1
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Bose SK, Stratigis JD, Ahn N, Pogoriler J, Hedrick HL, Rintoul NE, Partridge EA, Flake AW, Khalek N, Gebb J, Teefey CP, Soni S, Hamaguchi R, Moldenhauer J, Adzick NS, Peranteau WH. Prenatally Diagnosed Large Lung Lesions: Timing of Resection and Perinatal Outcomes. J Pediatr Surg 2023; 58:2384-2390. [PMID: 37813715 DOI: 10.1016/j.jpedsurg.2023.09.002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Fetuses with large lung lesions including congenital cystic adenomatoid malformations (CCAMs) are at risk for cardiopulmonary compromise. Prenatal maternal betamethasone and cyst drainage for micro- and macrocystic lesions respectively have improved outcomes yet some lesions remain large and require resection before birth (open fetal surgery, OFS), at delivery via an Ex Utero Intrapartum Treatment (EXIT), or immediately post cesarean section (section-to-resection, STR). We sought to compare prenatal characteristics and outcomes in fetuses undergoing OFS, EXIT, or STR to inform decision-making and prenatal counseling. METHODS A single institution retrospective review was conducted evaluating patients undergoing OFS, EXIT, or STR for prenatally diagnosed lung lesions from 2000 to 2021. Specimens were reviewed by an anatomic pathologist. Lesions were divided into "CCAMs" (the largest pathology group) and "all lung lesions" since pathologic diagnosis is not possible during prenatal evaluation when care decisions are made. Prenatal variables included initial, greatest, and final CCAM volume-ratio (CVR), betamethasone use/frequency, cyst drainage, and the presence of hydrops. Outcomes included survival, ECMO utilization, NICU length of stay (LOS), postnatal nitric oxide use, and ventilator days. RESULTS Sixty-nine percent (59 of 85 patients) of lung lesions undergoing resection were CCAMs. Among patients with pathologic diagnosis of CCAM, the initial, largest, and final CVRs were greatest in OFS followed by EXIT and STR patients. Similarly, the incidence of hydrops was significantly greater and the rate of hydrops resolution was lower in the OFS group. Although the rate of cyst drainage did not differ between groups, maternal betamethasone use varied significantly (OFS 60.0%, EXIT 100.0%, STR 74.3%; p = 0.0378). Notably, all OFS took place prior to 2014. There was no difference in survival, ventilator days, nitric oxide, NICU LOS, or ECMO between groups. In multiple variable logistic modeling, determinants of survival to NICU discharge among patients undergoing resection with a pathologic diagnosis of CCAM included initial CVR <3.5 and need for <3 maternal betamethasone doses. CONCLUSION For CCAMs that remain large despite maternal betamethasone or cyst drainage, surgical resection via OFS, EXIT, or STR are viable options with favorable and comparable survival between groups. In the modern era there has been a shift from OFS and EXIT procedures to STR for fetuses with persistently large lung lesions. This shift has been fueled by the increased use of maternal betamethasone and introduction of a Special Delivery Unit during the study period and the appreciation of similar fetal and neonatal outcomes for STR vs. EXIT and OFS with reduced maternal morbidity associated with a STR. Accordingly, efforts to optimize multidisciplinary perinatal care for fetuses with large lung lesions are important to inform patient selection criteria and promote STR as the preferred surgical approach in the modern era. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sourav K Bose
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John D Stratigis
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicholas Ahn
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Pogoriler
- Department of Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily A Partridge
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nahla Khalek
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julianna Gebb
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina Paidas Teefey
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shelly Soni
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryoko Hamaguchi
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie Moldenhauer
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William H Peranteau
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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2
