The First Modified Delphi Consensus-Building Exercise on Surgical Ward Rounds in the United Kingdom National Health Service.

BACKGROUND: The ward round is an integral part of everyday surgical practice. It is a complex clinical activity that requires both sound clinical management and communication skills. This study reports the results of a consensus-building exercise on the common aspects of the general surgical ward rounds. METHODS: The consensus-building committee involving a range of stakeholders from 16 United Kingdom (UK) National Health Service trusts took part in this consensus exercise. The members discussed and suggested a series of statements concerning surgical ward round. An agreement of ≥ 70% among members was regarded as a consensus. RESULTS: Thirty-two members voted on 60 statements. There was a consensus on fifty-nine statements after the first round of voting, and one statement was modified before it reached consensus in the second round. The statements covered nine sections: a preparation phase, team allocation, multidisciplinary approach to the ward round, structure of the round, teaching considerations, confidentiality and privacy, documentation, post-round arrangements, and weekend round. There was a consensus on spending time to prepare for the round, a consultant-led round, involvement of the nursing staff, an MDT round at the beginning and end of the week, a minimum of 5 min allocated to each patient, utilisation of a round checklist, afternoon virtual round, and a clear handover and plan for the weekend. CONCLUSION: The consensus committee achieved agreement on several aspects concerning the surgical ward rounds in the UK NHS. This should help improve the care of surgical patients in the UK.

Evaluation of the effect of narrow band-ultraviolet B on the expression of tyrosinase, TYRP-1, and TYRP-2 mRNA in vitiligo skin and their correlations with clinical improvement: A retrospective study.

Narrowband-ultraviolet B (NB-UVB) is considered one of the main therapeutic tools in vitiligo, which is able to induce repigmentation and halt depigmentation. However, little remains known about the effect of NB-UVB on TYR gene family, the main pigmentary genes, in vitiligo patients. To assess the effect of NB-UVB on expression of some genes related to the pigmentary problem of vitiligo; tyrosinase (TYR), tyrosinase related protein 1 (TYRP1) and tyrosinase related protein 2 (TYRP2), mRNA levels of those genes were quantitatively evaluated by Real-Time quantitative Polymerase Chain Reaction (RT-qPCR) in skin biopsies obtained from 30 patients with nonsegmental vitiligo and five healthy controls. Vitiligo patients were classified into two groups; group 1, involving 12 untreated vitiligo patients and group 2, including 18 vitiligo patients treated by NB-UVB. The levels of TYR, TYRP-1, and TYRP-2 mRNAs in untreated group were significantly lower than in control subjects (P < .001). In NB-UVB treated group, the three genes were significantly higher than in group 1 (P < .001), however, they were still significantly lower than in the control subjects (P < .001). A significant positive correlation was detected between TYR and TYRP-2 genes in group 2 (P = .03). This study demonstrated that mRNA level of TYR, TYRP-1, and TYRP-2, which decreased in vitiligo, was significantly increased upon treatment with NB-UVB. Accordingly, the mechanism of depigmentation in vitiligo disease and repigmentation by NB-UVB treatment may be related to the changes in the expression of these genes.

Management of resistant halo nevi.

BACKGROUND: Halo nevus (HN) is a rare dermatologic disorder characterized by typical whitish rim surrounding an existing melanocytic nevus resembling halo. It is a cosmetic problem that may be linked to vitiligo, and it is advised to remove these nevi in order to avoid development of vitiligo. OBJECTIVES: The aim of the present study is to evaluate the cosmetic outcome after nevus removal and leukoderma dermabrasion with epithelial graft followed by narrow-band ultraviolet B (NB-UVB) phototherapy as management of resistant halo nevi and avoidance of development of vitiligo. PATIENTS AND METHODS: Ten patients with persisting halo nevi were selected as candidates in this study. Superficial dermabrasion was carried out using proper diamond fraises on depigmented rim and then punch biopsy probes with suitable size were used to harvest the nevus. Thiersch graft was prepared and applied on the dermabraded depigmented area. After 1 week of the procedure, patients were exposed to NB-UVB twice weekly and were followed up for 3 months. RESULTS: Repigmentation was noticed in 2 weeks and was nearly fully accomplished in all 10 patients within the 3-month period. No other vitiligo lesions developed during this period in all patients except for one case. CONCLUSION: Excision of Sutton's nevus with combined dermabrasion and Thiersch grafting followed by phototherapy is a good aesthetic maneuver in treating halo nevi and helps in avoiding further vitiligo depigmentation.

