Injection of freshly collected adipose tissue for the treatment complex cryptoglandular anal fistula: case report

Introduction: Perianal fistula is a common colorectal disease which is caused mainly by cryptoglandular disease. Although most cases are treated successfully by surgery, management of complex perianal fistulas (CPAF) remains a challenge with limited results in recurrence and sometimes associated with fecal incontinence. The CPAF treatment with autologous adipose-derived mesenchymal stem cells (ASCs) had become a research hotspot. The technique started to be used in the treatment of Crohn's disease (CD) fistulas, where the studies showed safe and goods result from the procedure. Cultured ASCs have been used but this approach requires the preceding collection of adipose tissue, time for isolation of ASCs and subsequent in vitro expansion, need for laboratory facilities, and expertise in cell culturing. These factors have been getting over by using the commercially available alternative, allogenic ASCs. Treatment with allogeneic ASCs has shown good results in patients with CD fistulas, however with the disadvantage of being expensive. Objective: To show that the injection with freshly collected adipose tissue is an alternative to treatment with autologous or allogenic ASCs with several advantages. Methods: In this case report, we show our first experience in the treatment of CPAF with the application of collected adipose tissue in a tertiary referral hospital from Belo Horizonte, Brazil. Results The patient had a good postoperative recuperation with a complete fistula healing after 8 months without adverse effects. Conclusion: Injection with freshly collected adipose tissue is a promising and apparently safe sphincter-sparing technique in the treatment of CPAF. (AU)

Polyp detection in the cecum and ascending colon by dye based chromoendoscopy - Is its routine use justified?

INTRODUCTION: colonoscopy is the best method for detecting polyps, with a reduction in colorectal cancer mortality of 29% and reaching 47% for distal tumors. However, it fails to demonstrate a significant reduction in proximal colon cancer mortality, and is the most common segment with interval neoplasm. The present study aimed to evaluate the impact on detection of polyps of a second sequential evaluation of cecum and ascending colon, with or without the use of indigo carmine chromoendoscopy. METHODS: prospective, non-randomized clinical trial. Patients were divided into two groups. The first (G1) underwent a routine colonoscopy, followed by a second endoscopy assessment of ascending colon and cecum. The second group (G2) underwent a routine colonoscopy, followed by a second assessment of the ascending colon and cecum with indigo carmine chromoendoscopy. RESULTS: In total, 203 patients were analyzed, 101 in the G1 and 102 in the G2. Newer polyps were identified in both groups after the second assessment with a significantly higher number of polyps detected in the patients in the G2 (p=0.0001). The number of patients who had at least one polyp in the two endoscopic assessments was significantly higher in the G2 (53 or 52% vs 27 or 26.7%, p=0.0002). In the second endoscopic assessment, the number of polyps found was also significantly higher in the G2 (50 or 76.9%) compared to the G1 (15 or 23.1%), p<0.0001. CONCLUSIONS: the second assessment with dye-based chromoendoscopy increases the detection of polyps in the ascending colon and cecum.

Comparative study using propensity score matching analysis in patients undergoing surgery for colorectal cancer with or without multimodal prehabilitation.

INTRODUCTION: The complication rate after major abdominal surgery is from 35 to 50%. The multimodal prehabilitation covers all the pre-operative problems to guarantee a faster recovery and reduce the rate of morbidity and mortality after a colorectal procedure. METHODS: Observational study, in patients with CRC who underwent surgical treatment between November 2020 and September 2022. The data of the patients were placed in 2 groups: prehabilitation group (PPH) and no prehabilitation group (NPPH). Demographic data, type of cancer, operative data, and postoperative data were collected. Characteristics between the groups were compared after a propensity score matching (PSM) analysis for the detection of differences. RESULTS: After the PSM analysis, 46 patients were in PPH, and 63 patients were in NPPH. There was no significant difference in postoperative complications (p = 0.192). The median of comprehensive complication index (CCI) was 0 (p = 0.552). Patients in the NPPH had more hospital readmissions (p = 0.273) and more emergency room visits (p = 0.092). Multivariate log binomial regression adjusted for complications showed that pre-habilitation reduces the risk of a pos-operative complication (OR: 0.659, 95%CI, 0.434-1.00, p = 0.019). CONCLUSIONS: The postoperative complication rate and LOS were similar between patients who receive operative multimodal prehabilitation for CRC surgery and those who did not. Prehabilitation was associated with reduced risk of postoperative complication after multivariate log binomial regression adjusted for complications. Patients who underwent prehabilitation had a slightly lower tendency for postoperative ER visits and hospital readmissions.

Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision.

OBJECTIVES: the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE). METHODS: we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin. RESULTS: sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239). CONCLUSION: rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.

Identification and characterization of microRNAs in Biomphalaria tenagophila and comparative analysis of their expression in Schistosoma mansoni-resistant and -susceptible snail populations.

