Distinct mechanisms of immunosuppression as a consequence of major surgery

Primary Cesarean delivery and future risk of maternal autoimmune disease: A population-based cohort study

OBJECTIVES

To determine the association between primary Cesarean delivery and incident autoimmune disease in women.

METHODS

We conducted a population-based cohort study of 253,901 females in Ontario, Canada with a first childbirth between 2012 and 2017 and with no pre-existing autoimmune disease. Royston-Parmar models were used to estimate the time-varying association between Cesarean delivery (28.2 % of females) versus vaginal delivery (71.8 % of females; referent) and celiac disease, multiple sclerosis (MS), rheumatoid arthritis (RA), and systemic autoimmune rheumatic disease (SARD), separately, from date of delivery to date of diagnosis or censoring at death, loss of health insurance, or March 31, 2021. To account for potential confounding by indication for Cesarean delivery, models were generated using (i) overlap weighting based on propensity scores for mode of delivery and (ii) with restriction to low-risk pregnancies free of pre-labour Cesarean indications (n = 146,887).

RESULTS

At up to 9 years following childbirth (median = 6.5 years of follow-up), Cesarean delivery was associated with an increased risk of MS, but not celiac disease, RA, or SARD. Overall, cumulative incidence of MS was 0.28 % following Cesarean delivery and 0.21 % following vaginal delivery. After overlap weighting, the adjusted hazard ratio (AHR) curve formed a slight L-shape with the largest magnitude between birth and 3 years (1-year AHR 1.37, 95 % CI 1.04-1.69) and diminishing thereafter (5-year 1.23, 95 % CI 0.91-1.55; 7-year 1.21, 95 % CI 0.84-1.57). Results were similar when restricted to births following low-risk pregnancies.

CONCLUSIONS

Findings suggest a possible link between Cesarean delivery and MS development among females that warrants future replication and explanatory studies.

Early Systemic Immune Response to Silicone Breast Implants Analyzed by Flow Cytometry

Background Silicone breast implants are used in a variety of aesthetic and reconstructive procedures such as permanent implants or tissue expanders. As foreign biomaterials, they can potentially evocate either a local inflammatory reaction or a systemic immune response. This study aimed to quantify possible alterations in white blood cells and lymphocyte subpopulations in patients who underwent silicone implant-based breast augmentation through peripheral blood analysis with flow cytometry at three and 12 months postoperatively. The same patients acted as the control group with a preoperative peripheral blood collection. Methodology This retrospective study included 14 female patients (average age = 29 years; range = 18-44 years) who underwent breast augmentation with silicone implants. Flow cytometry was used to monitor their immunologic reactions. Peripheral blood samples were obtained before, three months, and 12 months after the operation. Flow cytometric analysis was performed to assess the distribution of total leukocytes and the expression of specific lymphocyte subsets using the following antibody panel: anti-CD3, anti-CD4, anti-CD8, anti-CD16/CD56, anti-CD19, and anti-CD25. Results The immunophenotypic analysis showed that the vast majority of the peripheral blood lymphocytes consisted of T lymphocytes (CD3+), followed by natural killer (NK) cells (CD3-/CD16+/CD56+, NK cells), and B lymphocytes (CD3-/CD19+) in all periods of the study. The peripheral blood CD3+ T-lymphocyte subsets were predominantly T-helper lymphocytes (CD3+/CD4+), followed by cytotoxic T lymphocytes (CTLs) (CD3+/CD8+, CTLs), and a small percentage were T-regulatory (Treg) cells (CD4+/CD25high, Treghigh cells). Interestingly, lymphocytes showed a slight increase and T-helper lymphocytes a slight decline postoperatively, with no evidence of statistically significant shifts. Overall, there was no statistically significant difference in the temporal distribution of the peripheral blood lymphocyte subpopulations. Conclusions To our knowledge, the novelty of our study is that the same patients who underwent breast augmentation with silicone implants were used as the control group. There was no evidence of an early specific systemic immune activation in these patients. Hence, flow cytometry could be a reliable method that can be used as an in vitro test to evaluate the biocompatibility of silicone implants and observe patients with immune activity for possible clinical manifestations of symptoms in the future.

Risk factors affecting delay of initiating adjuvant chemotherapy for stage III colorectal cancer

PURPOSE

Delay in initiating adjuvant chemotherapy (AC) after curative resection of colorectal cancer (CRC) has been reported to lead to poor prognosis, but few studies have looked at associated factors. This study aimed to identify risk factors for delay in initiating AC.

METHODS

Data from 200 consecutive patients who underwent curative resection and AC for stage III CRC between 2013 and 2018 were retrospectively collected and analyzed.

RESULTS

AC was initiated more than 8 weeks after surgery in 12.5% of patients (the delay group). Compared to those with no delay (the non-delay group), patients in the delay group had significantly higher rates of synchronous double cancers (2.3% vs. 16.0%, p = 0.001), preoperative bowel obstruction (10.3% vs. 32.0%, p = 0.003), laparotomy (56.0% vs. 80.0%, p = 0.02), concomitant resection (2.9% vs. 24.0%, p < 0.001), and postoperative complications (32.0% vs. 56.0%, p = 0.02), and a significantly longer length of hospital stay (median 12 vs. 30 days, p < 0.001). In multivariate analysis, synchronous double cancers (odds ratio 10.2, p = 0.008), preoperative bowel obstruction (odds ratio 4.6, p = 0.01), concomitant resection (odds ratio 5.2, p = 0.03), and postoperative complications of Clavien-Dindo grade ≥ IIIa (odds ratio 4.0, p = 0.03) were identified as independent risk factors for delay in initiating AC.

CONCLUSION

Careful preoperative treatment planning for CRC patients with synchronous double cancers, preoperative bowel obstruction, and concomitant resection, and management for postoperative complication are necessary to avoid delay in initiating AC.

Early versus late closure of protective loop ileostomy: functional significant results in a preliminary analysis

BACKGROUND

Protective loop ileostomy (PLI), commonly performed in rectal cancer surgery, is one of the most reliable methods to reduce the risk of sepsis associated with anastomotic complications. The correct timing of PLI closure is not well defined. Recently, most surgeons proposed to close early the PLI. The aim of this study was to evaluate the impact of the timing of stoma closure on postoperative outcomes.

METHODS

We analyzed prospectively data of patients who received PLI anterior resection for rectal cancer between January 2020 to June 2022. Patients were divided into 2 groups according to the timing of stoma closure, until four weeks (EC group) and more than four weeks (LC group). Outpatient clinic follow-up, perioperative data, postoperative complications and evidence of anterior resection syndrome with the Low-Anterior Resection Score (LARS) score were recorded.

RESULTS

In the EC group 24 patients were included while 27 patients were considered for LC group. There were no differences between the groups with respect to all parameters, except for recourse to adjuvant therapy, higher for LC group. Perioperative analyzed characteristics were similar among groups. There was no statistically significant difference between the EC group and the LC group for complication rate. LARS score was higher in the LC group for score >20 and >30.

CONCLUSIONS

Timing of PLI closure was not a significant independent predictor of post-closure complications rate. LARS incidence was significantly related to longer time of closure, with probably late recovery of motility function, but this should be confirmed by randomized studies.

Effect of Perioperative Blood Transfusion on Complications Following Emergency Non-trauma Laparotomy in Mulago Hospital: A Prospective Cohort Study

Background Although blood transfusion may be required during emergency non-trauma laparotomy, several retrospective cohort studies have identified blood transfusion as a significant predictor of postoperative infections and mortality. However, no study has explored such an association in a resource-limited setting. This study aims to determine the effect of perioperative blood transfusion on the 30-day risk of surgical site infections (SSIs) and mortality among patients undergoing emergency non-trauma laparotomy in a large urban tertiary hospital in a resource-limited setting. Methodology In this prospective, single-center, cohort study, we recruited 160 consecutive adult patients admitted to the general surgery wards 48 hours after emergency non-trauma laparotomy. We grouped them based on transfusion exposure status. Transfusion exposure and possible confounders were recorded on entry, while the presence or absence of SSIs and mortality were obtained over 30 days of follow-up. The data were analyzed using Epi Info version 7 and Stata version 14. P-values <0.05 indicated statistical significance. Results All 160 participants recruited, 28 (17.5%) transfusion-exposed and 132 (82.5%) non-exposed, were included in the final analysis. Transfusion exposure (relative risk = 8.16; 95% confidence interval (CI) = 2.73-24.37; p < 0.001) was an independent risk factor for SSI after multivariate logistic regression analysis adjusted for confounders. Inverse probability weighting with regression adjustment (IPWRA) revealed that transfusion exposure significantly increased the incidence of SSI by 36.2% (95% CI = 14.2%-58.2%; p = 0.001). Furthermore, transfusion exposure (hazard ratio (HR) = 3.62; 95% CI = 1.28-10.27; p = 0.015) and age ≥60 years (HR = 5.97; 95% CI = 1.98-18.01; p = 0.002) were independent risk factors for 30-day mortality after multivariate Cox regression analysis adjusted for confounders. IPWRA revealed that transfusion exposure significantly increased the incidence of mortality by 17.6% (95% CI = 1.4%-33.8%; p = 0.033). Conclusions This study suggests an independent association between perioperative blood transfusion and the occurrence of SSIs and mortality among patients undergoing emergency non-trauma laparotomy. A larger multicenter prospective cohort study considering more confounders and the use of established restrictive transfusion protocols is recommended.

