Full-thickness Biopsy Research Articles

Suaugusiųjų Hirschprungo ligos chirurginis gydymas subtotaline kolektomija: galima alternatyva

Suaugusiųjų Hirschprungo liga yra reta ir sunkiai diagnozuojama vidurių užkietėjimo priežastis. Straipsnyje aprašoma 19 metų mūsų gydytos moters istorija. Pacientė kreipėsi dėl visą gyvenimą trunkančio vidurių užkietėjimo ir pilvo skausmų. Radiologinio ir endoskopinio tyrimo duomenimis, tiesioji žarna normalaus pločio, o gaubtinė žarna labai plati ir pilna turinio. Viso storio tiesiosios žarnos biopsija patvirtino aganglinę tiesiąją žarną. Pacientė buvo operuota ir jai atlikta subtotalinė kolektomija ir ileorektostomija. Penkerių metų stebėjimas po operacijos parodė, kad pacientė gyvena kokybiškai. Manome, kad subtotalinė kolektomija ir ileorektostomija yra viena iš jaunų pacientų chirurginio gydymo alternatyvų.

The evaluation of rectal mucosal punch biopsy in the diagnosis of Hirschsprung's disease: a 30-year experience of 954 patients.

For 30years, we have consecutively performed rectal mucosal punch biopsy to diagnose Hirschsprung's disease. The aim of this study was to evaluate the safety of our technique. Patients with suspected Hirschsprung's disease who underwent punch biopsy, including our original "K-PUNCH" method using an S-moid forceps and non-specific blood-collecting tube at our department and branch hospital between April 1986 and March 2016 were included in the present study. Our punch biopsy technique is characterized by excellent visibility and a direct grasping sensation. The backgrounds and complications of the patients were retrospectively investigated. During this period, 954 patients (median age 4months; range 1day-73years) underwent punch biopsy. Although there were no cases of severe complications (i.e., rectal perforation, infection or full-thickness biopsy), one (0.1%) of the 954 cases in the early period showed liver dysfunction and required transfusion due to bleeding. In addition, inappropriate specimens were obtained in 37 patients (3.9%). Punch biopsy including the "K-PUNCH" method is considered safe and feasible and is associated with a low rate of complications and inappropriate specimen harvesting among patients of all ages. Comorbidities, including the potential for hemorrhage, should always be considered.

Development of a combined radiation and full thickness burn injury minipig model to study the effects of uncultured adipose-derived regenerative cell therapy in wound healing

Purpose: To develop an approach that models the cutaneous healing that occurs in a patient with full thickness thermal burn injury complicated by total body radiation exposure sufficient to induce sub-lethal prodromal symptoms. An assessment of the effects of an autologous cell therapy on wound healing on thermal burn injury with concomitant radiation exposure was used to validate the utility of the model.Methods: Göttingen minipigs were subjected to a 1.2 Gy total body irradiation by exposure to a 6 MV X-ray linear accelerator followed by ∼10 cm2 full thickness burns (pre-heated brass block with calibrated spring). Three days after injury, wounds were excised to the underlying fascia and each animal was randomized to receive treatment with autologous adipose-derived regenerative cells (ADRC) delivered by local or intravenous injection, or vehicle control. Blood counts were used to assess radiation-induced marrow suppression. All animals were followed using digital imaging to assess wound healing. Full-thickness biopsies were obtained at 7, 14, 21 and 30 days’ post-treatment.Results: Compared to animals receiving burn injury alone, significant transient neutropenia and thrombocytopenia were observed in irradiated subjects with average neutrophil nadir of 0.79 × 103/μl (day 15) and platelet nadir of 60 × 103/μl (day 12). Wound closure through a combination of contraction and epithelialization from the wound edges occurred over a period of approximately 28 days’ post excision and treatment. Re-epithelialization was accelerated in wounds treated with ADRC (mean 3.5-fold increase at 2 weeks post-treatment relative to control). This acceleration was accompanied by an average 67% increase in blood vessel density and 30% increase in matrix (collagen) deposition. Similar results were observed when ADRC were injected either directly into the wound or by intravenous administration.Conclusions: Although preliminary, this study provides a reproducible minipig model of thermal burn injury complicated by myelosuppressive total body irradiation that utilizes standardized procedures to evaluate novel countermeasures for potential use following attack by an improvised nuclear device.

