Development of the diaphragm -- a skeletal muscle essential for mammalian respiration

Impact of fetal treatments for congenital diaphragmatic hernia on lung development

The extent of lung hypoplasia impacts the survival and severity of morbidities associated with congenital diaphragmatic hernia (CDH). The alveoli of CDH infants and in experimental models of CDH have thickened septa with fewer type II pneumocytes and capillaries. Fetal treatments of CDH-risk preterm birth. Therefore, treatments must aim to balance the need for increased gas exchange surface area with the restoration of pulmonary epithelial type II cells and the long-term respiratory and neurodevelopmental consequences of prematurity. Achievement of sufficient lung development in utero for successful postnatal transition requires adequate intra-thoracic space for lung growth, maintenance of sufficient volume and appropriate composition of fetal lung fluid, regular fetal breathing movements, appropriate gas exchange area, and ample surfactant production. The review aims to examine the rationale for current and future therapeutic strategies to improve postnatal outcomes of infants with CDH.

Nanoscale Resolution Imaging of Whole Mouse Embryos Using Expansion Microscopy

Nanoscale imaging of whole vertebrates is essential for the systematic understanding of human diseases, yet this goal has not yet been achieved. Expansion microscopy (ExM) is an attractive option for accomplishing this aim; however, the expansion of even mouse embryos at mid- and late-developmental stages, which have fewer calcified body parts than adult mice, is yet to be demonstrated due to the challenges of expanding calcified tissues. Here, we introduce a state-of-the-art ExM technique, termed whole-body ExM, that utilizes cyclic digestion. This technique allows for the super-resolution, volumetric imaging of anatomical structures, proteins, and endogenous fluorescent proteins (FPs) within embryonic and neonatal mice by expanding them 4-fold. The key feature of whole-body ExM is the alternating application of two enzyme compositions repeated multiple times. Through the simple repetition of this digestion process with an increasing number of cycles, mouse embryos of various stages up to E18.5, and even neonatal mice, which display a dramatic difference in the content of calcified tissues compared to embryos, are expanded without further laborious optimization. Furthermore, the whole-body ExM's ability to retain FP signals allows the visualization of various neuronal structures in transgenic mice. Whole-body ExM could facilitate studies of molecular changes in various vertebrates.

Ageing impairs endothelium-dependent vasodilatation and alters redox signalling in diaphragm arterioles from male and female Fischer-344 rats

Diaphragm hyperaemia and regional blood flow distribution are impaired with ageing, potentially consequent to altered vascular structure and/or diminished vasomotor function. Evidence from locomotory skeletal muscle suggests that age-related diaphragm vasomotor dysfunction may be related to a blunted endothelium-mediated vasodilatation, decreased nitric oxide (NO) bioavailability and/or augmented reactive oxygen species (ROS) generation. We hypothesized that, in the medial costal diaphragm with old age, there would be fewer feed arteries (FAs) and impaired vasomotor function, via endothelium-specific mechanisms, in first-order (1A) arterioles. In young (Y) and old (O) Fischer-344 rats, the number of medial costal diaphragm FAs was quantified. 1A arterioles (117-220 µm) were isolated, cannulated and pressurized via hydrostatic reservoirs. Thereafter endothelium-dependent (via ACh) vasodilatory responses were assessed. In a separate set of arterioles, ACh-mediated dilatation was assessed before and after treatment with the superoxide dismutase mimetic Tempol (100 µm) and Tempol plus the hydrogen peroxide (H2O2) scavenger catalase (100 U/ml). The average number of medial costal FAs was lower in the rat diaphragm with old age (p = 0.001). Endothelium- and nitric oxide synthase (NOS)-dependent vasodilatation was 21% lower in medial costal 1A arterioles from O rats (p < 0.001). Tempol decreased ACh-mediated vasodilatation of medial costal 1A arterioles from Y and O rats but did not eliminate age-related differences. Tempol plus catalase further decreased ACh-mediated vasodilatation in O but not Y vessels. In the medial costal diaphragm vasculature, ageing is associated with (1) arterial rarefaction, (2) impaired endothelium-dependent vasodilatation via NOS- and ROS-dependent mechanisms and (3) increased reliance on ROS-mediated vasodilatation. KEY POINTS: Old age blunts the hyperaemic response and alters regional blood flow distribution in the diaphragm. The effect of ageing on vascular structure and function in respiratory skeletal muscle is unknown. In young and old Fischer-344 rats of both sexes, we quantified the number of feed arteries (FAs) and assessed the vasoreactivity of first-order (1A) arterioles in the medial costal diaphragm. The number of medial costal diaphragm FAs was lower in old rats. In 1A arterioles endothelium-dependent vasodilatation was blunted, and reactive oxygen species (ROS)-mediated vasodilatory signalling was greater in old rats. We found no evidence of sex differences in diaphragm macrovascular structure, endothelial function or ROS-mediated signalling in young or old rats. Our findings in the diaphragm vasculature with ageing provide a mechanistic basis for the age-related deficits in diaphragm blood flow capacity. Therapeutic interventions targeting the diaphragm vasculature to improve perfusion and oxygen delivery may reduce the burden of age-related diaphragm dysfunction.

Mesenchymal retinoic acid signaling is required for normal diaphragm development in mice

Congenital diaphragmatic hernia (CDH) is characterized by incomplete formation of the diaphragm, causing herniation of the abdominal organs and subsequent lung hypoplasia; however, the etiology of CDH is poorly understood. The Retinoid Hypothesis posits that abnormal retinoic acid signaling leads to the formation of diaphragmatic hernias. Our goal is to better understand diaphragm development and the etiology of CDH. To achieve this goal, we first performed single-cell RNA sequencing analysis of the developing diaphragm, then generated a conditional retinoic acid receptor dominant negative knock-in to inhibit retinoic acid signaling in the mesenchyme of the developing diaphragm. Our single-cell RNA sequencing analysis revealed 10 distinct cell populations in the developing diaphragm, with mesenchymal cells being the primary expresser of CDH and retinoic acid signaling-related genes. Transgenic inhibition of mesenchymal retinoic acid signaling in the developing diaphragm caused hernias in 100% of embryos, recapitulating the hallmarks of CDH. Overall, our studies show that retinoic acid signaling in the mesenchymal component of the diaphragm is required for normal diaphragm development.

A Simple, Low-Cost Implant for Reliable Diaphragm EMG Recordings in Awake, Behaving Rats

Breathing is a complex neuromuscular process vital to sustain life. In preclinical animal models, the study of respiratory motor control is primarily accomplished through neurophysiologic recordings and functional measurements of respiratory output. Neurophysiologic recordings that target neural or muscular output via direct nerve recordings or respiratory muscle electromyography (EMG) are commonly collected during anesthetized conditions. While offering tight control of experimental preparations, the use of anesthesia results in respiratory depression, may impact cardiovascular control, eliminates the potential to record volitional nonventilatory behaviors, and can limit translation. Since the diaphragm is a unique muscle which is rhythmically active and difficult to access, placing diaphragm EMGs to collect chronic recordings in awake animals is technically challenging. Here, we describe methods for fabricating and implanting indwelling diaphragm EMG electrodes to enable recordings from awake rodents for longitudinal studies. These electrodes are relatively easy and quick to produce (∼1 h), are affordable, and provide high-quality and reproducible diaphragm signals using a tethered system that allows animals to ad libitum behave. This system is also designed to work in conjunction with whole-body plethysmography to facilitate simultaneous recordings of diaphragm EMG and ventilation. We include detailed instructions and considerations for electrode fabrication and surgical implantation. We also provide a brief discussion on data acquisition, material considerations for implant fabrication, and the physiological implications of the diaphragm EMG signal.

