Characterisation of Nematoda and Digenea in selected Australian freshwater snails

Freshwater snails are integral to local ecosystems as a primary food source for various vertebrate species, thereby contributing significantly to ecological food webs. However, their role as intermediate hosts also makes them pivotal in the transmission of parasites. In Australia, research on freshwater snails has predominantly focused on their role as intermediate hosts for livestock parasites, while there has been limited exploration of the impact of these parasites on snail health and population dynamics. The aim of this study was to determine parasitic infection in freshwater snails. This study was conducted in the south-eastern region of Australia, in 2022. A total of 163 freshwater snails from four different species were collected and examined in the Murrumbidgee catchment area in the southeastern part of Australia during the Southern Hemisphere summer and autumn months (February to May). The species included Isidorella hainesii, Glyptophysa novaehollandica, Bullastra lessoni (endemic species), and Physella acuta (an introduced species). Through the analysis of sequence data from the various regions of the nuclear ribosomal DNA, we determined that the Digenea species in this study belonged to three distinct species, including Choanocotyle hobbsi, Petasiger sp. and an unidentified species belonging to Plagiorchioidea. Additionally, analysis of the sequences from Nematoda found in this study, revealed they could be categorized into two separate taxa, including Krefftascaris sp. and an unidentified nematode closely associated with plant and soil nematodes. This research holds significant implications for the future understanding and conservation of Australian freshwater ecosystems. Most parasites found in the present study complete their life cycle in snails and turtles. As many of freshwater snail and turtle species in Australia are endemic and face population threats, exploring the potential adverse impacts of parasitic infections on snail and turtle health, is crucial for advancing our understanding of these ecosystems and also paving the way for future research and conservation efforts. While none of the native snail species in the present study have been listed as endangered or threatened, this may simply be attributed to the absence of regular population surveys.

Effect of gastrointestinal digestion on the stability, antioxidant activity, and Caco-2 cellular transport of pigmented grain polyphenols

Grain polyphenols are known to possess several health properties. However, their digestive stability and intestinal absorption have not been fully elucidated. This study investigated the fate of pigmented grain polyphenols in the digestive system. Purple rice, purple barley, purple wheat, and blue wheat extracts were subjected to simulated gastric and intestinal phase digestion, followed by Caco-2 cellular transport. Phenolic profiling and antioxidant activity were determined using benchtop assays and an ultra-high-performance liquid chromatography-2,2'-azino-bis(3-ethylbenzothiazoline-6-sulfonic acid free radical) (UHPLC-ABTS•+ ) system. The results demonstrated a decrease in the total phenolic content of extracts after digestion, with purple rice extract retaining the highest phenolic content (79%) and ABTS•+ antioxidant activity (31%). Antioxidant activity was retained the most during the gastric phase; however, dominant antioxidant compounds were not detected after intestinal digestion. Significant variations in phenolic composition and radical scavenging activity were detected after digestion. Protocatechuic acid, vanillic acid, apigenin, and chrysoeriol were all transported across the intestinal barrier. The findings of this study provide novel insights into the in vitro stability and antioxidant activity of cereal grain polyphenols after simulated digestion.

Evaluation status of current and emerging minimally invasive robotic surgical platforms

BACKGROUND

The rapid adoption of robotics within minimally invasive surgical specialties has also seen an explosion of new technology including multi- and single port, natural orifice transluminal endoscopic surgery (NOTES), endoluminal and "on-demand" platforms. This review aims to evaluate the validation status of current and emerging MIS robotic platforms, using the IDEAL Framework.

METHODS

A scoping review exploring robotic minimally invasive surgical devices, technology and systems in use or being developed was performed, including general surgery, gynaecology, urology and cardiothoracics. Systems operating purely outside the abdomen or thorax and endoluminal or natural orifice platforms were excluded. PubMed, Google Scholar, journal reports and information from the public domain were collected. Each company was approached via email for a virtual interview to discover more about the systems and to quality check data. The IDEAL Framework is an internationally accepted tool to evaluate novel surgical technology, consisting of four stages: idea, development/exploration, assessment, and surveillance. An IDEAL stage, synonymous with validation status in this review, was assigned by reviewing the published literature.

RESULTS

21 companies with 23 different robotic platforms were identified for data collection, 13 with national and/or international regulatory approval. Of the 17 multiport systems, 1 is fully evaluated at stage 4, 2 are stage 3, 6 stage 2b, 2 at stage 2a, 2 stage 1, and 4 at the pre-IDEAL stage 0. Of the 6 single-port systems none have been fully evaluated with 1 at stage 3, 3 at stage 1 and 2 at stage 0.

CONCLUSIONS

The majority of existing robotic platforms are currently at the preclinical to developmental and exploratory stage of evaluation. Using the IDEAL framework will ensure that emerging robotic platforms are fully evaluated with long-term data, to inform the surgical workforce and ensure patient safety.

