Genomics Reveals the Origins of Historical Specimens.

Centuries of zoological studies have amassed billions of specimens in collections worldwide. Genomics of these specimens promises to reinvigorate biodiversity research. However, because DNA degrades with age in historical specimens, it is a challenge to obtain genomic data for them and analyze degraded genomes. We developed experimental and computational protocols to overcome these challenges and applied our methods to resolve a series of long-standing controversies involving a group of butterflies. We deduced the geographical origins of several historical specimens of uncertain provenance that are at the heart of these debates. Here, genomics tackles one of the greatest problems in zoology: countless old specimens that serve as irreplaceable embodiments of species concepts cannot be confidently assigned to extant species or population due to the lack of diagnostic morphological features and clear documentation of the collection locality. The ability to determine where they were collected will resolve many on-going disputes. More broadly, we show the utility of applying genomics to historical museum specimens to delineate the boundaries of species and populations, and to hypothesize about genotypic determinants of phenotypic traits.

IWATE criteria are associated with perioperative outcomes in robotic hepatectomy: a retrospective review of 225 resections.

BACKGROUND: Robotic hepatectomy (RH) is increasingly utilized for minor and major liver resections. The IWATE criteria were developed to classify minimally invasive liver resections by difficulty. The objective of this study was to apply the IWATE criteria in RH and to describe perioperative and oncologic outcomes of RH over the last decade at our institution. METHODS: Perioperative and oncologic outcomes of patients who underwent RH between 2011 and 2019 were retrospectively collected. The difficulty level of each operation was assessed using the IWATE criteria, and outcomes were compared at each level. Univariate linear regression was performed to characterize the relationship between IWATE criteria and perioperative outcomes (OR time, EBL, and LOS), and a multivariable model was also developed to address potential confounding by patient characteristics (age, sex, BMI, prior abdominal surgery, ASA class, and simultaneous non-hepatectomy operation). RESULTS: Two hundred and twenty-five RH were performed. Median IWATE criteria for RH were 6 (IQR 5-9), with low, intermediate, advanced, and expert resections accounting for 23% (n = 51), 34% (n = 77), 32% (n = 72), and 11% (n = 25) of resections, respectively. The majority of resections were parenchymal-sparing approaches, including anatomic segmentectomies and non-anatomic partial resections. 30-day complication rate was 14%, conversion to open surgery occurred in 9 patients (4%), and there were no deaths within 30 days postoperatively. In the univariate linear regression analysis, IWATE criteria were positively associated with OR time, EBL, and LOS. In the multivariable model, IWATE criteria were independently associated with greater OR time, EBL, and LOS. Two-year overall survival for hepatocellular carcinoma and intrahepatic cholangiocarcinoma was 94% and 50%, respectively. CONCLUSION: In conclusion, the IWATE criteria are associated with surgical outcomes after RH. This series highlights the utility of RH for difficult hepatic resections, particularly parenchymal-sparing resections in the posterosuperior sector, extending the indication of minimally invasive hepatectomy in experienced hands and potentially offering select patients an alternative to open hepatectomy or other less definitive liver-directed treatment options.

Aortic root valve-sparing repair and dissections in Marfans syndrome during pregnancy: A case series.

INTRODUCTION: Marfan syndrome is a connective tissue disorder caused by mutations in the fibrillar FBN-1 gene. Aortic dissection and rupture are major causes of morbidity and mortality and are of special concern during pregnancy. MATERIALS AND METHODS: The authors report four cases of aortic root repair with preservation of the native aortic valve that have has created a discussion between cardiothoracic surgeons, obstetricians, and gynecologists regarding the best care for Marfan syndrome patients. We present these cases here with a review of the literature. RESULTS: Surgery of the aorta and valves in Marfan syndrome is less risky than in previous eras and surgical management guidelines are generally accepted. Yet, we may be unnecessarily referring women to terminate pregnancies or to avoid pregnancy. We believe there may be alternative options for these patients. CONCLUSIONS: Marfan syndrome during pregnancy can be navigated with preconception counseling, antepartum care, and close postpartum follow-up involving an appropriate multidisciplinary team.

