioreactor. Simple aggregation kinetics were determined by periodically performing counts of non-aggregated single cells in the media. Organoids were harvested, stained with hematoxylin and eosin, and evaluated microscopically in terms of size and shape. The MYCN-amplified cell line (IMR32) aggregated much more rapidly than the unamplified cell lines, as indicated by a significantly lower area under its aggregation curve (single non-aggregated cells vs. time): IMR32=4.3, CHP-212 =12.4, SK-N-AS=9.8 (adhesion index ×10(5)). Further, the organoid morphology of the MYCN-amplified cell line was noticeably different compared to the unamplified lines. The CHP-212 and SK-N-AS cells formed spherical structures with average cross-sectional area 0.213 and 0.138 mm(2), respectively, and featured an outer viable zone of cells (average length of 0.175, 0.129 mm, respectively; the "diffusion distance"), surrounding an inner necrotic core. In contrast, the MYCN-amplified cell line formed a large single mass of cells but had a similar diffusion distance (0.175 mm). This microgravity assay provides a rapid, reproducible assessment of in vitro behavior of neuroblastoma, and the measured parameters, aggregation kinetics and organoid size and shape correlated with malignant potential in terms of MYCN amplification. This assay allows for the examination of cell-specific biologic and genetic factors that should provide valuable insight into the clinical behavior of neuroblastoma.

Hepaticoduodenostomy vs hepaticojejunostomy for reconstruction after resection of choledochal cyst.

PURPOSE: Roux-en-Y hepaticojejunostomy (HJ) is currently the favored reconstructive procedure after resection of choledochal cysts. Hepaticoduodenostomy (HD) has been argued to be more physiologically and technically easier but is feared to have associated complications. Here we compare outcomes of the 2 procedures. METHODS: A retrospective chart review identified 59 patients who underwent choledochal cyst resection within our institution from 1999 to 2009. Demographic and outcome data were compared using t tests, Mann-Whitney U tests, and Pearson χ(2) tests. RESULTS: Fifty-nine patients underwent repair of choledochal cyst. Biliary continuity was restored by HD in 39 (66%) and by HJ in 20 (34%). Open HD patients required less total operative time than HJ patients (3.9 vs 5.1 hours, P = .013), tolerated a diet faster (4.8 days compared with 6.1 days, P = .08), and had a shorter hospital stay (7.05 days for HD vs 9.05 days for HJ, P = .12). Complications were more common in HJ (HD = 7.6%, HJ = 20%, P = .21). Three patients required reoperation after HJ, but only one patient required reoperation after HD for a stricture (HD = 2.5%, HJ = 20%, P = .037). CONCLUSIONS: In this series, HD required less operative time, allowed faster recovery of bowel function, and produced fewer complications requiring reoperation.

Treatment of diabetic wounds with fetal murine mesenchymal stromal cells enhances wound closure.

Diabetes impairs multiple aspects of the wound-healing response. Delayed wound healing continues to be a significant healthcare problem for which effective therapies are lacking. We have hypothesized that local delivery of mesenchymal stromal cells (MSC) at a wound might correct many of the wound-healing impairments seen in diabetic lesions. We treated excisional wounds of genetically diabetic (Db-/Db-) mice and heterozygous controls with either MSC, CD45(+) cells, or vehicle. At 7 days, treatment with MSC resulted in a decrease in the epithelial gap from 3.2 +/- 0.5 mm in vehicle-treated wounds to 1.3 +/- 0.4 mm in MSC-treated wounds and an increase in granulation tissue from 0.8 +/- 0.3 mm(2) to 2.4 +/- 0.6 mm(2), respectively (mean +/- SD, P < 0.04). MSC-treated wounds also displayed a higher density of CD31(+) vessels and exhibited increases in the production of mRNA for epidermal growth factor, transforming growth factor beta 1, vascular endothelial growth factor, and stromal-derived growth factor 1-alpha. MSC also demonstrated greater contractile ability than fibroblast controls in a collagen gel contraction assay. The effects of locally applied MSC are thus sufficient to improve healing in diabetic mice. Possible mechanisms of this effect include augmented local growth-factor production, improved neovascularization, enhanced cellular recruitment to wounds, and improved wound contraction.

Structural and functional characterization of bladder smooth muscle in fetal rats with retinoic acid-induced myelomeningocele.

