Myeloid Wnt ligands are required for normal development of dermal lymphatic vasculature

Resident tissue myeloid cells play a role in many aspects of physiology including development of the vascular systems. In the blood vasculature, myeloid cells use VEGFC to promote angiogenesis and can use Wnt ligands to control vascular branching and to promote vascular regression. Here we show that myeloid cells also regulate development of the dermal lymphatic vasculature using Wnt ligands. Using myeloid-specific deletion of the WNT transporter Wntless we show that myeloid Wnt ligands are active at two distinct stages of development of the dermal lymphatics. As lymphatic progenitors are emigrating from the cardinal vein and intersomitic vessels, myeloid Wnt ligands regulate both their numbers and migration distance. Later in lymphatic development, myeloid Wnt ligands regulate proliferation of lymphatic endothelial cells (LEC) and thus control lymphatic vessel caliber. Myeloid-specific deletion of WNT co-receptor Lrp5 or Wnt5a gain-of-function also produce elevated caliber in dermal lymphatic capillaries. These data thus suggest that myeloid cells produce Wnt ligands to regulate lymphatic development and use Wnt pathway co-receptors to regulate the balance of Wnt ligand activity during the macrophage-LEC interaction

Speaking for Ourselves.

The improvement of the quality of life for older people is high on the agenda of national and local government, funding bodies, the health service and a large number of voluntary and non-governmental organisations. In particular there has been an emphasis in policy documents on the importance of involving older people in the planning and delivery of services and in the research process (DoH 1999a, 1999b, 2001, Scottish Executive 2000). Indeed the Department of Health has claimed that involving people in influencing decisions that may affect them has a positive effect on their self-esteem and self-confidence.NO DIVISION15pub1307pub

The problematic Soave cuff in Hirschsprung disease: Manifestations and treatment

Purpose Following a Soave pull-through for Hirschsprung disease (HD), some children struggle with obstructive symptoms. We hypothesized that these symptoms could result from a functional obstruction of the pull through caused by the Soave cuff, and that cuff resection might improve bowel emptying. Methods We reviewed patients referred to our center from 2008 to 2012 with obstructive problems following a Soave pull-through for HD (CCHMC IRB # 2011-2019). Only patients with an obstructing Soave cuff were analyzed. Patients with other reasons for obstruction (anastomotic stricture, transition zone, aganglionic segment) were excluded. Results Thirty-six patients underwent reoperation at our center for obstructive symptoms after an initial Soave pull-through. Seventeen of these patients had a Soave cuff only as the potential source of obstruction. Pre-operative symptoms included enterocolitis (10), constipation (6), and failure to thrive (1). Nine patients (53%) required irrigations to manage distension or enterocolitis pre-operatively. 14/17 patients (82%) had a palpable cuff on rectal exam. Eight patients (47%) had radiographic evidence of a cuff demonstrated by distal narrowing (4) or a prominent presacral space (4). Four children (23%) underwent excision of the cuff only. Thirteen (76%) had removal of the cuff and proximally dilated colon [(average length 7.2 cm) (12 performed transanally, and five needed laparotomy as well.)] Post-operatively, episodes of enterocolitis were reduced to zero, and need for irrigation to treat distension was reduced by 50%. Nine patients have voluntary bowel movements, and five are clean on enemas. 3/6 patients with pre-operative constipation or impaction now empty without enemas. (Follow up 1-17 months, mean 7 months.) Conclusions Recurrent enterocolitis, constipation, or failure to thrive can indicate a functional obstruction due to a Soave cuff when no other pathologic cause exists. Physical exam or contrast enema can identify a problematic cuff. Reoperation with cuff resection can dramatically improve bowel emptying. © 2014 Elsevier Inc. All rights reserved

Health-related quality of life and parental stress in children with fecal incontinence: A normative comparison

Copyright © ESPGHAL and NASPGHAN. All rights reserved. Objective: The aim of the present study was to describe the quality of life and parenting stress associated with a child with fecal incontinence (FI). Methods: Female caregivers (n=170) of children of 3 to 12 years age with FI completed a broad and general measure of quality of life and a measure of parenting stress. Results were compared with proxy reports for a normative sample of healthy children. Results: Caregivers of children with FI reported significantly impaired quality of life for their children and increased parenting stress in all of the respective domains relative to healthy controls. Impairments reported by caregivers were large in magnitude. Similarly, rates of parenting stress were at or greater than the 98th percentile for caregivers of children with FI. Conclusions: Children with fecal incontinence and their families are in need of interventions targeting their quality of life and the stress associated with caregiving. FI appears to be particularly stressful for caregivers who may be in need of support beyond medical management of their child\u27s bowel. Moreover, additional refinements in disease-specific quality of life assessment are needed in this population. Such refinement would allow for more precise measurement of the quality of life processes that are unique to FI

Myeloid <i>Wls</i> deficiency results in elevated numbers and migration of lymphatic progenitors.

