Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Transcriptomic analysis of the late stages of grapevine (Vitis vinifera cv. Cabernet Sauvignon) berry ripening reveals significant induction of ethylene signaling and flavor pathways in the skin

Background: Grapevine berry, a nonclimacteric fruit, has three developmental stages; the last one is when berrycolor and sugar increase. Flavors derived from terpenoid and fatty acid metabolism develop at the very end of thisripening stage. The transcriptomic response of pulp and skin of Cabernet Sauvignon berries in the late stages ofripening between 22 and 37 \ub0Brix was assessed using whole-genome micorarrays.Results: The transcript abundance of approximately 18,000 genes changed with \ub0Brix and tissue type. There were alarge number of changes in many gene ontology (GO) categories involving metabolism, signaling and abioticstress. GO categories reflecting tissue differences were overrepresented in photosynthesis, isoprenoid metabolismand pigment biosynthesis. Detailed analysis of the interaction of the skin and pulp with \ub0Brix revealed that therewere statistically significantly higher abundances of transcripts changing with \ub0Brix in the skin that were involved inethylene signaling, isoprenoid and fatty acid metabolism. Many transcripts were peaking around known optimalfruit stages for flavor production. The transcript abundance of approximately two-thirds of the AP2/ERF superfamilyof transcription factors changed during these developmental stages. The transcript abundance of a unique clade ofERF6-type transcription factors had the largest changes in the skin and clustered with genes involved in ethylene,senescence, and fruit flavor production including ACC oxidase, terpene synthases, and lipoxygenases. The transcriptabundance of important transcription factors involved in fruit ripening was also higher in the skin.Conclusions: A detailed analysis of the transcriptome dynamics during late stages of ripening of grapevine berriesrevealed that these berries went through massive transcriptional changes in gene ontology categories involvingchemical signaling and metabolism in both the pulp and skin, particularly in the skin. Changes in the transcriptabundance of genes involved in the ethylene signaling pathway of this nonclimacteric fruit were statisticallysignificant in the late stages of ripening when the production of transcripts for important flavor and aroma compoundswere at their highest. Ethylene transcription factors known to play a role in leaf senescence also appear to play a role infruit senescence. Ethylene may play a bigger role than previously thought in this non-climacteric fruit

The co-translocation of ERp57 and calreticulin determines the immunogenicity of cell death.

The exposure of calreticulin (CRT) on the plasma membrane can precede anthracycline-induced apoptosis and is required for cell death to be perceived as immunogenic. Mass spectroscopy, immunofluorescence and immunoprecipitation experiments revealed that CRT co-translocates to the surface with another endoplasmic reticulum-sessile protein, the disulfide isomerase ERp57. The knockout and knockdown of CRT or ERp57 inhibited the anthracycline-induced translocation of ERp57 or CRT, respectively. CRT point mutants that fail to interact with ERp57 were unable to restore ERp57 translocation upon transfection into crt(-/-) cells, underscoring that a direct interaction between CRT and ERp57 is strictly required for their co-translocation to the surface. ERp57(low) tumor cells generated by retroviral introduction of an ERp57-specific shRNA exhibited a normal apoptotic response to anthracyclines in vitro, yet were resistant to anthracycline treatment in vivo. Moreover, ERp57(low) cancer cells (which failed to expose CRT) treated with anthracyclines were unable to elicit an anti-tumor response in conditions in which control cells were highly immunogenic. The failure of ERp57(low) cells to elicit immune responses and to respond to chemotherapy could be overcome by exogenous supply of recombinant CRT protein. These results indicate that tumors that possess an intrinsic defect in the CRT-translocating machinery become resistant to anthracycline chemotherapy due to their incapacity to elicit an anti-cancer immune response

Activation of the NLRP3 inflammasome in dendritic cells induces IL-1beta-dependent adaptive immunity against tumors.

The therapeutic efficacy of anticancer chemotherapies may depend on dendritic cells (DCs), which present antigens from dying cancer cells to prime tumor-specific interferon-gamma (IFN-gamma)-producing T lymphocytes. Here we show that dying tumor cells release ATP, which then acts on P2X(7) purinergic receptors from DCs and triggers the NOD-like receptor family, pyrin domain containing-3 protein (NLRP3)-dependent caspase-1 activation complex ('inflammasome'), allowing for the secretion of interleukin-1beta (IL-1beta). The priming of IFN-gamma-producing CD8+ T cells by dying tumor cells fails in the absence of a functional IL-1 receptor 1 and in Nlpr3-deficient (Nlrp3(-/-)) or caspase-1-deficient (Casp-1(-/-)) mice unless exogenous IL-1beta is provided. Accordingly, anticancer chemotherapy turned out to be inefficient against tumors established in purinergic receptor P2rx7(-/-) or Nlrp3(-/-) or Casp1(-/-) hosts. Anthracycline-treated individuals with breast cancer carrying a loss-of-function allele of P2RX7 developed metastatic disease more rapidly than individuals bearing the normal allele. These results indicate that the NLRP3 inflammasome links the innate and adaptive immune responses against dying tumor cells

Nano-enabled pancreas cancer immunotherapy using immunogenic cell death and reversing immunosuppression

Pancreatic cancer remains difficult to treat mainly due to the drug delivery challenges posed by a strong stromal component. Here the authors develop nanocarriers that improve drug delivery efficiency and engage the host immune system against the tumor resulting in reduction of tumor growth and metastasis