Pediatric cervical spine clearance after blunt trauma and negative CT: What is the role of MRI?

BACKGROUND AND PURPOSE: The cervical spine in children has marked anatomical and biomechanical differences compared to adults, leading to significantly different patterns and incidence of spinal injury, and consequently to different X-ray and computed tomography (CT) imaging recommendations. Magnetic resonance imaging (MRI) has been validated to clear cervical spine trauma in adults, but not in pediatric patients. We hypothesized that MRI findings have a low probability to change management in children with spine trauma and negative CT findings. MATERIALS AND METHODS: We reviewed records for admitted pediatric patients due to blunt trauma from January 2011 to May 2021, and identified 212 patients who underwent MRI within 3 days of a negative CT. Two neuroradiologists independently reviewed all CT and MRI images for the following categories: fracture, subluxation, spinal canal compromise, ligamentous injury, spinal canal hemorrhage, cord contusion and soft tissue hemorrhage. We identified follow-up MRI examinations as negative or positive for the above categories, and calculated the prevalence of each category as a percentage of cases with negative CT. We also evaluated whether negative and positive MRI groups differed significantly with respect to age and sex of the patients. RESULTS AND CONCLUSIONS: In our study of 212 children with cervical spine trauma and a negative CT, most follow-up MRI scans were found to be negative (79.9 %). Positive MRI findings consisted mainly of ligamentous sprain without disruption (15.1 %). Ligamentous disruption and epidural or soft tissue hemorrhage were found in 4.5 %, and focal cord contusion in 0.5 %. There was no statically significant difference between negative and positive MRI groups with respect to age (P = 0.45) and sex (P = 0.52). CONCLUSION: In our patient group with a negative CT, MRI did not significantly impact management nor contribute to cervical spine clearance in children.

Examining How Formal Leadership Development Programs Positively Influence Hospital Leaders' Individual Competencies and Organizational Outcomes - An Evidence-Based Literature Review.

BACKGROUND: Leadership development programs (LDPs) are known to be educational and valuable, yet time consuming and costly for a healthcare organization and participants alike. This study is aimed to determine the impact that participation in a formal LDP has on hospital managers and leaders' competencies, as well as to identify the positive organizational outcomes that can be achieved. MATERIALS AND METHODS: We conducted a literature review focusing on hospital managers and leaders who participated in formal LDPs. From there, we extracted data to determine the outcomes achieved by participating in LDPs. RESULTS: The search yielded 7420 articles, of which 23 articles were used for this literature review. Overall, there were a wide range of positive outcomes for participants of LDPs and some outcomes appeared more frequently than others. The beneficial outcome that appeared most frequently was that participants were able to gain knowledge of management and leadership roles and responsibilities which appeared 13 times. An increase in participant's confidence and communication skills appeared 10 times, respectively. The ability to network with others within the organization and an increase in job positivity and satisfaction appeared 7 times each. DISCUSSION: LDPs provided an array of positive outcomes for hospital leaders who had participated. However, there was a lack of studies on the topic and more research is needed in order to have a better understanding of the correlation between LDPs and beneficial organizational outcomes.

Imaging properties of 3D printed breast phantoms for lesion localization and Core needle biopsy training.

BACKGROUND: Breast cancer is the most commonly diagnosed malignancy in females and frequently requires core needle biopsy (CNB) to guide management. Adequate training resources for CNB suffer tremendous limitations in reusability, accurate simulation of breast tissue, and cost. The relatively recent advent of 3D printing offers an alternative for the development of breast phantoms for training purposes. However, the feasibility of this technology for the purpose of ultrasound (US) guided breast intervention has not been thoroughly studied. METHODS: We designed three breast phantom models that were printed in multiple resins available through Stratasys, including VeroClear, TangoPlus and Tissue Matrix. We also constructed several traditional breast phantoms using chicken breast and Knox gelatin for comparison. These phantoms were compared side-by-side for ultrasound penetrance, simulation of breast tissue integrity, anatomic accuracy, reusability, and cost. RESULTS: 3D printed breast phantoms were more anatomically accurate models than traditional breast phantoms. The chicken breast phantom provided acceptable US beam penetration and material hardness for simulation of human breast tissue integrity. Sonographic image quality of the chicken breast phantom was the most accurate overall. The gelatin-based phantom also had acceptable US beam penetration and image quality; however, this material was too soft and poorly simulated breast tissue integrity. 3D printed phantoms were not visible under US. CONCLUSIONS: There is a large unmet need for a printable material that is truly compatible with multimodality imaging for breast and other soft tissue intervention. Further research is warranted to create a realistic, reusable and affordable material to 3D print phantoms for US-guided intervention training.