Multidisciplinary approach to the diagnosis of Contracaecum magnipapillatum infections in Australian black noddies, Anous minutus (Charadriiformes: Laridae)

We provide the incidental necropsy findings associated with anisakid nematode infections of black noddy terns, Anous minutus Boie, 1844 (Charadriiformes: Laridae), from offshore islands in the southern Great Barrier Reef, Queensland, Australia. Specimens collected from the proventriculi were identified morphologically as Contracaecum magnipapillatum Chapin, 1925 (Rhabditida: Anisakidae), using light and scanning electron microscopy (SEM). The entire nuclear ribosomal DNA internal transcribed spacer (ITS) region (ITS1-5.8S-ITS2) was amplified by polymerase chain reaction (PCR) and sequenced to provide reference sequences for morphologically well-identified voucher specimens. Interestingly, after an alignment with closely related taxa using BLAST, sequences of the ITS1 and ITS2 were 100% identical to the sequences assigned to Contracaecum septentrionale Kreis, 1955, from a razorbill, Alca torda Linnaeus, 1758 (Charadriiformes: Alcidae), from Spain. These results either raise questions about the ITS as a genetic marker for some members of Contracaecum, or the identity of the specimens assigned to C. septentrionale, given that no supporting morphological data was associated with them. We highlight the need for a combined morphological and molecular approach to parasite diagnostics and the use of multiple genetic loci to resolve the molecular taxonomy of cryptic species. Morphological identifications should be taxonomically robust, transparent and precede the deposition of molecular barcodes in public repositories. The gross and histopathological findings of our investigation concur with previous reports of widespread Contracaecum infections in black noddies and support the contention that Contracaecum spp. are an unlikely primary cause of mortality.

Occurrence of digenean parasites in freshwater snails in the Murrumbidgee catchment area, Australia

Freshwater snails are important hosts in the life cycles of many medically important parasites, particularly for digenetic trematodes such as liver flukes and schistosomes. The current study was conducted to determine the infection of freshwater snails with parasites that can potentially be transmitted to humans within the Murrumbidgee catchment area which is an area of widespread intensive aquaculture in Australia. A total of 116 freshwater snails, belonging to three species (Isidorella hainesii, Glyptophysa novaehollandica and Bullastra lessoni), were examined for the presence of parasites in both man-made and natural environments. The analysis of sequence data, including the internal transcribed spacers (ITS) of nuclear ribosomal DNA, small subunit (18S) ribosomal DNA, and large subunit (28S) ribosomal DNA, indicated that the collected parasites belonged to two distinct genera, namely Clinostomum and Echinostoma. It is noteworthy that species of both of these digenean parasites have the potential to be zoonotic. Cercariae of both Clinostomum and Echinostoma were observed in snails collected from aquaculture settings. It is important to highlight that infectious stages of Clinostomum  has been previously detected in edible fish within Australia. This information raises concerns regarding the potential transmission of these parasites to humans through the consumption of contaminated fish. These findings emphasize the importance of monitoring and controlling the presence of Clinostomum and Echinostoma in aquaculture environments to minimise the risk of zoonotic infections and ensure food safety. Further research and surveillance are needed to better understand the prevalence, transmission dynamics, and potential public health implications associated with these parasites in the context of aquaculture in Australia.

Description of two new species of Diplectanum Diesing, 1858 (Monogenea: Diplectanidae) collected from Protonibea diacanthus (Lacepède, 1802) (Teleostei: Sciaenidae) from waters off northern Australia

Two new species of the family Diplectanidae Monticelli, 1903 from the gills of Protonibea diacanthus (Lacepède, 1802) (Teleostei: Sciaenidae) off the northern Australian coast are described. Previous studies have either morphological or genetic results, whereas this study combines morphological and advanced molecular methods to provide the first detailed descriptions for species of Diplectanum Diesing, 1858 from Australia utilising both methodologies. Two new species, Diplectanum timorcanthus n. sp. and Diplectanum diacanthi n. sp., are morphologically described and genetically characterised using the partial nuclear 28S ribosomal RNA gene (28S rRNA) and the internal transcribed spacer 1 (ITS1) partial sequence.

Effect of a protease‐activated receptor‐2 antagonist ( GB88 ) on inflammation‐related loss of alveolar bone in periodontal disease

BACKGROUND AND OBJECTIVE

Protease-activated receptor-2 (PAR₂ ), a pro-inflammatory G-protein coupled receptor, has been associated with pathogenesis of periodontitis and the resulting bone loss caused by oral pathogens, including the keystone pathogen Porphyromonas gingivalis (P. gingivalis). We hypothesised that administration of a PAR₂ antagonist, GB88, might prevent inflammation and subsequent alveolar bone resorption in a mouse model of periodontal disease.

METHODS

Periodontitis was induced in mice by oral inoculations with P. gingivalis for a total of eight times over 24 days. The infected mice were treated with either GB88 or vehicle for the duration of the trial. Following euthanasia on day 56, serum was collected and used for the detection of mast cell tryptase. The right maxillae were defleshed and stained with methylene blue to measure the exposed cementum in molar teeth. The left maxillae were prepared for cryosections followed by staining for tartrate-resistant acid phosphatase to identify osteoclasts or with toluidine blue to identify mast cells. Reverse transcription quantitative PCR (RT-qPCR) was used to quantify the expression of inflammatory cytokines in the gingival tissue. Supernatants of T-lymphocyte cultures isolated from the regional lymph nodes were assayed using a cytometric bead array to measure the Th1/Th2/Th17 cytokine levels.

RESULTS

Measurement of the exposed cementum showed that GB88 reduced P. gingivalis-induced alveolar bone loss by up to 69%. GB88 also prevented the increase in osteoclast numbers observed in the infected mice. Serum tryptase levels were significantly elevated in both the infected groups, and not altered by treatment. RT-qPCR showed that GB88 prevented the upregulation of Il1b, Il6, Ifng and Cd11b. In T-lymphocyte supernatants, only IFNγ and IL-17A levels were increased in response to infection, but this was prevented by GB88 treatment.

CONCLUSIONS

GB88 significantly reduced osteoclastic alveolar bone loss in mice infected with P. gingivalis, seemingly by preventing the upregulation of several inflammatory cytokines. PAR₂ antagonism may be an effective treatment strategy for periodontal disease.

