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Aim: The gastrointestinal bile acid (BA)/microbiota axis has emerged as a potential mediator of health and disease, particularly in relation to pathologies such as inflammatory bowel disease (IBD) and colorectal cancer. Whilst it presents an exciting new avenue for therapies, it has not yet been characterized in surgical resection of the ileum, where BA reabsorption occurs. The identification of BA/microbiota signatures may provide future therapies with perioperative personalized medicine. In this work we conduct a systematic review with the aim of investigating the microbiome and BA changes that are associated with resection of the ileum. Method: The databases included were MEDLINE, EMBASE, Web of Science and Cochrane libraries. The outcomes of interest were faecal microbiome and BA signatures after ileal resection. Results: Of the initial 3106 articles, three studies met the inclusion/exclusion criteria for data extraction. A total of 257 patients (46% surgery, 54% nonsurgery controls) were included in the three studies. Two studies included patients with short bowel syndrome and the other included patients with IBD. Large‐scale microbiota changes were reported. In general, alpha diversity had decreased amongst patients with ileal surgery. Phylum‐level changes included decreased Bacteroidetes and increased Proteobacteria and Fusobacteria in patients with an intestinal resection. Surgery was associated with increased total faecal BAs, cholic acid and chenodeoxycholic acid. There were decreases in deoxycholic acid and glycine and taurine conjugated bile salts. Integrated BA and microbiota data identified correlations with several bacterial families and BA. Conclusion: The BA/microbiota axis is still a novel area with minimal observational data in surgery. Further mechanistic research is necessary to further explore this and identify its role in improving perioperative outcomes. [ABSTRACT FROM AUTHOR]

Background: Surgical Site Infection (SSI) of the abdominal incision is a dreaded complication following colorectal surgery. Identifying the intraoperative surgical site microbes may provide clarity in the pathogenesis of SSIs. Genomic sequencing has revolutionized the ability to identify microbes from clinical samples. Utilization of 16S rRNA amplicon sequencing to characterize the intraoperative surgical site may provide the critical information required to predict and prevent infection in colorectal surgery. Methods: This is a pilot, prospective observational study of 50 patients undergoing elective colorectal resection. At completion of surgery, prior to skin closure, swabs were taken from the subcutaneous tissue of the abdominal incision to investigate the microbial profile. Dual swabs were taken to compare standard culture technique and 16S rRNA sequencing to establish if a microbial profile was associated with postoperative SSI. Results: 8/50 patients developed an SSI, which was more likely in those undergoing open surgery (5/15 33.3% versus 3/35, 8.6%; P = 0.029). 16S rRNA amplicon sequencing was more sensitive in microbial detection compared to traditional culture. Both culture and 16S rRNA demonstrated contamination of the surgical site, predominantly with anaerobes. Culture was not statistically predictive of infection. 16S rRNA amplicon sequencing was not statistically predictive of infection, however, it demonstrated patients with an SSI had an increased biodiversity (not significant) and a greater relative abundance (not significant) of pathogens such as Bacteroidacaea and Enterobacteriaceae within the intraoperative site. Conclusions: 16S rRNA amplicon sequencing has demonstrated a potential difference in the intraoperative microbial profile of those that develop an infection. These findings require validation through powered experiments to determine the overall clinical significance. [ABSTRACT FROM AUTHOR]

Background: Sarcopenia has been shown to have significant adverse health outcomes in a range of patient populations. Particularly, sarcopenic patients having cancer surgery are a unique group who demonstrate poorer post‐operative outcomes. Currently, the gold standard in diagnosing sarcopenia is through the use of computed tomography. However, the widespread use of imaging to diagnose patients with sarcopenia is neither cost‐effective nor practical. Identifying a serum biomarker or a simple mobility scoring system as an alternative diagnostic tool may aid in identifying more patients at risk of sarcopenia. C1q, a novel biomarker, has previously been shown to correlate with sarcopenia. Similarly, we sought to explore whether mobility scores may provide a useful surrogate marker for sarcopenia. Methods: This was a prospective cohort study of patients who presented for colorectal cancer surgery between the dates of 6/10/2016 and 4/10/2017 at John Hunter Hospital. Computed tomography was utilized to calculate the psoas area at the L3 spinal level. Pre‐operative blood samples were obtained for C1q analysis and de Morton Mobility Index (DEMMI) was also performed. Results: A total of 51 patients were included in the study. The median age of the patients were 69 years old. We did not demonstrate a correlation between serum C1q and DEMMI scores with psoas area. Conclusion: Our findings suggest that neither C1q nor DEMMI scores are correlated with psoas area in a colorectal cancer population. [ABSTRACT FROM AUTHOR]

