Despite Recovery from Necrotizing Enterocolitis Infants Retain a Hyperinflammatory Response to Injury.

Background: Necrotizing enterocolitis (NEC) is the leading gastrointestinal cause of death of premature neonates. NEC is associated with prematurity, a hyperinflammatory response, and dysregulation of intestinal barrier function. We hypothesize that patients with NEC will have, and continue to have after recovery, an increased hyperinflammatory intestinal response compared to those patients without NEC. Methods: Neonates with NEC, those that have recovered from NEC, and those without NEC undergoing intestinal resections had specimens collected and snap frozen or generated into enteroids. The enteroids were treated with 100ug/mL lipopolysaccharide (LPS) and subjected to 24 hr of hypoxia together, then compared with untreated controls. Expression of Tumor Necrosis Factor (TNF-α) and interleukin 8 (IL-8) were evaluated via RT-qPCR and ELISA to measure inflammatory response. ANOVA determined statistical significance (p<0.05). Results: There was no difference in inflammatory markers in recovered NEC tissue compared to non-NEC tissue on RTqPCR (p=0.701 TNF-α and 0.861 IL-8). However, recovered NEC enteroids demonstrate elevated levels of inflammatory markers after treatment compared to non-NEC enteroids after treatment on RTqPCR (p=0.0485 TNF-α, p=0.0057 IL-8) and ELISA (p=0.0354 TNF-α, p=0.0011 IL-8). Recovered NEC enteroids that underwent treatment demonstrated increased inflammatory markers compared to recovered NEC enteroids without treatment on RTqPCR (p=0.0045 TNF-α, p=0.0002 IL-8) and ELISA (p=0.034 TNF-α, p=0.0002 IL-8) suggesting a heightened inflammatory response to a second hit. Conclusion: Intestinal tissue resected from neonates with NEC has an elevated hyperinflammatory response compared to neonates recovered from NEC and neonates without NEC. Enteroids generated from patients that have recovered from NEC have a heightened inflammatory response in response to NEC inducing stimuli compared to controls. This tendency towards an increased hyperinflammatory state may be correlated with an infant's proclivity to develop NEC and demonstrates the significance of a second hit on this tissue creating a heightened inflammatory response. This could be correlated with the impact and trajectory of an illness post recovery from NEC.

Persistent Proclivity to a Proinflammatory State in a Human Enteroid Model of Necrotizing Enterocolitis.

Background: Necrotizing enterocolitis (NEC) is a devastating disease of premature neonates with substantial morbidity and mortality. Necrotizing enterocolitis is associated with prematurity, a hyperinflammatory response, and dysregulation of intestinal barrier function. We hypothesize that patients with NEC will have an increased hyperinflammatory intestinal response compared with those without NEC. Patients and Methods: Enteroids were generated from intestinal tissue from neonates undergoing resection. They were treated with 100 mcg/mL lipopolysaccharide (LPS), subjected to 24 hours of hypoxia inducing experimental NEC, then compared with untreated controls. Expression of tumor necrosis factor (TNF-α) and interleukin 8 (IL-8) were evaluated via reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR) and enzyme-linked immunosorbent assay (ELISA) to measure inflammatory response. Analysis of variance (ANOVA) determined statistical significance (p < 0.05). Results: Treated NEC-derived enteroids expressed significantly higher levels of IL-8 (RT-qPCR, p = 0.003; ELISA, p = 0.0002) compared with untreated NEC-derived enteroids with an increase in inflammatory marker concentration in those with a greater degree of prematurity (ELISA, p = 0.0015). A higher level of IL-8 was seen in NEC-derived enteroids compared with control after treatment (RT-qPCR, p = 0.024). Tumor necrosis factor-α levels were elevated in treated NEC-derived enteroids compared with untreated NEC-derived enteroids (RT-qPCR, p = 0.006; ELISA, p = 0.002) and compared with treated non-NEC-derived enteroids (RT-qPCR, p = 0.025; ELISA, p < 0.0001). Conclusions: Enteroids generated from neonates with NEC have an elevated hyperinflammatory response in response to NEC-inducing stimuli compared with controls. Enteroids generated from neonates with NEC with a greater degree of prematurity have a larger increase in inflammatory markers. This tendency toward a hyperinflammatory state may be correlated with an infant's proclivity to develop NEC and further demonstrates the hyperinflammatory state of prematurity.

Blunt Cerebrovascular Injury in Pediatric Hanging Victims.

INTRODUCTION: Incidence of blunt cerebrovascular injury (BCVI) following hanging in the pediatric population is ill-defined. Current guidelines recommend screening imaging during the initial trauma evaluation. Necessity of screening is questioned given BCVI is considered rare after hanging, especially when asymptomatic. This study aims to elucidate the incidence of BCVI in pediatric hangings and determine the value of radiographic work-up. METHODS: A retrospective cohort study was performed of pediatric hangings reported to the National Trauma Data Bank (NTDB), 2017-2019. Imaging, diagnoses, and findings suggestive of BCVI, such as Glasgow Coma Scale (GCS) ≤8, presence of cervical injury, and soft tissue injury were considered. Statistical analysis was carried out to compare incidence. RESULTS: 197 patients met study criteria, with 179 arriving in the trauma bay with signs of life. BCVI incidence was 5.6% (10 of 179). Computed Tomography Angiography (CTA) of the neck was the only reported screening modality in this data set. A CTA was completed in 46% of the cases. DISCUSSION: BCVI incidence following pediatric hanging is more common than previously thought. Less than half of patients had a CTA reported in this cohort. This may result in an underestimate. Given the potentially devastating consequences of a missed BCVI, the addition of CTA to initial work-up may be worthwhile to evaluate for cervical vascular injury, but further studies into the outcomes of children who do receive prophylactic therapy are needed.