European Association for Endoscopic Surgery (EAES) consensus on Indocyanine Green (ICG) fluorescence-guided surgery

BACKGROUND

In recent years, the use of Indocyanine Green (ICG) fluorescence-guided surgery during open and laparoscopic procedures has exponentially expanded across various clinical settings. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on this topic with the aim of creating evidence-based statements and recommendations for the surgical community.

METHODS

An expert panel of surgeons has been selected and invited to participate to this project. Systematic reviews of the PubMed, Embase and Cochrane libraries were performed to identify evidence on potential benefits of ICG fluorescence-guided surgery on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by the panel; they were then submitted to all EAES members through a two-rounds online survey and results presented at the EAES annual congress, Barcelona, November 2021.

RESULTS

A total of 18,273 abstracts were screened with 117 articles included. 22 statements and 16 recommendations were generated and approved. In some areas, such as the use of ICG fluorescence-guided surgery during laparoscopic cholecystectomy, the perfusion assessment in colorectal surgery and the search for the sentinel lymph nodes in gynaecological malignancies, the large number of evidences in literature has allowed us to strongly recommend the use of ICG for a better anatomical definition and a reduction in post-operative complications.

CONCLUSIONS

Overall, from the systematic literature review performed by the experts panel and the survey extended to all EAES members, ICG fluorescence-guided surgery could be considered a safe and effective technology. Future robust clinical research is required to specifically validate multiple organ-specific applications and the potential benefits of this technique on clinical outcomes.

Occurrence and characterisation of Eustrongylides species in Australian native birds and fish

In Australia, nematodes belonging to the genus Eustrongylides were believed to be endemic species until the late 20th century when they were all considered to be E. excisus, invalid or inquirendae. Although these nematodes have frequently been reported in Australian fish, reptiles, and birds and cause disease or mortality among them, there has been no attempt to date to characterise them genetically. Globally, also, no one has validated or defined suitable genetic markers to distinguish between species of Eustrongylides. In this study, adult Eustrongylides from little black cormorant (Phalacrocorax sulcirostris; n = 3) and larvae from mountain galaxias (Galaxias olidus, n = 2) and a Murray cod (Maccullochella peelii, n = 1), and a Murray cod-trout cod hybrids (Maccullochella peelii x Maccullochella macquariensis, n = 1) were available for morphological examination and molecular characterisation. The adult nematodes from cormorants were identified as E. excisus. Sequences of the 18S and ITS regions were then obtained for all nematodes, which were identical among all specimens (larvae and adults) and also identical to those of E. excisus available in the GenBank. However, only one base pair difference exists between the 18S sequences of E. excisus and E. ignotus, with limited sequences available in GenBank accompanied with proper morphological data for the nematodes. With that limitation in mind, identifying our specimens as E. excisus suggests spill-over - that it is an introduced parasite species that has successfully established its life cycle among Australian native species - may have occurred. Our study is the first report of E. excisus in the little black cormorant, P. sulcirostris. Our results do not exclude the possibility of the occurrence of other species of Eustrongylides, either native or exotic, in Australia. This parasite is zoonotic and with increasing demand for fish and changing dietary preferences, such as the consumption of raw or undercooked fish, its occurrence in the flesh of the fish is concerning. This parasite is also associated with anthropogenic habitat alteration affecting the reproductive success of the infected hosts. Therefore, awareness among the relevant authorities of the presence of the parasite in Australia and its adverse impact on native animals is crucial for the success of conservation plans such as fish recovery and relocation efforts.

Investigating potential anti-proliferative activity of different statins against five cancer cell lines

Statins have been reported to have potential anti-proliferative effects through an unknown mechanism. This study aims to investigate the anti-proliferative activities of five statins, including simvastatin, rosuvastatin, fluvastatin, atorvastatin, and pravastatin, against five different cancer cell lines; cervical epithelial carcinoma DoTc2 4510, malignant melanoma A-375, muscle Ewing's sarcoma A-673, hepatocellular carcinoma HUH-7, as well as breast cancer cells MCF-7. At 100 µM, simvastatin and atorvastatin significantly inhibited 70% of cellular proliferation. At the same concentration, rosuvastatin and fluvastatin showed about 50% of inhibition only in A-375 and A-673 cancer cells in a time- and dose-dependent manner. Of all the statin drugs used, pravastatin had the least inhibitory effect on all the cancer cell lines. Western Blot analysis showed a decrease in mTOR level, and the expression of p53 tumour suppression and BCL-2 proteins was relatively elevated compared to the untreated cells. Simvastatin and atorvastatin may inhibit cellular proliferation via BCL-2/p53, Bax/Bak, and PI3K/Akt/mTOR signalling pathways. This is the first research to evaluate the anti-cancer effects of simvastatin, rosuvastatin, fluvastatin, atorvastatin, and pravastatin against five different cell lines from distinct origins and provided a relevant comparison of their efficacies for their anti-proliferative activity.

