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Sleep debt accumulates during wakefulness, leading to increased slow wave activity (SWA) during sleep, an encephalographic marker for sleep need. The use-dependent demands of prior wakefulness increase sleep SWA locally. However, the circuitry and molecular identity of this "local sleep" remain unclear. Using pharmacology and optogenetic perturbations together with transcriptomics, we find that cortical brain-derived neurotrophic factor (BDNF) regulates SWA via the activation of tyrosine kinase B (TrkB) receptor and cAMP-response element-binding protein (CREB). We map BDNF/TrkB-induced sleep SWA to layer 5 (L5) pyramidal neurons of the cortex, independent of neuronal firing per se. Using mathematical modeling, we here propose a model of how BDNF's effects on synaptic strength can increase SWA in ways not achieved through increased firing alone. Proteomic analysis further reveals that TrkB activation enriches ubiquitin and proteasome subunits. Together, our study reveals that local SWA control is mediated by BDNF-TrkB-CREB signaling in L5 excitatory cortical neurons., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: This in vitro study aimed to assess the impact of incorporating calcium glycerophosphate (CaGP) and sodium fluoride (NaF) in addition to 35% hydrogen peroxide concerning the enamel mechanical and morphological properties., Methods: Specimens of bovine enamel were chosen based on their initial surface hardness (SHi) and subsequently divided into five gel groups (n=12): 1) 35% Hydrogen Peroxide (HP) Gel; 2) HP + 0.1% NaF Gel (HP/NaF); 3) HP + 0.25% CaGP Gel (HP/CaGP); 4) HP + 0.1% NaF + 0.25% CaGP Gel (HP/NaF/CaGP) and 5) HP Blue 35% Gel (HP Blue). The bleaching gels were applied thrice, for 40 min, at intervals of 7 days each. After 21 days, the final surface hardness (SHf), integrated hardness (IH), Polydispersity Index (PdI) and Zeta Potential (Zp), surface roughness (Ra, after and before), and surface/structural analysis by Scanning Electron Microscopy (SEM) were determined. The data were submitted to ANOVA (one-way and two-way) followed by the Student-Newman-Keuls test (α=0.05)., Results: The addition of NaF to HP reduced demineralization by 11.5% in relation to HP (p<0.05). The NaF/CaGP association reduction is 22.8 and 20% higher in comparison to HP/NaF/CaGP and HP Blue, respectively. The IH when the PH/NaF/CaGP bleaching gel was applied, was 14% higher compared to HP and HP Blue groups., Conclusions: It can be concluded that the association of NaF and CaGP with the 35% hydrogen peroxide gel (HP/NaF/CaGP) significantly changed tooth enamel demineralization in terms of surface, depth, roughness, and enamel morphology., (©Operative Dentistry, 2024.)

Percutaneous closure of the left atrial appendage may be indicated in patients with contraindications to anticoagulation therapy, for example, after recurrent gastrointestinal bleeding. It is an effective and safe procedure but is not without complications. We present a patient who presented with severe aortic insufficiency due to migration of the left atrial appendage closure device, which required urgent cardiac surgery for its removal., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Covalent DNA-protein cross-links (DPCs) are toxic DNA lesions that block replication and require repair by multiple pathways. Whether transcription blockage contributes to the toxicity of DPCs and how cells respond when RNA polymerases stall at DPCs is unknown. Here we find that DPC formation arrests transcription and induces ubiquitylation and degradation of RNA polymerase II. Using genetic screens and a method for the genome-wide mapping of DNA-protein adducts, DPC sequencing, we discover that Cockayne syndrome (CS) proteins CSB and CSA provide resistance to DPC-inducing agents by promoting DPC repair in actively transcribed genes. Consequently, CSB- or CSA-deficient cells fail to efficiently restart transcription after induction of DPCs. In contrast, nucleotide excision repair factors that act downstream of CSB and CSA at ultraviolet light-induced DNA lesions are dispensable. Our study describes a transcription-coupled DPC repair pathway and suggests that defects in this pathway may contribute to the unique neurological features of CS., (© 2024. The Author(s).)

