Monday 14 November 2016

Paper Critique

Multiple independent appearances of the cecal appendix in mammalian evolution and an investigation of related ecological and anatomical factors.

Heather F. Smith, William Parker, Sanet H. Kotze, Michel Laurin.


Objectives

In this paper, scientists attempted to determine whether the presence of an appendix is correlated with other anatomical and ecological variables and to also obtain an accurate estimate of how many times the appendix evolved. The hypothesis was that the evolution of the appendix in animals was not associated with a decreasing cecum size as was previously assumed but instead associated with particular aspects of social behaviours or dietary factors which might increase the survival of advantageous intestinal bacteria.

Materials and Methods

The first step involved data compilation using a broad literature search of published studies on mammalian gastrointestinal anatomy. In order to correlate the presence of an appendix with ecological and anatomical variables, anatomical data was compiled at the species level. The anatomical data compiled were:
  • appendix presence and length
  • cecal size and morphology
  • colon length
  • presence of colonic separation mechanisms
  • stomach histological lining (either entirely glandular or some squamous epithelium)
This data was compiled from 361 species from all major mammalian clades.

In order to correlate the presence of an appendix with dietary factors, data on the dietary categories of the species was compiled. In addition, data on the activity pattern, body mass and mean social group size for each species was obtained. Scientists also collected data on whether each species practiced coprophagia: the regular eating of any type of feces in sufficient amounts to contribute to the nutrition of the animal.

Scientists scored diet type into a binary character in which state 0 represents a cellulose-poor diet (including carnivory, insectivory, omnivory and frugivory) and state 1 represents cellulose-rich diet (including folivory, granivory and gummivory).

In order to identify the cecal appendix in animals, the cecal appendix was defined as a narrow, close-ended extension off the apex of the cecum with a distinct change in diameter of the lumen between it and the cecum. To determine whether the cecal appendix was more frequently found in combination with any particular cecal shape, the cecal morphology was characterized according to the following states: 0, cecum absent; 1, appendix-like; 2, spherical; 3, cylindrical; 4, tapering; 5, spiral; 6, paired.

To compare the relative sizes of the various parts of the digestive system in each of the 361 species, scientists divided linear measurements by the cubic root of body mass estimates they collected from literature.

A phylogenetic tree was constructed which includes 361 animal species representing all mammalian clades. The tree contained 19 polytomies (nodes) each with three to thirteen daughter branches.

Scientists in this study had both pairwise and continuous data therefore Pairwise Comparison tests were used to effectively evaluate the association between two changes in variables. All tests of correlations were made using pairwise comparison.

Scientists in the study also used the process of Parsimony Optimization: a procedure which minimizes the changes on a tree to account for character state distribution.

To compare the evolutionary rates of the appendix in various clades in the phylogenetic tree, scientists divided the number of inferred transitions (using parsimony) in each clade by that clade's sampled phylogenetic diversity index. The phylogenetic diversity index was calculated using the Stratigraphic Tools of Mesquite.


Results

Appendix Presence

Of the 361 mammalian species sampled, 50 were found to have a cecal appendix. Several morphologies of the appendix were also found, see figure 1 for examples. Species in the clades Metatheria and Euarchontoglires were found to have an appendix. While species in the clade Laurasiatheria were found not to contain an appendix.

Source: H.F. Smith et al. / C. R. Palevol 12 (2013) 339–354.

Figure 1: The morphology of the cecal appendix in a variety of mammals. The black line indicates the approximate boundary of the appendix. (A) Human, Homo sapiens; (B) Orangutan, Pongo pygmaeus; (C) Southern hairy-nosed wombat, Lasiorhinus latofrons; (D) Echidna, Tachyglossus aculeatus; (E) Platypus, Ornithorhynchus anatinus; (F) Rabbit, Oryctolagus cuniculus; (G) Ground cuscus, Phalanger gymnotis; (H) Common brush-tail possum, Trichosurus vulpecula; (I) Cape dune mole-rat, Bathyergus suillus; (J) Brush-tailed porcupine, Atherurus africanus; (K) Beaver, Castor canadensis; (L) Koala, Phascolarctos cinereus; (M) Florida manatee, Trichechus manatus. 