A Case Series Focusing on Blunt Traumatic Diaphragm Injury at a Level 1 Trauma Center

Introduction: Detection of blunt traumatic diaphragm injury (TDI) can be challenging in the absence of surgical exploration. Our objective is to study the mechanisms of injury and detection modes for patients with blunt TDI. Methods: This is a single-center, retrospective review conducted in a level 1 trauma center from 2016 to 2023, inclusive. We identified seven patients with blunt TDI using the primary mechanisms and trauma type. Results: Out of seven patients, two were associated with motor vehicle collisions, four were pedestrians struck, and one fell down the stairs. The mean ISS was 48.4 (29-75). Of the seven patients with blunt TDI, four died in the trauma bay-two from traumatic arrest and two died spontaneously. Multiple rib fractures were one of the common injury patterns in six cases, whereas in the remaining case, blunt TDI was confirmed at laparotomy and repaired. One patient died two days after admission. Of the two patients who survived, one had a TDI identified during video-assisted thoracic surgery (VATS) for retained hemothorax, and one patient had a TDI repaired during emergent exploratory laparotomy for other injuries. In the remaining four patients, blunt TDI was confirmed based on their autopsy reports. Conclusions: Injuries in all seven cases were sustained with a high-energy injury mechanism. Multiple rib fractures were reported in six cases. Based on our findings, we recommend that clinicians maintain a high level of suspicion for blunt TDI in patients with thoracoabdominal trauma, especially in cases with rib fractures or high-impact trauma.

Dynamics of hiatal hernia recurrence: how important is a composite crural repair?

INTRODUCTION

Hiatal hernia recurrence rates vary widely. The true causes of recurrences are not fully understood but likely multifactorial. Surgical approaches and techniques have evolved over time to try and reduce recurrence rates after hiatal hernia repair. Our objective is to provide a current review on the physiology of hiatal hernias and the importance of a composite crural repair on hiatal hernia recurrence rates; more specifically, for this review, a composite repair is defined as a repair requiring more than primary closure of the crura.

METHODS

A recent review of the literature was conducted to identify studies reporting on hiatal hernia pathophysiology, stress, and tension, as well as the role of composite repair.

RESULTS

There is a paucity of studies focusing on the pathophysiology of hiatal hernias and recurrence rates. Articles that report on the pathophysiology of the hiatus were found to have alterations of the extracellular matrix, collagen composition, changes in metalloproteinases (MMPs), and differences in genetic composition. The role of composite repair on reducing recurrence rates is not well studied.

CONCLUSIONS

Hiatal hernias remain a complex problem with no ideal surgical technique. It is likely that the pathophysiology of hiatal hernias is multifactorial, and more studies need to be done to better understand the potential underlying mechanisms for hiatal hernias so this may also further identify the ideal surgical repair.

Mini Self-Retrieval Practices of Skeletal Muscles in the Human Gross Anatomy Course

Students in health professional studies are often faced with the daunting task of memorizing large volumes of information in a limited time. Gross anatomy is usually the first course students may take in their curriculum, and the volume and complexity of anatomical information students must memorize, including muscle names, become overwhelming. Here, we outline a teaching method and pedagogical application of self-retrieval in gross anatomy courses, where students were provided with a number system that served as goals and cues for easy retrieval of muscle names for different anatomical regions.

Effects of aging on diaphragm hyperemia and blood flow distribution in male and female Fischer 344 rats

Aging is associated with inspiratory muscle dysfunction; however, the impact of aging on diaphragm blood flow (BF) regulation, and whether sex differences exist, is unknown. We tested the hypotheses in young animals that diaphragm BF and vascular conductance (VC) would be greater in females and that aging would decrease the diaphragm's ability to increase BF with contractions. Young (4-6 mo) and old (22-24 mo) Fischer 344 rats were divided into four groups: young female (YF, n = 7), young male (YM, n = 8), old female (OF, n = 9), and old male (OM, n = 9). Diaphragm BF (mL/min/100 g) and VC (mL/mmHg/min/100 g) were determined, via fluorescent microspheres, at rest and during 1 Hz contractions. In YF versus OF, aging blunted the increase in medial costal diaphragm BF (44 ± 5% vs. 16 ± 12%; P < 0.05) and VC (43 ± 7% vs. 21 ± 12%; P < 0.05). Similarly, in YM versus OM, aging blunted the increase in medial costal diaphragm BF (43 ± 6% vs. 24 ± 12%; P < 0.05) and VC (50 ± 6% vs. 34 ± 10%; P < 0.05). In female rats, age increased dorsal costal diaphragm BF, whereas in male rats, age increased crural diaphragm BF (P < 0.05). Compared with age-matched females, dorsal costal diaphragm BF was lower in YM and OM (P < 0.05). In conclusion, aging results in an inability to augment medial costal diaphragm BF and alters regional diaphragm BF distribution in response to muscular contractions. Furthermore, sex differences in regional diaphragm BF are present in young and old animals.NEW & NOTEWORTHY This is the first study, to our knowledge, to demonstrate that old age impairs the hyperemic response and alters blood flow distribution in the diaphragm of both female and male rats. In addition, this investigation provides novel evidence of sex differences in regional diaphragm blood flow distribution with contractions. The data presented herein suggest that aging compromises diaphragm vascular function and provides a potential mechanism for the diaphragm contractile dysfunction associated with old age.

Cellular origins and translational approaches to congenital diaphragmatic hernia

Congenital Diaphragmatic Hernia (CDH) is a complex developmental abnormality characterized by abnormal lung development, a diaphragmatic defect and cardiac dysfunction. Despite significant advances in management of CDH, mortality and morbidity continue to be driven by pulmonary hypoplasia, pulmonary hypertension, and cardiac dysfunction. The etiology of CDH remains unknown, but CDH is presumed to be caused by a combination of genetic susceptibility and external/environmental factors. Current research employs multi-omics technologies to investigate the molecular profile and pathways inherent to CDH. The aim is to discover the underlying pathogenesis, new biomarkers and ultimately novel therapeutic targets. Stem cells and their cargo, non-coding RNAs and agents targeting inflammation and vascular remodeling have produced promising results in preclinical studies using animal models of CDH. Shortcomings in current therapies combined with an improved understanding of the pathogenesis in CDH have given rise to novel promising experimental treatments that are currently being evaluated in clinical trials. This review provides insight into current developments in translational research, ranging from the cellular origins of abnormal cardiopulmonary development in CDH and the identification of novel treatment targets in preclinical CDH models at the bench and their translation to clinical trials at the bedside.

Morphological comparative study of canine and feline diaphragms: Effect of bodyweight, body condition score, gender, age and breed

The canine diaphragm is a muscular and tendinous dome-like plate and is largely involved in digestive and respiratory functions. Very few studies compared morphology of the diaphragm between dogs and cats and no studies have investigated the effects of individual factors on this morphology. So the aim of this study was to (1) study the effects of individual factors on the morphology of the diaphragm and (2) to compare its morphology between cats and dogs. Surface measurements of 86 diaphragms were performed. The tendinous centre (TC), the lumbar part of the peripheral muscular (LP) and the sternal and costal parts of the peripheral muscular (SCPM) were measured. Measurement ratios (surface of anatomical part of the diaphragm/total surface of the diaphragm) were used for statistical analysis (TC%S, LP%S, SCPM%S). The SCPM%S are significantly lower, and the LP%S are significantly higher when bodyweight increases in dogs and cats. The TC%S are significantly lower when the body condition score of dogs increases. The SCPM%S are significantly higher, and therefore, the TC%S and LP%S lower in brachycephalic animals as opposed to mesocephalic animals. The TC%S are significantly higher in dogs than in cats and the SCPM%S are significantly higher in cats than in dogs. This study proposed a cartography of the diaphragm morphology in cats and dogs taking into account individual animal factors. Significant differences in the diaphragm morphology between cats and dogs and between mesocephalic and brachycephalic animals were found. Further studies are necessary to confirm these results and to investigate the consequences of these variations.