<p>Whole mount labeling of embryos at E10.5 (A-D) and E9.75 (F, G). LECs were labeled for PROX1 (green), blood vessels for PECAM1 (red) and nuclei with Hoechst 33258 (blue). (A), (C) and (F) show <i>Wls</i>^<i>fl/fl</i> embryos. (B), (D) and (G) show <i>Wls</i>^<i>fl/fl</i>; <i>Csf1r-icre</i> embryos. (E) Chart showing the total number of PROX1+ LECs in the region of jugular lymph sac in <i>Wls</i>^<i>fl/fl</i> and <i>Wls</i>^<i>fl/fl</i>; <i>Csf1r-icre</i> embryos at E10.5. (H and I) show the PROX1+ cells color-coded according to their distance from the cardinal vein. (J) Percentage of PROX1+ cells binned according to their distance from the cardinal vein. The chart shows cells divided into 6 equal sized bins from 0 to 500 μm. Arrows indicate PROX1+ cells in heart and lens region. For both quantifications, n = 3 animals for each time point from 2 independent litters were used. The p-value was calculated using Student’s t-test. The charts are plotted with SEM as error bars.</p

Myeloid Wnt5a gain-of-function results in elevated lymphatic vessel caliber.

<p>(A-B) Dermal tissues from <i>R26R</i>^<i>Wnt5a</i> and <i>R26R</i>^<i>Wnt5a</i>; <i>Csf1r-icre</i> animals at E15.5. Lymphatic vessels are labeled for PDPN in green. In these preparations, a wide region of dorsal skin was harvested and the lymphatic vessels visualized. The midline is marked by the dashed line. (C) Quantification of mean vessel diameter (caliber) of dermal lymphatic vessels in <i>R26R</i>^<i>Wnt5a</i> and <i>R26R</i>^<i>Wnt5a</i>; <i>Csf1r-icre</i> embryos at E15.5. (D) Quantification of branch-points per unit length of lymphatic vessels in dermal tissue from <i>R26R</i>^<i>Wnt5a</i> and <i>R26R</i>^<i>Wnt5a</i>; <i>Csf1r-icre</i> embryos at E15.5. <i>R26R</i>^<i>Wnt5a</i> (n = 3) and <i>R26R</i>^<i>Wnt5a</i>; <i>Csf1r-icre</i> (n = 4), from 3 independent litters. The p-value was calculated using Student’s t-test. NS, p value not significant. The charts are plotted with SEM as error bars.</p

Myeloid <i>Wls</i> deficiency does not change dermal myeloid cell numbers.

<p>(A-D) Labeling of lymphatic capillaries and myeloid cells for LYVE1 (green), blood vessels for PECAM1 (red) and for both (merge) in dorsal skin of <i>Wls</i>^<i>fl/fl</i> and <i>Wls</i>^<i>fl/fl</i>; <i>Csf1r-icre</i> embryos of the indicated gestational age. (C, D) Lymphatic vessel boundaries are outlined with white dotted line in LYVE1 panels. (E-F) Labeling of lymphatic capillaries for PDPN (green), for myeloid cells with F4/80 (red) and for nuclei with Hoechst 33258 (blue) in the dorsal skin of E14.5 <i>Wls</i>^<i>fl/fl</i> and <i>Wls</i>^<i>fl/fl</i>; <i>Csf1r-icre</i> embryos. (G) Scatter plot representing the number of F4/80+ macrophages per field in <i>Wls</i>^<i>fl/fl</i> and <i>Wls</i>^<i>fl/fl</i>; <i>Csf1r-icre</i> embryos at E14.5. n = 4 animals for each time point per genotype, from 3 separate litters. p-value was calculated using Student’s t-test. NS, p value not significant. The charts are plotted with SEM as error bars.</p

Flow sorting and <i>Wnt</i> expression in lymphatic-associated macrophages.