Introduction and Purpose: Bicuspid aortic valve (BAV) disease is associated with faster aortic valve degeneration and a high incidence of aortic stenosis (AS). In this study, we aimed to identify differences in the pathophysiology of AS between BAV and tricuspid aortic valve (TAV) patients in a multiomics study integrating metabolomics and transcriptomics as well as clinical data., Methods: Eighteen patients underwent aortic valve replacement due to severe aortic stenosis: 8 of them had a TAV, while 10 of them had a BAV. RNA sequencing (RNA-seq) and proton nuclear magnetic resonance spectroscopy (1H-NMR) were performed on these tissue samples to obtain the RNA profile and lipid and low-molecular-weight metabolites. These results combined with clinical data were posteriorly compared, and a multiomic profile specific to AS in BAV disease was obtained., Results: H-NMR results showed that BAV patients with AS had different metabolic profiles than TAV patients. RNA-seq also showed differential RNA expression between the groups. Functional analysis helped connect this RNA pattern to mitochondrial dysfunction. Integration of RNA-seq, 1H-NMR and clinical data helped create a multiomic profile that suggested that mitochondrial dysfunction and oxidative stress are key players in the pathophysiology of AS in BAV disease., Conclusions: The pathophysiology of AS in BAV disease differs from patients with a TAV and has a specific RNA and metabolic profile. This profile was associated with mitochondrial dysfunction and increased oxidative stress.

A defining property of circadian clocks is temperature compensation, characterized by the resilience of their near 24-hour free-running periods against changes in environmental temperature within the physiological range. While temperature compensation is evolutionary conserved across different taxa of life and has been studied within many model organisms, its molecular underpinnings remain elusive. Posttranscriptional regulations such as temperature-sensitive alternative splicing or phosphorylation have been described as underlying reactions. Here, we show that knockdown of cleavage and polyadenylation specificity factor subunit 6 (CPSF6), a key regulator of 3'-end cleavage and polyadenylation, significantly alters circadian temperature compensation in human U-2 OS cells. We apply a combination of 3'-end-RNA-seq and mass spectrometry-based proteomics to globally quantify changes in 3' UTR length as well as gene and protein expression between wild-type and CPSF6 knockdown cells and their dependency on temperature. Since changes in temperature compensation behavior should be reflected in alterations of temperature responses within one or all of the 3 regulatory layers, we statistically assess differential responses upon changes in ambient temperature between wild-type and CPSF6 knockdown cells. By this means, we reveal candidate genes underlying circadian temperature compensation, including eukaryotic translation initiation factor 2 subunit 1 (EIF2S1)., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Schmal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

SNAIL is a key transcriptional regulator in embryonic development and cancer. Its effects in physiology and disease are believed to be linked to its role as a master regulator of epithelial-to-mesenchymal transition (EMT). Here, we report EMT-independent oncogenic SNAIL functions in cancer. Using genetic models, we systematically interrogated SNAIL effects in various oncogenic backgrounds and tissue types. SNAIL-related phenotypes displayed remarkable tissue- and genetic context-dependencies, ranging from protective effects as observed in KRAS- or WNT-driven intestinal cancers, to dramatic acceleration of tumorigenesis, as shown in KRAS-induced pancreatic cancer. Unexpectedly, SNAIL-driven oncogenesis was not associated with E-cadherin downregulation or induction of an overt EMT program. Instead, we show that SNAIL induces bypass of senescence and cell cycle progression through p16 INK4A -independent inactivation of the Retinoblastoma (RB)-restriction checkpoint. Collectively, our work identifies non-canonical EMT-independent functions of SNAIL and unravel its complex context-dependent role in cancer., (© 2023. The Author(s).)

Aim: Integrated total pelvic floor ultrasound (TPFUS) may provide an alternative to defaecation proctography (DP) in decision making and treatment planning for patients with pelvic floor defaecatory dysfunction (PFDD). This study evaluates the use of TPUS as a screening tool, and its likelihood to predict long-term treatment outcomes., Methods: Two blinded clinicians reviewed 100 women who had historically presented to a tertiary referral colorectal unit with PFDD from October 2014 to April 2015. The clinical history of the patients together with TPFUS or DP results were used to decide on main impression, treatment plan, likelihood of surgery and certainty of plan. These were compared to the actual treatment received six months later and again after a median follow-up of 68 months (range 48-84)., Results: A total of 82 patients were treated with biofeedback only and 18 also underwent surgery. There were no complications in any of the patients who had surgery. When compared with the actual treatment received, 99 of the 100 of the TPFUS group would have been treated appropriately. The number of false positives for surgical treatment was lower with TPFUS compared to DP. Clinician confidence in the overall decision was significantly higher after review with DP., Conclusions: TPFUS is a reliable assessment tool for PFDD. It can identify patients who can go straight to biofeedback and is just as good as DP at predicting likelihood of surgery. We might be able to rely on TPFUS more significantly in the future, even for surgical planning., (© 2022 Wiley Periodicals LLC.)