Myelomeningocele (MMC) is the most common cause of neurogenic bladder dysfunction (NBD). We recently developed a novel retinoic acid (RA)-induced MMC model in fetal rats. The objective of this study was to use this model to assess functional and structural characteristics of the detrusor muscle in MMC-associated NBD. Time-dated pregnant Sprague-Dawley rats were gavage fed 60 mg/kg RA dissolved in olive oil or olive oil alone [embryonic day 10 (E10)]. Bladder specimens from olive oil-exposed fetuses (OIL; n = 71), MMC (n = 79), and RA-exposed-no MMC (RA, n = 62) were randomly assigned for functional and histopathological evaluation and protein analysis. Contractility responses to field and agonist-mediated stimulation (KCl and bethanecol) were analyzed. The expression patterns of alpha-smooth muscle actin, myosin, desmin, vimentin, and collagen III and I were analyzed by immunohistochemistry and Western blotting. Spatial and temporal distribution of nerve fibers within the detrusor muscle was monitored by neurotubulin-beta-III throughout gestation. Neither OIL, MMC, nor RA detrusor responded to field stimulation. MMC bladder strips showed a significant decrease in contractility after KCl and bethanechol stimulation compared with OIL and RA bladders. Bladder detrusor morphology and expression patterns of smooth muscle markers were similar between groups. Detrusor muscles in OIL and RA fetuses were densely innervated, possessing abundant intramural ganglia and nerve trunks that branch to supply smooth muscle bundles. In MMC bladders, neurotubulin-beta-III-positive nerve fibers were markedly decreased with advancing gestational age and were almost completely absent at term (E22). We conclude that the biomechanical properties of fetal rat MMC bladders are analogous to that seen in humans with MMC-associated NBD. Decreased nerve density indicates loss of peripheral neural innervation throughout gestation. The early observation of decreased innervation and decreased contractility in the absence of morphologic abnormalities in muscle structure or extracellular matrix supports a pathophysiological hypothesis that denervation is the primary insult preceding the observed alterations in bladder muscle structure and function.

Complementary roles of microtubules and microfilaments in the lung fibroblast-mediated contraction of collagen gels: Dynamics and the influence of cell density.

Fibroblasts are important cellular components in wound healing, scar formation, and fibrotic disorders; and the fibroblast-populated collagen-gel (FPCG) model allows examination of fibroblast behavior in an in vitro three-dimensional environment similar to that in vivo. Contraction of free-floating FPCGs depends on an active and dynamic cytoskeleton, and the contraction dynamics are highly influenced by cell density. We investigated mechanistic differences between high- and low-cell density FPCG contraction by evaluating contraction dynamics in detail, using specific cytoskeletal disruptors. Collagen gels were seeded with human lung fibroblasts at either high (HD) or low (LD) density, and incubated with or without cytoskeletal disruptors colchicine (microtubules) or cytochalasin D (microfilaments). Gel area was measured daily. FPCG contraction curves were essentially sigmoidal, featuring an initial period of no contraction (lag phase), followed by a period of rapid contraction (log phase). Contraction curves of HD-FPCGs were distinct from those of LD-FPCGs. For example, HD-FPCGs had a negligible lag phase (compared with 3 d for LD-FPCGs) and exhibited a higher rate of log-phase contraction. Both colchicine and cytochalasin dose-dependently inhibited contraction but specifically affected different phases of contraction in HD- and LD-FPCGs; and colchicine inhibited LD-FPCGs much more than HD-FPCGs. The data indicate that LD- and HD-FPCGs contract through different primary mechanisms. Microtubules and microfilaments are both complementarily and dynamically involved in the contraction of FPCGs, and cell density influences primary cytoskeletal mechanisms. These results provide valuable information about fibroblast behavior in healing and fibrosis, and may suggest novel treatment options.

Collagen crosslinking and cell density have distinct effects on fibroblast-mediated contraction of collagen gels.

