Follow-up after emergency laparotomy suggests high one- and five-year mortality with risk stratified by ASA

INTRODUCTION

We investigated all-cause mortality following emergency laparotomy at 1 and 5 years. We aimed to establish a basis from which to advise patients and relatives on long-term mortality.

METHODS

Local data from a historical audit of emergency laparotomies from 2010 to 2012 were combined with National Emergency Laparotomy Audit (NELA) data from 2017 to 2020. Covariates collected included deprivation status, preoperative blood work, baseline renal function, age, American Society of Anesthesiologists (ASA) grade, operative time, anaesthetic time and gender. Associations between covariates and survival were determined using multivariate logistic regression and Kaplan-Meier analysis. We used patients undergoing laparoscopic cholecystectomy between 2015 and 2020 as controls.

RESULTS

ASA grade was the best discriminator of long-term outcome following laparotomy (n=894) but was not a predictor of survival following cholecystectomy (n=1,834), with mortality being significantly greater in the laparotomy group. Following cholecystectomy, 95% confidence intervals for survival at 5 years were 98-99%. Following laparotomy these intervals were: ASA grade 1, 79-96%; ASA grade 2, 69-82%; ASA grade 3, 44-58%; ASA grade 4, 33-48%; and ASA grade 5, 4-51%. The majority of deaths occurred after 30 days.

CONCLUSIONS

Emergency laparotomy is associated with a significantly increased risk of death in the following 5 years. The risk is strongly correlated to ASA grade. Thirty-day mortality estimation is not a good basis on which to advise patients and carers on long-term outcomes. ASA grade can be used to predict long-term outcomes and to guide patient counsel.

47 Patient and Physician Positioning During Anterior Skull Base Surgery Impacts Physician Ergonomics

Aim

The effects of anterior skull base surgery on surgeon’s ergonomics remain unclear and this study explore the impact of patient, surgeon, and screen positioning on surgeon’s ergonomics during the surgery.

Method

A total of 20 different surgical positions involving the operating surgeon, assisting surgeon, patient head position, camera position and screen position/number were simulated. For each position, the ergonomic effects on the upper limb, neck, trunk, and lower limb of surgeons were analysed using the Rapid Upper Limb Assessment (RULA) tool.

Results

The majority of scores ranged from 2 to 3 suggesting the majority of positions have acceptable postures. The average RULA score of the right side of operating surgeon was 2.8 versus 2.95 on the left-side (p = 0.297). For the assisting surgeon, the average RULA score of the right side was 3.65 versus 3.25 for the left side (p = 0.053). The average combined (left and right) RULA score for the operating surgeon was 5.76 versus 6.9 for the assisting surgeon (p<0.001). Position 17 (operating surgeon to the right of patient, assisting surgeon to the left of patient, central patient head position and two screens) is the most ergonomically favourable position. Position 2 (operating and assisting surgeon to the right of patient, patient head position to the right and one screen position to the left of patient) is the least favourable position.

Conclusions

This simulation raises awareness of risk of musculoskeletal injury in anterior skull base surgery and highlights those certain positional behaviours are better for reducing injury risk than others.

The immunofluorescent era of membrane traffic

In recent years immunofluorescence microscopy has been increasingly used to study membrane traffic. In this article seven electron microscopists, all with considerable experience in using light microscopy, take a critical look at the immunofluorescence approach and argue that results obtained with this method are often overinterpreted.

Evidence for prebudding arrest of ER export in animal cell mitosis and its role in generating Golgi partitioning intermediates

