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Drucker NA, Cox CS. Adult presentation of congenital tracheooesophageal fistula treated as asthma and recurrent respiratory infections. Lancet 2023; 402:2326-2327. [PMID: 38103939 DOI: 10.1016/s0140-6736(23)02568-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/03/2023] [Accepted: 11/14/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Natalie A Drucker
- Department of Pediatric Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Charles S Cox
- Department of Pediatric Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Park Y, Drucker NA, Gray BW. Device updates in pediatric and neonatal ECMO. Semin Pediatr Surg 2023; 32:151334. [PMID: 37925997 DOI: 10.1016/j.sempedsurg.2023.151334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Since the early use of extracorporeal life support (ECLS), new innovations and technological advancements have augmented the ability to use this technology in children and neonates. Cannulae have been re-designed to maintain structure and allow for single cannula venovenous (VV) ECLS in smaller patients. Circuit technology, including pumps and tubing, has evolved to permit smaller priming volumes and lower flow rates with fewer thrombotic or hemolytic complications. New oxygenator developments also improve efficiency of gas exchange. This paper serves as an overview of recent device developments in ECLS delivery to pediatric and neonatal patients.
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Affiliation(s)
- Yujin Park
- Department of Surgery, Indiana University, Indianapolis, IN, USA; Section of Pediatric Surgery, Indiana University, Indianapolis, IN, USA
| | - Natalie A Drucker
- Department of Pediatric Surgery, University of Texas in Houston, USA
| | - Brian W Gray
- Section of Pediatric Surgery, Indiana University, Indianapolis, IN, USA.
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Hosfield BD, Hunter CE, Li H, Drucker NA, Pecoraro AR, Manohar K, Shelley WC, Markel TA. A hydrogen-sulfide derivative of mesalamine reduces the severity of intestinal and lung injury in necrotizing enterocolitis through endothelial nitric oxide synthase. Am J Physiol Regul Integr Comp Physiol 2022; 323:R422-R431. [PMID: 35912999 PMCID: PMC9512109 DOI: 10.1152/ajpregu.00229.2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 06/18/2022] [Accepted: 07/19/2022] [Indexed: 11/22/2022]
Abstract
Necrotizing enterocolitis (NEC) remains a devastating disease that affects preterm infants. Hydrogen sulfide (H2S) donors have been shown to reduce the severity of NEC, but the optimal compound has yet to be identified. We hypothesized that oral H2S-Mesalamine (ATB-429) would improve outcomes in experimental NEC, and its benefits would be dependent on endothelial nitric oxide synthase (eNOS) pathways. NEC was induced in 5-day-old wild-type (WT) and eNOS knockout (eNOSKO) pups by formula feeding and stress. Four groups were studied in both WT and eNOSKO mice: 1) breastfed controls, 2) NEC, 3) NEC + 50 mg/kg mesalamine, and 4) NEC + 130 mg/kg ATB-429. Mesalamine and ATB-429 doses were equimolar. Pups were monitored for sickness scores and perfusion to the gut was measured by Laser Doppler Imaging (LDI). After euthanasia of the pups, intestine and lung were hematoxylin and eosin-stained and scored for injury in a blind fashion. TLR4 expression was quantified by Western blot and IL-6 expression by ELISA. P < 0.05 was significant. Both WT and eNOSKO breastfed controls underwent normal development and demonstrated milder intestinal and pulmonary injury compared with NEC groups. For the WT groups, ATB-429 significantly improved weight gain, reduced clinical sickness score, and improved perfusion compared with the NEC group. In addition, WT ATB-429 pups had a significantly milder intestinal and pulmonary histologic injury when compared with NEC. ATB-429 attenuated the increase in TLR4 and IL-6 expression in the intestine. When the experiment was repeated in eNOSKO pups, ATB-429 offered no benefit in weight gain, sickness scores, perfusion, intestinal injury, pulmonary injury, or decreasing intestinal inflammatory markers. An H2S derivative of mesalamine improves outcomes in experimental NEC. Protective effects appear to be mediated through eNOS. Further research is warranted to explore whether ATB-429 may be an effective oral therapy to combat NEC.
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Affiliation(s)
- Brian D Hosfield
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chelsea E Hunter
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Hongge Li
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Natalie A Drucker
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Anthony R Pecoraro
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Krishna Manohar
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Troy A Markel
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- Riley Hospital for Children, Indiana University Health, Indianapolis, Indiana
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Wang SK, Severance S, Troja W, Drucker NA, Gray BW, Rouse TM, Dalsing MC, Maijub JG. Operative Traumatic Aortic Injuries at an Urban Pediatric Hospital. Am Surg 2020; 87:965-970. [PMID: 33291946 DOI: 10.1177/0003134820966272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Limited data are available describing the long-term results of pediatric patients undergoing aortic repair secondary to trauma. Therefore, this descriptive investigation was completed to abrogate this deficit. METHODS A retrospective review of an urban level 1 pediatric trauma database maintained at a high-volume dedicated children's hospital between 2008-2018 was completed to capture all cases of severe traumatic aortic injury and associated demographics, mechanisms, injury severity, treatment, and clinical outcomes. RESULTS In the prespecified interval, 2189 children (age <18 years) presented to our facility as a level 1 trauma activation. Of these cases, a total of 10 patients (.5%) had a demonstrable thoracic or abdominal aortic injury. The mean age of our study cohort was 10.4 ± 5.7 years. The mechanism of injury consisted of 8 participants involved in motor vehicle accidents, 1 pedestrian struck by a vehicle, and 1 struck by a falling boulder. Injuries were identified via CT angiogram (n = 9) or autopsy (n = 1) and consisted of 6 thoracic aortas and 4 abdominal aortas. The mean trauma injury severity score was 37.6 ± 19.9. Seven of the patients underwent open surgical intervention, 1 underwent endovascular intervention, 1 was treated with medical management, and 1 patient expired in the trauma bay before surgery could be performed. Aortic pathologies observed were 6 transections, 2 dissections, and 2 occlusions. Five of the ten patients underwent nonaortic surgical procedures. To determine operative outcomes, we excluded the 2 patients who did not receive aortic intervention. In the 8 remaining patients, the mean hospital length of stay was 12.8 ± 4.8 days with 6.8 ± 4.1 days in the intensive care unit. All 9 participants who survived the initial trauma evaluation were discharged from the hospital. Mean follow-up was 38.3 ± 43.0 months; during which, we observed no additional aortic-related morbidity, mortality, and reinterventions. The only stent-graft deployed remained in stable position without evidence of endoleak or migration by duplex. CONCLUSION Traumatic aortic injury is exceedingly rare in children and primarily of blunt etiology. Of the patients who survive the scene, operative repair seems to be associated with excellent perioperative and long-term survival.
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Affiliation(s)
- Shihuan K Wang
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Sarah Severance
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Weston Troja
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Natalie A Drucker
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Brian W Gray
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Thomas M Rouse
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - Michael C Dalsing
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
| | - John G Maijub
- Riley Hospital for Children, Divisions of Vascular and Pediatric Surgery, Department of Surgery, 12250Indiana University School of Medicine, IN, USA
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Drucker NA, Wang SK, Markel TA, Landman MP, Gray BW. Practice patterns in imaging guidance for ECMO cannulation: A survey of the American Pediatric Surgical Association. J Pediatr Surg 2020; 55:1457-1462. [PMID: 31837841 DOI: 10.1016/j.jpedsurg.2019.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 11/10/2019] [Accepted: 11/19/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Surgeon-specific variations in pediatric extracorporeal membrane oxygenation (ECMO) cannulation technique are not well characterized. Advances in technology have led to changing techniques with no formal consensus statement for reference. METHODS A survey was e-mailed to 1301 members of the American Pediatric Surgical Association (APSA). Categorical data was compared with Chi-squared and Kendall's tau-β tests, and multiple column comparisons were performed with the Bonferroni correction. RESULTS Response rate was 19%, with 248 pediatric general surgeons responding to the survey. 89.4% of respondents stated that cannulation was typically performed in the ICU. Venoarterial (VA) ECMO cannulation was more often performed open (88.6%) than venovenous (VV) ECMO (42.2%). Surgeons cannulate for VA ECMO and VV ECMO without imaging guidance 44% and 21.5% of the time, respectively. There was no difference in estimated rate of cannula repositioning by cannulation strategy. For venous and arterial cannulation in VA ECMO, surgeons were more likely to use the femoral as opposed to the neck when children were older than 13 years and weighed more than 35 kg regardless of the presence or absence of preexisting femoral arterial or venous access. CONCLUSION Practice patterns for ECMO cannulation are variable among pediatric surgeons. Standardization could reduce the occurrence of unsafe practices and potentially decrease complications and improve patient outcomes. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Natalie A Drucker
- Department of Surgery, Indiana University School of Medicine, Emerson Hall 545 Barnhill Drive, Room 125, Indianapolis, IN 46202.
| | - S Keisin Wang
- Department of Surgery, Indiana University School of Medicine, Emerson Hall 545 Barnhill Drive, Room 125, Indianapolis, IN 46202.
| | - Troy A Markel
- Department of Surgery, Indiana University School of Medicine, Emerson Hall 545 Barnhill Drive, Room 125, Indianapolis, IN 46202; Department of Surgery, Section of Pediatric Surgery, 705 Riley Hospital Dr. RI 2500, Indianapolis, IN 46202.
| | - Matthew P Landman
- Department of Surgery, Indiana University School of Medicine, Emerson Hall 545 Barnhill Drive, Room 125, Indianapolis, IN 46202; Department of Surgery, Section of Pediatric Surgery, 705 Riley Hospital Dr. RI 2500, Indianapolis, IN 46202.
| | - Brian W Gray
- Department of Surgery, Indiana University School of Medicine, Emerson Hall 545 Barnhill Drive, Room 125, Indianapolis, IN 46202; Department of Surgery, Section of Pediatric Surgery, 705 Riley Hospital Dr. RI 2500, Indianapolis, IN 46202.