Stochastic fracture of additively manufactured porous composites.

Extrusion-based fused deposition modeling (FDM) introduces inter-bead pores into dense materials, which results in part-to-part mechanical property variations, i.e., low mechanical reliability. In addition, the internal structure of FDMed materials can be made porous intentionally to tailor mechanical properties, introduce functionality, reduce material consumption, or decrease production time. Despite these potential benefits, the effects of porosity on the mechanical reliability of FDMed composites are still unclear. Accordingly, we investigated the stochastic fracture of 241 FDMed short-carbon-fiber-reinforced-ABS with porosity ranging from 13 to 53 vol.% under tensile load. Weibull analysis was performed to quantify the variations in mechanical properties. We observed an increase in Weibull modulus of fracture/tensile strength for porosity higher than ~40 vol.% and a decrease in Weibull modulus of fracture strain for an increase in porosity from 25 to 53 vol.%. Micromechanics-based 2D simulations indicated that the mechanical reliability of FDMed composites depends on variations in bead strength and elastic modulus of beads. The change in raster orientation from 45°/-45° to 0° more than doubled the Weibull modulus. We identified five different types of pores via high-resolution X-ray computed tomography. A 22% and 48% decrease in carbon fiber length due to extrusion was revealed for two different regions of the filament.

Fluctuations in dissolved oxygen concentration during a CHO cell culture process affects monoclonal antibody productivity and the sulfhydryl-drug conjugation process.

During a CHO cell culture production process, important parameters are generally well controlled by a feedback mechanism (PID loop) in order to ensure consistency in both productivity and product quality. These parameters typically include pH, dissolved oxygen (DO), and temperature. While most of these parameters are very well controlled within their specific deadband, stable DO control can be challenging. Oscillations in DO concentration are not uncommon and these fluctuations can be exacerbated with an efficient mass transfer aeration strategy. In this study, where an IgG2 producing cell line was used, we observed increased lactate accumulation accompanied by decreased titer production in lots with fluctuations in DO concentration (DOF ) when compared with lots with stable DO control (DOS ). We demonstrate that DOF had a greater impact on performance with respect to titer production and lactate accumulation than DO setpoint. Furthermore, we report that estimated specific oxygen uptake rates (qOURs) were lower in DOF lots when compared with DOS lots. We also report that purified mAb sourced from DOF lots yielded lower drug-to-antibody ratio (DAR) after the sulfhydryl-targeted maleimide conjugation process when equivalent reducing agent was used. All mAb lots were within the analytical specifications for release, though a slight increase in measureable trisulfides were observed in DOF mAb lots. DO control aimed to minimize fluctuations around DO setpoint was essential for us to produce consistent DAR without adjusting the conjugation process. © 2018 American Institute of Chemical Engineers Biotechnol. Prog., 34:1427-1437, 2018.

Efficient Remyelination Requires DNA Methylation.

Oligodendrocyte progenitor cells (OPCs) are the principal source of new myelin in the central nervous system. A better understanding of how they mature into myelin-forming cells is of high relevance for remyelination. It has recently been demonstrated that during developmental myelination, the DNA methyltransferase 1 (DNMT1), but not DNMT3A, is critical for regulating proliferation and differentiation of OPCs into myelinating oligodendrocytes (OLs). However, it remains to be determined whether DNA methylation is also critical for the differentiation of adult OPCs during remyelination. After lysolecithin-induced demyelination in the ventrolateral spinal cord white matter of adult mice of either sex, we detected increased levels of DNA methylation and higher expression levels of the DNA methyltransferase DNMT3A and lower levels of DNMT1 in differentiating adult OLs. To functionally assess the role of DNMT1 and DNMT3 in adult OPCs, we used mice with inducible and lineage-specific ablation of Dnmt3a and/or Dnmt1 (i.e., Plp-creER(t);Dnmt3a-flox, Plp-creER(t);Dnmt1-flox, Plp-creER(t);Dnmt1-flox;Dnmt3a-flox). Upon lysolecithin injection in the spinal cord of these transgenic mice, we detected defective OPC differentiation and inefficient remyelination in the Dnmt3a null and Dnmt1/Dnmt3a null mice, but not in the Dnmt1 null mice. Taken together with previous results in the developing spinal cord, these data suggest an age-dependent role of distinct DNA methyltransferases in the oligodendrocyte lineage, with a dominant role for DNMT1 in neonatal OPCs and for DNMT3A in adult OPCs.