During mitosis the interconnected Golgi complex of animal cells breaks down to produce both finely dispersed elements and discrete vesiculotubular structures. The endoplasmic reticulum (ER) plays a controversial role in generating these partitioning intermediates and here we highlight the importance of mitotic ER export arrest in this process. We show that experimental inhibition of ER export (by microinjecting dominant negative Sar1 mutant proteins) is sufficient to induce and maintain transformation of Golgi cisternae to vesiculotubular remnants during interphase and telophase, respectively. We also show that buds on the ER, ER exit sites and COPII vesicles are markedly depleted in mitotic cells and COPII components Sec23p, Sec24p, Sec13p and Sec31p redistribute into the cytosol, indicating ER export is inhibited at an early stage. Finally, we find a markedly uneven distribution of Golgi residents over residual exit sites of metaphase cells, consistent with tubulovesicular Golgi remnants arising by fragmentation rather than redistribution via the ER. Together, these results suggest selective recycling of Golgi residents, combined with prebudding cessation of ER export, induces transformation of Golgi cisternae to vesiculotubular remnants in mitotic cells. The vesiculotubular Golgi remnants, containing populations of slow or nonrecycling Golgi components, arise by fragmentation of a depleted Golgi ribbon independently from the ER.

Immunolocalisation of phospholipase D1 on tubular vesicular membranes of endocytic and secretory origin

We have examined the localisation of overexpressed phospholipase D1 (PLD1) using antibodies against its amino- and carboxyl-terminal domains. PLD1 overexpressed in COS-7 cells showed variable distribution by immunofluorescence but was mainly in punctate structures in the perinuclear region and at the plasma membrane. Downregulation by an anti-sense plasmid resulted in almost exclusively perinuclear distribution in punctate structures that contained immunoreactivity for the endogenous KDEL receptor and the early endosomal antigen EEA1 protein. Influenza haemagglutinin (HA) and HA-derived mutants designed to locate primarily to secretory or endocytic membranes were present in PLD1-positive membranes. Immunofluorescence analysis in permanent CHO cell lines that express PLD1 inducibly confirmed the presence of PLD1 on both endocytic and secretory membranes. Analysis of PLD1 distribution by immunocytochemistry and electron microscopy of intact CHO cells and of isolated membranes revealed that PLD1 was present in tubulovesicular elements and multivesicular bodies. Some of these were close to the Golgi region whereas others stained positive for endocytic cargo proteins. Morphometric analysis assigned the majority of PLD1 immunoreactivity on endosomal membranes and a smaller amount on membranes of secretory origin. PLD1, via signals that are currently not understood, is capable of localising in tubulovesicular membranes of both endocytic and secretory origin.

Merkel cells in the human oesophagus

Merkel cells (MCs) are well recognized in the basal layers of the skin and oral mucosa, but this paper describes for the first time the presence of MCs in the human oesophagus. These cells are not identified in neonatal oesophagus, but are seen singly and in clusters in adult specimens. Application of stereological techniques shows that MCs are more numerous in the mid-oesophageal region. Cells expressing established markers of MCs have also been demonstrated in two out of six primary small cell carcinomas of the oesophagus. Further investigation of the role of MCs in oesophageal innervation and epithelial biology will be of interest.

Role of phosphatidylinositol 3,4,5-trisphosphate in regulating the activity and localization of 3-phosphoinositide-dependent protein kinase-1

3-Phosphoinositide-dependent protein kinase-1 (PDK1) interacts stereoselectively with the d-enantiomer of PtdIns(3,4,5)P3 (KD 1.6 nM) and PtdIns(3,4)P2 (KD 5.2 nM), but binds with lower affinity to PtdIns3P or PtdIns(4,5)P2. The binding of PtdIns(3,4,5)P3 to PDK1 was greatly decreased by making specific mutations in the pleckstrin homology (PH) domain of PDK1 or by deleting it. The same mutations also greatly decreased the rate at which PDK1 activated protein kinase Balpha (PKBalpha) in vitro in the presence of lipid vesicles containing PtdIns(3,4,5)P3, but did not affect the rate at which PDK1 activated a PKBalpha mutant lacking the PH domain in the absence of PtdIns(3,4,5)P3. When overexpressed in 293 or PAE cells, PDK1 was located at the plasma membrane and in the cytosol, but was excluded from the nucleus. Mutations that disrupted the interaction of PtdIns(3,4,5)P3 or PtdIns(4,5)P2 with PDK1 abolished the association of PDK1 with the plasma membrane. Growth-factor stimulation promoted the translocation of transfected PKBalpha to the plasma membrane, but had no effect on the subcellular distribution of PDK1 as judged by immunoelectron microscopy of fixed cells. This conclusion was also supported by confocal microscopy of green fluorescent protein-PDK1 in live cells. These results, together with previous observations, indicate that PtdIns(3,4,5)P3 plays several roles in the PDK1-induced activation of PKBalpha. First, it binds to the PH domain of PKB, altering its conformation so that it can be activated by PDK1. Secondly, interaction with PtdIns(3,4,5)P3 recruits PKB to the plasma membrane with which PDK1 is localized constitutively by virtue of its much stronger interaction with PtdIns(3,4,5)P3 or PtdIns(4,5)P2. Thirdly, the interaction of PDK1 with PtdIns(3,4,5)P3 facilitates the rate at which it can activate PKB.