As seen in Figure 1, various morphologies of the cecal appendix were present:

  • Appendix-like as seen in C, D and E
  • Spherical as seen in A, B and J
  • Cylindrical as seen in I, K and M
  • Tapering as seen in F, G, H and L
  • Spiral and Paired morphologies were not pictured

Phylogenetic Signal

Table 1 shows the probability that the co-variation between character and phylogeny is random, this was assessed by comparing the number of steps (for discrete characters) or squared length (for continuous characters) over the reference tree to a population of 1000 random trees. Table 1 also shows the False Discovery Rate (FDR) threshold; the corrections for multiple testing were done through the False Discovery Rate. The sample size is the number of species in which the character is scored.

Source: H.F. Smith et al. / C. R. Palevol 12 (2013) 339–354.

Table 1: Phylogenetic Signal in the analyzed characters. 


The results show that most characters analyzed displayed a strong phylogenetic signal that is the characters analyzed are strongly related to the phylogenies constructed. This confirms that phylogeny-based analysis such as pairwise comparisons are required to assess any correlations between the characters. The results also confirm that parsimony optimizations can reliably be used to infer character history.

Correlation between the evolution of the appendix and the evolution of other characters

Initially, Darwin suggested that the appearance of the hominoid appendix occurred simultaneously with the decrease in cecum size and a shift from folivory to frugivory, that is a decrease in cellulose consumption in the diet (Darwin, 1871).

The results from parsimony optimization confirms that the appearance of the appendix in hominoids is associated with a decrease in cecum size. However, no statistical test was performed to assess the probability that this association is random. These changes were also not associated with changes in the state of cellulose richness in the diet or changes in cellulose digestion.

In mammals, the only pattern consistent with Darwin's hypothesis occurs only in Trichechus manatus. Some catarrhine primates (especially hominoids) exhibit the predicted combination of an appendix accompanying a small cecum

Darwin's hypothesis predicts a reverse relationship between size of the appendix and cecum in mammals however scientists found a fairly strong positive correlation (P=0.005) between changes in the relative lengths of the appendix, cecum and colon in mammals.

Based on the results of parsimony optimization of appendix presence and cecum presence and size, the suggestion that appendix appearance is linked to a decrease in cecum size within mammals is refuted. Based on this, the scientists reconstructed the ancestral mammal and monotreme to have a small cecum. 

Association between various characters and the evolution of the cecal appendix

The scientists tested the relationship between appendix and colon size, and between cecum and colon size in order to evaluate other relationships which might provide insight into the evolution of the morphology of the proximal colon. 

The results showed that all three parts of the digestive system were positively correlated with each other. The correlation between the cecum and colon length was the strongest (P<0.001), whereas the correlation between the appendix and colon was the weakest (P=0.0170) although still significant. These correlations hold partly because most species without an appendix appear to have a smaller colon and cecum than species with an appendix. However, the scientists were not able to determine whether the correlation holds true within species with an appendix due to the small sample size.

The results of the pairwise comparison test revealed no statistically significant correlations between changes in the appendix and changes in colonic separation mechanisms, cellulose in the diet, stomach wall histological composition or cecal haustrations (small pouches which give the colon a segmented appearance) during the course of evolution.

The results also showed that highly social animals living in large groups and/or diurnal animals do not appear to be more likely to have an appendix compared to species living in small groups.

Rate of evolution of the cecal appendix


Source: H.F. Smith et al. / C. R. Palevol 12 (2013) 339–354.

Table 2: Evolutionary rates of the appendix in several major mammalian clades

As seen in the results in Table 2, the appendix was found to have undergone 38 evolutionary events, including 32 to 38 gains and a maximum of six losses. The scientists interpreted the trend towards the appearance of an appendix as providing support to the hypothesis that the appendix is selectively advantageous to most mammals because if it were selectively neutral, losses should be about as common as gains.