Interactions and Trends of Interleukins, PAI-1, CRP, and TNF-α in Inflammatory Responses during the Perioperative Period of Joint Arthroplasty: Implications for Pain Management-A Narrative Review

Inflammation during the perioperative period of joint arthroplasty is a critical aspect of patient outcomes, influencing both the pathophysiology of pain and the healing process. This narrative review comprehensively evaluates the roles of specific cytokines and inflammatory biomarkers in this context and their implications for pain management. Inflammatory responses are initiated and propagated by cytokines, which are pivotal in the development of both acute and chronic postoperative pain. Pro-inflammatory cytokines play essential roles in up-regulating the inflammatory response, which, if not adequately controlled, leads to sustained pain and impaired tissue healing. Anti-inflammatory cytokines work to dampen inflammatory responses and promote resolution. Our discussion extends to the genetic and molecular influences on cytokine production, which influence pain perception and recovery rates post-surgery. Furthermore, the role of PAI-1 in modulating inflammation through its impact on the fibrinolytic system highlights its potential as a therapeutic target. The perioperative modulation of these cytokines through various analgesic and anesthetic techniques, including the fascia iliac compartment block, demonstrates a significant reduction in pain and inflammatory markers, thus underscoring the importance of targeted therapeutic strategies. Our analysis suggests that a nuanced understanding of the interplay between pro-inflammatory and anti-inflammatory cytokines is required. Future research should focus on individualized pain management strategies.

Intraoperative cell salvage: The impact on immune cell numbers

BACKGROUND

Patient outcomes are influenced by many confounding factors peri-operatively, including the type of surgery, anaesthesia, transfusion, and immune competence. We have previously demonstrated (in-vitro) that compared to allogeneic blood transfusion (ABT), intraoperative cell salvage (ICS) improves immune competence. The peri-operative immune response is complex. Altered or impaired immune responses may predispose patients to develop adverse outcomes (i.e., post-operative wound infection, pneumonia, urinary tract infection etc.) Surgical patients may develop infection, even without the confirmed presence of a definite microbiological pathogen. With all these factors in mind it is important to consider changes in immune cell numbers (and sub-populations) and functional capacity during peri-operative transfusion.

METHODS

In this TRIMICS-Cell (Transfusion Related Immune Modulation and Intraoperative Cell Salvage-Cell numbers) study (n = 17, October 2018-November 2019) we prioritized and analysed peri-operative changes in the number and proportions of immune cell populations and sub-populations (B cells (CD20+), NK (natural killer) cells (CD56+), monocytes (CD14+), T cells (total CD3+ and sub-populations: T helper cells (CD4+), cytotoxic T cells (CD8+), effector T cells (CD4+ CD127+), activated effector T cells (CD4+ CD25+ CD127+) and regulatory T cells (CD4+ CD25+ CD127-)), plasmacytoid dendritic cells (pDC; Lineage-, HLA-DR+, CD11c-, CD123+), classical dendritic cell (cDC) (Lineage-, HLA-DR+, CD11c+), and cDC activation (Lineage-, HLA-DR+, CD11c+), co-stimulatory/adhesion molecules and pDC (CD9+, CD38+, CD80+, CD83+, CD86+, CD123+). Firstly we analysed the whole cohort of study patients and secondly according to the relevant transfusion modality (i.e., three study groups: those who received no transfusion, received ICS only (ICS), or both ICS and allogeneic packed red blood cells (pRBC) (ICS&RBC)), during major orthopaedic surgery.

RESULTS

For the whole study cohort (all patients), changes in immune cell populations were significant: leucocytes and specifically neutrophils increased post-operatively, returning towards pre-operative numbers by 48h post-operatively (48h), and lymphocytes reduced post-operatively returning to pre-operative numbers by 48h. When considering transfusion modalities, there were no significant peri-operative changes in the no transfusion group for all immune cell populations studied (cell numbers and proportions (%)). Significant changes in cell population numbers (i.e., leucocytes, neutrophils and lymphocytes) were identified in both transfused groups (ICS and ICS&RBC). Considering all patients, changes in immune cell sub-populations (NK cells, monocytes, B cells, T cells and DCs) and functional characteristics (e.g., co-stimulation markers, adhesion, activation, and regulation) were significant peri-operatively and when considering transfusion modalities. Interestingly DC numbers and functional capacity were specifically altered following ICS compared to ICS&RBC and pDCs were relatively preserved post-operatively following ICS.

CONCLUSION

A transient peri-operative alteration with recovery towards pre-operative numbers by 48h post-surgery was demonstrated for many immune cell populations and sub-populations throughout. Immune cell sub-populations and functional characteristics were similar peri-operatively in those who received no transfusion but changed significantly following ICS and ICS&RBC. Interesting changes that require future study are a post-operative monocyte increase in the ICS&RBC group, changes in cDC considering transfusion modalities, and possibly preserved pDC numbers post-operatively following ICS. Future studies to assess changes in immune cell sub-populations, especially during peri-operative transfusion, while considering post-operative adverse outcomes, is recommended.

The optimal time of starting adjuvant chemotherapy after curative surgery in patients with colorectal cancer

BACKGROUND

Postoperative adjuvant chemotherapy (AC) is now well-accepted as standard for high-risk stage II and stage III colorectal cancer (CRC) patients, however the optimal time to initiate AC remains elusive.

METHODS

A comprehensive literature search was performed using the PubMed and Embase databases. The Hazard ratio (HR) with the corresponding 95% confidence interval (CI) was used as an effect measure to evaluate primary endpoints. All analyses were conducted using Stata software version 12.0 with the Random-effects model.

RESULTS

A total of 30 studies were included in our study. Upon comparison on overall survival (OS), we identified that delaying the initiation of AC for > 8 weeks after operation was significantly associated with poor OS (HR: 1.37; 95% CI: 1.27-1.48; P < 0.01). The poor prognostic value of AC delay for > 8 weeks was not undermined by subgroup analysis based on region, tumor site, sample size and study quality. No obvious differences were observed in survival between AC within 5-8 weeks and ≤ 4 weeks (HR: 1.03; 95% CI: 0.96 -1.10; P = 0.46). Moreover, two studies both highlighted that the survival benefit of AC was still statistically significant when AC was applied 5-6 months after surgery compared with the non-chemotherapy group.

CONCLUSIONS

Delaying the initiation of AC for > 8 weeks after surgery was significantly associated with poor OS. AC started within 8 weeks after surgery brought more benefits to CRC patients. There were no obvious differences in survival benefits between AC within 5-8 weeks and ≤ 4 weeks. Compared to patients not receiving AC after surgery, a delay of approximately 5-6 months was still useful to improve prognosis.

Dynamics of immune responses are inconsistent when trauma patients are grouped by injury severity score and clinical outcomes

The injury severity score (ISS) is used in daily practice to evaluate the severity of trauma patients; however, the score is not always consistent with the prognosis. After injury, systemic inflammatory response syndrome (SIRS) and compensatory anti-inflammatory response syndrome (CARS) are related to the prognosis of trauma patients. We aimed to evaluate the associations between the immune response and prognosis in trauma patients. Patients who admitted to the Trauma Intensive Care Unit (ICU) were eligible. Whole blood samples were collected at admission, and then 6, 12, 24, 48 and 72 h after admission. Natural killer (NK) cells, lymphocyte subset population and cytokines release were identified using flow cytometry. We grouped patients by their ISS (≤ 25 and > 25 as very severe injury) and ICU stay (≤ 10 days as a short ICU stay and > 10 days as a long ICU stay) for evaluation. Fifty-three patients were enrolled. ICU stay but not ISS was close correlated with activity daily living (ADL) at discharge. Patients with a long ICU stay had an immediate increase in NK cells followed by lymphopenia which persisted for 48 h. Immediate activation of CD8⁺ T cells and then exhaustion with a higher programmed cell death-1 (PD-1) expression and suppression of CD4⁺ T cells with a shift to an anti-inflammatory Th2 phenotype were also observed in the patients with a long ICU stay. When the patients were grouped by ISS, the dynamics of immune responses were inconsistent to those when the patients were grouped by ICU stay. Immune responses are associated with the prognosis of trauma patients, however the currently used clinical parameters may not accurately reflect immune responses. Further investigations are needed to identify accurate predictors of prognosis in trauma patients.

The relationship of different preoperative inflammatory markers with the prognosis of gastric carcinoma

BACKGROUND

It is aimed to determine the prognostic values of preoperative inflammatory biomarkers in patients undergoing curative surgery for gastric carcinoma and to contribute to the development of prognostic modeling.

OBJECTIVE

To investigate the effect of various different preoperative inflammatory markers on the prognosis of gastric carcinoma.

MATERIAL AND METHOD

The medical data and the mortality status of 91 patients who underwent total or subtotal gastrectomy operation for gastric carcinoma at Mersin City Training and Research Hospital between 2016 and 2020 were retrospectively reviewed from the hospital records and patient files. The patients' demographic characteristics, tumor location, histopathological diagnosis, pathological stage, tumor markers, and preoperative inflammatory and hematological markers were analyzed. Based on these data, tumor stage, metastatic lymph node ratio (MLR), lactate dehydrogenase albumin ratio (LAR), neutrophil-lymphocyte ratio (NLR), and platelet lymphocyte ratio (PLR) were calculated. The relationship between these parameters and postoperative survival was analyzed. Statistical analyses were performed with IBM SPSS for Windows, version 17.0 (IBM Corporation, Armonk, New York, United States).