BACKGROUND: Schistosomiasis is a neglected tropical disease caused by Schistosoma and affects over 240 million people worldwide. One of the most prominent causative agents is Schistosoma mansoni, which develops inside the intermediate host. Biomphalaria tenagophila is the second most important vector of schistosomiasis in Brazil and the Taim population is completely resistant to infection by S. mansoni. OBJECTIVE: This study aims to identify and characterize B. tenagophila microRNAs (miRNAs) and evaluate their differential expression in S. mansoni-susceptible and -resistant populations of B. tenagophila. METHODS: Two populations of B. tenagophila snails, susceptible and resistant to S. mansoni infection, were used to investigate the small RNA response of these snails after being infected with the parasite. Small RNA sequencing and quantitative real-time PCR were employed to identify and validate differentially expressed miRNAs. Bioinformatics analysis were performed to identify miRNA precursors and mature and evaluate their differential expression. FINDINGS: The study predicted 173 mature miRNAs and 123 precursors. Among them were six Lophotrochozoa-specific miRNAs, three mollusk-specific miRNAs, and six pre-miRNAs in a cluster. The small RNA sequencing and RT-PCR of B. tenagophila samples allowed assessing the expression patterns of miRNAs. MAIN CONCLUSIONS: The results obtained may support future studies in Biomphalaria spp., generating a global impact on disease control.

Assessing morbidity, mortality, and survival in patients with peritoneal carcinomatosis undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

OBJECTIVE: Peritoneal carcinomatosis (PC) indicates advanced stage cancer, which is generally associated with a poor outcome and a 6 to 12 months. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an option for treating patients with primary PC, such as mesothelioma, or secondary PC, such as colorectal cancer (CRC) or pseudomixoma. Until recently, such patients were deemed untreatable. The purpose of this study was to assess the results of CRS + HIPEC in patients with PC. Postoperative complications, mortality and survival rates were evaluated according to the diagnosis. RESULTS: Fifty-six patients with PC, undergoing full CRS + HIPEC between October 2004 and January 2020, were enrolled. The mortality rate was 3.8% and the morbidity rate was 61.5%. Complications were significantly higher in proportion to the duration of surgery (p<0.001). The overall survival rates, as shown in the Kaplan-Meyer curve, were respectively 81%, 74% and 53% at 12, 24 and 60 months. Survival rates according to each diagnosis for the same periods were 87%, 82% and 47% in patients with pseudomixoma, and 77%, 72% and 57% in patients with CRC (log-rank 0.371, p=0.543). CONCLUSION: CRS with HIPEC is an option for pacients with primary or secondary PC. Although complication rates are high, a longer survival rate may be attained compared to those seen in previously published results; in some cases, patients may even be cured.

Polyp detection in the cecum and ascending colon by dye based chromoendoscopy - Is its routine use justified? / Uso de cromoscopia com corante para detecção de pólipos em ceco e cólon ascendente - Deve ser utilizado de rotina?

ABSTRACT Introduction: colonoscopy is the best method for detecting polyps, with a reduction in colorectal cancer mortality of 29% and reaching 47% for distal tumors. However, it fails to demonstrate a significant reduction in proximal colon cancer mortality, and is the most common segment with interval neoplasm. The present study aimed to evaluate the impact on detection of polyps of a second sequential evaluation of cecum and ascending colon, with or without the use of indigo carmine chromoendoscopy. Methods: prospective, non-randomized clinical trial. Patients were divided into two groups. The first (G1) underwent a routine colonoscopy, followed by a second endoscopy assessment of ascending colon and cecum. The second group (G2) underwent a routine colonoscopy, followed by a second assessment of the ascending colon and cecum with indigo carmine chromoendoscopy. Results: In total, 203 patients were analyzed, 101 in the G1 and 102 in the G2. Newer polyps were identified in both groups after the second assessment with a significantly higher number of polyps detected in the patients in the G2 (p=0.0001). The number of patients who had at least one polyp in the two endoscopic assessments was significantly higher in the G2 (53 or 52% vs 27 or 26.7%, p=0.0002). In the second endoscopic assessment, the number of polyps found was also significantly higher in the G2 (50 or 76.9%) compared to the G1 (15 or 23.1%), p<0.0001. Conclusions: the second assessment with dye-based chromoendoscopy increases the detection of polyps in the ascending colon and cecum.

RESUMO Introdução: a colonoscopia é o melhor método para detecção de pólipos, com redução da mortalidade por câncer colorretal de 29% e chegando até 47% para tumores distais. No entanto, existe falha em demonstrar redução significativa na mortalidade no cólon proximal sendo o segmento mais comum de neoplasia de intervalo. O presente estudo avaliou o impacto na detecção de pólipos em uma segunda avaliação sequencial do ceco e cólon ascendente, com ou sem o uso de cromoendoscopia com Indigo carmim. Métodos: estudo prospectivo, não randomizado. Os pacientes foram divididos em dois grupos. O primeiro (G1) foi submetido à colonoscopia de rotina, seguida de segunda avaliação endoscópica do cólon ascendente e ceco. O segundo grupo (G2) foi submetido à colonoscopia de rotina, seguida de segunda avaliação do cólon ascendente e ceco com cromoendoscopia com índigo carmim. Resultados: no total, foram analisados 203 pacientes, sendo 101 do G1 e 102 do G2. Novos pólipos foram identificados em ambos os grupos após a segunda avaliação com número significativamente maior de pólipos detectados nos pacientes do G2 (p=0,0001). O número de pacientes que apresentaram pelo menos um pólipo nas duas avaliações endoscópicas foi significativamente maior no G2 (53 ou 52% vs 27 ou 26,7%, p=0,0002). Na segunda avaliação endoscópica, o número de pólipos encontrados também foi significativamente maior no G2 (50 ou 76,9%) em relação ao G1 (15 ou 23,1%), p<0,000. Conclusão: a segunda avaliação com cromoendoscopia com índigo carmim aumenta a detecção de pólipos no cólon ascendente e no ceco.