Functional Characterization of DNA Methylation in the Oligodendrocyte Lineage.

Oligodendrocytes derive from progenitors (OPCs) through the interplay of epigenomic and transcriptional events. By integrating high-resolution methylomics, RNA-sequencing, and multiple transgenic lines, this study defines the role of DNMT1 in developmental myelination. We detected hypermethylation of genes related to cell cycle and neurogenesis during differentiation of OPCs, yet genetic ablation of Dnmt1 resulted in inefficient OPC expansion and severe hypomyelination associated with ataxia and tremors in mice. This phenotype was not caused by lineage switch or massive apoptosis but was characterized by a profound defect of differentiation associated with changes in exon-skipping and intron-retention splicing events and by the activation of an endoplasmic reticulum stress response. Therefore, loss of Dnmt1 in OPCs is not sufficient to induce a lineage switch but acts as an important determinant of the coordination between RNA splicing and protein synthesis necessary for myelin formation.

Role of Tet1 and 5-hydroxymethylcytosine in cocaine action.

Ten-eleven translocation (TET) enzymes mediate the conversion of 5-methylcytosine (5mC) to 5-hydroxymethylcytosine (5hmC), which is enriched in brain, and its ultimate DNA demethylation. However, the influence of TET and 5hmC on gene transcription in brain remains elusive. We found that ten-eleven translocation protein 1 (TET1) was downregulated in mouse nucleus accumbens (NAc), a key brain reward structure, by repeated cocaine administration, which enhanced behavioral responses to cocaine. We then identified 5hmC induction in putative enhancers and coding regions of genes that have pivotal roles in drug addiction. Such induction of 5hmC, which occurred similarly following TET1 knockdown alone, correlated with increased expression of these genes as well as with their alternative splicing in response to cocaine administration. In addition, 5hmC alterations at certain loci persisted for at least 1 month after cocaine exposure. Together, these reveal a previously unknown epigenetic mechanism of cocaine action and provide new insight into how 5hmC regulates transcription in brain in vivo.

Chromatin landscape defined by repressive histone methylation during oligodendrocyte differentiation.

In many cell types, differentiation requires an interplay between extrinsic signals and transcriptional changes mediated by repressive and activating histone modifications. Oligodendrocyte progenitors (OPCs) are electrically responsive cells receiving synaptic input. The differentiation of these cells into myelinating oligodendrocytes is characterized by temporal waves of gene repression followed by activation of myelin genes and progressive decline of electrical responsiveness. In this study, we used chromatin isolated from rat OPCs and immature oligodendrocytes, to characterize the genome-wide distribution of the repressive histone marks, H3K9me3 and H3K27me3, during differentiation. Although both marks were present at the OPC stage, only H3K9me3 marks (but not H3K27me3) were found to be increased during differentiation, at genes related to neuronal lineage and regulation of membrane excitability. Consistent with these findings, the levels and activity of H3K9 methyltransferases (H3K9 HMT), but not H3K27 HMT, increased more prominently upon exposure to oligodendrocyte differentiating stimuli and were detected in stage-specific repressive protein complexes containing the transcription factors SOX10 or YY1. Silencing H3K9 HMT, but not H3K27 HMT, impaired oligodendrocyte differentiation and functionally altered the response of oligodendrocytes to electrical stimulation. Together, these results identify repressive H3K9 methylation as critical for gene repression during oligodendrocyte differentiation.

Common dysregulation network in the human prefrontal cortex underlies two neurodegenerative diseases.

