Accumulation of Cytochrome b558 at the Plasma Membrane: Hallmark of Oxidative Stress in Phagocytic Cells.

Neutrophils play a very key role in the human immune defense against pathogenic infections. The predominant players in this role during the activation of neutrophils are the release of cytotoxic agents stored in the granules and secretory vesicles and the massive production of reactive oxygen species (ROS) initiated by the enzyme NADPH oxidase. In addition, in living organisms, cells are continuously exposed to endogenous (inflammations, elevated neutrophil presence in the vicinity) and exogenous ROS at low and moderate levels (travels by plane, radiotherapy, space irradiation, blood banking, etc.). To study these effects, we used ROS induced by gamma radiation from low (0.2 Gy) to high (25 Gy) dose levels on PLB-985 cells from a myeloid cell line differentiated to neutrophil-like cells that are considered a good alternative to neutrophils. We determined a much longer lifetime of PLB-985 cells than that of neutrophils, which, as expected, decreased by increasing the irradiation dose. In the absence of any secondary stimulus, a very low production of ROS is detected with no significant difference between irradiated and non-irradiated cells. However, in phagocytosing cells, irradiation doses above 2 Gy enhanced oxidative burst in PLB-985 cells. Whatever the irradiation dose, NADPH oxidase devoid of its cytosolic regulatory units is observed at the plasma membrane in irradiated PLB-985 cells. This result is different from that observed for irradiated neutrophils in which irradiation also induced a translocation of regulatory subunits suggesting that the signal transduction mechanism or pathway operate differently in both cells.

Pre-existing diabetes is a risk factor for increased rates of cellular rejection after kidney transplantation: an observational cohort study.

AIM: To investigate whether people with diabetes have an elevated risk of kidney allograft rejection in a well characterized clinical cohort in the setting of contemporary immunosuppression. METHODS: We conducted a retrospective cohort study including all kidney allograft recipients at a single centre between 2007 and 2015, linking clinical, biochemical and histopathological data from electronic patient records. RESULTS: Data were analysed for 1140 kidney transplant recipients. The median follow-up was 4.4 years post-transplantation, and 117 of the kidney transplant recipients (10.2%) had diabetes at time of transplantation. Kidney allograft recipients with vs without diabetes were older (53 vs 45 years; P<0.001) and more likely to be non-white (41.0% vs 26.4%; P=0.001). Kidney allograft recipients with vs without diabetes had a higher risk of cellular rejection (19.7% vs 12.4%; P=0.024), but not of antibody-mediated rejection (3.4% vs 3.7%; P=0.564). Graft function and risk of death-censored graft loss were similar in the two groups, but kidney allograft recipients with diabetes had a higher risk of death and overall graft loss than those without diabetes. In a Cox regression model of non-modifiable risk factors at time of transplantation, diabetes was found to be an independent risk factor for cellular rejection (hazard ratio 1.445, 95% CI 1.023-1.945; P=0.042). CONCLUSIONS: Kidney allograft recipients with diabetes at transplantation should be counselled regarding their increased risk of cellular rejection but reassured regarding the lack of any adverse impact on short-to-medium term allograft function or survival.

Transplantation of Declined Liver Allografts Following Normothermic Ex-Situ Evaluation.

The demand for liver transplantation (LT) exceeds supply, with rising waiting list mortality. Utilization of high-risk organs is low and a substantial number of procured livers are discarded. We report the first series of five transplants with rejected livers following viability assessment by normothermic machine perfusion of the liver (NMP-L). The evaluation protocol consisted of perfusate lactate, bile production, vascular flows, and liver appearance. All livers were exposed to a variable period of static cold storage prior to commencing NMP-L. Four organs were recovered from donors after circulatory death and rejected due to prolonged donor warm ischemic times; one liver from a brain-death donor was declined for high liver function tests (LFTs). The median (range) total graft preservation time was 798 (range 724-951) min. The transplant procedure was uneventful in every recipient, with immediate function in all grafts. The median in-hospital stay was 10 (range 6-14) days. At present, all recipients are well, with normalized LFTs at median follow-up of 7 (range 6-19) months. Viability assessment of high-risk grafts using NMP-L provides specific information on liver function and can permit their transplantation while minimizing the recipient risk of primary graft nonfunction. This novel approach may increase organ availability for LT.