Insights and perspectives on the enigmatic alary muscles of arthropods

Three types of muscles, cardiac, smooth and skeletal muscles are classically distinguished in eubilaterian animals. The skeletal, striated muscles are innervated multinucleated syncytia, which, together with bones and tendons, carry out voluntary and reflex body movements. Alary muscles (AMs) are another type of striated syncytial muscles, which connect the exoskeleton to the heart in adult arthropods and were proposed to control hemolymph flux. Developmental studies in Drosophila showed that larval AMs are specified in embryos under control of conserved myogenic transcription factors and interact with excretory, respiratory and hematopoietic tissues in addition to the heart. They also revealed the existence of thoracic AMs (TARMs) connecting to specific gut regions. Their asymmetric attachment sites, deformation properties in crawling larvae and ablation-induced phenotypes, suggest that AMs and TARMs could play both architectural and signalling functions. During metamorphosis, and heart remodelling, some AMs trans-differentiate into another type of muscles. Remaining critical questions include the enigmatic modes and roles of AM innervation, mechanical properties of AMs and TARMS and their evolutionary origin. The purpose of this review is to consolidate facts and hypotheses surrounding AMs/TARMs and underscore the need for further detailed investigation into these atypical muscles.

Morgagni Hernia: A Rare Presentation in a Young Adult

Morgagni hernia is the rarest diaphragmatic hernia, occurring in only about 2% of all cases. Despite its infrequent presentation, it poses significant morbidity once the diagnosis is missed. We present a rare case of a young adult female with no predisposing factors who experienced dyspnea and retrosternal pain with unremarkable clinical findings. A posteroanterior view of the chest roentgenogram revealed a nonspecific triangular opacity at the right cardiophrenic angle. A computed tomography (CT) scan of the thorax confirmed the suspicion of a right anteromedial diaphragmatic defect with omental herniation. Exploratory laparoscopic primary repair of the hernia orifice was performed with non-absorbable sutures. CT helps in confirming the condition, and surgical repair is recommended. Morgagni hernia can present as asymptomatic or with respiratory symptoms. There is no consensus on the type of approach, but a minimally invasive approach is being preferred even in asymptomatic cases.

PLS3 missense variants affecting the actin-binding domains cause X-linked congenital diaphragmatic hernia and body-wall defects

Congenital diaphragmatic hernia (CDH) is a relatively common and genetically heterogeneous structural birth defect associated with high mortality and morbidity. We describe eight unrelated families with an X-linked condition characterized by diaphragm defects, variable anterior body-wall anomalies, and/or facial dysmorphism. Using linkage analysis and exome or genome sequencing, we found that missense variants in plastin 3 (PLS3), a gene encoding an actin bundling protein, co-segregate with disease in all families. Loss-of-function variants in PLS3 have been previously associated with X-linked osteoporosis (MIM: 300910), so we used in silico protein modeling and a mouse model to address these seemingly disparate clinical phenotypes. The missense variants in individuals with CDH are located within the actin-binding domains of the protein but are not predicted to affect protein structure, whereas the variants in individuals with osteoporosis are predicted to result in loss of function. A mouse knockin model of a variant identified in one of the CDH-affected families, c.1497G>C (p.Trp499Cys), shows partial perinatal lethality and recapitulates the key findings of the human phenotype, including diaphragm and abdominal-wall defects. Both the mouse model and one adult human male with a CDH-associated PLS3 variant were observed to have increased rather than decreased bone mineral density. Together, these clinical and functional data in humans and mice reveal that specific missense variants affecting the actin-binding domains of PLS3 might have a gain-of-function effect and cause a Mendelian congenital disorder.

Embryological, anatomical and clinical considerations on pleuroperitoneal communication

The pleural and peritoneal cavity share many related features due to their common celomic origin. Normally these two spaces are completely separated with the development of the diaphragm. Defects in diaphragm morphogenesis may result in congenital diaphragmatic hernias, which is the most known form of communication between the pleural and peritoneal cavity. However, in several cases, findings of pleuroperitoneal communication (PPC) have been described in adults through an apparently intact diaphragm. In this comprehensive review we systematically evaluate clinical scenarios of this form of "unexpected" PPC as reported in the literature and focus on the possible mechanisms involved.

Lung fusion with the liver in chick and quail embryos

Even in mammals with the diaphragm, the lung and liver are likely to attach mutually without separation by any structure in embryos. The aim of this study was to examine whether or not the lung attaches to the liver in embryonic development of birds without diaphragm. First, we ensured the topographical relation between the lung and liver in 12 human embryos at 5 weeks. After the serosal mesothelium was established, the human lung sometimes (3 embryos) attached tightly to the liver without interruption by the developing diaphragm in the pleuroperitoneal fold. Second, we observed the lung-liver interface in chick and quail embryos. At 3-5 days' incubation (stages 20-27), the lung and liver were fused at bilateral narrow areas just above the muscular stomach. Therein, mesenchymal cells, possibly derived from the transverse septum, were intermingled between the lung and liver. The interface tended to be larger in the quail than the chick. At and until 7 days' incubation, the fusion of the lung and liver disappeared and, instead, a membrane connected them bilaterally. The right membrane extended caudally to attach to the mesonephros and caudal vena cava. At 12 days' incubation, bilateral thick folds, containing the abdominal air sac and pleuroperitoneal muscle (striated muscle), separated the dorsally located lung from the liver. Therefore, the lung-liver fusion occurred transiently in birds. Rather than the presence of the muscular diaphragm, whether the lung and liver were fused seemed to depend on a timing and sequence of development of the mesothelial coverings of these viscera.

Mechanics of Lung Development

We summarize how skeletal muscle and lung developmental biology fields have been bridged to benefit from mouse genetic engineering technologies and to explore the role of fetal breathing-like movements (FBMs) in lung development, by using skeletal muscle-specific mutant mice. It has been known for a long time that FBMs are essential for the lung to develop properly. However, the cellular and molecular mechanisms transducing the mechanical forces of muscular activity into specific genetic programs that propel lung morphogenesis (development of the shape, form and size of the lung, its airways, and gas exchange surface) as well as its differentiation (acquisition of specialized cell structural and functional features from their progenitor cells) are only starting to be revealed. This chapter is a brief synopsis of the cumulative findings from that ongoing quest. An update on and the rationale for our recent International Mouse Phenotyping Consortium (IMPC) search is also provided.

Congenital Hepatopulmonary Fusion

Congenital hepatopulmonary fusion (HPF) is a rare anomaly characterized by a fusion between the liver and lung parenchyma. HPF cases have been scarcely reported in the literature. An extensive search of publications was performed in the PubMed and Google Scholar databases without a time limit. In total, 34 clinical case reports were found in the literature, and a study by the Congenital Diaphragmatic Hernia (CDH) Study Group reported data on 10 patients with HPF. Of these 44 infants, 20 were male, 20 were female, and four were reported without gender specification. Nineteen (43.2%) patients required intubation on the first day of life. Six (13.6%) patients had their clinical presentation during the first year of life, and four (9%) clinically presented with HPF between 2.5 and 11 years of age. In these patients, cough, asthma-like symptoms, dyspnea, hemoptysis, right-side chest pain, respiratory infections, and pneumonia were the relevant clinical signs. Right-lung vascular anomalies were present in 18 (40.9%) patients. A complete liver and lung separation was successful in 17 (38.6%) patients. The overall survival was 56.8%. Congenital HPF has no gender predominance. In most cases, it behaves similar to a right CDH in need of resuscitation and intubation after birth. The majority of the cases are discovered during the surgical procedure for CDH. The best surgical approach has not been established and depends on the degree of fusion and vascular anomalies. An advanced imaging assessment is necessary before a surgical approach is attempted. The prognosis is ominous.

