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Neuroblastoma is the most common extracranial solid tumor in children, and a leading cause of childhood cancer deaths. All neuroblastomas arise from neural crest-derived sympathetic neuronal progenitors, but numerous mutations, the most common of which is MYCN amplification, give rise to these lesions. Epigenetic aberrations also play a role in oncogenesis and tumor progression. To better understand biologic diversity of neuroblastomas, we performed joint single-nucleus ATAC sequencing and single-nucleus RNA sequencing on six neuroblastoma cell lines, three of which are MYCN amplified. After standard filtering for high-quality nuclei, we obtained chromatin accessibility and transcript abundance data from 41,733 neuroblastoma tumor cells. Preliminary analysis reveals significant diversity in chromatin landscape and gene expression across neuroblastoma cell lines. This dataset is a valuable resource for studying the transcriptional and epigenetic mechanisms of this deadly childhood disease., (© 2024. The Author(s).)

Objective: To describe the design, implementation, and evaluation of a two-week rotation intended to enhance junior surgical residents' preparation for their dedicated professional development time (PDT) and academic careers., Design: As part of a multifaceted effort to promote residents' academic development, we designed a two-week, nonclinical "Academic Development Block" (ADB) rotation for postgraduate year (PGY)-2 and -3 residents. During this rotation, residents meet with clinical, research, and peer mentors and work on academic activities, with relevant deliverables specific to each class year. We analyzed feedback from postrotation surveys and interviews, which were inductively coded and thematically analyzed, and data on resident grant applications and earnings before and after implementation., Setting: The general surgery residency program at a major urban, university-affiliated academic medical center. ADBs were first implemented in 2021., Participants: A total of 39 PGY-2 and PGY-3 residents rotated through the program with 51 ADBs over the first two years of implementation., Results: Surveys indicated overwhelmingly positive perceptions on the value of ADBs, including the amount of structure and resources available. Free-response and interview themes indicated appreciation for time to meet with mentors, develop ideas, and complete academic work. Residents believed the ADB rotation accelerated their transition into PDT and was a marker of institutional commitment. Areas for improvement pertained to the timing of ADBs and pairing of mentors. Both cohorts who participated in at least 1 ADB had higher proportions of residents who successfully applied for grants and a greater amount of total funding awarded compared to all 4 of the most recent cohorts prior to implementation., Conclusions: A short academic development rotation protected from clinical responsibilities is a well-regarded intervention to help residents refine their career goals and prepare for their PDT. Similar initiatives may be of interest to residency programs seeking to foster their residents' academic career development., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Here, we establish that plasticity exists within the postnatal enteric nervous system by demonstrating the reinnervation potential of post-mitotic enteric neurons (ENs). Employing BAF53b-Cre mice for selective neuronal tracing, the reinnervation capabilities of mature postnatal ENs are shown across multiple model systems. Isolated ENs regenerate neurites in vitro, with neurite complexity and direction influenced by contact with enteric glial cells (EGCs). Nerve fibers from transplanted ENs exclusively interface and travel along EGCs within the muscularis propria. Resident EGCs persist after Cre-dependent ablation of ENs and govern the architecture of the myenteric plexus for reinnervating ENs, as shown by nerve fiber projection tracing. Transplantation and optogenetic experiments in vivo highlight the rapid reinnervation potential of post-mitotic neurons, leading to restored gut muscle contractile activity within 2 weeks. These studies illustrate the structural and functional reinnervation capacity of post-mitotic ENs and the critical role of EGCs in guiding and patterning their trajectories., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Immune cell populations in the intestinal muscularis propria during colitis are poorly resolved. Maintaining homeostasis in this niche is critical, highlighted by the poorer prognosis of inflammatory bowel disease associated with muscularis propria inflammation., Methods: This study utilizes single-cell RNA sequencing to survey the immune cell populations within the muscularis propria of normal colon and dextran sodium sulfate-induced colitis. Findings are validated by immunohistochemistry, flow cytometry and cell-lineage tracing in vivo, and in vitro assays with muscularis macrophages (MMφ)., Results: In naïve conditions, transcriptional duality is observed in MMφs with 2 major subpopulations: conventional resident Cx3cr1+ MMφs and Lyve1+ MMφs. The Lyve1+ population is phagocytic and expresses several known MMφ markers in mouse and human, confirming their identity as a bona fide MMφ subset. Single-cell transcriptomics indicate that resident MMφs are retained during colitis and exhibit plasticity toward an inflammatory profile. Lyve1+ MMφs, which express anti-inflammatory marker CD163, are absent during colitis, as confirmed by flow cytometry. In contrast, lineage tracing finds that resident Cx3cr1+ MMφs remain during colitis and are not completely replaced by the inflammatory infiltrating monocytes. In vitro studies provide biological evidence of the plasticity of resident Cx3cr1+ MMφs in response to lipopolysaccharide (LPS), mirroring transcriptional observations in vivo of their inflammatory plasticity. Potential markers for colitic MMφs, validated in animal models and in individuals with ulcerative colitis, are identified., Conclusions: Our findings contribute to the understanding of the immune system in the muscularis propria niche during colitis by resolving the heterogeneity and origins of colitic MMφs., (© The Author(s) 2024. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Regenerative cell therapy to replenish the missing neurons and glia in the aganglionic segment of Hirschsprung disease represents a promising treatment option. However, the success of cell therapies for this condition are hindered by poor migration of the transplanted cells. This limitation is in part due to a markedly less permissive extracellular environment in the postnatal gut than that of the embryo. Coordinated interactions between enteric neural crest-derived cells (ENCDCs) and their local environment drive migration along the embryonic gut during development of the enteric nervous system. Modifying transplanted cells, or the postnatal extracellular environment, to better recapitulate embryonic ENCDC migration could be leveraged to improve the engraftment and coverage of stem cell transplants. We compared the transcriptomes of ENCDCs from the embryonic intestine to that of postnatal-derived neurospheres and identified 89 extracellular matrix (ECM)-associated genes that are differentially expressed. Agrin, a heparin sulfate proteoglycan with a known inhibitory effect on ENCDC migration, was highly over-expressed by postnatal-derived neurospheres. Using a function-blocking antibody and a shRNA-expressing lentivirus, we show that inhibiting agrin promotes ENCDC migration in vitro and following cell transplantation ex vivo and in vivo. This enhanced migration is associated with an increased proportion of GFAP + cells, whose migration is especially enhanced., (© The Author(s) 2024. Published by Oxford University Press.)

