Secretory immunoglobulin A (sIgA) deficiency in serum of patients with GALTectomy (appendectomy and tonsillectomy)

Associating Appendicitis with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A Novel Insight into an Unexpected Connection

BACKGROUND

The gut microbiome modulates the liver immune microenvironment and is deeply integrated into the pathophysiology of metabolic dysfunction-associated steatotic liver disease (MASLD). Appendectomies, which are performed in almost all patients diagnosed with appendicitis, cause long-term alterations to the gut microbiome, providing a potential link with the development of MASLD. We therefore investigated a potential link between appendicitis and the presence of MASLD in a large cohort of outpatients in Germany.

METHODS

The present study included 26,717 individuals with and 26,717 without appendicitis. Univariable Cox-regression analyses were conducted to assess the association between appendicitis and MASLD.

RESULTS

During the long-term follow-up, 4.8% of patients with appendicitis and 3.4% of those in the non-appendicitis group were diagnosed with MASLD (p < 0.001), corresponding to an incidence of 5.4 (appendicitis cohort) versus 3.5 (non-appendicitis cohort) cases per 1000 patient years. These findings were confirmed in regression analysis, revealing a strong and statistically significant association between appendicitis and the development of MASLD (HR: 1.57; 95% CI: 1.39-1.78). This link was observed for all age groups and was independent of patients' sex.

CONCLUSION

We provide evidence from a large cohort of outpatients in Germany suggesting a link between appendicitis and MASLD. This might help to better stratify patients according to their individual risk for the development of chronic liver diseases.

Expression of Homing Receptors in IgM+IgD+CD27+ B Cells and Their Frequencies in Appendectomized and/or Tonsillectomized Individuals

BACKGROUND

In humans, blood circulating IgM⁺IgD⁺CD27⁺ B cells are considered analogous to those described in the marginal zone of the spleen and are involved in important immunological processes. The homing receptors they express, and the organs involved in their development (for example, intestinal organs in rabbits) are only partially known. We recently reported that this population is heterogeneous and composed of at least two subsets: one expressing high levels of IgM - IgM^hi B cells - and another low levels - IgM^lo B cells.

OBJECTIVES

To evaluate the expression of homing receptors on IgD⁺CD27⁺ IgM^hi and IgM^lo B cells and quantify their frequencies in blood of control and appendectomized and/or tonsillectomized volunteers.

MATERIALS AND METHODS

Using spectral flow cytometry, the simultaneous expression of 12 previously reported markers that differentiate IgM^hi B cells and IgM^lo B cells and of α4β7, CCR9, CD22 and CCR10 were evaluated in blood circulating B cells of control and appendectomized and/or tonsillectomized volunteers.

RESULTS

The existence of phenotypically defined IgM^lo and IgM^hi B cell subsets was confirmed. They differentially expressed intestinal homing receptors, and the expression of α4β7 and CCR9 seems to determine new IgM subpopulations. IgM^lo and IgM^hi B cells were detected at lower frequencies in the appendectomized and/or tonsillectomized volunteers relative to controls.

CONCLUSIONS

Human blood circulating IgD⁺CD27⁺ IgM^lo and IgM^hi B cell subsets differentially express homing receptors, and it is necessary to investigate if mucosal organs are important in their development.

Association between prior appendectomy and the risk and course of Crohn's disease: A systematic review and meta-analysis

BACKGROUND AND AIMS

The appendix has an important immune function in both health and disease, and appendectomy may influence microbial ecology and immune function. This meta-analysis aims to assess the association between appendectomy and the risk and course of Crohn's disease (CD).

METHODS

PubMed, EMBASE, and the Cochrane Library were used to identify all studies published until June 2022. Data from studies evaluating the association between appendectomy and CD were reviewed.

RESULTS

A total of 28 studies were included in the final analysis, comprising 22 case-control and 6 cohort studies. A positive relationship between prior appendectomy and the risk of developing CD was observed in both case-control studies (odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.22-2.08) and cohort studies (relative risk [RR]: 2.28, 95% CI: 1.66-3.14). The elevated risk of CD persisted 5 years post-appendectomy (RR = 1.24, 95% CI: 1.12-1.36). The risk of developing CD was similarly elevated regardless of the presence (RR = 1.64, 95% CI: 1.17-2.31) or absence (RR = 2.77, 95% CI: 1.84-4.16) of appendicitis in patients. Moreover, significant differences were found in the proportion of terminal ileum lesions (OR = 1.63; 95% CI: 1.38-1.93) and colon lesions (OR = 0.70; 95% CI: 0.5-0.84) between CD patients with appendectomy and those without appendectomy.

CONCLUSIONS

The risk of developing CD following an appendectomy is significant and persists 5 years postoperatively. Moreover, the elevated risk of CD may mainly occur in the terminal ileum.

Increased plasma and brain immunoglobulin A in Alzheimer’s disease is lost in apolipoprotein E ε4 carriers

Background

Alzheimer’s disease (AD) is foremost characterized by β-amyloid (Aβ)-extracellular plaques, tau-intraneuronal fibrillary tangles (NFT), and neuroinflammation, but over the last years it has become evident that peripheral inflammation might also contribute to the disease. AD patients often demonstrate increased levels of circulating proinflammatory mediators and altered antibody levels in the blood. In our study, we investigated the plasma Immunoglobulin A (IgA) levels in association with apolipoprotein E (APOE) ε4 status and Aβ pathology.

Methods

IgA levels in antemortem-collected (cohort I) and postmortem-collected (cohort II) plasma samples from AD patients (n = 30 in cohort I and n = 16 in cohort II) and non-demented age-matched controls (NC) (n = 42 in cohort I and n = 7 in cohort II) were measured using ELISA. Hippocampal sections from cohort II were immunostained against IgA, and the IgA area fraction as well as the number of IgA positive (IgA+) cells in the cornu ammonis region were analysed using ImageJ. The relationship between plasma IgA levels and cognition, C-reactive protein (CRP), and cerebrospinal fluid (CSF) AD biomarkers in cohort I as well as neuropathology, IgA+ cell number, and IgA area fraction in cohort II was analysed before and after grouping the cohorts into APOEε4 carriers and APOEε4 non-carriers.

