Type 3 innate lymphoid cells maintain intestinal epithelial stem cells after tissue damage

Disruption of the intestinal epithelial barrier allows bacterial translocation and predisposes to destructive inflammation. To ensure proper barrier composition, crypt-residing stem cells continuously proliferate and replenish all intestinal epithelial cells within days. As a consequence of this high mitotic activity, mucosal surfaces are frequently targeted by anticancer therapies, leading to dose-limiting side effects. The cellular mechan

Integrin-Alpha IIb Identifies Murine Lymph Node Lymphatic Endothelial Cells Responsive to RANKL

Microenvironment and activation signals likely imprint heterogeneity in the lymphatic endothelial cell (LEC) population. Particularly LECs of secondary lymphoid organs are exposed to different cell types and immune stimuli. However, our understanding of the nature of LEC activation signals and their cell source within the secondary lymphoid organ in the steady state remains incomplete. Here we show that integrin alpha 2b (ITGA2b), known to be carried by platelets, megakaryocytes and hematopoietic progenitors, is expressed by a lymph node subset of LECs, residing in medullary, cortical and subcapsular sinuses. In the subcapsular sinus, the floor but not the ceiling layer expresses the integrin, being excluded from ACKR4+LECs but overlapping with MAdCAM-1 expression. ITGA2b expression increases in response to immunization, raising the possibility that heterogeneous ITGA2b levels reflect variation in exposure to activation signals. We show that alterations of the level of receptor activator of NF-κB ligand (RANKL), by overexpression, neutralization or deletion from stromal marginal reticular cells, affected the proportion of ITGA2b+LECs. Lymph node LECs but not peripheral LECs express RANK. In addition, we found that lymphotoxin-β receptor signaling likewise regulated the proportion of ITGA2b+LECs. These findings demonstrate that stromal reticular cells activate LECs via RANKL and support the action of hematopoietic cell-derived lymphotoxin

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

ITGA2b⁺ LECs are responsive to RANKL and lymphotoxin activation.

<p>(A) Mean ± SD (n = 6) percentage of ITGA2b⁺ LECs of peripheral (p)LNs (inguinal, axial and brachial) versus mesenteric (mes) LNs. (B) Mice were immunized with heat-inactivated <i>B</i>. <i>pertussis</i> and LEC ITGA2b expression of draining and non-draining LNs was compared. The graph shows the mean ± SD (n = 6) percentage of ITGA2b⁺ LECs, revealing increased ITGA2b proportions in response to immunization. (C) Flow cytometry histograms display representative ITGA2b expression ±SD (n = 6) by stromal subsets of inguinal and popliteal LNs draining the immunization site. (D) Histograms show reactivity to anti-GPIBβ labelling of stromal subsets of inguinal and popliteal LNs draining the immunization site. The percentage ±SD (n = 6) of cells labelled by the antibody is indicated. (E) The increase in the proportion of ITGA2b⁺ pLN LECs from RANK-Tg mice (overproducing soluble RANKL in the skin) compared with LECs of WT controls is shown as mean ± SD (n = 8). (F) Graph shows reduction in the percentage of ITGA2b⁺ LECs upon RANKL neutralization (mean ± SD, n = 5). (G) Confocal microscopy imaging in inguinal LN subcapsular and medullary sinuses of ITGA2b expression (green) by LECs (10.1.1, magenta) after RANKL-neutralization or after administration of isotype-control antibody. (H) Mean ± SD (n = 9) percentage of ITGA2b⁺ LECs from mice with conditional deficiency of RANKL in marginal reticular cells (KO) versus WT littermate controls. (I) Histograms of ITGA2b expression of LECs from mice treated with LTβR-Ig or IgG1 control. The graph depicts the mean ± SD (n = 3) percentage of ITGA2b⁺ LECs. *p<0.5, **p < 0.01, ***p < 0.001.</p

ITGA2b is heterogeneously expressed in the adult and embryonic LN.

<p>(A) Confocal microscopy images of an adult inguinal LN probed for ITGA2b together with LEC marker mCLCA1 (mAb 10.1.1) in the subcapsular, the medullary and the cortical sinus. Scale bars are indicated. (B) Confocal microscopy images of an embryonic (E18.5) inguinal LN of ITGA2b and LEC marker Lyve-1. Higher magnification of boxed area is shown below. (C) Flow cytometry counterplot of ITGA2b versus ACKR4 expression by LN LECs of ACKR4-GFP transgenic mice. The percentage ±SD (n = 3) of positive cells is indicated. (D) Mean ± SEM <i>Itga2b</i> mRNA expression of total LN from mice aged 5 days and 8 weeks, and of MAdCAM-1⁺ and MAdCAM-1^- cell-sorted LECs from mice aged 8 weeks. Statistical analysis: ***p<0.001, ns = non significant by one way Anova with the Bonferroni method.</p