The role of genes and environment in the etiology of congenital diaphragmatic hernias

Structural birth defects are a common cause of abnormalities in newborns. While there are cases of structural birth defects arising due to monogenic defects or environmental exposures, many birth defects are likely caused by a complex interaction between genes and the environment. A structural birth defect with complex etiology is congenital diaphragmatic hernias (CDH), a common and often lethal disruption in diaphragm development. Mutations in more than 150 genes have been implicated in CDH pathogenesis. Although there is generally less evidence for a role for environmental factors in the etiology of CDH, deficiencies in maternal vitamin A and its derivative embryonic retinoic acid are strongly associated with CDH. However, the incomplete penetrance of CDH-implicated genes and environmental factors such as vitamin A deficiency suggest that interactions between genes and environment may be necessary to cause CDH. In this review, we examine the genetic and environmental factors implicated in diaphragm and CDH development. In addition, we evaluate the potential for gene-environment interactions in CDH etiology, focusing on the potential interactions between the CDH-implicated gene, Gata4, and maternal vitamin A deficiency.

Fibroblast-derived Hgf controls recruitment and expansion of muscle during morphogenesis of the mammalian diaphragm

The diaphragm is a domed muscle between the thorax and abdomen essential for breathing in mammals. Diaphragm development requires the coordinated development of muscle, connective tissue, and nerve, which are derived from different embryonic sources. Defects in diaphragm development cause the common and often lethal birth defect, congenital diaphragmatic hernias (CDH). HGF/MET signaling is required for diaphragm muscularization, but the source of HGF and the specific functions of this pathway in muscle progenitors and effects on phrenic nerve have not been explicitly tested. Using conditional mutagenesis in mice and pharmacological inhibition of MET, we demonstrate that the pleuroperitoneal folds (PPFs), transient embryonic structures that give rise to the connective tissue in the diaphragm, are the source of HGF critical for diaphragm muscularization. PPF-derived HGF is directly required for recruitment of MET+ muscle progenitors to the diaphragm and indirectly (via its effect on muscle development) required for phrenic nerve primary branching. In addition, HGF is continuously required for maintenance and motility of the pool of progenitors to enable full muscularization. Localization of HGF at the diaphragm's leading edges directs dorsal and ventral expansion of muscle and regulates its overall size and shape. Surprisingly, large muscleless regions in HGF and Met mutants do not lead to hernias. While these regions are likely more susceptible to CDH, muscle loss is not sufficient to cause CDH.

Intra-abdominal ectopic bronchogenic cyst with a mucinous neoplasm harboring a GNAS mutation: A case report

BACKGROUND

Bronchogenic cysts are congenital cysts caused by abnormal sprouting from the ventral foregut during fetal life. They usually occur in the mediastinum or lung, but there are very rare cases of ectopic bronchogenic cysts that develop in the abdominal cavity. A unique intra-abdominal ectopic bronchogenic cyst with a mucinous neoplasm that was producing carcinoembryonic antigen (CEA), harboring a GNAS mutation, is reported. The present case may contribute to clarifying the mechanism of tumorigenesis and malignant transformation of ectopic bronchogenic cysts.

CASE SUMMARY

In 2007, a man in his 50s was incidentally found to have an intra-abdominal cystic mass, 8 cm in diameter. Surgical resection was recommended, but he preferred to remain under observation. In 2020, his serum CEA level increased to 26.7 ng/mL, and abdominal computed tomography showed a 15 cm × 12 cm, multifocal, cystic mass located predominantly on the lesser curvature of the stomach. Since malignancy could not be ruled out, he finally underwent surgical resection. Histologically, the cystic wall was lined by ciliated columnar epithelium, accompanied by bronchial gland-like tissue, bronchial cartilage, and smooth muscle. Part of the cyst consisted of atypical columnar epithelium with an MIB-1 index of 5% and positive for CEA. Moreover, a GNAS mutation (p.R201C) was detected in the atypical epithelium, leading to a diagnosis of an ectopic bronchogenic cyst with a low-grade mucinous neoplasm. The patient is currently undergoing outpatient follow-up without recurrence.

CONCLUSION

An extremely rare case of an abdominal bronchogenic cyst with a low-grade mucinous neoplasm harboring a GNAS mutation was reported.

VMP1 Regulated by chi-miR-124a Effects Goat Myoblast Proliferation, Autophagy, and Apoptosis through the PI3K/ULK1/mTOR Signaling Pathway

The production of goat meat is determined by the growth speed of muscle fibers, and the autophagy and apoptosis of myoblast cells is a crucial process in the growth of muscle fibers. The rapid growth of muscle fibers occurs from one month old to nine months old in goats; however, the mechanisms of myoblast cells’ autophagy and apoptosis in this process are still unknown. To identify candidate genes and signaling pathway mechanisms involved in myoblast apoptosis and autophagy, we compared the expression characteristics of longissimus dorsi tissues from Wu’an goats—a native goat breed of China—at 1 month old (mon1 group) and 9 months old (mon9 group). Herein, a total of 182 differentially expressed mRNAs (DEGs) in the mon1 vs. mon9 comparison, along with the KEGG enrichments, showed that the PI3K-Akt pathway associated with autophagy and apoptosis was significantly enriched. Among these DEGs, expression of vacuole membrane protein 1 (VMP1)—a key gene for the PI3K-Akt pathway—was significantly upregulated in the older goats relative to the 1-month-old goats. We demonstrated that VMP1 promotes the proliferation and autophagy of myoblasts, and inhibits their apoptosis. The integration analysis of miRNA–mRNA showed that miR-124a was a regulator of VMP1 in muscle tissue, and overexpression and inhibition of miR-124a suppressed the proliferation and autophagy of myoblasts. The PI3K/Akt/mTOR pathway was an important pathway for cell autophagy. Additionally, the activator of the PI3K/Akt/mTOR pathway, the expression of VMP1, and ULK1 were higher than the negative control, and the expression of mTOR was depressed. The expression of VMP1, ULK1, and mTOR was the opposite when the inhibitor was added to the myoblasts. These results show that the PI3K/Akt/mTOR pathway promoted the expression of VMP1 and ULK1. By using adenovirus-mediated apoptosis and proliferation assays, we found that that miR-124a inhibits myoblast proliferation and autophagy, and promotes their apoptosis by targeting VMP1. In conclusion, our results indicated that VMP1 was highly expressed in the LD muscle tissues of nine-month-old goats, and that it was regulated by miR-124a to inhibit myoblast cells’ apoptosis through the PI3K/Akt/mTOR pathway, and to promote proliferation and autophagy. These findings contribute to the understanding of the molecular mechanisms involved in myoblast proliferation, autophagy, and apoptosis.

Identification of enhancers responsible for the coordinated expression of myosin heavy chain isoforms in skeletal muscle

Background

Skeletal muscles consist of fibers of differing contractility and metabolic properties, which are primarily determined by the content of myosin heavy chain (MYH) isoforms (MYH7, MYH2, MYH1, and MYH4). The regulation of Myh genes transcription depends on three-dimensional chromatin conformation interaction, but the mechanistic details remain to be determined.

Results

In this study, we characterized the interaction profiles of Myh genes using 4C-seq (circular chromosome conformation capture coupled to high-throughput sequencing). The interaction profile of Myh genes changed between fast quadriceps and slow soleus muscles. Combining chromatin immunoprecipitation-sequencing (ChIP-seq) and transposase accessible chromatin with high-throughput sequencing (ATAC-seq), we found that a 38 kb intergenic region interacting simultaneously with fast Myh genes promoters controlled the coordinated expression of fast Myh genes. We also identified four active enhancers of Myh7, and revealed that binding of MYOG and MYOD increased the activity of Myh7 enhancers.

Conclusions

This study provides new insight into the chromatin interactions that regulate Myh genes expression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12864-022-08737-9.