Bioaccessibility and Antioxidant Activity of Polyphenols from Pigmented Barley and Wheat

Polyphenols in pigmented cereals are believed to enhance health outcomes through their antioxidant properties. This study aimed to characterise polyphenols from Hordeum vulgare (purple barley), Triticum turgidum (purple wheat) and Triticum aestivum (blue wheat) in order to evaluate their bioaccessibility and antioxidant activity. An ultra-high performance liquid chromatography mass spectrometry coupled with an online 2,2′-azino-bis (3-ethylbenzothiazoline-6-sulfonic acid) system was used to identify the polyphenols and quantify their relative antioxidant levels. Simulated gastrointestinal digestion of the cereals allowed for the assessment of polyphenol bioaccessibility using benchtop assays. Between cereals, the bioaccessible phenolic content was similar following digestion, but the antioxidant activity was significantly different (purple barley > purple wheat > blue wheat; p < 0.01). Among the polyphenols identified, flavan-3-ols and anthocyanins were the least bioaccessible whereas flavones were the most bioaccessible after digestion. This study demonstrated that these pigmented cereal varieties are sources of bioaccessible polyphenols with antioxidant activity. These findings may aid in utilising these pigmented grains for the future design and development of novel functional food products with enhanced health properties.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Pseudoepitheliomatous keratotic and micaceous balanitis: a series of eight cases

BACKGROUND

Pseudoepitheliomatous keratotic and micaceous balanitis (PEKMB) is a clinicopathological entity characterized clinically by micaceous scale on the glans, and histologically by acanthosis, hyperkeratosis and pseudoepitheliomatous hyperplasia. We present a series of eight cases of this rare condition, the first series of more than two cases to be reported.

OBJECTIVES

To determine the clinical and histological characteristics of cases of PEKMB, and evaluate treatments used and clinical course.

METHODS

This monocentric case series was conducted at the University College London Hospitals tertiary male genital dermatology clinic between April 2018 and August 2020. Eight patients with PEKMB were evaluated. Data were collected on demographics, clinical presentation, histological features, presence of human papilloma virus (HPV), history of lichen sclerosus, treatment of PEKMB and subsequent response, and presence or development of squamous cell carcinoma (SCC) or penile intraepithelial neoplasia (PeIN) during follow-up.

RESULTS

Eight Caucasian males presented with clinical and histological evidence of PEKMB. Seven had a background of lichen sclerosus; two had failed treatment with superpotent topical steroids and four had symptoms for three or more years prior to circumcision. There was no clinical or histological relationship with HPV infection, and p16 staining was negative. HPV PCR, performed in two cases, was negative. Basal atypia, insufficient to amount to PeIN, was present in six patients. One patient progressed to PeIN during follow-up, and no patient progressed to invasive malignancy. Five patients were treated successfully with glans resurfacing and split skin graft reconstruction.

CONCLUSIONS

Our observations demonstrate that PEKMB represents a form of chronic, undiagnosed or misdiagnosed, inadequately treated or treatment refractory, unstable lichen sclerosus. The significant potential for squamous carcinogenesis (differentiated PeIN and verrucous carcinoma) can be mitigated by timely diagnosis and treatment. Glans resurfacing and split skin graft reconstruction appears to be a successful treatment modality in patients with refractory disease.

Dolichoperoides macalpini (Nicoll, 1914) (Digenea: Dolichoperoididae) infecting venomous snakes (Elapidae) across Australia: molecular characterisation and infection parameters

Specimens of Dolichoperoides macalpini (Nicoll, 1914) (Digenea: Dolichoperoididae) were collected from Australian venomous snakes (Elapidae): Notechis scutatus Peters, 1861 and Austrelaps superbus (Günther, 1858) from Tasmania and surrounding islands and N. s. occidentalis Glauert, 1948 from wetlands near Perth, Western Australia. Despite variation in morphological measurements, genetic analysis showed that the one species of digeneans infected the snakes from all locations. This study presents the first DNA sequences for D. macalpini (internal transcribed spacer, 18S, 28S), confirming its placement in a family separate from the Reniferidae and Telorchiidae. Analysis of the infection dynamics of infection in Western Australian snakes showed significant differences in levels of infection between wetland locations, season and year of collection. Infection of D. macalpini was reported in the gastrointestinal tract, including the mouth, in freshly euthanised snakes in Western Australia, and in the lung in Tasmanian snakes, consistent with earlier reports. Differences in morphology and site of infection are suggested to be due to a combination of season and maturity of the digenean, with infection potentially occurring early in the season, as the snakes emerge from torpor. The need for research on the seasonal dynamics of infection with this parasite is discussed.

Development and evaluation of an objective laparoscopic assessment tool: LapPass®

INTRODUCTION

Laparoscopic surgery is technically challenging and assessment of competency is necessary to ensure patient safety and guide training. We report on the development of LapPass®, an accessible objective simulation assessment tool with credentialing potential. We provide a preliminary evaluation of its usability and aspects of validity.

METHODS

The domains of LapPass® were defined through a consensus process by the executive council of the Association of Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI). A survey of both assessors and trainees was used to test for usability, face and content validity of LapPass®. Internal consistency was tested with Cronbach's alpha, and a composite marker of validity and usability was obtained.

RESULTS

LapPass® was developed to consist of four tasks: (1) grasping and manipulation, (2) simulated appendicectomy, (3) cutting a disk and (4) intracorporeal suturing. A total of 76 participants contributed to the evaluation of LapPass®: 13 assessors and 63 trainees. For assessors, Cronbach's alpha for usability of tasks 1-4 was 0.84, 0.84, 0.76 and 0.86, whereas validity was 0.80, 0.85, 0.88, 0.95, respectively. For trainees, Cronbach's alpha was 0.75, 0.77, 0.80 and 0.85 for usability, and 0.79, 093, 0.87 and 0.91 for validity. Consensus was that each task was usable and had face and content validity, with median scores of 4.0 or higher (interquartile range 0.0-1.0).

CONCLUSION

LapPass® has potential for the objective assessment of basic laparoscopic skills but further research is required to explore its predictive capabilities in a clinical setting.