Quantitative immunoelectron microscopy reveals alpha2,6 sialyltransferase is concentrated in the central cisternae of rat hepatocyte Golgi apparatus

The Golgi apparatus is a membrane bound organelle involved in synthesis of N-linked oligosaccharides which are trimmed and then lengthened by a series of sugar transferases adding N-acetylglucosamine, galactose and sialic acid in sequence. We previously published qualitative work which localized Galbeta1,4GlcNAc alpha2,6 sialyltransferase of rat hepatocytes to the trans cisternae and the trans Golgi network. We now report the use of combined stereological and immunoelectron microscopical techniques for mapping the Golgi stack composition and distribution of sialyltransferase protein in rat hepatocytes. The Golgi stack showed substantial variation in composition consisting of 1, 2, 3, 4, or 5 cisternae with an average of 2.5 cisternae. Sialyltransferase labeling was mainly located in the central cisternae of the Golgi stacks irrespective of whether the stacks were oriented in a cis/trans direction using morphological criteria. Only 20% of the total sialyltransferase labeling was present in the transmost cisterna and 2% in the trans Golgi Network. The low labeling in the transmost cisterna was essentially due to the presence of a sialyltransferase negative cisterna. These data emphasize the importance of quantitation in obtaining a representative picture of Golgi enzyme distribution in three dimensions. They indicate that central cisternae, rather than the transmost cisterna and TGN, function in sialylation along the secretory pathway of rat hepatocytes.

ERK2 signalling from internalised epidermal growth factor receptor in broken A431 cells

Activation of extracellular signal-regulated kinase 2 (ERK2) signalling from epidermal growth factor receptors (EGFRs) is widely assumed to originate in the plasma membrane. Using an in vitro assay, we investigated whether EGF/EGFR complexes internalised by endocytosis in A431 cells can initiate signalling in the ERK2 pathway. At 0 degrees C, binding of EGF induced tyrosine phosphorlyation of EGFR and, when the cells were subsequently broken by scraping and warmed in the presence of exogenous cytosol, activation of ERK2 occurred. At 0 degrees C, washes with pH 4.5 media reversed EGF binding, tyrosine phosphorylation and ERK-2 activation in exogenous cytosol, providing conditions in which signalling from the cell surface and internalised EGFRs could be distinguished. When cells containing internalised EGF/EGFR complexes were first washed in low pH media at 0 degrees C and then broken and incubated in exogenous cytosol, substantial activation of ERK2 occurred. This activation reached a maximum after a 5-min internalisation and was almost completely prevented by incubation in 0.45 M sucrose, a known inhibitor of receptor-mediated endocytosis. These data are consistent with activation of the ERK2 signalling pathway by internalised EGRFs situated in endosomal compartments. Our observation that EGFR tyrosine dephosphorylation is incomplete above pH 5.5 suggests that signalling is initiated in early endosomes.