Purpose: Rectocele can be associated with both obstructed defecation and fecal incontinence. There exists a great variety of operative techniques to treat patients with rectocele. The purpose of this study was to evaluate the clinical outcome in a consecutive series of patients who underwent transperineal repair of rectocele when presenting with fecal incontinence as the predominant symptom., Methods: Twenty-three consecutive patients from April 2000 to July 2015 with symptomatic rectocele underwent transperineal repair by a single surgeon., Results: All patients had a history of vaginal delivery, with or without evidence of associated anal sphincter injury at the time. The median age of the cohort was 53 years (range, 21-90 years). None were fully continent preoperatively. However, continence improved to just rare mucus soiling or loss of flatus in all patients 6 months after their surgery. There was no operative mortality. Postoperative complications including urinary retention and wound dehiscence occurred in 3 patients., Conclusion: Fecal incontinence associated with rectocele is multifactorial and may be caused by preexisting anal sphincteric damage and attenuation. Our experience suggests that transperineal repair provides excellent anatomic and physiologic results with minimal morbidity in selected patients presenting with combined rectocele and anal sphincter defect.

We introduce Metis, a new plugin for the Perseus software aimed at analyzing quantitative multi-omics data based on metabolic pathways. Data from different omics types are connected through reactions of a genome-scale metabolic-pathway reconstruction. Metabolite concentrations connect through the reactants, while transcript, protein, and protein post-translational modification (PTM) data are associated through the enzymes catalyzing the reactions. Supported experimental designs include static comparative studies and time-series data. As an example for the latter, we combine circadian mouse liver multi-omics data and study the contribution of cycles of phosphoproteome and metabolome to enzyme activity regulation. Our analysis resulted in 52 pairs of cycling phosphosites and metabolites connected through a reaction. The time lags between phosphorylation and metabolite peak show non-uniform behavior, indicating a major contribution of phosphorylation in the modulation of enzymatic activity., Competing Interests: The authors declare no competing interests., (© 2022 The Author(s).)

KRAS-mutant pancreatic ductal adenocarcinoma (PDAC) is highly immunosuppressive and resistant to targeted and immunotherapies. Among the different PDAC subtypes, basal-like mesenchymal PDAC, which is driven by allelic imbalance, increased gene dosage and subsequent high expression levels of oncogenic KRAS, shows the most aggressive phenotype and strongest therapy resistance. In the present study, we performed a systematic high-throughput combination drug screen and identified a synergistic interaction between the MEK inhibitor trametinib and the multi-kinase inhibitor nintedanib, which targets KRAS-directed oncogenic signaling in mesenchymal PDAC. This combination treatment induces cell-cycle arrest and cell death, and initiates a context-dependent remodeling of the immunosuppressive cancer cell secretome. Using a combination of single-cell RNA-sequencing, CRISPR screens and immunophenotyping, we show that this combination therapy promotes intratumor infiltration of cytotoxic and effector T cells, which sensitizes mesenchymal PDAC to PD-L1 immune checkpoint inhibition. Overall, our results open new avenues to target this aggressive and therapy-refractory mesenchymal PDAC subtype., (© 2022. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Background: Lateral internal sphincterotomy (LIS) remains the gold standard surgical approach for the management of chronic anal fissures (CAF). The procedure however, is complicated by the risk of postoperative incontinence. Intrasphincteric Botulinum Toxin (BT) has gained popularity as an alternative approach, despite being inferior to LIS with regards to cure rates. In the real world, patients at high risk for postoperative incontinence are likely to be offered BT as a preliminary procedure. The aim of this study was to explore the real-world outcomes of LIS and BT for a cohort of CAF patients., Methods: 251 consecutive patients treated with either BT or LS for CAF by a single surgeon were reviewed. Patients were offered BT as a preliminary procedure if they had risk factors for faecal incontinence, whereas all other patients underwent LIS. Primary outcomes included rates of recurrence and faecal incontinence., Results: LIS was superior to BT with regards to recurrence rates throughout the mean follow up period of five years (5% vs 15%, p = 0.012). A total of 17 patients experienced a minor degree of flatal incontinence at the 6-week follow up, although there was no difference between LIS and BT (7% vs 6%, p = 1.000). Four LIS patients (2%) continued to experience some minor incontinence to flatus at the 12-month follow up and were managed with biofeedback., Conclusion: For patients with CAF, individualizing the treatment approach according to risk factors for incontinence could mitigate this risk in LIS. High risk patients should be offered BT as a preliminary procedure., (Copyright © 2021. Published by Elsevier Taiwan LLC.)