The scientists concluded that the appendix is unlikely to serve any digestive function due to its small and narrow structure. Furthermore, it was difficult to support an other evolutionary scenario beyond its function as an immune structure.


In conclusion, the scientists concluded that the evolution of the appendix does not appear to be strictly tied to individual factors such as changes in diet, sociality or cecal-reduction across all clades. Although there were some caveats for this conclusion, such as:

  • The scientists used group size as a measure of sociality; however group size alone does not capture all aspects of sociality.
  • The considerations of dietary intake do not take into account other important aspects of digestion such as the efficiency of energy extraction from ingested food.
Nevertheless, the scientists interpreted the trend towards the appearance of the appendix as providing support to the hypothesis that the appendix is selectively advantageous in most mammalian taxa because if it were selectively neutral, losses should be about as common as gains.

Critique

This paper by Smith et al. was very well structured. The introduction, materials and methods, results, discussion and conclusion were well formatted and easy to follow. All the figures were adequate for the results obtained. However, in the figures for the phylogeny trees shown in the paper, the species names were very hard to see which made it difficult to follow what was going on. Furthermore, the figures of the phylogeny trees were not thoroughly explained which made it even more difficult to understand the results obtained.

Most of the results from this paper were made using statistical analysis. Although this is a reliable means of interpreting data, it is difficult for readers without an advanced statistical knowledge to understand this paper.

In terms of the methods used in this experiment, the data used was from a compilation of a broad literature search of published studies. This led to some missing details as there was some data currently missing in the database. This led to a lack of power (the probability that the test correctly rejects the null hypothesis (H0) when the alternative hypothesis (H1) is true) in the statistical analysis. In particular, the lack of power was shown to affect a few of the tests, especially those concerning the concentration of lymphoid tissue in the cecum and appendix, colonic separation mechanism and coprophagia. The scientists however did note this and stated that the inclusion of additional species and additional data in the future could reveal patterns which were undetected by the present analysis.

Overall, the experiments seemed to be well conducted in this paper. However, there are a few things which the authors could have done differently. For example, in the results from parsimony optimization,  no statistical test was performed to assess the probability that the association of the appearance of the appendix in hominoids along with a decrease in cecum size was random. In the future, perhaps the authors could statistically assess this probability. Additionally, the scientists were not able to determine whether the correlation between appendix and colon size, and between cecum and colon size holds true within animals in a species due to the small sample size. In the future, a larger sample size could be used.

The authors also refuted Darwin's hypothesis of the appendix however I do not think that the scientists can confidently refute this hypothesis. In this study, hominoids were found to possess an appendix associated with a small cecum, this pattern is consistent with Darwin's hypothesis. A similar pattern was not observed in other mammalian clades, this indicates that Darwin's hypothesis cannot be applied to other clades. However, it is important to note that Darwin formulated his hypothesis regarding the evolution of the appendix based on his observations in humans and other hominoids; therefore Darwin's hypothesis is partly correct as the results of this study seem to corroborate the first half of his hypothesis. It would have been more appropriate for the scientists to not completely refute his hypothesis but instead to modify it to be more inclusive of other mammalian clades.

In conclusion, although the results of this paper refute the hypothesis that the evolution of the appendix is associated with individual factors such as particular aspects of diet, social behaviours or dietary factors. In the future, perhaps scientists could test the possibility that some combinations of these could have a significant effect or test other factors which are equally as important.

References

Darwin, C. (1871). The descent of man and selection in relation to sex. John Murray, London.

Smith, H., Parker, W., Kotzé, S. H., & Laurin, M. (2013). Multiple independent appearances of the cecal appendix in mammalian evolution and an investigation of related ecological and anatomical factors. Comptes Rendus - Palevol, 12(6): 339-354.