Laparoscopic Roux en-Y Gastric Bypass Using a Modified Retrocolic-Supracolic Approach: Outcomes from 300 Patients.

BACKGROUND: Laparoscopic Roux en-Y gastric bypass (LRYGB) achieves sustained long-term weight loss and reduced mortality in morbidly obese patients. It is routinely performed using an ante- or retrocolic approach with the jejuno-jejunostomy constructed in the infracolic compartment. We have modified the standard technique of performing LRYGB by constructing both anastomoses in the supracolic compartment. This study describes the outcomes of consecutive primary LRYGB performed using this novel retrocolic-supracolic approach. METHODS: Data were prospectively collected on consecutive primary LRYGB performed in a tertiary-referral Bariatric Centre in the United Kingdom from September 2009 to March 2013. Data included demographics, operative outcomes (duration of surgery, postoperative anastomotic leak/bleeding/reoperations), development of strictures, length of stay, excess weight loss (EWL) and resolution of diabetes mellitus. RESULTS: Hand-sewn LRYGB was successfully performed using the retrocolic-supracolic approach in 300 of 307 (98 %) consecutive patients (72 % female). Median (IQR) age, weight and baseline body mass index were 49 (41-56) years, 146 (134-163) kg and 52.9 (48.8-57.2) kg/m(2), respectively. There were 4 (1.3 %) anastomotic leaks and 8 (2.6 %) postoperative bleeds. The 30-day reoperation rate was 1.6 %. Median (IQR) hospital stay was 2 (2-2) days. Postoperative dysphagia requiring endoscopic balloon dilatation occurred in 19 (6.3 %) patients. Mean ± SD 12-month EWL was 69.9 ± 19.0 %. Within the follow-up period, 81 % of patients with type II diabetes mellitus achieved remission and 19 % reduced dosage of diabetes medication. CONCLUSIONS: LRYGB performed using the retrocolic-supracolic approach was safe, feasible, technically advantageous and resulted in clinical outcomes akin to the standard infracolic approach.

Mid-Term Remission of Type 2 Diabetes Mellitus After Laparoscopic Roux En-Y Gastric Bypass.

BACKGROUND: Laparoscopic Roux en-Y gastric bypass (LRYGB) is an established therapeutic modality for type 2 diabetes mellitus (T2DM). However, there is paucity of data on the outcomes of LRYGB on T2DM beyond 2 years. This study aimed to examine the medium-term effects of LRYGB on T2DM and determine the predictors of T2DM resolution. METHODS: Prospective data were collected for all consecutive LRYGB performed from September 2009 to November 2010. The American Diabetes Association guidelines were used to define complete (CR) or partial (PR) remission of diabetes. Diabetes status was considered improved when there was >50 % reduction in the dose of medications or when glycaemic control was achieved after stopping insulin. The effects of baseline characteristics, diabetes data and weight loss data at 4 years on T2DM remission were studied. RESULTS: Forty-six patients with T2DM underwent LRYGB with mean ± SD age and body mass index (BMI) of 48.6 ± 9.6 years and 50.4 ± 6.5 kg/m2, respectively. Median (IQR, interquartile range) duration of T2DM preoperatively was 60 (36-126) months. Median (IQR) follow-up was 52 (50-57) months. T2DM remission was achieved in 64 % of patients (44 % CR, 20 % PR), and a further 28 % of patients had improvement in their diabetes status. Multivariate analyses demonstrated significant excess weight loss (EWL) [P = 0.008] and lower BMI [P = 0.04] at 4 years to be the only independent predictors of T2DM medium-term outcomes. CONCLUSION: The medium-term effects of LRYGB on T2DM remission/improvement were maintained in 92 % of patients. EWL and lower BMI at 4 years were independent predictors of T2DM remission.