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Markel TA, Drucker NA, Jensen AR, Olson KR. Human Mesenchymal Stem Cell Hydrogen Sulfide Production Critically Impacts the Release of Other Paracrine Mediators After Injury. J Surg Res 2020; 254:75-82. [PMID: 32417499 DOI: 10.1016/j.jss.2020.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/09/2020] [Accepted: 04/11/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The use of mesenchymal stem cells (MSCs) for treatment during ischemia is novel. Hydrogen sulfide (H2S) is an important paracrine mediator that is released from MSCs to facilitate angiogenesis and vasodilation. Three enzymes, cystathionine-beta-synthase (CBS), cystathionine-gamma-lyase (CSE), and 3-mercaptopyruvate-sulfurtransferase (MPST), are mainly responsible for H2S production. However, it is unclear how these enzymes impact the production of other critical growth factors and chemokines. We hypothesized that the enzymes responsible for H2S production in human MSCs would also critically regulate other growth factors and chemokines. MATERIALS AND METHODS Human MSCs were transfected with CBS, MPST, CSE, or negative control small interfering RNA. Knockdown of enzymes was confirmed by polymerase chain reaction. Cells were plated in 12-well plates at 100,000 cells per well and stimulated with tumor necrosis factor-α (TNF-α; 50 ng/mL), lipopolysaccharide (LPS; 200 ng/mL), or 5% hypoxia for 24 h. Supernatants were collected, and cytokines measured by multiplex beaded assay. Data were compared with the Mann-Whitney U-test, and P < 0.05 was significant. RESULTS TNF-α, LPS, and hypoxia effectively stimulated MSCs. Granulocyte colony-stimulating factor (GCSF), epidermal growth factor, fibroblast growth factor, granulocyte/monocyte colony-stimulating factor (GMCSF), vascular endothelial growth factor, and interferon gamma-inducible protein 10 were all significantly elevated when CSE was knocked down during TNF-α stimulation (P < 0.05). Knockdown of MPST during LPS stimulation more readily increased GCSF and epidermal growth factor but decreased GMCSF (P < 0.05). CBS knockdown decreased production of GCSF, fibroblast growth factor, GMCSF, and vascular endothelial growth factor (P < 0.05) after hypoxia. CONCLUSIONS The enzymes that produce H2S in MSCs are also responsible for the production of other stem cell paracrine mediators under stressful stimuli. Therefore, reprogramming MSCs to endogenously produce more H2S as a therapeutic intervention could also critically impact other paracrine mediators, which may alter the desired beneficial effects.
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Affiliation(s)
- Troy A Markel
- Section of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; Department of Physiology, Indiana University School of Medicine, South Bend, Indiana.
| | - Natalie A Drucker
- Section of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Department of Physiology, Indiana University School of Medicine, South Bend, Indiana
| | - Amanda R Jensen
- Section of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Department of Physiology, Indiana University School of Medicine, South Bend, Indiana
| | - Kenneth R Olson
- Section of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; Department of Physiology, Indiana University School of Medicine, South Bend, Indiana
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Drucker NA, Wang SK, Puzio T, Kim B, Goze K, Nakeeb A. Emergent Pancreaticoduodenectomy for Duodenum to Superior Mesenteric Vein Fistulation. Am Surg 2020. [DOI: 10.1177/000313482008600205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Natalie A. Drucker
- Department of Surgery Indiana University School of Medicine Indianapolis, Indiana
| | - S. Keisin Wang
- Department of Surgery Indiana University School of Medicine Indianapolis, Indiana
| | - Thaddeus Puzio
- Department of Surgery Indiana University School of Medicine Indianapolis, Indiana
| | - Bradford Kim
- Department of Surgery Indiana University School of Medicine Indianapolis, Indiana
| | - Katherine Goze
- Department of Surgery Indiana University School of Medicine Indianapolis, Indiana
| | - Attila Nakeeb
- Department of Surgery Indiana University School of Medicine Indianapolis, Indiana
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Drucker NA, Wang SK, Puzio T, Kim B, Goze K, Nakeeb A. Emergent Pancreaticoduodenectomy for Duodenum to Superior Mesenteric Vein Fistulation. Am Surg 2020; 86:e61-e63. [PMID: 32167054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Moore HM, Drucker NA, Hosfield BD, Shelley WC, Markel TA. Sildenafil as a Rescue Agent Following Intestinal Ischemia and Reperfusion Injury. J Surg Res 2019; 246:512-518. [PMID: 31630883 DOI: 10.1016/j.jss.2019.09.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/20/2019] [Accepted: 09/18/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute mesenteric ischemia carries a significant morbidity. Measures to improve blood flow parameters to the intestine may ameliorate the disease. Sildenafil, a phosphodiesterase 5 inhibitor, increases cyclic guanosine monophosphate and has been shown to prevent the effects of ischemia when given before injury. However, its effects as a rescue agent have not been established. We therefore hypothesized that sildenafil, when given as a rescue agent for intestinal ischemia, would improve mesenteric perfusion, limit intestinal epithelial injury, and decrease intestinal leukocyte chemoattractants. METHODS Eight to 12 wk-old-male C57BL/6J mice underwent laparotomy and temporary occlusion of the superior mesenteric artery for 60 min. Following ischemia, reperfusion was permitted, and before closing the abdomen, sildenafil was injected intraperitoneally in a variety of concentrations. After 24 h, reperfusion was reassessed. Animals were euthanized and intestines evaluated for histologic injury and leukocyte chemoattractants. RESULTS Postischemic administration of sildenafil did not improve mesenteric perfusion following intestinal ischemia and reperfusion injury. However, sildenafil did improve histologic injury scores in dose ranges of 0.01 to 10 mg/kg. No difference was noted in histological injury with 100 mg/kg dose, and all members of the 1000 mg/kg group died within 24 h of injury. Epithelial protection was not facilitated by the leukocyte chemoattractants Regulated on Activation, Normal T Cell Expressed, and Secreted, macrophage inflammatory protein 1 alpha, monocyte chemoattractant protein, neutrophil activating protein, or granulocyte colony stimulating factor. CONCLUSIONS Administration of sildenafil following intestinal ischemia may limit intestinal mucosal injury but does not appear to alter mesenteric perfusion or leukocyte chemoattractant influx. TYPE: Basic science. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Hannah M Moore
- The Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana
| | - Natalie A Drucker
- The Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana; Department of Surgery, Section of Pediatric Surgery, Indiana University Health, Indianapolis, Indiana
| | - Brian D Hosfield
- The Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana; Department of Surgery, Section of Pediatric Surgery, Indiana University Health, Indianapolis, Indiana
| | - W Chris Shelley
- The Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana; Department of Surgery, Section of Pediatric Surgery, Indiana University Health, Indianapolis, Indiana
| | - Troy A Markel
- The Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana; Department of Surgery, Section of Pediatric Surgery, Indiana University Health, Indianapolis, Indiana; Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.
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Te Winkel J, John QE, Hosfield BD, Drucker NA, Das A, Olson KR, Markel TA. Mesenchymal stem cells promote mesenteric vasodilation through hydrogen sulfide and endothelial nitric oxide. Am J Physiol Gastrointest Liver Physiol 2019; 317:G441-G446. [PMID: 31343254 PMCID: PMC6842994 DOI: 10.1152/ajpgi.00132.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Mesenteric ischemia is a devastating process that can result in intestinal necrosis. Mesenchymal stem cells (MSCs) are becoming a promising treatment modality. We hypothesized that 1) MSCs would promote vasodilation of mesenteric arterioles, 2) hydrogen sulfide (H2S) would be a critical paracrine factor of stem cell-mediated vasodilation, 3) mesenteric vasodilation would be impaired in the absence of endothelial nitric oxide synthase (eNOS) within the host tissue, and 4) MSCs would improve the resistin-to-adiponectin ratio in mesenteric vessels. H2S was measured with a specific fluorophore (7-azido-3-methylcoumarin) in intact MSCs and in cells with the H2S-producing enzyme cystathionine β synthase (CBS) knocked down with siRNA. Mechanical responses of isolated second- and third-order mesenteric arteries (MAs) from wild-type and eNOS knockout (eNOSKO) mice were monitored with pressure myography, after which the vessels were snap frozen and later analyzed for resistin and adiponectin via multiplex beaded assay. Addition of MSCs to the myograph bath significantly increased vasodilation of norepinephrine-precontracted MAs. Knockdown of CBS in MSCs decreased H2S production by MSCs and also decreased MSC-initiated MA dilation. MSC-initiated vasodilation was further reduced in eNOSKO vessels. The MA resistin-to-adiponectin ratio was higher in eNOSKO vessels compared with wild-type. These results show that MSC treatment promotes dilation of MAs by an H2S-dependent mechanism. Furthermore, functional eNOS within the host mesenteric bed appears to be essential for maximum stem cell therapeutic benefit, which may be attributable, in part, to modifications in the resistin-to-adiponectin ratio.NEW & NOTEWORTHY Stem cells have been shown to improve survival, mesenteric perfusion, and histological injury scores following intestinal ischemia. These benefits may be due to the paracrine release of hydrogen sulfide. In an ex vivo pressure myography model, we observed that mesenteric arterial dilation improved with stem cell treatment. Hydrogen sulfide release from stem cells and endothelial nitric oxide synthase within the vessels were critical components of optimizing stem cell-mediated mesenteric artery dilation.
