One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis.

BACKGROUND: Recent randomized trials demonstrated that laparoscopic lavage compared with resection for Hinchey III perforated diverticulitis was associated with similar mortality, less stoma formation but a higher rate of early reintervention. The aim of this study was to compare 1-year outcomes in patients who participated in the randomized Scandinavian Diverticulitis (SCANDIV) trial. METHODS: Between February 2010 and June 2014, patients from 21 hospitals in Norway and Sweden presenting with suspected perforated diverticulitis were enrolled in a multicentre RCT comparing laparoscopic lavage and sigmoid resection. All patients with perforated diverticulitis confirmed during surgery were included in a modified intention-to-treat analysis of 1-year results. RESULTS: Of 199 enrolled patients, 101 were assigned randomly to laparoscopic lavage and 98 to colonic resection. Perforated diverticulitis was confirmed at the time of surgery in 89 and 83 patients respectively. Within 1 year after surgery, neither severe complications (34 versus 27 per cent; P = 0·323) nor disease-related mortality (12 versus 11 per cent) differed significantly between the lavage and surgery groups. Among the 144 patients with purulent peritonitis, the rate of severe complications (27 per cent (20 of 74) versus 21 per cent (15 of 70) respectively; P = 0·445) and disease-related mortality (8 versus 9 per cent) were similar. Laparoscopic lavage was associated with more deep surgical-site infections (32 versus 13 per cent; P = 0·006) but fewer superficial surgical-site infections (1 versus 17 per cent; P = 0·001). More patients in the lavage group underwent unplanned reoperations (27 versus 10 per cent; P = 0·010). Including stoma reversals, a similar proportion of patients required a secondary operation (28 versus 29 per cent). The stoma rate at 1 year was lower in the lavage group (14 versus 42 per cent in the resection group; P < 0·001); however, the Cleveland Global Quality of Life score did not differ between groups. CONCLUSION: The advantages of laparoscopic lavage should be weighed against the risk of secondary intervention (if sepsis is unresolved). Assessment to exclude malignancy (although uncommon) is advised. Registration number: NCT01047462 ( http://www.clinicaltrials.gov).

Weight-for-height Z-score improves in half of undernourished children hospitalized in surgical wards.

BACKGROUND: Overall, 10-15% of hospitalized children are undernourished. The present study focuses on pediatric surgical wards. We assessed the impact of undernutrition upon admission on the weight-for-height Z-score (Z-WFH) during hospitalization for surgery. Secondary aims were to investigate the influence of associated factors and to report on the use of nutritional support. METHODS: All children hospitalized for a surgical procedure between July 2015 and March 2016 were included in this monocentric, prospective study. Children were divided into two groups: whether the Z-WFH upon admission was below -2 standard deviations (undernourished) or not (not undernourished). RESULTS: A total of 161 of 278 eligible children were included; 27 were undernourished (17%). The change in Z-WFH during hospitalization was greater in undernourished children (0.31±0.11 vs. -0.05±0.05, P=0.005). Of undernourished children, 49% recovered a Z-WFH above -2 SD during hospitalization. There was no difference between undernourished children and not undernourished children regarding age, length of hospital stay, pre- and post-operative duration of nil per os, duration of surgical procedure, ASA score, emergency level of the surgical procedure, and enteral/parenteral nutrition. CONCLUSION: Our data suggest that the Z-WFH of undernourished children upon admission improved during hospitalization.

Corticotropin-releasing hormone (CRH) regulates macromolecular permeability via mast cells in normal human colonic biopsies in vitro.

