BACKGROUND:Bevonescein (ALM-488), a nerve-targeted peptide-dye conjugate, enables intraoperative fluorescence of degenerated peripheral nerves because of its extracellular matrix-binding mechanism. In contrast, myelin-based nerve-targeting agents would not be expected to label degenerated nerves because of demyelination. The authors compare the intraoperative fluorescence of chronically degenerated murine facial nerves produced by bevonescein and myelin-binding dye oxazine-4 and discuss its utility in peripheral nerve reconstruction. METHODS:Sixteen wild-type mice underwent transection of the marginal mandibular branch of the facial nerve. At 5 months, 10 mice were co-injected with bevonescein and oxazine-4 and underwent intraoperative facial nerve exploration with fluorescence imaging. The signal-to-background ratio (SBR) was calculated by comparing the mean gray value along each nerve segment to adjacent nonnerve tissue. RESULTS:All degenerated nerve segments were visible with bevonescein (100%; n = 20 nerves, 10 mice). In contrast, degenerated segments were invisible with oxazine-4 in 6 of 10 mice (60%; n = 12 nerves, 10 mice) and faintly perceptible in 4 of 10 mice (40%; n = 8 nerves, 10 mice). The mean SBR for oxazine-4 was lower than for bevonescein (1.27 ± 0.54 versus 3.31 ± 1.11; P < 0.001). Autonomic nerves demonstrated strong fluorescence with bevonescein (SBR, 1.77 ± 0.65; n = 7 nerves, 7 mice) but were invisible or faintly visible with oxazine-4 (SBR, 1.11 ± 0.14; n = 7 nerves, 7 mice; P = 0.02). CONCLUSIONS:Bevonescein produces successful intraoperative labeling of chronically degenerated and autonomic nerves in a rodent nerve transection model. In contrast, myelin-binding oxazine-4 does not meaningfully produce fluorescence labeling in these contexts. These findings may influence choice of nerve-labeling agents in the setting of delayed peripheral nerve construction. CLINICAL RELEVANCE STATEMENT:This study demonstrates the utility of bevonescein, a fluorescein-conjugated nerve-binding peptide, in the identification of degenerated facial nerves during fluorescence-guided surgery. This technology could benefit reconstructive surgeons who perform delayed peripheral nerve reconstruction.

Iatrogenic nerve injury is a surgical complication with significant morbidity. This clinical trial, now complete, investigates the systemic administration of bevonescein, which selectively binds to nerves, in a single-arm, prospective multi-center, dose-escalation Phase 1 trial in adult patients with head and neck neoplasms undergoing parotidectomy or thyroidectomy in the United States. Twenty-seven participants are enrolled in the trial and receive the systemic agent. The primary outcome is safety with no dose-limiting toxicity among the 27 patients, but a single adverse event was identified that was possibly related to the study drug (vomiting). Secondary outcomes include the pharmacokinetics, optimal dose, and timing of bevonescein. The half-life of bevonescein is 29-72 min, and the optimal dose is 500 mg by objective measures, with the fluorescence signal-to-background ratio (SBR; 2.1 ± 0.8) significantly higher compared to white light (1.3 ± 0.2; p = 0.003). The fluorescent SBR of nerves between the early (1-3 h) versus late (3-5 h) timing cohorts is not statistically different. Here, we present data of a nerve imaging agent showing that preoperative intravenous infusion of bevonescein is well tolerated. This trial is registered at ClinicalTrials.gov (NCT04420689) and is sponsored by Alume Biosciences (San Diego, CA).