Background: Preoperative skin antiseptics are used prior to surgery to reduce the risk of surgical site infection (SSI). There is debate as to which is the most effective. The aim of this network meta‐analysis (NMA) is to compare the effectiveness of different skin preparations at reducing SSIs in patients undergoing incisional surgery. Methods: The study protocol was published in PROSPERO (CRD4202181599) a priori with predefined search terms and inclusion/exclusion criteria. The skin preparations for comparison were: chlorhexidine/alcohol (CHA), chlorhexidine/water (CHW), poviodine/alcohol (PVIA), poviodine/water (PVIW). The records identified were screened by two authors independently by title, abstract and in full text. The revised tool for risk‐of bias (ROB2) assessment was used. Results: Twenty‐nine RCTs involving 15 796 patients were included in the NMA. A significant but small increase in the odds of infection was seen in the PVIW group compared to the CHA group (OR 1.34, 95%CrI 1.09–1.64), but other comparisons were not statistically significantly different. Ranking the treatment arms showed there was a 64% probability that CHA is the most effective and a 62.7% probability that PVIW is the least effective treatment. Conclusion: Chlorhexidine/alcohol (CHA) was found to be the most effective for prevention of superficial and deep SSI while PVIW was the least. There was no differences seen between CHA and PVIA, or CHW and PVIW. The superiority of CHA is likely due to the effect of the alcohol in the base. Hence the choice between CHA and PVIA should be based on health and cost considerations. [ABSTRACT FROM AUTHOR]

Sewage sludge is the essential by‐product of wastewater treatment and approaching 100% of the sludge generated in the United Kingdom is recycled to agricultural land. In collaboration with three major Water Utility companies in the United Kingdom, a critical statistical analysis of historical and contemporary sludge quality data was completed to demonstrate the long‐term patterns and improvements in the trace element (TE) content of sludge recycled to agriculture since 1989, and to indicate the current status of sludge quality in the United Kingdom. Comparisons with pollutant emission inventory data showed most of the TE concentrations in sludge were strongly linked to declining environmental emissions. A soil accumulation model showed that zinc and copper would be the first to approach their statutory soil limits in the long term and that nickel, cadmium, lead and mercury are no longer significant and, from a practical perspective, could be removed from the regulatory controls on agricultural use. [ABSTRACT FROM AUTHOR]

At laparotomy, an enormous cyst arising from the sigmoid mesentery and extending into the mesorectum was identified that was intricately related to the sigmoid colon, pushing it into the right upper quadrant. Computed tomography (CT) of the abdomen and pelvis demonstrated a large cystic mass in the pelvis and central abdomen measuring 24 × 19 × 12 cm displacing the sigmoid colon anteriorly and the bladder posteroinferiorally. A 58-year-old female presented with a 4-week history of intermittent dull right-sided abdominal pain, mild nausea and a sensation of incomplete bladder emptying upon micturition. [Extracted from the article]

Background: Post‐operative length of stay (LOS) is an increasingly important clinical indicator in general surgery. Despite this, no tool has been validated to predict LOS or readiness for discharge in general surgical patients. The de Morton Mobility Index (DEMMI) is a functional mobility assessment tool that has been validated in rehabilitation patient populations. In this prospective cohort study, we aimed to identify if trends in DEMMI scores were associated with discharge within 1 week and overall LOS in general surgical patients. Methods: A total of 161 patients who underwent elective gastrointestinal resections were included. DEMMI scores were performed preoperatively, on days 1, 2, 3 and 30 post‐operative. Statistical analysis was performed to identify any association between DEMMI scores and discharge within 1 week and LOS. Results: Functional recovery (measured by achieving 80% of baseline DEMMI score by post‐operative day 1) was significantly associated with discharge within 1 week. Presence of a stoma was associated with longer LOS. The area under the receiver operating characteristic curve using functional recovery on post‐operative day 1 as a predictor of discharge within 1 week is 0.772. Conclusion: The DEMMI score is a fast, easy and useful tool to, on post‐operative day 1, predict discharge within 1 week. The utility of this is to act as an anticipatory trigger for more proactive and efficient discharge planning in the early post‐operative period, and there is potential to use the DEMMI as a comparator in clinical trials to assess functional recovery. [ABSTRACT FROM AUTHOR]