The Potential for Sialic Acid and Sialylated Glycoconjugates as Feed Additives to Enhance Pig Health and Production

Simple Summary

This review discusses the current challenges in the pig industry and the potential nutritional significance of sialic acid (Sia) and glycoconjugates (Sia-GC’s) for pig health and nutrition. Sia is a nine-carbon acidic sugar which is present in various organs and body fluids of humans and animals. Sias contribute to many beneficial biological functions including pathogen resistance, immunomodulation, gut microbiota development, gut maturation, anti-inflammation and neurodevelopment. The role of Sias in regulating the metabolism of pigs has seldom been reported. However, we have documented significant beneficial effects of specific Sia-GC’s on health and production performance of sows and piglets. These findings are reviewed in relation to other studies while noting the beneficial effects of the inclusion of Sia, Sia containing oligosaccharide or the sialo-protein lactoferrin in the diets of gilts and sows. The importance of the passive transfer of of Sia and Sia-GC’s through milk to the young and the implications for their growth and development is also reviewed. This information will assist in optimizing the composition of sow/gilt milk replacers designed to increases the survival of IUGR piglets or piglets with dams suffering from agalactia, a common problem in pig production systems worldwide.

Abstract

Swine are one of the most important agricultural species for human food production. Given the significant disease challenges confronting commercial pig farming systems, introduction of a new feed additive that can enhance animal performance by improving growth and immune status represents a major opportunity. One such candidate is sialic acid (Sia), a diverse family of nine-carbon acidic sugar, present in various organs and body fluid, as well as an essential structural and functional constituent of brain ganglioside of humans and animals. Sias are key monosaccharide and biomarker of sialylated milk oligosaccharide (Sia-MOS’s), sialylated glycoproteins and glycolipids in milk and all vertebrate cells. Sias accomplish many critical endogenous functions by virtue of their physiochemical properties and via recognition by intrinsic receptors. Human milk sialylated glycoconjugates (Sia-GC’s) are bioactive compounds known to act as prebiotics that promote gut microbiota development, gut maturation, pathogen resistance, immunomodulation, anti-inflammation and neurodevelopment. However, the importance of Sia in pig health, especially in the growth, development, immunity of developing piglet and in pig production remains unknown. This review aims to critically discuss the current status of knowledge of the biology and nutritional role of Sia and Sia-GC’s on health of both female sow and newborn piglets.

Bioaccessibility and Bioactivity of Cereal Polyphenols: A Review

Cereal bioactive compounds, especially polyphenols, are known to possess a wide range of disease preventive properties that are attributed to their antioxidant and anti-inflammatory activity. However, due to their low plasma concentrations after oral intake, there is controversy regarding their therapeutic benefits in vivo. Within the gastrointestinal tract, some cereal polyphenols are absorbed in the small intestine, with the majority accumulating and metabolised by the colonic microbiota. Chemical and enzymatic processes occurring during gastrointestinal digestion modulate the bioactivity and bioaccessibility of phenolic compounds. The interactions between the cereal polyphenols and the intestinal epithelium allow the modulation of intestinal barrier function through antioxidant, anti-inflammatory activity and mucin production thereby improving intestinal health. The intestinal microbiota is believed to have a reciprocal interaction with polyphenols, wherein the microbiome produces bioactive and bioaccessible phenolic metabolites and the phenolic compound, in turn, modifies the microbiome composition favourably. Thus, the microbiome presents a key link between polyphenol consumption and the health benefits observed in metabolic conditions in numerous studies. This review will explore the therapeutic value of cereal polyphenols in conjunction with their bioaccessibility, impact on intestinal barrier function and interaction with the microbiome coupled with plasma anti-inflammatory effects.

Extensive mucocutaneous, oesophageal and otic lichen planus secondary to nivolumab therapy

We report a 73-year-old female with metastatic renal cell carcinoma who developed a widespread lichenoid reaction following nivolumab treatment. The timeline of the reaction strongly correlated with the nivolumab treatment and subsequent cessation. Our patient had cutaneous, mucosal, otic, ophthalmic and oesophageal involvement, demonstrating the potentially extensive nature of lichenoid reactions to anti-programmed cell death receptor-1 (anti-PD1) therapies. Although lichenoid reactions to anti-PD1 therapies are now well recognized, there have been no previous reports of otic or oesophageal involvement in the literature. Although cutaneous lichenoid reactions do not tend to be severe or treatment limiting, more widespread systemic lichenoid reactions are challenging to manage, particularly in the context of malignancy. This very unusual case highlights the importance of considering involvement beyond the skin in all lichenoid skin reactions.

CT diagnosis of ilioinguinal lymph node metastases in melanoma using radiological characteristics beyond size and asymmetry

Background

Diagnosis of lymph node (LN) metastasis in melanoma with non-invasive methods is challenging. The aim of this study was to evaluate the diagnostic accuracy of six LN characteristics on CT in detecting melanoma-positive ilioinguinal LN metastases, and to determine whether inguinal LN characteristics can predict pelvic LN involvement.

Methods

This was a single-centre retrospective study of patients with melanoma LN metastases at a tertiary cancer centre between 2008 and 2016. Patients who had preoperative contrast-enhanced CT assessment and ilioinguinal LN dissection were included. CT scans containing significant artefacts obscuring the pelvis were excluded. CT scans were reanalysed for six LN characteristics (extracapsular spread (ECS), minimum axis (MA), absence of fatty hilum (FH), asymmetrical cortical nodule (CAN), abnormal contrast enhancement (ACE) and rounded morphology (RM)) and compared with postoperative histopathological findings.

