Qualitative assessment and morphometry in the study of the ileal reservoir after restorative proctocolectomy

Little is known about the long-term effects on the reservoir mucosa in patients with ulcerative colitis and familial polyposis coli who undergo proctocolectomy with subsequent construction of ileal reservoir/pouch and ileoanal anastomosis. In these patients, questions regarding adaptation towards a more colon-like mucosa and/or development of (pre)malignant changes are of particular importance. With the aim of designing a method for reliable evaluation of the mucosa in the ileal pouch, biopsies from 10 patients were studied by semiquantitative assessment and morphometry. The findings were compared with those obtained from normal jejunum, ileum, and colon. The following parameters were found to be important: Villous surface density, quantity of goblet cells, number of mitoses, and the presence/absence of predominantly sulphated mucin+ goblet cells. The number of Paneth cells did not show significant changes. The villous surface density was determined by a cycloid test system applied to vertical sections. Semiquantitative assessment was a sufficiently precise method for the evaluation of the quantity of goblet cells. The counting of sulphated mucin+ goblet cells was not reproducible, instead a simple statement about the presence or absence of these cells was judged to be adequate. The number of mitoses and of Paneth cells were counted directly. During the first year of function the ileal pouch showed signs of adaptation towards a colon-like mucosa: Reduction of villous surface density, increased mitotic activity, and appearance of sulphated mucin+ goblet cells. The number of Paneth cells did not show significant changes. The amount of goblet cells was generally not increased, rather reduced in some patients.     

COVID-19 in solid organ transplant recipients: A national cohort study from Sweden

Solid organ transplant (SOT) recipients run a high risk for adverse outcomes from COVID-19, with reported mortality around 19%. We retrospectively reviewed all known Swedish SOT recipients with RT-PCR confirmed COVID-19 between March 1 and November 20, 2020 and analyzed patient characteristics, management, and outcome. We identified 230 patients with a median age of 54.0 years (13.2), who were predominantly male (64%). Most patients were hospitalized (64%), but 36% remained outpatients. Age >50 and male sex were among predictors of transition from outpatient to inpatient status. National early warning Score 2 (NEWS2) at presentation was higher in non-survivors. Thirty-day all-cause mortality was 9.6% (15.0% for inpatients), increased with age and BMI, and was higher in men. Renal function decreased during COVID-19 but recovered in most patients. SARS-CoV-2 antibodies were identified in 78% of patients at 1–2 months post-infection. Nucleocapsid-specific antibodies decreased to 38% after 6–7 months, while spike-specific antibody responses were more durable. Seroprevalence in 559 asymptomatic patients was 1.4%. Many patients can be managed on an outpatient basis aided by risk stratification with age, sex, and NEWS2 score. Factors associated with adverse outcomes include older age, male sex, greater BMI, and a higher NEWS2 score.     

Intrathoracic approach for subclavian and innominate artery reconstruction.

A subclavian or innominate artery obliteration may cause a retrograde flow in the vertebral artery, a subclavian steal. The steal has been associated with cerebral symptoms indicating vertebrobasilar ischaemia, the subclavian steal syndrome. As there still are no objective means of measuring the effect of the steal on the brain circulation, the syndrome can only be proved by experience from the results of surgical attempts to correct the steal. The steal was at first eliminated by direct reconstruction of the subclavian and innominate arteries through a thoracic approach. As the mortality was high, many surgeons have used cervical bypass procedures with considerably lower mortality. The present report is based on 15 years' experience with 85 patients operated on with direct artery reconstruction through a thoracotomy. A low mortality (1.3%) for the last ten years, a high patency of the reconstruction (80%) 8 years postoperatively and rather high rate of improvement (72%) in patients with subclavian steal syndrome were found. The study shows that the mortality rate with the thoracic approach need not necessarily be higher than with the cervical one. The high patency and the haemodynamically correct type of the reconstructions favour the thoracic approach. However, the direct reconstruction demands a technically advanced surgeon, who is well aquainted with the method. The results also showed that surgery still may be an alternative in patients with symptomatic subclavian steal.     

A longitudinal study of long-term quality of life after ileal pouch-anal anastomosis

BACKGROUND: There is a lack of longitudinal long-term studies of quality of life (QOL) after surgery with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, where cohorts of patients are used as their own controls. METHODS: Forty ulcerative colitis patients who had undergone IPAA were prospectively assessed while they had a temporary ileostomy, and at a median of 18 months and 7 years after ileostomy closure. QOL was measured with the Psychosocial Adjustment to Illness Scale and the Well-Being Profile. RESULTS: QOL was good at all three time points and, with some exceptions, did not change significantly between the assessments. There was a high degree of stability in the patients' evaluation of their QOL over time. CONCLUSIONS: QOL was already good when the patients had a temporary ileostomy and generally did neither improve nor deteriorate during 7 years after ileostomy closure. QOL was also quite stable in terms of individual differences.     