Neuroblastoma is the most common extracranial solid tumor of childhood and accounts for a significant share of childhood cancer deaths. Prior studies utilizing RNA sequencing of bulk tumor populations showed two predominant cell states characterized by high and low expression of neuronal genes. Although cells respond to treatment by altering their gene expression, it is unclear whether this reflects shifting balances of distinct subpopulations or plasticity of individual cells. Using mouse and human neuroblastoma cell lines lacking MYCN amplification, we show that the antigen CD49b (also known as ITGA2) distinguishes these subpopulations. CD49b expression marked proliferative cells with an immature gene expression program, whereas CD49b-negative cells expressed differentiated neuronal marker genes and were non-cycling. Sorted populations spontaneously switched between CD49b expression states in culture, and CD49b-negative cells could generate rapidly growing, CD49b-positive tumors in mice. Although treatment with the chemotherapy drug doxorubicin selectively killed CD49b-positive cells in culture, the CD49b-positive population recovered when treatment was withdrawn. We profiled histone 3 (H3) lysine 27 acetylation (H3K27ac) to identify enhancers and super enhancers that were specifically active in each population and found that CD49b-negative cells maintained the priming H3 lysine 4 methylation (H3K4me1) mark at elements that were active in cells with high expression of CD49b. Improper maintenance of primed enhancer elements might thus underlie cellular plasticity in neuroblastoma, representing potential therapeutic targets for this lethal tumor., Competing Interests: Competing Interests K.O. receives salary support from Wakunaga Pharmaceutical Co., (© 2023. Published by The Company of Biologists Ltd.)

Objective: To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis., Background: Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision., Methods: This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events., Results: A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P <0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity., Conclusions: Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The enteric nervous system (ENS) consists of glial cells (EGCs) and neurons derived from neural crest precursors. EGCs retain capacity for large-scale neurogenesis in culture, and in vivo lineage tracing has identified neurons derived from glial cells in response to inflammation. We thus hypothesize that EGCs possess a chromatin structure poised for neurogenesis. We use single-cell multiome sequencing to simultaneously assess transcription and chromatin accessibility in EGCs undergoing spontaneous neurogenesis in culture, as well as small intestine myenteric plexus EGCs. Cultured EGCs maintain open chromatin at genomic loci accessible in neurons, and neurogenesis from EGCs involves dynamic chromatin rearrangements with a net decrease in accessible chromatin. A subset of in vivo EGCs, highly enriched within the myenteric ganglia and that persist into adulthood, have a gene expression program and chromatin state consistent with neurogenic potential. These results clarify the mechanisms underlying EGC potential for neuronal fate transition., Competing Interests: Declaration of interests A.M.G. receives research funds from Takeda Pharmaceutical Company., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Enteric nervous system development relies on intestinal colonization by enteric neural crest-derived cells (ENCDCs). This is driven by a population of highly migratory and proliferative ENCDCs at the wavefront, but the molecular characteristics of these cells are unknown. ENCDCs from the wavefront and the trailing region were isolated and subjected to RNA-seq. Wavefront-ENCDCs were transcriptionally distinct from trailing ENCDCs, and temporal modelling confirmed their relative immaturity. This population of ENCDCs exhibited altered expression of ECM and cytoskeletal genes, consistent with a migratory phenotype. Unlike trailing ENCDCs, the wavefront lacked expression of genes related to neuronal or glial maturation. As wavefront ENCDC genes were associated with migration and developmental immaturity, the genes that remain expressed in later progenitor populations may be particularly pertinent to understanding the maintenance of ENCDC progenitor characteristics. Dusp6 expression was specifically upregulated at the wavefront. Inhibiting DUSP6 activity prevented wavefront colonization of the hindgut, and inhibited the migratory ability of post-colonized ENCDCs from midgut and postnatal neurospheres. These effects were reversed by simultaneous inhibition of ERK signaling, indicating that DUSP6-mediated ERK inhibition is required for ENCDC migration in mouse and chick., Competing Interests: Competing interests The authors declare no competing or financial interests., (© 2023. Published by The Company of Biologists Ltd.)