Histologic and metabolic assessment in a cohort of patients with genital prolapse: preoperative stage and recurrence investigations.

Biological basis of prolapse development and recurrence are still unclear. Aim of this observational and prospective study is to correlate clinical stage of anterior vaginal wall prolapse and anatomical recurrence to histological and metabolic characteristics of vaginal tissue. Patients undergoing surgery were divided into two groups according to anterior stage ≤II (group A) and ≥III (group B). Full-thickness excisional biopsies of the anterior vaginal wall were obtained after hysterectomy. Hystological characteristics and metalloproteinases activity (MMP-2) were analyzed. Sixty-nine patients (35 group A; 34 group B) completed evaluation. Mean follow-up was 35 months. Collagen amount and organization were significantly higher in group B both in lamina propria and fascia specimens, but MMP-2 activity was significantly lower in this group. Recurrence rate of anterior compartment was 10.1%. Collagen cellularity of fascia was higher in recurrence groups. On the contrary MMP-2 activity showed a close to significant correlation to surgical success (P=0.07). Patients with advanced stages of prolapse have increased collagen amount associated to decreased MMP-2 activity. This suggests that connective tissue is more abundant but less metabolically active in patients with severe prolapse. A similar trend can be found in recurrences.

Management of malignant pleural mesothelioma- part1: epidemiology, diagnosis, and staging : Consensus of the Austrian Mesothelioma Interest Group (AMIG).

SummaryMalignant pleural mesothelioma is a rare malignant disease that in the majority of cases is associated with asbestos exposure. The incidence in Europe is about 20 per million inhabitants and it is increasing worldwide. Initial symptoms are shortness of breath, pleural effusion, cough, and chest pain. The typical growth pattern is along the pleural surface; however, infiltration of the lung and/or mediastinal and chest wall structures can occur in a more advanced stage. Ultimately, distant metastases outside the chest can result. Several histological subtypes of pleural mesothelioma exist, which must be differentiated from either benign diseases or metastases in the pleural space by other tumor entities. This differential diagnosis can be very difficult and a large panel of immunohistochemical markers is required to establish the exact diagnosis. The standard procedure for confirming the disease and obtaining sufficient tissue for the diagnosis is videothoracoscopy. Full thickness biopsies are required, while transthoracic needle puncture of pleural fluid or tissue is considered to be insufficient for a cytological diagnosis. Complete and detailed staging is mandatory for categorization of the disease as well as for therapeutic decision making.

Pathological Changes of Lymphedematous Skin: Increased Mast Cells, Related Proteases, and Activated Transforming Growth Factor-β1.

Skin fibrosis is a clinically serious pathological process of secondary lymphedema (SLE). Previous studies have shown that mast cells (MCs) are involved in lymphedema (LE) and play a key role in the pathological process of skin fibrosis. However, the role of the protease chymase and transforming growth factor-β1 (TGF-β1) secreted by MCs in the fibrotic skins of patients with secondary lower limb LE has not been explored. In this study, full-thickness skin biopsies of lymphedematous limbs from seven SLE patients and control samples from seven healthy controls were harvested. The skin samples were assayed by Masson, immunohistochemical, and immunofluorescence staining and were analyzed by western blot and enzyme-linked immunosorbent assay. The number of MCs and the expression of proteases, TGF-β1, and latency-associated peptide TGF-β1 (LAP TGF-β1) were analyzed. The number of MCs and the expression of chymase, TGF-β1, and LAP TGF-β1 were increased in fibrotic skin compared with normal skin. The increased expression of TGF-β1 on lymphatic vessels, endothelial cells, and in skin interstitial tissues overlapped with chymase expression. Our results demonstrate that chymase and TGF-β1 expression was significantly increased in the fibrotic skin of secondary lower limb LE. The increased expression of chymase in the skin may play an important role in the development fibrosis in the lymphedematous skin. We speculate that chymase may facilitate the release of LAP TGF-β1 to generate activated TGF-β1, and the upregulation of active TGF-β1 can promote fibrosis in the SLE skin.