There is a clinical need for an effective nerve guidance conduit to treat peripheral nerve injuries. Many studies have explored different materials and active cues to guide neural regeneration, with some success. However, none have demonstrated a comparable or better functional recovery than the clinical standard autograft. Autografts are often insufficient for reconstruction of an injury to long nerves such as the sciatic or brachial plexus. Synthetic nerve guidance conduits (NGCs) have been investigated for these injuries to guide axonal regeneration and lead to functional recovery. We have designed a biologics-free hydrogel-based multi-channel conduit with defined microscale features to guide axonal outgrowth. To investigate extraneural vascular infiltration and its effects on functional recovery, we also designed a multi-microchannel conduit with defined regularly spaced micropores, orthogonal to the axon guidance channels. Using our custom-built Rapid Projection, Image-guided, Dynamic (RaPID) bioprinting system, we were able to fabricate each hydrogel conduit within minutes from a milliliter-volume prepolymer vat. With our state-of-the-art printing platform, we have achieved NGCs with a consistent channel wall width of 10 μm. We implanted the NGCs for 17 weeks in a murine sciatic nerve transection injury model. We assessed the functional recovery by dynamic gait analysis throughout the recovery period and by compound muscle action potential (CMAP) electrophysiology before NGC harvesting. Both the non-porous and micro-porous conduit groups led to functional nerve regeneration on par with the autograft group. Further, both conduit groups resulted in restoration of bulk motor function to pre-injury performance.

The pathogenic outcome of enteric virus infections is governed by a complex interplay between the virus, intestinal microbiota, and host immune factors, with metabolites serving as a key mediator. Noroviruses bind bile acid metabolites, which are produced by the host and then modified by commensal bacteria. Paradoxically, bile acids can have both proviral and antiviral roles during norovirus infections. Working in an infant mouse model of norovirus infection, we demonstrate that microbiota and their bile acid metabolites protect from norovirus diarrhea, whereas host bile acids promote disease. We also find that maternal bile acid metabolism determines the susceptibility of newborn mice to norovirus diarrhea during breastfeeding. Finally, targeting maternal and neonatal bile acid metabolism can protect newborn mice from norovirus disease. In summary, neonatal metabolic immaturity and breastmilk bile acids are central determinants of heightened newborn vulnerability to norovirus disease.

Objective:Facial palsy affects patients of all backgrounds, yet no existing studies describe differences in its treatment patterns between demographic groups. Methods:We used the National Surgical Quality Improvement Project database to investigate whether race and sex disparities exist in facial reanimation surgery. Patients were identified using CPT codes corresponding to facial-nerve procedures. Results:Seven hundred sixty-one patients met criteria; 681 self-identified as White (89.5%), 51 as Black (6.7%), 43 as Hispanic (5.6%), 23 as Asian (3.0%), and 5 patients as other (0.61%). White patients were more than twice as likely to undergo brow ptosis repair than Non-White patients (OR 2.49, 95% CI 1.16-6.15, p = .03). After controlling for malignancy, men had longer operative times than women (480.2 vs. 413.9 min, p = .04) and higher likelihood of free tissue transfer (OR 4.1, 95% CI 1.9-9.8), fascial free tissue transfer (OR 10.7, 95% CI 2.1-195), and ectropion repair (OR 1.8, 95% CI 1.2-2.8). Conclusion:Most patients undergoing facial reanimation surgery in the United States are White. Men have longer operative times and a higher likelihood of undergoing free fascial grafts and cutaneous and fascial free tissue transfer than women regardless of malignancy status. Level of Evidence:2c.

HCT-116 tumor xenografts have b3 integrin expression.

Tumor xenografts show cleavage dependent tumor contrast with radiometric ACPP.

Schematic model of therapeutic strategy utilizing tumor targeted MMAE delivery with ACPP.

Polycation conjugated MMAE is cytotoxic to tumor cells.

