Clinical Focus

  • Surgery, Pediatric
  • Pediatric Surgery

Academic Appointments

Administrative Appointments

  • Medical Director Pediatric Trauma Program, Packard Children's Hospital Stanford (2008 - Present)
  • Executive Director Program for Fetal and Maternal Health, Packard Children's Hospital Stanford (2013 - Present)
  • Associate Dean Maternal Child Health - Research, Stanford University School of Medicine (2016 - Present)

Professional Education

  • Board Certification: Pediatric Surgery, American Board of Surgery (2002)
  • Fellowship:The Children's Hospital of Philadelphia (1997) PA
  • Fellowship:Yale - New Haven Hospital (2001) CT
  • Residency:University of Pennsylvania (1999) PA
  • Internship:Hospital of the University of Pennsylvania (1993) PA
  • Medical Education:Jefferson Medical College (1992) PA

Research & Scholarship

Current Research and Scholarly Interests

Dr. Sylvester concurrently pursues three areas of related investigation. The general approach of his efforts are to combine the study of human disease samples and mouse models of human disease to pose new hypotheses and to test these hypotheses experimentally. The objective of Dr. Sylvester's studies is to derive a deeper understanding of human disease and to develop applications for possible new diagnostics and therapeutics.

In the laboratory the group studies the role of Wnt signaling in liver regeneration and response to injury. The Sylvester laboratory has demonstrated that Wnt and its signaling molecule beta-catenin have a strong influence over hepatocellular metabolism and resistance to oxidative stress. Ongoing studies to gain a deeper understanding of the mechanism by which Wnt and related pathways exert control over cellular metabolism, energy balance and redox balance are ongoing. Cellular energy and redox balance are central to the related processes of liver development, regeneration and tumorignesis.

Dr. Sylvester has established a network of academic children's hospitals and investigators to study the human newborn diseases Necrotizing Enterocolitis and sepsis. The group has published several papers describing their novel findings of molecular indicators or biomarkers of disease. The group is seeking to establish both molecular indicators of disease as well as biochemical indicators that accurately identify infants most at risk for disease in order to provide clinical strategies to prevent disease onset. Molecules and pathways of interest that have been identified in human specimens are studied further in experimental models of disease to gain a deeper insight to the specific mechanisms of disease.

Clinical Trials

  • Laparotomy vs. Drainage for Infants With Necrotizing Enterocolitis Not Recruiting

    This trial will compare the effectiveness of two surgical procedures -laparotomy versus drainage - commonly used to treat necrotizing enterocolitis (NEC) or isolated intestinal perforations (IP) in extremely low birth weight infants (≤1,000 g). Infants diagnosed with NEC or IP requiring surgical intervention, will be recruited. Subjects will be randomized to receive either a laparotomy or peritoneal drainage. Primary outcome is impairment-free survival at 18-22 months corrected age.

    Stanford is currently not accepting patients for this trial. For more information, please contact M. Bethany Ball, (650) 725 - 8342.

    View full details


2017-18 Courses

Stanford Advisees


All Publications

  • Advanced minimal access surgery in infants weighing less than 3kg: A single center experience. Journal of pediatric surgery Wall, J. K., Sinclair, T. J., Kethman, W., Williams, C., Albanese, C., Sylvester, K. G., Bruzoni, M. 2017


    Minimal access surgery (MAS) has gained popularity in infants less than 5kg, however, significant challenges still arise in very low weight infants.A retrospective chart review was performed to identify all infants weighing less than 3kg who underwent an advanced MAS or equivalent open procedure from 2009 to 2016. Advanced case types included Nissen fundoplication, duodenal atresia repair, Ladd procedure, congenital diaphragmatic hernia repair, esophageal atresia/tracheoesophageal fistula repair, diaphragmatic plication, and pyloric atresia repair. A comparative analysis was performed between the MAS and open cohorts.A total of 45 advanced MAS cases and 17 open cases met the inclusion criteria. Gestational age and age at operation were similar between the cohorts, while infants who underwent open procedures had significantly lower weight at operation (p=0.003). There were no deaths within 30days related to surgery in either group. Only 3 MAS cases required unintended conversion to open. There were 2 (4.4%) postoperative complications related to surgery in the MAS cohort and 2 (11.8%) in the open cohort.Advanced MAS may be performed in infants weighing less than 3kg with low mortality, acceptable rates of conversion, and similar rates of complications as open procedures.Prognosis study.Level III.

    View details for DOI 10.1016/j.jpedsurg.2017.05.006

    View details for PubMedID 28549685

  • Acylcarnitine Profiles Reflect Metabolic Vulnerability for Necrotizing Enterocolitis in Newborns Born Premature. journal of pediatrics Sylvester, K. G., Kastenberg, Z. J., Moss, R. L., Enns, G. M., Cowan, T. M., Shaw, G. M., Stevenson, D. K., Sinclair, T. J., Scharfe, C., Ryckman, K. K., Jelliffe-Pawlowski, L. L. 2017; 181: 80-85 e1


    To evaluate the association between newborn acylcarnitine profiles and the subsequent development of necrotizing enterocolitis (NEC) with the use of routinely collected newborn screening data in infants born preterm.A retrospective cohort study was conducted with the use of discharge records for infants born preterm admitted to neonatal intensive care units in California from 2005 to 2009 who had linked state newborn screening results. A model-development cohort of 94 110 preterm births from 2005 to 2008 was used to develop a risk-stratification model that was then applied to a validation cohort of 22 992 births from 2009.Fourteen acylcarnitine levels and acylcarnitine ratios were associated with increased risk of developing NEC. Each log unit increase in C5 and free carnitine /(C16 + 18:1) was associated with a 78% and a 76% increased risk for developing NEC, respectively (OR 1.78, 95% CI 1.53-2.02, and OR 1.76, 95% CI 1.51-2.06). Six acylcarnitine levels, along with birth weight and total parenteral nutrition, identified 89.8% of newborns with NEC in the model-development cohort (area under the curve 0.898, 95% CI 0.889-0.907) and 90.8% of the newborns with NEC in the validation cohort (area under the curve 0.908, 95% CI 0.901-0.930).Abnormal fatty acid metabolism was associated with prematurity and the development of NEC. Metabolic profiling through newborn screening may serve as an objective biologic surrogate of risk for the development of disease and thus facilitate disease-prevention strategies.

    View details for DOI 10.1016/j.jpeds.2016.10.019

    View details for PubMedID 27836286

  • Prediction of neonatal respiratory distress in pregnancies complicated by fetal lung masses. Prenatal diagnosis Girsen, A. I., Hintz, S. R., Sammour, R., Naqvi, A., El-Sayed, Y. Y., Sherwin, K., Davis, A. S., Chock, V. Y., Barth, R. A., Rubesova, E., Sylvester, K. G., Chitkara, R., Blumenfeld, Y. J. 2017


    The objective of this article is to evaluate the utility of fetal lung mass imaging for predicting neonatal respiratory distress.Pregnancies with fetal lung masses between 2009 and 2014 at a single center were analyzed. Neonatal respiratory distress was defined as intubation and mechanical ventilation at birth, surgery before discharge, or extracorporeal membrane oxygenation (ECMO). The predictive utility of the initial as well as maximal lung mass volume and congenital pulmonary airway malformation volume ratio by ultrasound (US) and magnetic resonance imaging (MRI) was analyzed.Forty-seven fetal lung mass cases were included; of those, eight (17%) had respiratory distress. The initial US was performed at similar gestational ages in pregnancies with and without respiratory distress (26.4 ± 5.6 vs 22.3 ± 3 weeks, p = 0.09); however, those with respiratory distress had higher congenital volume ratio at that time (1.0 vs 0.3, p = 0.01). The strongest predictors of respiratory distress were maximal volume >24.0 cm(3) by MRI (100% sensitivity, 91% specificity, 60% positive predictive value, and 100% negative predictive value) and maximal volume >34.0 cm(3) by US (100% sensitivity, 85% specificity, 54% positive predictive value, and 100% negative predictive value).Ultrasound and MRI parameters can predict neonatal respiratory distress, even when obtained before 24 weeks. Third trimester parameters demonstrated the best positive predictive value. © 2017 John Wiley & Sons, Ltd.

    View details for DOI 10.1002/pd.5002

    View details for PubMedID 28061000

  • Involvement of prolyl isomerase PIN1 in the cell cycle progression and proliferation of hepatic oval cells PATHOLOGY RESEARCH AND PRACTICE Risal, P., Shrestha, N., Chand, L., Sylvester, K. G., Jeong, Y. J. 2017; 213 (4): 373-380


    Liver regenerates remarkably after toxic injury or surgical resection. In the case of failure of resident hepatocytes to restore loss, repopulation is carried out by induction, proliferation, and differentiation of the progenitor cell. Although, some signaling pathways have been verified to contribute oval cell-mediated liver regeneration, role of Peptidyl-prolyl cis-trans isomerase NIMA-interacting 1(Pin1) in the oval cells proliferation is unknown. In the present study, we evaluate the role of Pin1 in oval cells proliferation. In our study, the expression of Pin1 in the mice liver increased after three weeks feeding of 3, 5-diethoxycarbonyl-1, 4-dihydrocollidine (DDC) diet along with the proliferation of oval cells. The expression of Pin1 was higher in oval cells compared to the hepatocytes.Pin1 inhibition by Juglone reduced oval cell proliferation, which was restored to normal when oval cells were treated with IGF-1. Consistent with increased cell growth, expression of Pin1, β-catenin and PCNA were increased in IGF-1 treated cells in a time dependent manner. In FACS analysis, siRNA-mediated knockdown of the Pin1 protein in the oval cells significantly increased the numbers of cells in G0/G1 phase. Furthermore, hepatocyte when treated with TGF-β showed marked reduction in cell proliferation and expression of Pin1 whereas this effect was not seen in the oval cells treated with TGF-β. In conclusion, Pin1 plays important role in the cell cycle progression and increase oval cells proliferation which may be crucial in chronic liver injury.

    View details for DOI 10.1016/j.prp.2017.01.005

    View details for Web of Science ID 000399513100014

    View details for PubMedID 28214206

  • Unique Molecular Patterns Uncovered in Kawasaki Disease Patients with Elevated Serum Gamma Glutamyl Transferase Levels: Implications for Intravenous Immunoglobulin Responsiveness PLOS ONE Wang, Y., Li, Z., Hu, G., Hao, S., Deng, X., Huang, M., Ren, M., Jiang, X., Kanegaye, J. T., Ha, K., Lee, J., Li, X., Jiang, X., Yu, Y., Tremoulet, A. H., Burns, J. C., Whitin, J. C., Shin, A. Y., Sylvester, K. G., McElhinney, D. B., Cohen, H. J., Ling, X. B. 2016; 11 (12)


    Resistance to intravenous immunoglobulin (IVIG) occurs in 10-20% of patients with Kawasaki disease (KD). The risk of resistance is about two-fold higher in patients with elevated gamma glutamyl transferase (GGT) levels. We sought to understand the biological mechanisms underlying IVIG resistance in patients with elevated GGT levels.We explored the association between elevated GGT levels and IVIG-resistance with a cohort of 686 KD patients (Cohort I). Gene expression data from 130 children with acute KD (Cohort II) were analyzed using the R square statistic and false discovery analysis to identify genes that were differentially represented in patients with elevated GGT levels with regard to IVIG responsiveness. Two additional KD cohorts (Cohort III and IV) were used to test the hypothesis that sialylation and GGT may be involved in IVIG resistance through neutrophil apoptosis.Thirty-six genes were identified that significantly explained the variations of both GGT levels and IVIG responsiveness in KD patients. After Bonferroni correction, significant associations with IVIG resistance persisted for 12 out of 36 genes among patients with elevated GGT levels and none among patients with normal GGT levels. With the discovery of ST6GALNAC3, a sialyltransferase, as the most differentially expressed gene, we hypothesized that sialylation and GGT are involved in IVIG resistance through neutrophil apoptosis. We then confirmed that in Cohort III and IV there was significantly less reduction in neutrophil count in IVIG non-responders.Gene expression analyses combining molecular and clinical datasets support the hypotheses that: (1) neutrophil apoptosis induced by IVIG may be a mechanism of action of IVIG in KD; (2) changes in sialylation and GGT level in KD patients may contribute synergistically to IVIG resistance through blocking IVIG-induced neutrophil apoptosis. These findings have implications for understanding the mechanism of action in IVIG resistance, and possibly for development of novel therapeutics.