OBJECTIVE: Persistent stress and life events affect the course of ulcerative colitis and irritable bowel syndrome by largely unknown mechanisms. Corticotropin-releasing hormone (CRH) has been implicated as an important mediator of stress-induced abnormalities in intestinal mucosal function in animal models, but to date no studies in human colon have been reported. The aim was to examine the effects of CRH on mucosal barrier function in the human colon and to elucidate the mechanisms involved in CRH-induced hyper-permeability. DESIGN: Biopsies from 39 volunteers were assessed for macromolecular permeability (horseradish peroxidase (HRP), (51)Cr-EDTA), and electrophysiology after CRH challenge in Ussing chambers. The biopsies were examined by electron and confocal microscopy for HRP and CRH receptor localisation, respectively. Moreover, CRH receptor mRNA and protein expression were examined in the human mast cell line, HMC-1. RESULTS: Mucosal permeability to HRP was increased by CRH (2.8+/-0.5 pmol/cm(2)/h) compared to vehicle exposure (1.5+/-0.4 pmol/cm(2)/h), p = 0.032, whereas permeability to (51)Cr-EDTA and transmucosal electrical resistance were unchanged. The increased permeability to HRP was abolished by alpha-helical CRH (9-41) (1.3+/-0.6 pmol/cm(2)/h) and the mast cell stabilizer, lodoxamide (1.6+/-0.6 pmol/cm(2)/h). Electron microscopy showed transcellular passage of HRP through colonocytes. CRH receptor subtypes R1 and R2 were detected in the HMC-1 cell line and in lamina propria mast cells in human colon. CONCLUSIONS: Our results suggest that CRH mediates transcellular uptake of HRP in human colonic mucosa via CRH receptor subtypes R1 and R2 on subepithelial mast cells. CRH-induced macromolecular uptake in human colon mucosa may have implications for stress-related intestinal disorders.

Depressed primary in vitro antibody response in untreated systemic lupus erythematosus. T helper cell defect and lack of defective suppressor cell function.

The in vitro antibody response of peripheral blood lymphocytes (PBL) from 19 patients with untreated systemic lupus erythematosus (SLE) was compared with that of 20 control patients and 44 normal subjects. Trinitrophenyl polyacrylamide beads (TNP-PAA) were used to induce IgM anti-TNP plaque-forming cells. SLE patients displayed a markedly depressed, and in most instances virtually absent, response. This was not due to an unusual kinetics of the response; nor could it be induced by preincubation of SLE patients' PBL. In co-cultures of SLE patients and normal PBL, the former, with few exceptions, did not exert a suppressive effect. In four patients the anti-TNP response of either unfractionated or T-depleted SLE PBL could be restored by T cells from a normal individual. Conversely in three of these patients, SLE T cells could not support the response of normal B cells, suggesting a T helper cell defect in SLE PBL. Concanavalin A (Con A)-induced suppressor cells of the antibody response could be assayed by two approaches: (a) in responder SLE patients, by the direct addition of Con A to TNP-PAA-stimulated cultures; (b) in seven patients by transfer of Con A-activated cells to the responding culture of a normal allogeneic donor. In both cases SLE PBL were able to exert a suppressive effect to the same extent as normal PBL.

Staphylococcal superantigens activate HIV-1 replication in naturally infected monocytes.

OBJECTIVES: To study the effects of microbial superantigens, Staphylococcal exotoxins (SE), on HIV replication in monocytes following binding to and signalling through major histocompatibility complex (MHC) class II molecules. METHODS: We investigated the effects of SE on HIV replication and monokine production in three different in vitro models of monocyte culture: chronically infected monocytic cell line U1, acute infection of normal monocytes by different HIV-1 strains, and naturally-infected monocytes from seropositive patients. p24 antigen, interleukin (IL)-6 and tumour necrosis factor (TNF)-alpha production was measured by specific enzyme-linked immunosorbent assay (ELISA). RESULTS: Staphylococcal enterotoxin B and toxic shock syndrome toxin-1 (1-1000 ng/ml) are powerful inducers of HIV-1 expression in U1 cells pretreated with granulocyte macrophage colony stimulating factor. SE induce viral replication in short-term cultures (days 6-21) of monocytes infected in vitro by HIVBa-L, HIVLAI, or naturally infected in vivo. Induction of HIV expression requires direct interactions of SE with MHC class II molecules but not T-cell receptor binding and T-cell-monocyte contact. Anti-TNF-alpha and anti-IL-6 neutralizing monoclonal antibodies inhibit by over 61% SE-induced HIV replication. CONCLUSIONS: Using SE we have linked two important pathways for the regulation of HIV replication in monocytes, namely signalling through MHC class II molecules and monokine production potentially mediated by induction of the pleiotropic cellular transcription factor NF-kappa B. In HIV-infected patients bacterial infections are common and could be an important cofactor in the immunopathogenesis of AIDS by inducing HIV replication in latently infected monocytes. Their prevention might emerge as beneficial in these patients.