Characterization of the T-cell receptor gamma chain gene rearrangements as an adjunct tool in the diagnosis of T-cell lymphomas in the gastrointestinal tract of cats

Feline alimentary lymphoma is the most common hematopoietic neoplasia in cats. It affects mainly the small intestines and is most frequently of T-cell origin. Evaluation of a fine needle aspirate is often the first step in the diagnostic work-up. Differentiation between a resident mature lymphocyte population as encountered in inflammatory bowel disease and small cell lymphoma cannot be achieved by cytology alone. Even full thickness biopsies evaluated by histopathology can be inconclusive. These cases warrant the application of complementary tools like PCR-based T-cell receptor (TCR) clonality testing for confirmation.The aim of this study was to optimize the DNA extraction protocol for formalin fixed and paraffin embedded tissues (FFPE) and to establish a heteroduplex analysis to enhance resolution of the PCR fragments of the T-cell receptor gamma (TCRG) V-J gene. The new protocols resulted in improved quantity and quality of the extracted DNA. Heteroduplex analysis of the samples improved the resolution of the electrophoresis results so that rules for interpretation of the different patterns could be established. Application of this improved setup detected clonal rearrangements in at least one TCRG primer reaction in 31 of 36 of our feline intestinal lymphoma samples after DNA quality testing.

Primary Myopathic Chronic Intestinal Pseudo-Obstruction in a Maltese Dog

An 11-year-old castrated male Maltese had vomiting, diarrhea, and abdominal distension for over two weeks and weight loss for several months. Clinical laboratory studies were not remarkable. Abdominal radiographs showed severe dilated intestine with a gravel sign. Colon was empty with normal diameter in the pneumocolon study. On ultrasonographs, most small bowel loops were dilated without normal peristalsis and showed abnormal thin wall. Barium contrast study revealed remarkably delayed gastric emptying and transit time up to 6th day. On exploratory laparotomy, there were no mechanical obstruction and extra-intestinal abnormalities except severe dilated small intestine. Chronic fibrosing lymphohistiocytic leiomyositis with atrophy of tunica muscularis in the small intestines and colon was identified through full thickness biopsy and histopathology. Therefore, primary myopathic chronic intestinal pseudoobstruction was diagnosed. This dog is survival with symptomatic treatments for eight months.

Current practice patterns of rectal suction biopsy in the diagnostic work-up of Hirschsprung's disease: results from an international survey.

The diagnosis of Hirschsprung's disease (HD) was revolutionized by the introduction of rectal suction biopsy (RSB), allowing specimens to be taken without general anesthesia on the ward or as an out-patient procedure. However, insufficient tissue samples are not uncommon, and subsequently histopathologists often remain reluctant to confirm the presence or absence of enteric ganglion cells merely on the basis of submucosal RSBs. The aim of this study was to evaluate the current usage of RSB in the diagnostic work-up of HD based on an international survey. A 15-item questionnaire was distributed among participants and faculty members at the 21st International Meeting of the Pediatric Colorectal Society. Eighty-seven pediatric surgeons from 30 countries completed the anonymous survey (response rate 70.2%), grouped into 68 (78.2%) staff surgeons and 19 (21.8%) trainees, with a median work experience of 18years (range 2-45years). Of these, 74 (85.1%) use RSB in the diagnostic work-up of patients with suspected HD, whereas 13 (14.9%) prefer open full-thickness biopsy under general anesthesia. In total, 47 (63.5%) respondents perform ≥20 RSBs (range 3-100 RSBs) per year. Five different RSB instruments were reported, the most common ones being rbi2 (65.0%), Solo-RBT (15.0%) and multipurpose suction biopsy kit (8.3%). Only 22 (29.7%) of the respondents use a defined negative suction pressure, with a median of 10mL air (range 6-25mL air). The most proximal reported biopsy site was located at a median of 2cm (range 1-15cm) above the pectinate line and a median of 2 (range 1-5) specimens are routinely taken, mainly from the posterior rectal wall. Insufficient tissue samples with need for repeat RSB were encountered in a median of 10% (range 0-40%). Most frequently used staining methods for rectal biopsies are hematoxylin/eosin (75.9%), acetylcholinesterase (73.6%), and calretinin (33.3%). Overall, 36 (48.6%) respondents had experienced RSB-related complications, including self-limiting rectal blood loss (n=28), persistent rectal bleeding requiring blood transfusion (n=9) and rectal perforation requiring surgical intervention (n=7). Although RSB is considered to be today's gold standard for the diagnosis of HD, many aspects of its current usage are lacking consensus. Therefore, a prospective multi-center study or larger global audit appears warranted to identify if the present survey reflects common surgical practice and to establish universal standards for RSB.