Stoma siting and the 'arcuate line' of Douglas: might it be of relevance to later herniation?

AIM: Preoperative stoma site marking aims to select an appropriate location for stoma positioning but there are no fixed anatomical points of reference. A stoma raised below the arcuate line (AL) of the posterior rectus sheath may be a contributing factor to later herniation. METHOD: The patients' preferred position for a stoma was marked preoperatively by a nurse stomatherapist in 75 unselected cases. The position of the AL was determined in relation to standard anatomical landmarks (umbilicus, xiphoid process, pubic symphysis and the anterior superior iliac spines). RESULTS: The proportion of patients whose stoma trephine was sited below the AL varied with the anatomical landmark examined. Measurements of symphysis pubis to xiphoid process or height above the iliac spines revealed 36-41% of chosen sites were at or below the AL. In 16 of 29 (55%) women the marked sites were at or below the AL. Of 44 patients who had their site marked above the AL, 23 (53%) were within 2 cm of the AL. In obese patients and those with a waist circumference greater than 100 cm over 50% had their site marked at or within 2 cm of the AL. CONCLUSION: To ensure a stoma site is above the AL of the posterior rectus sheath its centre should be at least 4 cm above a horizontal line between the anterior superior iliac spines. This might reduce later herniation rates.

'Treatment of the sportsman's groin': British Hernia Society's 2014 position statement based on the Manchester Consensus Conference.

INTRODUCTION: The aim was to produce a multidisciplinary consensus to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of Sportsman's groin (SG). METHODS: Experts in the diagnosis and management of SG were invited to participate in a consensus conference held by the British Hernia Society in Manchester, U.K. on 11-12 October 2012. Experts included a physiotherapist, a musculoskeletal radiologist and surgeons with a proven track record of expertise in this field. Presentations detailing scientific as well as outcome data from their own experiences were given. Records were made of the presentations with specific areas debated openly. RESULTS: The term 'inguinal disruption' (ID) was agreed as the preferred nomenclature with the term 'Sportsman's hernia' or 'groin' rejected, as no true hernia exists. There was an overwhelming agreement of opinion that there was abnormal tension in the groin, particularly around the inguinal ligament attachment. Other common findings included the possibility of external oblique disruption with consequent small tears noted as well as some oedema of the tissues. A multidisciplinary approach with tailored physiotherapy as the initial treatment was recommended with any surgery involving releasing the tension in the inguinal canal by various techniques and reinforcing it with a mesh or suture repair. A national registry should be developed for all athletes undergoing surgery. CONCLUSIONS: ID is a common condition where no true hernia exists. It should be managed through a multidisciplinary approach to ensure consistent standards and outcomes are achieved.

A comparative study of colorectal surgical outcome in a national audit separated by 15 years.

AIM: The Wales-Trent Bowel Cancer Audit (WTBA) was carried out in 1993, and since 2001 Welsh Bowel Cancer Audits (WBCA) have taken place annually. Screening for bowel cancer in Wales was introduced in 2008. This study compared patient variables, the role of surgery and operative mortality rates over the 15-year interval between the WTBA and the last WBCA before the introduction of population screening. METHOD: Data from the WTBA in 1993 were compared with those of the WBCA including patients diagnosed between April 2007 and March 2008. RESULTS: In 1993, 1536 patients were diagnosed with colorectal cancer (CRC) compared with 1793 in 2007-2008. Patient demographics and American Society of Anesthesiology (ASA) score did not change during these periods. Surgical treatment for CRC decreased (93% in 1993 vs 80% in 2007-2008; P < 0.001) particularly in the use of resectional surgery (84% in 1993 vs 71% in 2007-2008; P < 0.001). The 30-day postoperative mortality rate fell from 7.4% in 1993 to 5.9% in 2007-2008 (P = 0.097). Advanced disease at operation was more prevalent in the WTBA (25% of all operated patients were Stage IV in 1993 vs 13% in 2007-2008; P < 0.001). The use of surgery in patients with metastatic disease also declined over this period. CONCLUSION: Surgery is used less frequently in the management of CRC compared with 15 years previously, and is a factor in the reduction of the interpreted 30-day operative mortality.