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Affiliation(s)
- Jan Te Winkel
- 1Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana,2Indiana University School of Medicine, Indianapolis, Indiana
| | - Quincy E. John
- 1Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana,2Indiana University School of Medicine, Indianapolis, Indiana
| | - Brian D. Hosfield
- 1Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana,2Indiana University School of Medicine, Indianapolis, Indiana
| | - Natalie A. Drucker
- 1Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana,2Indiana University School of Medicine, Indianapolis, Indiana
| | - Amitava Das
- 1Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana,2Indiana University School of Medicine, Indianapolis, Indiana,3Indiana Center for Regenerative Medicine and Engineering, Indianapolis, Indiana
| | - Ken R. Olson
- 4Indiana University School of Medicine, South Bend, Indiana
| | - Troy A. Markel
- 1Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana,2Indiana University School of Medicine, Indianapolis, Indiana,5Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
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Drucker NA, Te Winkel JP, Shelley WC, Olson KR, Markel TA. Inhibiting hydrogen sulfide production in umbilical stem cells reduces their protective effects during experimental necrotizing enterocolitis. J Pediatr Surg 2019; 54:1168-1173. [PMID: 30879750 PMCID: PMC6545254 DOI: 10.1016/j.jpedsurg.2019.02.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 02/21/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Umbilical mesenchymal stem cells (USC) have been shown to reduce illness in animal models of necrotizing enterocolitis (NEC), possibly through the paracrine release of hydrogen sulfide (H2S). We hypothesized that animals treated with USCs with inhibited H2S synthesis would exhibit more severe disease. METHODS NEC was induced in five-day-old mouse pups by formula feeding and hypoxic and hypothermic stress. Experimental groups received intraperitoneal injection of either saline vehicle or 80,000cells/gram of one of the following cell types: USC, USCs with negative-control siRNA, or USCs with targeted siRNA inhibition of the H2S-producing enzymes. Pups were monitored by clinical assessment and after euthanasia, intestine and lung histologic injury were scored. Tissue was homogenized, and concentrations of IL-6, IL-10, and VEGF were determined by ELISA. For statistical analysis, p<0.05 was considered significant. RESULTS Animals treated with negative-control siRNA USCs were significantly improved compared to vehicle. Clinical sickness scores as well as intestinal and lung histologic injury scores in the targeted siRNA groups were significantly worse when compared to the negative-control siRNA group. IL-6, IL-10, and VEGF had varying patterns of expression in the different groups. CONCLUSION Inhibition of H2S production in USCs reduces the beneficial effects of these cells during therapy in experimental NEC. LEVEL OF EVIDENCE Animal studies are typically described as "foundational evidence" without a true level assigned. TYPE OF STUDY Animal Study.
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Affiliation(s)
- Natalie A Drucker
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, Indianapolis, IN.
| | - Jan P Te Winkel
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, Indianapolis, IN
| | - W Christopher Shelley
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Kenneth R Olson
- The Indiana University School of Medicine, South Bend, South Bend, IN
| | - Troy A Markel
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, Indianapolis, IN
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Drucker NA, Blaibel MF, Nagaraju S, Wang SK, Goggins W, Fajardo A. Renal Autotransplant and Celiac Artery Bypass for Aneurysmal Degeneration Related to Neurofibromatosis Type 1. Vasc Endovascular Surg 2019; 53:497-500. [PMID: 31043138 DOI: 10.1177/1538574419846711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present a case of an 18-year-old female with neurofibromatosis type 1 who presented with abdominal pain and weight loss secondary to chronic mesenteric ischemia due to celiac axis occlusion and was subsequently found to have multiple visceral artery aneurysms. Of clinical significance, 2 aneurysms of the right renal artery were noted at the hilum, with the larger one having a diameter of 2.4 cm. After initial endovascular treatment with stenting of a concurrent pancreaticoduodenal artery pseudoaneurysm, staged aorto-hepatic bypass and right nephrectomy with renal autotransplantation after back table resection of the aneurysmal segments were successfully completed.
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Affiliation(s)
- Natalie A Drucker
- 1 Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Maher F Blaibel
- 2 Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Santosh Nagaraju
- 1 Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,3 Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - S Keisin Wang
- 4 Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - William Goggins
- 1 Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,3 Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andres Fajardo
- 4 Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Te Winkel JP, Drucker NA, Morocho BS, Shelley WC, Markel TA. Interleukin-6 Therapy Improves Intestinal Recovery Following Ischemia. J Surg Res 2019; 239:142-148. [PMID: 30826565 DOI: 10.1016/j.jss.2019.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/20/2019] [Accepted: 02/01/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Interleukin-6 (IL6) has both proinflammatory and anti-inflammatory pathways, but its effects on intestinal recovery following ischemia are unknown. We hypothesized that administration of IL6 following intestinal ischemia would improve mesenteric perfusion and mucosal injury. METHODS Adult male C57Bl6J mice were anesthetized, and a laparotomy was performed. Baseline intestinal perfusion was assessed by laser Doppler imaging. Intestinal ischemia was induced for 60 min by temporarily occluding the superior mesenteric artery. After ischemia, treatments were administered intraperitoneally before closure (Vehicle: 250 μL phosphate-buffered-saline, IL6 low dose (20 ng), IL6 medium dose (200 ng), or IL6 high dose (2 μg)). Animals were allowed to recover for 24 h, were reanesthetized, and their mesenteric perfusion was reassessed. Perfusion was expressed as percentage of baseline. Animals were then sacrificed, and the intestines were explanted for histological analysis. Separate frozen samples were homogenized and analyzed by ELISA for vascular endothelial growth factor (VEGF) and interferon gamma-induced protein 10. RESULTS IL6 increased mesenteric perfusion in low dose groups only, whereas it improved postischemic mucosal injury scores in both low and medium dose groups. No differences in perfusion or histology were seen when high dose IL6 was utilized. Intestinal VEGF was higher in the low dose IL6 group compared to vehicle, whereas IP-10 levels were lower in low and medium dose groups compared to vehicle. No differences were noted compared to vehicle in intestinal VEGF and IP-10 with high dose IL6 therapy. CONCLUSIONS Lower doses of IL6 may serve as effective therapy to decrease intestinal injury after ischemia. Further studies are needed to elucidate the downstream mechanisms before widespread clinical use.
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Affiliation(s)
- Jan P Te Winkel
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana; The Indiana University School of Medicine, Indianapolis, Indiana
| | - Natalie A Drucker
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana; The Indiana University School of Medicine, Indianapolis, Indiana
| | - Bryant S Morocho
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana; The Indiana University School of Medicine, Indianapolis, Indiana
| | - W Christopher Shelley
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana; The Indiana University School of Medicine, Indianapolis, Indiana
| | - Troy A Markel
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana; The Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.
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Abstract
The improved understanding of trauma-induced coagulopathy in adults has led to an evolution in the strategies of damage-control resuscitation. While its impact on the care of pediatric trauma patients is of tremendous interest, the evidence is sparse, and a great deal of research is still needed in this domain. Areas of particular interest include age-related differences in hemostasis and balanced resuscitation, advances in functional coagulation assays and effective adjunctive medications, such as tranexamic acid, for hemorrhage control. This review examines the available pediatric data, reviews applicable adult data, and introduces areas of investigation that will impact pediatric trauma care in the future.
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Affiliation(s)
- Natalie A Drucker
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children, Indianapolis, IN, United States
| | - S Keisin Wang
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children, Indianapolis, IN, United States
| | - Christopher Newton
- Department Surgery, Children's Hospital of Oakland, Oakland, CA, United States.
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Drucker NA, Jensen AR, Te Winkel JP, Markel TA. Hydrogen Sulfide Donor GYY4137 Acts Through Endothelial Nitric Oxide to Protect Intestine in Murine Models of Necrotizing Enterocolitis and Intestinal Ischemia. J Surg Res 2018; 234:294-302. [PMID: 30527488 DOI: 10.1016/j.jss.2018.08.048] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 08/01/2018] [Accepted: 08/24/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) in premature infants is often a devastating surgical condition with poor outcomes. GYY4137 is a long-acting donor of hydrogen sulfide, a gasotransmitter that is protective against intestinal injury in experimental NEC, likely through protection against injury secondary to ischemia. We hypothesized that administration of GYY4137 would improve mesenteric perfusion, reduce intestinal injury, and reduce inflammatory responses in experimental NEC and ischemia-reperfusion injury, and that these benefits would be mediated through endothelial nitric oxide synthase-dependent pathways. METHODS NEC was induced in C57BL/6 wild-type (WT) and endothelial nitric oxide synthase (eNOS) knockout (eNOSKO) pups via maternal separation, formula feeding, enteral lipopolysaccharide, and intermittent hypoxic and hypothermic stress. Pups received daily intraperitoneal injections of 50 mg/kg GYY4137 or phosphate buffered saline vehicle. In separate groups, adult male WT and eNOSKO mice underwent superior mesenteric artery occlusion for 60 min. Before abdominal closure, 50 mg/kg GYY4137 or phosphate buffered saline vehicle was administered into the peritoneal cavity. Laser doppler imaging was used to assess mesenteric perfusion of pups at baseline and on postnatal day 9, and the adult mice at baseline and 24 h after ischemic insult. After euthanasia, the terminal ileum of each animal was fixed, paraffin embedded, sectioned, and stained with hematoxylin and eosin. Sections were blindly graded using published injury scores. Intestinal tissue was homogenized and cytokines measured by ELISA. Data were compared using Mann-Whitney U test, and P-values <0.05 were significant. RESULTS After NEC and ischemia reperfusion (I/R) injury, GYY4137 improved perfusion in WT mice compared to vehicle, but this effect was lost in the eNOSKO animals. Histologic injury followed a similar pattern with reduced intestinal injury in WT mice treated with GYY4137, and no significant improvement in the eNOSKO group. Cytokine expression after GYY4137 administration was altered by the ablation of eNOS in both NEC and I/R injury groups, with significant differences noted in Interleukin 6 and vascular endothelial growth factor. CONCLUSIONS GYY4137, a long-acting donor of hydrogen sulfide, has potential as a therapeutic compound for NEC. It improves mesenteric perfusion and intestinal injury in experimental NEC and intestinal I/R injury, and these benefits appear to be mediated through eNOS-dependent pathways.