Assessing morbidity, mortality, and survival in patients with peritoneal carcinomatosis undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy / Avaliação da morbimortalidade e da sobrevida em pacientes portadores de carcinomatose peritoneal submetidos a cirurgia citorretorredutora e quimioterapia hipertérmica intraperitoneal (HIPEC)

ABSTRACT Peritoneal carcinomatosis (PC) indicates advanced stage cancer, which is generally associated with a poor outcome and a 6 to 12 months. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an option for treating patients with primary PC, such as mesothelioma, or secondary PC, such as colorectal cancer (CRC) or pseudomixoma. Until recently, such patients were deemed untreatable. Objective: The purpose of this study was to assess the results of CRS + HIPEC in patients with PC. Postoperative complications, mortality and survival rates were evaluated according to the diagnosis. Results: Fifty-six patients with PC, undergoing full CRS + HIPEC between October 2004 and January 2020, were enrolled. The mortality rate was 3.8% and the morbidity rate was 61.5%. Complications were significantly higher in proportion to the duration of surgery (p<0.001). The overall survival rates, as shown in the Kaplan-Meyer curve, were respectively 81%, 74% and 53% at 12, 24 and 60 months. Survival rates according to each diagnosis for the same periods were 87%, 82% and 47% in patients with pseudomixoma, and 77%, 72% and 57% in patients with CRC (log-rank 0.371, p=0.543). Conclusion: CRS with HIPEC is an option for pacients with primary or secondary PC. Although complication rates are high, a longer survival rate may be attained compared to those seen in previously published results; in some cases, patients may even be cured.

RESUMO O diagnóstico de carcinomatose peritoneal (CP), indica um estágio avançado do câncer e em geral está associado a um mau prognóstico com sobrevida média variando de 6 a 12 meses. A cirurgia citorredutora (CRS) associada à quimioterapia intraperitoneal hipertérmica (HIPEC) tem sido descrita como uma opção de tratamento para os pacientes portadores de CP primária como nos portadores de mesotelioma, ou secundária como em portadores de cancer colorretal ou pseudomixoma, até recentemente considerados sem possibilidade terapêutica. Objetivo: Avaliar os resultados do tratamento de pacientes portadores de CP submetidos a CRS + HIPEC. Foram analisadas as taxas complicações pós-operatórias, mortalidade e a sobrevida desses pacientes. Resultados: Foram incluídos 56 pacientes com CP, submetidos a c CRS + HIPEC, no período de Outubro 2004 a Janeiro 2020. A taxa de mortalidade foi de 3,8% e taxa de morbidade de 61,5%, sendo a ocorrência de complicações significativamente maior quanto maior o tempo cirúrgico (p<0,001). A sobrevida global pela curva de Kaplan-Meyer foi de 81%, 74% e 53% em 12, 24 e 60 meses respectivamente. Já a sobrevida por diagnóstico nos mesmos períodos foi de 87%, 82%, 47% para os pacientes portadores de pseudomixoma e de 77%, 72% e 57% para pacientes portadores de câncer colorretal (Log -RANK 0,371, p=0,543). Conclusão: A CRS + HIPEC é uma opção de tratamento para pacientes portadores de CP primária ou secundária. Embora com taxa de complicações elevadas, pode proporcionar aumento da sobrevida quando comparado com resultados prévios da literatura e em alguns casos até a cura.

Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision / Tratamento cirúrgico do câncer retal: estudo coorte prospectivo com bons resultados oncológicos e baixas taxas de amputação abdominoperineal

ABSTRACT Objectives: the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE). Methods: we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin. Results: sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239). Conclusion: rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.