A Retrospective Case Control Study Examining Procalcitonin as a Biomarker for Necrotizing Enterocolitis.

Background: Procalcitonin (PCT) is a biomarker for sepsis, but its utility has not been investigated in necrotizing enterocolitis (NEC). Necrotizing enterocolitis is a devastating multisystem disease of infants that in severe cases requires surgical intervention. We hypothesize that an elevated PCT will be associated with surgical NEC. Patients and Methods: After obtaining Institutional Review Board (IRB) approval (#12655), we performed a single institution retrospective case control study between 2010 and 2021 of infants up to three months of age. Inclusion criteria was PCT drawn within 72 hours of NEC or sepsis diagnosis. Control infants had a PCT drawn in the absence of infectious symptoms. Recursive partitioning (RP) identified PCT cutoffs. Categorical variable associations were tested using Fisher exact or χ2 tests. Continuous variables were tested using Wilcoxon rank sum test, Student t-test, and Kruskal-Wallis test. Adjusted associations of PCT and other covariables with NEC or sepsis versus controls were obtained via multinomial logistic regression analysis. Results: We identified 49 patients with NEC, 71 with sepsis, and 523 control patients. Based on RP, we selected two PCT cutoffs: 1.4 ng/mL and 3.19 ng/ml. A PCT of ≥1.4 ng/mL was associated with surgical (n = 16) compared with medical (n = 33) NEC (87.5% vs. 39.4%; p = 0.0015). A PCT of ≥1.4 ng/mL was associated with NEC versus control (p < 0.0001) even when adjusting for prematurity and excluding stage IA/IB NEC (odds ratio [OR], 28.46; 95% confidence interval [CI], 11.27-71.88). A PCT of 1.4-3.19 ng/mL was associated with both NEC (adjusted odds ratio [aOR], 11.43; 95% CI, 2.57-50.78) and sepsis (aOR, 6.63; 95% CI, 2.66-16.55) compared with controls. Conclusions: A PCT of ≥1.4 ng/mL is associated with surgical NEC and may be a potential indicator for risk of disease progression.

Apical-Out Enteroids as an Innovative Model for Necrotizing Enterocolitis.

INTRODUCTION: Necrotizing enterocolitis (NEC) is a gastrointestinal disease of premature neonates. We previously validated a NEC enteroid model derived from human infant intestinal tissue. Typical enteroid configuration is basolateral-out (BO) without direct access to the luminal (apical) surface. Apical access is necessary to allow physiologic comparison of pathogen interaction with the intestinal epithelial barrier. We hypothesize that apical-out (AO) enteroids will provide a relevant NEC model to study this relationship. METHODS: Following the institutional review board approval (#11610-11611), neonatal intestinal tissue was collected from surgical specimens. Stem cells were collected; enteroids were generated and grown to maturity in BO conformation then everted to AO. Enteroids were untreated or treated for 24 h with 100 µg/mL lipopolysaccharide and hypoxia. Protein and gene expression were analyzed for inflammatory markers, tight junction (TJ) proteins and permeability characteristic of NEC. RESULTS: Apical TJ protein zonula occludens-1 and basolateral protein ß-catenin immunofluorescence confirmed AO configuration. Treated AO enteroids had significantly increased messenger RNA (P = 0.001) and protein levels (P < 0.0001) of tumor necrosis factor-α compared to controls. Corrected total cell fluorescence of toll-like receptor 4 was significantly increased in treated AO enteroids compared to control (P = 0.002). Occludin was found to have significantly decreased messenger RNA in treated AO enteroids (P = 0.003). Expression of other TJ proteins claudins-1, -4 and zonula occludens-1 was significantly decreased in treated AO enteroids (P < 0.05). CONCLUSIONS: AO enteroids present an innovative model for NEC with increased inflammation and gut barrier restructuring. This model allows for a biologically relevant investigation of the interaction between the pathogen and the intestinal epithelial barrier in NEC.

This is Our Lane: A Pilot Study Examining the Surgeon's Role in Social Justice Advocacy.

BACKGROUND: Despite the importance of social justice advocacy, surgeon attitudes toward individual involvement vary. We hypothesized that the majority of surgeons in this study, regardless of gender or training level, believe that surgeons should be involved in social justice movements. METHODS: A survey was distributed to surgical faculty and trainees at three academic tertiary care centers. Participation was anonymous with 123 respondents. Chi-square and Fisher's exact test were used for analysis with significance accepted when p < 0.05. Thematic analysis was performed on free responses. RESULTS: The response rate was 46%. Compared to men, women were more likely to state that surgeons should be involved (86% vs 64%, p = 0.01) and were personally involved in social justice advocacy (86% vs 51%, p = 0.0002). Social justice issues reported as most important to surgeons differed significantly by gender (p = 0.008). Generated themes for why certain types of advocacy involvement were inappropriate were personal choices, professionalism and relationships. CONCLUSIONS: Social justice advocacy is important to most surgeons in this study, especially women. This emphasizes the need to incorporate advocacy into surgical practice.