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Affiliation(s)
- Natalie A Drucker
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Amanda R Jensen
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jan P Te Winkel
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Troy A Markel
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
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Wang SK, Drucker NA, Raymond JL, Rouse TM, Fajardo A, Lemmon GW, Dalsing MC, Gray BW. Long-term outcomes after pediatric peripheral revascularization secondary to trauma at an urban level I center. J Vasc Surg 2018; 69:857-862. [PMID: 30292605 DOI: 10.1016/j.jvs.2018.07.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The purpose of this investigation was to determine our limb-related contemporary pediatric revascularization perioperative and follow-up outcomes after major blunt and penetrating trauma. METHODS A retrospective review was performed of a prospectively maintained pediatric trauma database spanning January 2010 to December 2017 to capture all level I trauma activations that resulted in a peripheral arterial revascularization procedure. All preoperative, intraoperative, and postoperative continuous variables are reported as a mean ± standard deviation; categorical variables are reported as a percentage of the population of interest. RESULTS During the study period, 1399 level I trauma activations occurred at a large-volume, urban children's hospital. The vascular surgery service was consulted in 2.6% (n = 36) of these cases for suspected vascular injury based on imaging or physical examination. Our study population included only patients who received an arterial revascularization, which was performed in 23 of the 36 consultations (1.6% of total traumas; median age, 11 years). These injuries were localized to the upper extremity in 60.9% (n = 14), lower extremity in 30.4% (n = 7), and neck in 8.7% (n = 2). The mean Injury Severity Score in the revascularized cohort was 14.0 (±7.6). Bone fractures were associated with 39.1% of the vascular injuries (90% of blunt injuries). Restoration of in-line flow was achieved by an endovascular solution in one patient and open surgery in the remainder, consisting of arterial bypass in 59.1% and direct repair in 40.9%. Within 30 days of the operation, we observed no deaths, no infections of the arterial reconstruction, and no major amputations. One patient required perioperative reintervention by the vascular team secondary to the development of a superficial seroma without evidence of graft involvement. Mean follow-up in our cohort was 43.3 (±35.4) months. During this phase, no additional deaths, amputations, chronic wounds, or limb length discrepancies were observed. All vascular repairs were patent, and all but one patient reported normal function of the affected limb at the latest clinic visit. CONCLUSIONS Traumatic peripheral vascular injury is rare in the pediatric population but is often observed secondary to a penetrating force or after long bone fracture. However, contemporary perioperative and long-term outcomes after surgical revascularization are excellent as demonstrated in this institutional case series.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind.
| | - Natalie A Drucker
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Jodi L Raymond
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Thomas M Rouse
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Gary W Lemmon
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael C Dalsing
- Division of Vascular Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
| | - Brian W Gray
- Division of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Ind
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Wang SK, Drucker NA, Sawchuk AP, Lemmon GW, Dalsing MC, Motaganahalli RL, Murphy MP, Fajardo A. Use of the Zenith Fenestrated platform to rescue failing endovascular and open aortic reconstructions is safe and technically feasible. J Vasc Surg 2018; 68:1017-1022. [DOI: 10.1016/j.jvs.2018.01.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/08/2018] [Indexed: 11/30/2022]
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Drucker NA, Winkel JP, Markel TA. Inhibiting Hydrogen Sulfide Production in Stem Cells Reduces Their Protective Effects During Experimental Necrotizing Enterocolitis. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wang SK, Green LA, Gutwein AR, Drucker NA, Murphy MP. Metformin Does Not Reduce Inflammation in AAA and At-Risk Patients. Ann Vasc Surg 2018. [DOI: 10.1016/j.avsg.2018.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Drucker NA, Marine MB, Rescorla FJ. Gastric pneumatosis: An unusual presentation of superior mesenteric artery syndrome. Journal of Pediatric Surgery Case Reports 2018. [DOI: 10.1016/j.epsc.2018.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Drucker NA, Jensen AR, Ferkowicz M, Markel TA. Hydrogen sulfide provides intestinal protection during a murine model of experimental necrotizing enterocolitis. J Pediatr Surg 2018; 53:1692-1698. [PMID: 29338840 DOI: 10.1016/j.jpedsurg.2017.12.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/24/2017] [Accepted: 12/10/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) continues to be a morbid surgical condition among preterm infants. Novel therapies for this condition are desperately needed. Hydrogen sulfide (H2S) is an endogenous gasotransmitter that has been found to have beneficial properties. We therefore hypothesized that intraperitoneal injection of various H2S donors would improve clinical outcomes, increase intestinal perfusion, and reduce intestinal injury in an experimental mouse model of necrotizing enterocolitis. METHODS NEC was induced in five-day-old mouse C57BL/6 mouse pups through maternal separation, formula feeding, and intermittent hypoxic and hypothermic stress. The control group (n=10) remained with their mother and breastfed ad lib. Experimental groups (n=10/group) received intraperitoneal injections of phosphate buffered saline (PBS) vehicle or one of the following H2S donors: (1) GYY4137, 50mg/kg daily; (2) Sodium sulfide (Na2S), 20mg/kg three times daily; (3) AP39, 0.16mg/kg daily. Pups were monitored for weight gain, clinical status, and intestinal perfusion via transcutaneous Laser Doppler Imaging (LDI). After sacrifice on day nine, intestinal appearance and histology were scored and cytokines were measured in tissue homogenates of intestine, liver, and lung. Data were compared with Mann-Whitney and p<0.05 was considered significant. RESULTS Clinical score and weight gain were significantly improved in all three H2S-treated groups as compared to vehicle (p<0.05 for all groups). Intestinal perfusion of the vehicle group was 22% of baseline while the GYY4137 group was 38.7% (p=0.0103), Na2S was 47.0% (p=0.0040), and AP39 was 43.0% (p=0.0018). The vehicle group had a median histology score of 2.5, while the GYY4137 group's was 1 (p=0.0013), Na2S was 0.5 (p=0.0004), and AP39 was 0.5 (p=0.0001). Cytokine analysis of the intestine of the H2S-treated groups revealed levels closer to breastfed pups as compared to vehicle (p<0.05 for all groups). CONCLUSION Intraperitoneal administration of H2S protects against development of NEC by improving mesenteric perfusion, and by limiting mucosal injury and altering the tissue inflammatory response. Further experimentation is necessary to elucidate downstream mechanisms prior to clinical implementation.
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Affiliation(s)
- Natalie A Drucker
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Amanda R Jensen
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Michael Ferkowicz
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Troy A Markel
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; Riley Hospital for Children at Indiana University Health, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN.
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Wang SK, Drucker NA, Gupta AK, Marshalleck FE, Dalsing MC. Diagnosis and management of the venous malformations of Klippel-Trénaunay syndrome. J Vasc Surg Venous Lymphat Disord 2018. [PMID: 28624001 DOI: 10.1016/j.jvsv.2016.10.084] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE A dearth of information exists in the literature regarding current practice in the management of Klippel-Trénaunay syndrome (KTS), a rare condition. We review and describe the etiology, diagnosis, and treatment of KTS. METHODS Relevant data were synthesized from a Medline review using a combination of the keyterms "Klippel" and "Trénaunay." The majority of hits described singular case reports and were subsequently excluded. The remaining papers were then reviewed and included on the basis of the quality of evidence and the authors' discretion. CONCLUSIONS KTS is characterized by a clinical triad of extremity varicosities, cutaneous vascular malformations, and hypertrophy of soft tissues and long bones. The diagnosis is clinically supplemented with magnetic resonance imaging and computed tomography. Although this syndrome is associated with significant comorbidities, such as pain, edema, ulcerations, and pruritus, it is rarely the cause of death. The backbone of treatment is nonoperative in nature but should be supplemented with minimally invasive, endovascular, and rarely open surgical procedures for refractory cases.
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Affiliation(s)
- S Keisin Wang
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind; Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Natalie A Drucker
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Alok K Gupta
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind; Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | | | - Michael C Dalsing
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind; Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind.