RESUMO Objetivos: o objetivo deste estudo foi avaliar os resultados da cirurgia do câncer de reto, em uma unidade que adota os princípios da excisão total do mesorreto (ETM) com baixa taxa de amputação abdominoperineal (AAP). Métodos: os pacientes com câncer retal extraperitoneal foram submetidos a ETM ou ETM com amputação abdominoperianeal. Pacientes com tumores de reto médio foram submetidos a EMT e pacientes com tumores de reto inferior e sem critérios para AAP foram submetidos a EMT e ressecção interesfincteriana. Aqueles em que o espaço interesfincteriano foi invadido e naqueles com margem distal livre menor que 1cm ou margem radial livre de tumor foram inatingíveis foram submetidos a AAP ou excisão abdominoperineal extraelevadora (ELAPE). Avaliamos as taxas de recorrência local, sobrevida global e envolvimento da margem radial. Resultados: sessenta (89,6%) pacientes realizaram ETM e sete (10,4%) ETM + AAP, dos quais cinco realizaram ELAPE. A recidiva local, em pacientes submetidos a ETM com ressecção anterior baixa, foi de 3,3% e em pacientes submetidos a AAP, 14,3%. A taxa de recorrência local (p=0,286) ou a taxa de recorrência à distância (p=1,000) foi semelhante entre os grupos. Não houve envolvimento das margens radiais. A sobrevida após 120 meses foi semelhante (p=0,239). Conclusão: as neoplasias malignas retais, incluindo aquelas localizadas no reto baixo, podem ser tratadas cirurgicamente com baixo índice de AAP, sem comprometer os princípios oncológicos e com baixo índice de recorrência local.

Conditions associated with worse acceptance of a simplified accelerated recovery after surgery protocol in laparoscopic colorectal surgery.

BACKGROUND: Enhanced Recovery Surgical Programs were initially applied to colorectal procedures and used as multimodal approach to relieve the response to surgical stress. An important factor that negatively impacts the success of these programs is the poor tolerance of these patients to certain items in the adopted protocol, especially with regard to post-operative measures. The identification of these factors may help to increase the success rate of such programs, ensuring that benefits reach a greater number of patients and that resources are better allocated. Thus, the aims of this study were to assess the results of the implementation of a Simplified Accelerated Recovery Protocol (SARP) and to identify possible factors associated with failure to implement postoperative protocol measures in patients submitted to laparoscopic colorectal surgery. METHODS: 161 patients were randomly divided into two groups. The SARP group (n = 84) was submitted to the accelerated recovery program and the CC group (n = 77), to conventional postoperative care. The SARP group was further divided into two subgroups: patients who tolerated the protocol (n = 51) and those who did not (n = 33), in order to analyze factors contributing to protocol nontolerance. RESULTS: The groups had similar sociodemographic and clinical characteristics. The SARP group had a shorter hospital stay, better elimination of flatus, was able to walk and to tolerate a diet sooner (p < 0.0001). Complications rates and readmissions to emergency room were similar between groups. Multivariate analysis revealed that prolonged operating time, stoma creation and rates of surgical complications were independently associated with poor adherence to SARP (p < 0.0001). CONCLUSIONS: The use of our SARP resulted in improved recovery from laparoscopic colorectal surgery and proved to be safe for patients. Extensive surgeries, occurrence of complications, and the need for ostomy were variables associated with poor program adhesion. Trial registration Trial Registry: RBR2b4fyr-Date of registration: 03 October 2017.

Deep sequencing of small RNAs reveals the repertoire of miRNAs and piRNAs in Biomphalaria glabrata.

BACKGROUND: Biomphalaria glabrata snails are widely distributed in schistosomiasis endemic areas like America and Caribe, displaying high susceptibility to infection by Schistosoma mansoni. After the availability of B. glabrata genome and transcriptome data, studies focusing on genetic markers and small non-coding RNAs have become more relevant. The small RNAs have been considered important through their ability to finely regulate the gene expression in several organisms, thus controlling the functions like cell growth, metabolism, and susceptibility/resistance to infection. OBJECTIVE: The present study aims on identification and characterisation of the repertoire of small non-coding RNAs in B. glabrata (Bgl-small RNAs). METHODS: By using small RNA sequencing, bioinformatics tools and quantitative reverse transcription polymerase chain reaction (RT-qPCR), we identified, characterised, and validated the presence of small RNAs in B. glabrata. FINDINGS: 89 mature miRNAs were identified and five of them were classified as Mollusk-specific. When compared to model organisms, sequences of B. glabrata miRNAs showed a high degree of conservation. In addition, several target genes were predicted for all the mature miRNAs identified. Furthermore, piRNAs were identified in the genome of B. glabrata for the first time. The B. glabrata piRNAs showed strong conservation of uridine as first nucleotide at 5' end, besides adenine at 10th position. Our results showed that B. glabrata has diverse repertoire of circulating ncRNAs, several which might be involved in mollusk susceptibility to infection, due to their potential roles in the regulation of S. mansoni development. MAIN CONCLUSIONS: Further studies are necessary in order to confirm the role of the Bgl-small RNAs in the parasite/host relationship thus opening new perspectives on interference of small RNAs in the organism development and susceptibility to infection.

Genome-wide identification, characterisation and expression profiling of the ubiquitin-proteasome genes in Biomphalaria glabrata.