Incomplete reporting of enhanced recovery elements and its impact on achieving quality improvement.

BACKGROUND: Enhanced recovery (ER) protocols are used widely in surgical practice. As protocols are multidisciplinary with multiple components, it is difficult to compare and contrast reports. The present study examined compliance and transferability to clinical practice among ER publications related to colorectal surgery. METHODS: PubMed, Embase and Cochrane Central Register databases were searched for current colorectal ER manuscripts. Each publication was assessed for the number of ER elements, whether the element was explained sufficiently so that it could be transferred to clinical practice, and compliance with the ER element. RESULTS: Some 50 publications met the reporting criteria for inclusion. A total of 22 ER elements were described. The median number of elements included in each publication was 9, and the median number of included patients was 130. The elements most commonly included in ER pathways were early postoperative diet advancement (49, 98 per cent) and early mobilization (47, 94 per cent). Early diet advancement was sufficiently explained in 43 (86 per cent) of the 50 publications, but only 22 (45 per cent) of 49 listing the variable reported compliance. The explanation for early mobilization was satisfactory in 41 (82 per cent) of the 50 publications, although only 14 (30 per cent) of 47 listing the variable reported compliance. Other ER elements had similar rates of explanation and compliance. The most frequently analysed outcome measures were morbidity (49, 98 per cent), length of stay (47, 94 per cent) and mortality (45, 90 per cent). CONCLUSION: The current standard of reporting is frequently incomplete. To transfer knowledge and facilitate implementation of pathways that demonstrate improvements in perioperative care and recovery, a consistent structured reporting platform is needed.

Resolving two centuries of mistaken identity: Reinterpretation of Papilio marcus Fabricius, 1787 (Lepidoptera: Nymphalidae, Hesperiidae).

Here, we untangle an oversight surrounding the application of the name Papilio marcus Fabricius, 1787 (Hesperiidae: Hesperiinae), currently in Troyus Warren & Turland, 2012, which has eluded taxonomists for nearly two centuries. First, we note that P. marcus is a junior primary homonym of Papilio marcus Schaller, 1785, a species currently in Morpho Fabricius, 1807 (Nymphalidae: Satyrinae). Second, we designate a lectotype for P. marcus Fabricius, 1787, and recognize it as conspecific with Papilio phyllus Cramer, 1777, a species currently in Vettius Godman, 1901. Therefore, P. marcus is also a junior subjective synonym of V. phyllus (new synonym). Third, aided by genomic sequencing of the lectotype of Vettius phyllides Röber, 1925, we find that this species is not conspecific with V. phyllus and represents instead a valid species of Troyus Warren & Turland, 2012, so that the relative epithet, currently considered as a junior subjective synonym of P. marcus, has to be reappreciated as Troyus phyllides (reinstated status, new combination). Moreover, T. phyllides is apparently the species that has been misidentified as P. marcus since 1832. As a result of this study, the name P. marcus Fabricius nec Cramer falls in synonymy with P. phyllus (currently in Vettius), and the species currently known as T. marcus becomes Troyus phyllides.

Radical nephrectomy and inferior vena caval thrombectomy: outcomes in a lower volume practice.