Evidence for fusion between multilamellar endosomes and autophagosomes in HeLa cells

The organelles of the endocytic and autophagic pathways were studied in HeLa cells using immunoelectron microscopy and stereological techniques. In the absence of autophagic stimulation, characteristic particulate structures containing closely packed layers of membrane received the fluid-phase marker horseradish peroxidase after 25 min uptake. These multilamellar endosomes contained the majority of the cellular immunogold labeling obtained by using a monoclonal antibody (1B5) directed against a lysosomal glycoprotein. Lysosomes with homogeneous dense content were only poorly labeled. After stimulation of autophagy, two classes of autophagosome profile appeared. One had a double limiting membrane and content that resembled the surrounding cytoplasm. The other most abundant type possessed a single limiting membrane and contained multilamellar structures which were strikingly similar to multilamellar endosomes, not only in form, but also in volume and membrane packing density. Immunogold labeling showed that now the majority of 1B5 labeling was located in the class of autophagosomes which contained multilamellar structures. Stereological methods showed that, after autophagic stimulation, multilamellar endosomes had become depleted, while multilamellar structures had appeared within the autophagosomes. Taken together, these data provide evidence that autophagosomes of HeLa cells fuse with preexisting multilamellar endosomes.

Selective adsorption: a new method for purification of protein A-gold complexes

Protein gold complexes are prepared by adding gold colloids to cytochemically active proteins in solution. The gold particles of the colloid form complexes with the protein spontaneously, but some of the protein remains uncomplexed. Currently, when protein A-gold complexes are prepared, the uncomplexed protein. A is separated from the complex by ultracentrifugation, which is a lengthy procedure and requires special equipment. This report describes a simple and rapid method for removing uncomplexed protein A from freshly-prepared "crude" protein A-gold at the laboratory bench. In this method, larger gold particles of 15-nm diameter are added to a crude protein A-gold preparation made with smaller particles (e.g.,6nm diameter). The 15-nm particles adsorb uncomplexed protein A preferentially, but do not form complexes with already-formed 6-nm protein A-gold. The adsorbed protein A, attached to the 15-nm particles, can then be sedimented in a bench centrifuge, leaving the purified 6-nm protein A-gold complexes in the supernatant. The stability, immunocytochemical activity, and degree of aggregation of the protein A-gold complexes prepared by this method are comparable to protein A-gold complexes prepared by ultracentrifugation. The method is simple to perform, avoids lengthy purification procedures, and yields complexes with reproducible labelling characteristics.

The pathway of Golgi cluster formation in okadaic acid-treated cells

Using stereology and immunoelectron microscopy we examined the pathway of Golgi cluster formation during treatment with the phosphatase inhibitor okadaic acid. During the first hour the Golgi stack of suspension HeLa cells lost 90% of its membrane without appreciable reduction in the number of cisternae. During this time clusters of tubules and vesicles (Golgi clusters) appeared and these contained only a fraction of the Golgi membrane present in untreated cells. Despite the overall reduction in membrane the total amount of immunolabeling for galactosyltransferase over the Golgi clusters of a typical cell was maintained, indicating that galactosyltransferase had been retained in Golgi membranes. The observation that, after 40 min okadaic acid treatment, labeling density for galactosyltransferase within trans Golgi cisternae increased 1.6-fold (n = 3, CE 10%) suggests that membrane loss from trans cisternae was selective. Careful evaluation of immunolabeled clusters showed that most of the galactosyltransferase labeling was located over complex tubular profiles and not vesicular profiles. Tubular structures were also observed during disassembly and these were found both connected to disassembling cisternae and within forming Golgi clusters, indicating that they were intermediates in cluster formation. We also investigated the role of vesicular transport in cluster formation. During disassembly we found no accumulation of COP-coated buds and vesicles over Golgi membrane. However, aluminium fluoride, previously found to arrest transport in the Golgi stack, completely inhibited membrane depletion and stack disassembly. Taken together, our results indicate that during Golgi cluster formation, membrane leaves the Golgi but galactosyltransferase is retained within a tubular reticulum which is a direct descendant of trans-Golgi cisternae. Membrane depletion may require ongoing vesicular transport and we postulate that it arises because of an imbalance in membrane traffic into and out of the Golgi apparatus.

