Open lateral sphincterotomy - A method of choice in the treatment of chronic anal fissure. Indications and results

Aim: The key to the treatment of chronic anal fissures is the reduction of the abnormal values of anal resting pressure. The aim of the surgical treatment is to reduce the activity of the internal anal sphincter and to provide proper conditions for the fissure to cure, which can be achieved by internal sphincterotomy. In the modern surgical practice the internal sphincterotomy is performed away from the fissure, lateral of the last, using open or closed technique.Methods: In our study we performed open lateral internal sphincterotomy (OLST) of 82 patients with chronic anal fissure, compared to a control group of 231 patients, treated with different methods. Results: We didn`t register any recurrences in the sixth post-operative moth after OLST. 11% of patients with OLST were with registered incontinence after the sixth post-operative month compared with 4.4% in non-OLST patients. The data was statistically significant (p=0.032)Conclusion: Choosing an OLST as a method for treatment of chronic anal fissure requires careful selection of patients. It is not recommended for patients with a risk of incontinence like those with a previous birth trauma, age beyond 60 years, previous ano-rectal operations, neurological diseases and low values in anal resting pressure.Aim: The key to the treatment of chronic anal fissures is the reduction of the abnormal values of anal resting pressure. The aim of the surgical treatment is to reduce the activity of the internal anal sphincter and to provide proper conditions for the fissure to cure, which can be achieved by internal sphincterotomy. In the modern surgical practice the internal sphincterotomy is performed away from the fissure, lateral of the last, using open or closed technique.Methods: In our study we performed open lateral internal sphincterotomy (OLST) of 82 patients with chronic anal fissure, compared to a control group of 231 patients, treated with different methods. Results: We didn`t register any recurrences in the sixth post-operative moth after OLST. 11% of patients with OLST were with registered incontinence after the sixth post-operative month compared with 4.4% in non-OLST patients. The data was statistically significant (p=0.032)Conclusion: Choosing an OLST as a method for treatment of chronic anal fissure requires careful selection of patients. It is not recommended for patients with a risk of incontinence like those with a previous birth trauma, age beyond 60 years, previous ano-rectal operations, neurological diseases and low values in anal resting pressure

Chemical characterisation of construction and demolitionwaste in Skopje city and its surroundings (Republic of Macedonia)

In the Republic of Macedonia, construction and demolition waste is often dumped, underestimating the potential recycling and re-use as raw materials for civil engineering works and/or cement/ceramic industries. SAMCODE (Sustainable Approach to Managing Construction and Demolition Waste) is a know-how exchange program, the focus of which is chemical characterisation in terms of major and trace elements in order to evaluate the possible Macedonian construction and demolition waste recycling. Thirty-nine waste samples were collected from different dumps in Skopje and surroundings. X-ray fluorescence analyses, carried out on powdered samples, show i) highly variable concentrations, indicative of the heterogenous nature of construction and demolition waste, and ii) high concentration in Cr, Ni, and Zn with respect to Italian, Chinese, and Dutch tolerance limits, probably due to the presence of these elements in ophiolitic rocks and sulphide-bearing deposits, used as raw material in building activity. Inductively coupled plasma mass spectrometry analyses of leachates, performed to assess the mobility of heavy metals, show significant concentrations of Cr, and to a lesser extent, Ni. Results suggest that homogenisation processes of the recycled materials should be implemented and preliminary screening of construction and demolition waste should be performed to eliminate heavy metals-bearing components

Deroofing - a method of choice in the treatment of suppurative perineal hidradenitis

Purpose: Suppurative hidradenitis is a chronic relapsing inflammatory disease that affects the apocrine sweat glands. Therefore, it is most often located in the axilla, groin and perianal area. Usually, people of working age affected. Perineal and perianal locations cover about 37% of the total morbidity rate and are more common in males. The objective of this study was to share our experience with the application of deroofing for the treatment of purulent perineal hidradenitis.Material and methods: This prospective interventional study covered 13 patients with suppurative fistulasing hidradenitis of perineum treated in Division of Coloproctology and Septic Surgery, Georgi Stranski University Hospital of Pleven for the period from 2008 till 2013.Results: The interval between the occurrence of disease and its surgical treatment was very long - from two to 36 years (average of 9,2 years). It resulted from the progression of the disease with enlarged soft tissue involvement. Sometimes, the disease was complicated by chroniosepsis. The average hospital stay was 13,5-day long. Operative wounds healed secondarily at an average of about 30 days. The patients were followedup for six months, one year and two years. Two patients with relapses on the sixth postoperative month were hospitalized again. The surgical intervention warranted good results.Conclusion: Treatment of suppurative hidradenitis of the perineum is complex, both in terms of local status and systematic violations resulting in chronic infection. There are numerous surgical techniques for treating this pathology. The advantages of deroofing are the following: minimal trauma to the patient, application by using local anesthesia at the early stage in order to minimize hospital stay, no need of special equipment, a lower recurrence rate than the other methods and formation of aesthetically acceptable scar