    View details for DOI 10.1371/journal.pone.0167434

    View details for Web of Science ID 000392853100008

    View details for PubMedID 28002448

    View details for PubMedCentralID PMC5176264

  • CK2 alpha/CSNK2A1 Phosphorylates SIRT6 and Is Involved in the Progression of Breast Carcinoma and Predicts Shorter Survival of Diagnosed Patients AMERICAN JOURNAL OF PATHOLOGY Bae, J. S., Park, S., Jamiyandorj, U., Kim, K. M., Noh, S. J., Kim, J. R., Park, H. J., Kwon, K. S., Jung, S. H., Park, H. S., Park, B., Lee, H., Moon, W. S., Sylvester, K. G., Jang, K. Y. 2016; 186 (12): 3297-3315


    Recently, the roles of sirtuins (SIRTs) in tumorigenesis have been of interest to oncologists, and protein kinase CK2 α1 (CSNK2A1) has been shown to be involved in tumorigenesis by phosphorylating various proteins, including SIRT1. Therefore, we evaluated the roles of CSNK2A1, SIRT6, and phosphorylated SIRT6 and their relationships in breast carcinoma. Nuclear expression of CSNK2A1 and SIRT6 predicted shorter overall survival and relapse-free survival by multivariate analysis. Inhibition of CSNK2A1 decreased the proliferative and invasive activity of cancer cells. In addition, CSNK2A1 was bound to SIRT6 and phosphorylated SIRT6; evidence for this is provided from immunofluorescence staining, co-immunoprecipitation of CSNK2A1 and SIRT6, a glutathione S-transferase pull-down assay, an in vitro kinase assay, and transfection of mutant CSNK2A1. Knockdown of SIRT6 decreased the proliferation and invasiveness of cancer cells. Overexpression of SIRT6 increased proliferation, but mutation at the Ser338 phosphorylation site of SIRT6 inhibited the proliferation of MCF7 cells. Moreover, both knockdown of SIRT6 and a mutation at the phosphorylation site of SIRT6 decreased expression of matrix metallopeptidase 9, β-catenin, cyclin D1, and NF-κB. Especially, SIRT6 expression was associated with the nuclear localization of β-catenin. This study demonstrates that CSNK2A1 and SIRT6 are indicators of poor prognosis for breast carcinomas and that CSNK2A1-mediated phosphorylation of SIRT6 might be involved in the progression of breast carcinoma.

    View details for DOI 10.1016/j.ajpath.2016.08.007

    View details for Web of Science ID 000389103800020

    View details for PubMedID 27746184

  • Mapping the Fetomaternal Peripheral Immune System at Term Pregnancy. Journal of immunology Fragiadakis, G. K., Baca, Q. J., Gherardini, P. F., Ganio, E. A., Gaudilliere, D. K., Tingle, M., Lancero, H. L., McNeil, L. S., Spitzer, M. H., Wong, R. J., Shaw, G. M., Darmstadt, G. L., Sylvester, K. G., Winn, V. D., Carvalho, B., Lewis, D. B., Stevenson, D. K., Nolan, G. P., Aghaeepour, N., Angst, M. S., Gaudilliere, B. L. 2016


    Preterm labor and infections are the leading causes of neonatal deaths worldwide. During pregnancy, immunological cross talk between the mother and her fetus is critical for the maintenance of pregnancy and the delivery of an immunocompetent neonate. A precise understanding of healthy fetomaternal immunity is the important first step to identifying dysregulated immune mechanisms driving adverse maternal or neonatal outcomes. This study combined single-cell mass cytometry of paired peripheral and umbilical cord blood samples from mothers and their neonates with a graphical approach developed for the visualization of high-dimensional data to provide a high-resolution reference map of the cellular composition and functional organization of the healthy fetal and maternal immune systems at birth. The approach enabled mapping of known phenotypical and functional characteristics of fetal immunity (including the functional hyperresponsiveness of CD4(+) and CD8(+) T cells and the global blunting of innate immune responses). It also allowed discovery of new properties that distinguish the fetal and maternal immune systems. For example, examination of paired samples revealed differences in endogenous signaling tone that are unique to a mother and her offspring, including increased ERK1/2, MAPK-activated protein kinase 2, rpS6, and CREB phosphorylation in fetal Tbet(+)CD4(+) T cells, CD8(+) T cells, B cells, and CD56(lo)CD16(+) NK cells and decreased ERK1/2, MAPK-activated protein kinase 2, and STAT1 phosphorylation in fetal intermediate and nonclassical monocytes. This highly interactive functional map of healthy fetomaternal immunity builds the core reference for a growing data repository that will allow inferring deviations from normal associated with adverse maternal and neonatal outcomes.

    View details for PubMedID 27793998

    View details for PubMedCentralID PMC5125527

  • Prospective stratification of patients at risk for emergency department revisit: resource utilization and population management strategy implications. BMC emergency medicine Jin, B., Zhao, Y., Hao, S., Shin, A. Y., Wang, Y., Zhu, C., Hu, Z., Fu, C., Ji, J., Wang, Y., Zhao, Y., Jiang, Y., Dai, D., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2016; 16 (1): 10-?


    Estimating patient risk of future emergency department (ED) revisits can guide the allocation of resources, e.g. local primary care and/or specialty, to better manage ED high utilization patient populations and thereby improve patient life qualities.We set to develop and validate a method to estimate patient ED revisit risk in the subsequent 6 months from an ED discharge date. An ensemble decision-tree-based model with Electronic Medical Record (EMR) encounter data from HealthInfoNet (HIN), Maine's Health Information Exchange (HIE), was developed and validated, assessing patient risk for a subsequent 6 month return ED visit based on the ED encounter-associated demographic and EMR clinical history data. A retrospective cohort of 293,461 ED encounters that occurred between January 1, 2012 and December 31, 2012, was assembled with the associated patients' 1-year clinical histories before the ED discharge date, for model training and calibration purposes. To validate, a prospective cohort of 193,886 ED encounters that occurred between January 1, 2013 and June 30, 2013 was constructed.Statistical learning that was utilized to construct the prediction model identified 152 variables that included the following data domains: demographics groups (12), different encounter history (104), care facilities (12), primary and secondary diagnoses (10), primary and secondary procedures (2), chronic disease condition (1), laboratory test results (2), and outpatient prescription medications (9). The c-statistics for the retrospective and prospective cohorts were 0.742 and 0.730 respectively. Total medical expense and ED utilization by risk score 6 months after the discharge were analyzed. Cluster analysis identified discrete subpopulations of high-risk patients with distinctive resource utilization patterns, suggesting the need for diversified care management strategies.Integration of our method into the HIN secure statewide data system in real time prospectively validated its performance. It promises to provide increased opportunity for high ED utilization identification, and optimized resource and population management.

    View details for DOI 10.1186/s12873-016-0074-5

    View details for PubMedID 26842066

    View details for PubMedCentralID PMC4739399

  • NLP based congestive heart failure case finding: A prospective analysis on statewide electronic medical records. International journal of medical informatics Wang, Y., Luo, J., Hao, S., Xu, H., Shin, A. Y., Jin, B., Liu, R., Deng, X., Wang, L., Zheng, L., Zhao, Y., Zhu, C., Hu, Z., Fu, C., Hao, Y., Zhao, Y., Jiang, Y., Dai, D., Culver, D. S., Alfreds, S. T., Todd, R., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2015; 84 (12): 1039-1047


    In order to proactively manage congestive heart failure (CHF) patients, an effective CHF case finding algorithm is required to process both structured and unstructured electronic medical records (EMR) to allow complementary and cost-efficient identification of CHF patients.We set to identify CHF cases from both EMR codified and natural language processing (NLP) found cases. Using narrative clinical notes from all Maine Health Information Exchange (HIE) patients, the NLP case finding algorithm was retrospectively (July 1, 2012-June 30, 2013) developed with a random subset of HIE associated facilities, and blind-tested with the remaining facilities. The NLP based method was integrated into a live HIE population exploration system and validated prospectively (July 1, 2013-June 30, 2014). Total of 18,295 codified CHF patients were included in Maine HIE. Among the 253,803 subjects without CHF codings, our case finding algorithm prospectively identified 2411 uncodified CHF cases. The positive predictive value (PPV) is 0.914, and 70.1% of these 2411 cases were found to be with CHF histories in the clinical notes.A CHF case finding algorithm was developed, tested and prospectively validated. The successful integration of the CHF case findings algorithm into the Maine HIE live system is expected to improve the Maine CHF care.

    View details for DOI 10.1016/j.ijmedinf.2015.06.007

    View details for PubMedID 26254876

  • Infant, maternal, and geographic factors influencing gastroschisis related mortality in Zimbabwe SURGERY Apfeld, J. C., Wren, S. M., Macheka, N., Mbuwayesango, B. A., Bruzoni, M., Sylvester, K. G., Kastenberg, Z. J. 2015; 158 (6): 1476-1481
  • Infant, maternal, and geographic factors influencing gastroschisis related mortality in Zimbabwe. Surgery Apfeld, J. C., Wren, S. M., Macheka, N., Mbuwayesango, B. A., Bruzoni, M., Sylvester, K. G., Kastenberg, Z. J. 2015; 158 (6): 1475-1480


    Survival for infants with gastroschisis in developed countries has improved dramatically in recent decades with reported mortality rates of 4-7%. Conversely, mortality rates for gastroschisis in sub-Saharan Africa remain as great as 60% in contemporary series. This study describes the burden of gastroschisis at the major pediatric hospital in Zimbabwe with the goal of identifying modifiable factors influencing gastroschisis-related infant mortality.We performed a retrospective cohort study of all cases of gastroschisis admitted to Harare Children's Hospital in 2013. Univariate and multivariate analyses were performed to describe infant, maternal, and geographic factors influencing survival.A total of 5,585 neonatal unit admissions were identified including 95 (1.7%) infants born with gastroschisis. Gastroschisis-related mortality was 84% (n = 80). Of infants with gastroschisis, 96% (n = 91) were born outside Harare Hospital, 82% (n = 78) were born outside Harare Province, and 23% (n = 25) were home births. The unadjusted odds of survival for these neonates with gastroschisis were decreased for low birth weight infants (<2,500 grams; odds ratio [OR], 0.15; 95% CI, 0.05-0.51), preterm births (<37 weeks gestational age; OR, 0.06; 95% CI, 0.01-0.50), and for those born to teenage mothers (<20 years of age; OR, 0.05; 95% CI, 0.01-0.46). There was also a trend toward decreased odds of survival for home births (OR, 0.16; 95% CI, 0.02-1.34) and for those born outside Harare Province (OR, 0.35; 95% CI, 0.10-1.22).Gastroschisis-related infant mortality in Zimbabwe is associated with well-known risk factors, including low birth weight, prematurity, and teenage mothers. However, modifiable factors identified in this study signify potential opportunities for developing innovative approaches to perinatal care in such a resource-constrained environment.