Precision real-time evaluation of bowel perfusion: accuracy of confocal endomicroscopy assessment of stoma in a controlled hemorrhagic shock model.

Confocal laser endomicroscopy (CLE) can provide real-time evaluation of bowel perfusion. We aimed to evaluate CLE perfusion imaging in a hemorrhagic shock model. Five pigs were equipped to ensure hemodynamic monitoring. Three ileostomies per animal (total n=15) were randomly created (T0). Blood was withdrawn targeting a mean arterial pressure of 40mmHg (shock phase, T1), for 90min. Infusion of Ringer's lactate was started and continued for 90min (T2). At the different time points: (a) stomas' mucosa was scanned with CLE; (b) capillary lactates were measured on blood obtained by puncturing stomas' mucosa; and (c) full-thickness stomas' biopsies were sampled for histology, mitochondrial respiratory rate (V 0=basal and V ADP=respiratory rate in excess of adenosine diphosphate), and levels of superoxide anion evaluation. Functional capillary density (FCD) was measured using ad hoc software. Confocal scanning provided consistent and specific imaging of bowel hypoperfusion at T1: vascular hyperpermeability (blurred and enlarged capillaries) and edema (enhanced visualization of the brush border due to increased intercellular spaces and fluorescein leakage). At the end of T2, there was an improved capillary flow. FCD-A index expressed statistically significant correlation with (1) stoma capillary lactates (p=0.023); (2) systemic capillary lactates (p=0.031); (3) inflammation pathology score (p=0.048); (4) central venous pressure (p=0.0043); and (5) pulmonary artery pressure (p=0.01). Stoma capillary lactates (mmol/L) were significantly increased at T1 (8.81±4.23; p<0.0001) and at T2 (4.77±3.13; p<0.01) when compared to T0 inclusion values (1.86±0.56). V 0 and V ADP (pmolO2/min/mg tissue) were both significantly decreased at T1 versus T0 (p<0.007 and p<0.01, respectively) and recovered by the end of reanimation (T2 vs. T0, p=n.s.). Mean O 2·- production (µmol/min/mg/dry tissue) increased at T1 and significantly decreased at T2. Confocal laser endomicroscopy (CLE) imaging could identify morphological signs congruent with biochemical markers of bowel perfusion and could be useful for assessment of stomas.

Nondermal irritating hyperosmotic nanoemulsions reduce treatment times in a contamination model of wound healing.

Increased microbial burden within the wound often complicates wound healing and may lead to subsequent infection or delayed healing. Here, we investigate a novel topical for addressing wound contamination that utilizes hyperosmotic saccharides with a cell membrane disrupting emulsion. These hyperosmotic nanoemulsions (HNE) were administered topically in a full-thickness biopsy model of wound healing. Results show that HNE were well tolerated in noninfected animals with no indications of dermal irritation or acute toxicity. Additionally, HNE was able to reduce bacterial bioburden (Escherichia coli and Enterococcus faecalis) levels by 3 logs within 24h when wounds were inoculated with 5×10(6) total CFU. These bactericidal values were similar to wounds treated with silver sulfadiazine. Wound closure showed HNE wounds closed in 7.6 ± 0.2 days while SSD and control required 10.2 ± 0.4 and 10.4 ± 0.3 days, respectively. HNE maintained a moist wound environment, were well debrided, and exhibited improved hemostatic response. Further histological examination revealed enhanced granulation tissue as compared to silver sulfadiazine and control cohorts. These results were corroborated with 3D topographical imprints of the wounds at day 14 which qualitatively showed a smoother surface. In contrast, silver sulfadiazine appeared to delay wound closure. Finally, dermal sensitization and irritation studies conducted in guinea pig and rabbits did not reveal any acute dermal side effects from HNE exposure. The cumulative data indicates nonantibiotic-based HNEs may be a promising topical treatment for the management of contaminated wounds.