Importance: The clinical significance of gangrenous, suppurative, or exudative (GSE) findings is poorly characterized in children with nonperforated appendicitis., Objective: To evaluate whether GSE findings in children with nonperforated appendicitis are associated with increased risk of surgical site infections and resource utilization., Design, Setting, and Participants: This multicenter cohort study used data from the Appendectomy Targeted Database of the American College of Surgeons Pediatric National Surgical Quality Improvement Program, which were augmented with operative report data obtained by supplemental medical record review. Data were obtained from 15 hospitals participating in the Eastern Pediatric Surgery Network (EPSN) research consortium. The study cohort comprised children (aged ≤18 years) with nonperforated appendicitis who underwent appendectomy from July 1, 2015, to June 30, 2020., Exposures: The presence of GSE findings was established through standardized, keyword-based audits of operative reports by EPSN surgeons. Interrater agreement for the presence or absence of GSE findings was evaluated in a random sample of 900 operative reports., Main Outcomes and Measures: The primary outcome was 30-day postoperative surgical site infections (incisional and organ space infections). Secondary outcomes included rates of hospital revisits, postoperative abdominal imaging, and postoperative length of stay. Multivariable mixed-effects regression was used to adjust measures of association for patient characteristics and clustering within hospitals., Results: Among 6133 children with nonperforated appendicitis, 867 (14.1%) had GSE findings identified from operative report review (hospital range, 4.2%-30.2%; P < .001). Reviewers agreed on presence or absence of GSE findings in 93.3% of cases (weighted κ, 0.89; 95% CI, 0.86-0.92). In multivariable analysis, GSE findings were associated with increased odds of any surgical site infection (4.3% vs 2.2%; odds ratio [OR], 1.91; 95% CI, 1.35-2.71; P < .001), organ space infection (2.8% vs 1.1%; OR, 2.18; 95% CI, 1.30-3.67; P = .003), postoperative imaging (5.8% vs 3.7%; OR, 1.70; 95% CI, 1.23-2.36; P = .002), and prolonged mean postoperative length of stay (1.6 vs 0.9 days; rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001)., Conclusions and Relevance: In children with nonperforated appendicitis, findings of gangrene, suppuration, or exudate are associated with increased surgical site infections and resource utilization. Further investigation is needed to establish the role and duration of postoperative antibiotics and inpatient management to optimize outcomes in this cohort of children.

Hirschsprung disease is most often characterized by aganglionosis limited to the distal colon and rectum, and mice lacking the Endothelin receptor type B (Ednrb) faithfully recapitulate this phenotype. However, despite the presence of enteric ganglia in the small intestine, both human patients and Ednrb-/- mice suffer from dysmotility and altered gastrointestinal function, thus raising the possibility of enteric nervous system (ENS) abnormalities proximal to the aganglionic region. We undertook the present study to determine whether abnormalities with the ENS in ganglionated regions may account for abnormal gastrointestinal function. We performed single-cell RNA sequencing on ENS cells from the small intestine of Ednrb-/- mice and compared the results to a published single-cell dataset. Our results identified a missing population of neurons marked by the enzyme Gad2, which catalyzes the production of γ -Aminobutyric acid (GABA), in the small intestine of Ednrb-/- animals. This result was confirmed by immunostaining enteric ganglia from Ednrb-/- mice and their wild-type littermates. These data show for the first time that ganglionated regions of the Hirschsprung gut lack a neuronal subpopulation, which may explain the persistent gastrointestinal dysfunction after surgical correction of Hirschsprung disease., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Bhave, Guyer, Picard, Omer, Hotta and Goldstein.)

Introduction: Traumatic rib fractures result in significant patient morbidity and mortality, which increases with patient age and number of rib fractures. A dedicated acute pain service (APS) providing expertize in multimodal pain management may reduce these risks and improve outcomes. We aimed to test the hypothesis that protocolized APS consultation decreases mortality and morbidity in traumatic rib fracture patients., Methods: This is a retrospective observational, propensity-matched cohort study of adult patients with trauma with rib fractures from 2012 to 2015, at a single, large level 1 trauma center corresponding to introduction and incorporation of APS consultation into the institutional rib fracture pathway. Using electronic medical records and trauma registry data, we identified adult patients presenting with traumatic rib fractures. Patients with hospital length of stay (LOS) ≥2 days were split into two cohorts based on presence of APS consult using 1:1 propensity matching of age, gender, comorbidities and injury severity. The primary outcome was difference in hospital mortality. Secondary outcomes included LOS and pulmonary morbidity., Results: 2486 patients were identified, with a final matched cohort of 621 patients receiving APS consult and 621 control patients. The mortality rate was 1.8% among consult patients and 6.6% among control patients (adjusted OR 0.25, 95% CI 0.13 to 0.50; p=0.001). The average treatment effect of consult on mortality was 4.8% (95% CI 1.2% to 8.5%;. p<0.001). APS consultation was associated with increased intensive care unit (ICU) LOS (1.19 day; 95% CI 0.48 to 1.90; p=0.001) and hospital LOS (1.61 days; 95% CI 0.81 to 2.41 days; p<0.001). No difference in pulmonary complications was observed., Discussion: An APS consult in rib fracture patients is associated with decreased mortality and no difference in pulmonary complications yet increased ICU and hospital LOS., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Stem cell therapies for nervous system disorders are hindered by a lack of accessible autologous sources of neural stem cells (NSCs). In this study, neural crest-derived Schwann cells are found to populate nerve fiber bundles (NFBs) residing in mouse and human subcutaneous adipose tissue (SAT). NFBs containing Schwann cells were harvested from mouse and human SAT and cultured in vitro. During in vitro culture, SAT-derived Schwann cells remodeled NFBs to form neurospheres and exhibited neurogenic differentiation potential. Transcriptional profiling determined that the acquisition of these NSC properties can be attributed to dedifferentiation processes in cultured Schwann cells. The emerging population of cells were termed SAT-NSCs because of their considerably distinct gene expression profile, cell markers, and differentiation potential compared to endogenous Schwann cells existing in vivo. SAT-NSCs successfully engrafted to the gastrointestinal tract of mice, migrated longitudinally and circumferentially within the muscularis, differentiated into neurons and glia, and exhibited neurochemical coding and calcium signaling properties consistent with an enteric neuronal phenotype. These cells rescued functional deficits associated with colonic aganglionosis and gastroparesis, indicating their therapeutic potential as a cell therapy for gastrointestinal dysmotility. SAT can be harvested easily and offers unprecedented accessibility for the derivation of autologous NSCs from adult tissues. Evidence from this study indicates that SAT-NSCs are not derived from mesenchymal stem cells and instead originate from Schwann cells within NFBs. Our data describe efficient isolation procedures for mouse and human SAT-NSCs and suggest that these cells have potential for therapeutic applications in gastrointestinal motility disorders.