    View details for DOI 10.1016/j.surg.2015.04.037

    View details for PubMedID 26071924

  • Augmented Wnt Signaling as a Therapeutic Tool to Prevent Ischemia/Reperfusion Injury in Liver: Preclinical Studies in a Mouse Model LIVER TRANSPLANTATION Liu, B., Zhang, R., Tao, G., Lehwald, N. C., Liu, B., Koh, Y., Sylvester, K. G. 2015; 21 (12): 1533-1542

    View details for DOI 10.1002/lt.24331

    View details for Web of Science ID 000368138700011

  • Development, Validation and Deployment of a Real Time 30 Day Hospital Readmission Risk Assessment Tool in the Maine Healthcare Information Exchange PLOS ONE Hao, S., Wang, Y., Jin, B., Shin, A. Y., Zhu, C., Huang, M., Zheng, L., Luo, J., Hu, Z., Fu, C., Dai, D., Wang, Y., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2015; 10 (10)

    View details for DOI 10.1371/journal.pone.0140271

    View details for Web of Science ID 000362511000113

    View details for PubMedID 26448562

  • Serological Targeted Analysis of an ITIH4 Peptide Isoform: A Preterm Birth Biomarker and Its Associated SNP Implications JOURNAL OF GENETICS AND GENOMICS Tan, Z., Hu, Z., Cai, E. Y., Alev, C., Yang, T., Li, Z., Sung, J., El-Sayed, Y. Y., Shaw, G. M., Stevenson, D. K., Butte, A. J., Sheng, G., Sylvester, K. G., Cohen, H. J., Ling, X. B. 2015; 42 (9): 507-510

    View details for DOI 10.1016/j.jgg.2015.06.001

    View details for Web of Science ID 000361919400006

    View details for PubMedID 26408095

  • Online Prediction of Health Care Utilization in the Next Six Months Based on Electronic Health Record Information: A Cohort and Validation Study JOURNAL OF MEDICAL INTERNET RESEARCH Hu, Z., Hao, S., Jin, B., Shin, A. Y., Zhu, C., Huang, M., Wang, Y., Zheng, L., Dai, D., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. 2015; 17 (9)


    The increasing rate of health care expenditures in the United States has placed a significant burden on the nation's economy. Predicting future health care utilization of patients can provide useful information to better understand and manage overall health care deliveries and clinical resource allocation.This study developed an electronic medical record (EMR)-based online risk model predictive of resource utilization for patients in Maine in the next 6 months across all payers, all diseases, and all demographic groups.In the HealthInfoNet, Maine's health information exchange (HIE), a retrospective cohort of 1,273,114 patients was constructed with the preceding 12-month EMR. Each patient's next 6-month (between January 1, 2013 and June 30, 2013) health care resource utilization was retrospectively scored ranging from 0 to 100 and a decision tree-based predictive model was developed. Our model was later integrated in the Maine HIE population exploration system to allow a prospective validation analysis of 1,358,153 patients by forecasting their next 6-month risk of resource utilization between July 1, 2013 and December 31, 2013.Prospectively predicted risks, on either an individual level or a population (per 1000 patients) level, were consistent with the next 6-month resource utilization distributions and the clinical patterns at the population level. Results demonstrated the strong correlation between its care resource utilization and our risk scores, supporting the effectiveness of our model. With the online population risk monitoring enterprise dashboards, the effectiveness of the predictive algorithm has been validated by clinicians and caregivers in the State of Maine.The model and associated online applications were designed for tracking the evolving nature of total population risk, in a longitudinal manner, for health care resource utilization. It will enable more effective care management strategies driving improved patient outcomes.

    View details for DOI 10.2196/jmir.4976

    View details for Web of Science ID 000361809800005

    View details for PubMedID 26395541

  • A robust estimation model for surgery durations with temporal, operational, and surgery team effects HEALTH CARE MANAGEMENT SCIENCE Kayis, E., Khaniyev, T. T., Suermondt, J., Sylvester, K. 2015; 18 (3): 222-233
  • Impaired Activity of Blood Coagulant Factor XIII in Patients with Necrotizing Enterocolitis SCIENTIFIC REPORTS Tao, G., Liu, B., Zhang, R., Liu, G., Abdullah, F., Harris, M. C., Brandt, M. L., Ehrenkranz, R. A., Bowers, C., Martin, C. R., Moss, R. L., Sylvester, K. G. 2015; 5

    View details for DOI 10.1038/srep13119

    View details for Web of Science ID 000359525400001

  • Urine biomarkers for necrotizing enterocolitis PEDIATRIC SURGERY INTERNATIONAL Sylvester, K. G., Moss, R. L. 2015; 31 (5): 421-429


    Necrotizing enterocolitis (NEC) remains a significant cause of morbidity and mortality in premature neonates. Despite decades of investigation, treating clinicians are still not able to determine which premature infants are at greatest risk of developing NEC and which of the affected infants will develop severe NEC requiring operation. A biomarker is a specific molecular indicator that can be used to identify or measure the progress of a disease. Many potential biomarkers have been studied for their potential relevance to NEC. Those showing promise include C-reactive protein, intestinal fatty acid-binding protein, platelet-activating factor and many others. None to date have achieved sufficient predictive value to be clinically useful. Distinguishing between the specific changes in NEC and the non-specific inflammation of sepsis has proven challenging. Urine is a particularly attractive site for potential biomarkers. It can be collected readily and non-invasively, and it is a rich source of both proteins and peptides. Preliminary work has revealed some promising biomarkers of NEC in urine. Combined with clinical data, they have been shown to be highly predictive in small series of patients. Advances in high-throughput molecular analysis have opened the door to finding biomarkers that may meaningfully improve the outcome of infants at risk for NEC.

    View details for DOI 10.1007/s00383-015-3693-0

    View details for Web of Science ID 000353218200001

    View details for PubMedID 25807901

  • CK2 alpha phosphorylates DBC1 and is involved in the progression of gastric carcinoma and predicts poor survival of gastric carcinoma patients INTERNATIONAL JOURNAL OF CANCER Bae, J. S., Park, S., Kim, K. M., Kwon, K. S., Kim, C. Y., Lee, H. K., Park, B., Park, H. S., Lee, H., Moon, W. S., Chung, M. J., Sylvester, K. G., Jang, K. Y. 2015; 136 (4): 797-809


    CK2α has diverse effects on the tumorigenesis owing to its kinase activity, which phosphorylates various proteins involved in tumorigenesis. We, therefore, investigated the expression and role of CK2α in the phosphorylation of deleted in breast cancer 1 (DBC1) in gastric carcinomas. We used 187 gastric carcinomas and human gastric cancer cells to investigate the roles and relationship between CK2α and DBC1 in gastric carcinomas. Positive expression of CK2α and phospho-DBC1 predicted shorter overall survival and relapse-free survival by univariate analysis. Especially, CK2α expression was an independent prognostic indicator for gastric carcinoma patients. In gastric carcinoma cells, CK2α was bound to DBC1 and phosphorylated DBC1. The phosphorylation of DBC1 by CK2α was evidenced by co-immunoprecipitation of CK2α and DBC1 in a GST pull-down assay, an in vitro kinase assay, and immunofluorescence staining. Inhibition of both CK2α and DBC1 decreased proliferation and invasive activity of cancer cells. Decreased migration and invasive activity was associated with a downregulation of MMP2, MMP9 and the epithelial-mesenchymal transition. A mutation at the phosphorylation site of DBC1 also downregulated the signals related with the epithelial-mesenchymal transition. Our study demonstrated that CK2α is an independent prognostic indicator for gastric carcinoma patients and is involved in tumorigenesis by regulating the phosphorylation of DBC1. In addition, the blocking of CK2α and DBC1 inhibited the proliferation and invasive potential of gastric cancer cells. Therefore, our study suggests that CK2α-DBC1 pathway might be a new therapeutic target for the treatment of gastric carcinoma.

    View details for DOI 10.1002/ijc.29043

    View details for Web of Science ID 000346089900027

    View details for PubMedID 24962073

  • Development, Validation and Deployment of a Real Time 30 Day Hospital Readmission Risk Assessment Tool in the Maine Healthcare Information Exchange. PloS one Hao, S., Wang, Y., Jin, B., Shin, A. Y., Zhu, C., Huang, M., Zheng, L., Luo, J., Hu, Z., Fu, C., Dai, D., Wang, Y., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2015; 10 (10)


    Identifying patients at risk of a 30-day readmission can help providers design interventions, and provide targeted care to improve clinical effectiveness. This study developed a risk model to predict a 30-day inpatient hospital readmission for patients in Maine, across all payers, all diseases and all demographic groups.Our objective was to develop a model to determine the risk for inpatient hospital readmission within 30 days post discharge. All patients within the Maine Health Information Exchange (HIE) system were included. The model was retrospectively developed on inpatient encounters between January 1, 2012 to December 31, 2012 from 24 randomly chosen hospitals, and then prospectively validated on inpatient encounters from January 1, 2013 to December 31, 2013 using all HIE patients.A risk assessment tool partitioned the entire HIE population into subgroups that corresponded to probability of hospital readmission as determined by a corresponding positive predictive value (PPV). An overall model c-statistic of 0.72 was achieved. The total 30-day readmission rates in low (score of 0-30), intermediate (score of 30-70) and high (score of 70-100) risk groupings were 8.67%, 24.10% and 74.10%, respectively. A time to event analysis revealed the higher risk groups readmitted to a hospital earlier than the lower risk groups. Six high-risk patient subgroup patterns were revealed through unsupervised clustering. Our model was successfully integrated into the statewide HIE to identify patient readmission risk upon admission and daily during hospitalization or for 30 days subsequently, providing daily risk score updates.The risk model was validated as an effective tool for predicting 30-day readmissions for patients across all payer, disease and demographic groups within the Maine HIE. Exposing the key clinical, demographic and utilization profiles driving each patient's risk of readmission score may be useful to providers in developing individualized post discharge care plans.

    View details for DOI 10.1371/journal.pone.0140271

    View details for PubMedID 26448562

  • Impaired Activity of Blood Coagulant Factor XIII in Patients with Necrotizing Enterocolitis. Scientific reports Tao, G., Liu, B., Zhang, R., Liu, G., Abdullah, F., Harris, M. C., Brandt, M. L., Ehrenkranz, R. A., Bowers, C., Martin, C. R., Moss, R. L., Sylvester, K. G. 2015; 5: 13119-?


    Necrotizing enterocolitis (NEC) is the most common gastrointestinal (GI) medical/surgical emergency of the newborn and a leading cause of preterm neonate morbidity and mortality. NEC is a challenge to diagnose since it often shares similar clinical features with neonatal sepsis. In the present study, plasma protein profiling was compared among NEC, sepsis and control cohorts using gel electrophoresis, immunoblot and mass spectrometry. We observed significant impairment in the formation of fibrinogen-γ dimers (FGG-dimer) in the plasma of newborns with NEC that could efficiently differentiate NEC and sepsis with a high level of sensitivity and specificity. Interestingly, the impaired FGG-dimer formation could be restored in NEC plasma by the addition of exogenous active factor XIII (FXIII). Enzymatic activity of FXIII was determined to be significantly lower in NEC subject plasma for crosslinking FGG when compared to sepsis. These findings demonstrate a potential novel biomarker and related biologic mechanism for diagnosing NEC, as well as suggest a possible therapeutic strategy.