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Wang SK, Green LA, Drucker NA, Motaganahalli RL, Fajardo A, Murphy MP. Rationale and design of the Clinical and Histologic Analysis of Mesenchymal Stromal Cells in AmPutations (CHAMP) trial investigating the therapeutic mechanism of mesenchymal stromal cells in the treatment of critical limb ischemia. J Vasc Surg 2018; 68:176-181.e1. [PMID: 29395424 PMCID: PMC6019117 DOI: 10.1016/j.jvs.2017.09.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/29/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Currently, there are no accepted nonsurgical therapies that improve the delivery of blood-derived nutrients to patients with critical limb ischemia. Here, we describe the ongoing phase 1/2 Clinical and Histologic Analysis of Mesenchymal Stromal Cells in AmPutations (CHAMP) trial, which will provide crucial evidence of the safety profile of mesenchymal stromal cells (MSCs) and explore their therapeutic mechanisms in the setting of critical limb ischemia requiring below-knee amputation (BKA). METHODS In the CHAMP and the parallel marrowCHAMP trials (hereafter grouped together as CHAMP), a total of 32 extremities with rest pain or tissue loss requiring BKA will be enrolled to receive intramuscular injections of allogeneic MSCs (CHAMP; n = 16) or autogenous concentrated bone marrow aspirate (marrowCHAMP; n = 16) along the distribution of the BKA myocutaneous flap and proximal tibialis anterior. After treatment, subjects are randomized to BKA at four time points after injection (days 3, 7, 14, and 21). At the time of amputation, skeletal muscle is collected at 2-cm increments from the tibialis injection site and used to determine proangiogenic cytokine description, MSC retention, quantification of proangiogenic hematopoietic progenitor cells, and histologic description. Clinical limb perfusion before and after treatment will be quantified using transcutaneous oximetry, toe-brachial index, ankle-brachial index, and indocyanine angiography. Additional clinical end points include all-cause mortality, need for amputation revision, and gangrene incidence during the 6-month post-treatment follow-up. RESULTS Enrollment is under way, with 10 patients treated per protocol thus far. We anticipate full conclusion of follow-up within the next 24 months. CONCLUSIONS CHAMP will be pivotal in characterizing the safety, efficacy, and, most important, therapeutic mechanism of allogeneic MSCs and autogenous concentrated bone marrow aspirate in ischemic skeletal muscle.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind
| | - Linden A Green
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind
| | - Natalie A Drucker
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind.
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Wang SK, Murphy MP, Gutwein AR, Drucker NA, Dalsing MC, Motaganahalli RL, Lemmon GW, Akingba AG. Perioperative Outcomes are Adversely Affected by Poor Pretransfer Adherence to Acute Limb Ischemia Practice Guidelines. Ann Vasc Surg 2018; 50:46-51. [DOI: 10.1016/j.avsg.2017.11.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/26/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
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Wang SK, Drucker NA, Dalsing MC, Sawchuk AP, Gupta AK, Motaganahalli RL, Murphy MP, Fajardo A. Adjunctive visceral artery chimney in patients undergoing Zenith Fenestrated aortic repair. J Vasc Surg 2018; 68:1688-1695. [PMID: 29929822 DOI: 10.1016/j.jvs.2018.03.421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/29/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Visceral artery chimneys have been employed as an adjunct to endovascular aneurysm repair (EVAR) to treat short-neck infrarenal and juxtarenal aortic aneurysms for more than two decades. With the widespread introduction of fenestrated endovascular aneurysm repair by the Food and Drug Administration-approved Zenith Fenestrated endograft (ZFEN; Cook Medical, Bloomington, Ind) to the United States in 2012, clinicians gained the ability to apply the chimney technique to these custom devices for difficult anatomy. The purpose of this report was to demonstrate feasibility and to provide evidence on the performance of chimneys for the treatment of complex juxtarenal aneurysms that could not be adequately treated with ZFEN alone. METHODS A retrospective analysis was performed of a prospectively maintained institutional ZFEN database capturing 110 fenestrated endovascular aneurysm repairs from October 2012 to January 2018 to identify patients undergoing a concomitant visceral artery chimney. All patients with <12 months of follow-up were excluded from further analysis. Demographic, anatomic, intraoperative, perioperative, and follow-up characteristics were tabulated and analyzed. RESULTS Six patients met criteria and were included in this investigation. They were universally male with a mean age of 76.2 years at the time of ZFEN/chimney. Chimneys were placed in a total of six visceral arteries (n = 1 per patient) consisting of three renal arteries, two celiac arteries, and one accessory renal artery. Mean estimated blood loss and operative time were 283 mL and 298 minutes, respectively. Technical success was achieved in all cases. Two small type IA "gutter" endoleaks were detected early; both spontaneously resolved on follow-up. We observed no instances of chimney migration, stenosis, or thrombosis perioperatively or on follow-up. Two reinterventions were performed in these six patients; these consisted of a repeated renal stent for ostial stenosis at a main body fenestration and a common femoral artery endarterectomy and patch angioplasty for an access-related common femoral artery occlusion. CONCLUSIONS Use of ZFEN in conjunction with a singular chimney is safe, feasible, and durable in patients with difficult anatomy who do not meet instructions for use as demonstrated in this limited series.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Natalie A Drucker
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael C Dalsing
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Alan P Sawchuk
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Alok K Gupta
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind.
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Drucker NA, Jensen AR, Te Winkel JP, Ferkowicz MJ, Markel TA. Loss of endothelial nitric oxide synthase exacerbates intestinal and lung injury in experimental necrotizing enterocolitis. J Pediatr Surg 2018; 53:1208-1214. [PMID: 29618412 PMCID: PMC5994357 DOI: 10.1016/j.jpedsurg.2018.02.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 02/27/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) continues to be a devastating condition among preterm infants. Nitric oxide, which is synthesized in the intestine by endothelial nitric oxide synthase (eNOS), acts as a potent vasodilator and antioxidant within the mesentery and may play a role in prevention of NEC. We hypothesized that loss of endothelial nitric oxide would worsen both intestinal and associated lung injury and increase local and systemic inflammation during experimental NEC. METHODS NEC was induced in five-day-old wild type (WT) and eNOS-knockout (eNOSKO) mouse pups. Experimental groups (n=10) were formula fed and subjected to intermittent hypoxic and hypothermic stress, while control groups (n=10) remained with their mother to breastfeed. Pups were monitored by daily clinical assessment. After sacrifice on day nine, intestine and lung were assessed for injury, and cytokines were measured in tissue homogenates by ELISA. Data were compared with Mann-Whitney, and p<0.05 was significant. RESULTS Each NEC group was compared to its respective strain's breastfed control to facilitate comparisons between the groups. Both NEC groups were significantly sicker than their breastfed controls. eNOSKO NEC animals had a median clinical assessment score of 3 (IQR=1-5), and the WT NEC animal's median score was 3 (IQR=2-5). Despite similar clinical scores, intestinal injury was significantly worse in the eNOSKO NEC groups compared to WT NEC groups (median injury scores of 3.25 (IQR=2.25-3.625) and 2 (IQR=1-3), respectively (p=0.0474). Associated lung injury was significantly worse in the eNOSKO NEC group as compared to the WT NEC group (median scores of 8.5 (IQR=6.75-11.25) and 6.5 (IQR=5-7.5), respectively, p=0.0391). Interestingly, cytokines in both tissues were very different between the two groups, with varying effects noted for each cytokine (IL-6, IL-1β, VEGF, and IL-12) in both tissues. CONCLUSION Nitric oxide from eNOS plays a key role in preventing the development of NEC. Without eNOS function, both intestinal and lung injuries are more severe, and the inflammatory cascade is significantly altered. Further studies are needed to determine how eNOS-derived nitric oxide facilitates these beneficial effects.
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MESH Headings
- Animals
- Animals, Newborn
- Cytokines/metabolism
- Disease Models, Animal
- Enterocolitis, Necrotizing/enzymology
- Enterocolitis, Necrotizing/pathology
- Enterocolitis, Necrotizing/prevention & control
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/enzymology
- Infant, Premature, Diseases/pathology
- Infant, Premature, Diseases/prevention & control
- Intestinal Mucosa/metabolism
- Intestines/pathology
- Lung Injury/pathology
- Mesentery/metabolism
- Mice
- Nitric Oxide Synthase Type III/metabolism
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Affiliation(s)
- Natalie A Drucker
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Amanda R Jensen
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Jan P Te Winkel
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Michael J Ferkowicz
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN
| | - Troy A Markel
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, IN; Riley Hospital for Children at Indiana University Health, Indianapolis, IN; The Indiana University School of Medicine, Indianapolis, IN.