BACKGROUND: Biomphalaria glabrata is the major species used for the study of schistosomiasis-related parasite-host relationships, and understanding its gene regulation may aid in this endeavor. The ubiquitin-proteasome system (UPS) performs post-translational regulation in order to maintain cellular protein homeostasis and is related to several mechanisms, including immune responses. OBJECTIVE: The aims of this work were to identify and characterise the putative genes and proteins involved in UPS using bioinformatic tools and also their expression on different tissues of B. glabrata. METHODS: The putative genes and proteins of UPS in B. glabrata were predicted using BLASTp and as queries reference proteins from model organism. We characterised these putative proteins using PFAM and CDD software describing the conserved domains and active sites. The phylogenetic analysis was performed using ClustalX2 and MEGA5.2. Expression evaluation was performed from 12 snail tissues using RPKM. FINDINGS: 119 sequences involved in the UPS in B. glabrata were identified, which 86 have been related to the ubiquitination pathway and 33 to proteasome. In addition, the conserved domains found were associated with the ubiquitin family, UQ_con, HECT, U-box and proteasome. The main active sites were lysine and cysteine residues. Lysines are responsible and the starting point for the formation of polyubiquitin chains, while the cysteine residues of the enzymes are responsible for binding to ubiquitin. The phylogenetic analysis showed an organised distribution between the organisms and the clades of the sequences, corresponding to the tree of life of the animals, for all groups of sequences analysed. The ubiquitin sequence was the only one with a high expression profile found in all libraries, inferring its wide range of performance. MAIN CONCLUSIONS: Our results show the presence, conservation and expression profile of the UPS in this mollusk, providing a basis and new knowledge for other studies involving this system. Due to the importance of the UPS and B. glabrata, this work may influence the search for new methodologies for the control of schistosomiasis.

Genome-wide identification, characterisation and expression profiling of the ubiquitin-proteasome genes in Biomphalaria glabrata

BACKGROUND Biomphalaria glabrata is the major species used for the study of schistosomiasis-related parasite-host relationships, and understanding its gene regulation may aid in this endeavor. The ubiquitin-proteasome system (UPS) performs post-translational regulation in order to maintain cellular protein homeostasis and is related to several mechanisms, including immune responses. OBJECTIVE The aims of this work were to identify and characterise the putative genes and proteins involved in UPS using bioinformatic tools and also their expression on different tissues of B. glabrata. METHODS The putative genes and proteins of UPS in B. glabrata were predicted using BLASTp and as queries reference proteins from model organism. We characterised these putative proteins using PFAM and CDD software describing the conserved domains and active sites. The phylogenetic analysis was performed using ClustalX2 and MEGA5.2. Expression evaluation was performed from 12 snail tissues using RPKM. FINDINGS 119 sequences involved in the UPS in B. glabrata were identified, which 86 have been related to the ubiquitination pathway and 33 to proteasome. In addition, the conserved domains found were associated with the ubiquitin family, UQ_con, HECT, U-box and proteasome. The main active sites were lysine and cysteine residues. Lysines are responsible and the starting point for the formation of polyubiquitin chains, while the cysteine residues of the enzymes are responsible for binding to ubiquitin. The phylogenetic analysis showed an organised distribution between the organisms and the clades of the sequences, corresponding to the tree of life of the animals, for all groups of sequences analysed. The ubiquitin sequence was the only one with a high expression profile found in all libraries, inferring its wide range of performance. MAIN CONCLUSIONS Our results show the presence, conservation and expression profile of the UPS in this mollusk, providing a basis and new knowledge for other studies involving this system. Due to the importance of the UPS and B. glabrata, this work may influence the search for new methodologies for the control of schistosomiasis.

Double blinded randomized clinical trial to assess the effectiveness of several preparations for colonoscopy / Ensaio clínico randomizado duplo cego para avaliar a eficácia de várias preparações para colonoscopia

ABSTRACT Introduction: Colonoscopy is the screening gold standard to investigate several conditions in the colon. The excellence of preparation is a determining factor for a quality colonoscopy. Objective: Compare the quality of colon preparations for colonoscopy with different kinds of laxative medications in a public hospital of Belo Horizonte, Brazil. Method: A prospective double blind randomized clinical trial was conducted from June 2016 to March 2017. A total of 117 Patients were randomised in four groups to receive a type of preparation (Sodium picosulfate, Mannitol, Lactitol, Lactulose). The patients answered a questionnaire and peripheral blood samples were collected before and after the preparation.The quality of the cleansing was accessed according to the Boston Bowel Preparation Scale. Results: 99.1% of patients have taken the recommended dose and 79.5% reported a good tolerability. Endoscopists performed complete colonoscopy in 89.7%, with an polipectomy rate of 47%. The total effectiveness rate of the solutions were 88%. There were no statistically significant differences between groups (p = 0.271). Regarding the laboratory parameters, differences were seen in the pre- and post-test values of sodium, chlorine and creatinine but without exceeding reference values. Conclusion: The four preparations were effective for colon cleansing, with good acceptance, differing only as for costs.