HIV-induced, HIV-specific in vitro antibody response by B-cells from HIV-seropositive individuals.

OBJECTIVE: Recent studies have shown that B-cells from HIV-infected patients can secrete anti-HIV antibodies in vitro and that they represent 20-40% of immunoglobulin (Ig)-secreting B-cells in vivo. This study was designed to investigate the precise role of HIV in this in vitro antibody production. DESIGN AND METHODS: B-cells from HIV-infected patients [asymptomatic, n = 28; symptomatic (AIDS), n = 14], from seronegative adult volunteers (n = 22) and subjects at high risk for HIV infection (n = 15) were cultured in vitro in the presence of pokeweed mitogen, Staphylococcus aureus cowan or HIV, and T-cells or interleukins (IL). Non-specific Ig production and specific anti-HIV antibody (Ab) production were measured by enzyme-linked immunosorbent and Western blot assays. RESULTS: We found that HIV induced a specific response in cultured B-cells from seropositive patients, in contrast with cultured B-cells from uninfected normal individuals. The characteristics of the HIV-induced response differed from those of a spontaneous or a mitogen-induced response. Anti-HIV Ab production was optimal on day 8-10, when B-cells were cultured with recombinant IL-2 and recombinant interferon-alpha in the presence of infectious virus or recombinant gp160 Env protein. The anti-HIV Ab were mainly directed against Env proteins. Interaction of HIV with B-cells involved surface IgG but not CD4 antigen. Autologous CD8+ T-cells had a non-specific inhibitory effect. Both CD5+ and CD5- B-cells produced anti-HIV Ab. No anti-HIV Ab production was observed in B-cells from high-risk HIV-seronegative individuals. CONCLUSION: HIV (infectious virus or gp160) can induce B-cells from infected patients to secrete specific anti-HIV Ab in vitro.

Primary in vitro antibody response in human cord blood lymphocytes.

Human cord blood lymphocytes were stimulated with trinitrophenyl--polyacrylamide beads (TNP--PAA) in order to induce a primary IgM anti-TNP response. With few exceptions, no anti-TPN response was obtained, whereas peripheral blood lymphomonocytic cells (PBL) from 18-mth-old children were able to respond to TNP-PAA. The addition of lipopolysaccharide (LPS) or of mitomycin-treated adult PBL to cultures of cord blood lymphocytes significantly enhanced their anti-TNP response, thus showing that functional anti-TNP B cell precursors are present in the human neonate.

Quantitative ELISA-polymerase chain reaction at saturation using homologous internal DNA standards and chemiluminescence revelation.

In this report, we describe the development and validation of a convenient, versatile and high throughput quantitative polymerase chain reaction (PCR) method. This assay is based on the use of only one concentration of an internal homologous standard (IS) easily obtained by replacing an 18 nt specific sequence using recombinant PCR. Target and IS amplicons are quantitated at the PCR plateau phase using ELISA which includes a hybridization step with either target or IS specific probes and luminometric revelation. Luminometry allows measurement of amplicon levels without the need for serial dilutions. Experimental values were obtained by comparing their target/IS signal ratios to those of an external scale. A linear dynamic range over four orders of magnitude and good reproducibility were obtained. We used this assay to investigate variations of IL-13 mRNA expression in HIV-infected patients under highly active antiretroviral therapy. Furthermore, we also report a variant of this method using Taqman assay in the ABI PRISM 7,700 apparatus.