Biliary tract cancer ranks among the most lethal human malignancies, representing an unmet clinical need. Its abysmal prognosis is tied to an increasing incidence and a fundamental lack of mechanistic knowledge regarding the molecular basis of the disease. Here, we show that the Pdx1-positive extrahepatic biliary epithelium is highly susceptible toward transformation by activated PIK3CAH1047R but refractory to oncogenic KrasG12D. Using genome-wide transposon screens and genetic loss-of-function experiments, we discover context-dependent genetic interactions that drive extrahepatic cholangiocarcinoma (ECC) and show that PI3K signaling output strength and repression of the tumor suppressor p27Kip1 are critical context-specific determinants of tumor formation. This contrasts with the pancreas, where oncogenic Kras in concert with p53 loss is a key cancer driver. Notably, inactivation of p27Kip1 permits KrasG12D-driven ECC development. These studies provide a mechanistic link between PI3K signaling, tissue-specific tumor suppressor barriers, and ECC pathogenesis, and present a novel genetic model of autochthonous ECC and genes driving this highly lethal tumor subtype., Significance: We used the first genetically engineered mouse model for extrahepatic bile duct carcinoma to identify cancer genes by genome-wide transposon-based mutagenesis screening. Thereby, we show that PI3K signaling output strength and p27Kip1 function are critical determinants for context-specific ECC formation. This article is highlighted in the In This Issue feature, p. 2945., (©2021 The Authors; Published by the American Association for Cancer Research.)

Purpose: Selection of an open or minimally invasive approach to total mesorectal excision (TME) is generally based on surgeon preference and an intuitive assessment of patient characteristics but there consensus on criteria to predict surgical difficulty. Pelvimetry has been used to predict the difficult surgical pelvis, typically using only bony landmarks. This study aimed to assess the relationship between pelvic soft tissue measurements on preoperative MRI and surgical difficulty., Methods: Preoperative MRIs for patients undergoing laparoscopic rectal resection in the Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT) were retrospectively reviewed by two blinded surgeons and pelvimetric variables measured. Pelvimetric variables were analyzed for predictors of successful resection of the rectal cancer, defined by clear circumferential and distal resection margins and completeness of TME., Results: There was no association between successful surgery and any measurement of distance, area, or ratio. However, the was a strong association between the primary outcome and the estimated total pelvic volume on adjusted logistic regression analysis (OR = 0.99, P = 0.01). For each cubic centimeter increase in the pelvic volume, there was a 1% decrease in the odds of successful laparoscopic rectal cancer surgery. Intuitive prediction of unsuccessful surgery was correct in 43% of cases, and correlation between surgeons was poor (ICC = 0.18)., Conclusions: A surgeon's intuitive assessment of the difficult pelvis, based on visible MRI assessment, is not a reliable predictor of successful laparoscopic surgery. Further assessment of pelvic volume may provide an objective method of defining the difficult surgical pelvis., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Chylous ascites (CA) is the uncommon extravasation of triglyceride-rich fluid into the abdominal cavity as a result of the disruption of the abdominal lymphatic system. A patient who had previously undergone a subtotal colectomy presented with a closed-loop small bowel obstruction (SBO), underwent an emergency laparotomy with adhesiolysis and had intra-operative findings of milky intra-abdominal free fluid confirmed on analysis as CA. His post-operative period was complicated by a prolonged ileus, and following resolution, he was subsequently discharged home. Here, we present a case of a closed-loop SBO in which CA may be an indicator of intestinal viability., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2021.)