    View details for DOI 10.1038/srep13119

    View details for PubMedID 26277871

  • Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis. JAMA pediatrics Kastenberg, Z. J., Lee, H. C., Profit, J., Gould, J. B., Sylvester, K. G. 2015; 169 (1): 26-32


    There has been a significant expansion in the number of low-level and midlevel neonatal intensive care units (NICUs) in recent decades. Infants with necrotizing enterocolitis represent a high-risk subgroup of the very low-birth-weight (VLBW) (<1500 g) population that would benefit from focused regionalization.To describe the current trend toward deregionalization and to test the hypothesis that infants with necrotizing enterocolitis represent a particularly high-risk subgroup of the VLBW population that would benefit from early identification, increased intensity of early management, and possible targeted triage to tertiary hospitals.A retrospective cohort study was conducted of NICUs in California. We used data collected by the California Perinatal Quality Care Collaborative from 2005 to 2011 to assess mortality rates among a population-based sample of 30 566 VLBW infants, 1879 with necrotizing enterocolitis, according to the level of care and VLBW case volume at the hospital of birth.Level and volume of neonatal intensive care at the hospital of birth.In-hospital mortality.There was a persistent trend toward deregionalization during the study period and mortality rates varied according to the level of care. High-level, high-volume (level IIIB with >100 VLBW cases per year and level IIIC) hospitals achieved the lowest risk-adjusted mortality. Infants with necrotizing enterocolitis born into midlevel hospitals (low-volume level IIIB and level IIIA NICUs) had odds of death ranging from 1.42 (95% CI, 1.08-1.87) to 1.51 (95% CI, 1.05-2.15, respectively). In the final year of the study, just 28.6% of the infants with necrotizing enterocolitis were born into high-level, high-volume hospitals. For infants born into lower level centers, transfer to a higher level of care frequently occurred well into the third week of life.These findings represent an immediate opportunity for local quality improvement initiatives and potential impetus for the regionalization of important NICU resources.

    View details for DOI 10.1001/jamapediatrics.2014.2085

    View details for PubMedID 25383940

  • Pilot Application of Magnetic Nanoparticle-Based Biosensor for Necrotizing Enterocolitis. Journal of proteomics & bioinformatics Kim, D., Fu, C., Ling, X. B., Hu, Z., Tao, G., Zhao, Y., Kastenberg, Z. J., Sylvester, K. G., Wang, S. X. 2015


    Necrotizing Enterocolitis (NEC) is a major source of neonatal morbidity and mortality. There is an ongoing need for a sensitive diagnostic instrument to discriminate NEC from neonatal sepsis. We hypothesized that magnetic nanopartile-based biosensor analysis of gut injury-associated biomarkers would provide such an instrument.We designed a magnetic multiplexed biosensor platform, allowing the parallel plasma analysis of C-reactive protein (CRP), matrix metalloproteinase-7 (MMp7), and epithelial cell adhesion molecule (EpCAM). Neonatal subjects with sepsis (n=5) or NEC (n=10) were compared to control (n=5) subjects to perform a proof of concept pilot study for the diagnosis of NEC using our ultra-sensitive biosensor platform.Our multiplexed NEC magnetic nanoparticle-based biosensor platform was robust, ultrasensitive (Limit of detection LOD: CRP 0.6 pg/ml; MMp7 20 pg/ml; and EpCAM 20 pg/ml), and displayed no cross-reactivity among analyte reporting regents. To gauge the diagnostic performance, bootstrapping procedure (500 runs) was applied: MMp7 and EpCAM collectively differentiated infants with NEC from control infants with ROC AUC of 0.96, and infants with NEC from those with sepsis with ROC AUC of 1.00. The 3-marker panel comprising of EpCAM, MMp7 and CRP had a corresponding ROC AUC of 0.956 and 0.975, respectively.The exploration of the multiplexed nano-biosensor platform shows promise to deliver an ultrasensitive instrument for the diagnosis of NEC in the clinical setting.

    View details for PubMedID 26798207

  • Hippo/YAP, ß-catenin, and the cancer cell: a "ménage à trois" in hepatoblastoma. Gastroenterology Sylvester, K. G., Colnot, S. 2014; 147 (3): 562-565

    View details for DOI 10.1053/j.gastro.2014.07.026

    View details for PubMedID 25072176

  • A novel urine peptide biomarker-based algorithm for the prognosis of necrotising enterocolitis in human infants. Gut Sylvester, K. G., Ling, X. B., Liu, G. Y., Kastenberg, Z. J., Ji, J., Hu, Z., Peng, S., Lau, K., Abdullah, F., Brandt, M. L., Ehrenkranz, R. A., Harris, M. C., Lee, T. C., Simpson, J., Bowers, C., Moss, R. L. 2014; 63 (8): 1284-1292


    Necrotising enterocolitis (NEC) is a major source of neonatal morbidity and mortality. The management of infants with NEC is currently complicated by our inability to accurately identify those at risk for progression of disease prior to the development of irreversible intestinal necrosis. We hypothesised that integrated analysis of clinical parameters in combination with urine peptide biomarkers would lead to improved prognostic accuracy in the NEC population.Infants under suspicion of having NEC (n=550) were prospectively enrolled from a consortium consisting of eight university-based paediatric teaching hospitals. Twenty-seven clinical parameters were used to construct a multivariate predictor of NEC progression. Liquid chromatography/mass spectrometry was used to profile the urine peptidomes from a subset of this population (n=65) to discover novel biomarkers of NEC progression. An ensemble model for the prediction of disease progression was then created using clinical and biomarker data.The use of clinical parameters alone resulted in a receiver-operator characteristic curve with an area under the curve of 0.817 and left 40.1% of all patients in an 'indeterminate' risk group. Three validated urine peptide biomarkers (fibrinogen peptides: FGA1826, FGA1883 and FGA2659) produced a receiver-operator characteristic area under the curve of 0.856. The integration of clinical parameters with urine biomarkers in an ensemble model resulted in the correct prediction of NEC outcomes in all cases tested.Ensemble modelling combining clinical parameters with biomarker analysis dramatically improves our ability to identify the population at risk for developing progressive NEC.

    View details for DOI 10.1136/gutjnl-2013-305130

    View details for PubMedID 24048736

  • Heterotaxy syndromes and abnormal bowel rotation. Pediatric radiology Newman, B., Koppolu, R., Murphy, D., Sylvester, K. 2014; 44 (5): 542-551


    Bowel rotation abnormalities in heterotaxy are common. As more children survive cardiac surgery, the management of gastrointestinal abnormalities has become controversial.To evaluate imaging of malrotation in heterotaxy with surgical correlation and provide an algorithm for management.Imaging reports of heterotaxic children with upper gastrointestinal (UGI) and/or small bowel follow-through (SBFT) were reviewed. Subsequently, fluoroscopic images were re-reviewed in conjunction with CT/MR studies. The original reports and re-reviewed images were compared and correlated with surgical findings.Nineteen of 34 children with heterotaxy underwent UGI, 13/19 also had SBFT. In 15/19 reports, bowel rotation was called abnormal: 11 malrotation, 4 non-rotation, no cases of volvulus. Re-review, including CT (10/19) and MR (2/19), designated 17/19 (90%) as abnormal, 10 malrotation (abnormal bowel arrangement, narrow or uncertain length of mesentery) and 7 non-rotation (small bowel and colon on opposite sides plus low cecum with probable broad mesentery). The most useful CT/MR findings were absence of retroperitoneal duodenum in most abnormal cases and location of bowel, especially cecum. Abnormal orientation of mesenteric vessels suggested malrotation but was not universal. Nine children had elective bowel surgery; non-rotation was found in 4/9 and malrotation was found in 5/9, with discrepancies (non-rotation at surgery, malrotation on imaging) with 4 original interpretations and 1 re-review.We recommend routine, early UGI and SBFT studies once other, urgent clinical concerns have been stabilized, with elective laparoscopic surgery in abnormal or equivocal cases. Cross-sectional imaging, usually obtained for other reasons, can contribute diagnostically. Attempting to assess mesenteric width is important in differentiating non-rotation from malrotation and more accurately identifies appropriate surgical candidates.

    View details for DOI 10.1007/s00247-013-2861-4

    View details for PubMedID 24419494

  • Urine protein biomarkers for the diagnosis and prognosis of necrotizing enterocolitis in infants. journal of pediatrics Sylvester, K. G., Ling, X. B., Liu, G. Y., Kastenberg, Z. J., Ji, J., Hu, Z., Wu, S., Peng, S., Abdullah, F., Brandt, M. L., Ehrenkranz, R. A., Harris, M. C., Lee, T. C., Simpson, B. J., Bowers, C., Moss, R. L. 2014; 164 (3): 607-12 e1 7


    To test the hypothesis that an exploratory proteomics analysis of urine proteins with subsequent development of validated urine biomarker panels would produce molecular classifiers for both the diagnosis and prognosis of infants with necrotizing enterocolitis (NEC).Urine samples were collected from 119 premature infants (85 NEC, 17 sepsis, 17 control) at the time of initial clinical concern for disease. The urine from 59 infants was used for candidate biomarker discovery by liquid chromatography/mass spectrometry. The remaining 60 samples were subject to enzyme-linked immunosorbent assay for quantitative biomarker validation.A panel of 7 biomarkers (alpha-2-macroglobulin-like protein 1, cluster of differentiation protein 14, cystatin 3, fibrinogen alpha chain, pigment epithelium-derived factor, retinol binding protein 4, and vasolin) was identified by liquid chromatography/mass spectrometry and subsequently validated by enzyme-linked immunosorbent assay. These proteins were consistently found to be either up- or down-regulated depending on the presence, absence, or severity of disease. Biomarker panel validation resulted in a receiver-operator characteristic area under the curve of 98.2% for NEC vs sepsis and an area under the curve of 98.4% for medical NEC vs surgical NEC.We identified 7 urine proteins capable of providing highly accurate diagnostic and prognostic information for infants with suspected NEC. This work represents a novel approach to improving the efficiency with which we diagnose early NEC and identify those at risk for developing severe, or surgical, disease.

    View details for DOI 10.1016/j.jpeds.2013.10.091

    View details for PubMedID 24433829

  • Urine protein biomarkers for the diagnosis and prognosis of necrotizing enterocolitis in infants. journal of pediatrics Sylvester, K. G., Ling, X. B., Liu, G. Y., Kastenberg, Z. J., Ji, J., Hu, Z., Wu, S., Peng, S., Abdullah, F., Brandt, M. L., Ehrenkranz, R. A., Harris, M. C., Lee, T. C., Simpson, B. J., Bowers, C., Moss, R. L. 2014; 164 (3): 607-612 e7

    View details for DOI 10.1016/j.jpeds.2013.10.091

    View details for PubMedID 24433829

  • A data-driven algorithm integrating clinical and laboratory features for the diagnosis and prognosis of necrotizing enterocolitis. PloS one Ji, J., Ling, X. B., Zhao, Y., Hu, Z., Zheng, X., Xu, Z., Wen, Q., Kastenberg, Z. J., Li, P., Abdullah, F., Brandt, M. L., Ehrenkranz, R. A., Harris, M. C., Lee, T. C., Simpson, B. J., Bowers, C., Moss, R. L., Sylvester, K. G. 2014; 9 (2)


    Necrotizing enterocolitis (NEC) is a major source of neonatal morbidity and mortality. Since there is no specific diagnostic test or risk of progression model available for NEC, the diagnosis and outcome prediction of NEC is made on clinical grounds. The objective in this study was to develop and validate new NEC scoring systems for automated staging and prognostic forecasting.A six-center consortium of university based pediatric teaching hospitals prospectively collected data on infants under suspicion of having NEC over a 7-year period. A database comprised of 520 infants was utilized to develop the NEC diagnostic and prognostic models by dividing the entire dataset into training and testing cohorts of demographically matched subjects. Developed on the training cohort and validated on the blind testing cohort, our multivariate analyses led to NEC scoring metrics integrating clinical data.MACHINE LEARNING USING CLINICAL AND LABORATORY RESULTS AT THE TIME OF CLINICAL PRESENTATION LED TO TWO NEC MODELS: (1) an automated diagnostic classification scheme; (2) a dynamic prognostic method for risk-stratifying patients into low, intermediate and high NEC scores to determine the risk for disease progression. We submit that dynamic risk stratification of infants with NEC will assist clinicians in determining the need for additional diagnostic testing and guide potential therapies in a dynamic manner. and smartphone application upon request.