Background: Tamoxifen is widely used for Cre-estrogen receptor-mediated genomic recombination in transgenic mouse models to mark cells for lineage tracing and to study gene function. However, recent studies have highlighted off-target effects of tamoxifen in various tissues and cell types when used for induction of Cre recombination. Despite the widespread use of these transgenic Cre models to assess gastrointestinal (GI) function, the effect of tamoxifen exposure on GI motility has not been described., Methods: We examined the effects of tamoxifen on GI motility by measuring total GI transit, gastric emptying, small intestinal transit, and colonic contractility in wild-type adult mice., Key Results: We observed a significant delay in total GI transit in tamoxifen-treated mice, with unaltered gastric emptying, accelerated small intestinal transit, and abnormal colonic motility., Conclusion: Our findings highlight the importance of considering GI motility alterations induced by tamoxifen when designing protocols that utilize tamoxifen as a Cre-driver for studying GI function., (© 2022 John Wiley & Sons Ltd.)

Background: The optimal age for endorectal pull-through (ERPT) surgery in infants with short-segment Hirschsprung disease varies, with a trend toward earlier surgery. However, it is unclear if the timing of surgery impacts functional outcomes. We undertook the present study to determine the optimal timing of ERPT in infants with short-segment Hirschsprung disease., Methods: The NCBI PubMed database was searched for English-language manuscripts published between 2000 and 2019 analyzing functional outcomes for patient following the initial Soave ERPT for short-segment Hirschsprung disease. Raw data from these studies was obtained from the corresponding author for each manuscript. We combined data from these papers with our own institutional data and performed a meta-analysis., Results: A total of 780 infants were included in our meta-analysis. Constipation occurred in 1.0-31.7%, soiling 1.3-26.0%, anastomotic stricture 0.0-14.6%, and anastomotic leak 0.0-3.4%. Regarding age at ERPT, younger infants at the time of initial corrective surgery had higher rates of soiling, stricture, and leak. On sub-group analysis, patients <2.5 months at their initial corrective surgery had higher rates of soiling (25.9% vs. 11.4%, p<0.01), as well as stricture (10.0% vs 1.7%, p<0.01) and leak (5.5% vs 1.3%, p<0.01)., Conclusion: While age at Soave endorectal pull-through for short-segment Hirschsprung disease has decreased over time, functional outcomes associated with this trend have only recently been examined. Our findings suggest that patients <2.5 months old at the time of endorectal pull-through may have worse functional outcomes, emphasizing the need to consider further study of the timing of surgery in this population., (Copyright © 2021 Elsevier Inc. All rights reserved.)

With recent technical advances and diminishing sequencing costs, single-cell sequencing modalities have become commonplace. These tools permit analysis of RNA expression, DNA sequence, chromatin structure, and cell surface antigens at single-cell resolution. Simultaneous measurement of numerous parameters can resolve populations including rare cells, thus revealing cellular diversity within organs and permitting lineage reconstruction in developing tissues. Application of these methods to the enteric nervous system has yielded a wealth of data and biological insights. We review recent papers applying single-cell sequencing tools to the nascent neural crest and to the developing and mature enteric nervous system. These studies have shown significant diversity of enteric neurons and glia, suggested paradigms for neuronal specification, and revealed signaling pathways active during development. As technology evolves and multiome techniques combining two or more of transcriptomic, genomic, epigenetic, and proteomic data become prominent, we anticipate these modalities will become commonplace in ENS research and may find a role in diagnostic testing and personalized therapeutics.