Biomass burning at Cape Grim: exploring photochemistry using multi-scale modelling

We have tested the ability of a high-resolution chemical transport model (CTM) to reproduce biomass burning (BB) plume strikes and ozone (O3) enhancements observed at Cape Grim in Tasmania, Australia, from the Robbins Island fire. The CTM has also been used to explore the contribution of near-field BB emissions and background sources to O3 observations under conditions of complex meteorology. Using atmospheric observations, we have tested model sensitivity to meteorology, BB emission factors (EFs) corresponding to low, medium, and high modified combustion efficiency (MCE), and spatial variability. The use of two different meteorological models (TAPM–CTM and CCAM–CTM) varied the first (BB1) plume strike time by up to 15 h and the duration of impact between 12 and 36 h, and it varied the second (BB2) plume duration between 50 and 57 h. Meteorology also had a large impact on simulated O3, with one model (TAPM–CTM) simulating four periods of O3 enhancement, while the other model (CCAM) simulating only one period. Varying the BB EFs, which in turn varied the non-methane organic compound (NMOC) ∕ oxides of nitrogen (NOx) ratio, had a strongly non-linear impact on simulated O3 concentration, with either destruction or production of O3 predicted in different simulations. As shown in previous work (Lawson et al., 2015), minor rainfall events have the potential to significantly alter EF due to changes in combustion processes. Models that assume fixed EF for O3 precursor species in an environment with temporally or spatially variable EF may be unable to simulate the behaviour of important species such as O3. TAPM–CTM is used to further explore the contribution of the Robbins Island fire to the observed O3 enhancements during BB1 and BB2. Overall, TAPM–CTM suggests that the dominant source of O3 observed at Cape Grim was aged urban air (age  = 2 days), with a contribution of O3 formed from local BB emissions. This work shows the importance of assessing model sensitivity to meteorology and EF and the large impact these variables can have in particular on simulated destruction or production of O3 in regional atmospheric chemistry simulations. This work also shows the importance of using models to elucidate the contribution from different sources to atmospheric composition, where this is difficult using observations alone

Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry

Background: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p <.001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01–1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90 ml/min/1.73 m2). Conclusion: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

Background: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients\u2019 clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward\u2019s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients\u2019 prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27\u20133.62; HR 3.42, 95%CI 2.72\u20134.31; HR 2.79, 95%CI 2.32\u20133.35), and Cluster 1 (HR 1.88, 95%CI 1.48\u20132.38; HR 2.50, 95%CI 1.98\u20133.15; HR 2.09, 95%CI 1.74\u20132.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

East Vardar Ophiolite from North Macedonia revised within the GECCOSPARK know-how exchange programme (KEP) project funded by the Central European Initiative (CEI)

This contribution is part of a CEI-KEP project (Ref. No. 1206.006-19) titled “Promoting geological, e cological and cultural heritage through sustainable development and creation of geo-parks”. It includes the study of Mesozoic ophiolite rocks, which are interpreted as the remnants of the Vardar TethysOcean. The East Vardar ophiolites are composed of basic magmatic sequences (pillow basalts, sheeted dykes, and gabbros), associated with intermediate and acid magmatic intrusions having subduction-related affinity and locally bearing an adakitic signature (Božović et al., 2013; Boev et al., 2018). To give new< insights on these ophiolites, new samples were collected from the Lipkovo and Demir Kapija localities, in the northern and southern part of North Macedonia, respectively. Three groups of rocks are distinguished on the basis of whole-rock major and trace element composition and major element composition of clinopyroxene. Group 1 is characterized by tholeiitic basalts from Demir Kapija that exhibit slight enrichments in light-Rare Earth Element (L-REE) and slight negative Nb anomaly. These features are comparable with those of back-arc basin basalts. Groups 2 and 3 are represented by calcalkaline rocks, showing typical subduction-related chemical affinity, as exemplified by N-MORB normalized spider diagrams showing typical Nb and Ta and, locally, P and Ti, negative anomalies along with Th-U positive anomalies. Group 2 rocks, which are from Demir Kapija, exhibit a weak adakitic affinity, as they are characterized by high LREE/HREE fractionation, high Sr/Y and La/Yb ratios. Additional insights were provided by δ13C and δ34S analyses. Group 2 and 3 rocks show more pronounced negative δ13C (-22‰ to -18‰) and positive δ34S (+2.3‰ to +4.9‰) values compared to those of Group 1 rocks (δ13C: -16‰ to -10‰; δ34S: +0.7‰ to +2.4‰), suggesting that Group 2 and 3 rocks record comparatively higher metasomatic interaction of their mantle sources with slab-derived components. On the whole, the results show that magmatic rocks from ophiolites of East Vardar in the North Macedonia display a widespread supra-subduction chemical signature, indicating the formation of these ophiolites in an arc - back-arc ensialic setting. The data provide information about the geological evolution and setting of this area, which should be disseminated using a didactic approach and simple concepts appealing for “nonexperts”, emphasizing that such studies are crucial to understand a unique geological system, which has no analogues in the present