RESUMO Introdução: a colonoscopia é o padrão ouro de triagem para pesquisa de várias doenças colônicas. A excelência de preparação é um fator determinante para uma colonoscopia de qualidade. Objetivo: Comparar a qualidade das preparações do cólon para colonoscopia com diferentes tipos de medicamentos laxantes em um hospital público de Belo Horizonte, Brasil. Método: Foi realizado um ensaio clínico randomizado duplo cego prospectivo de junho de 2016 a março de 2017. Um total de 117 pacientes foi randomizado em quatro grupos para receber um tipo de preparação (picossulfato sódico, manitol, lacticol, lactulose). Os pacientes responderam a um questionário e amostras de sangue periférico foram coletadas antes e depois da preparação. A qualidade da limpeza foi acessada de acordo com a Boston Bowel Preparation Scale. Resultados: 99,1% dos pacientes tomaram a dose recomendada e 79,5% relataram boa tolerabilidade. Os endoscopistas realizaram colonoscopia completa em 89,7%, com taxa de polipectomia de 47%. A taxa de eficácia total das soluções foi de 88%. Não houve diferenças estatisticamente significantes entre os grupos (p = 0,271). Em relação aos parâmetros laboratoriais, foram observadas diferenças nos valores pré e pós-teste de sódio, cloro e creatinina, mas sem exceder os valores de referência. Conclusão: As quatro preparações foram eficazes para limpeza do cólon, com boa aceitação, diferindo apenas quanto aos custos.

The applicability of POSSUM and P-POSSUM scores as predictors of morbidity and mortality in colorectal surgery.

OBJECTIVE: to apply the POSSUM and P-POSSUM scores as a tool to predict morbidity and mortality in colorectal surgery. METHODS: we conducted a prospective cohort study of 551 patients submitted to colorectal surgery in a colorectal surgery tertiary referral hospital in Brazil. We grouped patients into pre-established risk categories for comparison between expected and observed morbidity and mortality rates by the POSSUM and P-POSSUM scores. RESULTS: in the POSSUM morbidity analysis, the overall expected morbidity was significantly higher than that observed (39.2% vs. 15.6%). The same occurred with patients grouped in categories II (28.9% x 10.5) and III (64.6% x 24.5%). In category I, the expected and observed morbidities were similar (13.7% x 9.1%). Regarding the evaluation of mortality, it was statistically higher than that observed in category III patients and in the total number of patients (11.3% vs. 5.6%). In categories I and II, we observed the same pattern of category III, but without statistical significance. When evaluating mortality by the P-POSSUM score, the overall expected and observed mortality was similar (5.8% x 5.6%). Of the 31 patients who died, 20.2% underwent emergency procedures and sepsis was the main cause of death. CONCLUSION: the P-POSSUM score was an accurate tool to predict mortality and could be safely used in this population profile, unlike the POSSUM score.

Avaliação da tolerância a protocolo de recuperação pós-operatória acelerada em pacientes submetidos à cirurgia colorretal laparoscópica: estudo prospectivo e randomizado / Assessment of tolerance to accelerated postoperative recovery protocol in patients undergoing laparoscopic colorectal surgery: prospective and randomized study

O pós-operatório das operações colorretais tem morbi-mortalidade elevada, trazendo desconforto e, por vezes, sofrimento para os pacientes e familiares. Até recentemente, a maioria das medidas adotadas nos períodos pré, per e pós-operatório, tinham bases empíricas. O desenvolvimento do conceito de recuperação pós-operatória acelerada, Enhanced Recovery After Surgery, ("ERAS") é baseado na premissa de que, adotar protocolo com medidas cientificamente comprovadas, traz benefícios aos pacientes, permitindo recuperação mais rápida. O sucesso da implantação desses protocolos depende da adesão e da tolerância dos pacientes, sendo que a intolerância ocorre por motivos diversos e multifatoriais. Objetivo: avaliar a taxa de insucesso na implantação de protocolo simplificado de recuperação acelerada em pacientes submetidos a cirurgia colorretal por acesso laparoscópico e os possíveis motivos de não aceitação. Método: Foram avaliados e comparados de forma randomizada,161pacientes divididos em 2 grupos, o G1 (n=84) submetido ao protocolo de recuperação acelerada e o grupo G2 (n=77) que recebeu cuidados pós-operatórios convencionais. Os pacientes do G1 foram subdivididos em 2 subgrupos de pacientes que toleraram (n=51) ou não (n=33) o protocolo ERAS, sendo comparados entre si em relação a possíveis variáveis que pudessem influenciar na aceitação ou não do protocolo. Resultados: Noventa e seis pacientes eram do sexo feminino (59%). A idade variou de 25 a 95 anos, com média de 57,4 ± 12,6 anos. O IMC variou de 18,0 a 51,0 kg/m2 com mediana (Q1;Q3) 25,5kg/m2 (22,8;28,2kg/m2). Os dois grupos foram semelhantes em relação às características sociodemográficas e clínicas. Os pacientes do G1 apresentaram menor período de internação, eliminaram flatos, deambularam e toleraram a dieta mais precocemente (p<0, 0001). A taxa de tolerância ao protocolo de recuperação acelerada foi de 60%. Na análise multivariada dos subgrupos que toleraram ou não o protocolo, observou-se que o tempo cirúrgico prolongado, a confecção de estomia e a ocorrência de complicações foram variáveis que comprometeram a aceitação do mesmo (p<0,0001). Conclusões: O protocolo simplificado de recuperação pós-operatória acelerada é capaz de melhorar a recuperação de pacientes submetidos a operação colorretal laparoscópica, sendo que sua utilização pode não ser tolerada por parcela significativa de pacientes. A adoção de medidas que possam aumentar as taxas de sucesso desses protocolos poderia torná-los mais efetivos, reduzindo as consequências deletérias das alterações fisiológicas decorrentes das cirurgias colorretais.