Mastering the art of grant writing is one of the most essential skills to obtaining research funding. Given the importance of pursuing high-quality surgical research and supporting the academic goals of surgeon-scientists, ensuring that surgeons have the necessary skills to write effective and successful grants is of paramount importance. In this article, we present 10 strategies for composing a strong research grant application. These strategies apply to federal or nongovernmental funding agencies and are broadly relevant to basic, translational, and clinical investigators. We believe these recommendations can help surgeon-scientists be effective grant writers and compete successfully for research funding., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Hirschsprung disease (HSCR) is characterized by distal intestinal aganglionosis. While surgery is lifesaving, gastrointestinal (GI) motility disorders persist in many patients. Our objective was to determine whether enteric nervous system (ENS) abnormalities exist in the ganglionated portions of the GI tract far proximal to the aganglionic region and whether these are associated with GI dysmotility., Methods: Using Ednrb-null mice, a model of HSCR, immunohistochemical analysis was performed to evaluate quantitatively ENS structure in proximal colon, small intestine, and stomach. Gastric emptying and intestinal transit were measured in vivo and small and large bowel contractility was assessed by spatiotemporal mapping ex vivo., Results: Proximal colon of HSCR mice had smaller ganglia and decreased neuronal fiber density, along with a marked reduction in migrating motor complexes. The distal small intestine exhibited significantly fewer ganglia and decreased neuronal fiber density, and this was associated with delayed small intestinal transit time. Finally, in the stomach of HSCR mice, enteric neuronal packing density was increased and gastric emptying was faster., Conclusions: ENS abnormalities and motility defects are present throughout the ganglionated portions of the GI tract in Ednrb-deficient mice. This may explain the GI morbidity that often occurs following pull-through surgery for HSCR., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Appropriately balanced RET signaling is of crucial importance during embryonic neural crest cell migration, proliferation and differentiation. RET deficiency, for example, leads to intestinal aganglionosis (Hirschsprung disease), whereas overactive RET can lead to multiple endocrine neoplasia (MEN) syndromes. Some RET mutations are associated with both intestinal aganglionosis and MEN-associated tumors. This seemingly paradoxical occurrence has led to speculation of a 'Janus mutation' in RET that causes overactivation or impairment of RET activity depending on the cellular context. Using an intestinal catenary culture system to test the effects of GDNF-mediated RET activation, we demonstrate the concurrent development of distal colonic aganglionosis and intestinal ganglioneuromas. Interestingly, the tumors induced by GDNF stimulation contain enteric neuronal progenitors capable of reconstituting an enteric nervous system when transplanted into a normal developmental environment. These results suggest that a Janus mutation may not be required to explain co-existing Hirschsprung disease and MEN-associated tumors, but rather that RET overstimulation alone is enough to cause both phenotypes. The results also suggest that reprogramming tumor cells toward non-pathological fates may represent a possible therapeutic avenue for MEN-associated neoplasms., Competing Interests: Competing interestsThe authors declare no competing or financial interests., (© 2020. Published by The Company of Biologists Ltd.)

Numerical simulation of nonlinear elastic wave propagation in solids with cracks is indispensable for decoding the complicated mechanisms associated with the nonlinear ultrasonic techniques in Non-Destructive Testing (NDT). Here, we introduce a two-dimensional implementation of the combined finite-discrete element method (FDEM), which merges the finite element method (FEM) and the discrete element method (DEM), to explicitly simulate the crack induced nonlinear elasticity in solids with both horizontal and inclined cracks. In the FDEM model, the solid is discretized into finite elements to capture the wave propagation in the bulk material, and the finite elements along the two sides of the crack also behave as discrete elements to track the normal and tangential interactions between crack surfaces. The simulation results show that for cracked models, nonlinear elasticity is generated only when the excitation amplitude is large enough to trigger the contact between crack surfaces, and the nonlinear behavior is very sensitive to the crack surface contact. The simulations reveal the influence of normal and tangential contact on the nonlinear elasticity generation. Moreover, the results demonstrate the capabilities of FDEM for decoding the causality of nonlinear elasticity in cracked solid and its potential to assist in Non-Destructive Testing (NDT)., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Acute invasive fungal sinusitis (AIFS) is a rare, aggressive infection occurring in immunocompromised patients. In this study we examined factors that affect survival in AIFS, and whether immune-stimulating therapies (IST) improve survival., Methods: Pathology records of biopsy-proven AIFS were reviewed from 3 academic institutions from 1995 to 2016. Univariate and multivariate Cox regressions were performed at 1 and 3 months from diagnosis., Results: One hundred fourteen patients were included; 45 received IST. In the univariate analysis, the following factors were associated with worse survival: hematologic malignancy (3-month hazard ratio [HR], 3.7; p = 0.01); recent chemotherapy (within 1 month of AIFS diagnosis) (3-month HR, 2.3; p = 0.02); recent bone marrow transplant (BMT) (3-month HR, 2.5; p = 0.02); and infection with atypical fungi (1-month HR, 3.1; p = 0.04). The following were associated with improved survival in univariate analysis: increasing A1c% (1-month HR, 0.7; p = 0.01) and surgical debridement (1-month HR, 0.1; p = 0.001). One third of patients with a hematologic malignancy had an absolute neutrophil count (ANC) >1000 at the time of diagnosis. ANC was not associated with prognosis in these patients. The following were associated with worse survival in multivariate analyses: hematologic malignancy; recent chemotherapy; atypical organisms; and cavernous sinus extension. In multivariate analyses, IST was associated with a 70% reduction in mortality at 1 month (p = 0.02)., Conclusion: We presented the largest series of AIFS. Further studies are needed to examine the importance of ANC in diagnosis and prognosis. Patients diagnosed with atypical organisms may be at higher risk of death. IST likely improves short-term survival, but prospective studies are needed., (© 2018 ARS-AAOA, LLC.)

Approximately 25-30% of patients with renal cell carcinoma (RCC) have metastatic disease at the time of diagnosis, where the most common sites of metastasis are the lung (50-60% of patients with metastatic disease), bones (30-40%), liver (30-40%), and brain (5%). Although RCC metastasis to the small intestine is thought to be exceedingly rare, with predominantly isolated case reports and a few case series in the literature, we present below three additional cases at our institution of metastatic RCC to the small bowel presenting as GI bleeding. A literature review demonstrates that the number of published case reports has been increasing in recent years. We hypothesize that in the era of targeted chemotherapy and VEGF inhibitors to treat RCC that patients are living longer and have more time for their primary tumors to metastasize to the small bowel and become symptomatic, causing metastatic RCC to the small bowel to be less rare than previously thought.

