Current problems on operative strategy for complicated colon diverticular disease

Perforation of complicated diverticular disease of the colon with generalized peritonitis is common life-threatening emergency requiring surgical intervention. Although the absolute prevalence of perforated diverticulitis complicated by generalized peritonitis is low, its importance lies in the signifcant postoperative mortality, ranging from 4-26%, regardless of selected surgical strategy. The optimal treatment for perforated diverticulitis has been always a matter of debate, changing the ‘‘gold standard`` several times in the last decades. Primary resection has become the standard practice, but fear of anastomotic leakage of ten deterred many surgeons from performing primary anastomosis. Therefore, for many surgeons Hartmann`s procedure has remained the favored option. We share our 10 years de part mental experience in complicated diverticular disease of the colon studying 146 cases with diverticular disease treated in our clinic between 2000-2010. The indications for operation were diverticulitis complications - perforation, obstructiuon and bleeding, demonstrated on clinically by generalized peritonitis - 21, acute obstruction - 4 and rectorrhagia - 2. Operation was performed in 29 patients in urgent setting. Primary resection with anastomosis was done in 12 patients (41.38%). Manual anastomoses were performed in 4 cases, while mechanical anastomoses with staplers were accomplished in 8 cases. In 6/50%/ of the latter we used our standardized technique for linear stapler latero-lateral/functional end-to-end anastomosis, formerly implemented by as for colonic cancer resections and anastomoses. We had have 2 /6.9%/ anastomosis dehiscenses. Hartmann`s procedure was per formed in 17 patients (58.62%).We did not have any complications or death with standardized stapler resections and anastomoses. Hospital operative mortality was 13.79% /4 cases/. We advocate the primary anastomosis as the standard procedure, especially for older patients. Using a standardized technique with linear stapler for primary colon resection and anastomosis in complicated diverticular disease we favor the patient`s outcome with safety, efficiency and effectiveness

Clinical and diagnostic assessment of Goodsall`s rule in anorectal fistulas

The exact identification of the internal opening in the surgical treatment of anorectal fistulae is of basic importance for their radical treatment. The rule of Goodsall enables identification of the internal opening. 184 patients with anorectal fistulae have been studied (145 male è 39 female). According to the type of the fistulae patients were distributed as follows: 86(46.74%) with transsphincteric, 57(30.98%) with extrasphincteric and 41(22.28%) with intrasphincteric. Most of them 126(68.48%) have had posterior external opening, while 58(31.52%) had anterior external opening. The internal opening has been identified in 169(91.85%) cases. The Goodsall`s rule was observed in 131(77.51%) Exception of this rule was registered in 38 patients - 20 cases with transsphincteric fistulae, 12 with extrasphincteric, 5 with re current fistulae and 1 with intersphincteric. 87.30%(110/126) of the posterior anorectal fistulae fulfilled the rule of Goodsall, while the anterior ones this rule was observed in 33/58(56.90%). From the cases with intersphincteric fistulae in 97.56 % there is match with the rule of Goodsall. The Goodsall`s rule predicts the position of the internal opening, according to the localization of the external opening. Exceptions of this rule were in the anterior fistulae and lying more than 3 cm from the anus /sensitivity of 56.90 %/. The Goodsall`s rule demonstrates highest informativity in posterior fistulae/sensitivity was 87.30 %/

Autologous blood donation in elective surgery of colorectal cancer - is it possible?

Reports from recent studies indicate a causal relationship between all transfusion, infectious complications and recurrent disease in surgical patients. The aim of the presented study is to elucidate the possibilities and indications for autologous haemotransfusion in the elective surgery of the colorectal cancer. Retrospective analysis was per formed over 724 electively operated patients with colorectal cancer. The prospective part includes observation of 20 radically operated patients. In these patients autologous haemotransfusion was per - formed. As indications for autologous haemotransfusion we consider age up to 80 years, hemoglobin levels at least 130 g/l, plasma protein > 65 g/l, body weight > 50 kg, good general condition and absence of decompensated cardiovascular or endocrine dis eases. In two patients with hemoglobin level between 90 - 110 g/l we per formed stimulation by means of Erythropoietin. According to retrospective data ad mission hemoglobin levels varies from 54 g/l to 175 g/l (mean 119 g/l ± 22, 6). From all electively operated patients 33, 9% had hemoglobin values over 130 g/l. The frequency of post-operative infectious complications increases from 9.1% in non-transfused patients to 38,7 % in patients with more than 4 units of allogenic blood trans fused. The prospective part of the study is designed to establish feasibility of the autologous haemotransfusion in clinical practice. The fall of hemoglobin values on the next day after donation varies from 11g/l to 19g/l (mean 15.5 g/l ± 2,19). Erythropoietin stimulation was not found to increase hemoglobin values significantly. There were no complications in the post-operative period in autologous haemotransfusion group with exception of one superficial wound infection. Autologous haemotransfusion is feasible in approximately 1/3 of electively operated patients with colorectal cancer with no ad verse effects or post-operative complications. It de creases the necessity of allogenic bioproducts and hence the risks related. Autologous haemotransfusion is easy to perform and propose ben e fits both from medical and logistic nature. Concerning to stimulation with Erythropoetin in our opinion it is without proven short term efficacy in general surgery so far