Embryology of the Abdominal Wall and Associated Malformations—A Review

In humans, the incidence of congenital defects of the intraembryonic celom and its associated structures has increased over recent decades. Surgical treatment of abdominal and diaphragmatic malformations resulting in congenital hernia requires deep knowledge of ventral body closure and the separation of the primary body cavities during embryogenesis. The correct development of both structures requires the coordinated and fine-tuned synergy of different anlagen, including a set of molecules governing those processes. They have mainly been investigated in a range of vertebrate species (e.g., mouse, birds, and fish), but studies of embryogenesis in humans are rather rare because samples are seldom available. Therefore, we have to deal with a large body of conflicting data concerning the formation of the abdominal wall and the etiology of diaphragmatic defects. This review summarizes the current state of knowledge and focuses on the histological and molecular events leading to the establishment of the abdominal and thoracic cavities in several vertebrate species. In chronological order, we start with the onset of gastrulation, continue with the establishment of the three-dimensional body shape, and end with the partition of body cavities. We also discuss well-known human etiologies.

Regenerating dynamic organs using biomimetic patches

The regeneration of dynamic organs remains challenging because they are intrinsically anisotropic and undergo large volumetric deformation during normal or pathological function. This hampers the durability and applicability of regenerative medicine approaches. To address the challenges of organ dynamics, a new class of patches have emerged with anisotropic and auxetic properties that mimic native tissue biomechanics and accommodate volumetric deformation. Here, we outline the critical design, materials, and processing considerations for achieving optimal patch biomechanics according to target pathology and summarize recent advances in biomimetic patches for dynamic organ regeneration. Furthermore, we discuss the challenges and opportunities which, if overcome, would open up new applications in organ regeneration and expedite the clinical translation of patch-based therapeutics.

Physiological pulmonary assessments in the management of bilateral diaphragmatic eventration

Objectives

To describe the importance of comprehensive assessment to determine the underlying diagnosis and the role of physiological pulmonary measurements in the management of congenital bilateral eventration of the diaphragm.

Case presentation

A female infant born at 34 weeks gestation required intubation and ventilation at birth. Chest radiographical imaging revealed bilateral density to the bases of both lung fields with raised hemi-diaphragms. Ultrasound imaging showed focal diaphragmatic eventration with bulging of the dome of the liver into the right and left hemithoraces. Assessment of the electrical activity of the diaphragm during a spontaneous breathing trial demonstrated a mean amplitude consistent with that of ventilated infants of the same gestational age with intact diaphragms. Hence she was extubated which was successful. Chest radiographic thoracic area measured post extubation was 1,654 mm2, equivalent to that of a term infant with severe congenital diaphragmatic hernia. As the electrical activity of the diaphragm was normal this suggests replacement of the diaphragmatic muscle tissue with fibrous bands was likely to be only partial, and hence why extubation was successful. She had other abnormalities presenting in the neonatal period including dermal melancytosis, central hypotonia, hyperinsulinism and poor feeding. The infant underwent extensive investigation which revealed a KMT2D gene mutation associated with Kabuki syndrome.

Conclusions

Physiological pulmonary measurements may add clinical management in bilateratal diaphragmatic eventration.

Feasibility and Efficacy of Inspiratory Muscle Training in Patients with Head and Neck Cancer receiving Concurrent Chemoradiotherapy

OBJECTIVES

Patients with head and neck cancer (HNC) undergoing concurrent chemoradiotherapy (CCRT) often experience pulmonary symptoms. This study evaluated if a 7-week inspiratory muscle training (IMT) program during CCRT is feasible, adherent, and safe in patients with HNC. This study also evaluated the effect of IMT on diaphragm thickness, mobility, and cardiorespiratory parameters in patients with HNC receiving CCRT.

METHODS

Ten participants with advanced stage HNC receiving CCRT were recruited for the study. Feasibility, adherence, and safety of the intervention were the primary outcomes. Changes in diaphragm thickness and mobility, maximal inspiratory pressure, maximal expiratory pressure, forced vital capacity, forced expiratory volume in first second and functional capacity using 6-MWT were measured at baseline and post 7 weeks of CCRT. IMT was performed at one session per day for 5 days a week for 7 weeks. Eight sets of two minutes of inspiratory manoeuvres with one minute rest period between them with intensity of 40% MIP were given.

RESULTS

Ten participants  were included in this study out of the 13 patients screened, indicating the feasibility to be 76.9%. Participants completed a total of 260 training sessions out of the 350 planned sessions denoting the adherence level as 74%. Diaphragm thickness and MEP remained significantly unchanged while significant decline was seen in diaphragm mobility, MIP,FVC, FEV1 and 6-MWD at the end of 7 weeks. No adverse events were reported following the intervention.

CONCLUSION

Inspiratory muscle training did not show significant effect on the diaphragm thickness, mobility, and cardiorespiratory parameters; however, it was feasible, adherent, and safe in patients with HNC receiving CCRT.

Cellular Origin(s) of Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) is a structural birth defect characterized by a diaphragmatic defect, lung hypoplasia and structural vascular defects. In spite of recent developments, the pathogenesis of CDH is still poorly understood. CDH is a complex congenital disorder with multifactorial etiology consisting of genetic, cellular and mechanical factors. This review explores the cellular origin of CDH pathogenesis in the diaphragm and lungs and describes recent developments in basic and translational CDH research.

An infant with congenital respiratory insufficiency and diaphragmatic paralysis: A novel BICD2 phenotype?

Monoallelic pathogenic variants in BICD2 are associated with autosomal dominant Spinal Muscular Atrophy Lower Extremity Predominant 2A and 2B (SMALED2A, SMALED2B). As part of the cellular vesicular transport, complex BICD2 facilitates the flow of constitutive secretory cargoes from the trans-Golgi network, and its dysfunction results in motor neuron loss. The reported phenotypes among patients with SMALED2A and SMALED2B range from a congenital onset disorder of respiratory insufficiency, arthrogryposis, and proximal or distal limb weakness to an adult-onset disorder of limb weakness and contractures. We report an infant with congenital respiratory insufficiency requiring mechanical ventilation, congenital diaphragmatic paralysis, decreased lung volume, and single finger camptodactyly. The infant displayed appropriate antigravity limb movements but had radiological, electrophysiological, and histopathological evidence of myopathy. Exome sequencing and long-read whole-genome sequencing detected a novel de novo BICD2 variant (NM_001003800.1:c.[1543G>A];[=]). This is predicted to encode p.(Glu515Lys); p.Glu515 is located in the coiled-coil 2 mutation hotspot. We hypothesize that this novel phenotype of diaphragmatic paralysis without clear appendicular muscle weakness and contractures of large joints is a presentation of BICD2-related disease.

Whole-mount Staining of Mouse Diaphragm Neuromuscular Junctions

The neuromuscular junction (NMJ) is a specialized synapse that connects the terminal end of a motor neuron and a skeletal muscle fiber. Defects in NMJ cause abnormalities of neuromuscular transmission, leading to NMJ disorders. The mammalian diaphragm muscle is essential for respiration and has been widely used to study NMJ formation. Here, we provide a simple and straightforward protocol for preparing diaphragms from embryonic, neonatal, and adult mice and for subsequent NMJ staining.

Morgagni hernia in adult: A case report

INTRODUCTION AND IMPORTANCE

Morgagni Hernia is a congenital diaphragmatic hernia but can rarely present in adults. It occurs due to a congenital defect in the development of the diaphragm. Here we present a case of symptomatic Morgagni hernia diagnosed in a 53 years' female.

CASE PRESENTATION

A 53 years' female presented with recurrent chest symptoms and was found to have bowel contents herniated into the right hemithorax on chest X-ray and CECT. Reduction of hernia was done laparoscopically and the hernia was repaired with non-absorbable suture in an interrupted manner.