Background: Concerted management of the traumatic hemothorax is ill-defined. Surgical management of specific hemothoraces may be beneficial. A comprehensive strategy to delineate appropriate patients for additional procedures does not exist. We developed an evidence-based algorithm for hemothorax management. We hypothesize that the use of this algorithm will decrease additional interventions., Methods: A pre-/post-study was performed on all patients admitted to our trauma service with traumatic hemothorax from August 2010 to September 2013. An evidence-based management algorithm was initiated for the management of retained hemothoraces. Patients with length of stay (LOS) less than 24 hours or admitted during an implementation phase were excluded. Study data included age, Injury Severity Score, Abbreviated Injury Scale chest, mechanism of injury, ventilator days, intensive care unit (ICU) LOS, total hospital LOS, and interventions required. Our primary outcome was number of patients requiring more than 1 intervention. Secondary outcomes were empyema rate, number of patients requiring specific additional interventions, 28-day ventilator-free days, 28-day ICU-free days, hospital LOS, all-cause 6-month readmission rate. Standard statistical analysis was performed for all data., Results: Six hundred forty-two patients (326 pre and 316 post) met the study criteria. There were no demographic differences in either group. The number of patients requiring more than 1 intervention was significantly reduced (49 pre vs. 28 post, p = 0.02). Number of patients requiring VATS decreased (27 pre vs. 10 post, p < 0.01). Number of catheters placed by interventional radiology increased (2 pre vs. 10 post, p = 0.02). Intrapleural thrombolytic use, open thoracotomy, empyema, and 6-month readmission rates were unchanged. The "post" group more ventilator-free days (median, 23.9 vs. 22.5, p = 0.04), but ICU and hospital LOS were unchanged., Conclusion: Using an evidence-based hemothorax algorithm reduced the number of patients requiring additional interventions without increasing complication rates. Defined criteria for surgical intervention allows for more appropriate utilization of resources., Level of Evidence: Therapeutic study, level IV.

In this Letter, the tensorial nature of the nonequilibrium dynamics in nonlinear mesoscopic elastic materials is evidenced via multimode resonance experiments. In these experiments the dynamic response, including the spatial variations of velocities and strains, is carefully monitored while the sample is vibrated in a purely longitudinal or a purely torsional mode. By analogy with the fact that such experiments can decouple the elements of the linear elastic tensor, we demonstrate that the parameters quantifying the nonequilibrium dynamics of the material differ substantially for a compressional wave and for a shear wave. This result could lead to further understanding of the nonlinear mechanical phenomena that arise in natural systems as well as to the design and engineering of nonlinear acoustic metamaterials.

This paper introduces a unifying theory for describing complex behavior for porous materials. The key ingredients are the stored energy in solid-fluid interaction as well as the solid-solid and fluid-fluid interactions. A finite element formulation is employed which naturally accounts for the pore-pore network effects and is easily applicable to most pore geometries such as cellular solids and foams. The interactions, built in at the finite element level, give rise to the mechanical response of the macroscopic material unit. Through numerical studies, we show that there is strong coupling between fluid and solid that induces complex mechanical response, i.e., hysteresis and anisotropy. It is demonstrated that hysteresis arises directly from the fluid-solid coupling. We term this type of hysteresis emergent hysteresis.

PAR3 suppresses tumor growth and metastasis in vivo and cell invasion through matrix in vitro. We propose that PAR3 organizes and limits multiple signaling pathways and that inappropriate activation of these pathways occurs without PAR3. Silencing Pard3 in conjunction with oncogenic activation promotes invasion and metastasis via constitutive STAT3 activity in mouse models, but the mechanism for this is unknown. We now show that loss of PAR3 triggers increased production of interleukin-6, which induces STAT3 signaling in an autocrine manner. Activation of atypical protein kinase C ι/λ (aPKCι/λ) mediates this effect by stimulating NF-κB signaling and IL-6 expression. Our results suggest that PAR3 restrains aPKCι/λ activity and thus prevents aPKCι/λ from activating an oncogenic signaling network., (© 2015 by The American Society for Biochemistry and Molecular Biology, Inc.)

Cerebrospinal fluid (CSF) leak is one of several complications that can occur after traumatic skull base injury. Although most patients present soon after the injury occurs, some can present years later, with resulting morbidity and the need for additional procedures. We present a case of a patient with a sphenoid sinus CSF leak who presented 12 years after a closed head injury that included a sphenoethmoid skull base fracture. We also reviewed the literature on this topic, with a discussion of previous reports of CSF leaks that occurred months, years, or decades after trauma. A late onset CSF leak appears to be a rare but important complication of traumatic skull base injury. This case highlights the need for clinicians to remain vigilant to the possibility of delayed CSF rhinorrhea, even years after traumatic head injury.

This paper reports results of a three-dimensional discrete element method modeling investigation of the role of boundary vibration in perturbing stick-slip dynamics in a sheared granular layer. The focus is on the influence of vibration within a range of amplitudes and on the fact that above a threshold early slip will be induced. We study the effects of triggering beyond the vibration interval and their origins. A series of perturbed simulations are performed for 30 large slip events selected from different reference runs, in the absence of vibration. For each of the perturbed simulations, vibration is applied either about the middle of the stick phase or slightly before the onset of a large expected slip event. For both cases, a suppression of energy release is on average observed in the perturbed simulations, within the short term following the vibration application. For cases where vibration is applied in the middle of the stick phase, a significant clock advance of the large slip event occurs. In the long term after vibration, there is a recovery period with higher-energy release and increased activity in the perturbed simulations, which compensates for the temporary suppression observed within the short term.