Using expression profiles from postmortem prefrontal cortex samples of 624 dementia patients and non-demented controls, we investigated global disruptions in the co-regulation of genes in two neurodegenerative diseases, late-onset Alzheimer's disease (AD) and Huntington's disease (HD). We identified networks of differentially co-expressed (DC) gene pairs that either gained or lost correlation in disease cases relative to the control group, with the former dominant for both AD and HD and both patterns replicating in independent human cohorts of AD and aging. When aligning networks of DC patterns and physical interactions, we identified a 242-gene subnetwork enriched for independent AD/HD signatures. This subnetwork revealed a surprising dichotomy of gained/lost correlations among two inter-connected processes, chromatin organization and neural differentiation, and included DNA methyltransferases, DNMT1 and DNMT3A, of which we predicted the former but not latter as a key regulator. To validate the inter-connection of these two processes and our key regulator prediction, we generated two brain-specific knockout (KO) mice and show that Dnmt1 KO signature significantly overlaps with the subnetwork (P = 3.1 × 10(-12)), while Dnmt3a KO signature does not (P = 0.017).

Cerebrospinal fluid ceramides from patients with multiple sclerosis impair neuronal bioenergetics.

Axonal damage is a prominent cause of disability and yet its pathogenesis is incompletely understood. Using a xenogeneic system, here we define the bioenergetic changes induced in rat neurons by exposure to cerebrospinal fluid samples from patients with multiple sclerosis compared to control subjects. A first discovery cohort of cerebrospinal fluid from 13 patients with multiple sclerosis and 10 control subjects showed that acute exposure to cerebrospinal fluid from patients with multiple sclerosis induced oxidative stress and decreased expression of neuroprotective genes, while increasing expression of genes involved in lipid signalling and in the response to oxidative stress. Protracted exposure of neurons to stress led to neurotoxicity and bioenergetics failure after cerebrospinal fluid exposure and positively correlated with the levels of neurofilament light chain. These findings were validated using a second independent cohort of cerebrospinal fluid samples (eight patients with multiple sclerosis and eight control subjects), collected at a different centre. The toxic effect of cerebrospinal fluid on neurons was not attributable to differences in IgG content, glucose, lactate or glutamate levels or differences in cytokine levels. A lipidomic profiling approach led to the identification of increased levels of ceramide C16:0 and C24:0 in the cerebrospinal fluid from patients with multiple sclerosis. Exposure of cultured neurons to micelles composed of these ceramide species was sufficient to recapitulate the bioenergetic dysfunction and oxidative damage induced by exposure to cerebrospinal fluid from patients with multiple sclerosis. Therefore, our data suggest that C16:0 and C24:0 ceramides are enriched in the cerebrospinal fluid of patients with multiple sclerosis and are sufficient to induce neuronal mitochondrial dysfunction and axonal damage.

Combinatorial actions of Tgfß and Activin ligands promote oligodendrocyte development and CNS myelination.

In the embryonic CNS, development of myelin-forming oligodendrocytes is limited by bone morphogenetic proteins, which constitute one arm of the transforming growth factor-ß (Tgfß) family and signal canonically via Smads 1/5/8. Tgfß ligands and Activins comprise the other arm and signal via Smads 2/3, but their roles in oligodendrocyte development are incompletely characterized. Here, we report that Tgfß ligands and activin B (ActB) act in concert in the mammalian spinal cord to promote oligodendrocyte generation and myelination. In mouse neural tube, newly specified oligodendrocyte progenitors (OLPs) are first exposed to Tgfß ligands in isolation, then later in combination with ActB during maturation. In primary OLP cultures, Tgfß1 and ActB differentially activate canonical Smad3 and non-canonical MAP kinase signaling. Both ligands enhance viability, and Tgfß1 promotes proliferation while ActB supports maturation. Importantly, co-treatment strongly activates both signaling pathways, producing an additive effect on viability and enhancing both proliferation and differentiation such that mature oligodendrocyte numbers are substantially increased. Co-treatment promotes myelination in OLP-neuron co-cultures, and maturing oligodendrocytes in spinal cord white matter display strong Smad3 and MAP kinase activation. In spinal cords of ActB-deficient Inhbb(-/-) embryos, apoptosis in the oligodendrocyte lineage is increased and OLP numbers transiently reduced, but numbers, maturation and myelination recover during the first postnatal week. Smad3(-/-) mice display a more severe phenotype, including diminished viability and proliferation, persistently reduced mature and immature cell numbers, and delayed myelination. Collectively, these findings suggest that, in mammalian spinal cord, Tgfß ligands and ActB together support oligodendrocyte development and myelin formation.