Infection of infants with human herpesvirus type 6 may be associated with reduced allergic sensitization and T‐helper type 2 development

Background Epidemiological studies point to an inverse relationship between microbial exposure and the prevalence of allergic diseases. The underlying mechanism for this observation remains largely unknown, as well as the nature of the microbes involved. Objective To investigate the effects of early infection with human herpesviruses (HHVs) on IgE formation and T‐helper type 2 (Th2) development in infants. Methods Serum was collected from children aged 18 months and assessed for IgE to common allergens and IgG to five common herpesviruses. Cord blood plasmacytoid dendritic cells (pDC) were exposed to HHV type 6 in vitro and mixed with allogeneic cord blood CD4⁺ T cells. Cytokine levels were determined by ELISA and by flow cytometry. Results We found that children seropositive at 18 months of age to HHV type 6 were significantly less often IgE sensitized than seronegative children [odds ratio (OR): 0.08, 95% confidence interval (CI): 0.009–0.68]. HHV type 6 also decreased the production of the Th2‐associated cytokines IL‐5 and IL‐13 by CD4⁺ T cells when co‐cultured with allogeneic cord blood pDC. This was associated with an increased production of IFN‐α by pDC exposed to HHV type 6. Conclusion These data indicate that an early childhood infection with HHV type 6 could down‐regulate Th2 responses and reduce IgE formation to common allergens in a young child.     

Localization of a functional autoimmune epitope on the muscarinic acetylcholine receptor-2 in patients with idiopathic dilated cardiomyopathy.

A peptide corresponding to the sequence 169-193 of the second extracellular loop of the human muscarinic acetylcholine receptor-2 was used as an antigen to screen sera from patients with idiopathic dilated cardiomyopathy (DCM, n = 36) and healthy blood donors (HBD, n = 40). The sera from 14 patients with DCM (38.8%) and 3 HBD (7.5%) recognized the muscarinic receptor peptide at dilutions varying from 1:20 to 1:160 in ELISA. A highly significant correlation (P = 0.006) was found between the presence of antimuscarinic receptor-2 autoantibodies and anti-beta-adrenoceptor-1 autoantibodies in the patients' sera. Affinity-purified autoantibodies from positive sera of patients with DCM recognized on the electrotransferred protein of rat ventricular membrane a major band of about 80 kD. Incubation of autoantibodies with membrane resulted not only in a decrease in the maximal binding sites (Bmax) but also in an increase in Kd of radioligand binding in a concentration-dependent manner. This suggests a mixed-type of inhibition. Moreover, preincubation with atropine abolished the inhibitory effect of autoantibodies on the receptor binding whereas carbachol appeared to have no effect on the activity of the autoantibodies. These data define a subgroup of patients with idiopathic DCM who have in their sera functionally active autoantibodies against muscarinic receptor-2.     

Gains and losses with stapling and omission of loop ileostomy in pelvic pouch surgery: a matched control study

After 10 years experience of pelvic pouch surgery with handsewn pouch and ileoanal anastomosis, mucosectomy, and covering loop ileostomy, the surgical technique was altered. Twenty patients were operated on with staple technique in pouch and ileoanal anastomosis but without mucosal proctectomy and loop ileostomy. This study group was compared with a matched control group of patients from our previous series with respect to duration of surgery, blood loss, hospital stay, complications, and functional outcome after 2 months, 12 months, and 60 months. It was found that staple technique significantly reduced the duration of surgery and the need of blood transfusions. Length of hospital stay after pouch surgery did not differ between the two groups, but omitting loop ileostomy reduced total hospital stay by about 2 weeks. Ileoanal anastomotic insufficiency occurred in two patients in the study group. Treatment by establishment of a defunctioning loop ileostomy, local saline perfusion, and administration of antibiotics was successful; the anastomosis healed within 2 weeks, and the long-term functional outcome did not differ from the average. Increased temperature persisted postoperatively in seven patients in the study group. Transient peroneal paresis occurred in three patients in the control group. Only in the control group was there stenosis in the ileoanal anastomosis requiring dilatation and fibrosis at the levator plane demanding emptying by a catheter. Concerning functional outcome, nighttime continence was significantly better in the study group than in the control group. The evacuation rate per 24 h was significantly higher in the study group after 2 and 12 months but not after 60 months. The outcome concerning other functional parameters such as urgency to evacuate, capacity to discriminate between gas and stool, deferral time, and perianal symptoms, did not differ significantly. Staple technique without mucosal proctectomy and loop ileostomy thus results in shorter duration of surgery and shorter hospital stay. In patients with increased risk of insufficiency of the anastomosis, however, covering loop ileostomy may be justified because of the risk for more serious consequences if anastomotic leakage occurs. Accepted: 18 June 1999     

Abdominal aortic aneurysms. II. Long-term follow-up of operated and unoperated patients

Survival rate, causes of late death, employment, general health, walking capacity and sexual activity were investigated in 87 patients operated on for abdominal aortic aneurysms and 44 unoperated patients. The life expectancy was higher in the operated patients. The higher mortality for the non-operated patients was mainly due to aneurysmal rupture. Both groups of patients succumbed to atherosclerotic diseases, which before death had restricted their physical activity. More non-operated than operated patients left their employment due to the aneurysm disease. Eleven of 31 still living male operated patients had lost ability of erection postoperatively and 18 had abnormal or absent ejaculation. For the 12 still living non-operated patients indication for surgery was again considered and 3 of these patients will be recommended operation.     

Gender,smoking, body size,and aneurysm geometry influence the biomechanical rupture risk of abdominal aortic aneurysms as estimated by finite element analysis

Objective

Finite element analysis (FEA) has been suggested to be superior to maximal diameter measurements in predicting rupture of abdominal aortic aneurysms (AAAs). Our objective was to investigate to what extent previously described rupture risk factors were associated with FEA-estimated rupture risk.