<p>(A) Dot plots showing the gating used for sorting CD45+, CD11b+ and F4/80+ macrophages from embryonic dermis at E15.5. DN, population double negative for CD11b and F4/80. (B) End-point PCR showing the expression of Wnt ligand transcripts in dermal macrophages and whole embryos at E15.5. (C, D) Expression of transcripts for the <i>Frizzled</i> family receptors (C) and the co-receptors <i>Lrp5</i> and <i>Lrp6</i> (D), in dermal macrophages and whole embryos from E15.5. The observations were repeated for total of n = 3 from as many litters.</p

Myeloid <i>Lrp5</i> deficiency results in elevated dermal lymphatic caliber.

<p>(A-F) Visualization of lymphatic capillary vessels with PDPN (green), blood vessels with PECAM1 (red) and both (merge) in dorsal skin of <i>Lrp5</i>^<i>fl/fl</i> and <i>Lrp5</i>^<i>fl/fl</i>; <i>Csf1r-icre</i> embryos of the indicated gestational age. (G) Scatter plot showing the mean lymphatic vessel caliber at different embryonic stages of development in <i>Lrp5</i>^<i>fl/fl</i> and <i>Lrp5</i>^<i>fl/fl</i>; <i>Csf1r-icre</i> embryos E14.5 (<i>Lrp5</i>^<i>fl/fl</i>; n = 4 and <i>Lrp5</i>^<i>fl/fl</i>; <i>Csf1r-icre</i>; n = 5), E16.5 (<i>Lrp5</i>^<i>fl/fl</i>; n = 4 and <i>Lrp5</i>^<i>fl/fl</i>; <i>Csf1r-icre</i>; n = 4) and E18.5 (<i>Lrp5</i>^<i>fl/fl</i>; n = 4 and <i>Lrp5</i>^<i>fl/fl</i>; <i>Csf1r-icre</i>; n = 4). (H) Scatter plot quantifying branch-points per unit length of lymphatic capillary plexus in <i>Lrp5</i>^<i>fl/fl</i> and <i>Lrp5</i>^<i>fl/fl</i>; <i>Csf1r-icre</i> embryos at E14.5 (<i>Lrp5</i>^<i>fl/fl</i>; n = 5 and <i>Lrp5</i>^<i>fl/fl</i>; <i>Csf1r-icre</i>; n = 4), E16.5 (<i>Lrp5</i>^<i>fl/fl</i>; n = 5 and <i>Lrp5</i>^<i>fl/fl</i>; <i>Csf1r-icre</i>; n = 4) and E18.5 (<i>Lrp5</i>^<i>fl/fl</i>; n = 4 and <i>Lrp5</i>^<i>fl/fl</i>; <i>Csf1r-icre</i>; n = 4), from a total of 3 independent litters for each stage. p-value was calculated using Student’s t-test. NS, p value not significant. The charts are plotted with SEM as error bars.</p

Rectal Prolapse Following Repair of Anorectal Malformation: Incidence, Risk Factors, and Management

BACKGROUND: The incidence and optimal management of rectal prolapse following repair of an anorectal malformation (ARM) has not been well-defined. METHODS: A retrospective cohort study was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium registry. All children with a history of ARM repair were included. Our primary outcome was rectal prolapse. Secondary outcomes included operative management of prolapse and anoplasty stricture following operative management of prolapse. Univariate analyses were performed to identify patient factors associated with our primary and secondary outcomes. A multivariable logistic regression was developed to assess the association between laparoscopic ARM repair and rectal prolapse. RESULTS: A total of 1140 patients met inclusion criteria; 163 (14.3%) developed rectal prolapse. On univariate analysis, prolapse was significantly associated with male sex, sacral abnormalities, ARM type, ARM complexity, and laparoscopic ARM repairs (p \u3c 0.001). ARM types with the highest rates of prolapse included rectourethral-prostatic fistula (29.2%), rectovesical/bladder neck fistula (28.8%), and cloaca (25.0%). Of those who developed prolapse, 110 (67.5%) underwent operative management. Anoplasty strictures developed in 27 (24.5%) patients after prolapse repair. After controlling for ARM type and hospital, laparoscopic ARM repair was not significantly associated with prolapse (adjusted odds ratio (95% CI): 1.50 (0.84, 2.66), p = 0.17). CONCLUSION: Rectal prolapse develops in a significant subset of patients following ARM repair. Risk factors for prolapse include male sex, complex ARM type, and sacral abnormalities. Further research investigating the indications for operative management of prolapse and operative techniques for prolapse repair are needed to define optimal treatment. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: II