Is a dissection balloon beneficial in totally extraperitoneal endoscopic hernioplasty (TEP)? A randomized prospective multicenter study.

BACKGROUND: Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to facilitate the creation of the initial working space in totally extraperitoneal endoscopic hernioplasty (TEP), but their use adds to the cost of the operation. METHODS: A total of 322 men with unilateral, primary, or recurrent inguinal hernias were randomized to undergo TEP with or without a dissection balloon. RESULTS: In the group with the balloon, three of 161 patients (2.5%) required conversion to transabdominal preperitoneal hernioplasty (TAPP), or open herniorraphy, whereas 17 of 161 patients (10.6%) were converted to TAPP or open herniorraphy in the group without the balloon (p = 0.002). The mean operation time was 55 min in the group with the balloon and 63 min in the group without the balloon (p = 0.004). There was no difference between them in postoperative morbidity, and there were no major complications in either group. The recurrence rate was 3.1% in the group with the balloon and 3.7 % in the group without the balloon (p = 0.8). CONCLUSION: The use of a dissection balloon in TEP reduces the conversion rate and may be especially beneficial early in the learning curve.

Is a dissection balloon beneficial in bilateral, totally extraperitoneal, endoscopic hernioplasty? A randomized, prospective, multicenter study.

SUMMARY: Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to gain the initial working space in totally extraperitoneal endoscopic (TEP) hernioplasty, but this increases its cost. Forty-four men with bilateral, primary or recurrent inguinal hernias were randomized to undergo TEP with or without dissection balloon. There were two conversions to transabdominal preperitoneal hernioplasty, or open herniorrhaphy, in the group with balloon and four in the group without balloon. There was no difference in the postoperative morbidity or operation time between the two groups, and there were no major complications in either group. The recurrence rate was 4.3% in the group with the balloon and 7.1% in the group without the balloon. There were no statistically significant differences between the groups. Although our study population is too small to detect small differences between the groups, it seems that the use of a dissection balloon is not beneficial in a bilateral TEP.

The effects of probiotics on barrier function and mucosal pouch microbiota during maintenance treatment for severe pouchitis in patients with ulcerative colitis.

BACKGROUND: A total of 10-15% of patients with an ileoanal pouch develop severe pouchitis necessitating long-term use of antibiotics or pouch excision. Probiotics reduce the risk of recurrence of pouchitis, but mechanisms behind these effects are not fully understood. AIM: To examine mucosal barrier function in pouchitis, before and after probiotic supplementation and to assess composition of mucosal pouch microbiota. METHODS: Sixteen patients with severe pouchitis underwent endoscopy with biopsies of the pouch on three occasions: during active pouchitis; clinical remission by 4 weeks of antibiotics; after 8 weeks of subsequent probiotic supplementation (Ecologic 825, Winclove, Amsterdam, the Netherlands). Thirteen individuals with a healthy ileoanal pouch were sampled once as controls. Ussing chambers were used to assess transmucosal passage of Escherichia coli K12, permeability to horseradish peroxidase (HRP) and 5¹Cr-EDTA. Composition and diversity of the microbiota was analysed using Human Intestinal Tract Chip. RESULTS: Pouchitis Disease Activity Index (PDAI) was significantly improved after antibiotic and probiotic supplementation. Escherichia coli K12 passage during active pouchitis [3.7 (3.4-8.5); median (IQR)] was significantly higher than in controls [1.7 (1.0-2.4); P < 0.01], did not change after antibiotic treatment [5.0 (3.3-7.1); P = ns], but was significantly reduced after subsequent probiotic supplementation [2.2 (1.7-3.3); P < 0.05]. No significant effects of antibiotics or probiotics were observed on composition of mucosal pouch microbiota; however, E. coli passage correlated with bacterial diversity (r = -0.40; P = 0.018). Microbial groups belonging to Bacteroidetes and Clostridium clusters IX, XI and XIVa were associated with healthy pouches. CONCLUSIONS: Probiotics restored the mucosal barrier to E. coli and HRP in patients with pouchitis, a feasible factor in prevention of recurrence during maintenance treatment. Restored barrier function did not translate into significant changes in mucosal microbiota composition, but bacterial diversity correlated with barrier function.