We perform a systematic statistical investigation of the effect of harmonic boundary vibrations on a sheared granular layer undergoing repetitive, fully dynamic stick-slip motion. The investigation is performed using two-dimensional discrete element method simulations. The main objective consists of improving the understanding of dynamic triggering of slip events in the granular layer. Here we focus on how the vibration amplitude affects the statistical properties of the triggered slip events. The results provide insight into the granular physical controls of dynamic triggering of failure in sheared granular layers.

Background: Medicaid and uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes after coronary artery bypass grafting (CABG) in the United States is dependent on primary payer status., Methods and Results: From 2003 to 2007, 1,250,619 isolated CABG operations were evaluated using the Nationwide Inpatient Sample (NIS) database. Patients were stratified by primary payer status: Medicare, Medicaid, uninsured, and private insurance. Hierarchical multiple regression models were applied to assess the effect of primary payer status on postoperative outcomes. Unadjusted mortality for Medicare (3.3%), Medicaid (2.4%), and uninsured (1.9%) patients were higher compared with private insurance patients (1.1%, P<0.001). Unadjusted length of stay was longest for Medicaid patients (10.9 ± 0.04 days) and shortest for private insurance patients (8.0 ± 0.01 days, P<0.001). Medicaid patients accrued the highest unadjusted total costs ($113 380 ± 386, P<0.001). Importantly, after controlling for patient risk factors, income, hospital features, and operative volume, Medicaid (odds ratio, 1.82; P<0.001) and uninsured (odds ratio, 1.62; P<0.001) payer status independently conferred the highest adjusted odds of in-hospital mortality. In addition, Medicaid payer status was associated with the longest adjusted length of stay and highest adjusted total costs (P<0.001)., Conclusions: Medicaid and uninsured payer status confers increased risk adjusted in-hospital mortality for patients undergoing coronary artery bypass grafting operations. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors. Possible explanations include delays in access to care or disparate differences in health maintenance.

A nonlinear scatterer is simulated in the body of a sample and demonstrates a technique to locate and define the elastic nature of the scatterer. Using the principle of time reversal, elastic wave energy is focused at the interface between blocks of optical grade glass and aluminum. Focusing of energy at the interface creates nonlinear wave scattering that can be detected on the sample perimeter with time-reversal mirror elements. The nonlinearly generated scattered signal is bandpass filtered about the nonlinearly generated components, time reversed and broadcast from the same mirror elements, and the signal is focused at the scattering location on the interface., (© 2011 Acoustical Society of America)

The behavior of hysteretic, coupled elastic and fluid systems is modeled. The emphasis is on quasistatic equilibrium in response to prescribed chemical potential (μ) protocols and prescribed stress (σ) protocols. Hysteresis arises in these models either from the presence of hysterons or from the presence of self-trapping internal fields. This latter mechanism is modeled in finite element calculations which serve to illustrate the creation of hysteresis in a range of circumstances that go from conventionally hysteretic systems, a sandstone, to systems like a wood fiber. An essential ingredient in the behavior of these systems, the interaction between the mechanical variables and the fluid variables, is accorded special attention. The proper venue for the exploration of these systems is (μ,σ) space and appropriate μ protocols, σ protocols, and combined μ-σ protocols.

Rationale and Objectives: Estimation of regional lung function parameters from hyperpolarized gas magnetic resonance images can be very sensitive to presence of noise. Clustering pixels and averaging over the resulting groups is an effective method for reducing the effects of noise in these images, commonly performed by grouping proximal pixels together, thus creating large groups called "bins." This method has several drawbacks, primarily that it can group dissimilar pixels together, and it degrades spatial resolution. This study presents an improved approach to simplifying data via principal component analysis (PCA) when noise level prohibits a pixel-by-pixel treatment of data, by clustering them based on similarity to one another rather than spatial proximity. The application to this technique is demonstrated in measurements of regional lung oxygen tension using hyperpolarized (3)He magnetic resonance imaging (MRI)., Materials and Methods: A synthetic dataset was generated from an experimental set of oxygen tension measurements by treating the experimentally derived parameters as "true" values, and then solving backwards to generate "noiseless" images. Artificial noise was added to the synthetic data, and both traditional binning and PCA-based clustering were performed. For both methods, the root-mean-square (RMS) error between each pixel's "estimated" and "true" parameters was computed and the resulting effects were compared., Results: At high signal-to-noise ratios (SNRs), clustering did not enhance accuracy. Clustering did, however, improve parameter estimations for moderate SNR values (below 100). For SNR values between 100 and 20, the PCA-based K-means clustering analysis yielded greater accuracy than Cartesian binning. In extreme cases (SNR<5), Cartesian binning can be more accurate., Conclusions: The reliability of parameters estimation in imaging-based regional functional measurements can be improved in the presence of noise by utilizing principal component analysis-based clustering without sacrificing spatial resolution compared to Cartesian binning. Results suggest that this approach has a great potential for robust grouping of pixels in hyperpolarized (3)He MRI maps of lung oxygen tension.

Early changes of lung function and structure were studied in the presence of an elastase-induced model of emphysema in 35 Sprague-Dawley rats at mild (5 U/100 g) and moderate (10 U/100 g) severities. Lung ventilation was measured on a regional basis (at a planar resolution of 3.2 mm) by hyperpolarized 3He MRI at 5 and 10 wk after model induction. Subsequent to imaging, average alveolar diameter was measured from histological slices taken from the centers of each lobe. Changes of mean fractional ventilation, mean linear intercept, and intrasubject heterogeneity of ventilation were studied during disease progression. Mean fractional ventilation was significantly different between healthy controls (0.23 +/- 0.04) and emphysematous animals at both time points in the 10-unit group (0.06 +/- 0.02 and 0.12 +/- 0.05, respectively). Changes in average alveolar diameter were not statistically observable until the 10th wk between healthy (37 +/- 10 microm) and emphysematous rats (73 +/- 25 and 95 +/- 31 microm, for 5 and 10 units, respectively). Assessment of function-structure correlation suggested that the majority of the decline in fractional ventilation occurred in the first 5 wk, while enlargement of alveolar diameters appeared primarily between the 5th and 10th wk. A thresholding metric, based on the 20th percentile of fractional ventilation over the entire lung, was utilized to detect the onset of the disease with confidence, independent of whether the regional ventilation measurements were normalized with respect to the delivered tidal volume and estimated functional residual capacity of each individual rat.