Increased brain lactate is central to the development of brain edema in rats with chronic liver disease.

BACKGROUND & AIMS: The pathogenesis of brain edema in patients with chronic liver disease (CLD) and minimal hepatic encephalopathy (HE) remains undefined. This study evaluated the role of brain lactate, glutamine and organic osmolytes, including myo-inositol and taurine, in the development of brain edema in a rat model of cirrhosis. METHODS: Six-week bile-duct ligated (BDL) rats were injected with (13)C-glucose and de novo synthesis of lactate, and glutamine in the brain was quantified using (13)C nuclear magnetic resonance spectroscopy (NMR). Total brain lactate, glutamine, and osmolytes were measured using (1)H NMR or high performance liquid chromatography. To further define the interplay between lactate, glutamine and brain edema, BDL rats were treated with AST-120 (engineered activated carbon microspheres) and dichloroacetate (DCA: lactate synthesis inhibitor). RESULTS: Significant increases in de novo synthesis of lactate (1.6-fold, p<0.001) and glutamine (2.2-fold, p<0.01) were demonstrated in the brains of BDL rats vs. SHAM-operated controls. Moreover, a decrease in cerebral myo-inositol (p<0.001), with no change in taurine, was found in the presence of brain edema in BDL rats vs. controls. BDL rats treated with either AST-120 or DCA showed attenuation in brain edema and brain lactate. These two treatments did not lead to similar reductions in brain glutamine. CONCLUSIONS: Increased brain lactate, and not glutamine, is a primary player in the pathogenesis of brain edema in CLD. In addition, alterations in the osmoregulatory response may also be contributing factors. Our results suggest that inhibiting lactate synthesis is a new potential target for the treatment of HE.

Epigenome-wide differences in pathology-free regions of multiple sclerosis-affected brains.

Using the Illumina 450K array and a stringent statistical analysis with age and gender correction, we report genome-wide differences in DNA methylation between pathology-free regions derived from human multiple sclerosis-affected and control brains. Differences were subtle, but widespread and reproducible in an independent validation cohort. The transcriptional consequences of differential DNA methylation were further defined by genome-wide RNA-sequencing analysis and validated in two independent cohorts. Genes regulating oligodendrocyte survival, such as BCL2L2 and NDRG1, were hypermethylated and expressed at lower levels in multiple sclerosis-affected brains than in controls, while genes related to proteolytic processing (for example, LGMN, CTSZ) were hypomethylated and expressed at higher levels. These results were not due to differences in cellular composition between multiple sclerosis and controls. Thus, epigenomic changes in genes affecting oligodendrocyte susceptibility to damage are detected in pathology-free areas of multiple sclerosis-affected brains.

Epigenetic mechanisms in multiple sclerosis: implications for pathogenesis and treatment.

Clinical neurologists and scientists who study multiple sclerosis face open questions regarding the integration of epidemiological data with genome-wide association studies and clinical management of patients. It is becoming evident that the interplay of environmental influences and individual genetic susceptibility modulates disease presentation and therapeutic responsiveness. The molecular mechanisms through which environmental signals are translated into changes in gene expression include DNA methylation, post-translational modification of nucleosomal histones, and non-coding RNAs. These mechanisms are regulated by families of specialised enzymes that are tissue selective and cell-type specific. A model of multiple sclerosis pathogenesis should integrate underlying risk related to genetic susceptibility with cell-type specific epigenetic changes occurring in the immune system and in the brain in response to ageing and environmental stimuli.

Systemic oxidative stress is implicated in the pathogenesis of brain edema in rats with chronic liver failure.