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Jensen AR, Drucker NA, te Winkel JP, Ferkowicz MJ, Markel TA. The route and timing of hydrogen sulfide therapy critically impacts intestinal recovery following ischemia and reperfusion injury. J Pediatr Surg 2018; 53:1111-1117. [PMID: 29622397 PMCID: PMC5994359 DOI: 10.1016/j.jpedsurg.2018.02.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 02/27/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE Hydrogen sulfide (H2S) has many beneficial properties and may serve as a novel treatment in patients suffering from intestinal ischemia-reperfusion injury (I/R). The purpose of this study was to examine the method of delivery and timing of administration of H2S for intestinal therapy during ischemic injury. We hypothesized that 1) route of administration of hydrogen sulfide would impact intestinal recovery following acute mesenteric ischemia and 2) preischemic H2S conditioning using the optimal mode of administration as determined above would provide superior protection compared to postischemic application. METHODS Male C57BL/6J mice underwent intestinal ischemia by temporary occlusion of the superior mesenteric artery. Following ischemia, animals were treated according to one of the following (N=6 per group): intraperitoneal or intravenous injection of GYY4137 (H2S-releasing donor, 50mg/kg in PBS), vehicle, inhalation of oxygen only, inhalation of 80ppm hydrogen sulfide gas. Following 24-h recovery, perfusion was assessed via laser Doppler imaging, and animals were euthanized. Perfusion and histology data were assessed, and terminal ileum samples were analyzed for cytokine production following ischemia. Once the optimal route of administration was determined, preischemic conditioning with H2S was undertaken using that route of administration. All data were analyzed using Mann-Whitney. P-values <0.05 were significant. RESULTS Mesenteric perfusion following intestinal I/R was superior in mice treated with intraperitoneal (IP) GYY4137 (IP vehicle: 25.6±6.0 vs. IP GYY4137: 79.7±15.1; p=0.02) or intravenous (IV) GYY4137 (IV vehicle: 36.3±5.9 vs. IV GYY4137: 100.7±34.0; p=0.03). This benefit was not observed with inhaled H2S gas (O2 vehicle: 66.6±11.4 vs. H2S gas: 81.8±6.0; p=0.31). However, histological architecture was only preserved with intraperitoneal administration of GYY4127 (IP vehicle: 3.4±0.4 vs. IP GYY4137: 2±0.3; p=0.02). Additionally, IP GYY4137 allowed for significant attenuation of inflammatory chemokine production of IL-6, IP-10 and MIP-2. We then analyzed whether there was a difference between pre- and postischemic administration of IP GYY4137. We found that preconditioning of animals with intraperitoneal GYY4137 only added minor improvements in outcomes compared to postischemic application. CONCLUSION Therapeutic benefits of H2S are superior with intraperitoneal application of an H2S donor compared to other administration routes. Additionally, while intraperitoneal treatment in both the pre- and postischemic period is beneficial, preischemic application of an H2S donor was found to be slightly better. Further studies are needed to examine long term outcomes and further mechanisms of action prior to widespread clinical application. TYPE OF STUDY Basic science. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Amanda R. Jensen
- Department of Surgery, Section of Pediatric Surgery,The Indiana University School of Medicine Indianapolis, IN
| | - Natalie A. Drucker
- Department of Surgery, Section of Pediatric Surgery,The Indiana University School of Medicine Indianapolis, IN
| | - Jan P. te Winkel
- Department of Surgery, Section of Pediatric Surgery,The Indiana University School of Medicine Indianapolis, IN
| | - Michael J. Ferkowicz
- Department of Surgery, Section of Pediatric Surgery,The Indiana University School of Medicine Indianapolis, IN
| | - Troy A. Markel
- Department of Surgery, Section of Pediatric Surgery,Riley Hospital for Children at Indiana University Health,The Indiana University School of Medicine Indianapolis, IN
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Wang SK, Lemmon GW, Drucker NA, Motaganahalli RL, Dalsing MC, Gutwein AR, Gray BW, Murphy MP. Results of nonoperative management of acute limb ischemia in infants. J Vasc Surg 2018; 67:1480-1483. [DOI: 10.1016/j.jvs.2017.09.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
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Wang SK, Green LA, Gutwein AR, Drucker NA, Motaganahalli RL, Gupta AK, Fajardo A, Murphy MP. Description of human AAA by cytokine and immune cell aberrations compared to risk-factor matched controls. Surgery 2018; 164:354-358. [PMID: 29716755 DOI: 10.1016/j.surg.2018.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/01/2018] [Accepted: 03/07/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The pathogenesis driving the formation of abdominal aortic aneurysms continues to be poorly understood. Therefore, we systemically define the cytokine and circulating immune cell environment observed in human abdominal aortic aneurysm compared with risk-factor matched controls. METHODS From 2015 to 2017, a total of 274 patients donated blood to the Indiana University Center for Aortic Disease. Absolute concentrations of circulating cytokines were determined, using enzyme-linked immunosorbent assays while the expression of circulating immune cell phenotypes were assayed via flow cytometric analysis. RESULTS Human abdominal aortic aneurysm is characterized by a significant depletion of the antigen-specific, CD4+ Tr1 regulatory lymphocyte that corresponds to an upregulation of the antigen-specific, inflammatory Th17 cell. We found no differences in the incidence of Treg, B10, and myeloid-derived suppressor regulatory cells. Similarly, no disparities were noted in the following inflammatory cytokines: IL-1β, C-reactive protein, tumor necrosis factor α, interferon γ, and IL-23. However, significant upregulation of the inflammatory cytokines osteopontin, IL-6, and IL-17 were noted. Additionally, no changes were observed in the regulatory cytokines IL-2, IL-4, IL-13, TNF-stimulated gene 6 protein, and prostaglandin E2, but we did observe a significant decrease in the essential regulatory cytokine IL-10. CONCLUSION In this investigation, we systematically characterize the abdominal aortic aneurysm-immune environment and present preliminary evidence that faulty immune regulation may also contribute to aneurysm formation and growth.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Linden A Green
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ashley R Gutwein
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Natalie A Drucker
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alok K Gupta
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael P Murphy
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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Wang SK, Green LA, Gutwein AR, Drucker NA, Babbey CM, Gupta AK, Fajardo A, Motaganahalli RL, Wilson MG, Murphy MP. Ethnic minorities with critical limb ischemia derive equal amputation risk reduction from autologous cell therapy compared with whites. J Vasc Surg 2018; 68:560-566. [PMID: 29503004 DOI: 10.1016/j.jvs.2017.11.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/28/2017] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Ethnic minorities (nonwhites) with critical limb ischemia (CLI) have historically performed worse compared with whites with regard to major amputation risk reduction and amputation-free survival (AFS) after peripheral vascular intervention. This post hoc analysis was completed to determine whether this precedent also extended to treatment of CLI without a suitable revascularization option with intramuscular injections of concentrated bone marrow aspirate (cBMA). METHODS The treatment arm of the randomized, double-blind, multicenter MarrowStim PAD Kit for the Treatment of Critical Limb Ischemia in Subjects with Severe Peripheral Arterial Disease (MOBILE) trial was stratified by ethnicity and evaluated for demographics, comorbidities, and outcomes. The primary and therapeutic end point was 1-year AFS and major amputation, respectively. Noninferiority analysis was performed with the margin set at historically reported hazard ratios. RESULTS Thirty-seven minority (African American, Hispanic, other) CLI patients (9 placebo, 28 cBMA) with no suitable revascularization option were randomized to cBMA or placebo at a 3:1 ratio during the MOBILE trial. At 1-year follow-up for the treatment group, overall AFS was 80%. Of the 28 minority patients randomized to cBMA intervention, an 89% AFS rate was observed compared with 77% in whites. Specifically, 22 of 24 (92%) African Americans survived amputation free at 1-year follow-up. Noninferiority testing confirmed no difference between whites and the ethnic minority treated with cBMA with respect to major amputation reduction; however, noninferiority could not be confirmed with regard to AFS. No significant differences favoring whites treated with cBMA were noted in the secondary end points of vascular quality of life, limb pain, ankle-brachial index, toe-brachial index, transcutaneous oximetry, and 6-minute walk testing. CONCLUSIONS This post hoc analysis of the MOBILE trial demonstrates noninferiority of cBMA intervention in minorities with no-option CLI for the therapeutic end point of major amputation prevention. cBMA represents a novel treatment paradigm and should be explored for minorities with poor revascularization options who face impending amputation secondary to progressive CLI.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Linden A Green
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Ashley R Gutwein
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Natalie A Drucker
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Clifford M Babbey
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Alok K Gupta
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael G Wilson
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind.
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Wang SK, Gutwein AR, Drucker NA, Murphy MP, Fajardo A, Dalsing MC, Motaganahalli RL, Lemmon GW. Cryopreserved Homografts in Infected Infrainguinal Fields Are Associated with Frequent Reinterventions and Poor Amputation-Free Survival. Ann Vasc Surg 2018; 49:24-29. [PMID: 29421428 DOI: 10.1016/j.avsg.2017.10.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/10/2017] [Accepted: 10/16/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Single-length saphenous vein continues to be the conduit of choice in infected-field critical limb ischemia. However, half of these individuals have inadequate vein secondary to previous use or chronic venous disease. We reviewed our outcomes of infected-field infrainguinal bypasses performed with cryopreserved homografts (CHs), a widely accepted alternative to autogenous vein in this setting. METHODS This is a retrospective, institutional descriptive analysis of infected-field infrainguinal revascularizations between 2012 and 2015. RESULTS Twenty-four operations were performed in the same number of patients for limb ischemia with signs of active infection. The mean age of the cohort examined was 62.5 ± 14.4 (standard deviation) years. Mean Society of Vascular Surgery risk score was 3.9 with a baseline Rutherford's chronic ischemia score of 4.3 at presentation. Emergent procedures constituted 29% of cases, and the remainder cases were urgent procedures. The CH bypass captured was a reoperative procedure in all but one of the patients. Culture positivity was present in 75% of cases with Staphylococcus aureus (29%), the most commonly isolated organism. Thirty-day mortality and major adverse cardiovascular events were both 4%. Amputation-free survival (AFS) was 75% at 30 days. Similarly, 30-day reintervention was 38% with debridement (43%) and bleeding (29%), the most common indications. Average duration of follow-up was 27.9 ± 20.4 months (range: 0.5-60.4). Mean length of stay was 14.8 days. Reinfection requiring an additional procedure or antibiotic regimen separate from the index antibiotic course was 13%. Primary patency and AFS at 1 year was 50% and 58%, respectively. Primary patency and AFS at 2 years was 38% and 52%, respectively. Limb salvage at 1 and 2 years was 70% and 65%, respectively. Fifteen patients (63%) required reintervention during the follow-up period with 40% of those subjects undergoing multiple procedures. CONCLUSIONS CHs remain a marginal salvage conduit in the setting of infection and no autogenous choices. Therefore, clinicians should individualize usage of this high-cost product in highly selected patients only.