Results

Plasma IgA levels were higher in AD patients compared to NC in both cohorts. Also, AD patients demonstrated higher IgA area fraction and IgA+ cell number compared to NC. When APOEε4 status was considered, higher plasma IgA levels in AD patients were only seen in APOEε4 non-carriers. Finally, plasma IgA levels, exclusively in APOEε4 non-carriers, were associated with cognition, CRP, and CSF Aβ levels in cohort I as well as with IgA area fraction, IgA+ cell number, and Aβ, Lewy body, and NFT neuropathology in cohort II.

Conclusions

Our study suggests that AD pathology and cognitive decline are associated with increased plasma IgA levels in an APOE allele-dependent manner, where the associations are lost in APOEε4 carriers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13195-022-01062-z.

Tonsillectomy in Adults over 40 Years of Age Does Not Increase the Risk of Pneumonia: A Three-Year Longitudinal Follow-Up Study

To evaluate the effect of tonsillectomy on the subsequent risk of pneumonia in an adult population, a longitudinal follow-up case control study was conducted using a national health screening cohort dataset between 2003 and 2012. A total of 1005 tonsillectomy participants were 1:4 matched with 4020 control participants for age, sex, income, and region of residence. The number of pneumonia diagnoses were counted from the index date (ID) to the date after the first-year (post-ID 1y), second-year (post-ID 2y), and third-year (post-ID 3y) periods. Simple linear regression and multiple linear regression were conducted to calculate estimated values (EVs) and 95% confidence intervals for each post-ID pneumonia and compared between the two groups. Subgroup analyses were performed according to age, sex, and the number of pneumonia cases during the year prior to the ID (pre-ID 1y). In the simple linear regression model, post-ID pneumonia did not show a significant correlation with tonsillectomy (post-ID 1y: EV = 0.003; post-ID 2y: EV = 0.007; post-ID 3y: EV = 0.013; all p > 0.05). In the multiple regression model, post-ID pneumonia also did not show a significant correlation with tonsillectomy (post-ID 1y: EV = 0.001; post-ID 2y: EV = 0.006; post-ID 3y: EV = 0.011; all p > 0.05). In the subgroup analyses, tonsillectomy did not show a significant correlation with post-ID pneumonia in either the simple linear regression or multiple linear regression models (all p > 0.05). Tonsillectomy performed in the adult population did not show any effect in increasing the incidence of pneumonia during the first three postoperative years.

Tonsillectomy as a risk factor of periodontitis: a population-based cohort study

AIM

To determine whether patients who had undergone tonsillectomy would have higher risks of postoperative periodontitis.

METHODS

Data were collected from the Taiwan Longitudinal Health Insurance Dataset from 1999 to 2013, a population-based cohort study consisting of cases of newly-onset sleep apnoea, chronic diseases of tonsils and adenoids, peritonsillar abscess, and periodontal diseases. 1,482 tonsillectomy cases and 14,796 non-tonsillectomy controls were selected. Propensity score matching between the tonsillectomy group and the non-tonsillectomy group was conducted to exclude the confounding effect resulting from indications of tonsillectomy. Cox proportional hazard model and subgroup analyses were conducted to identify subpopulations at risk of tonsillectomy-associated periodontitis, and a sub-outcome analysis was applied to identify the subtype of tonsillectomy-associated periodontitis.

RESULTS

A total of 648 patients who had undergone tonsillectomy and 648 out of 6,509 propensity score-matched controls were retrieved, among which 230 cases in the tonsillectomy group were associated with post-surgical periodontitis (adjusted HR = 1.31, 95% CI = 1.08-1.59). The association persisted in a subpopulation of patients with periodontitis who received mechanical and surgical treatments for periodontitis (adjusted HR = 1.33, 95% CI = 1.09-1.63). The incidence of periodontitis was significantly high in the individuals who underwent tonsillectomy and was particularly high in those that were below 12 years of age (HR = 1.58, 95% CI = 1.10-2.27). The risk of periodontitis increased 4 years after tonsillectomy (HR = 1.82; 95% CI = 1.29-2.59). The majority of post-tonsillectomy periodontitis was aggressive and acute periodontitis (HR = 1.37; 95% CI = 1.10 - 1.71).

CONCLUSIONS

Tonsillectomy performed in paediatric patients of less than 12 years old, increased the risk of developing periodontitis. Aggressive and acute periodontitis as a long-term, postoperative adverse event took place at 4 years or longer after tonsillectomy. This article is protected by copyright. All rights reserved.

Adenotonsillectomy Does not Alter the Risk of Upper Airway Infections in Children

OBJECTIVE

Given the conflicting evidence regarding adenotonsillectomy and the risk of upper airway infections (UAIs), including acute pharyngitis (APT), rhinosinusitis (ARS), and otitis media (AOM), we evaluated the risk of developing UAIs following adenotonsillectomy in a childhood population.

METHODS

In this population-based follow-up study, we used data from the National Health Insurance Service-National Sample Cohort. The adenotonsillectomy group (n = 2,377) included patients aged <10 years who underwent an adenotonsillectomy. For every patient with APT (n = 2,309), ARS (n = 2,308), and AOM (n = 2,207) who had an adenotonsillectomy, four participants were randomly selected for the control groups (n = 9,204, n = 9,196, and n = 8,788, respectively) using propensity score matching. The number of postoperative hospital visits for UAIs was recorded for 1 to 9 years, and the equivalence test was used to compare the number of visits between the adenotonsillectomy and control groups.