Biological differences between functionalis and basalis endometria in women with and without adenomyosis

ObjectiveEndometriosis is commonly believed to originate from functionalis endometrium and adenomyosis from basalis endometrium. Due to the lack of enough information, we investigated the biological differences between these two layers of endometrium in women with and without adenomyosis. Study designThis was a case-controlled study with 12 control women and 17 women with adenomyosis undergoing hysterectomy. Full thickness (extending from the endometrium to the myometrium) biopsy specimens were obtained after the hysterectomy. Based on the phases of the menstrual cycle, the expression patterns of estrogen receptor (ER), progesterone receptor (PR), Ki-67, and activated Caspase-3 were analyzed by immunohistochemistry in the functionalis and basalis endometria. Apoptotic cells were evaluated by TdT-mediated dUTP-biotin nick end-labeling (TUNEL) assay. ResultsA similar pattern of ER and PR expression was found in the functionalis and basalis endometria during the proliferative phase. In contrast, a significantly lower ER and PR expression was found in the basalis endometria than in the functionalis endometria during the secretory phase and the menstrual phase. This was equally observed in control women and in women with adenomyosis. Except Ki-67 indices, TUNEL-positive cells, and expression of activated Caspase-3 were significantly lower in the basalis endometria than in the functionalis endometria during the secretory phase. ConclusionA significant biological difference was found between the functionalis and the basalis endometria derived from women with adenomyosis.

A Rare Cause of Chronic Abdominal Pain

Gastroentero Question: A 70year-old man was referred initially for a gastroenterology consultation in 1984 with a 20-year history of chronic abdominal pain since early adulthood. His symptomatology was predominantly postprandial, with nausea and vomiting, bloating, and epigastric discomfort. His clinical course was characterized by protracted periods of bothersome symptomatology with interspersed episodes of disabling symptoms requiring hospitalization and some brief stretches of symptomatic remission. There was no history of dysphagia, odynophagia, weight loss, or jaundice, neither at initial presentation nor in long-standing follow-up. The patient also denied any use of nonsteroidal antiinflammatory drugs or alcohol. However, he did experience 1 episode of upper gastrointestinal bleeding manifested by melena. This resolved with conservative management and proton pump inhibitor therapy without the need for therapeutic endoscopic intervention. Initially, the etiology of his abdominal pain was thought to originate from the biliary tree given ultrasound evidence of small gallstones and a corresponding history of postprandial symptoms. However, the patient did not experience any benefit from cholecystectomy. His past medical history was otherwise significant for psoriasis, treated with etanercept. Repeated physical examination in follow-up was benign without evidence of peritonitis, hepatosplenomegaly, or lymphadenopathy. Laboratory investigations were also nonrevealing, with a normal hemoglobin (149 g/L) and ferritin (316 mg/L). On esophagogastroduodenoscopy, the gastric mucosa of the entire stomach appeared nodular and severely inflamed (Figure A). This was a consistent finding on repeated endoscopic evaluation over the course of 3 decades of followup. However, the mucosa of the esophagus, duodenum, and colon seemed to be spared. Repeated testing for Helicobacter pylori infection was negative. Multiple biopsy specimens were obtained at endoscopy and confirmed with full-thickness surgical gastric biopsy. Representative histology is shown in Figure B. What is the cause of this man’s abdominal pain? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Gastrointestinal biopsies from the pathologist's point of view

Both full-thickness and endoscopic biopsies of the gastrointestinal (GI) tract may be presented to the pathologist for the diagnosis of GI disease. This article discusses the role of gastrointestinal biopsies in the diagnosis of alimentary tract disease, as well as highlighting certain conditions that may be missed by endoscopic biopsies as opposed to surgical (fullthickness) biopsies. It outlines the World Small Animal Veterinary Association guidelines used by pathologists to assess inflammatory diseases present, discussing some of the key points of these guidelines and also some of their pitfalls.