Background: Adequate post‐operative analgesia is essential for recovery following abdominal surgery. Abdominal wall nerve blocks have been shown to be beneficial in this respect following surgery. The purpose of this trial was to examine the efficacy of infusional versus intermittent bolus delivery of abdominal wall blocks in patients undergoing abdominal resectional gastrointestinal surgery. Methods: A prospective randomized clinical trial, involving 120 patients undergoing gastrointestinal surgery, was undertaken across three hospitals. Insertion of abdominal wall catheters was performed and patients were randomized to receive ropivacaine 0.2% by either continuous infusion or regular intermittent bolus. The primary outcome was respiratory function, as measured by spirometry on post‐operative days 1–3 and 30. Secondary outcomes were pain, mobility, return of gut function, length of hospital stay, complication rates and patient satisfaction with analgesia. Results: All 120 patients were followed up to trial completion. Patients were well matched with regards to demographics. There was no difference between groups with regards to the primary outcome of post‐operative respiratory function. The bolus group had improved mobility scores on post‐operative day 1 (P = 0.025). There were no complications associated with blockade, and no other differences were identified between assessed outcomes. Conclusions: Continuous infusion and intermittent bolus are both safe ways of delivering abdominal wall nerve blockade, with equivalent analgesic outcomes. Bolus delivery appears to provide superior early mobility in comparison with continuous infusion. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leakage is a feared complication following colorectal surgery. Early prediction results in improved clinical outcome, but accurate predictive factors remain elusive. Many biomarkers have been studied with respect to diagnosis of anastomotic leakage but the concept of trajectory testing, using biomarkers, has not been assessed with regards to early diagnosis of anastomotic leak. Methods: C‐reactive protein (CRP), procalcitonin (PCT), white cell count (WCC) and gamma‐glutamyl transferase were assessed for predictive utility in diagnosing anastomotic leakage with emphasis on identifying an association with change in their levels or trajectory. Levels were collected preoperatively and daily for the first 5 post‐operative days on patients undergoing elective colorectal surgery, involving an anastomosis. Anastomotic leakage was defined clinically by operative or radiological intervention. Comparison was made between biomarkers and clinical anastomotic leakage, using receiver operator characteristic curves for logistic models, based on trajectory of the four biomarkers. Results: A total of 197 consecutive patients were analysed. Eleven patients developed clinical anastomotic leakage. An association of biomarker trajectory with anastomotic leakage was observed for WCC, PCT and CRP, but not for gamma‐glutamyl transferase. CRP was the superior biomarker based on trajectory, with area under the receiver operator curve of 0.961. Conclusion: This study identifies change in CRP, WCC and PCT as potential markers of anastomotic leakage following colorectal surgery and in particular highlights CRP trajectory as extremely accurate in diagnosing anastomotic leakage requiring intervention. External validation should be sought before incorporating this into routine clinical practice, given the numbers in this study. [ABSTRACT FROM AUTHOR]

Background: The presence of an indwelling urinary catheter (IDUC) is routine following colorectal resections. In Enhanced Recovery After Surgery programmes, excessive intravenous fluids (IVFs) are avoided. This study sought to determine whether the routine absence of an IDUC following colorectal surgery improved post‐operative outcomes and minimized fluid prescription. Methods: A retrospective comparative cohort study was performed on patients undergoing colorectal resection at a tertiary referral teaching hospital, over a 7‐year period. A policy of no routine IDUC was introduced over the last 3 years. Patients were divided into cohorts based on the presence or absence of an IDUC on leaving the operating theatre. The outcomes assessed were IVF prescription, length of stay, mortality and morbidity. Results: Of the 213 resections over the time period, 131 met the inclusion criteria (87 IDUC and 44 no IDUC). There was no difference between groups with respect to baseline demographics. Fluid administration was less in the group without routine IDUC (total fluid 6.16 L versus 10.89 L; P < 0.0001, fluid in the first 24 h 3.82 L versus 5.3 L; P < 0.0001 and fluid in the first 48 h 5.15 L versus 7.23 L; P < 0.0001). Length of stay was less in the ‘no IDUC’ group (5.9 days versus 10.1 days; P = 0.0009). There was no difference in morbidity and mortality. Conclusion: A policy of no IDUC following colectomy was associated with a reduction in IVF administration and length of stay. A randomized controlled trial is recommended in order to more accurately determine the degree of causal relationship. [ABSTRACT FROM AUTHOR]