How safe is it to manage diverticular colovesical fistulation non-operatively?

AIM: Colovesical fistula (CVF) is an uncommon condition. Diagnosis and management varies according to presentation and aetiology. The identification of patients suitable for conservative management and their outcome following this approach has not been well documented. METHODS: The clinical outcomes of all patients diagnosed with a CVF over a 7-year period from an uro-radiological database were reviewed. Cases secondary to diverticular disease were analysed with respect to the approach by which they were managed: those treated surgically and those managed conservatively. RESULTS: Sixty-two patients (32 men) were diagnosed with CVF of whom 53 (85%) had diverticular disease. Twenty-seven (mean age 69 years, range 42-90) underwent surgery (with a stoma in 59%) with a 30-day mortality of 15%. Those managed conservatively (n = 26) were older (mean age 76 years, range 39-87) and frailer (62% American Society of Anesthesiologists Grades III and IV). At 1 and 3 years following diagnosis there was no difference in mortality between these two groups and only one death was as a consequence of urosepsis. CONCLUSION: Many patients with CVF secondary to diverticular disease can be safely managed non-operatively.

Impact of climate change on risk of incursion of Crimean-Congo haemorrhagic fever virus in livestock in Europe through migratory birds.

AIMS: To predict the risk of incursion of Crimean-Congo haemorrhagic fever virus (CCHFV) in livestock in Europe introduced through immature Hyalomma marginatum ticks on migratory birds under current conditions and in the decade 2075-2084 under a climate-change scenario. METHODS AND RESULTS: A spatial risk map of Europe comprising 14 282 grid cells (25 × 25 km) was constructed using three data sources: (i) ranges and abundances of four species of bird which migrate from sub-Saharan Africa to Europe each spring, namely Willow warbler (Phylloscopus trochilus), Northern wheatear (Oenanthe oenanthe), Tree pipit (Anthus trivialis) and Common quail (Coturnix coturnix); (ii) UK Met Office HadRM3 spring temperatures for prediction of moulting success of immature H. marginatum ticks and (iii) livestock densities. On average, the number of grid cells in Europe predicted to have at least one CCHFV incursion in livestock in spring was 1·04 per year for the decade 2005-2014 and 1·03 per year for the decade 2075-2084. In general with the assumed climate-change scenario, the risk increased in northern Europe but decreased in central and southern Europe, although there is considerable local variation in the trends. CONCLUSIONS: The absolute risk of incursion of CCHFV in livestock through ticks introduced by four abundant species of migratory bird (totalling 120 million individual birds) is very low. Climate change has opposing effects, increasing the success of the moult of the nymphal ticks into adults but decreasing the projected abundance of birds by 34% in this model. SIGNIFICANCE AND IMPACT OF THE STUDY: For Europe, climate change is not predicted to increase the overall risk of incursion of CCHFV in livestock through infected ticks introduced by these four migratory bird species.

CT evaluation for 'quiescent' herniation following closure of diverting loop ileostomy.

AIM: The prevalence of abdominal wall herniation at the site of a previous temporary stoma is uncertain. This cohort study investigated the frequency of radiological abnormalities at the site of a closed diverting loop ileostomy. METHOD: All patients in whom an ileostomy was raised and later closed during a 5-year period formed the study group. When colorectal cancer surveillance computed tomography (CT) was undertaken the images were scrutinized and graded as to defined anatomical abnormalities. RESULTS: One hundred and seventy-nine patients had an ileostomy, of which 92 were diverting. Fifty-nine (64%) were closed at various intervals (median time to closure 6 (2-22) months and 43 underwent a surveillance CT at 1-3 (median 2) years. At 1 year an abnormality (atrophy or defect) at the site of closure was seen in 16 (37%) CT scans. These were more frequent with increasing duration of follow-up. One asymptomatic hernia was detected at 2 years but there was no deterioration in the abdominal wall at 3 years when compared with that at 2 years. CONCLUSION: Abnormalities in the abdominal wall at the site of a closed diverting ileostomy are common but true herniation is unusual. The routine use of prophylactic mesh at ileostomy closure may be unnecessary.