RESULTS

The correlation analysis of the parameters affecting survival showed that, in addition to an advanced tumor stage, inflammatory parameters like NLR, PLR, and LAR adversely affected survival.

CONCLUSION

Preoperative NLR, PLR, LAR, and advanced tumor stage may help determine the survival of gastric carcinoma patients. Multiple studies with larger series are needed on this subject.

The Good and the Bad: Monocytes' and Macrophages' Diverse Functions in Inflammation

Monocytes and macrophages are central players of the innate immune response and play a pivotal role in the regulation of inflammation. Thereby, they actively participate in all phases of the immune response, from initiating inflammation and triggering the adaptive immune response, through to the clearance of cell debris and resolution of inflammation. In this review, we described the mechanisms of monocyte and macrophage adaptation to rapidly changing microenvironmental conditions and discussed different forms of macrophage polarization depending on the environmental cues or pathophysiological condition. Therefore, special focus was placed on the tight regulation of the pro- and anti-inflammatory immune response, and the diverse functions of S100A8/S100A9 proteins and the scavenger receptor CD163 were highlighted, respectively. We paid special attention to the function of pro- and anti-inflammatory macrophages under pathological conditions.

Flow cytometry-based high-throughput RNAi screening for miRNAs regulating MHC class II HLA-DR surface expression

HLA‐DR isotype is a MHC‐II cell‐surface receptor found on APCs and plays a key role in initiating immune responses. In severely immunocompromised patients with conditions like sepsis, the number of HLA‐DR molecules expressed on leukocytes is considered to correlate with infectious complications and patients’ probability of survival. The underlying regulatory mechanisms of HLA‐DR expression remain largely unknown. One probable path to regulation is through microRNAs (miRNAs), which have been implicated as regulatory elements of both innate and adaptive immune system development and function. In our study, flow cytometry‐based high‐throughput miRNA screening was performed in a stable HLA‐DR‐expressing human melanoma cell line, MelJuSo, for either up‐ or downregulating miRNAs of the surface HLA‐DR expression. By the end of the screening, the top ten upregulators and top five downregulators were identified, and both the HLA‐DR protein and mRNA regulations were further verified and validated. In‐silico approaches were applied for functional miRNA‐mRNA interaction prediction. The potential underlying gene regulations of different miRNAs were proposed. Our results promote the study of miRNA‐mediated HLA‐DR regulation under both physiological and pathological conditions, and may pave the way for potential clinical applications.

Transient Liver Damage and Hemolysis Are Associated With an Inhibition of Ebola Virus Glycoprotein-Specific Antibody Response and Lymphopenia

Numerous studies have demonstrated the importance of the adaptive immunity for survival following Ebola virus (EBOV) infection. To evaluate the contribution of tissue damage to EBOV-induced immune suppression, acute liver damage or hemolysis, 2 symptoms associated with lethal EBOV infection, were chemically induced in vaccinated mice. Results show that either liver damage or hemolysis was sufficient to inhibit the host humoral response against EBOV glycoprotein and to drastically reduce the level of circulating T cells. This study thus provides a possible mechanism for the limited specific antibody production and lymphopenia in individuals with lethal hemorrhagic fever infections.

A Micro-Environment Regulator for Filling the Clinical Treatment Gap after a Glioblastoma Operation

The rapid postoperative recurrence and short survival time of glioblastoma (GBM) patients necessitate immediate and effective postoperative treatment. Herein, an immediate and mild postoperative local treatment strategy is developed that regulates the postoperative microenvironment and delays GBM recurrence. Briefly, an injectable hydrogel system (imGEL) loaded with Zn(II)₂ -AMD3100 (AMD-Zn) and CpG oligonucleotide nanoparticles (CpG NPs) is injected into the operation cavity, with long-term function to block the recruitment of microglia/ macrophages and activate cytotoxic T cells. The finding indicated that the imGEL can regulate the immune microenvironment, inhibit GBM recurrence, and gain valuable time for subsequent adjuvant clinical chemotherapy.

Potential Immune Indicators for Predicting the Prognosis of COVID-19 and Trauma: Similarities and Disparities

Although cellular and molecular mediators of the immune system have the potential to be prognostic indicators of disease outcomes, temporal interference between diseases might affect the immune mediators, and make them difficult to predict disease complications. Today one of the most important challenges is predicting the prognosis of COVID-19 in the context of other inflammatory diseases such as traumatic injuries. Many diseases with inflammatory properties are usually polyphasic and the kinetics of inflammatory mediators in various inflammatory diseases might be different. To find the most appropriate evaluation time of immune mediators to accurately predict COVID-19 prognosis in the trauma environment, researchers must investigate and compare cellular and molecular alterations based on their kinetics after the start of COVID-19 symptoms and traumatic injuries. The current review aimed to investigate the similarities and differences of common inflammatory mediators (C-reactive protein, procalcitonin, ferritin, and serum amyloid A), cytokine/chemokine levels (IFNs, IL-1, IL-6, TNF-α, IL-10, and IL-4), and immune cell subtypes (neutrophil, monocyte, Th1, Th2, Th17, Treg and CTL) based on the kinetics between patients with COVID-19 and trauma. The mediators may help us to accurately predict the severity of COVID-19 complications and follow up subsequent clinical interventions. These findings could potentially help in a better understanding of COVID-19 and trauma pathogenesis.

Incidence of anti-D alloimmunization in D-negative individuals receiving D-positive red blood cell transfusion: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

The transfusion of D-negative red blood cells (RBCs) to D-negative patients has been widely adopted to prevent anti-D alloimmunization, especially in women of childbearing age. Still, transfusion of D-positive RBCs to D-negative recipients is occasionally inevitable in practice, and the resulting incidence of anti-D in different D-negative groups of patients has not been well summarized.

MATERIALS AND METHODS

We searched the relevant literature using PubMed, Cochrane Library, and Embase databases from inception date to 30 September 2021. We looked for studies of anti-D occurring in D-negative recipients who received D-positive RBC transfusions. The anti-D incidence was summarized with 95% confidence intervals (CIs). Data with similar characteristics were combined using a random-effects model.

RESULTS

About 42 studies (2226 cases), which found anti-D, the exact volume of D-positive RBC transfused, and the follow-up time for anti-D detection, met the inclusion criteria. The pooled anti-D incidence was 64% (95% CI, range 55%-74%) in volunteers receiving small volumes of D-positive RBCs, 84% (95% CI, 74%-94%) in those receiving whole units, 26% (95% CI, 19%-32%) in mixed patients, 12% (95% CI, 8%-16%) in oncology patients, 27% (95% CI, 13%-40%) in trauma patients, 4% (95% CI, 0%-8%) in immune-compromised transplant patients, and 6% (95% CI, 1%-39%) in those with AIDS.

CONCLUSION

Compared with the high frequency of anti-D in healthy D-negative volunteers given D-positive RBCs, we found a lower rate of anti-D immunization in various D-negative patients and almost none in transplant and AIDS patients.

The Value of the C-Reactive Protein-to-Lymphocyte Ratio for Predicting Lymphovascular Invasion Based on Nutritional Status in Gastric Cancer

Preoperative nutrition and inflammation are closely related to tumors (T). Many hematological marker assessment tools comprise nutritional and systemic inflammatory indexes, evaluating essential factors for cancer nutrition, growth, and progression. This study retrospectively investigated whether the C-reactive protein (CRP)-to-lymphocyte ratio (CLR) could predict lymphovascular invasion (LVI) in gastric cancer (GC) patients based on their nutritional status. We included 262 patients who underwent GC surgery between 2019 and 2020. The patient's nutritional status was assessed using the Patient-Generated Subjective Global Assessment (PG-SCA), and patients with scores ≥4 were classified as malnourished. First, we examined 7 hematological marker combinations using receiver operating characteristic (ROC) curves to determine which one best predicted malnutrition. The CLR predicted malnutrition more accurately than other ratios (area under the curve: 0.62, 95% confidence interval [CI]: 0.55-0.69, P = .002); the optimal cut-off value for malnutrition was 1.04. Next, we evaluated the relationship between the 7 combinations and postoperative LVI. A CLR higher than 1.04 (odds ratio [OR]: 1.81, 95% CI: 1.09-3.00, P = .021) and a platelet-to-lymphocyte ratio (PLR) higher than 129.00 (OR: 1.64, 95% CI: 1.00-2.67, P = .049) were associated with LVI in the univariate analysis, and the CLR was an independent predictor of LVI in the multivariate analysis (OR: 1.73, 95% CI: 1.04-2.87, P = .036). The preoperative CLR can assess nutritional status and independently predict LVI in GC.

Effects of two formulations containing Phyllanthus emblica and Tinospora cordifolia with and without Ocimum sanctum in immunocompromised mice

Background

Current pandemic has led us to explore the role of traditional system of medicine to look for formulations that enhance immunity.

Objective

The obejctive of this experimental study was to evaluate the immunomodulatory effects of two formulations, Tinospora cordifolia (Tc) and Phyllanthus emblica (Pe) with and without coating of Ocimum sanctum (Os).

Materials and methods

After obtaining Institutional Animal Ethics Committee approval, present experimental study was conducted to evaluate the immunomodulatory effects of plant drug formulations against infection induced in mice subjected to major surgical stress. Hemisplenectomy was selected to induce major stress and the procedure for hemisplenectomy was standardized. A model of secondary fungal infection after hemisplenectomy was established followed by the treatment of mice with plant drugs and controls. They were subjected to hemisplenectomy or sham operation and 10⁵ C. albicans were injected intravenously. The therapy continued for next 14 days. Kidneys were isolated to estimate fungal load. Fungal load of the kidneys was estimated on post-operative Day 15.