Small intestinal biopsy and resection in standing sedated horses

SummaryDiagnostic laparotomy and laparoscopy are surgical techniques commonly used for the investigation of chronic abdominal disease and weight loss. They can both be usefully carried out in the standing sedated horse, allowing a thorough examination of the dorsal abdominal cavity and biopsies to be harvested. Small intestinal disease is an important cause of weight loss and recurrent colic. Inflammatory or neoplastic bowel disease may not always be apparent grossly and histopathological assessment of full thickness biopsies may be required to provide a definitive diagnosis. Details of cases of 15 horses that underwent small intestinal biopsy or enterectomy while sedated and standing are presented. Three incisional infections occurred causing delayed wound healing. Three horses were subjected to euthanasia before hospital discharge: two had persistent gastric reflux and one had colitis. A further six were subjected to euthanasia in the first 4 months due to their underlying inflammatory bowel condition. One horse was subjected to euthanasia for severe laminitis that was presumed to be caused by treatment with a corticosteroid 4 years later, and one died of acute colic 2.3 years after successful resection and anastomosis. Five horses were alive at the time of review, median 2.7, range 1.2–4.3 years. Overall therefore, 3 (20%) horses died during hospitalisation and 5 (33%) were still alive at the end of the study. Results from this series suggest that minimising the number of intestinal biopsies may reduce morbidity, but the underlying pathological process appears to be the most important prognostic factor for survival. Resection and anastomosis in the standing sedated horse proved feasible.

Host response to synthetic mesh in women with mesh complications

Despite good anatomic and functional outcomes, urogynecologic polypropylene meshes that are used to treat pelvic organ prolapse and stress urinary incontinence are associated with significant complications, most commonly mesh exposure and pain. Few studies have been performed that specifically focus on the host response to urogynecologic meshes. The macrophage has long been known to be the key cell type that mediates the foreign body response. Conceptually, macrophages that respond to a foreign body can be dichotomized broadly into M1proinflammatory and M2 proremodeling subtypes. A prolonged M1 response is thought to result in chronic inflammation and the formation of foreign body giant cells with potential for ongoing tissue damage and destruction. Although a limited M2 predominant response is favorable fortissue integration and ingrowth, excessive M2 activity can lead to accelerated fibrillar matrix deposition and result in fibrosis and encapsulation of the mesh. The purpose of this study was to define and compare the macrophage response in patients who undergo mesh excision surgery for the indication of pain vs a mesh exposure. Patients who were scheduled to undergo a surgical excision of mesh for pain or exposure at Magee-Womens Hospital were offered enrollment. Twenty-seven mesh-vagina complexes that were removed for the primary complaint of a mesh exposure (n= 15) vs pain inthe absence of an exposure (n= 12) were compared with 30 full-thickness vaginal biopsy specimens from women who underwent benign gynecologic surgery without mesh. Macrophage M1 proinflammatory vs M2 proremodeling phenotypes were examined via immunofluorescent labeling for cell surface markers CD86 (M1) vs CD206 (M2)and M1 vs M2 cytokines via enzyme-linked immunosorbent assay. The amount of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) proteolytic enzymes were quantified by zymography and substrate degradation assays, as an indication of tissue matrix degradation. Statistics were performed with the use of 1-way analysis of variance with appropriate post hoc tests, t-tests, and Fisher's Exact test. Twenty-seven mesh-vaginal tissue complexes were excised from 27 different women with mesh complications: 15 incontinence mid urethral slings and 12 prolapse meshes. On histologic examination, macrophages surrounded each mesh fiber in both groups, with predominance of the M1 subtype. M1 and M2 cytokines/chemokines, MMP-9 (pro- and active), and MMP-2 (active) were increased significantly in mesh-vagina explants, as compared with vagina without mesh. Mesh explants that were removed for exposure had 88.4% higher pro-MMP-9 (P= .035) than those removed for pain. A positive correlation was observed between the profibrotic cytokine interleukin-10 and the percentage of M2 cells (r= 0.697; P= .037) in the pain group. In women with complications, mesh induces a proinflammatory response that persists years after implantation. The increase in MMP-9 in mesh explants that were removed for exposure indicates degradation; the positive association between interleukin-10 and M2 macrophages in mesh explants that are removed for pain is consistent with fibrosis.

Sa1709 Comparison of Mucosal Neuronal Density With Full Thickness Biopsies, Gastrointestinal Symptoms and Gastric Emptying in Patients With Symptoms of Gastroparesis

Sa1709 Comparison of Mucosal Neuronal Density With Full Thickness Biopsies, Gastrointestinal Symptoms and Gastric Emptying in Patients With Symptoms of Gastroparesis

NOD-like receptor signaling and inflammasome-related pathways are highlighted in psoriatic epidermis.