    View details for DOI 10.1371/journal.pone.0089860

    View details for PubMedID 24587080

  • Risk prediction of emergency department revisit 30 days post discharge: a prospective study. PloS one Hao, S., Jin, B., Shin, A. Y., Zhao, Y., Zhu, C., Li, Z., Hu, Z., Fu, C., Ji, J., Wang, Y., Zhao, Y., Dai, D., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2014; 9 (11)

    View details for DOI 10.1371/journal.pone.0112944

    View details for PubMedID 25393305

  • Risk prediction of emergency department revisit 30 days post discharge: a prospective study. PloS one Hao, S., Jin, B., Shin, A. Y., Zhao, Y., Zhu, C., Li, Z., Hu, Z., Fu, C., Ji, J., Wang, Y., Zhao, Y., Dai, D., Culver, D. S., Alfreds, S. T., Rogow, T., Stearns, F., Sylvester, K. G., Widen, E., Ling, X. B. 2014; 9 (11)


    Among patients who are discharged from the Emergency Department (ED), about 3% return within 30 days. Revisits can be related to the nature of the disease, medical errors, and/or inadequate diagnoses and treatment during their initial ED visit. Identification of high-risk patient population can help device new strategies for improved ED care with reduced ED utilization.A decision tree based model with discriminant Electronic Medical Record (EMR) features was developed and validated, estimating patient ED 30 day revisit risk. A retrospective cohort of 293,461 ED encounters from HealthInfoNet (HIN), Maine's Health Information Exchange (HIE), between January 1, 2012 and December 31, 2012, was assembled with the associated patients' demographic information and one-year clinical histories before the discharge date as the inputs. To validate, a prospective cohort of 193,886 encounters between January 1, 2013 and June 30, 2013 was constructed. The c-statistics for the retrospective and prospective predictions were 0.710 and 0.704 respectively. Clinical resource utilization, including ED use, was analyzed as a function of the ED risk score. Cluster analysis of high-risk patients identified discrete sub-populations with distinctive demographic, clinical and resource utilization patterns.Our ED 30-day revisit model was prospectively validated on the Maine State HIN secure statewide data system. Future integration of our ED predictive analytics into the ED care work flow may lead to increased opportunities for targeted care intervention to reduce ED resource burden and overall healthcare expense, and improve outcomes.

    View details for DOI 10.1371/journal.pone.0112944

    View details for PubMedID 25393305

  • A data-driven algorithm integrating clinical and laboratory features for the diagnosis and prognosis of necrotizing enterocolitis. PloS one Ji, J., Ling, X. B., Zhao, Y., Hu, Z., Zheng, X., Xu, Z., Wen, Q., Kastenberg, Z. J., Li, P., Abdullah, F., Brandt, M. L., Ehrenkranz, R. A., Harris, M. C., Lee, T. C., Simpson, B. J., Bowers, C., Moss, R. L., Sylvester, K. G. 2014; 9 (2)

    View details for DOI 10.1371/journal.pone.0089860

    View details for PubMedID 24587080

  • Wnt/ß-Catenin Signaling Protects Mouse Liver against Oxidative Stress-induced Apoptosis through the Inhibition of Forkhead Transcription Factor FoxO3. journal of biological chemistry Tao, G., Lehwald, N., Jang, K. Y., Baek, J., Xu, B., Omary, M. B., Sylvester, K. G. 2013; 288 (24): 17214-17224


    Numerous liver diseases are associated with extensive oxidative tissue damage. It is well established that Wnt/β-catenin signaling directs multiple hepatocellular processes, including development, proliferation, regeneration, nutrient homeostasis, and carcinogenesis. It remains unexplored whether Wnt/β-catenin signaling provides hepatocyte protection against hepatotoxin-induced apoptosis. Conditional, liver-specific β-catenin knockdown (KD) mice and their wild-type littermates were challenged by feeding with a hepatotoxin 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC) diet to induce chronic oxidative liver injury. Following the DDC diet, mice with β-catenin-deficient hepatocytes demonstrate increased liver injury, indicating an important role of β-catenin signaling for liver protection against oxidative stress. This finding was further confirmed in AML12 hepatocytes with β-catenin signaling manipulation in vitro using paraquat, a known oxidative stress inducer. Immunofluorescence staining revealed an intense nuclear FoxO3 staining in β-catenin-deficient livers, suggesting active FoxO3 signaling in response to DDC-induced liver injury when compared with wild-type controls. Consistently, FoxO3 target genes p27 and Bim were significantly induced in β-catenin KD livers. Conversely, SGK1, a β-catenin target gene, was significantly impaired in β-catenin KD hepatocytes that failed to inactivate FoxO3. Furthermore, shRNA-mediated deletion of FoxO3 increased hepatocyte resistance to oxidative stress-induced apoptosis, confirming a proapoptotic role of FoxO3 in the stressed liver. Our findings suggest that Wnt/β-catenin signaling is required for hepatocyte protection against oxidative stress-induced apoptosis. The inhibition of FoxO through its phosphorylation by β-catenin-induced SGK1 expression reduces the apoptotic function of FoxO3, resulting in increased hepatocyte survival. These findings have relevance for future therapies directed at hepatocyte protection, regeneration, and anti-cancer treatment.

    View details for DOI 10.1074/jbc.M112.445965

    View details for PubMedID 23620592

    View details for PubMedCentralID PMC3682526

  • WNT/B-CATENIN AND MITOCHONDRIAL FUNCTION IN RESPONSE TO METABOLIC STRESS AND ALD 36th Annual Scientific Meeting of the Research-Society-on-Alcoholism Liu, B., Zhang, R., Tao, G., Lehwald, N. C., Liu, B., Sylvester, K. G. WILEY-BLACKWELL. 2013: 297A–297A
  • Heme oxygenase-1 deficiency promotes the development of necrotizing enterocolitis-like intestinal injury in a newborn mouse model. American journal of physiology. Gastrointestinal and liver physiology Schulz, S., Wong, R. J., Jang, K. Y., Kalish, F., Chisholm, K. M., Zhao, H., Vreman, H. J., Sylvester, K. G., Stevenson, D. K. 2013; 304 (11): G991-G1001


    Necrotizing enterocolitis (NEC) is typified by mucosal destruction, which subsequently can lead to intestinal necrosis. Prematurity, enteral feeding, and bacterial colonization are the main risk factors and, combined with other stressors, can cause increased intestinal permeability, injury, and an exaggerated inflammatory response. Heme oxygenase-1 (HO-1) mediates intestinal protection due to anti-inflammatory, antioxidative, and antiapoptotic effects of its products carbon monoxide, biliverdin, and bilirubin. This study investigates a possible role of HO-1 in the pathogenesis of NEC using a newborn mouse model. We induced NEC-like intestinal injury in 7-day-old HO-1 heterozygous (HO-1 Het, Hmox1(+/-)) and wild-type (Wt, Hmox1(+/+)) mice by gavage feeding and hypoxic exposures. Control (Con) pups of both genotypes were dam-fed. Intestines of HO-1 Het Con pups appeared predisposed to injury, with higher histological damage scores, more TUNEL-positive cells, and a significant reduction in muscularis externa thickness compared with Wt Con pups. The increase in HO activity after HO-1 induction by the substrate heme or by hypoxic stress was significantly impaired in HO-1 Het pups. After induction of intestinal injury, HO-1 Het pups displayed significantly higher NEC incidence (78 vs. 43%), mortality (83 vs. 54%), and median scores (2.5 vs. 1.5) than Wt NEC pups. PCR array analyses revealed increased expressions of IL-1β, P-selectin, matrix metallopeptidase 2, collagen type XVIII-α1, serpine 1, and others in NEC-induced HO-1 Het ileal and jejunal tissues. We conclude that a partial HO-1 deficiency promotes experimental NEC-like intestinal injury, possibly mediated by exaggerated inflammation and disruption in tissue repair.

    View details for DOI 10.1152/ajpgi.00363.2012

    View details for PubMedID 23578787

    View details for PubMedCentralID PMC3680684

  • The surgical management of necrotizing enterocolitis. Clinics in perinatology Kastenberg, Z. J., Sylvester, K. G. 2013; 40 (1): 135-148


    Necrotizing enterocolitis (NEC), a common cause of neonatal morbidity and mortality, is strongly associated with prematurity and typically occurs following initiation of enteral feeds. Mild NEC is adequately treated by cessation of enteral feeding, empiric antibiotics, and supportive care. Approximately 50% of affected infants will develop progressive intestinal necrosis requiring urgent operation. Several surgical techniques have been described, but there is no clear survival benefit for any single operative approach. While debate continues regarding the optimal surgical management for infants with severe NEC, future progress will likely depend on the development of improved diagnostic tools and preventive therapies.

    View details for DOI 10.1016/j.clp.2012.12.011

    View details for PubMedID 23415269

  • SIRT1 and c-Myc Promote Liver Tumor Cell Survival and Predict Poor Survival of Human Hepatocellular Carcinomas PLOS ONE Jang, K. Y., Noh, S. J., Lehwald, N., Tao, G., Bellovin, D. I., Park, H. S., Moon, W. S., Felsher, D. W., Sylvester, K. G. 2012; 7 (9)


    The increased expression of SIRT1 has recently been identified in numerous human tumors and a possible correlation with c-Myc oncogene has been proposed. However, it remains unclear whether SIRT1 functions as an oncogene or tumor suppressor. We sought to elucidate the role of SIRT1 in liver cancer under the influence of c-Myc and to determine the prognostic significance of SIRT1 and c-Myc expression in human hepatocellular carcinoma. The effect of either over-expression or knock down of SIRT1 on cell proliferation and survival was evaluated in both mouse and human liver cancer cells. Nicotinamide, an inhibitor of SIRT1, was also evaluated for its effects on liver tumorigenesis. The prognostic significance of the immunohistochemical detection of SIRT1 and c-Myc was evaluated in 154 hepatocellular carcinoma patients. SIRT1 and c-Myc regulate each other via a positive feedback loop and act synergistically to promote hepatocellular proliferation in both mice and human liver tumor cells. Tumor growth was significantly inhibited by nicotinamide in vivo and in vitro. In human hepatocellular carcinoma, SIRT1 expression positively correlated with c-Myc, Ki67 and p53 expression, as well as high á-fetoprotein level. Moreover, the expression of SIRT1, c-Myc and p53 were independent prognostic indicators of hepatocellular carcinoma. In conclusion, this study demonstrates that SIRT1 expression supports liver tumorigenesis and is closely correlated with oncogenic c-MYC expression. In addition, both SIRT1 and c-Myc may be useful prognostic indicators of hepatocellular carcinoma and SIRT1 targeted therapy may be beneficial in the treatment of hepatocellular carcinoma.

