State-based analysis of necrotizing enterocolitis outcomes.

BACKGROUND: Necrotizing enterocolitis (NEC) is a devastating disease of the newborn. We hypothesized that patient and institution level factors lead to NEC-related outcome disparities. METHODS: We analyzed the California Office of Statewide Health Planning and Development database for the years 1999-2004. We selected NEC-specific ICD-9-CM diagnosis and procedure codes. Mortality rate was the primary outcome measure, and length of stay was used a secondary end-point. We stratified the data by birth weight, gender, race/ethnicity, treatment, median household income, insurance status, admission type (inborn or outborn), and NICU levels. RESULTS: We identified 3328 infants with NEC (incidence of 1 per 1000 live births). Overall mortality within the NEC cohort was 12.5% (13.4 deaths per 100,000 live births). Male or Hispanic neonates were less likely to survive. Socioeconomic factors, including insurance status and parental median household income, were not predictors of mortality. Neonates treated surgically had a greater mortality rate compared with ones treated nonsurgically. PDA was present in 32% of patients with NEC, and these neonates were more likely to undergo gastrointestinal surgery. The odds of NEC-associated mortality in level IIIC units were significantly greater than any other NICU level. Admission type (inborn versus outborn) was not associated with increased mortality. CONCLUSIONS: Disparities in NEC outcomes are multifactorial with patient- and treatment-specific factors contributing significantly to the unfavorable outcomes. These data suggest that advances in prediction modeling, prevention, and treatment algorithms are needed for clinicians and state health planners to positively impact this costly neonatal condition.

Enterobacter sakazakii enhances epithelial cell injury by inducing apoptosis in a rat model of necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is an inflammatory intestinal disorder that affects 2%-5% of all premature infants. Enterobacter sakazakii, a common contaminant of milk-based powdered infant formula, has been implicated as a causative agent of sepsis, meningitis, and NEC in newborn infants, with high mortality rates. However, the role played by E. sakazakii in the pathogenesis of NEC is, to date, not known. Here, we demonstrate for the first time that E. sakazakii can induce clinical and histological NEC in newborn rats. E. sakazakii was found to bind to enterocytes in rat pups at the tips of villi and to intestinal epithelial cells (IEC-6) in culture, with no significant invasion. Exposure to E. sakazakii induced apoptosis and increased the production of interleukin-6 in IEC-6 cells and in the animal model. These data suggest that E. sakazakii could be a potential pathogen that induces NEC and triggers intestinal disease by modulating enterocyte intracellular signaling pathways.

Understanding the susceptibility of the premature infant to necrotizing enterocolitis (NEC).

Necrotizing enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency encountered in the neonatal intensive care unit. Despite advances in neonatal care, NEC remains a leading cause of morbidity and mortality among premature infants. Epidemiologic studies have identified multiple factors that increase an infant's risk for the development of NEC, although premature birth, bacterial colonization, and enteral feeding are thought to play central roles in disease pathogenesis. Appreciating factors that underlie the susceptibility of prematurely born infants to NEC is important for the development of new strategies aimed at the prevention and treatment of disease. In this review, we discuss defense mechanisms in the intestine and discuss how these systems may be insufficient in the prematurely born infant and thereby further contribute to initiation of NEC. In addition, based on a review of the literature, we suggest that, although numerous bacterial and viral pathogens have been associated with NEC, no individual organism is known to be responsible for disease. Finally, we comment on the possible role for probiotics in promoting maturation of intestinal defense mechanisms thereby attenuating or preventing the sequence of events that lead to NEC.

Mathematical modeling in necrotizing enterocolitis--a new look at an ongoing problem.

Necrotizing enterocolitis (NEC) is the most common and lethal disease that affects the gastrointestinal (GI) tract of the premature infant. The etiology of NEC remains undefined. The only consistent epidemiological precursors for NEC are prematurity and enteral alimentation. Various inflammatory mediators, including tumor necrosis factor (TNF)-a, interleukin (IL)-1, IL-6, IL-8, IL-10, IL-18, platelet-activating factor (PAF), and nitric oxide (NO) have been implicated in the pathogenesis of NEC, but the kinetics and role of these agents are ill-defined. Currently, there are no biomarker predictors of NEC risk and severity. Sera or tissue from early time points in the development of the disease may help delineate early inflammatory events that predispose an individual to NEC, thus providing an interventional opportunity. We suggest that the lack of diagnostic and therapeutic modalities for NEC are due to the absence of a systems view of the disease, which in turn is hindered by a lack of sensitive physiological measurements that predict perturbations in the intestinal tissue compartment and an inability to reliably test serial samples for the presence of inflammatory mediators in small volumes and in a high-throughput manner. Computational modeling is a useful tool in the study of complex systems such as the inflammatory process. Computation models provide an "existence proof" for a given mechanism, uncover subtle inconsistencies between the underlying hypotheses and quantitative data, and force one to ask how much is known. We suggest that a properly validated and calibrated mathematical model of inflammation and its pathologic consequences in NEC will be useful for predicting the physiologic and biologic response in infants suffering from the disease.