Background: The pursuit of better management for haemorrhoidal disease (HD) is far from over, and even with the latest surgical procedures, none of the treatment options is close to perfect. The aims of this study were to review our experience with patients treated for symptomatic HD, compare the different treatment strategies in terms of complication and recurrence rates and determine predictors of recurrence., Methods: A total of 1958 patients who underwent a procedure for HD performed by a single colorectal consultant surgeon between 2000 and 2015 were reviewed., Results: The treatment performed was rubber band ligation (RBL) in 73%, excisional haemorrhoidectomy (EH) in 16% and stapled haemorrhoidopexy (SH) in 11%. After a mean follow-up of 42.1 months, 242 patients (12%) developed recurrence. Logistic regression analysis of multiple factors showed that treatment received was a significant predictor of recurrence. RBL had the lowest post-operative complication rate but had the highest recurrence rate. EH had the lowest recurrence rate. SH had the highest complication rate but with similar recurrence rates to EH. Complications included pain, anal fissure, bleeding and urinary retention., Conclusion: Low-grade HD can initially be treated with RBL with good results. Although conventional EH remains a mainstay operation for recurrent and complicated HD, SH can also be considered in selected cases particularly when performed by a surgeon with adequate experience. Treatment should be tailored to the individual based on patient preference, suitability, degree of haemorrhoids and symptomatology., (© 2021 Royal Australasian College of Surgeons.)

Background: Colorectal cancer (CRC) is one of the most commonly diagnosed malignancies globally; however, a survival paradox has been observed unique to this malignancy. The aim of this study was to review survival outcomes of patients diagnosed with stage II and stage III rectal cancer, to determine whether a survival paradox is present in our centre and assess for patient-related factors that can explain the observed paradox or were predictors of prognosis., Methods: A retrospective review of data collected from 2006 to 2018 of patients diagnosed with rectal cancer in three separate centres was conducted. Percentages pertaining to patient and tumour characteristics, presentation, management and subsequent recurrence were reported. Preoperative and postoperative factors associated with survival were determined using univariable and multivariable logistic regression analysis., Results: Stage IIB/C patients had significantly higher carcinoembryonic antigen (CEA) levels compared to stage IIA and stage IIIA patients (P < 0.001). Stage IIB/C patients had significantly larger primary rectal tumour and were more symptomatic (i.e. rectal bleeding, altered bowel habits and obstruction) at the time of diagnosis (P = 0.007). Preoperative CEA was an independent prognostic factor for cancer-specific survival in patients diagnosed with stage IIB/C and stage IIIA disease (P = 0.008) on multivariable analysis. Overall survival was greatest in stage IIIA disease, which was significantly greater than stage IIB/C disease., Conclusion: This study confirms the existence of a survival paradox in patients diagnosed with CRC in an Australian tertiary centre and adds further weight to the revision of the TNM staging to provide more emphasis on the T stage., (© 2021 Royal Australasian College of Surgeons.)