Dynamics of mucosal permeability and inflammation in collagenous colitis before, during, and after loop ileostomy.

Collagenous colitis has become a more frequent diagnosis but the aetiology of this disease is still unknown. We describe a female patient with intractable collagenous colitis who was treated with a temporary loop ileostomy. She was followed clinically, histopathologically, and functionally by measuring mucosal permeability before surgery, after ileostomy, and after bowel reconstruction. In our case report, active collagenous colitis was combined with increased transcellular and paracellular mucosal permeability. Diversion of the faecal stream decreased inflammation of the mucosa and normalised epithelial degeneration and mucosal permeability. After restoration of bowel continuity, mucosal permeability was altered prior to the appearance of a collagenous layer.

[Search for specific factors in culture media of embryos]. / Recherche de facteurs spécifiques dans les milieux de culture des embryons.

Mitogenic activity of culture media having contained either unfertilized or cleaved embryos have been studied. In these media human eggs have been cultured for one day, beginning 20 hours following in vitro insemination. B-lymphocyte proliferation was estimated by thymidine incorporation following 3 day culture in the presence of eggs or embryo culture media. No reproducible effect on B lymphocyte proliferation was observed. Therefore the viability of embryos could not be ascertained by the mitogenic activity of their culture media.

Interferon-alpha can synergize with interleukin 2 for human in vitro antibody response.

We tested the effect of interferon (IFN)-alpha on the specific anti-2,4,6-trinitrophenyl (TNP) response induced by TNP-conjugated polyacrylamide beads in cultures of purified human B cells. IFN-alpha alone had no effect. Interleukin 2 (IL2) alone had a restorative effect which could be considerably (10X) enhanced by IFN-alpha. This reflected a true synergy most apparent with IL2 concentrations of 10 U/ml and IFN-alpha concentrations of 10(3)-10(5) U/ml. The highest concentrations of IFN-alpha were not inhibitory. In contrast, IFN-alpha did not enhance the effect of an IL2-free T cell-derived supernatant able to support the B cell differentiation. Sequential incubations showed that IFN-alpha acted earlier than IL2 on B cell response. The effect of IFN-alpha was dependent on an efficient interaction between IL2 and its receptor which could be inhibited by a monoclonal antibody toward the CD25 antigen. Thus, IFN-alpha can positively interact with a well defined interleukin, IL2, at a pre or post receptor level to potentiate antibody response.

[Immunologic deficiency linked to aging. Role of monocytes]. / Déficit immunitaire lié au vieillissement. Rôle des monocytes.

The capacity of mononuclear cells from individuals over 70 years of age to mount a primary in vitro antibody response is profoundly decreased. We show that the removal of a nylon-adherent cell restores this response. The suppressor cell is plastic adherent, phagocytic non-T and radio-resistant, thus probably a monocyte. Its effect is inhibited by indomethacin, which suggests that its action if mediated by prostaglandins.

Age-related impairment of the in vitro antibody response in the human.

We have used trinitrophenyl polyacrylamide beads (TNP-PAA) to induce a primary in vitro antibody response toward TNP in cultures of peripheral blood lymphocytes (PBL) from aged individuals. The response was virtually non-existent whereas PBL from young control individuals were able to respond. Recombination experiments showed that: (1) aged PBL did not suppress the response of young PBL; (2) young T cells enhanced the response of aged (unfractionated or T-depleted) cells; (3) aged T cells were unable to restore the response of young T-depleted cells, in contrast to young allogeneic T cells. Upon stimulation with Concanavalin A (Con A) aged PBL displayed a moderately diminished proliferative response and a normal ability to suppress the anti-TNP response of autologous PBL (in the few responders). However, contrasting with young PBL they could not suppress the anti-TNP response of young allogeneic PBL.