Elastic seton procedure for surgical treatment of anorectal fistulas

The anorectal fistula is a disease requiring careful assessment of the local signs and precise localization of the fistula channel. The Seton procedure for treatment of the fistula-in-ano we apply only for the management of trans- or extrasphincteric anorectal fistula. 152 patients with high trans- or extrasphincteric fistula-in-ano were operated. Men were 123/80.92%/, women-29/19.08%/. In 70 /46.05%/ fistula were extrasphincteric, while in 82/53.95%/ they were transsphincteric. Ba sic step is to identify the internal opening of the fistula channel following Goodsal`s rule. The Seton is trespassed through the internal opening and we tight it moderately. Every next tightening is performed at 3 days intervals. Recurrences ware registered in the first 6 months in 8 patients/5.26%/. We conclude that that seton procedure for treatment of trans- and extrasphincteric fistula is an easy to learn and practice radical one stage surgical method with a cure rate of nearly 95%. Elastic Seton ligation technique is a modification of the known from ancient times conventional ligation procedure. The following procedure is an effective method for difficult and high fistula-in-ano

A cell cycle-coordinated Polymerase II transcription compartment encompasses gene expression before global genome activation

© 2019, The Author(s). Most metazoan embryos commence development with rapid, transcriptionally silent cell divisions, with genome activation delayed until the mid-blastula transition (MBT). However, a set of genes escapes global repression and gets activated before MBT. Here we describe the formation and the spatio-temporal dynamics of a pair of distinct transcription compartments, which encompasses the earliest gene expression in zebrafish. 4D imaging of pri-miR430 and zinc-finger-gene activities by a novel, native transcription imaging approach reveals transcriptional sharing of nuclear compartments, which are regulated by homologous chromosome organisation. These compartments carry the majority of nascent-RNAs and active Polymerase II, are chromatin-depleted and represent the main sites of detectable transcription before MBT. Transcription occurs during the S-phase of increasingly permissive cleavage cycles. It is proposed, that the transcription compartment is part of the regulatory architecture of embryonic nuclei and offers a transcriptionally competent environment to facilitate early escape from repression before global genome activation

Dual-initiation promoters with intertwined canonical and TCT/TOP transcription start sites diversify transcript processing

Variations in transcription start site (TSS) selection reflect diversity of preinitiation complexes and can impact on post-transcriptional RNA fates. Most metazoan polymerase II-transcribed genes carry canonical initiation with pyrimidine/purine (YR) dinucleotide, while translation machinery-associated genes carry polypyrimidine initiator (5'-TOP or TCT). By addressing the developmental regulation of TSS selection in zebrafish we uncovered a class of dual-initiation promoters in thousands of genes, including snoRNA host genes. 5'-TOP/TCT initiation is intertwined with canonical initiation and used divergently in hundreds of dual-initiation promoters during maternal to zygotic transition. Dual-initiation in snoRNA host genes selectively generates host and snoRNA with often different spatio-temporal expression. Dual-initiation promoters are pervasive in human and fruit fly, reflecting evolutionary conservation. We propose that dual-initiation on shared promoters represents a composite promoter architecture, which can function both coordinately and divergently to diversify RNAs

System of insufficiency of the modern theory of long-term resistance of reinforced concrete and designers’ warnings

Aim of the research. The essence of the failure of the globally widespread theory of long-term resistance of reinforced concrete is defined and analyzed. Methods. This failure includes the following interconnected parts: 1) the set of ten basic fundamental properties of structural concrete is completely distorted (for example, instantaneous linear properties are Maxwell scheme); 2) mathematical rules are violated when recording the rates of elastic deformation and creep deformation, due to a misunderstanding of the Boltzmann principle (these violations distort the whole structure of the theory); 3) the rules of classical mechanics are violated, what is caused by substitution of fundamental properties of concrete with various “chain models” (for example, the principle of independence of action of forces, which is the fourth fundamental law of Galileo - Newton, is violated); 4) sections of the general “world theory of creep of reinforced concrete”, based on its algebraization, in their essence reject the fundamental law of natural science - Newton's second law: not only the inertial component is rejected, but also forces depending on speed (in this way the “world theory of creep of reinforced concrete” is degraded to the level of Aristotle’s mechanics); 5) unacceptably idealized creep theories and structural models that endow concrete with unrealizable properties, especially flagrant in zones of cracks, are incorporated in the normative calculations of structures; 6) solid design companies of the world show that concrete creep is not a scientific theory: this is a warning to designers. Results. The performed analysis is accompanied by necessary mathematical calculations and experimental estimates