Outcomes of linear-stapled versus hand-sewn gastrojejunal anastomosis in laparoscopic Roux en-Y gastric bypass.

BACKGROUND: In laparoscopic Roux en-Y gastric bypass (LRYGB), the gastrojejunal anastomosis (GJA) may be performed using linear-stapled (LS) or completely hand-sewn (HS) techniques. No published study has compared operative and clinical outcomes following LS and HS LRYGB when performed by surgeons beyond the learning curve. This study examined outcomes of both techniques performed by two 'technique-specific' bariatric fellowship-trained surgeons. METHODS: Data on consecutive primary LRYGB undertaken in two university hospitals were prospectively collected over 28-months and included demographics, co-morbidities, postoperative morbidity, mortality, length of stay (LOS), reoperations, and excess weight loss (EWL). Data were presented as mean ± SD. RESULTS: There were 366 LRYGB studied (LS = 144 and HS = 222 patients) with 96 % 12-month follow-up. All procedures were completed laparoscopically with no anastomotic leak or mortality. The LS cohort had a lower body mass index (48.3 ± 5.0 vs 53.8 ± 7.1, P < 0.001), greater incidence of diabetes mellitus (P = 0.009) and sleep apnea (P = 0.007). The HS cohort had more patients in Obesity Surgery Mortality Risk Score classes B and C (P = 0.004 and P = 0.01), and shorter operating time (127 ± 30 vs 172 ± 30 min, P < 0.001). There were no differences in LOS, complications, or reoperations. The HS technique was associated with more GJA stenoses requiring endoscopic dilatation (7.7 vs 0 %, P < 0.001). At 12 months, EWL (%) was comparable between the two techniques (LS 71.0 ± 15.5 vs HS 66.5 ± 13.7, P = 0.09). CONCLUSIONS: When performed by 'technique-specific' surgeons, both LS and HS GJA in LRYGB may be performed safely with no significant differences in morbidity, reoperations, or EWL.

Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent 'pre-renal' acute kidney injury?: con.

The high chloride content of 0.9% saline leads to adverse pathophysiological effects in both animals and healthy human volunteers, changes not seen after balanced crystalloids. Small randomized trials confirm that the hyperchloremic acidosis induced by saline also occurs in patients, but no clinical outcome benefit was demonstrable when compared with balanced crystalloids, perhaps due to a type II error. A strong signal is emerging from recent large propensity-matched and cohort studies for the adverse effects that 0.9% saline has on the clinical outcome in surgical and critically ill patients when compared with balanced crystalloids. Major complications are the increased incidence of acute kidney injury and the need for renal replacement therapy, and that pathological hyperchloremia may increase postoperative mortality. However, there are no large-scale randomized trials comparing 0.9% saline with balanced crystalloids. Some balanced crystalloids are hypo-osmolar and may not be suitable for neurosurgical patients because of their propensity to cause brain edema. Saline may be the solution of choice used for the resuscitation of patients with alkalosis and hypochloremia. Nevertheless, there is evidence to suggest that balanced crystalloids cause less detriment to renal function than 0.9% saline, with perhaps better clinical outcome. Hence, we argue that chloride-rich crystalloids such as 0.9% saline should be replaced with balanced crystalloids as the mainstay of fluid resuscitation to prevent 'pre-renal' acute kidney injury.

The Effects of Preoperative Glycaemic Control (HbA1c) on Bariatric and Metabolic Surgery Outcomes: Data from a Tertiary-Referral Bariatric Centre in the UK.