RESULTS

There were no significant differences in the incidence of APT, ARS, or AOM at the margin of equivalence of difference (-0.5 < 95% confidence interval of difference < 0.5) between the two groups from postoperative year 1 to year 9. The hospital visits for these diseases gradually decreased over time in both groups. There was a significant decrease in the number of visits for APT, ARS, and AOM in the 5-9 years age group when compared with those in the <4 years age group (P < .01).

CONCLUSION

Our results suggest that adenotonsillectomy does not alter the frequency of UAIs in children.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2021.

Endoscopic treatment for acute appendicitis with coexistent acute pancreatitis: Two case reports

BACKGROUND

Appendectomy is the procedure of choice for the treatment of acute appendicitis. However, surgery may not be appropriate for patients with coexisting severe illness or comorbidities such as acute pancreatitis (AP). Endoscopic retrograde appendicitis treatment (ERAT) may be a novel alternative to surgery for treating such patients where existing medical therapies have failed.

CASE SUMMARY

We report 2 cases of moderately severe AP who developed acute uncomplicated appendicitis during their hospital stay and did not respond to traditional medical therapy. One patient had moderately severe AP due to hyperlipidemia, while the other patient had a gallstone induced by moderately severe AP. Neither patient was fit to undergo an appendectomy procedure because of the concurrent AP. Therefore, the alternative and minimally invasive ERAT was considered. After written informed consent was collected from the patients, the ERAT procedure was performed. Both patients exhibited fast postoperative recovery after ERAT with minimal surgical trauma.

CONCLUSION

ERAT is a safe and effective minimally invasive endoscopic procedure for acute appendicitis in patients with coexistent AP.

Impact of tonsillectomy on irritable bowel syndrome: A nationwide population-based cohort study

Tonsillectomy is a commonly performed surgical procedure worldwide; however, the possible long-term consequences have not been fully explored. The tonsils are secondary lymphoid tissue providing a defensive barrier against pathogens. There are few data in the literature on the relationship between prior tonsillectomy and the risk of irritable bowel syndrome (IBS). The aim of this study was to evaluate the risk of developing IBS in patients who underwent tonsillectomy using a nationwide longitudinal population-based cohort. We identified 1300 patients with tonsillectomy and 2600 matched controls from the Longitudinal Health Insurance Research Database of the National Health Insurance Research Database in Taiwan. Propensity score analysis was used for matching age, gender, comorbidities, medications, and index year at a ratio of 1:2. Multiple Cox regression analysis was used to estimate the adjusted hazard ratio of IBS. Furthermore, sensitivity tests and a stratified analysis were conducted. The incidence of IBS was 3 per 1,000 person-years in tonsillectomy patients, which was higher than the rate of 1.8 per 1,000 person-years found in non-tonsillectomy patients. After adjustment for patients’ age, gender, comorbidities, and medications, patients who underwent tonsillectomy had a 1.84-fold risk of developing IBS compared to those without tonsillectomy (adjusted hazard ratio [HR]:1.84; 95% CI, 1.09–3.09). Stratified analysis revealed that a higher adjusted HR of 3.79 (95% CI, 1.35–10.64) in patients ≥50 years old, and there was a marginally significantly higher adjusted HR of 1.98 (95% CI, 0.99–3.95) of developing IBS when the follow-up period was longer than 3 years. Tonsillectomy was associated with a higher risk of developing IBS. Physicians should provide appropriate monitoring of IBS in patients undergoing tonsillectomy.

The Appendix in Parkinson's Disease: From Vestigial Remnant to Vital Organ?

Parkinson’s disease (PD) has long been considered a brain disease, but studies now point to the gastrointestinal (GI) tract as a potential starting point for PD. In particular, the human vermiform appendix has been implicated in PD. The appendix is a tissue rich in immune cells, serving as part of the gut-associated lymphoid tissue and as a storehouse for the gut microbiome. The functions of the appendix converge with recent evidence demonstrating that gut inflammation and shifts in the microbiome are linked to PD. Some epidemiological studies have linked removal of the appendix to lowered PD risk, though there is controversy among these associations. What is apparent is that there is an abundance of aggregated forms of α-synuclein in the appendix relevant to PD pathology. α-Synuclein pathology is thought to propagate from gut to brain via the vagus nerve, which innervates GI tract locations, including the appendix. Remarkably, α-synuclein aggregates in the appendix occur not only in PD patients, but are also present in healthy individuals. This has led to the proposal that in the appendix α-synuclein aggregates are not unique to PD. Moreover, the molecular events leading to PD and the mechanisms by which α-synuclein aggregates transfers from gut to brain may be identifiable in the human appendix. The influence of the appendix on GI inflammation, autoimmunity, microbiome storage, and the lymphatic system may be yet unexplored mechanisms by which the appendix contributes to PD. Overall, the appendix represents a promising tissue site to advance our understanding of PD pathobiology.

Prior tonsillectomy is associated with an increased risk of esophageal adenocarcinoma

BACKGROUND

Esophageal cancer is a deadly cancer with 5-year survival <20%. Although multiple risk factors for esophageal adenocarcinoma (EAC) including obesity, GERD and smoking have been identified, these risk factors do not fully explain the rising incidence of EAC. In this study, we evaluated the association between prior history of tonsillectomy and EAC. Our goal was to determine whether tonsillectomies were more frequent in patients with EAC (cases) than in our thoracic surgery controls.

METHODS

Cases included 452 esophagectomy cases, including 396 with EAC and 56 who underwent esophagectomy for Barrett's esophagus (BE) with high grade dysplasia (HGD). 1,102 thoracic surgery patients with surgical indications other than dysplastic BE or esophageal cancer represented the controls for our analysis. The association of tonsillectomy and HGD/EAC were primarily evaluated by using univariate tests and then verified by logistic regression analysis. Baseline demographics, medical history, and thoracic surgery controls were compared by using χ2 tests or 95% CIs. Significant risk factors were considered as covariates in the multivariate models while evaluating the association between tonsillectomy and HGD/EAC. P-values or odds ratios were estimated with 95% confidence limits to identify significances which was more appropriate.