Quantitation of gold labelling and antigens in immunolabelled ultrathin sections

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Quantitation of gold labeling and estimation of labeling efficiency with a stereological counting method

The amount of immunolabeling over a cell compartment of an average cell was estimated by use of an adaptation of the double disector method introduced by Gundersen. The first and last sections of a stack of ultra-thin sections formed a disector in which cell number could be estimated and related to a defined reference volume to give the cell density. Another stack section, selected at random, was immunolabeled and the number of gold particles associated with unit volume reference space (gold "density") estimated in quadrats placed systematically across the section. The ratio of gold density to cell density was used to estimate the number of gold particles lying over a chosen compartment of an average cell, N(gold)/N(cell). Such estimates required neither cell volume nor section thickness measurement and were reproducible. By combining the number of gold particles per cell with estimates of the number of protein antigens per cell, the number of gold particles associated with each antigen could be found (labeling efficiency).

Ultrastructural localization of hyaluronan in myelin sheaths of the rat central and rat and human peripheral nervous systems using hyaluronan-binding protein-gold and link protein-gold

Neural tissue of central (rat spinal cord) and peripheral origin (rat sciatic nerve, nerve fascicles of rat skin and iris and of human conjunctiva) was processed by osmium tetroxide/microwave fixation and embedded in epoxy resin. Hyaluronan-binding proteins and link proteins coupled to 15-20-nm gold particles were used as markers in a one-step post-embedding procedure for identifying hyaluronan (hyaluronic acid) at the ultrastructural level. All myelin sheaths in both rat and human material were found to be intensely labelled. The specificity of the hyaluronan-binding probes was demonstrated by the total loss of labelling following treatment of sections with hyaluronidase or by preincubating either the probes with hyaluronan oligosaccharides or the sections with unlabelled hyaluronan-binding protein. The identified hyaluronan appears to be located extracellularly, but is precise role here remains to be elucidated.

Okadaic acid induces Golgi apparatus fragmentation and arrest of intracellular transport

The specific phosphatase inhibitor okadaic acid (OA) induced fragmentation of the Golgi apparatus in interphase HeLa cells. Immunoelectron microscopy for galactosyltransferase identified a major Golgi fragment composed of a cluster of vesicles and tubules that was morphologically indistinguishable from the ‘Golgi cluster’ previously described in mitotic cells. The presence of homogeneous immunofluorescence staining for galactosyltransferase in OA-treated cells also suggested that isolated Golgi vesicles, previously found in mitotic cells, existed along with the clusters. After removal of OA, both clusters and vesicles appeared to participate in a reassembly pathway that strongly resembled that occurring during telophase. OA also induced inhibition of intracellular transport, another feature of mitotic cells. OA treatment prevented newly synthesised G protein of vesicular stomatitis virus (VSV) from acquiring resistance to endoglycosidase H and from arriving at the cell surface. In addition, fluid phase endocytosis of horseradish peroxidase (HRP) was reduced to less than 10% of control values. All these effects were dose-dependent and reversible. OA should be a useful tool to study the Golgi division and membrane traffic.

Formation of coated vesicles from coated pits in broken A431 cells

Biochemical and morphological techniques were used to demonstrate the early steps in the endocytosis of transferrin in broken A431 cells. After binding 125I-transferrin, the cells were broken by scraping and then warmed. 125I-transferrin became inaccessible to exogenous anti-transferrin antibody providing a measure of the internalization process. Parallel morphological experiments using transferrin coupled to horseradish peroxidase confirmed internalization in broken cells. The process was characterized and compared with endocytosis in intact cells and showed many similar features. The system was used to show that both the appearance of new coated pits and the scission of coated pits to form coated vesicles were dependent on the addition of cytosol and ATP whereas invagination of pits was dependent on neither.

Nonrandom positioning of Golgi apparatus in pancreatic B cells

The Golgi apparatus has a polarized distribution in a variety of cell types, and in certain epithelia its intracellular position correlates with the direction of vectorial transport and release of secretory products. We have studied quantitatively the orientation of the Golgi apparatus in pancreatic islet B cells by examining its location with respect to the juxtacapillary face of the cell. This was done a) at the light microscope level on semithin sections of osmium-impregnated islets, and b) at the ultrastructural level on thin sections of intact pancreas. The data obtained with both methods show that in pancreatic B cells the Golgi apparatus is preferentially located in the position opposite to the juxtacapillary face of the cell. These results suggest a structural polarization of B cells, which may be important for the coordinate function of islets of Langerhans.