Avoiding extraction site herniation after laparoscopic right colectomy.

Transverse abdominal wall incisions are favoured as part of enhanced recovery programmes. We explored the use of rectus-preserving extraction site incisions in laparoscopic right colectomy. The approach involved minimal anterior abdominal wall disruption with preservation of the rectus abdominis muscle: the rectus abdominis muscle extraction site (RAMES). In 15 patients, a RAMES was used electively in right colectomy for malignancy. The median wound length was 6 cms. There was no clinical or radiological evidence of incisional herniation in the 15 patients at 12-month and in the 12 survivors at 24-month follow-up. An anatomical dissection at specimen extraction site reduces early incisional herniation rates and should be of benefit in the longer term.

The lateral rectus abdominis positioned stoma (LRAPS) in the construction of end colostomies, loop ileostomies and ileal conduits.

BACKGROUND: Stomas are traditionally constructed through the belly of the rectus muscle. Parastomal herniation is common with the use of mesh prophylaxis still deliberated. METHODS: A novel trephine, the lateral rectus abdominis positioned stoma or LRAPS, that minimises damage to the musculature of the anterior abdominal wall, has been used in the construction of end colostomies, loop ileostomies and ileal conduits. RESULTS: In a cohort of 106 patients with end colostomy, the cumulative rate of parastomal herniation at 1, 2 and 3 years were 6, 10 and 17%, respectively. In 56 patients in whom an ileal conduit was performed, there was no clinical or radiological evidence of parastomal herniation at 1 year. CONCLUSION: In contrast to a traditional trephine through the belly of the muscle, this technique avoids damage to the rectus abdominis muscle. Early symptomatic parastomal herniation is unusual after LRAPS.

Outcomes of primary and recurrent inguinal hernia repair with prosthetic mesh in a single region over 15 years.

BACKGROUND: Sutured inguinal hernia repairs are now uncommon, with evidence suggesting that those augmented with mesh are associated with a lower recurrence rate. We aimed to explore the suggestion that the established use of mesh does indeed lower the rate of operation for recurrence in a single National Health Service region. METHOD: We collected retrospective Office of Population Censuses and Surveys coded data across one region of all primary and recurrent inguinal hernia repairs over 15 years (2004-2019). Electronic records of recurrent repairs were scrutinised to identify year and type of previous primary repair. RESULTS: In total, 7,234 repairs were performed during this time, of which 289 (4%) were for symptomatic recurrence. Operations for primary repair increased year on year (111 in 2004 to 402 in 2019). Frequency of operation for recurrent herniation declined with increasing use of mesh (8.8% in 2004 to 3.5% in 2019). The majority of repairs (73%) for recurrence were by an open approach. As opposed to an open mesh repair, a primary laparoscopic repair was associated with an earlier recurrence. CONCLUSIONS: Inguinal hernia repairs are increasing in frequency but operations for later symptomatic recurrence following an open primary prosthetic mesh repair are not.

Radiation-induced reactive oxygen species partially assemble neutrophil NADPH oxidase.

Neutrophils are key cells from the innate immune system that destroy invading bacteria or viruses, thanks mainly to the non-mitochondrial reactive oxygen species (ROS) generated by the enzyme NADPH oxidase. Our aim was to study the response of neutrophils to situations of oxidative stress with emphasis on the impact on the NADPH oxidase complex. To mimic oxidative stress, we used gamma irradiation that generated ROS (OH•, O2•- and H2O2) in a quantitative controlled manner. We showed that, although irradiation induces shorter half-lives of neutrophil (reduced by at least a factor of 2), it triggers a pre-activation of surviving neutrophils. This is detectable by the production of a small but significant amount of superoxide anions, proportional to the dose (about 3 times that of sham). Investigations at the molecular level showed that this ROS increase was generated by the NADPH oxidase enzyme after neutrophils irradiation. The NADPH oxidase complex undergoes an incomplete assembly which includes p47phox and p67phox but excludes the G-protein Rac. Importantly, this irradiation-induced pre-activation is capable of considerably improving neutrophil reactivity. Indeed, we have observed that this leads to an increase in the production of ROS and the capacity of phagocytosis, leading to the conclusion that radiation induced ROS clearly behave as neutrophil primers.