CLINICAL DISCUSSION

Morgagni hernias are mostly diagnosed incidentally on a chest radiograph or can present with cardiorespiratory or abdominal symptoms. Our case was an adult who was diagnosed to have Morgagni hernia presenting with chest symptoms. The investigation of choice to diagnose and evaluate this condition is CECT of chest and repair of hernia without the use mesh is advised in asymptomatic cases also due to feared complications like strangulation and incarceration.

CONCLUSION

The treatment of Morgagni Hernia is primary surgical repair which can be done either transthoracically or transabdominally. It is advised that surgical repair should be done even in asymptomatic cases.

Management of Congenital Diaphragmatic Hernia (CDH): Role of Molecular Genetics

Congenital diaphragmatic hernia (CDH) is a relatively common major life-threatening birth defect that results in significant mortality and morbidity depending primarily on lung hypoplasia, persistent pulmonary hypertension, and cardiac dysfunction. Despite its clinical relevance, CDH multifactorial etiology is still not completely understood. We reviewed current knowledge on normal diaphragm development and summarized genetic mutations and related pathways as well as cellular mechanisms involved in CDH. Our literature analysis showed that the discovery of harmful de novo variants in the fetus could constitute an important tool for the medical team during pregnancy, counselling, and childbirth. A better insight into the mechanisms regulating diaphragm development and genetic causes leading to CDH appeared essential to the development of new therapeutic strategies and evidence-based genetic counselling to parents. Integrated sequencing, development, and bioinformatics strategies could direct future functional studies on CDH; could be applied to cohorts and consortia for CDH and other birth defects; and could pave the way for potential therapies by providing molecular targets for drug discovery.

Morphofunctional Characterization of Different Tissue Factors in Congenital Diaphragmatic Hernia Affected Tissue

Congenital diaphragm hernia (CDH) is a congenital disease that occurs during prenatal development. Although the morbidity and mortality rate is rather significant, the pathogenesis of CDH has been studied insignificantly due to the decreased accessibility of human pathological material. Therefore the aim of our work was to evaluate growth factors (transforming growth factor-beta (TGF-β), basic fibroblast growth factor (bFGF), insulin-like growth factor 1 (IGF-1), hepatocyte growth factor (HGF)) and their receptors (fibroblast growth factor receptor 1 (FGFR1), insulin-like growth factor 1 (IGF-1R)), muscle (dystrophin, myosin, alpha actin) and nerve quality (nerve growth factor (NGF), nerve growth factor receptor (NGFR), neurofilaments (NF)) factors, local defense factors (ß-defensin 2, ß-defensin 4), programmed cell death (TUNEL), and separate gene (Wnt-1) expression in human pathological material to find immunohistochemical marker differences between the control and the CDH patient groups. A semi-quantitative counting method was used for the evaluation of the tissues and structures in the Biotin-Streptavidin-stained slides. Various statistically significant differences were found in immunoreactive expression between the patient and the control group tissue and the morphological structures as well as very strong, strong, and moderate correlations between immunoreactives in different diaphragm cells and structures. These significant changes and various correlations indicate that multiple morphopathogenetic pathways are affected in CDH pathogenesis. This work contains the evaluation of the causes for these changes and their potential involvement in CDH pathogenesis.

Pbx1, Meis1, and Runx1 Expression Is Decreased in the Diaphragmatic and Pulmonary Mesenchyme of Rats with Nitrofen-Induced Congenital Diaphragmatic Hernia

INTRODUCTION

 Congenital diaphragmatic hernia (CDH) and associated pulmonary hypoplasia (PH) are thought to originate from mesenchymal defects in pleuroperitoneal folds (PPFs) and primordial lungs. Pre-B-cell leukemia homeobox 1 (Pbx1), its binding partner myeloid ecotropic integration site 1 (Meis1), and runt-related transcription factor 1 (Runx1) are expressed in diaphragmatic and lung mesenchyme, functioning as transcription cofactors that modulate mesenchymal cell proliferation. Furthermore, Pbx1 ^-/- mice develop diaphragmatic defects and PH similar to human CDH. We hypothesized that diaphragmatic and pulmonary Pbx1, Meis1, and Runx1 expression is decreased in the nitrofen-induced CDH model.

MATERIALS AND METHODS

 Time-mated rats were exposed to nitrofen or vehicle on gestational day 9 (D9). Fetal diaphragms (n = 72) and lungs (n = 48) were microdissected on D13, D15, and D18, and were divided into control and nitrofen-exposed specimens. Diaphragmatic and pulmonary gene expression levels of Pbx1, Meis1, and Runx1 were analyzed by quantitative real-time polymerase chain reaction. Immunofluorescence-double-staining for Pbx1, Meis1, and Runx1 was combined with mesenchymal/myogenic markers Gata4 and myogenin to evaluate protein expression.

RESULTS

 Relative mRNA expression of Pbx1, Meis1, and Runx1 was significantly decreased in PPFs (D13), developing diaphragms/lungs (D15), and muscularized diaphragms/differentiated lungs (D18) of nitrofen-exposed fetuses compared with controls. Confocal-laser-scanning-microscopy revealed markedly diminished Pbx1, Meis1, and Runx1 immunofluorescence in diaphragmatic and pulmonary mesenchyme, associated with less proliferating mesenchymal cells in nitrofen-exposed fetuses on D13, D15, and D18 compared with controls.

CONCLUSION

 Decreased Pbx1, Meis1, and Runx1 expression during diaphragmatic development and lung branching morphogenesis may reduce mesenchymal cell proliferation, causing malformed PPFs and disrupted airway branching, thus leading to diaphragmatic defects and PH in the nitrofen-induced CDH model.

The prevalence of hearing loss in children with congenital diaphragmatic hernia: A longitudinal population-based study

BACKGROUND

The true prevalence of hearing loss among children with congenital diaphragmatic hernia (CDH) is unknown, with some studies reporting rates up to 60%.

PURPOSE

The purpose of this study was to determine the prevalence of hearing loss among children with CDH and compare it to age-matched controls.

METHODS

We used population-based datasets to compare the number of hearing loss diagnoses in children younger than 10 years-of-age born between 1992 and 2009 with CDH to date-of-birth matched controls without CDH. Factors associated with CDH disease severity were analyzed to determine their effect on the prevalence of hearing loss. A sensitivity analysis was performed to determine if selection bias of improved care over the course of the study affected hearing loss in CDH patients. The prevalences of hearing loss were compared using Fisher's exact tests and statistical significance was defined as p < 0.05.

RESULTS

A total of 529 children, 38 CDH cases and their 491 date-of-birth matched controls, met the inclusion criteria. Hearing loss was found in 7 children with CDH (18.4%) compared to 26 (5.3%) controls; the risk ratio (RR) of hearing loss was 3.48 (95%CI = 1.61-7.49, p = 0.006). There was no association between CDH disease severity and hearing loss.

CONCLUSIONS

CDH is associated with hearing loss compared to the general population. Our results suggest that congenital factors may contribute to hearing loss in CDH more than perinatal exposures.

LEVEL OF EVIDENCE

3.

Resolving the heterogeneity of diaphragmatic mesenchyme: a novel mouse model of congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a relatively common developmental defect with considerable mortality and morbidity. Formation of the diaphragm is a complex process that involves several cell types, each with different developmental origins. Owing to this complexity, the aetiology of CDH is not well understood. The pleuroperitoneal folds (PPFs) and the posthepatic mesenchymal plate (PHMP) are transient structures that are essential during diaphragm development. Using several mouse models, including lineage tracing, we demonstrate the heterogeneous nature of the cells that make up the PPFs. The conditional deletion of Wilms tumor 1 homolog (Wt1) in the non-muscle mesenchyme of the PPFs results in CDH. We show that the fusion of the PPFs and the PHMP to form a continuous band of tissue involves movements of cells from both sources. The PPFs of mutant mice fail to fuse with the PHMP and exhibit increased RALDH2 (also known as ALDH1A2) expression. However, no changes in the expression of genes (including Snai1, Snai2, Cdh1 and Vim) implicated in epithelial-to-mesenchymal transition are observed. Additionally, the mutant PPFs lack migrating myoblasts and muscle connective tissue fibroblasts (TCF4⁺/GATA4⁺), suggesting possible interactions between these cell types. Our study demonstrates the importance of the non-muscle mesenchyme in development of the diaphragm.