Dynamic regulation of the transcription initiation landscape at single nucleotide resolution during vertebrate embryogenesis

Spatiotemporal control of gene expression is central to animal development. Core promoters represent a previously unanticipated regulatory level by interacting with cis-regulatory elements and transcription initiation in different physiological and developmental contexts. Here, we provide a first and comprehensive description of the core promoter repertoire and its dynamic use during the development of a vertebrate embryo. By using cap analysis of gene expression (CAGE), we mapped transcription initiation events at single nucleotide resolution across 12 stages of zebrafish development. These CAGE-based transcriptome maps reveal genome-wide rules of core promoter usage, structure, and dynamics, key to understanding the control of gene regulation during vertebrate ontogeny. They revealed the existence of multiple classes of pervasive intra- and intergenic post-transcriptionally processed RNA products and their developmental dynamics. Among these RNAs, we report splice donor site-associated intronic RNA (sRNA) to be specific to genes of the splicing machinery. For the identification of conserved features, we compared the zebrafish data sets to the first CAGE promoter map of Tetraodon and the existing human CAGE data. We show that a number of features, such as promoter type, newly discovered promoter properties such as a specialized purine-rich initiator motif, as well as sRNAs and the genes in which they are detected, are conserved in mammalian and Tetraodon CAGE-defined promoter maps. The zebrafish developmental promoterome represents a powerful resource for studying developmental gene regulation and revealing promoter features shared across vertebrates.publishedVersio

Полинейромиопатия критических состояний (обзор литературы)

Neuromuscular disorders are extremely common in critically ill patients; they significantly affect the recovery time and limit the quality of subsequent  life. Until now, it is difficult to assess the presence of such disorders in intensive care units. The presented literature analysis of the current state of  the issues of epidemiology, pathogenesis and pathophysiology of critical illness polyneuromyopathy (CIPNM) determines the current directions  in the diagnosis and treatment of this pathology Нервно-мышечные расстройства чрезвычайно распространены у больных в критическом состоянии, они значительно влияют на сроки  выздоровления и ограничивают качество последующей жизни. До сих пор оценка наличия таких нарушений в отделениях реанимации  и интенсивной терапии представляет трудности. Представленный анализ литературы современного состояния вопросов эпидемиологии,  патогенеза и патофизиологии полинейромиопатии критических состояний (ПНМКС) определяет актуальные направления диагностики  и лечения этой патологии

Acute diverticulitis in immunocompromised patients: evidence from an international multicenter observational registry (Web-based International Register of Emergency Surgery and Trauma, Wires-T)

Background: Immunocompromised patients with acute diverticulitis are at increased risk of morbidity and mortality. The aim of this study was to compare clinical presentations, types of treatment, and outcomes between immunocompromised and immunocompetent patients with acute diverticulitis. Methods: We compared the data of patients with acute diverticulitis extracted from the Web-based International Registry of Emergency Surgery and Trauma (WIRES-T) from January 2018 to December 2021. First, two groups were identified: medical therapy (A) and surgical therapy (B). Each group was divided into three subgroups: nonimmunocompromised (grade 0), mildly to moderately (grade 1), and severely immunocompromised (grade 2). Results: Data from 482 patients were analyzed—229 patients (47.5%) [M:F = 1:1; median age: 60 (24–95) years] in group A and 253 patients (52.5%) [M:F = 1:1; median age: 71 (26–94) years] in group B. There was a significant difference between the two groups in grade distribution: 69.9% versus 38.3% for grade 0, 26.6% versus 51% for grade 1, and 3.5% versus 10.7% for grade 2 (p < 0.00001). In group A, severe sepsis (p = 0.027) was more common in higher grades of immunodeficiency. Patients with grade 2 needed longer hospitalization (p = 0.005). In group B, a similar condition was found in terms of severe sepsis (p = 0.002), quick Sequential Organ Failure Assessment score > 2 (p = 0.0002), and Mannheim Peritonitis Index (p = 0.010). A Hartmann’s procedure is mainly performed in grades 1–2 (p < 0.0001). Major complications increased significantly after a Hartmann’s procedure (p = 0.047). Mortality was higher in the immunocompromised patients (p = 0.002). Conclusions: Immunocompromised patients with acute diverticulitis present with a more severe clinical picture. When surgery is required, immunocompromised patients mainly undergo a Hartmann’s procedure. Postoperative morbidity and mortality are, however, higher in immunocompromised patients, who also require a longer hospital stay