Noroviruses are the leading cause of severe childhood diarrhea and foodborne disease worldwide. While they are a major cause of disease in all age groups, infections in the very young can be quite severe, with annual estimates of 50,000–200,000 fatalities in children under 5 years old. In spite of the remarkable disease burden associated with norovirus infections, very little is known about the pathogenic mechanisms underlying norovirus diarrhea, principally because of the lack of tractable small animal models. The development of the murine norovirus (MNV) model nearly two decades ago has facilitated progress in understanding host–norovirus interactions and norovirus strain variability. However, MNV strains tested thus far either do not cause intestinal disease or were isolated from extraintestinal tissue, raising concerns about translatability of research findings to human norovirus disease. Consequently, the field lacks a strong model of norovirus gastroenteritis. Here we provide a comprehensive characterization of a new small animal model system for the norovirus field that overcomes prior weaknesses. Specifically, we demonstrate that the WU23 MNV strain isolated from a mouse naturally presenting with diarrhea causes a transient reduction in weight gain and acute self-resolving diarrhea in neonatal mice of several inbred mouse lines. Moreover, our findings reveal that norovirus-induced diarrhea is associated with infection of subepithelial cells in the small intestine and systemic spread. Finally, type I interferons (IFNs) are critical to protect hosts from norovirus-induced intestinal disease whereas type III IFNs exacerbate diarrhea. This latter finding is consistent with other emerging data implicating type III IFNs in the exacerbation of some viral diseases. This new model system should enable a detailed investigation of norovirus disease mechanisms.

MMAE enhances comet tail length following irradiation in pancreatic tumor cell lines.

Combination of increased delivery of ACPP-cRGD-MMAE with IR significantly improved tumor regression.

OBJECTIVE Delayed peripheral nerve repair is complicated by nerve degeneration and atrophy that can prevent identification. We use a murine facial nerve transection model to demonstrate the efficacy of ALM-488 (bevonescein) in labeling degenerated facial nerves with quantitative image analysis and qualitative survey data. STUDY DESIGN Prospective cohort study. SETTING Laboratory. METHODS Ten wild-type mice underwent transection of the lower facial nerve division with subsequent degeneration. Either 9 (n = 5 mice) or 12 (n = 5 mice) weeks later, mice underwent intravenous infusion of ALM-488 with in vivo real-time fluorescence imaging (FL) of the facial nerve. Using ImageJ, the mean gray value of each nerve segment under white light reflectance (WLR) and FL was compared to that of adjacent soft tissue to calculate the signal-to-background ratio (SBR). A survey was distributed to evaluate the perceived utility of ALM-488 in surgeon identification of degenerated nerves. RESULTS The mean SBR of degenerated nerves was 1.08 (standard deviation [SD]: 0.07) under WLR and 2.11 (SD: 0.31) under FL (p < 0.001). In mice with degenerated nerves, survey participants identified on average 3.01 (SD: 1.84) nerve branches under WLR and 5.73 (SD: 1.88) under FL (p < 0.0001). Under FL, 47 of 48 survey responses correctly identified isolated, degenerated nerves; in contrast, only 12 responses identified degenerated nerves under WLR (p < 0.0001). CONCLUSION Preoperative intravenous infusion of ALM-488 with FL improves the identification of degenerated facial nerves. ALM-488 also improves surgeon confidence in nerve identification, particularly in degenerated nerve branches that are not visible with WLR.

MMAE enhances γH2Ax foci formation following irradiation.

Objective Fluorescence‐guided surgery (FGS) is a rapidly developing intraoperative technology, and many contrast agents are currently under investigation. We sought to provide a review of the current state of FGS clinical trials in Otolaryngology, emphasizing its oncologic applications. Methods According to the preferred reporting Items for systematic reviews and meta‐analyses (PRISMA) workflow for scoping reviews, a clinical trial search was performed across multiple international clinical trials registries, searching for permutations of “fluorescence,” “tumor,” “surgery,” and “nerve” to identify all relevant studies. Studies that were active, enrolling, or soon to be enrolling patients undergoing head and neck surgery were included. Results Nineteen studies were eligible for inclusion. Seventeen studies are focused on FGS for oncologic resection and lymph node detection. One study assesses peripheral nerve fluorescence, and one evaluates normal parathyroid function after thyroidectomy. Contrast agents under development are conjugated to fluorophores that excite in the 800 nm (indocyanine green), 410 nm (5‐a minolevulinic acid), 700 nm (Cyanine 5.5), and 525 nm ranges (fluorescein derivatives). Conclusion Presently, there are 19 ongoing trials investigating novel FGS contrast agents for their safety, efficacy, and utility in Otolaryngology—Head and Neck Surgery. These agents rely on unique fluorophores and absorption ranges in the near‐infrared and visible light spectra. FGS studies are expanding within Otolaryngology—Head and Neck Surgery with profound implications in oncologic surgery, lymph node detection, and anatomic and functional assessment. Laryngoscope , 132:36–44, 2022