[Primary antibody response in vitro of human blood lymphocytes]. / Réponse anticorps primaire in vitro des lymphocytes du sang humain

A method for the induction of a primary in vitro antibody response toward a hapten, using human blood lymphocytes is presented. The stimulation of human lymphomonocytic cells with trinitrophenyl (TNP) conjugates of polyacrylamide beads elicits the production of IgM antibody forming cells specific for TNP, with a peak on day 7-day 9. The response is reproducible in its magnitude in the same individual. This model should facilitate clinical and fundamental studies of human antibody response.

Primary in vitro antibody response from human peripheral blood lymphocytes.

A method for the induction of a primary in vitro antibody response from human peripheral blood lymphocytes is presented. Upon cultivation with trinitrophenyl conjugated polyacrylamide beads (TNP-PAA), an anti-TNP response can be obtained as indicated by the appearance of direct plaque-forming cells from day 5 of culture, with a reproducible peak on day 8. These plaques correspond to cells actively producing antibody of the IgM type, as shown by their inhibition by cycloheximide and by anti-human IgM serum, but not by anti-human Fc gamma serum. Their specificity for the TNP hapten can be demonstrated by the effector cell blockade phenomenon, with highly substituted TNP-human IgG. Although the anti-TNP response induced by TNP-PAA in mouse spleen cell cultures appears T independent the same response in human PBL may involve in addition the participation of T cells, since E-RFC depletion before culture led to a markedly decreased number of plaque-forming cells. A significant response could be obtained from the PBL of all of the 30 normal individuals tested. Importantly, the response was reproducible in its magnitude in the six individuals tested in at least three different experiments. Thus, the in vitro stimulation of human PBL by TNP-PAA can be proposed as a reliable test for the study of human B cell function in a specific primary antibody response.

Positive effects of interferon-alpha on B cell-type chronic lymphocytic leukemia proliferative response.

We studied the effect of recombinant interferon-alpha (IFN-alpha) on the proliferative response of normal human B cells and of lymphocytes from 10 patients with B cell-type chronic lymphocytic leukemia. We show that IFN-alpha, which has no effect on B cell proliferation when used alone, can synergize with anti-mu antibody and can support DNA synthesis by anti-mu activated B cells. This was observed with normal B cells and in 4 of 10 patients with B cell-type chronic lymphocytic leukemia. These four patients were all responders to B cell growth factor (BCGF), whereas the responsiveness to IFN-alpha was not correlated with that of IL-2. The positive functional relationship between IFN-alpha and BCGF in these patients is emphasized by the synergistic effect of these two factors in two of these patients, and the lack of inhibition of BCGF response by even supraoptimal concentrations of IFN-alpha. Among the subgroup of patients unable to respond to IFN-alpha, a synergy between IFN-alpha and IL-2 could be observed.

Human immunodeficiency virus gp120 inhibits interleukin-12 secretion by human monocytes: an indirect interleukin-10-mediated effect.

Interleukin-12 (IL-12), a cytokine with in vitro and in vivo immunomodulatory effects, is produced mostly by activated monocytes and macrophages. To study the effect of human immunodeficiency virus (HIV) infection on IL-12 production, we investigated the expression of IL-12 at mRNA and protein levels by human monocytes preincubated with HIV-gp120. In these conditions, we show that monocytes have a decreased ability to express IL-12 mRNA subunits and to produce IL-12 p40 and bioactive p70 proteins in response to Staphylococcus aureus strain cowan I (SAC). We showed that in human monocyte cultures, HIV-gp120 induces a significant IL-10 synthesis, which in turn inhibits IL-12 subunits mRNA accumulation and protein secretion after SAC-activation. Similar data were obtained with human macrophages. These results suggest that, during HIV infection, gp120 induces in uninfected monocytes and macrophages IL-10/IL-12 disregulation, which can alter immune response.