Tuesday 25 October 2016

My Favorite Organ: The Human Appendix

The origin of the Appendix


Figure 1: The Location of the Appendix within the Abdomen

     The origin of the appendix was first discussed by Charles Darwin in his book: "The Descent of Man and Selection in Relation to Sex". According to Darwin, the shift from a predominantly herbivorous ancestor to a descendant which became less reliant on cellulose rich plants for energy and thus required less fermentation led to a reduction in the size of the cecum which in turn led to the appearance of the appendix. According to Darwin, humans evolved from having a large cecum without an appendix to a having a small cecum with an appendix, he formulated this hypothesis based on his observations of humans and other hominoids (Darwin, 1871).
     However, a recent study has demonstrated two problems with this hypothesis. First, several living species such as lemurs, certain rodents and certain flying squirrels still have an appendix attached to a large cecum which is still being used in digestion (Smith et al., 2013). Second, during Darwin's time, the presence of an appendix had not yet been documented in many nonhuman taxa. However, recent discoveries have shown that the appendix is actually widespread in nature; the study found that more than 70 percent of all primate and rodent groups contain species with an appendix (Smith et al., 2013).
     Based on database from 361 mammalian species, the study showed that the appendix has evolved minimally 32 times but has been lost fewer than seven times (Smith et al., 2013). Therefore, according to scientists, the appendix is more than just an evolutionary remnant. A new hypothesis has been developed which states that the appendix evolved as a microbial safe-house under selection pressure from gastrointestinal pathogens transmitted via a wide range of mechanisms as opposed to the mechanism put forth by Charles Darwin (Smith et al., 2013).


The Structure of the Human Appendix

The human appendix also known as the 'vermiform appendix' or 'cecal appendix' is located in the right lower quadrant of the abdomen, it is a narrow, worm-shaped tube arising from the cecum.The length of the appendix usually ranges from 2-20cm, with an average length of 9cm. The opening of the appendix occasionally contains a semicircular fold of mucous membrane known as the Gerlach's valve (Golalipour et al., 2003) .


Figure 2: A narrow worm-shaped appendix arisimg from the cecum



Fun Fact! The Guinness World Record (2006) for the longest appendix ever removed measured at 26cm (10.24 inches). It was removed from a 72 year old man named Safranco August from Croatia during an autopsy. However, doctors have recently removed a 27 cm long appendix from a 15 year Kenyan girl in 2015. See video below.



The base of the appendix is attached to the posteromedial surface of the cecum about 2cm or less below the end of the ileum, this attachment is seen across species. However, the tip of the appendix could be retrocecal, pelvic, subcecal, pre-ileal or post-ileal in position (Golalipour et al, 2003). See the various positions of the appendix below:

Figure 3: The various positions in which the tip of the appendix be found
Source: By Grant, John Charles Boileau - An atlas of anatomy, / by regions 1962, Public Domain, https://commons.wikimedia.org/w/index.php?curid=41038416


The appendix is connected to the lower part of the ileal mesentery by a short mesoappendix . The mesoappendix contains blood vessels such as the appendicular artery and appendicular vein. In addition, the mesoappendix also contains sympathetic and parasympathetic nerves from the superior mesenteric plexus and lymph follicles which first appear about 2 weeks after birth (Golalipour et al., 2003). The epithelial lining of the appendix contains a surface coat of immunoglobulins which are involved in immune surveillance (Golalipour et al., 2003).



Figure 4: The appendicular artery which is contained within the mesoappendix
Source: By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below) Bartleby.com: Gray's Anatomy, Plate 536, Public Domain, https://commons.wikimedia.org/w/index.php?curid=541393

The function of the Human Appendix

   The function of the appendix was first discussed by Charles Darwin. According to Darwin, the human appendix lacked an important biological function. Despite its location in the intestinal tract, the size and structure made it incapable of participating in any notable degree in digestion (Darwin, 1871). However, recent studies have begun to show that the human appendix actually functions as a safe house for beneficial bacteria with the capacity to re-inoculate the gut following the depletion of the normal flora after diarrheal illness (Smith et al., 2009). The identification of this function was based on a number of observations such as:

  • The size, shape and location of the appendix: The anatomical location of the appendix is in isolation from the main flow of the digestive tract and the narrow lumen of the appendix makes it suitable for inoculation of the gut and for avoidance of contamination by pathogens which might affect the main fecal stream (Smith et al., 2009; Smith et al., 2013).
  • The appendix is associated with large amounts of Gut Associated Lymphoid Tissue (GALT) which is involved in the immune response (Smith et al., 2013). In addition, the immune system supports the growth of microbial biofilms in the large intestine, furthermore it was observed that these microbial biofilms are in constant state of growth and shedding (Smith et al., 2009). These discoveries support the hypothesis that the appendix functions as a safe house.
  • Diarrhoeal illness has a large biological impact in the absence of modern medicine, clean drinking water and sewage systems. Furthermore, the occurrence of Appendicitis has been associated with modern medicine and hygiene (Smith et al., 2009). These observations suggest that the presence of an appendix may be important for survival following diarrheal disease.
   Based on these observations, it was concluded by Bollinger et al., 2007 that the apparent function of the human appendix is to serve as a safe house for maintenance of beneficial symbiotic gut bacteria. Therefore, when the intestine becomes infected with a pathogenic species of bacteria and a diarrheal response develops in which feacal matter is rapidly flushed from the colon; the appendix which serves as a source of normal gut bacteria can help to inoculate the gut with its normal bacteria flora (Bollinger et al., 2007; Smith et al., 2009). Furthermore, this rapid replacement of the gut bacterial flora is critical for survival in an environment where diarrheal illness, a lack of water and lack of nutrition is common (Smith et al., 2009).


The Histology of the Human Appendix



Figure 5: A Histological Cross Section of the Appendix


The Human Appendix is composed of four layers which are characteristic of organs found in the gastrointestinal system: mucosa, submucosa, muscularis externa and serosa.




Figure 6: The Four Layers of the Appendix

      The Mucosa

The epithelium of the mucosa contains:
  • Absorptive Cells: Also known as enterocytes, they are simple columnar cells with microvilli (or brush border)
Figure 7: The Absorptive Cells of the Mucosa
  • M-cells: Also known as Micro-Fold Cells, they cover lymph nodules and have small folds on their surface. This differentiates them from absorptive cells which have microvilli.
Figure 8: The M-Cells of the Mucosa

  • Goblet Cells: They secrete mucus for lubrication.
Figure 9: The Goblet Cells of the Mucosa
  • Lamina Propria: This underlies the epithelium and contains intestinal glands also known as Crypts of Lieberkuhn. These glands are lined with simple columnar epithelium, are less developed, shorter and are spaced further apart than those of the colon.
Figure 10: The Lamina Propria with crypts of lieberkuhn embedded within it
  • Lymph Nodules: These nodules are abundant and are also present within the submucosa.
Figure 10: The Lymph Nodules contained within the submucosa
  • Muscularis mucosa: This is a layer of smooth muscle which separates the mucosa from the submucosa.
Figure 11: The muscularis mucosa of the mucosa layer

The Submucosa

The submucosa contains numerous blood vessels and lymph nodules. These lymph nodules contain germinal centers, they originate in the lamina propria and may extend from the surface epithelium into the submucosa.

Figure 12: The submucosa of the human appendix showing lymph nodules

The Muscularis Externa

The muscularis externa consists of two layers of smooth muscle: the inner circular layer and the outer longitudinal layer. Between these two layers is the parasympathetic ganglia of the myenteric plexus.


Figure 13: The muscularis externa of the human appendix

The Serosa

The serosa covers the outer surface of the appendix and contain adipose cells.


Figure 14: The Serosa of the human appendix

Pathologies of the Human Appendix

Appendicitis

Appendicitis occurs when the appendix is inflamed. The appendix often becomes infected and can sometimes rupture. Appendicitis causes pain in the lower right part of the abdomen (where the appendix is located) and is usually accompanied with nausea and vomiting (Hoffman, WedMD.com).