Results

The test formulations Tc + Pe and Tc + Pe + Os showed significant reduction in the fungal burden of kidneys as compared to hemisplenectomized control group. However, Tc alone exerted better degree of protection as compared to Tc + Pe and Tc + Pe + Os.

Conclusion

The formulations, Tc + Pe and Tc + Pe + Os that were developed on the basis of theoretical concepts were not found to be superior to Tc. Though the individual ingredients have been shown to possess immunnostimulant activities, in combination, Pe and Os blunted the effects of Tc. The basis for this drug interaction needs further exploration. Thus, the current experimental study validates immunomodulatory role of Tc. However, the addition of Pe with bhavana of Os does not lead to any augmentation of immunomodulatory activity of Tc. This study also underlines the need to generate data on Ayurveda formulations to understand the rationality of the multi-ingredient Ayurvedic formulations.

Timing of adjuvant chemotherapy after limb amputation and effect on outcome in dogs with appendicular osteosarcoma without distant metastases

OBJECTIVE

To determine an optimal time interval between amputation and initiation of adjuvant chemotherapy (TI_amp-chemo) in dogs with appendicular osteosarcoma without distant metastases and whether TI_amp-chemo was associated with outcome.

ANIMALS

168 client-owned dogs treated at 9 veterinary oncology centers.

PROCEDURES

Data were collected from the dogs' medical records concerning potential prognostic variables and outcomes. Dogs were grouped as to whether they received chemotherapy within 3, 5, 7, 10, 15, 20, 30, or > 30 days after amputation of the affected limb. Analyses were performed to identify variables associated with time to tumor progression and survival time after limb amputation and to determine an optimal TI_amp-chemo.

RESULTS

Median TI_amp-chemo was 14 days (range, 1 to 210 days). Median time to tumor progression for dogs with a TI_amp-chemo ≤ 5 days (375 days; 95% CI, 162 to 588 days) was significantly longer than that for dogs with a TI_amp-chemo > 5 days (202 days; 95% CI, 146 to 257 days). Median overall survival time for dogs with a TI_amp-chemo ≤ 5 days (445 days; 95% CI, 345 to 545 days) was significantly longer than that for dogs with a TI_amp-chemo > 5 days (239 days; 95% CI, 186 to 291 days).

CONCLUSIONS AND CLINICAL RELEVANCE

Findings indicated that early (within 5 days) initiation of adjuvant chemotherapy after limb amputation was associated with a significant and clinically relevant survival benefit for dogs with appendicular osteosarcoma without distant metastases. These results suggested that the timing of chemotherapy may be an important prognostic variable.

Anti-D alloimmunization in Rh(D) negative adults with severe traumatic injury

INTRODUCTION

Widely varying rates of alloimmunization associated with transfusing uncrossmatched RBC products to trauma patients as part of hemostatic resuscitation have been reported. We characterized the rates of RBC alloimmunization in our severely injured Rh(D) negative trauma population who received uncrossmatched Rh(D) positive RBC products.

METHODS

In a 10-year retrospective analysis to assess Rh(D) alloimmunization risks, Rh(D) negative adult trauma patients initially requiring uncrossmatched group O Rh(D) positive RBC products with either RBC units or low titer group O whole blood as part of massive transfusion protocol (MTP) activation were identified. Only those Rh(D) negative patients whose initial antibody screenings were negative were included. Duration of serologic follow-up from date of MTP activation to either date of anti-D detection or most recent negative antibody screening was calculated.

RESULTS

There were 129 eligible Rh(D) negative trauma patients identified. Median injury severity score was 25. Anti-D was detected in 10 (7.8%) patients after a median of 161.5 days; the median duration of serologic follow-up in those who did not have anti-D detected was 220 days. Patients who had anti-D detected were less severely injured and received fewer Rh(D) positive RBC products versus those who did not.

DISCUSSION

In our severely injured adult trauma patients with MTP activation requiring uncrossmatched group O Rh(D) positive RBC products, the rate of anti-D detection was low. Additional studies are necessary to determine generalizability of these findings and fully characterize alloimmunization risks in trauma patients with varying extents of injury.

Clinical Outcomes of Ileostomy Closure before Adjuvant Chemotherapy after Rectal Cancer Surgery: An Observational Study from a Chinese Center

Background

The optimal timing of temporary ileostomy closure with respect to the time of adjuvant chemotherapy following sphincter-saving surgery for rectal cancer remains unclear. The aim of this study is to investigate the clinical and oncological outcomes of ileostomy closure before, during, and after adjuvant chemotherapy following curative rectal cancer resection.

Methods

Patients diagnosed with rectal adenocarcinoma who underwent low anterior resection and temporary loop ileostomy during May 2015 and September 2019 were retrospectively evaluated. Patients undergoing ileostomy closure before adjuvant chemotherapy (Group I) were compared to patients undergoing closure during (Group II) and after (Group III) adjuvant chemotherapy.

Results

A total of 225 patients were evaluated for eligibility, and 132 were finally selected and divided into 3 groups (24 in Group I, 53 in Group II, and 55 in Group III). No significant differences were observed in operative time, postoperative hospital stay, postoperative complications, total adjuvant chemotherapy cycles, and low anterior resection syndrome scores among the three groups. There was no significant difference in disease-free survival (p = 0.834) and overall survival (p = 0.462) between the three groups.

Conclusion

Temporary ileostomy closure before adjuvant chemotherapy following curative rectal cancer resection can achieve a clinical and oncological safety level equal to stoma closure during or after chemotherapy in selected patients.

[Surgical site infections-Prevention and treatment strategies]

Surgical site infections (SSI) are the most frequent nosocomial infection in Germany. They are defined as an infection of the surgical site that occurs within 30 days after a surgical procedure. The diagnostic criteria include localized pain or tenderness, localized swelling, erythema, excess warmth, purulent drainage from the incision and cultural detection of pathogens in an aseptically obtained specimen from the incision. Wound infections are differentiated into superficial incisional (grade 1), deep incisional (grade 2) and infections of organs and body cavities in the region of the operation (grade 3). Risk factors for SSI include anemia, immunosuppression, diabetes mellitus, obesity, smoking and malnutrition. The crucial preoperative preventive measures are antisepsis of the surgical area and antibiotic prophylaxis. Intraoperative subcutaneous wound irrigation with an antiseptic solution reduces SSI in visceral surgery. The primary treatment encompasses the liberal debridement of the wound.

Computational Derivation of Core, Dynamic Human Blunt Trauma Inflammatory Endotypes

Systemic inflammation ensues following traumatic injury, driving immune dysregulation and multiple organ dysfunction (MOD). While a balanced immune/inflammatory response is ideal for promoting tissue regeneration, most trauma patients exhibit variable and either overly exuberant or overly damped responses that likely drive adverse clinical outcomes. We hypothesized that these inflammatory phenotypes occur in the context of severe injury, and therefore sought to define clinically distinct endotypes of trauma patients based on their systemic inflammatory responses. Using Patient-Specific Principal Component Analysis followed by unsupervised hierarchical clustering of circulating inflammatory mediators obtained in the first 24 h after injury, we segregated a cohort of 227 blunt trauma survivors into three core endotypes exhibiting significant differences in requirement for mechanical ventilation, duration of ventilation, and MOD over 7 days. Nine non-survivors co-segregated with survivors. Dynamic network inference, Fisher Score analysis, and correlations of IL-17A with GM-CSF, IL-10, and IL-22 in the three survivor sub-groups suggested a role for type 3 immunity, in part regulated by Th17 and γδ 17 cells, and related tissue-protective cytokines as a key feature of systemic inflammation following injury. These endotypes may represent archetypal adaptive, over-exuberant, and overly damped inflammatory responses.

Postoperative cancer treatments: In-situ delivery system designed on demand

The keys to the prevention of tumor recurrence after operation are the elimination of residual tumor cells and the reversal of microenvironments that induce recurrence. In the formulation of a treatment scheme, building an appropriate drug delivery system is essential. An in-situ drug delivery system (ISDDS) is regarded as an effective treatment route for postoperative use that increases drug delivery efficiency and mitigates side-effects. ISDDS technology has been considerably improved through a clearer understanding of the mechanisms of postoperative recurrence and the development of drug delivery materials. This paper describes the initiation and characteristics of postoperative recurrence mechanisms. Based on this information, design principles for ISDDS are proposed, and a variety of practical drug delivery systems that fulfil specific therapeutic needs are presented. Challenges and future opportunities related to the application of in-situ drug carriers for inhibiting cancer recurrence are also discussed.

Does the timing of protective ileostomy closure post-low anterior resection have an impact on the outcome? A retrospective study

BACKGROUND

The optimal timing for ileostomy closure remains controversial, most of the surgeons are closing ileostomy after two to three months, although ileostomy closure considered a simple procedure, it can cause significant morbidity; this study aims to clarify any relation between the post-closure complications rate and the time from its creation to the repair.