INTRODUCTION: Surgical volume correlates with improved outcomes for some complex urologic procedures. We reviewed the outcomes of a lower volume practice (1-2 cases per year) experience with radical nephrectomy with infra/retrohepatic vena caval thrombectomy (RNCT). METHODS: We retrospectively reviewed 10 patients who underwent RNCT performed by a single surgeon at a single state institution over 7 years (2002-2009). Patient demographics, presenting symptoms, preoperative imaging, intraoperative findings, pathology, hospital course, outcomes, level of caval involvement, renal artery embolization, liver mobilization, blood loss, transfusion requirements and follow up times were recorded. RESULTS: Median patient BMI (n = 8) was 25.7 (18.3-31.9). Eight patients underwent renal artery embolization prior to RNCT. A vascular or liver surgeon assisted in all 10 RNCT cases. Six thrombi were infrahepatic and four were retrohepatic requiring liver mobilization. Median operative time was 340 minutes (220-480) with a median vena cava clamp time of 17 minutes (11-22). Eight (80%) patients required intraoperative transfusion. Median pathologic tumor size was 9.5 cm (range 6-21). Median hospital stay was 7.5 days (5-15). Four patients had complications including colonic mesenteric rent (n = 2), abscess (n = 1), retroperitoneal hematoma (n = 1), distal pancreatic injury (n = 1), and splenic capsular tear (n = 1). One patient had postoperative liver metastasis. Two patients died from postoperative metastasis, at 5 months and 11 months. CONCLUSIONS: RNCT can be performed, with the assistance of a vascular/liver transplant surgeon, for an infrahepatic or retrohepatic thrombus satisfactorily in a lower volume practice.

Biomechanical Effects of Blood Flow Restriction Training after ACL Reconstruction.

INTRODUCTION: After anterior cruciate ligament reconstruction surgery, returning the knee to previous levels of strength and function is challenging, with the failure to do so associated with an increased risk of reinjury and long-term degenerative problems. Blood flow restriction (BFR) is gaining popularity as a rehabilitation technique; however, its effects on the mechanics of these exercises have not been fully explored. In this study, we aimed to determine the acute effects of BFR on the performance of a step-up exercise protocol and to assess the acceptability of the technique. METHODS: Twenty individuals (12 female/8 male; mean age, 30.6 yr) who had recently undergone anterior cruciate ligament reconstruction and 20 controls (11 female/9 male, mean age 28.0 yr) performed a step-up exercise protocol with and without BFR. Lower limb kinematics and kinetics were measured and compared between groups and conditions. Testing was completed in June 2019. RESULTS: Participants in both groups had increased external rotation of the tibia of 2° (P < 0.001) and reductions in knee flexion and rotation torques around the joint of around 50% (P < 0.001) when using BFR compared with nonrestricted step-up exercise. The intervention was found to increase the difficulty of the exercise and induce moderate levels of discomfort (P < 0.001). CONCLUSION: The present study provides cautious support for the use of BFR, showing that there are minimal changes in knee joint mechanics when performing the same exercise without BFR, and that the changes do not increase joint torques at the knee. From an acute biomechanical perspective, the intervention appears safe to use under qualified supervision; however, effects of repetitive use and long-term outcomes should be monitored.

Patient-Reported Outcomes Accurately Measure the Value of an Enhanced Recovery Program in Liver Surgery.

BACKGROUND: Enhanced recovery (ER) pathways have become increasingly integrated into surgical practice. Studies that compare ER and traditional pathways often focus on outcomes confined to inpatient hospitalization and rarely assess a patient's functional recovery. The aim of this study was to compare functional outcomes for patients treated on an Enhanced Recovery in Liver Surgery (ERLS) pathway vs a traditional pathway. STUDY DESIGN: One hundred and eighteen hepatectomy patients rated symptom severity and life interference using the validated MD Anderson Symptom Inventory preoperatively and postoperatively at every outpatient visit until 31 days after surgery. The ERLS protocol included patient education, narcotic-sparing anesthesia and analgesia, diet advancement, restrictive fluid administration, early ambulation, and avoidance of drains and tubes. RESULTS: Seventy-five ERLS pathway patients were clinically comparable with 43 patients simultaneously treated on a traditional pathway. The ERLS patients reported lower immediate postoperative pain scores and experienced fewer complications and decreased length of stay. As measured by symptom burden on life interference, ERLS patients were more likely to return to baseline functional status in a shorter time interval. The only independent predictor of faster return to baseline interference levels was treatment on an ERLS pathway (p = 0.021; odds ratio = 2.62). In addition, ERLS pathway patients were more likely to return to intended oncologic therapy (95% vs 87%) at a shorter time interval compared to patients on the traditional pathway (44.7 vs 60.2 days). CONCLUSIONS: In oncologic liver surgery, enhanced recovery's primary mechanism of action is reduction in life interference by postoperative surgical symptoms, allowing patients to return sooner to normal function and adjuvant cancer therapies.