BACKGROUND: Current recommendations advocate the achievement of an optimal glucose control (HbA1c < 69 mmol/mol) prior to elective surgery to reduce risks of peri- and post-operative complications, but the relevance for this glycaemic threshold prior to Bariatric Metabolic Surgery (BMS) following a specialist weight management programme remains unclear. METHODS: We undertook a retrospective cohort study of patients with type 2 diabetes mellitus (T2DM) who underwent BMS over a 6-year period (2016-2022) at a regional tertiary referral following completion of a specialist multidisciplinary weight management. Post-operative outcomes of interest included 30-day mortality, readmission rates, need for Intensive Care Unit (ICU) care and hospital length of stay (LOS) and were assessed according to HbA1c cut-off values of < 69 (N = 202) and > 69 mmol/mol (N = 67) as well as a continuous variable. RESULTS: A total of 269 patients with T2D were included in this study. Patients underwent primary Roux en-Y gastric bypass (RYGB, n = 136), Sleeve Gastrectomy (SG, n = 124), insertion of gastric band (n = 4) or one-anastomosis gastric bypass (OAGB, n = 4). No significant differences in the rates of complications were observed between the two groups of pre-operative HbA1c cut-off values. No HbA1c threshold was observed for glycaemic control that would affect the peri- and post-operative complications following BMS. CONCLUSIONS: We observed no associations between pre-operative HbA1C values and the risk of peri- and post-operative complications. In the context of a specialist multidisciplinary weight management programme, optimising pre-operative HbA1C to a recommended target value prior to BMS may not translate into reduced risks of peri- and post-operative complications.

Regulation of food intake after surgery and the gut brain axis.

PURPOSE OF REVIEW: To highlight recent developments relating control of food intake after surgery and the gut-brain axis by reviewing clinically relevant English language articles mainly from January 2011 to March 2013. RECENT FINDINGS: The gut-brain axis involves a number of complex interactions between hypothalamic nuclei and the gastrointestinal tract. In the postoperative period, release of cytokines and neuromodulators are involved in the control of food intake. Analogues of neuromodulators have been developed and tested in animal studies. The emerging field of metabolic surgery has allowed study of these mechanisms in greater detail. SUMMARY: The current epidemic of worldwide obesity demands further research into the mechanisms underlying control of food intake.

Repigmentation of poliosis after epithelial grafting for vitiligo.

BACKGROUND: Vitiligo is a disease of color loss from skin and possibly also from hair. The presence of white hair follicles is known to be a bad prognostic sign. OBJECTIVES: To evaluate the possibility of repigmentation of white hair follicles after epithelial grafting. METHODS: Patients with recalcitrant vitiligo with loss of hair pigment were treated using Chinese cupping blisters or ultrathin Thiersch grafting after de-epithelialization of vitiliginous patches by dermabrasion. Phototherapy was used afterward to enhance success. RESULTS: Repigmentation of the skin surface was obtained with as little as 1 to 2 months of phototherapy, as expected, and further follow-up of cases revealed the re-coloring of hair follicles after 4 to 11 months. CONCLUSION: Re-coloring of poliosis with vitiligo is possible but was unexpected because of the difference in mechanism and signaling required between hair bulb melanization and the surface skin. One likely mechanism to explain this change is that melanocyte stem cells are stimulated and migrate to supply hair bulbs with new mature melanocytes. Epithelial grafting of vitiligo with poliosis in hairy areas should be a treatment of choice when white hair tufts cause cosmetic disfigurement.

Linear neutrophilic dermatitis: a seasonal outbreak of Paederus dermatitis in upper Egypt.

In this retrospective study, we investigated a mysterious acute linear eruption that was reported yearly in 300 Egyptian patients, with peaks in June and September, without a clear diagnosis. The lesions evolved suddenly in all patients and presented as an erythematous linear eruption with a grayish center and vesicles and/or pustules located in the middle of the plaques. Only areas that were not covered by clothing were affected. Microscopic examination of skin biopsies revealed striking neutrophilic spongiotic lacunae within a degenerated epidermis and moderate dermal infiltrate. After excluding other possible differential diagnoses associated with linear lesions, the Paederus beetle was concluded to be the initiator of this irritant dermatitis reaction. An outbreak of acute linear neutrophilic dermatitis may develop due to exposure to the Paederus beetle with no sex or age predilections.