METHOD

From January 2010 to December 2017, data retrieved for a 405 patients who had protective ileostomy closure after rectal cancer surgery, our sample has been enrolled into two arms, the first arm includes whose ileostomies closed at or before three months, and the second arm involved whose ileostomies closed after three months from the index surgery, statistical analysis was performed and compared in both arms, RESULT: The overall post-closure complications in our hospital was 23.7%, there was no significant difference between the overall complications rate for both early and late closure groups (26.8% and 22.7%) respectively (P = 0.499), The majority of the complications were intestinal obstruction, and superficial surgical site infection, there was no significant association between the interval to ileostomy reversal and the intestinal obstruction although it was higher in the late closure group, in the other hand the surgical site infection complication found to be significantly higher in the early closure group than the late closure group (15.4% Vs 5.1%) with (P = 0.002).

CONCLUSION

The duration between the creation of protective ileostomy and its reversal was not a significant independent predictor of post-closure complications rate.

Hematological and Chemical Profiles in a Porcine Model of Severe Multiple Trauma

BACKGROUND

Clinical chemistry and hematological tests are widely used to monitor the clinical course of several diseases. However, these parameters are sparse in large-animal models of multiple trauma (MT). Thus, we aimed to provide these missing data to improve future experimental setups in trauma research.

METHODS

Male pigs (German Landrace pigs) were randomized into either an MT group (n = 8) including blunt thoracic trauma, tibial fracture, and controlled hemorrhage or a sham group (n = 8) without any trauma. After trauma induction, all animals received intensive care treatment for 72 h under anesthesia, including mechanical ventilation and volume resuscitation. Blood and urine samples were obtained to measure common hematological and chemical parameters before trauma (0 h), after trauma (1.5 h), during resuscitation (2.5 h), after fracture stabilization (3.5 h), and at 12, 24, 48, and 72 h. Statistical analyses were performed using a linear mixed model (group × time) and Welch's ANOVA.

RESULTS

MT led to a perceptible immunological reaction. Between groups, significantly different time courses of leukocyte counts (p = 0.034) and lymphocyte proportions (p = 0.001) were observed. Moreover, MT changed the time course of total protein (p = 0.006). Significantly lower concentrations compared to sham were found in MT at each single time point starting at 1.5 h to the end of the observation period (all p < 0.05).

CONCLUSIONS

Our results indicate that a traumatic insult leads to significant alterations in the immune system already shortly after trauma. Together with the additional catabolic reactions observed, these alterations might contribute to the occurrence of later complications. The presented data provide valid references for further experimental setups with prolonged observation times, especially in similar porcine models of MT.

Operative Trauma and Blood Loss - Impact on Tumor Growth and Recurrence

ABSTRACT

In cancer patients, surgical removal of the primary tumor is one of the major steps within a multimodal therapy concept toward eliminating the disease and limiting further progression. In this respect, surgical trauma can have potent effects on the patient's immune system. Intraoperative blood loss associated with major surgical trauma leads to reduced blood flow, regional hypoxia, metabolic, and microenvironmental alterations stimulating an inflammatory response characterized by the release of pro-inflammatory cytokines (i.e., TNF-α, IL-6) and acute-phase proteins. The inflammatory state is accompanied by and intertwined with a counter-regulatory anti-inflammatory response reflected in the rise of anti-inflammatory cytokines (i.e., transforming growth factor-β) and prostaglandins (i.e., prostaglandin E2) which can lead to a depression of cell-mediated immunity and systemic immunosuppression. This results in a highly vulnerable state with concurrent expression of pro- and anti-inflammatory cytokines alternately predominating. The immunosuppressive state is characterized by a reduced antigen-presentation capacity of macrophages, alterations in lymphocyte proliferation, and activation as well as a shift of the Th1/Th2 (T helper cells 1 and 2) balance toward Th2 and a decrease in natural killer cell activity. The severity of the immunosuppression thereby correlates with the extent and the duration of the surgical procedure. Growing evidence suggests that the immunosuppressive state following hemorrhage and surgical trauma might not only be a risk factor for postoperative complications but also facilitate tumor proliferation, metastatic growth, and recurrence. This article provides an overview of the cascade of events and underlying mechanisms resulting in immunosuppression and describes the impact of hemorrhage and major surgical trauma on tumor growth and recurrence. Attempts to control for perioperative inflammation thereby reducing the adverse effects of postoperative immunosuppression could have positive effects on tumor growth, metastasis formation, and recurrence.

Damage-associated molecular patterns in trauma

In 1994, the "danger model" argued that adaptive immune responses are driven rather by molecules released upon tissue damage than by the recognition of "strange" molecules. Thus, an alternative to the "self versus non-self recognition model" has been provided. The model, which suggests that the immune system discriminates dangerous from safe molecules, has established the basis for the future designation of damage-associated molecular patterns (DAMPs), a term that was coined by Walter G. Land, Seong, and Matzinger. The pathological importance of DAMPs is barely somewhere else evident as in the posttraumatic or post-surgical inflammation and regeneration. Since DAMPs have been identified to trigger specific immune responses and inflammation, which is not necessarily detrimental but also regenerative, it still remains difficult to describe their "friend or foe" role in the posttraumatic immunogenicity and healing process. DAMPs can be used as biomarkers to indicate and/or to monitor a disease or injury severity, but they also may serve as clinically applicable parameters for optimized indication of the timing for, i.e., secondary surgeries. While experimental studies allow the detection of these biomarkers on different levels including cellular, tissue, and circulatory milieu, this is not always easily transferable to the human situation. Thus, in this review, we focus on the recent literature dealing with the pathophysiological importance of DAMPs after traumatic injury. Since dysregulated inflammation in traumatized patients always implies disturbed resolution of inflammation, so-called model of suppressing/inhibiting inducible DAMPs (SAMPs) will be very briefly introduced. Thus, an update on this topic in the field of trauma will be provided.

Is Early Initiation of Adjuvant Chemotherapy Beneficial for Locally Advanced Rectal Cancer Following Neoadjuvant Chemoradiotherapy and Radical Surgery?

AIM

This study aimed to evaluate whether earlier initiation (< 4 weeks) of adjuvant chemotherapy (ACT) confer any oncological benefits for locally advanced rectal cancer (LARC) patients undergoing neoadjuvant chemoradiotherapy (nCRT) and radical surgery.

METHOD

Clinicopathological and survival outcomes were compared. Propensity score matching (PSM) was performed to adjust for differences between groups. Cox regression analysis was performed to evaluate the impact of earlier ACT initiation on overall survival (OS) and disease-free survival (DFS).

RESULTS

Totally, 443 eligible patients were included. More laparoscopic surgeries, less postoperative complications, and more ACT completion were observed in patients whose ACT was initiated within 4 weeks after surgery (all P < 0.001). With a mean follow-up of 59 months, the 5-year OS and DFS rate was 89.8% and 82.0% in the early group, significantly higher than 81.6% and 73.1% in the late group (P = 0.007, and P = 0.022, respectively). After PSM, the 5-year OS and DFS rate was 90.9% and 84.4% in the early group, significantly higher than 83.4% and 68.8% in the late group (P = 0.047, and P = 0.017, respectively). Cox regression analysis demonstrated that time to ACT initiation (early vs. late, HR = 0.486, P = 0.008) was independently associated with OS.

CONCLUSION

Early initiation of ACT (<4 weeks) confers a survival benefit, and is an independent prognostic factor of OS in LARC patients following nCRT. Further investigations are needed to define the role of earlier initiation of ACT in patients with LARC after nCRT.

Risk Factors of Bacteremia following Multiple Traumas

Background

Bacteremia is a major nosocomial infection that frequently occurs in trauma patients, increasing morbidity and mortality. The aim of this study was to identify risk factors and to describe epidemiological patterns for early onset (EOB) and late onset (LOB) bacteremia after trauma.

Methods

We retrospectively reviewed medical records of all trauma patients admitted to the surgical intensive care unit and general ward between January 2011 and December 2015. The information was collected for each patient and recorded in a computer database: early onset bacteremia (EOB) was defined as when onset occurred within 7 days after trauma, and late onset bacteremia (LOB) was defined as when onset occurred after 7 days from trauma.

Results

Thirty-four patients of 859 (4%) developed bacteremia during their hospital stay: 4 (11.8%) developed EOB, 26 (76.4%) LOB, and 4 (11.8%) patients developed both of them. Sixty events of bacteremia happened to these patients: 9 (15.0%) EOB and 51 (85.0%) LOB. Gram-positive cocci were isolated more frequently than Gram-negative bacilli in both groups. Gram-positive cocci were more frequently isolated in EOB than in LOB; otherwise, there was no statistical significance (77.8% vs. 64.7%, p=0.683). Central line-associated blood stream infection (CLABSI) and surgical site infection (SSI) were the most common identified source for LOB. Presence of liver (OR: 2.66, p=0.035) and pelvic injury (OR: 2.25, p=0.038), gastrointestinal tract perforation (OR: 5.48, p=0.002), and massive transfusion (OR: 3.36, p=0.006) represented risk factors for bacteremia.

Conclusions

Presence of pelvic and liver injury on arrival in emergency department, gastrointestinal tract perforation, and massive transfusion within the first 24 hours after trauma appears to be significant risk factors for bacteremia.

A Review of the Effects of Pain and Analgesia on Immune System Function and Inflammation: Relevance for Preclinical Studies

One of the most significant challenges facing investigators, laboratory animal veterinarians, and IACUCs, is how to balance appropriate analgesic use, animal welfare, and analgesic impact on experimental results. This is particularly true for in vivo studies on immune system function and inflammatory disease. Often times the effects of analgesic drugs on a particular immune function or model are incomplete or don't exist. Further complicating the picture is evidence of the very tight integration and bidirectional functionality between the immune system and branches of the nervous system involved in nociception and pain. These relationships have advanced the concept of understanding pain as a protective neuroimmune function and recognizing pathologic pain as a neuroimmune disease. This review strives to summarize extant literature on the effects of pain and analgesia on immune system function and inflammation in the context of preclinical in vivo studies. The authors hope this work will help to guide selection of analgesics for preclinical studies of inflammatory disease and immune system function.