Colorectal surgeries are associated with increased postoperative morbimortality, causing discomfort and even suffering for patients and relatives. Until recently, the majority of the adopted measures during the pre, per, and postoperative periods were empirical. The Enhanced Recovery After Surgery (ERAS) program development is based on the premise that adopting a protocol with scientifically proven measures brings benefits to patients, allowing a faster recovery. The success of its implementation depends on patient adherence and tolerance, and intolerance can be related to several and multifactorial reasons. Objective: to assess the insuccess rate of implantation of a simplified Enhanced Recovery After Surgery Program (SERSP) protocol in patients undergoing laparoscopic colorectal surgery and the possible reasons for its non-acceptance. Method: 161 patients were randomly divided into 2 groups G1 (n = 84) submitted to the SERSP protocol and G2 group (n = 77) who received conventional postoperative care. Groups were assessed and compared with respect to factors that could affect ERAS tolerance. The G1 patients were subdivided into 2 subgroups of patients who tolerated (n = 51) or not (n = 33) the SERSP protocol, being compared to each other in relation to possible variables that could influence protocol acceptance. Results: There were 96 females (59%) and the mean age was 57.4(± 12.6 years ranging from 25 to 96 years old). The BMI ranged from 18.0 to 51.0 kg / m2 with median (Q1; Q3) 25.5kg / m2 (22.8; 28.2kg / m2). Groups were similar with respect to socio-demographic and clinical characteristics. Group 1 patients had significantly shorter length of stay, and eliminated flatus, wandered and tolerated the diet earlier (p <0.0001). The rate of tolerance to the accelerated recovery protocol was 60%.In the comparative analysis of the subgroups that accepted or not the SERSP protocol, it was observed that the prolonged surgical time, ostomy preparation and the occurrence of complications were variables that compromised the acceptance of SERSP (p <0.0001). Conclusions: The accelerated postoperative recovery protocol is capable of improving the recovery of patients undergoing laparoscopic colorectal surgery, but its use may not be tolerated by a significant number of patients. Adopting measures that can increase the success rates of these protocols could make them more effective.

Results of surgical treatment of colorectal cancer in nonagenarian patients / Resultados do tratamento cirúrgico do câncer colorretal em pacientes nonagenários

ABSTRACT Purpose: The objective of the present study was to compare the results of surgical treatment of nonagenarian patients having colorectal cancer with patients younger than 90 years. Methods: A total of 622 patients who underwent curative surgery were included in the present study. The database of the surgical service, in the period from 2007 to 2013, was used to obtain the sample. This is a descriptive, retrospective study that compared the profiles of 17 nonagenarian patients (Group I) with 605 patients younger than 90 years (Group II). The groups were compared regarding surgical complications, length of hospital stay, type of surgery performed and ASA classification. Results: The mean age between the groups was 92.2 years and 61.2 years. The mean length of hospital stay in Groups I and II was 17.3 days and 8.75 days, respectively. The surgery performed most frequently was the right colectomy, in both groups. The most common postoperative complication was sepsis (11.8%) among the nonagenarians, and paralytic ileus (4.5%) among those younger than 90 years. Laparoscopic surgery was performed on 5 out of a total of 17 patients evaluated in Group I. Among the three mortalities registered in this latter group, two were classified as ASA III and only one as ASA I. Conclusion: The results indicate that colorectal surgery may be performed in this group, with acceptable morbidity and mortality rates, in patients with low preoperative risk (ASA I/II).

RESUMO Finalidade: O objetivo do presente estudo foi comparar os resultados do tratamento cirúrgico de pacientes nonagenários portadores de câncer colorretal versus pacientes com menos de 90 anos. Métodos: O estudo envolveu 622 pacientes que foram submetidos à cirurgia curativa. Para obtenção da amostra, utilizamos o banco de dados do serviço de cirurgia, abrangendo o período de 2007-2013. Este é um estudo retrospectivo descritivo que comparou os perfis de 17 pacientes nonagenários (Grupo I) versus 605 pacientes com menos de 90 anos (Grupo II). Os grupos foram comparados para complicações cirúrgicas, duração da permanência no hospital, tipo de cirurgia realizada e classificação ASA. Resultados: A média de idade para os Grupos I e II foi, respectivamente, 92,2 e 61,2 anos. A duração média de permanência no hospital nos Grupos I e II foi, respectivamente, 17,3 dias e 8,75 dias. A cirurgia mais frequentemente realizada foi colectomia direita, nos dois grupos. A complicação pós-operatória mais comum foi sepse (11,8%) entre os nonagenários, e íleo paralítico (4.5%) entre os pacientes com menos de 90 anos. Cirurgia laparoscópica foi realizada em 5 pacientes, em um total de 17 pacientes avaliados no Grupo I. Considerando as três mortalidades registradas nesse último grupo, duas foram classificadas como ASA III e apenas uma como ASA I. Conclusão: Os resultados obtidos indicam que, nesse grupo, a cirurgia colorretal é opção válida, com percentuais aceitáveis de morbidade e mortalidade, em pacientes com baixo risco pré-operatório (ASA I/II).