Untreated sewage sludge potentially contains a wide range of enteric pathogens that present a risk to human health. Mesophilic anaerobic digestion (MAD) is the most-favoured process for sewage sludge treatment in the United Kingdom. It is a well-established approach to sludge stabilisation, but the mechanisms responsible for pathogen removal are poorly understood. Operational data collected by Thames Water from conventional MAD sites were statistically scrutinised to examine the effects of primary and secondary digestion on the removal of the enteric indicator bacteria, Escherichia coli, by using the IBM SPSS statistical software package for ANOVA, post-hoc and multiple regression analysis. The results showed that the process temperature conditions at the MAD plants were equivalent to or exceeded the minimum estimated by the analysis necessary to comply with the 2 log10 removal standard for E. coli. The results also showed that primary digestion conditions (specifically temperature) sublethally damaged E. coli and increased decay in secondary digestion and therefore over the whole digestion process. [ABSTRACT FROM AUTHOR]

A main distinction between anaerobic digestion (AD) technologies for treatment of municipal and industrial biodegradable wastes is the operating process solids content. Wet AD systems operate at low total solids (<10-20% TS) and dry systems have high operating solids (20->40% TS). The performance of wet and dry AD systems was quantified in relation to: technical operation (footprint, capacity, feedstock characteristics, pretreatment and post-treatment, retention time, water usage), energy balance (biogas productivity, parasitic energy, methane [CH4] content, utilization of biogas and produced energy), digestate management and economic performance (capital and operational costs, revenues, specific capital costs [per t of waste and per m³ biogas]). Wet AD plants had improved energy balance and economic performance compared to dry AD plants. However, dry AD plants offered several benefits, including greater flexibility in the type of feedstock accepted, shorter retention times, reduced water usage and more flexible management of, and opportunities for marketing, the end-product. [ABSTRACT FROM AUTHOR]

BK polyomavirus ( BKV) infection continues to be a significant source of allograft dysfunction in kidney transplant recipients. The optimal screening method to detect BKV remains undetermined. In this retrospective analysis of 347 consecutive kidney transplant recipients, we compare the diagnostic and screening performance of urine electron microscopy ( EM) with plasma polymerase chain reaction ( PCR) in testing for BKV, using biopsy-proved polyomavirus-associated nephropathy ( PVAN) as the gold standard. Sixty-nine of 347 recipients had a positive screening test for BKV infection. Twenty-nine patients underwent biopsy, and 11 were diagnosed with PVAN. Sensitivity rates of urine EM and plasma PCR were 88% and 100%, respectively. Specificity rates of urine EM and plasma PCR were 91% and 78%. There was no statistical difference in the operating characteristics of the two tests. The majority of both plasma PCR and urine EM tests were positive in the six months prior to a diagnostic biopsy confirming PVAN. In those patients who had evidence of BKV infection but did not have PVAN, the percentage of positive screening tests decreased with aggressive lowering of immunosuppression. We conclude that urine EM and plasma PCR both function well in screening for BKV infection and in the diagnosis of PVAN. There is an opportunity to detect viral replication, lower immunosuppression, and to prevent PVAN in this population. [ABSTRACT FROM AUTHOR]

Goetzinger AM, Blumenthal JA, O'Hayer CV, Babyak MA, Hoffman BM, Ong L, Duane Davis R, Smith SR, Rogers JG, Milano CA, Smith AD, Kuo PC, Palmer SM. Stress and coping in caregivers of patients awaiting solid organ transplantation. Clin Transplant 2012: 26: 97-104. © 2011 John Wiley & Sons A/S. Abstract: Caregivers for patients undergoing solid organ transplantation play an essential role in the process of transplantation. However, little is known about stress and coping among these caregivers. Six hundred and twenty-one primary caregivers of potential candidates for lung (n = 317), liver (n = 147), heart (n = 115), and/or kidney (n = 42) transplantation completed a psychometric test battery at the time of the candidate's initial pre-transplant psychosocial evaluation. Caregivers were generally well adjusted, with only 17% exhibiting clinical symptoms of depression (Beck Depression Inventory-II score >13) and 13% reporting clinical levels of anxiety (State Trait Anxiety Inventory score >48). Greater caregiver burden and negative coping styles were associated with higher levels of depression. Greater objective burden and avoidant coping were associated with higher levels of anxiety. Caregivers evidenced a high degree of socially desirable (i.e., defensive) responding, which may reflect a deliberate effort to minimize fears or worries so as to not jeopardize patients' listing status. [ABSTRACT FROM AUTHOR]

Background. Malakoplakia is a very rare chronic inflammatory disorder, first described in 1902. In 75% of cases, the condition affects the genitourinary tract. Five cases of malakoplakia affecting the neck were previously reported in the literature. Methods and Results. An 83-year-old woman presented with an enlarging mass in the posterior triangle of the neck that was histologically confirmed as malakoplakia. Presenting features are often nonspecific, and the diagnosis is dependent on histological findings. The characteristic microscopic findings are of Michaelis–Gutmann (M-G) bodies that stain positive with periodic acid–Schiff reagent, von Kossa's reaction for calcium, and Perl's ferrocyanide reaction to ferric iron. Conclusion. Although rare, a diagnosis of malakoplakia should be considered in patients with an enlarging mass. This may mimic the presentation of malignancy, particularly in patients in whom erosion through skin occurs, and histological confirmation is advocated. © 2009 Wiley Periodicals, Inc. Head Neck 32:1269–1272, 2010 [ABSTRACT FROM AUTHOR]