SUBDUCTION SIGNATURE OF THE VARDAR OPHIOLITE OF NORTH MACEDONIA: NEW CONSTRAINTS FROM GEOCHEMICAL AND STABLE ISOTOPE DATA

Volatiles such as carbon (C) and sulphur (S) are commonly transferred into the mantle from subduction of oceanic lithosphere and overlying sediments. C and S isotopic signatures of magmatic rocks could be used as proxies of the slab components involved in the petrogenesis of subduction-related ophiolites. Therefore, in this work we investigated the major and trace element composition, as well as the C and S elemental contents and isotopic ratios (13C/12C and 34S/32S) of subvolcanic and volcanic rocks of the Vardar ophiolites of North Macedonia, which represent the remnants of the Mesozoic Tethyan oceanic lithosphere formed in supra-subduction zone tectonic settings. The ophiolites were sampled at Lipkovo and Demir Kapija localities, in the northern and southern part of North Macedonia, respectively. Based on whole-rock major and trace element composition, three groups of rocks can be distinguished: i) Group 1 rocks, which are subalkaline basalts having backarc affinity, ii) Group 2a and iii) Group 2b rocks, which are calc-alkaline basalts having arc affinity, with and without adakitic signatures, respectively. The qualitative petrogenetic models indicate that studied rocks formed by partial melting of mantle sources variably metasomatized by subduction-related components, such as aqueous fluids, sediment melts, and adakitic melts. Accordingly, all the North Macedonia ophiolites are characterized by C and S signatures which deviate from those typical for mantle and Mid Ocean Ridge melts. The variably low δ13C values recorded by Group 1 and 2 rocks could be related to the different contributions of melts released by subducting sediments rich in organic matter. However, we cannot exclude that such C-enriched signature is the result of isotopic fractionation during degassing process. In contrast, the enriched S isotopic signatures of the North Macedonia ophiolites suggest a major involvement of melts derived from the subducting sediments rich in sulphate phases. In particular, the calc-alkaline basalts of Group 2 rocks record more positive δ34S values than the subalkaline basalts of Group 1 formed in backarc basin suggesting that the subarc mantle sources were more affected by slab-released fluids than those of the backarc basin, which were more distal from the trench

Carbon and sulphur isotopic composition of Vardar ophiolite of North Macedonia: implications for volatiles cycling in subduction zones.

The North Macedonia is part of the Dinaric-Hellenic belt, an Alpine collisional belt extending from Slovenia to Greece. It resulted from the Mesozoic-Cenozoic convergence between Eurasia and Adria, ophiolite obduction, and continental collision after the closure of the Tethys Ocean. In this work we investigated the subvolcanic and volcanic rocks of the Vardar ophiolites of the North Macedonia, which represent the remnants of the Mesozoic Tethyan oceanic lithosphere formed in supra-subduction zone tectonic setting. Samples were collected at Lipkovo and Demir Kapija localities, in the northern and southern part of North Macedonia, respectively. Based on whole-rock major and trace element composition, two main groups of rocks can be distinguished: i) Group 1 rocks, which are subalkaline basalts showing backarc affinity and ii) Group 2 rocks, which are calc-alkaline basalts showing arc affinity. Petrogenetic modelling, based on trace and REE, indicates that Group 1 mantle sources were affected by limited metasomatic processes by slab-released components, in particular aqueous fluids and sediment melts, whereas the Group 2 mantle sources were strongly metasomatized by sediment melts and/or adakitic melts. In addition to this, the isotopic ratios of volatiles such as carbon (C) and sulphur (S) were also investigated to better constrain the nature and composition of the slab-components responsible for the metasomatism. In fact, volatiles are commonly transferred into the mantle from subduction of oceanic lithosphere and overlying sediments, whose C and S isotopic composition is well distinguishable from that of the mantle. The Group 1 rocks exhibit C-enriched and S-depleted signatures slightly different from those typical for the mantle, indicating a minor involvement of melts from the subducting sediments in the backarc basin settings. On the contrary, the C-depleted and S-enriched isotopic signatures of the Group 2 rocks suggest a major involvement of melts derived from the subducting sediments rich in organic matter and sulphate phases. Therefore, both geochemical and isotopic data of the North Macedonia ophiolites indicate that the sub-arc mantle sources are more affected by slab-released fluids than those of the backarc basin, which are more distal from the trench. This approach may be useful to better constrain the composition of the metasomatic agents, as well as to understand the origin and the fate of volatiles near subduction zones