Elimination of laparoscopic lens fogging using directional flow of CO2.

BACKGROUND AND OBJECTIVES: Surgeons constantly struggle with the formation of condensation on the lens of a laparoscope, which prolongs procedures and reduces visibility of the abdominal cavity. The goal of this project was to build a device that would direct a flow of carbon dioxide (CO2) into an open chamber surrounding the lens of a laparoscope, acting to keep moisture away from the lens and eliminate condensation. METHODS: The device isolates the lens of the laparoscope from the humid environment of the intraperitoneal cavity by creating a microenvironment of dry CO2. This was accomplished by building a communicating sleeve that created an open chamber around the distal 2 to 3 cm of the scope. Into this cavity, dry cool CO2 was pumped in from an insufflator so that the path of the gas would surround the lens of the scope and escape through a single outlet location through which the scope views the intraperitoneal cavity. This chamber is proposed to isolate the lens with a high percentage of dry CO2 and low humidity. The device was tested in 7 different adverse conditions that were meant to challenge the ability of the device to maintain the viewing field with no perceptible obstruction. RESULTS: In all of the conditions tested, 25 trials total, the device successfully prevented and/or eliminated laparoscopic lens fogging. CONCLUSIONS: The device designed for this project points to the potential of a simple and effective mechanical method for eliminating laparoscopic lens fogging.

Genomic signatures of positive selection in humans and the limits of outlier approaches.

Identifying regions of the human genome that have been targets of positive selection will provide important insights into recent human evolutionary history and may facilitate the search for complex disease genes. However, the confounding effects of population demographic history and selection on patterns of genetic variation complicate inferences of selection when a small number of loci are studied. To this end, identifying outlier loci from empirical genome-wide distributions of genetic variation is a promising strategy to detect targets of selection. Here, we evaluate the power and efficiency of a simple outlier approach and describe a genome-wide scan for positive selection using a dense catalog of 1.58 million SNPs that were genotyped in three human populations. In total, we analyzed 14,589 genes, 385 of which possess patterns of genetic variation consistent with the hypothesis of positive selection. Furthermore, several extended genomic regions were found, spanning >500 kb, that contained multiple contiguous candidate selection genes. More generally, these data provide important practical insights into the limits of outlier approaches in genome-wide scans for selection, provide strong candidate selection genes to study in greater detail, and may have important implications for disease related research.

Comparative transcriptional profiling of two human embryonic stem cell lines.

Human embryonic stem cells (ESCs) have generated enormous interest due to their ability to self-renew and produce many different cell types. In conjunction with microarray technology, human ESCs provide a powerful tool for employing a systems-based approach to deciphering the molecular mechanisms that control pluripotency and early development. Recent work has focused on defining "stemness" and pluripotency based on different experimental and analytical approaches in both mouse and human ESCs. Using a mixed linear model statistical approach, we report a stringent direct comparison between data sets obtained from two human ESCs (BG01 and H1) in order to obtain a list of genes that are enriched in ESCs. In addition, we used another pluripotent population derived from BG01 ESCs to obtain a list of genes that we consider important to the maintenance of pluripotency. A total of 133 genes overlapped between the three pluripotent populations. A majority of the 133 genes were classified under the key functional categories of cell-cycle regulation, signaling, and regulation of transcription. Key genes expressed were Oct4, Sox2, LeftyA, and Fgf2. Also found to be enriched in all three populations is FLJ10713, a gene encoding a hypothetical protein of unknown function that has been shown in earlier studies to possess a homolog in mouse ESCs and also to cluster tightly with Oct4 in human ESCs. Although there were many genes unique to each pluripotent population, they shared similarities based on functional ontologies that define pluripotency. The significance of our studies underscores the need for direct comparison of stem cell populations that share biological similarities using uniform stringent analytical approaches, in order to better define pluripotency. Our findings have important implications for the maintenance of pluripotency and in developing directed differentiation strategies for various regenerative applications.