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Affiliation(s)
- S Keisin Wang
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
| | - Ashley R Gutwein
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Natalie A Drucker
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael P Murphy
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Andres Fajardo
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael C Dalsing
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Raghu L Motaganahalli
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Gary W Lemmon
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
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Abstract
Stem cell therapy is a promising treatment modality for necrotizing enterocolitis. Among the many promising stem cells identified to date, it is likely that mesenchymal stem cells will be the most useful and practical cell-based therapies for this condition. Using acellular components such as exosomes or other paracrine mediators are promising as well. Multiple mechanisms are likely at play in the positive effects provided by these cells, and further research is underway to further elucidate these effects.
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Affiliation(s)
- Natalie A. Drucker
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children, Indianapolis, IN
| | - Christopher J. McCulloh
- Department of Pediatric Surgery, Center for Perinatal Research, Nationwide Children’s Hospital, Columbus, OH
| | - Bo Li
- Division of General and Thoracic Surgery, Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gail E. Besner
- Department of Pediatric Surgery, Center for Perinatal Research, Nationwide Children’s Hospital, Columbus, OH
| | - Troy A. Markel
- Department of Surgery, Section of Pediatric Surgery, Riley Hospital for Children, Indianapolis, IN
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Jensen AR, Drucker NA, Ferkowicz MJ, Markel TA. Umbilical mesenchymal stromal cells provide intestinal protection through nitric oxide dependent pathways. J Surg Res 2017; 224:148-155. [PMID: 29506832 DOI: 10.1016/j.jss.2017.11.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/31/2017] [Accepted: 11/29/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Umbilical-derived mesenchymal stromal cells (USCs) have shown promise in the protection of ischemic organs. We hypothesized that USCs would improve mesenteric perfusion, preserve intestinal histological architecture, and limit inflammation by nitric oxide-dependent mechanisms following intestinal ischemia/reperfusion (IR) injury. METHODS Adult wild-type C57BL/6J (WT) and endothelial nitric oxide synthase knock out (eNOS KO) mice were used: (1) WT IR + vehicle, (2) WT IR + USC, (3) eNOS KO IR + vehicle, and (4) eNOS KO IR + USC. Mice were anesthetized, and a midline laparotomy was performed. The superior mesenteric artery was clamped with a nonoccluding clamp for 60-min. Following IR, mice were treated with an injection of 250 μL phosphate buffered saline or 2 × 106 USCs suspended in 250-μL phosphate buffered saline solution. Mesenteric perfusion images were acquired using laser Doppler imaging. Perfusion was analyzed as a percentage of baseline. At 24 h, mice were euthanized, and intestines were harvested. Intestines were evaluated for injury, and data were analyzed using the Mann-Whitney or Kruskal-Wallis tests. RESULTS Intestinal mesenteric perfusion was significantly improved in WT mice treated with USC therapy compared with eNOS KOs. Intestinal histological architecture was preserved with USC therapy in WT mice. However, in eNOS KO mice, this benefit was abolished. Finally, the presence of several cytokines and growth factors were significantly improved in WT mice compared with eNOS KO mice treated with USCs. CONCLUSIONS The benefits of USC-mediated therapy following intestinal IR injury likely occur via nitric oxide-dependent pathways. Further studies are required to define the molecular mechanisms by which USCs activate endothelial nitric oxide synthase to bring about their protective effects.
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Affiliation(s)
- Amanda R Jensen
- Section of Pediatric Surgery, Department of Surgery, Indianapolis, Indiana; The Indiana University School of Medicine, Indianapolis, Indiana
| | - Natalie A Drucker
- Section of Pediatric Surgery, Department of Surgery, Indianapolis, Indiana; The Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael J Ferkowicz
- Section of Pediatric Surgery, Department of Surgery, Indianapolis, Indiana; The Indiana University School of Medicine, Indianapolis, Indiana
| | - Troy A Markel
- Section of Pediatric Surgery, Department of Surgery, Indianapolis, Indiana; The Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.
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Drucker NA, McDuffie L, Groh E, Hackworth J, Bell TM, Markel TA. Physical Examination is the Best Predictor of the Need for Abdominal Surgery in Children Following Motor Vehicle Collision. J Emerg Med 2017; 54:1-7. [PMID: 29107481 DOI: 10.1016/j.jemermed.2017.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/28/2017] [Accepted: 08/08/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Exploratory laparotomy in children after motor vehicle collision (MVC) is rare. In the absence of definitive hemorrhage or free abdominal air on radiographic imaging, predictors for operative exploration are conflicting. OBJECTIVE The purpose of this study was to explore objective findings that may aid in determining which children require operative abdominal exploration after MVC. METHODS Data from 2010-2014 at an American College of Surgeons-certified level 1 pediatric trauma center were retrospectively reviewed. Demographics, vital signs, laboratory data, radiologic studies, operative records, associated injuries, and outcomes were analyzed and p < 0.05 was considered statistically significant. RESULTS Eight hundred sixty-two patients 0-18 years of age presented to the hospital after an MVC during the study period. Seventeen patients (2.0%) required abdominal exploration and all were found to have intraabdominal injuries. Respiratory rate was the only vital sign that was significantly altered (p = 0.04) in those who required abdominal surgery compared with those who did not. Physical examination findings, such as the seat belt sign, abdominal bruising, abdominal wound, and abdominal tenderness, were present significantly more frequently in those requiring abdominal surgery (p < 0.0001). Each finding had a negative predictive value for the need for operative exploration of at least 0.98. There were no significant differences in trauma laboratory values or radiographic findings between the 2 groups. CONCLUSION Data from this study solidify the relationship between specific physical examination findings and the need for abdominal exploration after MVC in children. In addition, these data suggest that a lack of the seat belt sign, abdominal bruising, abdominal wounds, or abdominal tenderness are individually predictive of patients who will not require surgical intervention.
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Affiliation(s)
- Natalie A Drucker
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Lucas McDuffie
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Eric Groh
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Jodi Hackworth
- Riley Hospital for Children, Indiana University Health, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Teresa M Bell
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Troy A Markel
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana; Riley Hospital for Children, Indiana University Health, Section of Pediatric Surgery, Indianapolis, Indiana; Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana
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Wang SK, Green LA, Gutwein AR, Drucker NA, Motaganahalli RL, Fajardo A, Babbey CM, Murphy MP. Rationale and Design of the ARREST Trial Investigating Mesenchymal Stem Cells in the Treatment of Small Abdominal Aortic Aneurysm. Ann Vasc Surg 2017; 47:230-237. [PMID: 28916304 DOI: 10.1016/j.avsg.2017.08.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/21/2017] [Accepted: 08/27/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Abdominal aortic aneurysms (AAAs) are a major source of morbidity and mortality despite continuing advances in surgical technique and care. Although the inciting factors for AAA development continue to be elusive, accumulating evidence suggests a significant periaortic inflammatory response leading to degradation and dilation of the aortic wall. Previous human trials have demonstrated safety and efficacy of mesenchymal stem cells (MSCs) in the treatment of inflammation-related pathologies such as rheumatoid arthritis, graft versus host disease, and transplant rejection. Therefore, herein, we describe the Aortic Aneurysm Repression with Mesenchymal Stem Cells (ARREST) trial, a phase I investigation into the safety of MSC infusion for patients with small AAA and the cells' effects on modulation of AAA-related inflammation. METHODS ARREST is a phase I, single-center, double-blind, randomized controlled trial (RCT) investigating infusion both dilute and concentrated MSCs compared to placebo in 36 small AAA (35-45 mm) patients. Subjects will be followed by study personnel for 12 months to ascertain incidence of adverse events, immune cell phenotype expression, peripheral cytokine profile, and periaortic inflammation. Maximum transverse aortic diameter will be assessed regularly for 5 years by a combination of computed tomography and duplex sonography. RESULTS Four patients have thus far been enrolled, randomized, and treated per protocol. We anticipate the conclusion of the treatment phase within the next 24 months with ongoing long-term follow-up. CONCLUSIONS ARREST will be pivotal in assessing the safety of MSC infusion and provide preliminary data on the ability of MSCs to favorably modulate the pathogenic AAA host immune response. The data gleaned from this phase I trial will provide the groundwork for a larger, phase III RCT which may provide the first pharmaceutical intervention for AAA.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Linden A Green
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Ashley R Gutwein
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Natalie A Drucker
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Clifford M Babbey
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Michael P Murphy
- Division of Vascular Surgery, Department of Surgery, IU Health Center for Aortic Disease, Indiana University School of Medicine, Indianapolis, IN; VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Richard L. Roudebush VA Medical Center, Indianapolis, IN.