The dependence of hyperpolarized (HP) (3)He T(1) on local oxygen concentration provides the basis for measuring the partial pressure of oxygen (pO(2)) and oxygen depletion rate (R) in the lungs. Precise measurements of this type are difficult because the oxygen effect manifests itself through a decay of signal, leading to noisy images at the end of the series. The depolarization caused by RF excitation pulses further complicates the problem. It is therefore important to optimize scan parameters, such as measurement timing and flip angle, to obtain accurate and reproducible measurements. This work presents a new single-acquisition technique in conjunction with the multiple regression fitting method for data evaluation. Analytical expressions for the measurement uncertainties are derived. A total of four types of single-acquisition timing schemes are investigated; simulation shows a large uncertainty variation between these schemes (pO(2): 7.5-30.2%; R: 47.4-173.7%). A basic procedure for optimizing scan parameters is then described. A phantom experiment was conducted to verify the simulation results. Repeated in vivo measurements with the optimal scheme in a rabbit experiment showed that average variation of global mean is 6.2% for pO(2) and 12.0% for R, and that the average variation of percentiles (10th, 25th, 50th, 75th, and 90th) is 8.7% for pO(2) and 19.0% for R., (2007 Wiley-Liss, Inc)

This Letter reports on work performed to locate and interrogate a nonlinear scatterer in a linearly elastic medium through the use of a time reversal mirror in combination with nonlinear dynamics. Time reversal provides the means to spatially and temporally localize elastic energy on a scattering feature while the nonlinear dynamics spectrum allows one to determine whether the scatterer is nonlinear (e.g., mechanical damage). Here elastic waves are measured in a solid and processed to extract the nonlinear elastic response. The processed elastic signals are then time reversed, rebroadcast, and found to focus on the nonlinear scatterer, thus defining a time-reversed nonlinear elastic wave spectroscopy process. Additionally, the focusing process illuminates the complexity of the nonlinear scatterer in both space and time, providing a means to image and investigate the origins and physical mechanisms of the nonlinear elastic response.

Non-linear resonant ultrasound spectroscopy (NRUS) is a technique exploiting the significant non-linear behavior of damaged materials, related to the presence of damage. This study shows for the first time the feasibility of this technique for damage assessment in bone. Two samples of bovine cortical bone were subjected to a progressive damage experiment. Damage accumulation was progressively induced in the samples by mechanical testing. For independent assessment of damage, X-ray CT imaging was performed at each damage step, but only helped in the detection of the prominent cracks. Synchrotron micro-CT imaging and histology using epifluorescence microscopy were performed in one of the two samples at the last damage step and allowed detection of micro-cracks for this step. As the quantity of damage accumulation increased, NRUS revealed a corresponding increase in the non-linear response. The measured change in non-linear response is much more sensitive than the change in elastic modulus. The results suggest that NRUS could be a potential tool for micro-damage assessment in bone. Further work has to be carried out for a better understanding of the physical nature of damaged bone, and for the ultimate goal of in vivo implementation of the technique where bone access will be a challenging problem.

We studied the kinetics of sublimating crystals with single-particle resolution by experiments with colloidal spheres and by computer simulations. A short-range attraction between spheres led to crystallites one to three layers thick. The spheres were tracked with optical microscopy while the attraction was reduced and the crystals sublimated. Large crystallites sublimated by escape of particles from the perimeter. The rate of shrinkage was greatly enhanced, however, when the size decreased to less than 20 to 50 particles, depending on the location in the phase diagram. At this size, the crystallites transformed into a dense amorphous structure, which rapidly vaporized. The enhancement of kinetics by metastable or unstable phases may play a major role in the melting, freezing, and annealing of crystals.

Resonant ultrasound spectroscopy (RUS) is a method whereby the elastic tensor of a sample is extracted from a set of measured resonance frequencies. RUS has been used successfully to determine the elastic properties of single crystals and homogeneous samples. In this paper, we study the application of RUS to macroscopic samples of mesoscopically inhomogeneous materials, specifically rock. Particular attention is paid to five issues: the scale of mesoscopic inhomogeneity, imprecision in the figure of the sample, the effects of low Q, optimizing the data sets to extract the elastic tensor reliably, and sensitivity to anisotropy. Using modeling and empirical testing, we find that many of the difficulties associated with using RUS on mesoscopically inhomogeneous materials can be mitigated through the judicious choice of sample size and sample aspect ratio.

Experimental properties of a new form of creep dynamics are reported, as manifest in a variety of sandstones, limestone, and concrete. The creep is a recovery behavior, following the sharp drop in elastic modulus induced either by nonlinear acoustic straining or rapid temperature change. The extent of modulus recovery is universally proportional to the logarithm of the time after source discontinuation in all samples studied, over a scaling regime covering at least 10(3) s. Comparison of acoustically and thermally induced creep suggests a single origin based on internal strain, which breaks the symmetry of the inducing source.