Preoperative lymphocyte-to-monocyte ratio predicts postoperative infectious complications after laparoscopic colorectal cancer surgery

BACKGROUND AND AIM

Postoperative infectious complications (POI), which can increase length of hospital stay, medical cost, and worsen overall survival, are a concern in minimally invasive colorectal cancer (CRC) surgeries. Recent reports showed that relatively new inflammation-based score, lymphocyte-to-monocyte ratio (LMR) is an independent predictor of long-term outcomes after CRC surgeries. In this study, LMR was evaluated as a predictor of short-term postoperative outcomes.

PATIENTS AND METHODS

This was a single-institutional retrospective study of 211 consecutive patients who had undergone laparoscopic CRC surgery with primary tumor resection from January 2014 to August 2015 at Nippon Medical School Chiba Hokusoh Hospital. The patients were divided into two groups (no POI; n = 176 and POI; n = 35). The associations between inflammation-based scores, namely neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and LMR, and the occurrence of POI were investigated. Receiving operator characteristic curve analysis was used to determine the cutoff point of preoperative LMR.

RESULTS

Low LMR (cut-off 3.46), long operative time, and smoking were found to be independent predictors of POI in a multivariate analysis (LMR: Odds ratio 5.61, 95% confidence interval 1.98-15.9, P = 0.001). Patients with low LMR also appeared to have more advanced and aggressive tumours.

CONCLUSION

This is the first study to report that the lower LMR is a predictive factor of POI after laparoscopic CRC surgery, and it may provide additional information for treatment decisions to prevent POI.

Perioperative Blood Transfusion is Associated with Postoperative Systemic Inflammatory Response and Poorer Outcomes Following Surgery for Colorectal Cancer

Background

The present study investigated relationships between perioperative blood transfusion, postoperative systemic inflammatory response, and outcomes following surgery for colorectal cancer.

Methods

Data were recorded for patients (n = 544) undergoing potentially curative, elective surgery for colorectal cancer at a single center between 2012 and 2017. Transfusion history was obtained retrospectively from electronic records. Associations between blood transfusion, postoperative C-reactive protein (CRP), albumin, hemoglobin, complications, cancer-specific survival and overall survival (OS) were assessed using propensity score matching (n =116).

Results

Of 544 patients, the majority were male (n =294, 54%), over 65 years of age (n =350, 64%), and with colonic (n =347, 64%) node-negative disease (n =353, 65%). Eighty-six patients (16%) required perioperative blood transfusion. In the unmatched cohort, blood transfusion was associated with higher median postoperative day (POD) 3 CRP {143 [interquartile range (IQR) 96–221 mg/L] vs. 120 (IQR 72–188 mg/L); p = 0.004}, lower median POD 3 albumin [24 (IQR 20–26 g/L) vs. 27 (IQR 24–30 g/L); p < 0.001], more postoperative complications [odds ratio (OR) 3.28, 95% confidence interval (CI) 2.03–5.29] and poorer OS [hazard ratio (HR) 3.18, 95% CI 2.08–4.84]. In the propensity score matched cohort, blood transfusion was similarly associated with higher median POD 3 CRP [130 (IQR 93–196 mg/L) vs. 113 (IQR 66–173 mg/L); p = 0.046], lower median POD 3 albumin [24 (IQR 20–26 g/L) vs. 26 (IQR 24–30 g/L); p < 0.001], more postoperative complications (OR 2.91, 95% CI 1.36–6.20) and poorer OS (HR 2.38, 95% CI 0.99–5.73).

Conclusions

Perioperative blood transfusion was associated with postoperative inflammation, complications, and poorer survival in patients undergoing colorectal cancer surgery, with and without propensity score techniques.

Biomarkers for Evaluating the Inflammation Status in Patients with Cancer

Inflammation can be a causative factor for carcinogenesis or can result from a consequence of cancer progression. Moreover, cancer therapeutic interventions can also induce an inflammatory response. Various inflammatory parameters are used to assess the inflammatory status during cancer treatment. It is important to select the most optimal biomarker among these parameters. Additionally, suitable biomarkers must be examined if there are no known parameters. We briefly reviewed the published literature for the use of inflammatory parameters in the treatment of patients with cancer. Most studies on inflammation evaluated the correlation between host characteristics, effect of interventions, and clinical outcomes. Additionally, the levels of C-reactive protein, albumin, lymphocytes, and platelets were the most commonly used laboratory parameters, either independently or in combination with other laboratory parameters and clinical characteristics. Furthermore, the immune parameters are classically examined using flow cytometry, immunohistochemical staining, and enzyme-linked immunosorbent assay techniques. However, gene expression profiling can aid in assessing the overall peri-interventional immune status. The checklists of guidelines, such as STAndards for Reporting of Diagnostic accuracy and REporting recommendations for tumor MARKer prognostic studies should be considered when designing studies to investigate the inflammatory parameters. Finally, the data should be interpreted after adjusting for clinically important variables, such as age and cancer stage.

Late immune consequences of combat trauma: a review of trauma-related immune dysfunction and potential therapies

With improvements in personnel and vehicular body armor, robust casualty evacuation capabilities, and damage control resuscitation strategies, more combat casualties are surviving to reach higher levels of care throughout the casualty evacuation system. As such, medical centers are becoming more accustomed to managing the deleterious late consequences of combat trauma related to the dysregulation of the immune system. In this review, we aim to highlight these late consequences and identify areas for future research and therapeutic strategies. Trauma leads to the dysregulation of both the innate and adaptive immune responses, which places the injured at risk for several late consequences, including delayed wound healing, late onset sepsis and infection, multi-organ dysfunction syndrome, and acute respiratory distress syndrome, which are significant for their association with the increased morbidity and mortality of wounded personnel. The mechanisms by which these consequences develop are complex but include an imbalance of the immune system leading to robust inflammatory responses, triggered by the presence of damage-associated molecules and other immune-modifying agents following trauma. Treatment strategies to improve outcomes have been difficult to develop as the immunophenotype of injured personnel following trauma is variable, fluid and difficult to determine. As more information regarding the triggers that lead to immune dysfunction following trauma is elucidated, it may be possible to identify the immunophenotype of injured personnel and provide targeted treatments to reduce the late consequences of trauma, which are known to lead to significant morbidity and mortality.

Impact of epidural analgesia on the systemic biomarker response after hepatic resection

Background

Perioperative inflammation is associated with poor oncologic outcomes. Regional analgesia has been shown mitigate some of these inflammatory changes and be associated with better oncologic outcomes in patients with hepatic malignancies. The mechanism for this effect, however, remains unclear. The authors sought to compare systemic biomarker concentrations in a comprehensive and oncologically relevant panel in the perioperative setting between patients undergoing thoracic epidural analgesia (TEA) and intra-venous patient- controlled analgesia (IV-PCA) for resection of hepatic metastatic disease.

Results

Clinicopathologic variables and baseline biomarkers were similar between TEA (n = 46) and IV-PCA (n = 16) groups. Of the biomarkers which were significantly changed from baseline, there was a lower fold change from baseline in the TEA patients compared to IV-PCA including IL-6 (13.5vs19.1), MCP-1 (1.9vs3.0), IL-8 (2.4vs3.0), and Pentraxin-3 (10.8vs15.6). Overall decreased systemic concentrations of TGFb signaling were noted in TEA patients on POD1 TGFb3 (243.2 vs. 86.0, p = 0.005), POD3 TGFb1 (6558.0 vs. 2063.3, p = 0.004), POD3 TGFb2 (468.3 vs. 368.9, p = 0.036), POD3 TGFb3 (132.2 vs. 77.8, p = 0.028), and POD5 TGFb3 (306.5 vs. 92.2, p = 0.032). POD1 IL-12p70 concentrations were significantly higher in TEA patients (8.3 vs. 1.6, p = 0.024).

Conclusion

Epidural analgesia damped the postoperative inflammatory response and systemic immunosuppressive signaling, as well as promoted Th1 systemic signaling early in the post-operative period after hepatic resection for metastatic disease. These differences elaborate on known mechanisms for improved oncologic outcomes with regional anesthesia, and may be considered for biomarker monitoring of effective regional anesthesia in oncologic surgery.

Materials and Methods

Patient data, including clinicopathologic variables were collected for this study from the database of a randomized controlled trial comparing perioperative outcomes in patients undergoing hepatic resection with TEA vs. IV-PCA. Patients undergoing resection for metastatic disease were selected for this study. Plasma concentrations (pg/mL) of well-studied biomarkers (IL-1b/2/4/5/6/7/8/10/12p70/13/17, MCP-1 IFNγ, TNFα, MIP-1b, GM-CSF, G-CSF, VEGF, Resistin, TGFb1, TGFb2, and TGFb3), as well as novel perioperative markers (CXCL12, CXCL10, Omentin-1, sLeptin R, Vaspin, Pentraxin-3, Galactin-3, FGF-23, PON-1, FGF-21) were measured preoperatively, and on postoperative day (POD)1, POD3, and POD5 using multiplex bead assays. Clinicopathologic variables and perioperative variations in these biomarkers were compared between TEA vs IV-PCA groups.