RESULTS

Tonsillectomy was more common in cases than controls and was found to have a significant association with esophageal cancer (19.9% vs. 12.7%; p-value = 0.0003). This significant association persisted after controlling for other known risk factors/covariates.

CONCLUSION

A prior history of tonsillectomy was significantly associated with HGD/EAC and may represent an independent risk factor for the development of EAC. However, the underlying biology driving this association remains unclear.

Long-term impacts of tonsillectomy on children's immune functions

Background

There exist a wide level of discrepancy regarding the role of tonsils and its indication among pediatricians and ENT specialists. This fact sometimes causes confusion and delay in making the right decisions by parents and specialists for appropriate treatment of patients.

Objectives

Thus, the aim of this study was to investigate the effects of long-term tonsillectomy on the immune system of patients.

Methods

In this case-control study we measured the status of immune system in 34 children (aged 9-15 years) following 4 to 6 years of tonsillectomy. We have also enrolled 30 healthy children with similar age group. Venous blood samples were taken and the serum levels of IgG, IgA, and IgM were detected along with expression of CD4, CD8, CD10 and CD56. Data were analyzed by SPSS version 18 software and a P < 0.05 was considered as significant.

Results

We found that the mean serum levels IgM, IgA, and IgG in the case group was significantly (P < 0.0001) lower than the control group. Whereby, the CD4, CD8 and CD56 expressions was examined, there was no significant difference in both groups while only CD10 expression was lower in tonssiloctomized patients (P = 0.108).

Conclusion

Overall, according to these findings, CD10 as a marker of B lymphocytes in children undergoing tonsillectomy was significantly less than those healthy children. This may indicate a decrease in B cells and further reduced antibody production in these patients.

Increased risk of appendectomy due to appendicitis after tonsillectomy in women: A longitudinal follow-up study using a national sample cohort

The purpose of this study was to evaluate the risk of appendectomy due to appendicitis after tonsillectomy in Koreans using national cohort data. Using the national cohort study from the Korean Health Insurance Review and Assessment Service, 1:4 matched tonsillectomy participants (9015) and control participants (36,060) were selected. The Cox-proportional hazard model was used. In this analysis, a crude and adjusted model for age, sex, income, region of residence, and the past medical histories of hypertension, diabetes mellitus, and dyslipidemia were used. For the subgroup analyses, the participants were divided as follows: children (≤14 years old) vs adolescents and adults (≥15 years old) and men vs women. The adjusted hazard ratio (HR) of tonsillectomy for appendectomy was 1.06 (95% confidence interval, CI = 0.89-1.27, P = .517). In the subgroup analysis, the HR was 1.03 (95% CI = 0.82-1.30, P = .804) in children and 1.10 (95% CI = 0.84-1.47, P = .468) in adolescents and adults. In another subgroup analysis, the HR was 0.89 (95% CI = 0.70-1.12, P = .314) in men and 1.39 (95% CI = 1.06-1.83, P = .018) in women. The risk of appendectomy was higher in the tonsillectomy group but only in women.

Tonsillectomy increases the risk of retropharyngeal and parapharyngeal abscesses in adults, but not in children: A national cohort study

Objectives

The purpose of this study is to evaluate the risk of retropharyngeal and parapharyngeal abscesses (deep neck infection) after tonsillectomy in Koreans using national cohort data.

Methods

Using the national cohort study from the Korean Health Insurance Review and Assessment Service, participants who had undergone a tonsillectomy (5,299) and control participants (21,196) were selected and matched 1:4 (for age, sex, income, region of residence, and pre-operative upper respiratory infection visits). The Cox-proportional hazard model was used. A crude model and an adjusted model for age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia were used in this analysis. For the subgroup analyses, the participants were divided into 2 groups: children (≤ 14 years old) and adolescents and adults (≥ 15 years old).

Results

The adjusted hazard ratio of deep neck infection after tonsillectomy was 1.43 (95% confidence interval, CI = 1.18–1.72, P < 0.001). In subgroup analysis, this ratio was 1.12 (95% CI = 0.86–1.47, P = 0.390) in children and 1.87 (95% CI = 1.43–2.45, P < 0.001) in adolescents and adults. The crude hazard ratios were almost the same as the adjusted ratios.

Conclusion

The risk of deep neck infection was higher in the tonsillectomy group. The subgroup analysis showed a similar finding in the adolescent and adult group but not in the child group.

The immune impact of mimic endoscopic retrograde appendicitis therapy and appendectomy on rabbits of acute appendicitis

This study was conducted to evaluate the immune impact of mimic endoscopic retrograde appendicitis therapy and appendectomy on rabbits of acute suppurative appendicitis and to determine whether TLR4/MYD88/NF-κB signaling pathway was activated in this process. 48 rabbits were assigned into 4 groups: group I, the mimic endoscopic retrograde appendicitis therapy group; group II, the appendectomy group; group III, the model group; and group IV, the blank group. White blood cells decreased, while levels of C-reactive protein, tumor necrosis factor-α, interleukin-6, interleukin-4, and interleukin-10 increased on the 2^nd day in group I and II. IgA in feces decreased at 2 weeks, while fecal microbiota changed at 2 and 4 weeks after appendectomy. CD8⁺ cells in appendix of group I increased within 8 weeks. Upregulated expression of TLR4, MYD88, and nuclear NF-κB were detected on the 2^nd day in group I and II. Mimic endoscopic retrograde appendicitis therapy and appendectomy are effective ways for acute suppurative appendicitis. Mimic endoscopic retrograde appendicitis therapy was more preferable due to its advantage in maintaining intestinal immune function. TLR4/MYD88/NF-κB signaling pathway was activated in acute phase of appendicitis.

A tonsillectomy increased the risk of chronic rhinosinusitis among children: A three-year follow-up study

OBJECTIVES

The study aimed to estimate the risk of developing chronic rhinosinusitis (CRS) among children who had undergone a tonsillectomy by utilizing a cohort study based on a population-based database.