    View details for DOI 10.1371/journal.pone.0045119

    View details for Web of Science ID 000308860100058

    View details for PubMedID 23024800

    View details for PubMedCentralID PMC3443243

  • beta-Catenin Regulates Hepatic Mitochondrial Function and Energy Balance in Mice GASTROENTEROLOGY Lehwald, N., Tao, G., Jang, K. Y., Papandreou, I., Liu, B., Liu, B., Pysz, M. A., Willmann, J. K., Knoefel, W. T., Denko, N. C., Sylvester, K. G. 2012; 143 (3): 754-764


    Wnt signaling regulates hepatic function and nutrient homeostasis. However, little is known about the roles of β-catenin in cellular respiration or mitochondria of hepatocytes.We investigated β-catenin's role in the metabolic function of hepatocytes under homeostatic conditions and in response to metabolic stress using mice with hepatocyte-specific deletion of β-catenin and their wild-type littermates, given either saline (sham) or ethanol (as a model of binge drinking and acute ethanol intoxication).Under homeostatic conditions, β-catenin-deficient hepatocytes demonstrated mitochondrial dysfunctions that included impairments to the tricarboxylic acid cycle and oxidative phosphorylation (OXPHOS) and decreased production of adenosine triphosphate (ATP). There was no evidence for redox imbalance or oxidative cellular injury in the absence of metabolic stress. In mice with β-catenin-deficient hepatocytes, ethanol intoxication led to significant redox imbalance in the hepatocytes and further deterioration in mitochondrial function that included reduced OXPHOS, fatty acid oxidation (FAO), and ATP production. Ethanol feeding significantly increased liver steatosis and oxidative damage, compared with wild-type mice, and disrupted the ratio of nicotinamide adenine dinucleotide. β-catenin-deficient hepatocytes also had showed disrupted signaling of Sirt1/peroxisome proliferator-activated receptor-α signaling.β-catenin has an important role in the maintenance of mitochondrial homeostasis, regulating ATP production via the tricarboxylic acid cycle, OXPHOS, and fatty acid oxidation; β-catenin function in these systems is compromised under conditions of nutrient oxidative stress. Reagents that alter Wnt-β-catenin signaling might be developed as a useful new therapeutic strategy for treatment of liver disease.

    View details for DOI 10.1053/j.gastro.2012.05.048

    View details for Web of Science ID 000308399300039

    View details for PubMedID 22684045

  • HEME OXYGENASE-1 DEFICIENCY PROMOTES NECROTIZING ENTEROCOLITIS DEVELOPMENT IN A MURINE MOUSE MODEL Western Regional Meeting of the American-Federation-for-Medical-Research Schulz, S., Jang, K., Kalish, F. S., Zhao, H., Vreman, H. J., Sylvester, K. S., Wong, R. J., Stevenson, D. K. LIPPINCOTT WILLIAMS & WILKINS. 2012: 158–58
  • Improving prediction of surgery duration using operational and temporal factors. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium Kayis, E., Wang, H., Patel, M., Gonzalez, T., Jain, S., Ramamurthi, R. J., Santos, C., Singhal, S., Suermondt, J., Sylvester, K. 2012; 2012: 456-462


    Inherent uncertainties in surgery durations impact many critical metrics about the performance of an operating room (OR) environment. OR schedules that are robust to natural variability in surgery durations require surgery duration estimates that are unbiased, with high accuracy, and with few cases with large absolute errors. Earlier studies have shown that factors such as patient severity, personnel, and procedure type greatly affect the accuracy of such estimations. In this paper we investigate whether operational and temporal factors can be used to improve these estimates further. We present an adjustment method based on a combination of these operational and temporal factors. We validate our method with two years of detailed operational data from an electronic medical record. We conclude that while improving estimates of surgery durations is possible, the inherent variability in such estimates remains high, necessitating caution in their use when optimizing OR schedules.

    View details for PubMedID 23304316

  • Notch signaling inhibits hepatocellular carcinoma following inactivation of the RB pathway JOURNAL OF EXPERIMENTAL MEDICINE Viatour, P., Ehmer, U., Saddic, L. A., Dorrell, C., Andersen, J. B., Lin, C., Zmoos, A., Mazur, P. K., Schaffer, B. E., Ostermeier, A., Vogel, H., Sylvester, K. G., Thorgeirsson, S. S., Grompe, M., Sage, J. 2011; 208 (10): 1963-1976


    Hepatocellular carcinoma (HCC) is the third cancer killer worldwide with >600,000 deaths every year. Although the major risk factors are known, therapeutic options in patients remain limited in part because of our incomplete understanding of the cellular and molecular mechanisms influencing HCC development. Evidence indicates that the retinoblastoma (RB) pathway is functionally inactivated in most cases of HCC by genetic, epigenetic, and/or viral mechanisms. To investigate the functional relevance of this observation, we inactivated the RB pathway in the liver of adult mice by deleting the three members of the Rb (Rb1) gene family: Rb, p107, and p130. Rb family triple knockout mice develop liver tumors with histopathological features and gene expression profiles similar to human HCC. In this mouse model, cancer initiation is associated with the specific expansion of populations of liver stem/progenitor cells, indicating that the RB pathway may prevent HCC development by maintaining the quiescence of adult liver progenitor cells. In addition, we show that during tumor progression, activation of the Notch pathway via E2F transcription factors serves as a negative feedback mechanism to slow HCC growth. The level of Notch activity is also able to predict survival of HCC patients, suggesting novel means to diagnose and treat HCC.

    View details for DOI 10.1084/jem.20110198

    View details for Web of Science ID 000295318900005

    View details for PubMedID 21875955

  • Wnt-beta-catenin Signaling Protects Against Hepatic Ischemia and Reperfusion Injury in Mice GASTROENTEROLOGY Lehwald, N., Tao, G., Jang, K. Y., Sorkin, M., Knoefel, W. T., Sylvester, K. G. 2011; 141 (2): 707-U417


    Ischemia and reperfusion injury are common causes of oxidative tissue damage associated with many liver diseases and hepatic surgery. The Wnt-β-catenin signaling pathway is an important regulator of hepatic development, regeneration, and carcinogenesis. However, the role of Wnt signaling in the hepatocellular response to ischemia-reperfusion (I/R) injury has not been determined.Hepatic injury following ischemia or I/R was investigated in hepatocyte-specific, β-catenin-deficient mice, as well as Wnt1-overexpressing and wild-type (control) mice.Wnt-β-catenin signaling was affected by the cellular redox balance in hepatocytes. Following ischemia or I/R, mice with β-catenin-deficient hepatocytes were significantly more susceptible to liver injury. Conversely, mice that overexpressed Wnt1 in hepatocytes were resistant to hepatic I/R injury. Hypoxia inducible factor (HIF)-1α signaling was reduced in β-catenin-deficient liver but increased in hepatocytes that overexpressed Wnt1 under hypoxia and following I/R, indicating an interaction between β-catenin and HIF-1α signaling in the liver. The mechanism by which Wnt signaling protects against liver injury involves the role of β-catenin as a transcriptional coactivator of HIF-1α signaling, which promotes hepatocyte survival under hypoxic conditions.Cellular redox balance affects Wnt-β-catenin signaling, which protects against hypoxia and I/R injury. These findings might be used to develop strategies for protection of hepatocytes, regeneration of liver, and inhibition of carcinogenesis.

    View details for DOI 10.1053/j.gastro.2011.04.051

    View details for Web of Science ID 000293523300049

    View details for PubMedID 21679710

    View details for PubMedCentralID PMC4084974

  • Intestinal involvement during 3,5-diethoxycarbonyl-1,4-dihydrocollidine-induced chronic liver injury in a mouse model JOURNAL OF PEDIATRIC SURGERY Sukhotnik, I., Kuscuoglu, U., Altindag, B., Tao, G., Lehwald, N., Sylvester, K. G. 2011; 46 (8): 1495-1502


    Although a physiologic relationship between intestinal mucosal integrity and hepatic function has been previously described, the effect of primary liver disease on intestinal mucosal homeostasis has not been previously well documented. In the current study, we studied the effects of chronic liver injury as a primary injury on enterocyte turnover (proliferation and apoptosis) in a mouse model.The liver toxin 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC)-enriched diet was used to induce chronic cholestatic liver injury in mice. Livers and intestine were harvested after 3 weeks of dietary treatment of histologic analysis and a determination of cell proliferation (immunohistochemistry for Ki67), or apoptosis (immunohistochemistry for caspase-3), as well as a determination of Wnt/β-catenin signaling activity.All DDC-fed animals exhibited histologic evidence of liver damage that was associated with the expansion of atypical ductal proliferation near the periportal areas and increased oxidative stress. In the intestine, DDC-induced liver damage was associated with decreased villus height, decreased enterocyte proliferation, and increased cell apoptosis compared with control animals. There was also evidence for decreased β-catenin expression by immunostaining in crypt and villus cells of DDC-fed mice compared with control animals.Primary liver injury and cholestasis is associated with intestinal mucosal hypoplasia. Decreased cell proliferation and increased cell apoptosis may be responsible for decreased intestinal epithelial cell mass. The observed decrease in cell turnover is accompanied by an alteration in Wnt/β-catenin signaling.

    View details for DOI 10.1016/j.jpedsurg.2011.04.007

    View details for Web of Science ID 000293950100014

    View details for PubMedID 21843714

  • Risk Factors for Parenteral Nutrition-associated Liver Disease Following Surgical Therapy for Necrotizing Enterocolitis JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Duro, D., Mitchell, P. D., Kalish, L. A., Martin, C., Mccarthy, M., Jaksic, T., Dunn, J., Brandt, M. L., Nobuhara, K. K., Sylvester, K. G., Moss, R. L., Duggan, C. 2011; 52 (5): 595-600


    The aim of the study was to prospectively determine risk factors for the development of parenteral nutrition-associated liver disease (PNALD) in infants who underwent surgery for necrotizing enterocolitis (NEC), the most common cause of intestinal failure in children.: From February 2004 to February 2007, we diagnosed 464 infants with NEC, of whom 180 had surgery. One hundred twenty-seven patients were available for full analysis. PNALD was defined as serum direct bilirubin ≥ 2 mg/dL or ALT ≥ 2 × the upper limit of normal in the absence of sepsis after ≥ 14 days of exposure to PN.Median gestational age was 26 weeks and 68% were boys. Seventy percent of the cohort developed PNALD and the incidence of PNALD varied significantly across the 6 study sites, ranging from 56% to 85% (P = 0.05). Multivariable logistic regression analysis identified small-bowel resection or creation of jejunostomy (odds ratio [OR] 4.96, 95% confidence interval [CI] 1.97-12.51, P = 0.0007) and duration of PN in weeks (OR 2.37, 95% CI 1.56-3.60, P < 0.0001) as independent risk factors for PNALD. Preoperative exposure to PN was also associated with the development of PNALD; the risk of PNALD was 2.6 (95% CI 1.5-4.7; P = 0.001) times greater in patients with ≥ 4 weeks of preoperative PN compared with those with less preoperative PN use. Breast milk feedings, episodes of infection, and gestational age were not related to the development of PNALD.The incidence of PNALD is high in infants with NEC undergoing surgical treatment. Risk factors for PNALD are related to signs of NEC severity, including the need for small-bowel resection or proximal jejunostomy, as well as longer exposure to PN. Identification of these and other risk factors can help in the design of clinical trials for the prevention and treatment of PNALD and for clinical assessment of patients with NEC and prolonged PN dependence.