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Egan CE, Lee YJ, Stratigis JD, Ku J, Greenberg JA, Beninato T, Zarnegar R, Fahey TJ, Agrusa CJ, Finnerty BM. An Original Study: Is There an Optimal Time to Complete Dedicated Research During Surgical Residency? Twelve Years of Research Experience After PGY2 or PGY3. J Surg Educ 2023; 80:1207-1214. [PMID: 37442697 DOI: 10.1016/j.jsurg.2023.06.014] [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] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 06/01/2023] [Accepted: 06/11/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE We aimed to determine if there is an optimal time to complete dedicated research during surgical residency. BACKGROUND Research is an integral part of academic general surgical residency, and dedicated research usually occurs after the 2nd or 3rd post-graduate year (PGY). The timing of dedicated research and its association with resident productivity, self-assessed competency (including technical skills), and fellowship match is not known. METHODS PubMed was queried for publications resulting after dedicated research time for graduating surgical residents at a single institution from 2010 to 2021. Graduates were surveyed about their research experience and placed into 2 groups: research after PGY2 or PGY3. RESULTS Sixty-six of 91 (73%) graduating residents completed dedicated research (after PGY2, n=28; after PGY3, n=38). Median number of total and first author publications was similar between groups; however, research after PGY2 was associated with an increased number of basic science publications by fellowship application deadlines (PGY2: 1.0[0-13] vs PGY3: 0.0[0-6], p=0.02). With a 79% survey response rate, there were no differences in self-assessed competencies upon return from research between cohorts. Most surveyed residents matched at their top fellowship choice (PGY2:70% vs PGY3:62%, p=0.77). CONCLUSIONS Research after PGY2 or PGY3 had no association with residents' total number of publications, self-assessed competency, or rates of matching at first choice fellowship. As research after PGY2 had an increased number of basic science publications by time of fellowship application, surgical residents applying to fellowships that highly value basic science research may benefit from completing dedicated research after PGY2.
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Affiliation(s)
- Caitlin E Egan
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York.
| | - Yeon Joo Lee
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
| | - John D Stratigis
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
| | - Joyce Ku
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
| | - Jacques A Greenberg
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
| | - Toni Beninato
- Department of Surgery, Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
| | - Christopher J Agrusa
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
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3
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Riley JS, McClain LE, Stratigis JD, Coons BE, Bose SK, Dave A, White BM, Li H, Loukogeorgakis SP, Fachin CG, Dias AIBS, Flake AW, Peranteau WH. Fetal allotransplant recipients are resistant to graft-versus-host disease. Exp Hematol 2023; 118:31-39.e3. [PMID: 36535408 PMCID: PMC9898145 DOI: 10.1016/j.exphem.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
In utero hematopoietic cell transplantation (IUHCT) is an experimental treatment for congenital hemoglobinopathies, including Sickle cell disease and thalassemias. One of the principal advantages of IUHCT is the predisposition of the developing fetus toward immunologic tolerance. This allows for engraftment across immune barriers without immunosuppression and, potentially, decreased susceptibility to graft-versus-host disease (GVHD). We demonstrate fetal resistance to GVHD following T cell-replete allogeneic hematopoietic cell transplantation compared with the neonate. We show that this resistance is associated with elevated fetal serum interleukin-10 conducive to the induction of regulatory T cells (Tregs). Finally, we demonstrate that the adoptive transfer of Tregs from IUHCT recipients to neonates uniformly prevents GVHD, recapitulating the predisposition to tolerance observed after fetal allotransplantation. These findings demonstrate fetal resistance to GVHD following hematopoietic cell transplantation and elucidate Tregs as important contributors.
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Affiliation(s)
- John S Riley
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lauren E McClain
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - John D Stratigis
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Barbara E Coons
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sourav K Bose
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Apeksha Dave
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Brandon M White
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Haiying Li
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Camila G Fachin
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Andre I B S Dias
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alan W Flake
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - William H Peranteau
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, PA.