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Jensen AR, Drucker NA, Khaneki S, Ferkowicz MJ, Markel TA. Hydrogen sulfide improves intestinal recovery following ischemia by endothelial nitric oxide-dependent mechanisms. Am J Physiol Gastrointest Liver Physiol 2017; 312:G450-G456. [PMID: 28280145 PMCID: PMC5451562 DOI: 10.1152/ajpgi.00444.2016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/02/2017] [Accepted: 03/03/2017] [Indexed: 01/31/2023]
Abstract
Hydrogen sulfide (H2S) is an endogenous gasotransmitter that has vasodilatory properties. It may be a novel therapy for intestinal ischemia-reperfusion (I/R) injury. We hypothesized that 1) H2S would improve postischemic survival, mesenteric perfusion, mucosal injury, and inflammation compared with vehicle and 2) the benefits of H2S would be mediated through endothelial nitric oxide. C57BL/6J wild-type and endothelial nitric oxide synthase knockout (eNOS KO) mice were anesthetized, and a midline laparotomy was performed. Intestines were eviscerated, the small bowel mesenteric root identified, and baseline intestinal perfusion was determined using laser Doppler. Intestinal ischemia was established by temporarily occluding the superior mesenteric artery. Following ischemia, the clamp was removed, and the intestines were allowed to recover. Either sodium hydrosulfide (2 nmol/kg or 2 µmol/kg NaHS) in PBS vehicle or vehicle only was injected into the peritoneum. Animals were allowed to recover and were assessed for mesenteric perfusion, mucosal injury, and intestinal cytokines. P values < 0.05 were significant. H2S improved mesenteric perfusion and mucosal injury scores following I/R injury. However, in the setting of eNOS ablation, there was no improvement in these parameters with H2S therapy. Application of H2S also resulted in lower levels of intestinal cytokine production following I/R. Intraperitoneal H2S therapy can improve mesenteric perfusion, intestinal mucosal injury, and intestinal inflammation following I/R. The benefits of H2S appear to be mediated through endothelial nitric oxide-dependent pathways.NEW & NOTEWORTHY H2S is a gaseous mediator that acts as an anti-inflammatory agent contributing to gastrointestinal mucosal defense. It promotes vascular dilation, mucosal repair, and resolution of inflammation following intestinal ischemia and may be exploited as a novel therapeutic agent. It is unclear whether H2S works through nitric oxide-dependent pathways in the intestine. We appreciate that H2S was able to improve postischemic recovery of mesenteric perfusion, mucosal integrity, and inflammation. The beneficial effects of H2S appear to be mediated through endothelial nitric oxide-dependent pathways.
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Affiliation(s)
- Amanda R. Jensen
- 1Section of Pediatric Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; ,3Indiana University School of Medicine, Indianapolis, Indiana
| | - Natalie A. Drucker
- 1Section of Pediatric Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; ,3Indiana University School of Medicine, Indianapolis, Indiana
| | - Sina Khaneki
- 1Section of Pediatric Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana;
| | - Michael J. Ferkowicz
- 1Section of Pediatric Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; ,3Indiana University School of Medicine, Indianapolis, Indiana
| | - Troy A. Markel
- 1Section of Pediatric Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; ,2Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana; and ,3Indiana University School of Medicine, Indianapolis, Indiana
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Jensen AR, Manning MM, Khaneki S, Drucker NA, Markel TA. Harvest tissue source does not alter the protective power of stromal cell therapy after intestinal ischemia and reperfusion injury. J Surg Res 2016; 204:361-370. [PMID: 27565072 DOI: 10.1016/j.jss.2016.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 04/29/2016] [Accepted: 05/03/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Transplantation of mesenchymal stromal cells (MSCs) may be a novel treatment for intestinal ischemia. The optimal stromal cell source that could yield maximal protection after injury, however, has not been identified. We hypothesized that (1) MSCs would increase survival and mesenteric perfusion, preserve intestinal histologic architecture, and limit inflammation after intestinal ischemia and reperfusion (I/R) injury, and (2) MSCs harvested from different sources of tissue would have equivalent protective properties to the intestine after I/R inury. METHODS Adult male mice were anesthetized, and a midline laparotomy was performed. The intestines were eviscerated, the small bowel mesenteric root was identified, and baseline intestinal perfusion was determined using laser Doppler imaging. Intestinal ischemia was established by temporarily occluding the superior mesenteric artery for 60 min with a noncrushing clamp. After ischemia, the clamp was removed and the intestines were allowed to recover. Before abdominal closure, 2 × 10(6) human umbilical cord-derived MSCs, bone marrow-derived MSCs, or keratinocytes in 250 μL of phosphate-buffered saline vehicle were injected into the peritoneum. Animals were allowed to recover for 12 or 24 h (perfusion, histology, and inflammatory studies) or 7 d (survival studies). Survival data was analyzed using the log-rank test. Perfusion was expressed as a percentage of the baseline, and 12- and 24-h data was analyzed using one-way analysis of variance and the Student t-test. Nonparametric data was compared using the Mann-Whitney U-test. A P value of <0.05 was considered statistically significant. RESULTS All MSCs increased 7-d survival after I/R injury and were superior to vehicle and keratinocytes (P < 0.05). All MSCs increased mesenteric perfusion more than vehicle at 12 and 24 h after injury (P < 0.05). All MSCs provided superior perfusion compared with keratinocytes at 24 h after injury (P < 0.05). Administration of each MSC line improved intestinal histology after I/R injury (P < 0.05). Multiple proinflammatory chemokines were downregulated after the application of MSCs, suggesting a decreased inflammatory response after MSC therapy. CONCLUSIONS Transplantation of MSCs after intestinal I/R injury, irrespective of a tissue source, significantly increases survival and mesenteric perfusion and at the same time limits intestinal damage and inflammation. Further studies are needed to identify the mechanism that these cells use to promote improved outcomes after injury.
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Affiliation(s)
- Amanda R Jensen
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana; Indiana University School of Medicine, Indianapolis, Indiana
| | - Morenci M Manning
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana; Indiana University School of Medicine, Indianapolis, Indiana
| | - Sina Khaneki
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Natalie A Drucker
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana; Indiana University School of Medicine, Indianapolis, Indiana
| | - Troy A Markel
- Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana; Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.
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Abstract
A simple and efficient method to convert aldehydes into alpha,beta-unsaturated aldehydes with a two-carbon homologation is presented. Hydroboration of ethoxy acetylene with BH(3).SMe(2) generates tris(ethoxyvinyl) borane. Transmetalation with diethylzinc, addition to aldehydes or ketones, and acidic workup affords enals. When the addition is quenched with anilinium hydrochloride, 1,2-dithioglycol, or acetic anhydride, the unsaturated imine, dithiolane, or 1,1-diacetate is isolated in high yield. These transformations can be performed in a one-pot procedure.
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Affiliation(s)
- Petr Valenta
- P. Roy and Diana T. Vagelos Laboratories, Department of Chemistry, University of Pennsylvania, 231 South 34th Street, Philadelphia, Pennsylvania 19104-6323, USA
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Drucker NA, Newburger JW. Viral myocarditis: diagnosis and management. Adv Pediatr 1997; 44:141-71. [PMID: 9265970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Drucker NA, Colan SD, Lewis AB, Beiser AS, Wessel DL, Takahashi M, Baker AL, Perez-Atayde AR, Newburger JW. Gamma-globulin treatment of acute myocarditis in the pediatric population. Circulation 1994; 89:252-7. [PMID: 8281654 DOI: 10.1161/01.cir.89.1.252] [Citation(s) in RCA: 302] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Myocardial damage in myocarditis is mediated, in part, by immunological mechanisms. High-dose intravenous gamma-globulin (IVIG) is an immunomodulatory agent that is beneficial in myocarditis secondary to Kawasaki disease, as well as in murine myocarditis. Since 1990, the routine management of presumed acute myocarditis at Children's Hospital, Boston, and Children's Hospital, Los Angeles, has included administration of high-dose IVIG. METHODS AND RESULTS We treated 21 consecutive children presenting with presumed acute myocarditis with IVIG, 2 g/kg, over 24 hours, in addition to anticongestive therapies. A comparison group comprised 25 recent historical control patients meeting identical eligibility criteria but not receiving IVIG therapy. Left ventricular function was assessed during five time intervals: 0 to 7 days, 1 to 3 weeks, 3 weeks to 3 months, 3 to 6 months, and 6 to 12 months. At presentation, the IVIG and non-IVIG groups had comparable left ventricular enlargement and poor fractional shortening. Compared with the non-IVIG group, those treated with IVIG had a smaller mean adjusted left ventricular end-diastolic dimension and higher fractional shortening in the periods from 3 to 6 months (P = .008 and P = .033, respectively) and 6 to 12 months (P = .072 and P = .029, respectively). When adjusting for age, biopsy status, intravenous inotropic agents, and angiotensin-converting enzyme inhibitors, patients treated with IVIG were more likely to achieve normal left ventricular function during the first year after presentation (P = .03). By 1 year after presentation, the probability of survival tended to be higher among IVIG-treated patients (.84 versus .60, P = .069). We observed no adverse effects of IVIG administration. CONCLUSIONS These data suggest that use of high-dose IVIG for treatment of acute myocarditis is associated with improved recovery of left ventricular function and with a tendency to better survival during the first year after presentation.
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Affiliation(s)
- N A Drucker
- Department of Cardiology, Children's Hospital, Boston, Mass. 02115
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Abstract
The question addressed in this study was whether exogenous insulin can enhance the rate of assimilation of blood glucose after prolonged hypovolemia when homeostasis is waning. Twenty-three well-fed mongrel dogs were maintained at a mean arterial blood pressure of 50 mm Hg by bleeding. Periodic analyses were made of arterial and venous plasma concentration of glucose, femoral blood flow, arterial plasma concentration of insulin, and hematocrit. At the onset of physiologic deterioration signaled by the need to reinfuse 50 ml of shed blood to maintain 50 mm Hg blood pressure, dogs received either 10 ml saline (control; n=15) or 10 ml saline containing 2 units insulin (treated; n=8). Administration of 2 units of insulin to eight of the dogs caused a significantly faster decline of blood glucose than that observed in saline-treated animals. Despite the more rapid decline in plasma concentration of glucose in animals that received insulin, there was no significant difference in glucose uptake between the two groups of animals. The hemoconcentration reflected by a rising hematocrit that develops when hypovolemia persists was accentuated by the administration of insulin without supplementary fluids. The absence of any effect of insulin on glucose uptake in the hindlimb in the late phase of hypovolemic shock suggests that the accelerated decline in arterial glucose levels may be due to inhibitory effects of insulin on hepatic glucose release. These results are not consistent with the resistance of plasma glucose to insulin in the late phases of hypovolemic shock.
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