There has been little investigation of the ecological interactions between major organisms brought about by the application of wastewater biosolids to agricultural soil. This paper provides an overview of the possible effects of biosolids application on these ecosystems by using what is known about the ecology and diversity of microbial populations in soil and biosolids. Areas considered include interactions between indigenous and introduced bacterial populations, impacts of biosolids application on soil protozoa and the role of phages in bacterial population dynamics. These ecological processes are particularly relevant, for instance, to increase an understanding of the fundamental mechanisms responsible for inactivation of potentially infectious enteric microorganisms in biosolids-amended agricultural soil. [ABSTRACT FROM AUTHOR]

Background: Although innate immunity is crucial to host defense against pathogens, the extent to which innate immune mechanisms participate in the rejection of allogenic tissues in humans is unknown. We hypothesize that activation of innate immunity through Toll-like receptors (TLRs) critically regulates the development of renal allograft rejection. We have recently demonstrated decreased acute rejection in lung transplant recipients heterozygous for either of two functional polymorphisms in TLR4 associated with endotoxin hyporesponsiveness. In the present investigation, we sought to evaluate the role of innate immune activation through TLR4, in either donor or recipient, upon the development of renal allograft rejection. Methods: Patients and donors were screened for the TLR4 functional polymorphisms (Asp299Gly and Thr399Ile) by polymerase chain reaction (PCR) using sequence-specific primers. Results: The incidence of biopsy-proven acute renal allograft rejection was significantly reduced in patients receiving donor grafts heterozygous for the Asp299Gly or Thr399Ile alleles, when compared with wild type (22% vs. 0%, respectively, p = 0.02). There was no association with recipient TLR4 allele and rejection. Conclusions: The results suggest activation of innate immunity through TLR4 in the donor kidney contributes to the development of acute rejection after renal transplantation. [ABSTRACT FROM AUTHOR]

Rocha PN, Plumb TJ, Miller SE, Howell DN, Smith SR. Risk factors for BK polyomavirus nephritis in renal allograft recipients. Clin Transplant 2004 DOI: 10.1111/j.1399-0012.2004.00191.x © Blackwell Munksgaard, 2004 Recurrent episodes of acute rejection (AR) and/or the intense immunosuppression used for their treatment have been proposed as risk factors for BK nephritis (BKN; BK refers to the initials of the first patient from whom this polyomavirus was isolated). To further examine the relationship between AR and BKN, we analyzed all kidney transplants performed at our center between January 1999 and August 2001 (n = 286). After a mean follow-up of 737 ± 22 d, we identified nine cases of BKN (3.1%). The mean time to diagnosis of BKN was 326 ± 56 d. No patient with BKN had a prior history of AR. During the same period, 62 patients were diagnosed with AR (22%). The mean time to diagnosis of AR was 197 ± 40 d (p = 0.01 vs. time to diagnosis of BKN). Despite aggressive therapy with methylprednisolone and, in some cases, anti-lymphocyte antibody, none of these patients with AR developed BKN. We compared the baseline characteristics of patients in both groups and found that BKN patients were more likely to be white people (78 vs. 44%, p = 0.05) and male (89 vs. 53%, p = 0.04). Moreover, the mean tacrolimus (TAC) levels before diagnosis were higher in BKN than in AR patients (11.7 ± 0.5 vs. 6.5 ± 0.6 ng/mL, p < 0.001). In summary, our study shows that BKN often occurs in the absence of prior episodes of AR. In addition, our findings suggest that white males exposed to higher TAC levels are at greater risk of developing BKN. [ABSTRACT FROM AUTHOR]

The article discusses the preservation of arteriovenous (AV) access during the management of clinically significant arterial steal to restore perfusion to the distal extremity. It is noted that the preservation of AV access can be accomplished by relieving proximal arterial lesions. It also highlights the role of arterial stenosis in the development of distal ischemia. According to the authors, arterial steal poses a problem among patients on chronic hemodialysis.

Reports on a case of lipohyperplasia of the ileo-caecal valve in a 48-year-old man who presented with appendicitis. Findings of the physical examination; Histopathology of the caecal lesion; Modes of clinical presentation.