Psoriatic skin differs distinctly from normal skin by its thickened epidermis. Most gene expression comparisons utilize full-thickness biopsies, with substantial amount of dermis. We assayed the transcriptomes of normal, lesional, and non-lesional psoriatic epidermis, sampled as split-thickness skin grafts, with 5′-end RNA sequencing. We found that psoriatic epidermis contains more mRNA per total RNA than controls, and took this into account in the bioinformatic analysis. The approach highlighted innate immunity-related pathways in psoriasis, including NOD-like receptor (NLR) signaling and inflammasome activation. We demonstrated that the NLR signaling genes NOD2, PYCARD, CARD6, and IFI16 are upregulated in psoriatic epidermis, and strengthened these findings by protein expression. Interestingly, PYCARD, the key component of the inflammasome, showed an altered expression pattern in the lesional epidermis. The profiling of non-lesional skin highlighted PSORS4 and mitochondrially encoded transcripts, suggesting that their gene expression is altered already before the development of lesions. Our data suggest that all components needed for the active inflammasome are present in the keratinocytes of psoriatic skin. The characterization of inflammasome pathways provides further opportunities for therapy. Complementing previous transcriptome studies, our approach gives deeper insight into the gene regulation in psoriatic epidermis.

Suction rectal biopsy yields adequate tissue in children

Background/purposeHirschsprung disease (HD) is diagnosed by rectal biopsy, with suction rectal biopsy (SRB), the preferred technique in neonates. Reported SRB adequacy has varied overall with concern for decreased diagnostic yield in older children. The study aim was to assess SRB adequacy by age in children with the current device used at our institution. MethodsFollowing IRB approval, a retrospective cohort of children (1 to 18years) evaluated by SRB for HD was identified through billing records. Data regarding demographics, procedure, results, and complications were collected and analyzed using SPSS. Results56 children (median age 3.9years) underwent SRB with an 80.4% overall success rate. Patients older than 5years had 90.5% adequacy rate compared to 74.3% in those younger. Univariate analysis revealed weak association of inadequate specimens with younger age and males, and no association with insurance, race/ethnicity, weight–height or BMI percentile, sedation type, or procedure location. SRB under general anesthesia (GA) had 100% adequacy (n=6). Patients with inadequate initial biopsy achieved diagnosis by SRB with increased sedation (n=5) or full thickness biopsy under GA (n=5). ConclusionWith adequacy of 80.4% overall and 90.5% for patients greater than 5years, SRB is effective in evaluating the older child for HD.

Immunomodulation for treatment of drug and device refractory gastroparesis

ObjectivePatients with generalized autoimmune dysautonomia may also present with gastroparesis. Immune dysfunction in such patients can be evaluated using antibodies to glutamic acid decarboxylase (GAD) and full thickness biopsy of stomach. In this study, we utilize immunotherapy for treatment of drug and Gastric Electrical Stimulation (GES) resistant gastroparetic patients with evidence of neuroinflammation on full thickness gastric biopsy and had positive GAD65 autoantibodies. Material and methodsWe conducted a retrospective chart review of 11 female patients with drug and device resistant gastroparesis. Patients were treated for a total of 8–12 weeks with either intravenous immunoglobulin (IVIg), or combined mycophenolate mofetil (MM) and methylprednisolone, or only MM. Patients were excluded if they had previous side effects from steroid therapy, low scores on dual-energy X-ray absorptiometry (DEXA) scan results, immune-compromised conditions with infections like tuberculosis and zoster. Symptoms of nausea, vomiting, abdominal pain, early satiety/anorexia, bloating and total symptom score (TSS) as reported by the patients were recorded before and after the treatment at a follow up visit 2 to 16 weeks after initiation of therapy. ResultsMaximum symptom improvement was seen in patients treated with IVIg (67%). 6 patients (55%) had improvement in vomiting, whereas 5 patients (45%) had improvements in nausea, abdominal pain and bloating. ConclusionsImmunomodulatory therapy shows positive outcomes in improving vomiting symptom in some gastroparetic patients who have coexisting positive autoimmune profiles. This preliminary data suggests the need for further investigations in immunotherapy targeted to patients with gastroparetic symptoms refractory to approved drug and device therapies.