BACKGROUND/PURPOSE: Fibroblasts are actively and dynamically involved in wound healing (dermal regeneration, wound contraction, and scar contracture) and fibrosis. Fibroblast-seeded collagen gels provide an in vitro model for these processes. Over time, fibroblasts will contract the gels, but the mechanisms are not completely understood. This research investigated the influence of cell density and collagen crosslinking on the contraction of fibroblast-populated gels by varying seeding density and blocking the catalyzing enzyme lysyl oxidase, respectively. METHODS: Collagen gels were seeded with fibroblasts at either 3 x 104 or 1 x 105 cells/mL and incubated with or without the lathyrogen beta-aminoproprionitrile (BAPN) for 8 days. In all, four experimental groups were analyzed: low cell density control, high cell density control, low density plus BAPN, and high density plus BAPN. Digital images were taken daily and gel area was calculated. RESULTS: Contraction was dependent on cell concentration, with higher density gels being contracted to a greater extent. BAPN had no effect until after day 2 when it inhibited (high density) or almost completely blocked (low density) the gel contraction. BAPN also reduced total long-term contraction. CONCLUSION: The results demonstrated a bimodal nature to fibroblast-mediated gel contraction: a cell density-dependent component, most likely mediated through cellular forces, and a delayed collagen crosslinking component that could be blocked by BAPN. In the long-term, similar contraction rates among the four experimental groups, particularly between the two BAPN groups, implies that the collagen crosslinking effect is discrete and independent of cell density.

Real-time, high-definition, three-dimensional microscopy for evaluating problematic cervical Papanicolaou smears classified as atypical squamous cells of undetermined significance.

BACKGROUND: The perceived inadequacies of the cervical Papanicolaou (Pap) smear have been attributed to sampling, screening, or interpretive errors. Within this type of cytologic preparation, there are thick cell clusters in which the cells are obscured. It may not possible to evaluate these areas by conventional microscopy. The authors clinically tested the hypothesis that high-definition, three-dimensional (3-D) microscopy based on multiple oblique illumination (MOI), with its ability to penetrate into thick areas, would be useful in evaluating problematic cervical Pap smears, particularly those diagnosed as atypical squamous cells of undetermined significance (ASCUS). METHODS: ASCUS Pap smears and corresponding surgical biopsy specimens were evaluated prospectively using standard, axially illuminated microscopes and a new high-definition, 3-D microscope employing MOI. The Pap smears were reviewed in a blinded fashion with both types of microscopy. The rendered diagnoses were then compared with the subsequent tissue biopsies, which also were blinded, as the definitive end point. RESULTS: It was immediately apparent that the high-definition, 3-D MOI microscope had better resolution compared with the standard microscopes. Pap smears and biopsy diagnoses were correlated significantly for MOI (P < 0.001), and there were significant improvements (P = 0.0108) in accuracy when 3-D, high-definition microscopy was compared with conventional microscopy. The authors found no statistically significant correlation between ASCUS diagnoses that were rendered by using standard microscopes compared with the subsequent biopsy. CONCLUSIONS: Due to enhanced visualization through thick cell clusters, an increased depth of field, light penetration, and resolution, high-definition, 3-D microscopy based on MOI produced superior accuracy compared with conventional light microscopy in evaluating cervical Pap smears.

Engineering a composite neotrachea with surgical adhesives.

BACKGROUND/PURPOSE: Reconstructive surgery often is limited by the availability of normal tissue. Tissue engineering provides promise in the development of "artificial tissues." The purpose of this study was to test the efficacy and viability of the use of a biologic surgical adhesive TISSEEL in combining engineered bronchial epithelium with engineered cartilage. METHODS: Using isolated human cells, bronchial epithelium and mature cartilage were engineered. Using a contact adhesive technique, TISSEEL was used to biologically fuse the bronchial epithelium and the cartilage. The fused composite then was supported for 5 days in tissue culture. The mechanical properties of the adhesion were tested, and the construct was studied morphologically to assess viability of the cartilage and the bronchial epithelium. The bronchial epithelium showed a normal cell size (337.2 microm2) and epithelial thickness (46.47 microm). RESULTS: TISSEEL was effective in fusing the epithelium to the cartilage. The construct remained viable for 5 days in culture. There was no difference in the dimensions of the bronchial epithelium or the epithelial cells. Mechanical adhesion was achieved. CONCLUSIONS: Biologically compatible fibrin glue is an effective surgical adhesive that allows the tissue types to be fused while remaining viable and morphologically accurate. Surgical adhesives may show promise in the development of composite tissue development in the field of bioengineering.