Background: Kawasaki disease (KD) disproportionately affects children of Asian descent. San Diego is home to a large Vietnamese population but no previous study has addressed the outcome of KD in this group. Methods: We performed a retrospective review of Vietnamese patients seen at Rady Children’s Hospital San Diego from 2001 to 2019. Non-Vietnamese Asian and non-Asian KD patients were matched (2:1) based on date of onset and age with Vietnamese patients. Demographic, clinical, and echocardiographic data were compared. Interviews with cardiologists at the Children’s Hospital 1 in Ho Chi Minh City, Vietnam, explored local practices in the diagnosis and management of KD patients. KD publications in Vietnamese were translated and summarized. Results: Of 978 KD patients for whom both parents had the same ethnicity, 20 were Vietnamese (2.1%), 168 (17%) were non-Vietnamese Asian, and 789 (81%) were non-Asian. Vietnamese and non-Vietnamese Asians had an earlier median day of diagnosis at day 6 (interquartile range [IQR] 5–6) and 5.5 (IQR 4–6.75), respectively, compared with non-Asians (day 7, IQR 5–8.75, P = 0.02). Prominent cervical lymphadenopathy at diagnosis was more common in both Vietnamese and non-Vietnamese Asians (20% and 40%, respectively) compared with non-Asians (12.5%, P = 0.01). Importantly, Vietnamese KD patients had a higher rate of coronary artery aneurysms (60% vs. 27.5%) compared to non-Asians (P = 0.024). Vietnamese literature review and structured interviews suggested a high incidence and severity of KD in Vietnamese children. Conclusions: Physicians should be aware that Vietnamese children may be disproportionately affected by KD and have worse coronary artery outcomes.

Given the current coronavirus disease 2019 (COVID-19) pandemic, coinfection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza A virus (IAV) is a major concern for public health. However, the immunopathogenic events occurring with coinfections of SARS-CoV-2 and IAV remain unclear. Here, we report the pathogenic and immunological consequences of SARS-CoV-2 and IAV H1N1 coinfection in the K18-hACE2 transgenic mouse model. Compared with a single infection with SARS-CoV-2 or IAV, coinfections not only prolonged the primary virus infection period but also increased immune cell infiltration and inflammatory cytokine levels in bronchoalveolar lavage fluid leading to severe pneumonia and lung damage. Moreover, coinfections caused severe lymphopenia in peripheral blood, resulting in reduced total IgG, neutralizing antibody titers, and CD4+ T cell responses against each virus. This study sheds light on the immunopathogenesis of SARS-CoV-2 and IAV coinfection, which may guide the development of effective therapeutic strategies for the treatment of patients coinfected with these viruses. IMPORTANCE The cocirculation of influenza virus merging with the COVID-19 pandemic raises a potentially severe threat to public health. Recently, increasing numbers of SARS-CoV-2 and influenza virus coinfection have been reported from many countries. It is a worrisome issue that SARS-CoV-2 coinfection with other pathogens may worsen the clinical outcome and severity of COVID-19 and increase fatality. Here, we evaluated SARS-CoV-2 and IAV coinfection using the K18-hACE2 mouse model. Coinfected mice exhibited increased mortality with prolonged IAV shedding. Furthermore, coinfected mice showed a higher level of cytokines and chemokines than a single infection condition. Interestingly, our data show that coinfected mice showed significantly fewer virus-specific and neutralizing antibodies than the mice with a single infection. Overall, this study suggests that coinfection aggravates viral pathology by impaired neutralizing antibody response.