    View details for DOI 10.1097/MPG.0b013e31820e8396

    View details for Web of Science ID 000289671900018

    View details for PubMedID 21464752

  • ROLE OF IIEME OXYGENASE IN A MURINE MODEL OF EARLY NECROTIZING ENTEROCOLITIS Western Regional Meeting of the American-Federation-for-Medical-Research Schulz-Geske, S., Kalish, F. S., Jang, K. Y., Zhao, H., Huey, M., Vreman, H. J., Sylvester, K. S., Wong, R. J., Stevenson, D. K. LIPPINCOTT WILLIAMS & WILKINS. 2011: 126–27
  • Risk Factors for Intestinal Failure in Infants with Necrotizing Enterocolitis: A Glaser Pediatric Research Network Study JOURNAL OF PEDIATRICS Duro, D., Kalish, L. A., Johnston, P., Jaksic, T., Mccarthy, M., Martin, C., Dunn, J. C., Brandt, M., Nobuhara, K. K., Sylvester, K. G., Moss, R. L., Duggan, C. 2010; 157 (2): 203-U50


    To determine risk factors for intestinal failure (IF) in infants undergoing surgery for necrotizing enterocolitis (NEC).Infants were enrolled in a multicenter prospective cohort study. IF was defined as the requirement for parenteral nutrition for >or= 90 days. Logistic regression was used to identify predictors of IF.Among 473 patients enrolled, 129 had surgery and had adequate follow-up data, and of these patients, 54 (42%) developed IF. Of the 265 patients who did not require surgery, 6 (2%) developed IF (OR 31.1, 95% CI, 12.9 - 75.1, P < .001). Multivariate analysis identified the following risk factors for IF: use of parenteral antibiotics on the day of NEC diagnosis (OR = 16.61, P = .022); birth weight < 750 grams, (OR = 9.09, P < .001); requirement for mechanical ventilation on the day of NEC diagnosis (OR = 6.16, P = .009); exposure to enteral feeding before NEC diagnosis (OR=4.05, P = .048); and percentage of small bowel resected (OR = 1.85 per 10 percentage point greater resection, P = .031).The incidence of IF among infants undergoing surgical treatment for NEC is high. Variables characteristic of severe NEC (low birth weight, antibiotic use, ventilator use, and greater extent of bowel resection) were associated with the development of IF.

    View details for DOI 10.1016/j.jpeds.2010.02.023

    View details for Web of Science ID 000279871700011

    View details for PubMedID 20447649



    Urine-based proteomic profiling is a novel approach that may result in the discovery of noninvasive biomarkers for diagnosing patients with different diseases, with the aim to ultimately improve clinical outcomes. Given new and emerging analytical technologies and data mining algorithms, the urine peptidome has become a rich resource to uncover naturally occurring peptide biomarkers for both systemic and renal diseases. However, significant analytical hurdles remain in sample collection and storage, experimental design, data analysis, and statistical inference. This study summarizes, focusing on our experiences and perspectives, the progress in addressing these challenges to enable high-throughput urine peptidomics-based biomarker discovery.

    View details for DOI 10.1016/S0065-2423(10)51007-2

    View details for Web of Science ID 000281865700007

    View details for PubMedID 20857622

  • Clinical parameters do not adequately predict outcome in necrotizing enterocolitis: a multi-institutional study JOURNAL OF PERINATOLOGY Moss, R. L., Kalish, L. A., Duggan, C., Johnston, P., Brandt, M. L., Dunn, J. C., Ehrenkranz, R. A., Jaksic, T., Nobuhara, K., Simpson, B. J., McCarthy, M. C., Sylvester, K. G. 2008; 28 (10): 665-674


    Necrotizing enterocolitis (NEC) remains a major cause of neonatal morbidity and mortality. Some infants recover uneventfully with medical therapy whereas others develop severe disease (that is, NEC requiring surgery or resulting in death). Repeated attempts to identify clinical parameters that would reliably identify infants with NEC most likely to progress to severe disease have been unsuccessful. We hypothesized that comprehensive prospective data collection at multiple centers would allow us to develop a model which would identify those babies at risk for progressive NEC.This prospective, observational study was conducted at six university children's hospitals. Study subjects were neonates with suspected or confirmed NEC. Comprehensive maternal and newborn histories were collected at the time of enrollment, and newborn clinical data were collected prospectively, thereafter. Multivariate logistic regression analysis was used to develop a predictive model of risk factors for progression.Of 455 neonates analyzed, 192 (42%) progressed to severe disease, and 263 (58%) advanced to full feedings without operation. The vast majority of the variables studied proved not to be associated with progression to severe disease. A total of 12 independent predictors for progression were identified, including only 3 not previously described: having a teenaged mother (odds ratio, OR, 3.14; 95% confidence interval, CI, 1.45 to 6.96), receiving cardiac compressions and/or resuscitative drugs at birth (OR, 2.51; 95% CI, 1.17 to 5.48), and having never received enteral feeding before diagnosis (OR, 2.41; 95% CI, 1.08 to 5.52).Our hypothesis proved false. Rigorous prospective data collection of a sufficient number of patients did not allow us to create a model sufficiently predictive of progressive NEC to be clinically useful. It appears increasingly likely that further analysis of clinical parameters alone will not lead to a significant improvement in our understanding of NEC. We believe that future studies must focus on advanced biologic parameters in conjunction with clinical findings.

    View details for DOI 10.1038/jp.2008.119

    View details for Web of Science ID 000259675900003

    View details for PubMedID 18784730

  • Hepatotoxin-Induced Changes in the Adult Murine Liver Promote MYC-Induced Tumorigenesis PLOS ONE Beer, S., Komatsubara, K., Bellovin, D. I., Kurobe, M., Sylvester, K., Felsher, D. W. 2008; 3 (6)


    Overexpression of the human c-MYC (MYC) oncogene is one of the most frequently implicated events in the pathogenesis of hepatocellular carcinoma (HCC). Previously, we have shown in a conditional transgenic mouse model that MYC overexpression is restrained from inducing mitotic cellular division and tumorigenesis in the adult liver; whereas, in marked contrast, MYC induces robust proliferation associated with the very rapid onset of tumorigenesis in embryonic and neonatal mice.Here, we show that non-genotoxic hepatotoxins induce changes in the liver cellular context associated with increased cellular proliferation and enhanced tumorigenesis. Both 5-diethoxycarbonyl-1,4-dihydrocollidine (DDC) and carbon tetrachloride (CCl(4)) cooperate with MYC to greatly accelerate the onset of liver cancer in an adult host to less than 7 days versus a mean latency of onset of over 35 weeks for MYC alone. These hepatotoxin-enhanced liver tumors grossly and histologically resemble embryonic and neonatal liver tumors. Importantly, we found that MYC overexpression is only capable of inducing expression of the mitotic Cyclin B1 in embryonic/neonatal hosts or adult hosts that were treated with either carcinogen.Our results suggest a model whereby oncogenes can remain latently activated, but exposure of the adult liver to hepatotoxins that promote hepatocyte proliferation can rapidly uncover their malignant potential.

    View details for DOI 10.1371/journal.pone.0002493

    View details for Web of Science ID 000263280700056

    View details for PubMedID 18560566

  • Doxycycline sclerotherapy as primary treatment of head and neck lymphatic malformations in children JOURNAL OF PEDIATRIC SURGERY Nehra, D., Jacobson, L., Barnes, P., Mallory, B., Albanese, C. T., Sylvester, K. G. 2008; 43 (3): 451-460


    The authors report their experience with doxycycline sclerotherapy as primary treatment of head and neck lymphatic malformations (LMs) in children.A retrospective chart review was used to collect data on 11 patients treated with doxycycline sclerotherapy for LMs of the head and neck at our institution since 2003. Radiographic imaging allowed classification of patient LM as macrocystic, microcystic, or mixed according to previously published guidelines. Only patients with macrocystic or mixed lesions were offered doxycycline sclerotherapy. Radiographic imaging and physical examination were used to determine efficacy of treatment. After each treatment, the clinical and radiographic response was characterized as excellent (> or = 95% decrease in lesion size), satisfactory (> or = 50% decrease in volume and asymptomatic), or poor (< 50% decrease in volume or symptomatic).Eleven patients underwent a total of 23 sclerotherapies with an average of 2 treatments per patient (range, 1-4). All 7 patients with macrocystic lesions achieved complete clinical resolution with an average radiographic resolution of 93%. The 4 patients with mixed lesions achieved only partial clinical resolution and an average of 73% radiographic resolution. No patient experienced any adverse effects related to the treatment. At a median follow-up of 8 months, 2 patients (18%) experienced lesion recurrence in the setting of concomitant infection.Doxycycline sclerotherapy is safe and effective as a primary treatment modality for macrocystic and mixed LMs of the head and neck in the pediatric population.

    View details for DOI 10.1016/j.jpedsurg.2007.10.009

    View details for Web of Science ID 000254803500008

    View details for PubMedID 18358281

  • Hepatic parenchymal replacement in mice by transplanted allogeneic hepatocytes is facilitated by bone marrow transplantation and mediated by CD4 cells HEPATOLOGY Streetz, K. L., Doyonnas, R., Grimm, D., Jenkins, D. D., Fuess, S., Perryman, S., Lin, J., Trautwein, C., Shizuru, J., Blau, H., Sylvester, K. G., Kay, M. A. 2008; 47 (2): 706-718


    The lack of adequate donor organs is a major limitation to the successful widespread use of liver transplantation for numerous human hepatic diseases. A desirable alternative therapeutic option is hepatocyte transplantation (HT), but this approach is similarly restricted by a shortage of donor cells and by immunological barriers. Therefore, in vivo expansion of tolerized transplanted cells is emerging as a novel and clinically relevant potential alternative cellular therapy. Toward this aim, in the present study we established a new mouse model that combines HT with prior bone marrow transplantation (BMT). Donor hepatocytes were derived from human alpha(1)-antitrypsin (hAAT) transgenic mice of the FVB strain. Serial serum enzyme-linked immunosorbent assays for hAAT protein were used to monitor hepatocyte engraftment and expansion. In control recipient mice lacking BMT, we observed long-term yet modest hepatocyte engraftment. In contrast, animals undergoing additional syngeneic BMT prior to HT showed a 3- to 5-fold increase in serum hAAT levels after 24 weeks. Moreover, complete liver repopulation was observed in hepatocyte-transplanted Balb/C mice that had been transplanted with allogeneic FVB-derived bone marrow. These findings were validated by a comparison of hAAT levels between donor and recipient mice and by hAAT-specific immunostaining. Taken together, these findings suggest a synergistic effect of BMT on transplanted hepatocytes for expansion and tolerance induction. Livers of repopulated animals displayed substantial mononuclear infiltrates, consisting predominantly of CD4(+) cells. Blocking the latter prior to HT abrogated proliferation of transplanted hepatocytes, and this implied an essential role played by CD4(+) cells for in vivo hepatocyte selection following allogeneic BMT.The present mouse model provides a versatile platform for investigation of the mechanisms governing HT with direct relevance to the development of clinical strategies for the treatment of human hepatic failure.

    View details for DOI 10.1002/hep.22012

    View details for Web of Science ID 000252939500040

    View details for PubMedID 18220289

  • Wnt/beta-catenin signaling in murine hepatic transit amplifying progenitor cells GASTROENTEROLOGY Hu, M., Kurobe, M., Jeong, Y. J., Fuerer, C., Ghole, S., Nusse, R., Sylvester, K. G. 2007; 133 (5): 1579-1591


    Oval cells are postnatal hepatic progenitors with high proliferative potential and bipotent differentiation ability to become hepatocytes and cholangiocytes. Because Wnt/beta-catenin signaling is a known regulatory pathway for liver development and regeneration, we studied the role of Wnt signaling in oval cells using a mouse model of chronic liver injury.A 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC)-enriched diet was used to stimulate oval cell proliferation. Livers were harvested for histologic analysis and determination of Wnt family gene expression by quantitative reverse transcription-polymerase chain reaction and in situ hybridization. The transgenic beta-catenin reporter mouse (TOPGAL) was use to confirm canonical Wnt/beta-catenin signal transduction in proliferating oval cells within atypical ductal proliferations (ADPs). Confocal fluorescence microscopy and immunohistochemistry was used to confirm colocalization of beta-catenin with the oval cell antigen A-6.Several Wnt ligands were significantly induced in the liver of DDC-fed mice and localized to proliferating cells in and adjacent to the ADPs. Oval cells isolated from DDC-fed mouse livers showed the presence of active beta-catenin in the nucleus along with cell-cycle entry in response to purified Wnt3a in vitro. Moreover, Wnt3a-induced beta-catenin/T-cell factor/lymphoid enhancer factor (TCF/LEF) transcriptional activation was quantified by TCF/LEF luciferase reporter assays.From these data, we conclude that oval cells respond to Wnt ligands (Wnt3a) in vitro with an increase in amino-terminus dephosphorylated beta-catenin and cell-cycle entry and that canonical Wnt/beta-catenin/TCF signaling is active in proliferating facultative hepatic progenitor cells in vivo. These findings may lend insight to the consequences of increased canonical Wnt signaling during periods of chronic liver injury.