Metabolic conditioning to attenuate the adverse effects of perioperative fasting and improve patient outcomes.

PURPOSE OF REVIEW: To review recent articles, published between October 2009 and September 2011, that examined the adverse metabolic consequences of perioperative fasting and interventions that may be utilized to minimize these effects. RECENT FINDINGS: Fasting induces metabolic stress and insulin resistance consequent upon effects on cellular mitochondria, gene and protein expression. Development of perioperative insulin resistance leads to increased postoperative morbidity and mortality. Preoperative carbohydrate loading attenuates insulin resistance via effects on cellular gene and protein expression, but its effects on clinical outcomes remain unclear. Perioperative arginine-supplemented diets were shown to be associated with significant reductions in infectious complications and length of hospital stay in patients undergoing elective surgery. Perioperative metabolic conditioning using glutamine and L-carnitine may be used to modulate insulin sensitivity but further studies need to determine whether these interventions result in clinical benefit. Finally, energy and protein provision to critically ill patients remains inadequate and is hampered by a number of factors including reliance on inaccurate means of estimating energy expenditure and enteral feed tolerance, conflicting data on the effects of energy deficit on clinical outcomes, and poor methodological quality of studies of perioperative nutritional interventions. SUMMARY: Numerous perioperative interventions are available, which if utilized should help attenuate the adverse effects of perioperative fasting and lead to improved patient outcomes.

One- and two-year outcomes and predictors of mortality following emergency laparotomy: a consecutive series from a United Kingdom teaching hospital.

BACKGROUND: Data on outcomes of patients who underwent emergency laparotomy (EML) are limited. This prospective observational study examined aspects of inpatient care and outcomes following EML with a view to identifying predictors of mortality. METHODS: Data collected from consecutive inpatients who underwent EML in a UK teaching hospital over a 3-month period included perioperative physiology, treatment, morbidity, and mortality (30-day, in-hospital, 12-month, and 24-month). Univariate and multiple logistic regression analyses were used to identify predictors of mortality. RESULTS: Eighty-five patients (44 male) with a mean ± SD age of 61 ± 18 years were studied. Postoperatively, 51 % of patients were admitted to the intensive care (ICU) or the high-dependency unit (HDU). 30-day, in-hospital, 12-month, and 24-month mortality was 14, 16.5, 22.4, and 25.9 %, respectively. After adjusting for confounding variables, age ≥70 years (odds ratio [OR] = 9.2, P = 0.004) and a need for postoperative ICU/HDU (OR = 15.0, P = 0.014) were independent predictors of 30-day mortality. Independent predictors of in-hospital mortality were age ≥70 years (OR = 18.2, P = 0.016), ASA ≥III (OR = 22.1, P = 0.034), preoperative sepsis (OR = 20.6, P = 0.045), and need for postoperative ICU/HDU (OR = 21.5, P = 0.038). Independent predictors of 12-month mortality were preoperative urea >7.5 mmol/L (OR = 3.5, P = 0.038) and need for postoperative ICU/HDU (OR = 3.7, P = 0.044). Age ≥70 years was the only independent predictor of 24-month mortality (OR = 4.5, P = 0.014). Almost all deaths recorded in the 24 months following surgery resulted from disseminated malignancy. CONCLUSION: Patients who underwent EML had favourable outcomes, with 2-year survival close to 75 %. Age ≥70 years and the need for postoperative ICU/HDU care were independent predictors of mortality.

What's new in perioperative nutritional support?