Prospective study on the safety and feasibility of early ileostomy closure 2 weeks after lower anterior resection for rectal cancer

Purpose

Transient loop ileostomies in rectal cancer surgery are generally closed after 2 or more months to allow adequate time for anastomotic healing. Maintaining the ileostomy may cause medical, surgical, or psychological complications; it also reduces the quality of life, and increase treatment costs. We performed this study to evaluate the safety and feasibility of early ileostomy closure 2 weeks postoperatively.

Methods

If a patient who underwent total mesorectal excision had 2 or more risk factors for anastomotic leakage, a loop ileostomy was created. After confirmation of intact anastomosis via sigmoidoscopy and proctography 1 week postoperatively, the patient was enrolled and ileostomy was closed 2 weeks postoperatively. The primary endpoint was the frequency of complication after ileostomy repair.

Results

Thirty patients were enrolled in the study and 6 were excluded due to anastomotic leakage. Except for 1 case of wound infection (4.2%), no patient experienced any complication including newly developed leakage after the ileostomy closure. The mean duration to repair was 13.1 days (range, 8–16 days) and mean duration to the start of adjuvant treatment after radical surgery was 5.37 weeks (range, 3.0–8.1 weeks).

Conclusion

Transient loop ileostomy, which is confirmed to be intact endoscopically and radiologically, can be safely closed 2 weeks postoperatively without requiring a significant delay in adjuvant chemotherapy.

Knee replacement surgery significantly elevates the urinary inflammatory biomarkers neopterin and 7,8-dihydroneopterin

CONTEXT

Knee arthroplasty surgery is significant trauma, leading to an activated immune system causing inflammation and oxidative stress. Many current biomarkers are invasive, costly, and often slow to analyse, limiting their use for rapid inflammatory measurements.

OBJECTIVES

We have examined the use of urinary neopterin and total neopterin in knee arthroplasty patients to non-invasively measure oxidative stress and inflammation from immune system activation. We aim to validate the use of these biomarkers for quick, cost effective and predictive measurements of post-surgical inflammation assessment.

METHODOLOGY

19 Knee arthroplasty patients were analysed pre-operatively and for a defined post-operative period to determine the urinary levels of neopterin and total neopterin (neopterin +7,8-dihydroneopterin) using high performance liquid chromatography with fluorescence detection. These results were then compared to a control group of 20 participants with normal knee function.

RESULTS

7,8-Dihydroneopterin was stable in urine over 12 h when refrigerated. Knee arthritis was associated with an increase in pre-operative neopterin (oxidative stress) and total neopterin (inflammation). The subsequent arthroplasty surgery generated a significant increase neopterin and total neopterin. Both biomarkers were reduced immediately post-operatively, before becoming elevated on the following days. There was no clear evidence of an association between initial neopterin and total neopterin levels and a patient's level of inflammation during in-hospital recovery.

CONCLUSIONS

The stability of 7,8-dihydroneopterin in urine allows for its use as an inflammatory marker. Urinary neopterin and total neopterin provided a fast, non-invasive, and simple measure of oxidative stress and inflammation after knee arthroplasty.

Monocyte-Dependent Suppression of T-Cell Function in Postoperative Patients and Abdominal Sepsis

INTRODUCTION

Surgical trauma causes inflammation and postoperative immunosuppression. Previous studies have shown a T-cell-dependent suppression of MHC II expression and other functions of antigen-presenting cells. The aim of this study was to determine which immune cell initiates postoperative immunosuppression and consecutive sepsis.

METHODS

We separated T-cells and monocytes in human abdominal surgery (n = 11) patients preoperatively as well as 24 h postoperatively and in patients who developed postoperative sepsis (n = 6). We analyzed their surface markers and then coincubated these cells with naïve preoperative cells of the other cell type, respectively. Cytokine secretion from naïve cells was measured by a multiplex immunoassay, serving as a bioassay for the function of the stimulating postoperative cell.

RESULTS

Surface marker analysis showed a postoperative suppression of CD3 cells and the activation marker CD28 (P = 0.02), which was further reduced in septic patients. FACS analysis revealed a significant increase in CD14 monocytes (P = 0.02) and CD14CD86, CD14HLA-DR subpopulations 2 h postoperatively. In sepsis patients, HLA-DR expression was reduced compared with postoperative levels (P < 0.01). After coincubation with postoperative T-cells, secretion of IL-6 (P < 0.01) and IL-10 (P < 0.01) from naïve monocytes was increased, whereas T-cells from sepsis patients resulted in suppressed cytokine secretion. After coincubation with postoperative monocytes, secretion of IFN-gamma (P < 0.01) and IL-10 (P < 0.01) from naïve T-cells was significantly diminished, whereas monocytes from septic patients triggered only insignificant IL-10 secretion from naïve and septic T-cells.

CONCLUSIONS

Our results show that in the early postoperative period, T-cells are suppressed but able to trigger the release of cytokines from monocytes, whereas activated monocytes seem to induce T-cell suppression. In sepsis patients, a global suppression of both cell types in terms of absolute numbers and function seems to occur.

Impact of timing of adjuvant chemotherapy on survival in stage III colon cancer: a population-based study

Background

There is no consensus regarding the optimal time to initiate adjuvant chemotherapy after surgery for stage III colon cancer, and the relevant postoperative complications that cause delays in adjuvant chemotherapy are unknown.

Methods

Eligible patients aged ≥66 years who were diagnosed with stage III colon cancer from 1992 to 2008 were identified using the linked Surveillance, Epidemiology, and End Results-Medicare database. Kaplan-Meier analysis and a Cox proportional hazards model were utilized to evaluate the impact of the timing of adjuvant chemotherapy on overall survival (OS).

Results

A total of 18,491 patients were included. Delayed adjuvant chemotherapy was associated with worse OS (9–12 weeks: hazard ratio [HR] = 1.222, 95% confidence interval [CI] = 1.063–1.405; 13–16 weeks: HR = 1.252, 95% CI = 1.041–1.505; ≥ 17 weeks: HR = 1.969, 95% CI = 1.663–2.331). The efficacies of adjuvant chemotherapy within 5–8 weeks and ≤4 weeks were similar (HR = 1.045, 95% CI = 0.921–1.185). Compared with the non-chemotherapy group, chemotherapy initiated at ≥21 weeks did not significantly improve OS (HR = 0.882, 95% CI = 0.763–1.018). Patients with postoperative complications, particularly cardiac arrest, ostomy infection, shock, and septicemia, had a significantly higher risk of a 4- to 11-week delay in adjuvant chemotherapy (p < 0.05).

Conclusions

Adjuvant chemotherapy initiated within 8 weeks was acceptable for patients with stage III colon cancer. Delayed adjuvant chemotherapy after 8 weeks was significantly associated with worse OS. However, adjuvant chemotherapy might still be useful even with a delay of approximately 5 months. Moreover, postoperative complications were significantly associated with delayed adjuvant chemotherapy.

Polymicrobial sepsis and non-specific immunization induce adaptive immunosuppression to a similar degree

Sepsis is frequently complicated by a state of profound immunosuppression, in its extreme form known as immunoparalysis. We have studied the role of the adaptive immune system in the murine acute peritonitis model. To read out adaptive immunosuppression, we primed post-septic and control animals by immunization with the model antigen TNP-ovalbumin in alum, and measured the specific antibody-responses via ELISA and ELISpot assay as well as T-cell responses in a proliferation assay after restimulation. Specific antibody titers, antibody affinity and plasma cell counts in the bone marrow were reduced in post-septic animals. The antigen-induced splenic proliferation was also impaired. The adaptive immunosuppression was positively correlated with an overwhelming general antibody response to the septic insult. Remarkably, antigen “overload” by non-specific immunization induced a similar degree of adaptive immunosuppression in the absence of sepsis. In both settings, depletion of regulatory T cells before priming reversed some parameters of the immunosuppression. In conclusion, our data show that adaptive immunosuppression occurs independent of profound systemic inflammation and life-threatening illness.

Innate immunity recovers earlier than acquired immunity during severe postoperative immunosuppression

Background: Postoperative immune suppression, particularly a loss of cell-mediated immunity, is commonly seen after surgery and is associated with worse outcome, i.e. delayed wound healing, infections, sepsis, multiple-organ failure and cancer recurrence. However, the recovery of immune cells focusing on differences between innate and acquired immunity during severe postoperative immunosuppression is not investigated. Methods: In this retrospective randomized controlled trial (RCT) subgroup analysis, 10 postoperatively immune suppressed patients after esophageal or pancreatic resection were analyzed. Innate and acquired immune cells, the expression of human leukocyte antigen-D related on monocytes (mHLA-DR), lipopolysaccharide (LPS)-induced monocytic TNF-α and IL-10 secretion ex vivo, Concanavalin A (Con A)-induced IFN-γ, TNF-α, IL-2, IL-4, IL-5 and IL-10 release were measured preoperatively (od) until day 5 after surgery (pod5). Recovery of immune cells was defined by a significant decrease respectively increase after a significant postoperative alteration. Statistical analyses were performed using nonparametric statistical procedures. Results: Postoperative alterations of innate immune cells recovered on pod2 (eosinophils), pod3 (neutrophils) and pod5 (mHLA-DR, monocytic TNF-α and IL-10 secretion), whereas alterations of acquired immune cells (lymphocytes, T cells, T helper cells, and cytotoxic T cells) did not recover until pod5. Peripheral blood T cells showed an impaired production of the T helper (Th) 1 cytokine IFN-γ upon Con A stimulation on pod1, while Th2 specific cytokine release did not change until pod5.Conclusions: Innate immunity recovered earlier than acquired immunity during severe postoperative immunosuppression. Furthermore, we found a more anti- than pro-inflammatory T cell function on the first day after surgery, while T cell counts decreased.