Design and fabrication of polycaprolactone/gelatin composite scaffolds for diaphragmatic muscle reconstruction

Diaphragmatic wall defects caused by congenital disorders or disease remain a major challenge for physicians worldwide. Polymeric patches have been extensively explored within research laboratories and the clinic for soft tissue and diaphragm reconstruction. However, patch usage may be associated with allergic reaction, infection, granulation, and recurrence of the hernia. In this study, we designed and fabricated a porous scaffold using a combination of 3D printing and freeze-drying techniques. A 3D printed polycaprolactone (PCL) mesh was used to reinforcegelatin scaffolds, representing an advantage over previously reported examples since it provides mechanical strength and flexibility. In vitro studies showed that adherent cells were anchorage-dependent and grew as a monolayer attached to the scaffolds. Microscopic observations indicated better cell attachments for the scaffolds with higher gelatin content as compared with the PCL control samples. Tensile testing demonstrated the mechanical strength of samples was significantly greater than adult diaphragm tissue. The biocompatibility of the specimens was investigated in vivo using a subcutaneous implantation method in Bagg albino adult mice for 20 days, with the results indicating superior cellular behavior and attachment on scaffolds containing gelatin in comparison to pure PCL scaffolds, suggesting that the porous PCL/gelatin scaffolds have potential as biodegradable and flexible constructs for diaphragm reconstruction.

The Failed Clinical Story of Myostatin Inhibitors against Duchenne Muscular Dystrophy: Exploring the Biology behind the Battle

Myostatin inhibition therapy has held much promise for the treatment of muscle wasting disorders. This is particularly true for the fatal myopathy, Duchenne Muscular Dystrophy (DMD). Following on from promising pre-clinical data in dystrophin-deficient mice and dogs, several clinical trials were initiated in DMD patients using different modality myostatin inhibition therapies. All failed to show modification of disease course as dictated by the primary and secondary outcome measures selected: the myostatin inhibition story, thus far, is a failed clinical story. These trials have recently been extensively reviewed and reasons why pre-clinical data collected in animal models have failed to translate into clinical benefit to patients have been purported. However, the biological mechanisms underlying translational failure need to be examined to ensure future myostatin inhibitor development endeavors do not meet with the same fate. Here, we explore the biology which could explain the failed translation of myostatin inhibitors in the treatment of DMD.

Cellular dynamics of myogenic cell migration: molecular mechanisms and implications for skeletal muscle cell therapies

Directional cell migration is a critical process underlying morphogenesis and post-natal tissue regeneration. During embryonic myogenesis, migration of skeletal myogenic progenitors is essential to generate the anlagen of limbs, diaphragm and tongue, whereas in post-natal skeletal muscles, migration of muscle satellite (stem) cells towards regions of injury is necessary for repair and regeneration of muscle fibres. Additionally, safe and efficient migration of transplanted cells is critical in cell therapies, both allogeneic and autologous. Although various myogenic cell types have been administered intramuscularly or intravascularly, functional restoration has not been achieved yet in patients with degenerative diseases affecting multiple large muscles. One of the key reasons for this negative outcome is the limited migration of donor cells, which hinders the overall cell engraftment potential. Here, we review mechanisms of myogenic stem/progenitor cell migration during skeletal muscle development and post-natal regeneration. Furthermore, strategies utilised to improve migratory capacity of myogenic cells are examined in order to identify potential treatments that may be applied to future transplantation protocols.

Cell culture system to assay candidate genes and molecular pathways implicated in congenital diaphragmatic hernias

The mammalian muscularized diaphragm is essential for respiration and defects in the developing diaphragm cause a common and frequently lethal birth defect, congenital diaphragmatic hernia (CDH). Human genetic studies have implicated more than 150 genes and multiple molecular pathways in CDH, but few of these have been validated because of the expense and time to generate mouse mutants. The pleuroperitoneal folds (PPFs) are transient embryonic structures in diaphragm development and defects in PPFs lead to CDH. We have developed a system to culture PPF fibroblasts from E12.5 mouse embryos and show that these fibroblasts, in contrast to the commonly used NIH 3T3 fibroblasts, maintain expression of key genes in normal diaphragm development. Using pharmacological and genetic manipulations that result in CDH in vivo, we also demonstrate that differences in proliferation provide a rapid means of distinguishing healthy and impaired PPF fibroblasts. Thus, the PPF fibroblast cell culture system is an efficient tool for assaying the functional significance of CDH candidate genes and molecular pathways and will be an important resource for elucidating the complex etiology of CDH.

Sequential Minimally Invasive Fetal Interventions for Two Life-Threatening Conditions: A Novel Approach

INTRODUCTION

In utero interventions are performed in fetuses with "isolated" major congenital anomalies to improve neonatal outcomes and quality of life. Sequential in utero interventions to treat 2 anomalies in 1 fetus have not yet been described.

CASE PRESENTATION

Here, we report a fetus with a large left-sided intralobar bronchopulmonary sequestration (BPS) causing mediastinal shift, a small extralobar BPS, and concomitant severe left-sided congenital diaphragmatic hernia (CDH). At 26-week gestation, the BPS was noted to be increasing in size with a significant reduction in right lung volume and progression to fetal hydrops. The fetus underwent ultrasound-guided ablation of the BPS feeding vessel leading to complete tumor regression. However, lung development remained poor (O/E-LHR: 0.22) due to the left-sided CDH, prompting fetal endoscopic tracheal occlusion therapy at 28-week gestation to allow increased lung growth. After vaginal delivery, the newborn underwent diaphragmatic repair with resection of the extralobar sequestration. He was discharged home with tracheostomy on room air at 9 months.

DISCUSSION/CONCLUSION

Sequential in utero interventions to treat 2 severe major anomalies in the same fetus have not been previously described. This approach may be a useful alternative in select cases with otherwise high morbidity/mortality. Further studies are required to confirm our hypothesis.

The Periostin/Integrin-αv Axis Regulates the Size of Hematopoietic Stem Cell Pool in the Fetal Liver

We earlier showed that outside-in integrin signaling through POSTN-ITGAV interaction plays an important role in regulating adult hematopoietic stem cell (HSC) quiescence. Here, we show that Itgav deletion results in increased frequency of phenotypic HSCs in fetal liver (FL) due to faster proliferation. Systemic deletion of Postn led to increased proliferation of FL HSCs, albeit without any loss of stemness, unlike Vav-Itgav^−/− HSCs. Based on RNA sequencing analysis of FL and bone marrow HSCs, we predicted the involvement of DNA damage response pathways in this dichotomy. Indeed, proliferative HSCs from Postn-deficient FL tissues showed increased levels of DNA repair, resulting in lesser double-strand breaks. Thus POSTN, with its expression majorly localized in the vascular endothelium of FL tissue, acts as a regulator of stem cell pool size during development. Overall, we demonstrate that the duality of response to proliferation in HSCs is developmental stage dependent and can be correlated with DNA damage responses.