PURPOSE OF REVIEW: To highlight recent developments in the field of perioperative nutritional support by reviewing clinically pertinent English language articles from October 2008 to December 2010, that examined the effects of malnutrition on surgical outcomes, optimizing metabolic function and nutritional status preoperatively and postoperatively. RECENT FINDINGS: Recognition of patients with or at risk of malnutrition remains poor despite the availability of numerous clinical aids and clear evidence of the adverse effects of poor nutritional status on postoperative clinical outcomes. Unfortunately, poor design and significant heterogeneity remain amongst many studies of nutritional interventions in surgical patients. Patients undergoing elective surgery should be managed within a multimodal pathway that includes evidence-based interventions to optimize nutritional status perioperatively. The aforementioned should include screening patients to identify those at high nutritional risk, perioperative immuno-nutrition, minimizing 'metabolic stress' and insulin resistance by preoperative conditioning with carbohydrate-based drinks, glutamine supplementation, minimal access surgery and enhanced recovery protocols. Finally gut-specific nutrients and prokinetics should be utilized to improve enteral feed tolerance thereby permitting early enteral feeding. SUMMARY: An evidence-based multimodal pathway that includes interventions to optimize nutritional status may improve outcomes following elective surgery.

Cellular mechanisms underlying the protective effects of preoperative feeding: a randomized study investigating muscle and liver glycogen content, mitochondrial function, gene and protein expression.

OBJECTIVE: To investigate the effects of preoperative feeding with a carbohydrate-based drink that also contained glutamine and antioxidants (oral nutritional supplement [ONS], Fresenuis Kabi, Germany) on glycogen reserves, mitochondrial function, and the expression of key metabolic genes and proteins. SUMMARY BACKGROUND DATA: Preoperative carbohydrate loading attenuates the decline in postoperative insulin sensitivity but the cellular mechanisms underlying this remain unclear. METHODS: Two groups of 20 patients undergoing laparoscopic cholecystectomy participated in this randomized placebo-controlled double-blind study. Patients received either 600 mL of ONS or placebo the evening before surgery, and again 300 mL 3 to 4 hours before anesthesia. A 300-mL aliquot of ONS contained 50 g of carbohydrate, 15 g of glutamine and antioxidants. Blood was sampled before ingestion of the evening drink, after induction of anesthesia, and on postoperative day 1 for measurement of concentrations of glucose, glutamine, and antioxidants. Rectus abdominis muscle and liver biopsies were performed intraoperatively to determine glycogen and glutamine concentrations, mitochondrial function, pyruvate dehydrogenase kinase (PDK4), forkhead transcription factor 1 (FOXO1), and metallothionein 1A (Mt1A) expression. RESULTS: There were no drink-related complications. ONS ingestion led to increased intraoperative liver glycogen reserves (44%, P < 0.001) and plasma glutamine and antioxidant concentrations, the latter 2 remaining elevated up to the first postoperative day. Muscle PDK4 mRNA, PDK4 protein expression, and Mt1A mRNA expression were 4-fold (P < 0.001), 44% (P < 0.05), and 1.5-fold (P < 0.001), respectively, lower in the ONS group. There were no differences in FOXO1 mRNA and protein expression. CONCLUSIONS: The changes in muscle PDK4 may explain the mechanism by which preoperative feeding with carbohydrate-based drinks attenuates the development of postoperative insulin resistance.

Hypo- and hypernatraemia in surgical patients: is there room for improvement?