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4
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Gu L, Berkowitz CL, Stratigis JD, Collins LK, Mostyka M, Spigland NA. Presacral epidermoid cyst in a pediatric patient. Journal of Pediatric Surgery Case Reports 2021. [DOI: 10.1016/j.epsc.2021.101904] [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] Open
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5
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Loukogeorgakis SP, Shangaris P, Bertin E, Franzin C, Piccoli M, Pozzobon M, Subramaniam S, Tedeschi A, Kim AG, Li H, Fachin CG, Dias AIBS, Stratigis JD, Ahn NJ, Thrasher AJ, Bonfanti P, Peranteau WH, David AL, Flake AW, De Coppi P. In Utero Transplantation of Expanded Autologous Amniotic Fluid Stem Cells Results in Long-Term Hematopoietic Engraftment. Stem Cells 2019; 37:1176-1188. [PMID: 31116895 PMCID: PMC6773206 DOI: 10.1002/stem.3039] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 12/06/2018] [Accepted: 12/23/2018] [Indexed: 12/20/2022]
Abstract
In utero transplantation (IUT) of hematopoietic stem cells (HSCs) has been proposed as a strategy for the prenatal treatment of congenital hematological diseases. However, levels of long‐term hematopoietic engraftment achieved in experimental IUT to date are subtherapeutic, likely due to host fetal HSCs outcompeting their bone marrow (BM)‐derived donor equivalents for space in the hematopoietic compartment. In the present study, we demonstrate that amniotic fluid stem cells (AFSCs; c‐Kit+/Lin−) have hematopoietic characteristics and, thanks to their fetal origin, favorable proliferation kinetics in vitro and in vivo, which are maintained when the cells are expanded. IUT of autologous/congenic freshly isolated or cultured AFSCs resulted in stable multilineage hematopoietic engraftment, far higher to that achieved with BM‐HSCs. Intravascular IUT of allogenic AFSCs was not successful as recently reported after intraperitoneal IUT. Herein, we demonstrated that this likely due to a failure of timely homing of donor cells to the host fetal thymus resulted in lack of tolerance induction and rejection. This study reveals that intravascular IUT leads to a remarkable hematopoietic engraftment of AFSCs in the setting of autologous/congenic IUT, and confirms the requirement for induction of central tolerance for allogenic IUT to be successful. Autologous, gene‐engineered, and in vitro expanded AFSCs could be used as a stem cell/gene therapy platform for the in utero treatment of inherited disorders of hematopoiesis. stem cells2019;37:1176–1188
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Affiliation(s)
- Stavros P Loukogeorgakis
- Stem Cells and Regenerative Medicine, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom.,Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Panicos Shangaris
- Stem Cells and Regenerative Medicine, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom.,Research Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London, London, United Kingdom
| | - Enrica Bertin
- Stem Cell and Regenerative Medicine Laboratory, Fondazione Instituto di Ricerca Pediatrica Città della Speranza, University of Padova, Padova, Italy
| | - Chiara Franzin
- Stem Cell and Regenerative Medicine Laboratory, Fondazione Instituto di Ricerca Pediatrica Città della Speranza, University of Padova, Padova, Italy
| | - Martina Piccoli
- Stem Cell and Regenerative Medicine Laboratory, Fondazione Instituto di Ricerca Pediatrica Città della Speranza, University of Padova, Padova, Italy.,Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Michela Pozzobon
- Stem Cell and Regenerative Medicine Laboratory, Fondazione Instituto di Ricerca Pediatrica Città della Speranza, University of Padova, Padova, Italy
| | - Sindhu Subramaniam
- Stem Cells and Regenerative Medicine, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Alfonso Tedeschi
- Stem Cells and Regenerative Medicine, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Aimee G Kim
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Haiying Li
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Camila G Fachin
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Federal University of São Paulo, São Paulo, Brazil.,Federal University of Paraná, Curitiba, Brazil
| | - Andre I B S Dias
- Stem Cells and Regenerative Medicine, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom.,Federal University of São Paulo, São Paulo, Brazil.,Federal University of Paraná, Curitiba, Brazil
| | - John D Stratigis
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nicholas J Ahn
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Adrian J Thrasher
- Molecular and Cellular Immunology Section, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Paola Bonfanti
- Stem Cells and Regenerative Medicine, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom.,The Francis Crick Institute, London, United Kingdom
| | - William H Peranteau
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anna L David
- Research Department of Maternal and Fetal Medicine, Institute for Women's Health, University College London, London, United Kingdom
| | - Alan W Flake
- Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Paolo De Coppi
- Stem Cells and Regenerative Medicine, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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6
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Alapati D, Zacharias WJ, Hartman HA, Rossidis AC, Stratigis JD, Ahn NJ, Coons B, Zhou S, Li H, Singh K, Katzen J, Tomer Y, Chadwick AC, Musunuru K, Beers MF, Morrisey EE, Peranteau WH. In utero gene editing for monogenic lung disease. Sci Transl Med 2019; 11:eaav8375. [PMID: 30996081 PMCID: PMC6822403 DOI: 10.1126/scitranslmed.aav8375] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [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: 10/24/2018] [Accepted: 01/03/2019] [Indexed: 12/13/2022]
Abstract