Radical gastric cancer surgery results in widespread upregulation of pro-tumourigenic intraperitoneal cytokines

BACKGROUND

Radical surgical resection is the mainstay of curative treatment for oesophagogastric malignancy. However, survival and recurrence rates remain poor. Theoretical data suggests that the inflammatory response to surgery can promote tumour recurrence. The local and systemic inflammatory response to radical oesophagogastric cancer surgery has not been fully characterized. We aimed to measure this response, particularly factors associated with tumour implantation.

METHODS

Consecutive patients undergoing radical junctional or gastric cancer resection over 12 months were recruited. Repeated serum and adipose tissue were collected intra-operatively. Adipose tissue was collected adjacent and remote to the tumour, and cytokine messenger RNA (mRNA) expression was measured. Post-operatively, daily serum was collected for 7 days, and analysed for inflammatory cell profile and cytokine concentration.

RESULTS

There were nine patients recruited (67.1 ± 2.1 years). mRNA expression of interleukin-6 (IL-6), CC-chemokine ligand-2 and IL-1β increased in adipose tissue intra-operatively (P < 0.05), equally both adjacent and remote from the tumour site. Serum IL-6 concentration increased from 23.3 pg/mL to 161.8 pg/mL intra-operatively (P < 0.05) before falling steadily to 35.7 pg/mL post-operatively (P < 0.05). Serum tumour necrosis factor-α was elevated throughout, and IL-1β levels were unaffected. Leukocyte and neutrophil populations increased, while T-cell and dendritic cell populations decreased intra-operatively (P < 0.05).

CONCLUSION

Radical surgery dramatically upregulates the expression of pro-tumourigenic cytokines in the peritoneum. There is also a marked systemic immune and inflammatory response to surgery, including downregulation of T-cell and dendritic cell populations. This offers two potential pathways that may facilitate tumour progression - local inflammation promoting peritoneal adherence and implantation, and secondary suppression of immunosurveillance due to circulating inflammatory response.

The impact of delayed commencement of adjuvant chemotherapy (eight or more weeks) on survival in stage II and III colon cancer: a national population-based cohort study

BACKGROUND

To examine the impact of chemotherapy delay on survival in patients with stage II or III colon cancer and the factors associated with the delay (≥8 weeks) of adjuvant chemotherapy.

METHODS

Patients undergoing curative resection and adjuvant chemotherapy in a national population-based cohort were included.

RESULTS

Among 5355 patients, 154 (2.9%) received chemotherapy more than 8 weeks after surgery. Based on a multivariate analysis, the risk factors associated with chemotherapy delay ≥8 weeks were older age [65 to 74 years (hazard ratio [HR]=1.48) and ≥75 years (HR=1.69), p=0.0354], medical aid status in the health security system (HR=1.76, p=0.0345), and emergency surgery (HR=2.43, p=0.0002). Using an 8-week cutoff, the 3-year overall survival rate was 89.62% and 80.98% in the <8 weeks and ≥8 weeks groups, respectively (p=0.008). Independent prognostic factors for inferior overall survival included chemotherapy delay ≥8 weeks (HR=1.49, p=0.0365), older age [65 to 74 years (HR=1.94) and ≥75 years (HR=3.41), p<0.0001], TNM stage III (HR=2.46, p<0.0001), emergency surgery (HR=1.89, p<0.0001), American Society of Anesthesiologists score of 3 or higher (HR=1.50, p<0.0001), and higher transfusion amounts (HR=1.09, p=0.0392).

CONCLUSIONS

This study shows that delayed commencement of adjuvant chemotherapy, defined as ≥ 8 weeks, is associated with inferior overall survival in colon cancer patients with stage II or III disease. The delay to initiation of adjuvant chemotherapy is influenced by several multidimensional factors, including patient factors (older age), insurance status (medical aid), and treatment-related factors (emergency surgery).

Surgical Site Infections: An Update

Surgical site infections (SSIs) lead to adverse patient outcomes, including prolonged hospitalization and death. Wound contamination occurs with each incision, but proven strategies exist to decrease the risk of SSI. In particular, improved adherence to evidence-based preventative measures related to appropriate antimicrobial prophylaxis can decrease the rate of SSI. Aggressive surgical debridement and effective antimicrobial therapy are needed to optimize the treatment of SSI.

Molecular analysis of sentinel lymph node in colon carcinomas by one-step nucleic acid amplification (OSNA) reduces time to adjuvant chemotherapy interval

BACKGROUND

The interval between surgery and adjuvant chemotherapy (AC) is a predictive factor of survival in high-risk colon cancer (CC). This study aimed to evaluate the impact of intraoperative sentinel lymph node (SLN) analysis using the one-step nucleic acid amplification (OSNA) technique on the time interval between surgery and AC.

METHODS

We performed a prospective study analyzing 56 consecutive patients who had surgery for CC between July 2012 and October 2014, including 20 patients needing AC. SLN status was determined intraoperatively in 17 patients in the OSNA group; when positive, a portacath (PAC) was placed during the procedure for upcoming AC. In the remaining patients, we proceeded without SLN status determination and the PAC was installed after definitive histopathological analysis of the specimen if needed.

RESULTS

There was no difference between the groups regarding cancer staging, duration of hospitalization (7.5days in the OSNA group and 10days in the control group, p=0.43) and major complications (20% vs 30% respectively, p=0.55). The time interval between surgery and adjuvant chemotherapy was significantly shorter in the OSNA group at 35 (±8) days vs 67 (±36) days (p=0.021).

CONCLUSION

SLN status determination by the OSNA technique is safe, feasible and could significantly reduce time between surgery and adjuvant chemotherapy in a pilot study.

Early versus delayed initiation of adjuvant treatment for pancreatic cancer

Background

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive tumor showing a tendency for early recurrence, even after curative resection. Although adjuvant treatment improves survival, it is unclear whether early adjuvant treatment initiation yields better outcomes in patients with PDAC.

Methods

We retrospectively enrolled 113 patients who underwent chemotherapy or chemoradiotherapy after curative resection of PDAC: Fifty-six and 57 patients were in the early and delayed groups, respectively based on the median time of treatment initiation (35 days [range, 20–83 days]).

Results

Patient baseline characteristics were comparable in both groups, except for grade III or IV postoperative complications (5.4% in the early group vs. 22.8% in the delayed group). With a median 20.3-month follow-up, the overall survival (OS) and disease-free survival (DFS) times were 29.5 and 14.7 months, respectively. The early group had significantly prolonged OS (39.1 vs. 21.1 months, p = 0.018) and DFS (18.8 vs. 10.0 months, p = 0.034), compared to the delayed group. Among 71 patients who completed planned adjuvant treatment, patients in the early group tended to have longer, though not statistically significant, OS and DFS times than those in the delayed group. In 67 patients without postoperative complications, patients in the early group had longer OS (42.8 vs. 20.5 months, p = 0.002) and DFS (19.6 vs. 9.1 months, p = 0.005) than those in the delayed group. By multivariate analysis, incompletion of treatment (hazard ratio [HR]: 4.039, 95% confidence interval [CI]: 2.334–6.992), delayed treatment initiation (HR: 1.822, 95% CI: 1.081–3.070), and positive angiolymphatic invasion (HR: 2.116, 95% CI: 1.160–3.862) were significantly associated with shorter OS.

Conclusions

Adjuvant treatment should be delivered earlier and completed for better outcomes in resected PDAC patients, especially without postoperative complications.

Postoperative Elevation of the Neutrophil: Lymphocyte Ratio Predicts Complications Following Esophageal Resection

BACKGROUND

Complications following esophagectomy are a significant source of morbidity. The aim of this study was to investigate the utility of the neutrophil:lymphocyte ratio (NLR) in the early identification of complications following esophagectomy, as compared to other routinely available parameters.

METHODS

We performed a retrospective cohort study of patients undergoing Ivor-Lewis esophagectomy at a single centre. Baseline characteristics and complications occurring within the first 30 days of surgery were recorded. White blood cell counts and C-reactive protein (CRP) levels immediately following surgery (day 0) and over the subsequent three postoperative days were analysed.

RESULTS

Sixty-five patients were included, of whom 29 (45 %) developed complications. The median NLR was similar among patients with and without a complicated recovery on day 0 (12.7 vs 13.6, p = 0.70) and day 1 (10.0 vs 9.3, p = 0.29). Patients who subsequently developed complications had a higher NLR on day 2 (11.8 vs 7.5, p < 0.001) and day 3 (9.0 vs 6.5, p = 0.001) compared to those whose recovery was uncomplicated. Receiver-operating-characteristic plots for the diagnostic performance of the NLR, neutrophil count, lymphocyte count and CRP level at each time point demonstrated that the NLR on day 2 had the greatest discriminatory ability in predicting complications, with an area under the curve of 0.83 (95 % CI 0.73-0.94). An NLR of >8.3 on day 2 had a sensitivity of 93 % and a specificity of 72 % for predicting complications.

CONCLUSION

The NLR is a simple and routinely available parameter which has a high sensitivity in the early detection of complications following esophagectomy.