BACKGROUND: Up to 30% of surgical inpatients develop complications related to fluid and electrolyte therapy. We sought to study the occurrence of hypo- and hypernatraemia in these patients to inform current standards of care. METHODS: This prospective audit took place over 80 days in a university hospital. Patients with a serum sodium concentration less than 130 or greater than 150 mmol/l were included. Daily intakes of Na(+), K(+) and Cl(-), and fluid balance were recorded before and after development of dysnatraemia. Fluid balance charts were assessed, as was the presence of documented patient weights. Patients were followed up until one of these milestones was reached: normonatraemia, death, or hospital discharge. RESULTS: During the study period 55 (4%) of the 1,383 surgical admissions met the inclusion criteria. Fifteen patients had hypernatraemia, 13 (87%) of whom were identified on ICU/HDU. In the days preceding the hypernatraemia, patients received (in mmol/day) a median (IQR) of 157 (76-344) Na(+), 38 (6-65) K(+), 157 (72-310) Cl(-), and 1.96 (1.13-2.96) L water. In the days preceding the hyponatraemia, patients received 50 (0-189) Na(+), 0 (0-10) K(+), 56 (0-188) Cl(-), and 1.45 (0-2.60) L water. Before the dysnatraemias only 28% of fluid balance charts were completed accurately. During the audit 42% of patients were not weighed. Dysnatraemic patients had a higher hospital mortality rate than those who did not develop dysnatraemia (12.7 vs. 2.3%, P < 0.001). CONCLUSIONS: Four percent of surgical inpatients developed dysnatraemias, which were associated with increased mortality. Fluid balance documentation was suboptimal and daily weights were not measured routinely, even in patients with severe electrolyte derangements.

Evaluation of Liver Function Tests and Risk Score Assessment to Screen Patients for Significant Liver Disease Prior to Bariatric and Metabolic Surgery.

Bariatric and metabolic surgery is associated with significant improvement in obesity-related comorbidities, but for patients with non-alcoholic fatty liver disease (NAFLD), clinical outcomes are dependent on the severity of liver disease, i.e. improvement of NAFLD in most patients but increased risks of fulminant hepatic failure and/or bleeding varices in patients with more advanced cirrhosis. Our study showed that absolute values of liver enzymes were poor indicator of risk of liver fibrosis. The use of AST/ALT ratio, Fib 4 or NAFLD scores were appropriate screening tools, with each risk score appearing to pick out a certain phenotype of patients based on age, BMI or individual values of ALT, AST or platelet count. There is lack of agreement in some cases between FIB-4 scores and NAFLD scores when ruling out patients at high risk of liver fibrosis. Meticulous screening of patients at risk of liver fibrosis is crucial in order to reduce the risk of liver-related complications following bariatric and metabolic surgery.

Correction to: Evaluation of Liver Function Tests and Risk Score Assessment to Screen Patients for Significant Liver Disease Prior to Bariatric and Metabolic Surgery.

The name of author Anthony Antypas was misspelled in the original article. It is correct here.

Expression of immune checkpoints in active nonsegmental vitiligo: a pilot study.

BACKGROUND: Vitiligo is a depigmentary skin disfigurement resulting from destruction of melanocytes caused by a possible malfunctioning immunity. This destruction could be linked to an aberrant T-cell-mediated immune response. Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) and programmed death-1 (PD-1) are immune checkpoints capable of downregulating T-cell immune functions. OBJECTIVES: To evaluate the pattern of expression of PD-1 and CTLA-4 in active vitiligo skin. METHODS: Thirty nonsegmental vitiligo (NSV) patients had been included in this pilot study. Marginal, lesional, and nonlesional skin biopsies were obtained. PD-1 and CTLA-4 immunohistochemistry expression in the mononuclear inflammatory infiltrates were evaluated using digital images. RESULTS: The marginal and lesional inflammatory infiltrates were significantly abundant when compared to nonlesional ones. The marginal infiltrates were significantly abundant when compared to the lesional ones. PD-1 and CTLA-4 were significantly expressed in the marginal and lesional infiltrates when compared to nonlesional skin. Moreover, the marginal expression of PD-1 was significantly higher than the lesional expression. However, no similar significant difference in CTLA-4 expression was found between the marginal and lesional infiltrates. Significant positive correlations were found between the expressions of PD-1 and CTLA-4 in marginal and lesional infiltrates. CONCLUSION: Programmed death-1 and CTLA-4 are expressed within the inflammatory infiltrate of active NSV. Further studies are required to confirm their significance in the development or limitation of the disease.