Monogenic lung diseases that are caused by mutations in surfactant genes of the pulmonary epithelium are marked by perinatal lethal respiratory failure or chronic diffuse parenchymal lung disease with few therapeutic options. Using a CRISPR fluorescent reporter system, we demonstrate that precisely timed in utero intra-amniotic delivery of CRISPR-Cas9 gene editing reagents during fetal development results in targeted and specific gene editing in fetal lungs. Pulmonary epithelial cells are predominantly targeted in this approach, with alveolar type 1, alveolar type 2, and airway secretory cells exhibiting high and persistent gene editing. We then used this in utero technique to evaluate a therapeutic approach to reduce the severity of the lethal interstitial lung disease observed in a mouse model of the human SFTPCI73T mutation. Embryonic expression of SftpcI73T alleles is characterized by severe diffuse parenchymal lung damage and rapid demise of mutant mice at birth. After in utero CRISPR-Cas9-mediated inactivation of the mutant SftpcI73T gene, fetuses and postnatal mice showed improved lung morphology and increased survival. These proof-of-concept studies demonstrate that in utero gene editing is a promising approach for treatment and rescue of monogenic lung diseases that are lethal at birth.
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Affiliation(s)
- Deepthi Alapati
- Department of Pediatrics Nemours, Alfred I duPont Hospital for Children, Wilmington, DE 19803, USA
- Department of Pediatrics Sidney Kimmel Medical College, Thomas Jefferson University Philadelphia, Philadelphia, PA 19107, USA
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Center for Pulmonary Biology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Cardiovascular Institute, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia, PA 19104, USA
| | - William J Zacharias
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Center for Pulmonary Biology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Cardiovascular Institute, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia, PA 19104, USA
- Division of Pulmonary Biology Cincinnati Children's Hospital, Department of Pediatrics University of Cincinnati College of Medicine, Cincinnati, OH 45529, USA
| | - Heather A Hartman
- Center for Fetal Research, Division of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Avery C Rossidis
- Center for Fetal Research, Division of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - John D Stratigis
- Center for Fetal Research, Division of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Nicholas J Ahn
- Center for Fetal Research, Division of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Barbara Coons
- Center for Fetal Research, Division of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Su Zhou
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Cardiovascular Institute, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia, PA 19104, USA
| | - Hiaying Li
- Center for Fetal Research, Division of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Kshitiz Singh
- Center for Fetal Research, Division of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jeremy Katzen
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Center for Pulmonary Biology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Yaniv Tomer
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Center for Pulmonary Biology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Alexandra C Chadwick
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Cardiovascular Institute, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia, PA 19104, USA
| | - Kiran Musunuru
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Cardiovascular Institute, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia, PA 19104, USA
| | - Michael F Beers
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Center for Pulmonary Biology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Edward E Morrisey
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
- Penn Center for Pulmonary Biology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Penn Cardiovascular Institute, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia, PA 19104, USA
| | - William H Peranteau
- Center for Fetal Research, Division of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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7
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Ahn NJ, Stratigis JD, Coons BE, Flake AW, Nah-Cederquist HD, Peranteau WH. Intravenous and Intra-amniotic In Utero Transplantation in the Murine Model. J Vis Exp 2018. [PMID: 30371676 DOI: 10.3791/58047] [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] [Indexed: 01/16/2023] Open
Abstract
In utero transplantation (IUT) is a unique and versatile mode of therapy that can be used to introduce stem cells, viral vectors, or any other substances early in the gestation. The rationale behind IUT for therapeutic purposes is based on the small size of the fetus, the fetal immunologic immaturity, the accessibility and proliferative nature of the fetal stem or progenitor cells, and the potential to treat a disease or the onset of symptoms prior to birth. Taking advantage of these normal developmental properties of the fetus, the delivery of hematopoietic stem cells (HSC) via an IUT has the potential to treat congenital hematologic disorders such as sickle cell disease, without the required myeloablative or immunosuppressive conditioning required for postnatal HSC transplants. Similarly, the accessibility of progenitor cells in multiple organs during development potentially allows for a more efficient targeting of stem/progenitor cells following an IUT of viral vectors for gene therapy or genome editing. Additionally, IUT can be used to study normal developmental processes including, but not limited to, the development of immunologic tolerance. The murine model provides a valuable and affordable means to understanding the potential and limitations of IUT prior to pre-clinical large animal studies and an eventual clinical application. Here, we describe a protocol for performing an IUT in the murine fetus through intravenous and intra-amniotic routes. This protocol has been used successfully to elucidate the necessary conditions and mechanisms behind in utero hematopoietic stem cell transplantation, tolerance induction, and in utero gene therapy.