Figure 15: An Inflammed Appendix
Source: By Ed Uthman from Houston, TX, USA - Acute Appendicitis, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=1656138

Acute appendicitis is characterized histologically by neutrophils in the muscularis propria as seen below:

Figure 16: A histological section of an inflammed appendix showing neutrofils in the muscularus propria 
Source: By Nephron - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=15375467

Tests to determine Appendicitis

  • Physical examination of the abdomen enables physicians to tell if appendicitis is present and how far it has progressed.
  • CT scan (Computed Tomography): Using x-rays, a CT-scan can show if the appendix is inflamed and can also determine whether it has ruptured.
  • Ultrasound: Utilizes sound waves to detect any signs of appendicitis.
  • Complete Blood Count (CBC): An increased number of white blood cells is a sign of infection and inflammation.
  • Other imaging procedures such as MRI (Magnetic Resonance Imaging) and X-rays can also detect signs of appendicitis.

Treatment of Appendicitis

The treatment of appendicitis usually involves antibiotics to treat infections along with an appendectomy which involves surgical removal of the appendix.

Appendectomy

Traditional/Open Appendectomy

An open appendectomy also known as a laparotomy involves removal of the infected appendix through a single large incision in the lower right portion of the abdomen. The incision in a laparotomy is usually 2 to 3 inches (51 to 76 mm) long(Appendicitis, niddk.nih.gov). Below is an example of an open appendectomy surgical procedure:


Laparoscopic Appendectomy

This involves making three to four incisions in the abdomen. A special surgical tool known as a laparoscope which is connected to a monitor outside the patient's body is inserted into one if the incisions. The other incisions are used for removing the appendix using surgical instruments. This procedure leads to less post-operative pain for the patient (Appendicitis, niddk.nih.gov). Below is a video of a laparoscopic appendectomy procedure: 



More recently, doctors have started to remove the appendix using our natural orifices such as the mouth, urethra, vagina and rectum as a way to avoid incisions and scarring from surgery. See the video below for more information:




Fun Fact! 

 In 1961, Soviet surgeon Leonid Rogozov performed an appendectomy on himself while stuck in Antartica. Follow the link for more details:
 http://www.theatlantic.com/technology/archive/2011/03/antarctica-1961-a-soviet-surgeon-has-to-remove-his-own-appendix/72445/      






References

Darwin, C. (1871). The descent of man and selection in relation to sex. John Murray, London.

Smith, H., Parker, W., Kotzé, S. H., & Laurin, M. (2013). Multiple independent appearances of the cecal appendix in mammalian evolution and an investigation of related ecological and anatomical factors. Comptes Rendus - Palevol, 12(6): 339-354.

Golalipour, M.J., Arya, B., Jahanshahi, M., Azarhoosh, R. (2003). Anatomical Variations of Vermiform Appendix in South-East Caspian Sea. Anat. Soc. India. 52(2): 141-143.

Guiness World Record: http://www.guinnessworldrecords.com/world-records/largest-appendix-removed

Smith, H., Fisher, R., Everett, M., Thomas, A., Randal Bollinger, R., & Parker, W. (2009). Comparative anatomy and phylogenetic distribution of the mammalian cecal appendix. Journal of Evolutionary Biology, 22(10), 1984-1999.

Bollinger, R.B., Barbas, A.S., Bush, E.L., Lin, S.S. & Parker, W. (2007). Biofilms in the large bowel suggest an apparent function of the human vermiform appendix. J. Theor. Biol. 249: 826– 831.

Hoffman, M. Appendix. Retrieved 25 October, 2016 from http://www.webmd.com/digestive-disorders/picture-of-the-appendix.

"Appendicitis". National Institute of Diabetes and Digestive and Kidney Diseases. U.S Department of Health and Human Services. Retrieved 2010-02-01. https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/appendicitis/Pages/treatment.aspx.