Background Total parotidectomy with facial nerve sacrifice creates 2 challenging reconstructive problems: restoration of facial contour and facial nerve rehabilitation. Strong evidence suggesting that vascularized nerve grafts are superior to nonvascularized nerve grafts motivated our team to develop a chimeric scapulodorsal flap combining the usual harvestable local tissues with the vascularized latissimus dorsi motor nerve (SD-LDVxN). We present our experiences developing a new program at University of California, San Diego, highlighting our first case here, and present preliminary retrospective results focusing on the functional outcomes of facial nerve reanimation. Materials and Methods The first case performed in the United States was a 57-year-old woman with stage IVA left parotid adenoid cystic carcinoma and House-Brackmann grade 6 facial palsy. She underwent total parotidectomy with facial nerve sacrifice and a free chimeric SD-LDVxN flap reconstruction. She had an unremarkable postoperative course, and 3- and 6-month follow-up functional results are reported. Preliminary functional results from our total series of 25 patients were reported. Results At her 3-month follow-up, she was a House-Brackmann 5 with a static eFACE score of 37, dynamic eFACE score of 31, and smile eFACE score of 48. At her 6-month follow-up, she was a House-Brackmann 5 with a static eFACE score of 50, dynamic eFACE score of 27, and smile eFACE score of 53. Preliminary results from our total series of 25 patients with an average of 5 years of follow-up were a House-Brackmann 2.5 and eFACE scores of 83.1 for static facial symmetry, 67.5 for dynamic facial symmetry, and 77.7 for smile score. Twenty of the 25 patients had postoperative radiotherapy. No local tumor recurrence had been reported. The average reinnervation time was 9 months and ranged from 3 to 15 months. Conclusions The SD-LDVxN flap is a highly resourceful solution to reconstruct complex parotid defects, especially those that sacrifice the facial nerve. The vascularized nerve graft allows for primary facial reanimation. Nerve recovery may be superior to what could be expected with a conventional nerve graft.

Significance: Surgery is often paramount in the management of many solid organ malignancies because optimal resection is a major factor in disease-specific survival. Cancer surgery has multiple challenges including localizing small lesions, ensuring negative surgical margins around a tumor, adequately staging patients by discriminating positive lymph nodes, and identifying potential synchronous cancers. Intraoperative molecular imaging (IMI) is an emerging potential tool proposed to address these issues. IMI is the process of injecting patients with fluorescenttargeted contrast agents that highlight cancer cells prior to surgery. Over the last 5 to 7 years, enormous progress has been achieved in tracer development, near-infrared camera approvals, and clinical trials. Therefore, a second biennial conference was organized at the University of Pennsylvania to gather surgical oncologists, scientists, and experts to discuss new investigative findings in the field. Our review summarizes the discussions from the conference and highlights findings in various clinical and scientific trials. Aim: Recent advances in IMI were presented, and the importance of each clinical trial for surgical oncology was critically assessed. A major focus was to elaborate on the clinical endpoints that were being utilized in IMI trials to advance the respective surgical subspecialties. Approach: Principal investigators presenting at the Perelman School of Medicine Abramson Cancer Center's second clinical trials update on IMI were selected to discuss their clinical trials and endpoints. Results: Multiple phase III, II, and I trials were discussed during the conference. Since the approval of 5-ALA for commercial use in neurosurgical malignancies, multiple tracers and devices have been developed to address common challenges faced by cancer surgeons across numerous specialties. Discussants also presented tracers that are being developed for delineation of normal anatomic structures that can serve as an adjunct during surgical procedures. Conclusions: IMI is increasingly being recognized as an improvement to standard oncologic surgical resections and will likely advance the art of cancer surgery in the coming years. The endpoints in each individual surgical subspecialty are varied depending on how IMI helps each specialty solve their clinical challenges. (C) The Authors. Published by SPIE under a Creative Commons Attribution 4.0 Unported License.

EDITORIAL article Front. Surg., 12 April 2021 | https://doi.org/10.3389/fsurg.2021.624124