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Affiliation(s)
- Nicholas J Ahn
- Division of General, Thoracic, and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia
| | - John D Stratigis
- Division of General, Thoracic, and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia
| | - Barbara E Coons
- Division of General, Thoracic, and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia
| | - Alan W Flake
- Division of General, Thoracic, and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia
| | - Hyun-Duck Nah-Cederquist
- Division of Plastic Reconstructive Surgery, Center for Fetal Research, Children's Hospital of Philadelphia
| | - William H Peranteau
- Division of General, Thoracic, and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia;
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8
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Riley JS, McClain LE, Stratigis JD, Coons BE, Li H, Hartman HA, Peranteau WH. Pre-Existing Maternal Antibodies Cause Rapid Prenatal Rejection of Allotransplants in the Mouse Model of In Utero Hematopoietic Cell Transplantation. J Immunol 2018; 201:1549-1557. [PMID: 30021770 DOI: 10.4049/jimmunol.1800183] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/11/2018] [Indexed: 01/07/2023]
Abstract
In utero hematopoietic cell transplantation (IUHCT) is a nonmyeloablative nonimmunosuppressive alternative to postnatal hematopoietic stem cell transplantation for the treatment of congenital hemoglobinopathies. Anti-HLA donor-specific Abs (DSA) are associated with a high incidence of graft rejection following postnatal hematopoietic stem cell transplantation. We determine if DSA present in the mother can similarly cause graft rejection in the fetus following IUHCT. Ten million C57BL/6 (B6, H2kb) bone marrow cells were transplanted in utero into gestational day 14 BALB/c (H2kd) fetuses. The pregnant BALB/c dams carrying these fetuses either had been previously sensitized to B6 Ag or were injected on gestational days 13-15 with serum from B6-sensitized BALB/c females. Maternal-fetal Ab transmission, Ab opsonization of donor cells, chimerism, and frequency of macrochimeric engraftment (chimerism >1%) were assessed by flow cytometry. Maternal IgG was transmitted to the fetus and rapidly opsonized donor cells following IUHCT. Donor cell rejection was observed as early as 4 h after IUHCT in B6-sensitized dams and 24 h after IUHCT in dams injected with B6-sensitized serum. Efficient opsonization was strongly correlated with decreased chimerism. No IUHCT recipients born to B6-sensitized dams or dams injected with B6-sensitized serum demonstrated macrochimeric engraftment at birth compared with 100% of IUHCT recipients born to naive dams or dams injected with naive serum (p < 0.001). In summary, maternal donor-specific IgG causes rapid, complete graft rejection in the fetus following IUHCT. When a third-party donor must be used for clinical IUHCT, the maternal serum should be screened for DSA to optimize the chance for successful engraftment.