Transcriptional profiling of initial differentiation events in human embryonic stem cells.

Currently, there are no differentiation strategies for human embryonic stem cells (hESCs) that efficiently produce one specific cell type, possibly because of lack of understanding of the genes that control signaling events prior to overt differentiation. sed HepG2 cell conditioned medium (MEDII), which induces early differentiation in mouse ES cells while retaining pluripotent markers, to query gene expression in hESCs. Treatment of adherent hESCs with 50% MEDII medium effected differentiation to a cell type with gene expression similar to primitive streak stage cells of mouse embryos. MEDII treatment up-regulates TDGF1 (Cripto), a gene essential for anterior-posterior axis and mesoderm formation in mouse embryos and a key component of the TGFB1/NODAL signaling pathway. LEFTYA, an antagonist of NODAL/TDGF1 signaling expressed in anterior visceral endoderm, is down-regulated with MEDII treatment, as is FST, an inhibitor of mesoderm induction via the related INHBE1 pathway. In summary, the TGFB1/NODAL pathway is important for primitive-streak and mesoderm formation and in using MEDII, we present a means for generating an in vitro cell population that maintains pluripotent gene expression (POU5F1, NANOG) and SSEA-4 markers while regulating genes in the TGFB1/NODAL pathway, which may lead to more uniform formation of mesoderm in vitro.

Human embryonic stem cell lines derived from discarded embryos.

Human pluripotent embryonic stem (ES) cells have important potential in regenerative medicine and as models for human preimplantation development; however, debate continues over whether embryos should be destroyed to produce human ES cells. We have derived four ES cell lines on mouse embryonic fibroblast cells in medium supplemented with basic fibroblast growth factor, human recombinant leukemia inhibitory factor, and fetal bovine serum. The source of these cell lines was poor-quality embryos that in the course of routine clinical practice would have been discarded. After continuous proliferation in vitro for more than 12 months, these ES cell lines maintained their developmental potential to form trophoblast and somatic cells, including cardiac muscle and neuronal tissue.

Differentiation of rhesus embryonic stem cells to neural progenitors and neurons.

Embryonic stem (ES) cells are pluripotent cells capable of differentiating into cell lineages derived from all primary germ layers including neural cells. In this study we describe an efficient method for differentiating rhesus monkey ES cells to neural lineages and the subsequent isolation of an enriched population of Nestin and Musashi positive neural progenitor (NP) cells. Upon differentiation, these cells exhibit electrophysiological characteristics resembling cultured primary neurons. Embryoid bodies (EBs) were formed in ES growth medium supplemented with 50% MEDII. After 7 days in suspension culture, EBs were transferred to adherent culture and either differentiated in serum containing medium or expanded in serum free medium. Immunocytochemistry on differentiating cells derived from EBs revealed large networks of MAP-2 and NF200 positive neurons. DAPI staining showed that the center of the MEDII-treated EBs was filled with rosettes. NPs isolated from adherent EB cultures expanded in serum free medium were passaged and maintained in an undifferentiated state by culture in serum free N2 with 50% MEDII and bFGF. Differentiating neurons derived from NPs fired action potentials in response to depolarizing current injection and expressed functional ionotropic receptors for the neurotransmitters glutamate and gamma-aminobutyric acid (GABA). NPs derived in this way could serve as models for cellular replacement therapy in primate models of neurodegenerative disease, a source of neural cells for toxicity and drug testing, and as a model of the developing primate nervous system.