    View details for DOI 10.1053/j.gastro.2007.08.036

    View details for Web of Science ID 000250820100025

    View details for PubMedID 17983805

  • Evidence for canonical beta-catenin signaling in neuroblastomas 93rd Annual Clinical Congress of the American-College-of-Surgeons Ghole, S. A., Kuscuoglu, U., Hu, M., Jeong, Y. J., Sylvester, K. G. ELSEVIER SCIENCE INC. 2007: S66–S66
  • Stem cells: tissue regeneration and cancer. Seminars in pediatric surgery Tataria, M., Perryman, S. V., Sylvester, K. G. 2006; 15 (4): 284-292


    Regenerative medicine is the promised paradigm of replacement and repair of damaged or senescent tissues. As the building blocks for organ development and tissue repair, stem cells have unique and wide-ranging capabilities, thus delineating their potential application to regenerative medicine. The recognition that consistent patterns of molecular mechanisms drive organ development and postnatal tissue regeneration has significant implications for a variety of pediatric diseases beyond replacement biology. The observation that organ-specific stem cells derive all of the differentiated cells within a given tissue has led to the acceptance of a stem cell hierarchy model for tissue development, maintenance, and repair. Extending the tissue stem cell hierarchical model to tissue carcinogenesis may revolutionize the manner in which we conceptualize cancer therapeutics. In this review, the clinical promise of these technologies and the emerging concept of "cancer stem cells" are examined. A basic understanding of stem cell biology is paramount to stay informed of this emerging technology and the accompanying research in this area with the potential for clinical application.

    View details for PubMedID 17055959

  • Laparotomy versus peritoneal drainage for necrotizing enterocolitis and perforation NEW ENGLAND JOURNAL OF MEDICINE Moss, R. L., Dimmitt, R. A., Barnhart, D. C., Sylvester, K. G., Brown, R. L., Powell, D. M., Islam, S., Langer, J. C., Sato, T. T., Brandt, M. L., Lee, H., Blakely, M. L., Lazar, E. L., Hirschl, R. B., Kenney, B. D., Hackam, D. J., Zelterman, D., Silverman, B. L. 2006; 354 (21): 2225-2234


    Perforated necrotizing enterocolitis is a major cause of morbidity and mortality in premature infants, and the optimal treatment is uncertain. We designed this multicenter randomized trial to compare outcomes of primary peritoneal drainage with laparotomy and bowel resection in preterm infants with perforated necrotizing enterocolitis.We randomly assigned 117 preterm infants (delivered before 34 weeks of gestation) with birth weights less than 1500 g and perforated necrotizing enterocolitis at 15 pediatric centers to undergo primary peritoneal drainage or laparotomy with bowel resection. Postoperative care was standardized. The primary outcome was survival at 90 days postoperatively. Secondary outcomes included dependence on parenteral nutrition 90 days postoperatively and length of hospital stay.At 90 days postoperatively, 19 of 55 infants assigned to primary peritoneal drainage had died (34.5 percent), as compared with 22 of 62 infants assigned to laparotomy (35.5 percent, P=0.92). The percentages of infants who depended on total parenteral nutrition were 17 of 36 (47.2 percent) in the peritoneal-drainage group and 16 of 40 (40.0 percent) in the laparotomy group (P=0.53). The mean (+/-SD) length of hospitalization for the 76 infants who were alive 90 days after operation was similar in the primary peritoneal-drainage and laparotomy groups (126+/-58 days and 116+/-56 days, respectively; P=0.43). Subgroup analyses stratified according to the presence or absence of radiographic evidence of extensive necrotizing enterocolitis (pneumatosis intestinalis), gestational age of less than 25 weeks, and serum pH less than 7.30 at presentation showed no significant advantage of either treatment in any group.The type of operation performed for perforated necrotizing enterocolitis does not influence survival or other clinically important early outcomes in preterm infants. ( number, NCT00252681.).

    View details for Web of Science ID 000237758900004

    View details for PubMedID 16723614

  • Absence of the p53 tumor suppressor gene promotes osteogenesis in mesenchymal stem cells 57th Annual Meeting of the American-Academy-of-Pediatrics Tataria, M., Quarto, N., Longaker, M. T., Sylvester, K. G. W B SAUNDERS CO-ELSEVIER INC. 2006: 624–32


    Osteosarcoma arises predominantly in the metaphyseal growth plate of children during the growth spurt years. These tumors develop during physiological growth from an expanding cell population, suggesting that the transformed cell is a bone-forming progenitor. An absence of the p53 oncogene has been implicated in the origin and progression of osteosarcoma, and because mesenchymal stem cells (MSCs) are the physiological osteogenic progenitor cell population, we hypothesized that a p53-/- mutation would enhance bone differentiation of MSC in a mouse model of in vitro osteogenesis.Clonal MSC populations were derived from p53-/- mice. P53-/- and wild-type cells were placed in osteogenic culture and assessed via Alizarin Red quantification and alkaline phosphatase staining. The osteogenic marker genes Cbfa1, osteopontin, and osteocalcin were assessed by quantitative real time polymerase chain reaction during differentiation.Bone nodule formation and alkaline phosphatase staining was accelerated and enhanced in the p53-/- cells. The early and intermediate osteogenic markers, Cbfa1 and osteopontin, were upregulated in p53-/- MSCs compared with wild-type cells during osteogenesis. The terminal osteogenic marker gene osteocalcin was paradoxically lower in p53-/- MSCs indicating impaired terminal differentiation.The p53-/- mutation enhances and accelerates early osteogenesis in MSCs, but prevents terminal differentiation toward a mature osteocyte phenotype. These findings may have important implications for the regulation of the MSC compartment during the derivation of osteosarcoma in children.

    View details for DOI 10.1016/j.jpedsurg.2005.12.001

    View details for Web of Science ID 000237015800002

    View details for PubMedID 16567167

  • Repair and regeneration: opportunities for carcinogenesis from tissue stem cells JOURNAL OF CELLULAR AND MOLECULAR MEDICINE Perryman, S. V., Sylvester, K. G. 2006; 10 (2): 292-308


    This review will discuss the mechanisms of repair and regeneration in various tissue types and how dysregulation of these mechanisms may lead to cancer. Normal tissue homeostasis involves a careful balance between cell loss and cell renewal. Stem and progenitor cells perform these biologic processes as the functional units of regeneration during both tissue homeostasis and repair. The concept of tissue stem cells capable of giving rise to all differentiated cells within a given tissue led to the concept of a cellular hierarchy in tissues and in tumors. Thus, only a few cells may be necessary and sufficient for tissue repair or tumor regeneration. This is known as the hierarchical model of tumorigenesis. This report will compare this model with the stochastic model of tumorigenesis. Under normal circumstances, the processes of tissue regeneration or homeostasis are tightly regulated by several morphogen pathways to prevent excessive or inappropriate cell growth. This review presents the recent evidence that dysregulation of these processes may provide opportunities for carcinogenesis for the long-lived, highly proliferative tissue stem cell population. New findings of cancer initiating tissue stem cells identified in several solid and circulating cancers including breast, brain and hematopoietic tumors will also be reviewed. Finally, this report reviews the cellular biology of cancer and its relevance to the development of more effective cancer treatment protocols.

    View details for Web of Science ID 000239799000005

    View details for PubMedID 16796800

  • Multipotent progenitors from MSCs are regulated by Wnt/beta-catenin signaling 91st Annual Clinical Congress of the American-College-of-Surgeons Tataria, M., Ailles, L., Jenkins, D., Longaker, M. T., Weissman, I., Sylvester, K. ELSEVIER SCIENCE INC. 2005: S45–S45
  • Cell therapy for hepatocyte replacement through bone marrow derived myelomonocytic progenitors 91st Annual Clinical Congress of the American-College-of-Surgeons Sylvester, K. G., Jenkins, D., Streetz, K., Doyannis, R., Perryman, S., Kay, M., Blau, H. ELSEVIER SCIENCE INC. 2005: S47–S48
  • The role of injury on the long-term expression of a hepatocyte transgene from bone marrow 91st Annual Clinical Congress of the American-College-of-Surgeons Perryman, S. V., Jenkins, D., Streetz, K., Doyonnas, R., Sylvester, K. ELSEVIER SCIENCE INC. 2005: S89–S89
  • Donor-derived, liver-specific protein expression after bone marrow transplantation TRANSPLANTATION Jenkins, D. D., Streetz, K., Tataria, M., Sahar, D., Kurobe, M., Longaker, M. T., Kay, M. A., Sylvester, K. G. 2004; 78 (4): 530-536


    Bone marrow transplantation (BMT) may represent a novel mechanism to deliver a functional gene to a deficient liver. Bone marrow-derived hepatocytes are rare and without a defined contribution to liver function. Consequently, the clinical significance of BMT to treat liver disease is unclear. We sought to quantify bone marrow-derived hepatocyte protein expression after BMT and determine whether the process is inducible with liver injury.Mice transgenic for human alpha-1 antitrypsin (hAAT) under a hepatocyte-specific promoter were used as bone marrow donors. Adenoviral transduction of modified urokinase plasminogen activator (Ad-muPA) was used to induce liver injury. Eight weeks after lethal irradiation and BMT, recipients were stratified into two groups: BMT alone (n = 5) and BMT + Ad-muPA (n= 10). Both groups of animals were bled before (t = 0) and at 2, 4, 8, and 16 weeks after Ad-muPA administration, and the serum samples were assessed for hAAT by enzyme-linked immunosorbent assay.Transgenic donor mice expressed 5 to 10 mg/mL of hAAT. Recipients of BMT alone expressed less than 80 ng/mL of hAAT over all time periods. Animals receiving BMT + Ad-muPA showed sustained and stable hAAT expression of approximately 200 ng/mL. Differences were statistically significant at each time point.Serum protein levels from liver-specific transgene expression are detectable and persist after BMT. Expression is low, but inducible with liver injury. We are currently developing strategies to augment donor-derived, liver-specific protein expression after BMT.

    View details for DOI 10.1097/01.TP.0000130180.42573.BI

    View details for Web of Science ID 000223486500008

    View details for PubMedID 15446311

  • Functional measurement of fusion in the liver after bone-marrow transplantation over time 39th Annual Meeting of the European-Association-for-the-Study-of-the-Liver Streetz, K. L., Jenkins, D., Longaker, G., Sylvester, K., Kay, M. A. ELSEVIER SCIENCE BV. 2004: 109–109
  • Hepatocyte targeting for quantifiable and functional cellular transplantation 89th Annual Clinical Congress of the American-College-of-Surgeons Jenkins, D. D., Streetz, K., Kay, M., Longaker, M., Sylvester, K. ELSEVIER SCIENCE INC. 2003: S15–S15