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Affiliation(s)
- John S Riley
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Lauren E McClain
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - John D Stratigis
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Barbara E Coons
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Haiying Li
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Heather A Hartman
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - William H Peranteau
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA 19104
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Tarui T, Kim A, Flake A, McClain L, Stratigis JD, Fried I, Newman R, Slonim DK, Bianchi DW. Amniotic fluid transcriptomics reflects novel disease mechanisms in fetuses with myelomeningocele. Am J Obstet Gynecol 2017; 217:587.e1-587.e10. [PMID: 28735706 DOI: 10.1016/j.ajog.2017.07.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/14/2017] [Accepted: 07/17/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cell-free RNA in amniotic fluid supernatant reflects developmental changes in gene expression in the living fetus, which includes genes that are specific to the central nervous system. Although it has been previously shown that central nervous system-specific transcripts are present in amniotic fluid supernatant, it is not known whether changes in the amniotic fluid supernatant transcriptome reflect the specific pathophysiologic condition of fetal central nervous system disorders. In myelomeningocele, there is open communication between the central nervous system and amniotic fluid. OBJECTIVES The purpose of this study was to identify molecular pathophysiologic changes and novel disease mechanisms that are specific to myelomeningocele by the analysis of amniotic fluid supernatant cell-free RNA in fetuses with open myelomeningocele. STUDY DESIGN Amniotic fluid supernatant was collected from 10 pregnant women at the time of the open myelomeningocele repair in the second trimester (24.5±1.0 weeks); 10 archived amniotic fluid supernatant from sex and gestational age-matched euploid fetuses without myelomeningocele were used as controls (20.9±0.9 weeks). Differentially regulated gene expression patterns were analyzed with the use of human genome expression arrays. RESULTS Fetuses with myelomeningocele had 284 differentially regulated genes (176 up- and 108 down-regulated) in amniotic fluid supernatant. Known genes that were associated with myelomeningocele (PRICKLE2, GLI3, RAB23, HES1, FOLR1) and novel dysregulated genes were identified in association with neurodevelopment and neuronal regeneration (up-regulated, GAP43 and ZEB1) or axonal growth and guidance (down-regulated, ACAP1). Pathway analysis demonstrated a significant contribution of inflammation to disease and a broad influence of Wnt signaling pathways (Wnt1, Wnt5A, ITPR1). CONCLUSION Transcriptomic analyses of living fetuses with myelomeningocele with the use of amniotic fluid supernatant cell-free RNA demonstrated differential regulation of specific genes and molecular pathways relevant to this central nervous system disorder, which resulted in a new understanding of pathophysiologic changes. The data also suggested the importance of pathways that involve secondary disease, such as inflammation, in myelomeningocele. These newly identified pathways may lead to hypotheses that can test novel therapeutic targets as adjuncts to fetal surgical repair.
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Boelig MM, Kim AG, Stratigis JD, McClain LE, Li H, Flake AW, Peranteau WH. The Intravenous Route of Injection Optimizes Engraftment and Survival in the Murine Model of In Utero Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:991-999. [PMID: 26797401 DOI: 10.1016/j.bbmt.2016.01.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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: 10/27/2015] [Accepted: 01/11/2016] [Indexed: 01/16/2023]
Abstract
In utero hematopoietic cell transplantation (IUHCT) has the potential to treat a number of congenital hematologic disorders. Clinical application is limited by low levels of donor engraftment. Techniques that optimize donor cell delivery to the fetal liver (FL), the hematopoietic organ at the time of IUHCT, have the potential to enhance engraftment and the clinical success of IUHCT. We compared the 3 clinically applicable routes of injection (intravenous [i.v.], intraperitoneal [i.p.], and intrahepatic [i.h.]) and assessed short- and long-term donor cell engraftment and fetal survival in the murine model of IUHCT. We hypothesized that the i.v. route would promote direct donor cell homing to the FL, resulting in increased engraftment and allowing for larger injectate volumes without increased fetal mortality. We demonstrate that the i.v. route results in (1) rapid diffuse donor cell population of the FL compared with delayed diffuse engraftment after the i.p. and i.h. routes; (2) higher FL and spleen engraftment at early prenatal time points; (3) enhanced stable long-term peripheral blood donor cell engraftment; and (4) improved survival at higher injectate volumes, allowing for higher donor cell doses and increased long-term engraftment. These findings support the use of an i.v. route for clinical protocols of IUHCT.