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Interruption of POSTN-ITGAV interaction leads to HSC expansion in fetal liver

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HSC from fetal liver in comparison with adult BM excel in their DNA damage responses

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POSTN is a potential component of the vascular niche for HSCs in the fetal liver

Routes of Transdiaphragmatic Migration from the Abdomen to the Chest

The diaphragm serves as an anatomic border between the abdominal and thoracic cavities. Pathologic conditions traversing the diaphragm are often incompletely described and may be overlooked, resulting in diagnostic delays. Several routes allow abdominal contents or pathologic processes to spread into the thorax, including along normal transphrenic structures, through congenital defects in the diaphragm, through inherent areas of weakness between muscle groups, or by pathways created by tissue destruction, trauma, or iatrogenic injuries. A thorough knowledge of the anatomy of the diaphragm can inform an accurate differential diagnosis. Often, intraperitoneal pathologic conditions crossing the diaphragm may be overlooked if axial imaging is the only approach to this complex region because of the horizontal orientation of much of the diaphragm. Multiplanar capabilities of volumetric CT and MRI provide insight into the pathways where pathologic conditions may traverse this border. Knowledge of these characteristic routes and use of multiplanar imaging are critical for depiction of specific transdiaphragmatic pathologic conditions.^©RSNA, 2020.

Trans-diaphragmatic Pathologies: Anatomical Background and Spread of Disease on Cross-sectional Imaging

The diaphragm is not only a sheet of muscle separating the abdominal and thoracic cavities: it plays an essential role in ventilation and can act as a gateway for the spread of different disease processes between the abdominal and the thoracic cavity. Careful attention to the appearance of the diaphragm on various imaging modalities is essential to ensure the accurate diagnosis of diaphragmatic disorders, which may be secondary to functional or anatomical derangements.

Alary muscles and thoracic alary-related muscles are atypical striated muscles involved in maintaining the position of internal organs

Alary muscles (AMs) have been described as a component of the cardiac system in various arthropods. Lineage-related thoracic muscles (TARMs), linking the exoskeleton to specific gut regions, have recently been discovered in Drosophila Asymmetrical attachments of AMs and TARMs, to the exoskeleton on one side and internal organs on the other, suggested an architectural function in moving larvae. Here, we analysed the shape and sarcomeric organisation of AMs and TARMs, and imaged their atypical deformability in crawling larvae. We then selectively eliminated AMs and TARMs by targeted apoptosis. Elimination of AMs revealed that AMs are required for suspending the heart in proper intra-haemocelic position and for opening of the heart lumen, and that AMs constrain the curvature of the respiratory tracheal system during crawling; TARMs are required for proper positioning of visceral organs and efficient food transit. AM/TARM cardiac versus visceral attachment depends on Hox control, with visceral attachment being the ground state. TARMs and AMs are the first example of multinucleate striated muscles connecting the skeleton to the cardiac and visceral systems in bilaterians, with multiple physiological functions.

Neurophysiological Assessment of Prolonged Recovery From Neuromuscular Blockade in the Neonatal Intensive Care Unit

Objective: To evaluate recovery from neuromuscular blockade in infants using Train-of-Four nerve stimulation. Study Design: Ulnar nerve stimulation was used to evoke thumb twitch and reported as Train-of-Four ratio. Thumb twitch was also recorded visually in real-time. Primary outcome was time to near recovery of muscle function (Train-of-Four ratio >70%). Secondary analyses were time to greater degrees of recovery (Train-of-Four ratio >80, 90%), sensitivity of accelerometry vs. visual thumb-twitch and clinical variates to assess safety. Results: Patients were enrolled following rocuronium-boluses (n = 10) and vecuronium-infusions (n = 9). Median recovery time to Train-of-Four ratio >70% was 14 h following rocuronium-bolus dosing and 34 h following cessation of continuous vecuronium infusion. Median stimulus threshold for accelerometry was 27.5 mA and visual observation was 20 mA. There were no safety concerns. Conclusion(s): Neuromuscular monitoring using Train-of-Four nerve stimulation is feasible in infants. Some infants exhibited prolonged recovery from neuromuscular-blockade. These pilot data may facilitate future standardized pediatric protocols on neuromuscular monitoring for safer dosing.

Expression of SUMO enzymes is fiber type dependent in skeletal muscles and is dysregulated in muscle disuse

SUMOylation is a dynamic, reversible, enzymatic drug-targetable post-translational modification (PTM) reaction where the Small Ubiquitin-like Modifier (SUMO) moieties are attached to proteins. This reaction regulates various biological functions like cell growth, differentiation, and it is crucial for maintaining organ homeostasis. However, the actions of SUMO in skeletal muscle pathophysiology are still not investigated. In this study, we quantified the abundance of the SUMO enzymes and determined the distribution of SUMOylated proteins along the fibers of nine different muscles. We find that skeletal muscles contain a distinctive group of SUMO enzymes and SUMOylated proteins in relation to their different metabolism, functions, and fiber type composition. In addition, before the activation of protein degradation pathways, this unique set is quickly altered in response to muscle sedentariness. Finally, we demonstrated that PAX6 acts as an upstream regulator of the SUMO conjugation reaction, which can become a potential therapeutic marker to prevent muscle diseases generated by inactivity.

Standardization and reproducibility of sonographic stomach position grades in fetuses with congenital diaphragmatic hernia

OBJECTIVES

The purpose of this study was to evaluate the reproducibility of stomach position grading in congenital diaphragmatic hernia (CDH) as proposed by Cordier et al and Basta et al after standardization of the methods at our center.

METHODS

We collected sonographic images from 23 fetuses with left-sided CDH at our center from 2010 to 2018. Nine operators (one maternal fetal medicine expert and eight sonographers) reviewed the selected images and graded the stomach position according to the methods of Cordier et al and Basta et al. We assessed the interoperator agreement with Fleiss's kappa statistics.

RESULTS

Overall agreement amongst all operators was moderate for both methods proposed by Cordier et al (k = 0.60, SE 0.07, 95% CI 0.47-0.73, P < .0001) and Basta et al (k = 0.60, SE 0.06, 95% CI 0.47-0.73, P < .0001). Interoperator agreement was moderate for grade 3 with the method by Cordier et al (k = 0.45, SE 0.09, 95% CI 0.27-0.64, P < .0001) and fair for grade 4 with the method by Basta et al (k = 0.33, SE 0.08, 95% CI 0.18-0.49 P < .0001).

CONCLUSIONS

Our study demonstrates a fair to moderate interoperator agreement of the stomach position grading methods proposed in the literature after standardization of the methods at our center. Further multicenter studies are needed to confirm our results.

Novel features of PIK3CA-Related Overgrowth Spectrum: Lesson from an aborted fetus presenting a de novo constitutional PIK3CA mutation

PIK3CA-Related Overgrowth Spectrum (PROS) encompass a group of disorders which are mainly characterized by segmental overgrowth of several tissues as well as venous and lymphatic malformations. It is caused by heterozygous, usually somatic mosaic, pathogenic variants in the PIK3CA gene. However, some patients presenting mainly isolated megalencephaly or "Cowden-like" features have been described harboring constitutional mutations of PIK3CA. Here, we report the case of a woman whose pregnancy was interrupted at 34 weeks of gestation after the detection of the following ultrasound abnormalities: left diaphragmatic hernia with intrathoracic stomach, right deviation of heart, intrathoracic double bubble sign, macrocephaly and polyhydramnios. Fetal autopsy contributed to better characterize the phenotype, showing megalencephaly, left diaphragmatic eventration, facial dysmorphism (hypertelorism, abnormal hair line implantation) and duplication of distal portion of the small bowel. Clinical exome sequencing identified a de novo constitutional variant c.1030G>A p.(Val344Met) in PIK3CA. Although this mutation has been previously described (as constitutional variant) in pediatric patients, our case represents the first detailed description of the prenatal features found in association with a constitutional PIK3CA mutation. Moreover, this case contributes to delineate novel features (diaphragmatic eventration and duplication of the distal part of the small bowel) which could be identified in association with PROS.