Results

A total of 90 patients were included. Median age was 58 (range 23–85) years. Eighty-eight patients (98 per cent) had pathology-positive inguinal disease and, of these, 45 (51 per cent) had concurrent pelvic disease. The most common CT characteristics found in pathology-positive inguinal LNs were MA greater than 10 mm (97 per cent), ACE (80 per cent), ECS (38 per cent) and absence of RM (38 per cent). In multivariable analysis, inguinal LN characteristics on CT indicative of pelvic disease were RM (odds ratio (OR) 3.3, 95 per cent c.i. 1.2 to 8.7) and ECS (OR 4.2, 1.6 to 11.3). Cloquet’s node is known to be a poor predictor of pelvic spread. Pelvic LN disease was present in 50 per cent patients, but only 7 per cent had a pathology-positive Cloquet’s node.

Conclusion

Additional CT radiological characteristics, especially ECS and RM, may improve diagnostic accuracy and aid clinical decisions regarding the need for inguinal or ilioinguinal dissection.

Development and early outcomes of the national training initiative for transanal total mesorectal excision in the UK

AIM

Transanal total mesorectal excision (TaTME) has attracted substantial interest amongst colorectal surgeons but its technical challenges may underlie the early reports of visceral injuries and oncological concerns. The aim of this study was to report on the feasibility, development and the outcome of the national pilot training initiative for TaTME-UK.

METHODS

TaTME-UK was successfully launched in September 2017 in partnership with the healthcare industry and endorsed by the Association of Coloproctology of Great Britain and Ireland. This multi-modal training curriculum consisted of three phases: (i) set-up; (ii) selection of pilot sites; and (iii) formal proctorship programme. Bespoke Global Assessment Scoring (GAS) forms were designed and completed by both trainees and mentors. Data were collected on patient demographics, tumour characteristics and perioperative clinical and histological outcomes.

RESULTS

Twenty-four proctored cases were performed by 10 colorectal surgeons from five selected pilot sites. Median operative time was 331 ± 90 (195-610) min which was reduced to 283 ± 62 (195-340) min in the final case. Independent performance (GAS score of 5) was achieved for most operative steps by case 5. There was one conversion (4.2%), but no visceral injuries. Pathological data confirmed no bowel perforation and intact quality of the mesorectal TME specimens with clear distal margin in all cases and circumferential margins in 23/24 cases (96%).

CONCLUSION

This exploratory study demonstrates acceptable early outcomes in a small cohort suggesting that a competency-based multi-modal training programme for TaTME can be feasible and safe to implement at a national level.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Rice Bran Phenolic Extracts Modulate Insulin Secretion and Gene Expression Associated with β-Cell Function

Oxidative stress is known to modulate insulin secretion and initiate gene alterations resulting in impairment of β-cell function and type 2 diabetes mellitus (T2DM). Rice bran (RB) phenolic extracts contain bioactive properties that may target metabolic pathways associated with the pathogenesis of T2DM. This study aimed to examine the effect of stabilized RB phenolic extracts on the expression of genes associated with β-cell function such as glucose transporter 2 (Glut2), pancreatic and duodenal homeobox 1 (Pdx1), sirtuin 1 (Sirt1), mitochondrial transcription factor A (Tfam), and insulin 1 (Ins1) in addition to evaluating its impact on glucose-stimulated insulin secretion. It was observed that treatment with different concentrations of RB phenolic extracts (25-250 µg/mL) significantly increased the expression of Glut2, Pdx1, Sirt1, Tfam, and Ins1 genes and glucose-stimulated insulin secretion under both normal and high glucose conditions. RB phenolic extracts favourably modulated the expression of genes involved in β-cell dysfunction and insulin secretion via several mechanisms such as synergistic action of polyphenols targeting signalling molecules, decreasing free radical damage by its antioxidant activity, and stimulation of effectors or survival factors of insulin secretion.

The Antioxidant and Anti-Inflammatory Properties of Rice Bran Phenolic Extracts

Oxidative stress and inflammation are known to be linked to the development of chronic inflammatory conditions, such as type 2 diabetes and cardiovascular disease. Dietary polyphenols have been demonstrated to contain potent bioactivity against specific inflammatory pathways. Rice bran (RB), a by-product generated during the rice milling process, is normally used in animal feed or discarded due to its rancidity. However, RB is known to be abundant in bioactive polyphenols including phenolic acids. This study investigates the antioxidant and anti-inflammatory effects of RB phenolic extracts (25, 50, 100, and 250 µg/mL) on RAW264.7 mouse macrophage cells stimulated with hydrogen peroxide and lipopolysaccharide. Biomarkers of oxidative stress and inflammation such as malondialdehyde (MDA), intracellular reactive oxygen species, nitric oxide and pro-inflammatory cytokines such as interleukin-6 (IL-6), monocyte chemoattractant protein 1 (MCP-1), interleukin-10 (IL-10), tumor necrosis factor-α (TNF-α), interleukin-12, p70 (IL-12p70), and interferon-γ (IFN-γ) were measured in vitro. Treatment with RB extracts significantly decreased the production of MDA, intracellular reactive oxygen species, nitric oxide and pro-inflammatory cytokines (IL-6, IL-12p70, and IFN-γ) when compared to the control. It is proposed that RB phenolic extracts, via their metal chelating properties and free radical scavenging activity, target pathways of oxidative stress and inflammation resulting in the alleviation of vascular inflammatory mediators.