T cells in cryptopatch aggregates share TCR gamma variable region junctional sequences with gamma delta T cells in the small intestinal epithelium of mice.

The role of cryptopatch aggregates in the development of intestinal intraepithelial lymphocytes (IEL) is a matter of controversy. Therefore, an important question is whether T cells in cryptopatch aggregates are lineally related to IEL. We hypothesized that if gammadelta+ IEL derive from T cells in cryptopatch aggregates, then a clonal relationship would exist between the two populations. To test this hypothesis, we compared the sequence of rearranged TCR gamma variable region 5 genes in gammadelta+ IEL and cryptopatch cells. We purified IEL by FACS and cryptopatch cells were isolated from frozen sections of the intestine by laser-assisted microdissection. PCR showed that TCR gamma variable region 5 was rearranged in gammadelta+ IEL and in CD3+ cryptopatch cells, but not in CD3- cryptopatch cells. DNA sequence analysis showed that the frequency of in-frame junctions in cryptopatch aggregates was at a level consistent with positive selection in both wild-type and athymic nude mice. In addition, the predicted amino acid sequences of V-J junctions present in gammadelta+ IEL and cryptopatch cells were encoded by identical nucleotide sequences. By contrast, the frequency of in-frame joints was significantly reduced in cryptopatch cells isolated from TCR delta-deficient mice, indicating that the enrichment of in-frame joints in cryptopatch cells must normally depend on expression of surface gammadelta TCR. Our results are consistent with the hypothesis that a subset of gammadelta+ IEL are related to T cells in cryptopatch aggregates. The precise role of cryptopatch aggregates in intestinal gammadelta+ T cell homeostasis still needs to be determined.

Late postnatal expansion of self-reactive CD8alphaalpha+ intestinal intraepithelial lymphocytes in mice.

The intestinal epithelium is unique in that it harbors auto-reactive T cells largely absent from the peripheral TCR repertoire in normal mice. Intestinal intraepithelial lymphocytes (IEL) expressing self-reactive TCR are mostly CD8alphaalpha+ cells in adult H-Y TCR RAG(-/-) male mice homozygous for the restricting MHC I allele, H-2D(b). By contrast, in male mice heterozygous for the restricting and non-restricting MHC I allele, H-2D(d) (MHC F(1), H-2D(b/d)), IEL are composed of CD8alphabeta and CD8alphaalpha+ T cells. Here we demonstrate that IEL in the immediate postnatal period of MHC homozygous male mice were mostly CD8(-) T cells, while IEL in MHC F(1) male mice were CD8(-) and CD8alphabeta+ T cells. Regardless of the MHC I configuration and the ability to support positive selection of CD8alphabeta+ cells in the thymus, the expansion of CD8alphaalpha+ IEL was a late postnatal event that followed a reduction in CD8(-) IEL. Furthermore, although in vivo treatment with the specific peptide antigen resulted in an earlier accumulation of activated IEL, the expansion of CD8alphaalpha+ IEL remained inefficient until late in postnatal life. Finally, as CD8(-) IEL stimulated with TCR agonists in vitro, acquired expression of CD8alphaalpha, we propose that CD8alphaalpha+ IEL derive from CD8(-) IEL intermediates. Whether CD8(-) IEL are CD8alphabeta-lineage cells that escape deletion in the thymus or are T cells targeted to the intestine from the thymus because of the early and high level TCR transgene expression in this model, is not clear. The signals required for the expansion of CD8alphaalpha+ IEL are however, incomplete in the immediate postnatal intestine. Determining the factors required for the expansion or retention of CD8alphaalpha+ IEL bearing high affinity, self-specific TCR will further elucidate the in vivo role of these T cells in intestinal homeostasis and perhaps, autoimmunity.

A nonredundant role for the adapter protein Shc in thymic T cell development.

Signaling via the pre-T cell receptor (pre-TCR) regulates survival, proliferation, allelic exclusion and differentiation of thymocytes. The role played by the adapter protein Shc in T cells has remained controversial, and its role in pre-TCR signaling has not been addressed. We examined Shc function in thymic T cell development using two genetic approaches. Cre-loxP-mediated inducible expression in transgenic mice of a phosphorylation-defective mutant of Shc impaired signaling through the pre-TCR as well as subsequent proliferation and differentiation. Conditional deletion of the Shc locus in thymocytes also affected thymic maturation at the same pre-TCR developmental stage. Thus, both Shc expression and its tyrosine phosphorylation play an essential and nonredundant role in thymic T cell development.