METHODS

Data for this retrospective cohort study were sourced from the Taiwan "Longitudinal Health Insurance Database 2000". We included 202 children who had undergone a tonsillectomy as the study group and 2020 sex- and age-matched children as the comparison group. We used stratified Cox proportional hazard regressions to calculate the hazard ratio (HR) and its corresponding 95% confidence interval (CI) for CRS during the 3-year follow-up period.

RESULTS

Of 2222 sampled children, the incidence rate of CRS during the 3-year follow-up period was 3.2 (95% CI = 2.0-4.8) 1000 person-years; 18.2 (95% CI = 9.1-32.5) per 1000 person-years and 1.7 (95% CI = 0.8-3.0) per 1000 person-years for the study and comparison group, respectively. The stratified Cox proportional analysis showed that the adjusted hazard ratio for CRS during the 3-year follow-up period was 8.28 (95% CI = 3.24-21.16) for children who had undergone a tonsillectomy than comparison patients.

CONCLUSIONS

We demonstrated that the risk of developing CRS is significantly increased among children who have undergone a tonsillectomy.

A quantitative enzyme-linked immunosorbent assay for quantification of secretory immunoglobulin A in serum

Secretory immunoglobulin A (SIgA) in serum is possibly the best index of SIgA presence in mucosal secretions in digestive tract and the mirror of its immunologic barrier against many pathogenic aggressions. The measurement of salivary SigA alone may be affected by total salivary secretion and its final concentration in the gland lumen is probably not useful as an appropriate index of mucosal secretions in the digestive tract. The usefulness of the determination of SigA against various epitopes in serum from patients with various autoimmune disease has been demonstrated. The aetiology of many digestive related disorders could be triggered by an alteration of mucose SIgA barrier. The determination of Igs is important for different liver diseases and specifically the SIgA in autoimmune diseases such as rheumatoid arthritis. We developed an easy and efficient immunologic assay to quantify SIgA in serum samples.

Association between prior appendectomy and/or tonsillectomy in women and subsequent pregnancy rate: a cohort study

OBJECTIVE

To study pregnancy rates after appendectomy and/or tonsillectomy.

DESIGN

Population-based cohort study using the United Kingdom (U.K.) primary health care-based Clinical Practice Research Datalink (CPRD).

SETTING

Not applicable.

PATIENT(S)

Female patients who underwent appendectomy, tonsillectomy, or both from 1987 to 2012 and appropriate comparators.

INTERVENTION(S)

Timed follow-up until first pregnancy after surgery. The association between prior surgery and subsequent pregnancy was determined with the use of Cox regression models.

MAIN OUTCOME MEASURE(S)

Pregnancy rate and time to first pregnancy after surgery.

RESULT(S)

The analyses included 54,675 appendectomy-only patients, 112,607 tonsillectomy-only patients, 10,340 patients who had both appendectomy and tonsillectomy, and 355,244 comparators matched for exact age and practice from the rest of female patients in the database. There were 29,732 (54.4%), 60,078 (53.4%), and 6,169 (59.7%) pregnancies in the appendectomy-only, tonsillectomy-only, and both appendectomy tonsillectomy cohorts, respectively versus 155,079 (43.7%) in the comparator cohort during a mean follow-up of 14.7 ± 9.7 years. Adjusted hazard ratios (HRs) for subsequent birth rates were 1.34 (95% confidence interval [CI] 1.32-1.35), 1.49 (95% CI 1.48-1.51), and 1.43 (95% CI 1.39-1.47), respectively. Time to pregnancy was shortest after both appendectomy and tonsillectomy followed by appendectomy only and then tonsillectomy only compared with the rest of the population.

CONCLUSION(S)

Appendectomy and/or tonsillectomy was associated with increased subsequent pregnancy rates and shorter time to pregnancy. The effect of the surgical procedures on the pregnancy outcome was cumulative.

Tonsillectomy and the risk of inflammatory bowel disease: A systematic review and meta-analysis

BACKGROUND AND AIM

Tonsillectomy remains a controversial environmental factor in the etiology of inflammatory bowel disease (IBD). This meta-analysis aims to elucidate a more defined role of tonsillectomy in the development of IBD.

METHODS

Four databases, including PubMed, EMBASE, the Cochrane Library, and Web of Science, were searched for studies exploring the association between tonsillectomy and the risk of IBD. The pooled estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. Heterogeneity was assessed using chi-squared and I(2) statistical analysis. A funnel plot was performed to assess publication bias.

RESULTS

A total of 23 observational studies involving 19 569 patients were included in our meta-analysis. Of these, 17 studies investigated the association between tonsillectomy and Crohn's disease (CD), and 22 studies explored its relationship with ulcerative colitis (UC). Overall, a positive relationship between tonsillectomy and development of CD (OR 1.37, 95% CI: 1.16-1.62) was observed, while there was no association between tonsillectomy and UC (OR 0.94, 95% CI: 0.84-1.05). When ORs were adjusted for smoking, the pooled OR for CD increased to 1.66 (95% CI: 1.03-2.68) and, for UC, changed to 1.03 (95% CI: 0.74-1.44).

CONCLUSIONS

This meta-analysis demonstrates that tonsillectomy is associated with an increased risk of developing CD. We found no evidence to suggest that tonsillectomy exerts a protective effect on the development of UC, as is the case with appendectomy. Further prospective studies are required to confirm the validity of these observations.

Tonsillectomy in a European Cohort of 1,147 Patients with IgA Nephropathy

BACKGROUND

Tonsillectomy has been considered a treatment for IgA nephropathy (IgAN). It is aimed at removing a source of pathogens, reducing mucosa-associated lymphoid tissue and decreasing polymeric IgA synthesis. However, its beneficial effect is still controversial. In Asia, favorable outcomes have been claimed mostly in association with corticosteroids. In Europe, small, single-center uncontrolled studies have failed to show benefits.