Milk lactoferrin concentration of primiparous and multiparous sows during lactation

Lactoferrin (LF), a sialylated iron-binding glycoprotein, has numerous vital physiological functions including immunomodulation and protection against a large group of microorganisms, improving neurodevelopment, health, growth performance, and milk production. Lactoferrin occurs in human milk at a higher concentration compared with bovine milk, but little information is available on LF concentrations in porcine milk and the effects of sow parity on milk LF concentration. The objective of this study was to quantify the LF concentration in porcine milk and to compare that concentration between gilts and sows during lactation. We also investigated the effect of genetic background and litter size of the female pig on the LF concentration of porcine milk. The milk from 30 gilts and 35 sows was collected at 3 stages of lactation, namely colostrum, transition, and mature milk. Standard and experimental samples were analyzed by ultra-high performance liquid chromatography using a diode array UV detector. The following findings were reported: (1) porcine milk contained significant levels of LF with the highest concentration in colostrum, which decreased by ∼62% and ∼67% in transitional and mature milk, respectively; (2) mature gilt milk contained a 22% higher concentration of LF compared with sow milk, which was statistically significant; (3) breed line had an overall significant effect on the LF content of porcine milk; however, when the breed was considered, no significant difference was observed; and (4) LF concentration of porcine milk was not significantly influenced by the litter size. The presence of LF in a higher concentration in porcine milk suggests that LF is an important constituent of pig milk that might contribute to the optimum growth and development of piglets.

Dietary Polyphenols and Gene Expression in Molecular Pathways Associated with Type 2 Diabetes Mellitus: A Review

Type 2 diabetes mellitus (T2DM) is a complex metabolic disorder with various contributing factors including genetics, epigenetics, environment and lifestyle such as diet. The hallmarks of T2DM are insulin deficiency (also referred to as β-cell dysfunction) and insulin resistance. Robust evidence suggests that the major mechanism driving impaired β-cell function and insulin signalling is through the action of intracellular reactive oxygen species (ROS)-induced stress. Chronic high blood glucose (hyperglycaemia) and hyperlipidaemia appear to be the primary activators of these pathways. Reactive oxygen species can disrupt intracellular signalling pathways, thereby dysregulating the expression of genes associated with insulin secretion and signalling. Plant-based diets, containing phenolic compounds, have been shown to exhibit remedial benefits by ameliorating insulin secretion and insulin resistance. The literature also provides evidence that polyphenol-rich diets can modulate the expression of genes involved in insulin secretion, insulin signalling, and liver gluconeogenesis pathways. However, whether various polyphenols and phenolic compounds can target specific cellular signalling pathways involved in the pathogenesis of T2DM has not been elucidated. This review aims to evaluate the modulating effects of various polyphenols and phenolic compounds on genes involved in cellular signalling pathways (both in vitro and in vivo from human, animal and cell models) leading to the pathogenesis of T2DM.

Serum lactoferrin concentration of primiparous sow during gestation and lactation, and comparison between sow-fed and formula-fed piglets

Lactoferrin (LF) is a sialylated iron-binding glycoprotein, occurring in several biological secretions like milk, saliva, and seminal fluids and is a major component of a mammalian innate immune system. It plays multiple protective roles against large group of microorganisms and performs anti-inflammatory and anti-cancer activities. The concentration of serum LF in gilt (primiparous sow) and their piglets remains unknown. We determined serum LF concentration in gilts during gestation and lactation to that of 19-d-old piglets, including sow-fed and formula-fed piglets using enzyme-linked immunosorbent assay (ELISA). We found that the concentration of serum LF in gilts varied during gestation (0.77 ± 0.10 µg/mL) and lactation (0.62 ± 0.11 µg/mL). The mean concentration of serum LF in gilts (0.72 ± 0.06 µg/mL) was significantly higher than that of piglets (0.42 ± 0.07 µg/mL, P = 0.004). Additionally, a marginal significant difference (P =0.06) was observed for serum LF concentration in sow-fed piglets (0.42 ± 0.03 µg/mL) at 19 d old compared to that of formula-fed piglets (0.33 ± 0.04 µg/mL) at 37 d old. This study provides noble information regarding the serum LF concentration in the healthy gilts and piglets and thereby the data can be used as a standard reference point for future studies on the role of LF in pig reproduction.

A systematic review showing the lack of diagnostic criteria and tools developed for lower-limb cellulitis

Background

Cellulitis can be a difficult diagnosis to make. Furthermore, 31% of patients admitted from the emergency department with suspected lower‐limb cellulitis have been misdiagnosed, with incorrect treatment potentially resulting in avoidable hospital admission and the prescription of unnecessary antibiotics.

Objectives

We sought to identify diagnostic criteria or tools that have been developed for lower‐limb cellulitis.

Methods

We conducted a systematic review using Ovid MEDLINE and Embase databases in May 2018, with the aim of describing diagnostic criteria and tools developed for lower‐limb cellulitis, and we assessed the quality of the studies identified using the Quality Assessment of Diagnostic Accuracy Studies‐2 tool. We included all types of study that described diagnostic criteria or tools.

Results

Eight observational studies were included. Five studies examined biochemical markers, two studies assessed imaging and one study developed a diagnostic decision model. All eight studies were considered to have a high risk for bias in at least one domain. The quantity and quality of available data was low and results could not be pooled owing to the heterogeneity of the findings.

Conclusions

There is a lack of high‐quality publications describing criteria or tools for diagnosing lower‐limb cellulitis. Future studies using prospective designs, validated in both primary and secondary care settings, are needed.

What's already known about this topic?

Diagnosing lower‐limb cellulitis on first presentation is challenging.

Approximately one in three patients admitted from the emergency department with suspected lower‐limb cellulitis do not have cellulitis and are given another diagnosis on discharge. Consequently, this results in potentially avoidable hospital admissions and the prescription of unnecessary antibiotics.

There are no diagnostic criteria available for lower‐limb cellulitis in the U.K.

What does this study add?

This systematic review has identified a key research gap in the diagnosis of lower‐limb cellulitis.