Differential expression of small RNA pathway genes associated with the Biomphalaria glabrata/Schistosoma mansoni interaction.

The World Health Organization (WHO) estimates that approximately 240 million people in 78 countries require treatment for schistosomiasis, an endemic disease caused by trematodes of the genus Schistosoma. In Brazil, Schistosoma mansoni is the only species representative of the genus whose passage through an invertebrate host, snails of the genus Biomphalaria, is obligatory before infecting a mammalian host, including humans. The availability of the genome and transcriptome of B. glabrata makes studying the regulation of gene expression, particularly the regulation of miRNA and piRNA processing pathway genes, possible. This might assist in better understanding the biology of B. glabrata as well as its relationship to the parasite S. mansoni. Some aspects of this interaction are still poorly explored, including the participation of non-coding small RNAs, such as miRNAs and piRNAs, with lengths varying from 18 to 30 nucleotides in mature form, which are potent regulators of gene expression. Using bioinformatics tools and quantitative PCR, we characterized and validated the miRNA and piRNA processing pathway genes in B. glabrata. In silico analyses showed that genes involved in miRNA and piRNA pathways were highly conserved in protein domain distribution, catalytic site residue conservation and phylogenetic analysis. Our study showed differential expression of putative Argonaute, Drosha, Piwi, Exportin-5 and Tudor genes at different snail developmental stages and during infection with S. mansoni, suggesting that the machinery is required for miRNA and piRNA processing in B. glabrata at all stages. These data suggested that the silencing pathway mediated by miRNAs and piRNAs can interfere in snail biology throughout the life cycle of the snail, thereby influencing the B. glabrata/S. mansoni interaction. Further studies are needed to confirm the participation of the small RNA processing pathway proteins in the parasite/host relationship, mainly the effective participation of small RNAs in regulating their target genes.

Comparative sequence analysis reveals regulation of genes in developing schistosomula of Schistosoma mansoni exposed to host portal serum.

Once inside a vertebrate host after infection, individual schistosomula of the parasite Schistosoma mansoni find a new and complex environment, which requires quick adjustments for survival, such as those that allow it to avoid the innate immune response of the host. Thus, it is very important for the parasite to remain within the skin after entering the host for a period of about 3 days, at which time it can then reach the venous system, migrate to the lungs and, by the end of eighth day post-infection, it reach the portal venous system, while undergoing minimal changes in morphology. However, after just a few days in the portal blood system, the parasite experiences an extraordinary increase in biomass and significant morphological alterations. Therefore, determining the constituents of the portal venous system that may trigger these changes that causes the parasite to consolidate its development inside the vertebrate host, thus causing the disease schistosomiasis, is essential. The present work simulated the conditions found in the portal venous system of the vertebrate host by exposing schistosomula of S. mansoni to in vitro culture in the presence of portal serum of the hamster, Mesocricetus auratus. Two different incubation periods were evaluated, one of 3 hours and one of 12 hours. These time periods were used to mimic the early contact of the parasite with portal serum during the course of natural infection. As a control, parasites were incubated in presence of hamster peripheral serum, in order to compare gene expression signatures between the two conditions. The mRNA obtained from parasites cultured under both conditions were submitted to a whole transcriptome library preparation and sequenced with a next generation platform. On average, nearly 15 million reads were produced per sample and, for the purpose of gene expression quantification, only reads mapped to one location of the transcriptome were considered. After statistical analysis, we found 103 genes differentially expressed by schistosomula cultured for 3 hours and 12 hours in the presence of hamster portal serum. After the subtraction of a second list of genes, also differentially expressed between schistosomula cultured for 3 hours and 12 hours in presence of peripheral serum, a set of 58 genes was finally established. This pattern was further validated for a subset of 17 genes, by measuring gene expression through quantitative real time polymerase chain reaction (qPCR). Processes that were activated by the portal serum stimulus include response to stress, membrane transport, protein synthesis and folding/degradation, signaling, cytoskeleton arrangement, cell adhesion and nucleotide synthesis. Additionally, a smaller number of genes down-regulated under the same condition act on cholinergic signaling, inorganic cation and organic anion membrane transport, cell adhesion and cytoskeleton arrangement. Considering the role of these genes in triggering processes that allow the parasite to quickly adapt, escape the immune response of the host and start maturation into an adult worm after contact with the portal serum, this work may point to unexplored molecular targets for drug discovery and vaccine development against schistosomiasis.