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Affiliation(s)
- Matthew M Boelig
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aimee G Kim
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John D Stratigis
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lauren E McClain
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Haiying Li
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan W Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William H Peranteau
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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Abstract
OBJECTIVE To describe a case of a rare type of venous aneurysm (posterior tibial) with associated pulmonary embolus. We will discuss options and considerations germane to the diagnostic evaluation and possible interventions for this challenging clinical scenario. METHODS Case presentation and literature review. RESULTS A 36-year-old man presented to an outside hospital with a three-day history of left calf pain, acute shortness of breath and syncope elicited by exercise. Work-up demonstrated a pulmonary embolus and a posterior tibial venous aneurysm with mural thrombus. The patient presented to us 18 months later with persistent calf pain seeking an alternative to recommendations of lifelong anticoagulation. The patient was treated with surgical resection of the venous aneurysm with subsequent discontinuation of his anticoagulation. There were no surgical or thrombotic complications of this treatment course and the patient's discomfort improved. CONCLUSION Primary aneurysms of the tibial veins as a cause of pulmonary emboli are rare. A review of the literature suggests that anticoagulation alone does not provide effective amelioration of thromboembolic risk from lower extremity venous aneurysms. We have reported a case of successful surgical treatment of a posterior tibial venous aneurysm and recommend that surgical correction be strongly considered for accessible venous aneurysms.
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Affiliation(s)
- O P Haqqani
- Department of Vascular Surgery, Cardiovascular Center, Tufts Medical Center, Boston, MA 02111, USA.
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Logan CA, Cressey BD, Wu RY, Janicki AJ, Chen CX, Bolourchi ML, Hodnett JL, Stratigis JD, Mackey WC, Fairchild DG. Monitoring universal protocol compliance through real-time clandestine observation by medical students results in performance improvement. J Surg Educ 2012; 69:41-46. [PMID: 22208831 DOI: 10.1016/j.jsurg.2011.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 04/10/2011] [Accepted: 05/26/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To measure universal protocol compliance through real-time, clandestine observation by medical students compared with chart audit reviews, and to enable medical students the opportunity to become conscious of the importance of medical errors and safety initiatives. DESIGN With endorsement from Tufts Medical Center's (TMC's) Chief Medical Officer and Surgeon-in-Chief, 8 medical students performed clandestine observation audits of 98 cases from April to August 2009. A compliance checklist was based on TMC's presurgical checklist. Our initial results led to interventions to improve our universal protocol procedures, including modifications to the operating room white board and presurgical checklist, and specific feedback to surgical departments. One year later, 6 medical students performed observations of 100 cases from June to August 2010. SETTING Tufts Medical Center, Boston, Massachusetts, which is an academic medical center and the principal teaching hospital for Tufts University School of Medicine. PARTICIPANTS An operating room coordinator placed the medical students into 1 of our 25 operating rooms with students entering under the premise of observing the anesthesiologist for clinical education. The observations were performed Monday to Friday between 7 am and 4 pm. Although observations were not randomized, no single service or type of surgery was targeted for observation. RESULTS A broad range of departments was observed. In 8.2% of cases, the surgical site was unmarked. A Time Out occurred in 89.7% of cases. The entire surgical team was attentive during the time out in 82% of cases. The presurgical checklist was incomplete before incision in 13 cases. Images were displayed in 82% of cases. The operating room "white board" was filled out completely in 49% of cases. Team introductions occurred in 13 cases. One year later, compliance increased in all Universal Protocol dimensions. CONCLUSIONS Direct, real-time observation by medical students provides an accurate and granular assessment of compliance with specific components of the universal protocol and engages medical students in the quality improvement process, raises their awareness of the gravity of medical errors, and ensures appreciation of the importance of quality and safety initiatives.
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Affiliation(s)
- Catherine A Logan
- Department of Surgery, Tufts University Medical Center, Boston, Massachusetts 02111, USA.
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