METHODS

The European validation study of the Oxford classification of IgAN (VALIGA) collected data from 1,147 patients with IgAN over a follow-up of 4.7 years. We investigated the outcome of progression to end-stage renal disease (ESRD) and/or 50% loss of estimated glomerular filtration rate (eGFR) and the annual loss of eGFR in 61 patients who had had tonsillectomy.

RESULTS

Using the propensity score, which is a logistic regression model, we paired 41 patients with tonsillectomy and 41 without tonsillectomy with similar risk of progression (gender, age, race, mean blood pressure, proteinuria, eGFR at renal biopsy, previous treatments and Oxford MEST scores). No significant difference was found in the outcome. Moreover, we performed an additional propensity score pairing 17 patients who underwent tonsillectomy after the diagnosis of IgAN and 51 without tonsillectomy with similar risk of progression at renal biopsy and subsequent treatments. No significant difference was found in changes in proteinuria, or in the renal end point of 50% reduction in GFR and/or ESRD, or in the annual loss of eGFR.

CONCLUSION

In the large VALIGA cohort of European subjects with IgAN, no significant correlation was found between tonsillectomy and renal function decline.

Epstein-Barr virus is related with 5-aminosalicylic acid, tonsillectomy, and CD19+ cells in Crohn’s disease

AIM: To study anti-Epstein-Barr virus (EBV) IgG antibodies in Crohn´s disease in relation to treatment, immune cells, and prior tonsillectomy/appendectomy.

METHODS: This study included 36 CD patients and 36 healthy individuals (controls), and evaluated different clinical scenarios (new patient, remission and active disease), previous mucosa-associated lymphoid tissue removal (tonsillectomy and appendectomy) and therapeutic regimens (5-aminosalicylic acid, azathioprine, anti-tumor necrosis factor, antibiotics, and corticosteroids). T and B cells subsets in peripheral blood were analyzed by flow cytometry (markers included: CD45, CD4, CD8, CD3, CD19, CD56, CD2, CD3, TCRαβ and TCRγδ) to relate with the levels of anti-EBV IgG antibodies, determined by enzyme-linked immunosorbent assay.

RESULTS: The lowest anti-EBV IgG levels were observed in the group of patients that were not in a specific treatment (95.4 ± 53.9 U/mL vs 131.5 ± 46.2 U/mL, P = 0.038). The patients that were treated with 5-aminosalicylic acid showed the highest anti-EBV IgG values (144.3 U/mL vs 102.6 U/mL, P = 0.045). CD19⁺ cells had the largest decrease in the group of CD patients that received treatment (138.6 vs 223.9, P = 0.022). The analysis of anti-EBV IgG with respect to the presence or absence of tonsillectomy showed the highest values in the tonsillectomy group of CD patients (169.2 ± 20.7 U/mL vs 106.1 ± 50.3 U/mL, P = 0.002). However, in the group of healthy controls, no differences were seen between those who had been tonsillectomized and subjects who had not been operated on (134.0 ± 52.5 U/mL vs 127.7 ± 48.1 U/mL, P = 0.523).

CONCLUSION: High anti-EBV IgG levels in CD are associated with 5-aminosalicylic acid treatment, tonsillectomy, and decrease of CD19⁺ cells.

Tonsillectomy and the risk for deep neck infection-a nationwide cohort study

BACKGROUND

Although the tonsils contribute to first line immunity against foreign pathogens in the upper aero-digestive tract, the association of tonsillectomy with the risk of deep neck infection remains unclear. The aim of this study was to assess the incidence rate and risk of deep neck infection among patients who had undergone a tonsillectomy.

METHODS

This retrospective cohort study evaluated all patients who had undergone tonsillectomy between 2001 and 2009 as identified from the Taiwan National Health Insurance Research Database. For each post-tonsillectomy patient, 10 age-, sex-, and index date-matched controls without a history of tonsillectomy were randomly selected. Cox Proportional hazard model and propensity score model were performed to evaluate the association between tonsillectomy and deep neck infection after adjusting for demographic and clinical data.

RESULTS

There were 34 (71.6 cases per 100,000 person-years) and 174 (36.6 cases per 100,000 person-years) patients that developed deep neck infection in the tonsillectomized and comparison cohorts, respectively. After adjusting for covariates, patients who had undergone a tonsillectomy had a 1.71-fold greater risk of deep neck infection by both Cox proportional hazard model (95% confidence interval, 1.13-2.59) and propensity score model (95% confidence interval, 1.10-2.66). This association was not altered regardless of the indication for tonsillectomy (i.e. chronic/recurrent tonsillitis or sleep apnea/hypertrophy of tonsil) (p = 0.9797).

CONCLUSIONS

Based on our review of a nationwide cohort study we identified that the risk of deep neck infection is significantly increased among patients who have undergone a tonsillectomy. Additional research is needed to explore the possible mechanisms behind these findings.

Endoscopic retrograde appendicitis therapy (ERAT) : a multicenter retrospective study in China

BACKGROUND

Endoscopic retrograde appendicitis therapy (ERAT) is a new procedure for the treatment of acute uncomplicated appendicitis. The aim of the study was to review the clinical outcomes of ERAT and further examine its effectiveness and safety.

METHODS

The study was performed on patients who underwent ERAT for acute uncomplicated appendicitis at three tertiary hospitals in China from December 2009 to May 2013. Patient demographics, technique aspects of the ERAT procedures, clinical success (resolution of symptoms and normalization of laboratory tests), time until resumption of diet, and hospital stay were analyzed, and complications and recurrence were followed up.