Chronic liver failure leads to hyperammonemia, a central component in the pathogenesis of hepatic encephalopathy (HE); however, a correlation between blood ammonia levels and HE severity remains controversial. It is believed oxidative stress plays a role in modulating the effects of hyperammonemia. This study aimed to determine the relationship between chronic hyperammonemia, oxidative stress, and brain edema (BE) in two rat models of HE: portacaval anastomosis (PCA) and bile-duct ligation (BDL). Ammonia and reactive oxygen species (ROS) levels, BE, oxidant and antioxidant enzyme activities, as well as lipid peroxidation were assessed both systemically and centrally in these two different animal models. Then, the effects of allopurinol (xanthine oxidase inhibitor, 100mg/kg for 10days) on ROS and BE and the temporal resolution of ammonia, ROS, and BE were evaluated only in BDL rats. Similar arterial and cerebrospinal fluid ammonia levels were found in PCA and BDL rats, both significantly higher compared to their respective sham-operated controls (p<0.05). BE was detected in BDL rats (p < 0.05) but not in PCA rats. Evidence of oxidative stress was found systemically but not centrally in BDL rats: increased levels of ROS, increased activity of xanthine oxidase (oxidant enzyme), enhanced oxidative modifications on lipids, as well as decreased antioxidant defense. In PCA rats, a preserved oxidant/antioxidant balance was demonstrated. Treatment with allopurinol in BDL rats attenuated both ROS and BE, suggesting systemic oxidative stress is implicated in the pathogenesis of BE. Analysis of ROS and ammonia temporal resolution in the plasma of BDL rats suggests systemic oxidative stress might be an important "first hit", which, followed by increases in ammonia, leads to BE in chronic liver failure. In conclusion, chronic hyperammonemia and oxidative stress in combination lead to the onset of BE in rats with chronic liver failure.

A rare myelin protein zero (MPZ) variant alters enhancer activity in vitro and in vivo.

BACKGROUND: Myelin protein zero (MPZ) is a critical structural component of myelin in the peripheral nervous system. The MPZ gene is regulated, in part, by the transcription factors SOX10 and EGR2. Mutations in MPZ, SOX10, and EGR2 have been implicated in demyelinating peripheral neuropathies, suggesting that components of this transcriptional network are candidates for harboring disease-causing mutations (or otherwise functional variants) that affect MPZ expression. METHODOLOGY: We utilized a combination of multi-species sequence comparisons, transcription factor-binding site predictions, targeted human DNA re-sequencing, and in vitro and in vivo enhancer assays to study human non-coding MPZ variants. PRINCIPAL FINDINGS: Our efforts revealed a variant within the first intron of MPZ that resides within a previously described SOX10 binding site is associated with decreased enhancer activity, and alters binding of nuclear proteins. Additionally, the genomic segment harboring this variant directs tissue-relevant reporter gene expression in zebrafish. CONCLUSIONS: This is the first reported MPZ variant within a cis-acting transcriptional regulatory element. While we were unable to implicate this variant in disease onset, our data suggests that similar non-coding sequences should be screened for mutations in patients with neurological disease. Furthermore, our multi-faceted approach for examining the functional significance of non-coding variants can be readily generalized to study other loci important for myelin structure and function.

Defining the chromatin landscape in demyelinating disorders.

An intricate network of epigenetic factors regulates cell differentiation by modulating the chromatin structure and ultimately affecting gene expression. This review describes the chromatin landscape defining oligodendrocyte progenitor differentiation during development and remyelination. We shall discuss the current knowledge regarding modifications of chromatin components during the progression of progenitors into myelinating cells and discuss the potential contribution of histone variants, microRNAs, and DNA methylation. We shall also briefly address how changes to this chromatin landscape can disturb this natural progression and alter the capacity to remyelinate.

Oligodendroglial and pan-neural crest expression of Cre recombinase directed by Sox10 enhancer.

Utilizing a recently identified Sox10 distal enhancer directing Cre expression, we report S4F:Cre, a transgenic mouse line capable of inducing recombination in oligodendroglia and all examined neural crest derived tissues. Assayed using R26R:LacZ reporter mice expression was detected in neural crest derived tissues including the forming facial skeleton, dorsal root ganglia, sympathetic ganglia, enteric nervous system, aortae, and melanoblasts, consistent with Sox10 expression. LacZ reporter expression was also detected in non-neural crest derived tissues including the oligodendrocytes and the ventral neural tube. This line provides appreciable differences in Cre expression pattern from other transgenic mouse lines that mark neural crest populations, including additional populations defined by the expression of other SoxE proteins. The S4F:Cre transgenic line will thus serve as a powerful tool for lineage tracing, gene function characterization, and genome manipulation in these populations.