There is a current lack of robustly developed and validated diagnostic criteria or tools for use in clinical practice.

Linked Comment: https://doi.org/10.1111/bjd.18317.

https://doi.org/10.1111/bjd.18569 available online

Awareness of surgical expenditure amongst UK trainees and consultants: A questionnaire study

INTRODUCTION

Limited knowledge of surgical device and service costs restricts a surgeon's ability to make cost efficient choices and contribute to the efficiency savings required by the NHS to reduce the financial deficit. This study aims to assess how aware surgeons are of surgical equipment and regularly used services.

METHODS

A single sided hard copy questionnaire asking for the estimate cost of 24 surgical devices/services was handed out to individuals at two separate UK annual conferences. Items and services which are regularly used and/or clinically significant were selected and, where possible, alternatives to those items were included for comparison. Participants were also asked for their grade and specialty. An estimate was deemed correct if it was within 20% of the actual cost. Planned subgroup analyses for grade and specialty were performed.

RESULTS

The 143 participants consisted of 23 (16%) consultants, 39 (27%) registrars, 33 (23%) SHOs and 48 (34%) foundation doctors. Of the 95 participants who were SHO grade or more senior, 67 (71%) work within general surgery. Across all items, only 9.6% of estimates were correct. There was no statistically significant difference between training levels (consultant 11.5%, registrar 10.1%, SHO 8.6%, foundation 8.9%; p = 0.253). Participants were significantly less successful in correctly estimating the cost of high value (>£150 [USD $198; EUR €175]) items (8.5% vs. 11.1%); p = 0.011, and the cost of devices as compared to the cost of services (7.4% vs. 15.0%); p = 0.001.

CONCLUSION

Surgeons across all grades and specialties have poor knowledge of device and service costs. It is important that this improves in order to allow surgeons to make a meaningful contribution to NHS efficiency savings by making informed decisions about their use of devices and services.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Keratinocyte-specific ablation of protease-activated receptor 2 prevents gingival inflammation and bone loss in a mouse model of periodontal disease

Chronic periodontitis is characterised by gingival inflammation and alveolar bone loss. A major aetiological agent is Porphyromonas gingivalis, which secretes proteases that activate protease-activated receptor 2 (PAR₂ ). PAR₂ expressed on oral keratinocytes is activated by proteases released by P. gingivalis, inducing secretion of interleukin 6 (IL-6), and global knockout of PAR₂ prevents bone loss and inflammation in a periodontal disease model in mice. To test the hypothesis that PAR₂ expressed on gingival keratinocytes is required for periodontal disease pathology, keratinocyte-specific PAR₂ -null mice were generated using K14-Cre targeted deletion of the PAR₂ gene (F2rl1). These mice were subjected to a model of periodontitis involving placement of a ligature around a tooth, combined with P. gingivalis infection ("Lig + Inf"). The intervention caused a significant 44% decrease in alveolar bone volume (assessed by microcomputed tomography) in wildtype (K14-Cre:F2rl1^wt/wt ), but not littermate keratinocyte-specific PAR₂ -null (K14-Cre:F2rl1^fl/fl ) mice. Keratinocyte-specific ablation of PAR₂ prevented the significant Lig + Inf-induced increase (2.8-fold) in the number of osteoclasts in alveolar bone and the significant up-regulation (2.4-4-fold) of the inflammatory markers IL-6, IL-1β, interferon-γ, myeloperoxidase, and CD11b in gingival tissue. These data suggest that PAR₂ expressed on oral epithelial cells is a critical regulator of periodontitis-induced bone loss and will help in designing novel therapies with which to treat the disease.

Penile lymphoedema: approach to investigation and management

BACKGROUND

Penile lymphoedema (with and without cellulitis) is a rare, often chronic, clinically heterogeneous entity with an uncertain pathogenesis and an important differential diagnosis. It creates significant physical and psychosexual morbidity, and presents considerable therapeutic challenges. The existing literature is limited.

AIM

To describe and share our updated cumulative experience of a cohort of patients with penile lymphoedema.

METHODS

This was a retrospective review of the case records of patients with chronic penile lymphoedema seen in two dedicated male genital dermatology clinics between January 2011 and July 2016.

RESULTS

In total, 41 cases were identified. Over a third had Crohn disease (CD) (which was occult in one-third of these), and over a third had serological evidence of streptococcal infection. All patients responded to systemic antibiotics and specialized urological surgery circumcision and excision).

CONCLUSIONS

Penile lymphoedema should be investigated to exclude underlying pathology especially CD and streptococcal infection. Treatment with antibiotics should be considered early and long term to try to preserve the foreskin: most patients are uncircumcised. Some patients may benefit from a course or courses of oral steroids. The development of gross dysfunction of the prepuce usually dictates circumcision and excision of lymphoedematous tissue once the situation is medically stabilized.

Morphoea with prominent plasma cell endoneuritis

Morphoea (localized scleroderma) is a cutaneous inflammatory condition characterized by the development of indurated and discoloured plaques. The histological features of morphoea typically include a superficial and deep perivascular and periadnexal chronic inflammatory infiltrate associated with variable degrees of dermal and/or subcutaneous sclerosis. The infiltrate is typically composed of lymphocytes, macrophages and conspicuous plasma cells. The early stages of morphoea may have a very prominent inflammatory infiltrate associated with subtle sclerosis. In addition, the inflammatory infiltrate may show a perineural and rarely intraneural distribution. We report two cases of morphoea that histologically showed plasma cell endoneuritis associated with subtle dermal sclerosis. These two cases highlight the potential for diagnostic confusion with infectious and inflammatory diseases, particularly leprosy and lupus.