RESULTS

Forty-one patients were entered, among which 34 patients were definitely diagnosed as having acute uncomplicated appendicitis; in 7 patients, acute appendicitis was excluded by endoscopic retrograde appendicography. Thirty-three patients completed ERAT except one patient who failed appendiceal cannulation. Abdominal pain resolved immediately in 32 patients, and clinical success rate was 97 %. There was one failure case (3 %) that complicated perforation after 48 h received emergency appendectomy. The median follow-up period was 12 months (IQR = 9-23 months). During follow-up, there were no long-term complication; 2 patients (6.2 %) had recurrent abdominal pain and received appendectomy (one had a histologically normal appendix).

CONCLUSIONS

ERAT is an effective method to diagnose and treat acute uncomplicated appendicitis. Multicenter prospective clinical trials are needed to confirm its utility and place in the management of suspected acute appendicitis.

IgA deficiency and autoimmunity

IgA is the most abundant immunoglobulin in the human body, and performs a very specialized role which involves mucosal immunity, development of tolerance and protection against infection. IgA is the key immunoglobulin in the respiratory and gastrointestinal tracts, which provide the most intimate interface between the environment and self. Normal levels of IgA are based on early studies consisting of only small numbers of patients. The international consensus definition of IgA deficiency is a level of 0.07g/l after the age of four years in the absence of IgG and IgM deficiencies. The epidemiology of IgA deficiency reveals interesting variances between geographical regions - the incidence in Caucasians being much higher than that in Asians. IgA deficiency has also been found to co-exist with autoimmune diseases, allergies and malignancies. The association with autoimmunity is particularly interesting because it suggests a common genetic linkage that could potentially also explain the diversity in geoepidemiology. Both MHC and non-MHC associations have been described and the 8.1 haplotype has been significantly associated with autoimmunity in IgA deficiency patients over controls. Non-MHC genetic associations include IFIH1 and CLEC16A. The mutations leading to IgA deficiency have not been defined, but in some cases of IgA deficiency it has been suggested that the pathogenesis involves a failure in switched memory B cells that can lead to this cohort experiencing an increased incidence of recurrent bacterial infections or autoimmune diseases. Attempts to investigate the role of cytokines that can induce IgA synthesis in cells of patients with IgA deficiency, such as IL21 or the combination of CD40L/anti-CD40, IL-4 and IL10, are underway.

Clinical significance and diagnostic usefulness of serologic markers for improvement of outcome of tonsillectomy in adults with chronic tonsillitis

Background

The aim of the present study was to explore serological biomarkers which predict the outcome of tonsillectomy for chronic tonsillitis.

Methods

A case study in a University ENT department of 24 adult patients with chronic tonsillitis (CHT) in comparison to 24 patients with acute peritonsillar abscess (PTA) was performed. Blood samples for clinical routine hematological and serological parameters were assessed prior to surgery (T-1) and five days (T5) after tonsillectomy. Outcome 6 months later (T180) was documented using the Glasgow Benefit Inventory (GBI) and the Specific Benefits from Tonsillectomy Inventory (SBTI). Correlation analyses between CHT and PTA group as well as between the different time points within each group concerning the serological parameters and the outcome parameters were performed.

Results

At T-1, patients in the CHT group presented with significantly higher lymphocytes counts (relative and absolute), basophils (relative and absolute) and eosinophils but less white-cells, monocytes, neutrophils (absolute and relative), alpha-1, alpha-2, beta globulins, immunoglobulin and lower C-reactive protein and procalcitonin values than patients in the PTA group (all p < 0.05, respectively). Within each group, different significant changes of the serum parameters (often in opposite direction) were observed between T-1 and T5. SBTI scores at T-1 were significantly lower in the CHT group. In contrast, most GBI scores at T180 were significantly higher in the CHT group. Between T-1 and T180 the SBTI scores improved in three quarters of the CHT patients but only in three fifths of the PTA patients. Higher eosinophil counts and immunoglobulin E levels at T-1 predicted higher GBI scores at T180 in the CHT group.

Conclusions

This pilot study showed a specific serological pattern for patients with chronic tonsillitis with a specific pattern of changes after tonsillectomy. But there is no established role for biomarkers currently used in clinical practice to predict the outcome of tonsillectomy for chronic tonsillitis.

Association Between Appendectomy and Fibrosis Progression in Nonalcoholic Fatty Liver Disease

Background

A two-hit theory explaining the progression of nonalcoholic fatty liver disease (NAFLD) to nonalcoholic steatohepatitis (NASH) and fibrosis is widely accepted. Endotoxins entering the portal vein from the gut are thought to be one cause of this second hit, and the literature frequently mentions associations between gut-derived endotoxins and progression of fibrosis in NAFLD. The appendix regulates intestinal immunity to protect the gut from the invasion of bacteria and antigens. Appendectomy may thus contribute to progression of fibrosis in NAFLD, but this association has not yet been clarified. We therefore investigated the association between appendectomy and progression of fibrosis in NAFLD.

Methods

Fifty two patients with NAFLD who underwent liver biopsy in our department were included in this study. Based on Brunt’s scores, patients with NAFLD were classified into a mild fibrosis group and advanced fibrosis group.

Results

History of appendectomy was found to be significantly more frequent in patients with advanced fibrosis than in patients with mild fibrosis (P = 0.014). Multivariate logistic analysis was conducted with age, sex, albumin, platelet count, steatosis grade, and history of appendectomy as covariates and advanced fibrosis as the dependent variable. Significant differences were identified for platelet count and history of appendectomy, identifying these as independent risk factors for advanced fibrosis in NAFLD patients. The odds ratio for appendectomy history was 39.415 (P = 0.044).

Conclusions

History of appendectomy was significantly more frequent in NAFLD patients with advanced fibrosis, suggesting that appendectomy may represent a risk factor for advanced fibrosis in NAFLD.

Childhood appendectomy, tonsillectomy, and risk for premature acute myocardial infarction--a nationwide population-based cohort study

AIMS

Although inflammation contributes to cardiovascular disease, the associations of appendectomy and tonsillectomy, which remove mucosa-associated lymphoid tissue, with risk of acute myocardial infarction (AMI) are unknown. Our aim was to assess the association between these operations performed in childhood and AMI risk later in life.

METHODS AND RESULTS

We conducted a prospective matched cohort study among all Swedish residents born between 1955 and 1970. A national register identified all appendectomies and tonsillectomies. For each patient undergoing appendectomy or tonsillectomy, we randomly selected five controls without the history of the respective operation, matched on sex, age, and county of residence. Participants were followed for fatal and non-fatal AMI for an average of 23.5 years. Because appendiceal and tonsillar tissues have reduced function after adolescence, our primary analyses were restricted to individuals below age 20 at the time of surgery (54 449 appendectomies and 27 284 tonsillectomies). We derived hazard ratios (HRs) from proportional hazard models adjusted for parental occupation and parental history of AMI. Operations before 20 years of age were associated with an increased risk for AMI (417 and 216 events in the appendectomy and tonsillectomy datasets, respectively), with adjusted HRs of 1.33 [95% confidence interval (CI), 1.05-1.70] for appendectomy and 1.44 (95% CI, 1.04-2.01) for tonsillectomy. This association was graded, with the highest risk among those undergoing both procedures, and generally similar among both males and females. Appendectomy and tonsillectomy performed at or above 20 years of age were not associated with the risk of AMI.

CONCLUSIONS

We found a higher risk of AMI related to surgical removal of the tonsils and appendix before age 20. These results are consistent with the hypothesis that subtle alterations in immune function following these operations may alter the subsequent cardiovascular risk, but further studies are needed to confirm these findings and to explore possible mechanisms.

Oral priming with Salmonella Typhi vaccine strain CVD 909 followed by parenteral boost with the S. Typhi Vi capsular polysaccharide vaccine induces CD27+IgD-S. Typhi-specific IgA and IgG B memory cells in humans

Attenuated live oral typhoid vaccine candidate CVD 909 constitutively expresses Salmonella Typhi capsular polysaccharide antigen (Vi). A randomized, double-blind, heterologous prime-boost clinical study was conducted to determine whether immunity to licensed parenteral Vi vaccine could be enhanced by priming with CVD 909. Priming with CVD 909 elicited higher and persistent, albeit not significant, anti-Vi IgG and IgA following immunization with Vi, than placebo-primed recipients. Vi-specific IgA B memory (B(M)) cells were significantly increased in CVD 909-primed subjects. S. Typhi-specific LPS and flagella IgA B(M) cells were observed in subjects immunized with CVD 909 or with the licensed Vi-negative oral typhoid vaccine Ty21a. CVD 909-induced B(M) cells exhibited a classical B(M) phenotype (i.e., CD3(-)CD19(+)IgD(-)CD27(+)). This is the first demonstration of classical B(M) cells specific for bacterial polysaccharide or protein antigens following typhoid immunization. The persistent IgA B(M) responses demonstrate the capacity of oral typhoid vaccines to prime mucosally relevant immune memory.

Differential effect of appendectomy and tonsillectomy on anti-Kudoa sp. antibodies in patients with MALTectomy

We found an association between tonsillectomized patients and subsequent appendicitis. We also observed that MALTectomy significantly decreased secretory IgA levels in serum of patients, being this decrease more pronounced when both operations (tonsillectomy and appendectomy) had been performed. The elevated humoral responses detected previously by us in BALB/c mice immunized with Kudoa sp. pseudocyst extracts and the high IgG1 and IgE levels induced by the oral administration of Kudoa sp. pseudocysts to BALB/c mice showed the possible immunopathological effects in man from the ingestion of Kudoa sp. infected fish. We use the ELISA method to investigate the possible relationship between MALTectomy (tonsillectomy and appendectomy) and specific antibody levels to Kudoa sp. Both anti-Kudoa sp. specific antibody levels and the number of patients that recognized Kudoa sp. antigens were greater in tonsillectomy patients when compared to the control and the other studied groups (appendectomized and appendectomized+tonsillectomies patients). Tonsillectomy was associated to a switch in the class of immunoglobulins involved in these responses and these responses may be abrogated by appendectomy. Tonsils and appendix may respond in different ways to Kudoa sp. antigens and these different reactions may be involved in some immunopathological reactions.

Evaluation of long-term impacts of tonsillectomy on immune functions of children: a follow-up study

OBJECTIVE

The purpose of this follow-up study was to investigate the long-term effects of tonsillectomy in comparison with their short-term results.

PATIENTS AND METHODS

We successfully retrieved 20 out of our previously reported 37 patients who underwent tonsillectomy in our clinic 54 months ago. The blood levels of CD3+, CD4+, CD8+, CD19+, CD25+ and CD16++56+ (cellular immunity), and IgG, IgA, IgM, C3 and C4 (humoral immunity) were determined and compared with their previously reported short-term respective values.

RESULTS

There were no statistically significant differences between the short-term (1 month) and long-term (54 months) values of IgA, IgG, IgM and C4 levels of the patients (P>0.05). There was a slight but statistically significant decrease in complement factor C3 value compared to its the early-stage value (P<0.05) but this was not significantly different from age-matched healthy controls (P>0.05). The levels of CD4+ and CD19+ were higher and the levels of CD16++56+ and CD25+ were lower in the late-stage (54 months) compared to their early-stage values (P<0.05). When the long-term immune parameters of the tonsillectomized patients were compared with aged-match healthy controls, there were no significant differences between the levels of immunoglobulins, complements and lymphocytes (IgA, IgG, IgM, C3, C4, CD3+, CD4+, CD8+, CD19+, CD25+, CD16++56+) (P>0.05).

CONCLUSION

The results of this long-term follow-up study indicate that tonsillectomy do not compromise the immune functions of children as humoral and cellular immunity of patients recovered compared to their early-stage immune status (1 month), as they have similar immune capacity compared to their age-matched healthy controls at both early- and late-stages. Although a small sample of patients enrolled, our results are of importance with respect to the reassuring in settling the widely held urban myth that tonsillectomy compromises life long immunity.