Background: Gastroschisis is often complicated by fetal growth restriction, preterm delivery, and prolonged neonatal hospitalization. Prenatal management and delivery decisions are often based on estimated fetal weight and interval growth; however, appropriate interval growth from week to week across gestation for these fetuses is poorly understood., Objective: This study aimed to determine the median increase in overall estimated fetal weight and individual biometric measurements across each week of gestation in pregnancies with fetal gastroschisis and to assess whether lower in utero fetal weight gain is predictive of postnatal growth or adverse neonatal outcomes., Study Design: This was a retrospective cohort study of pregnancies with gastroschisis evaluated at 5 institutions of the University of California Fetal-Maternal Consortium from December 2014 to December 2019. The inclusion criteria were prenatally diagnosed gastroschisis with at least 1 ultrasound performed at a University of California Fetal-Maternal Consortium institution. Estimated fetal weight and individual biometric measurements were recorded for each ultrasound performed at a University of California Fetal-Maternal Consortium institution from the time of gastroschisis diagnosis to delivery. Median estimated fetal weight and biometric measurements were calculated for each gestational age in 1-week increments. Neonatal outcomes collected were birthweight, length of stay, complications of gastroschisis (bowel atresia, bowel stricture, ischemic bowel before closure, or severe pulmonary hypoplasia), and growth failure at discharge., Results: We identified 95 pregnancies with fetal gastroschisis who, in aggregate, had 360 growth ultrasounds at a University of California Fetal-Maternal Consortium institution. The median interval growth was 130 g/wk. The median estimated fetal weight and abdominal circumference in fetal gastroschisis cases were approximately the tenth percentile on the Hadlock growth curve across gestation. Moreover, the median biparietal diameter, head circumference, and femur length measurements remained below the 50th percentile on the Hadlock growth curve across gestation. The median birthweight for neonates with less than the median weekly prenatal weight gain was less than for those with greater than the median weekly prenatal weight gain (2185 g vs 2780 g; P<.01). There was no difference in prenatal weight gain trajectory when comparing neonates who had or did not have bowel complications of gastroschisis., Conclusion: In this multicenter cohort of pregnancies with fetal gastroschisis, the median interval growth was 130 g/wk, and overall, in utero growth closely followed the tenth percentile on the Hadlock curve. Poor prenatal growth in cases of fetal gastroschisis correlates with lower neonatal weights but did not predict a more complicated course., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The number of cases of rectal cancer in our older cohort is expected to rise with our ageing population. In this study, we analysed patterns in treatment and the long-term outcomes of patients older than 80 years with rectal cancer across a health district., Methods: All cases of rectal cancer managed at the Illawarra Cancer Care Centre, Australia between 2006 and 2018 were analysed from a prospectively maintained database. Patients were stratified into three age groups: ≤65 years, 66-79 years and ≥80 years of age. The clinicopathological characteristics, operative and non-operative treatment approach and survival outcomes of the three groups were compared., Results: Six hundred and ninety-nine patients with rectal cancer were managed, of which 118 (17%) were aged 80 and above. Patients above 80 were less likely to undergo surgery (71% vs. 90%, p < 0.001) or receive adjuvant/neoadjuvant chemoradiotherapy ( p < 0.05). Of those that underwent surgical resection, their tumours were on average larger (36.5 vs. 31.5 mm, p = 0.019) and 18 mm closer the anal verge ( p = 0.001). On Kaplan-Meier analysis, those above 80 had poorer cancer-specific survival when compared to their younger counterparts ( p = 0.032), but this difference was no longer apparent after the first year ( p = 0.381)., Conclusion: Patients above the age of 80 with rectal cancer exhibit poorer cancer-specific survival, which is accounted for in the first year after diagnosis. Priority should be made to optimise care during this period. There is a need for further research to establish the role of chemoradiotherapy in this population, which appears to be underutilised.

Aim: This study aims to assess surgical outcomes and survival following first, second and third pelvic exenterations for pelvic malignancy., Method: Consecutive patients undergoing pelvic exenteration for pelvic malignancy at a quaternary referral centre from January 1994 and December 2017 were included. Demographics and surgical outcomes were compared between patients who underwent first, second and third pelvic exenterations by generalized mixed modelling with repeated measures. Survival was assessed using Cox proportional hazards models and Kaplan-Meier plots., Results: Of the 642 exenterations reviewed, 29 (4.5%) were second and 6 (0.9%) were third exenterations. Patients selected for repeat exenteration were more likely to have asymptomatic local recurrences detected on routine surveillance (P < 0.001). Postoperative wound complications increased with repeat exenteration (6%, 17%, 33%; P = 0.003, respectively). Additionally, postoperative length of stay increased from 27 to 38 and 48 days, respectively (P = 0.004). Median survival from first exenteration was 4.75, 5.30 and 8.14 years respectively amongst first, second and third exenteration cohorts (P = 0.849). Median survival from the most recent exenteration was 4.75 years after a first exenteration, 2.02 years after a second exenteration and 1.45 years after a third exenteration (P = 0.0546)., Conclusion: This study demonstrates that repeat exenteration for recurrent pelvic malignancy is feasible but is associated with increased complication rates and length of admission and reduced likelihood of attaining R0 margin. Moreover, these data indicate that repeat exenteration does not afford a survival advantage compared with patients having a single exenteration. These data suggest that repeat exenteration for recurrent pelvic malignancy may be of questionable therapeutic value., (© 2020 The Association of Coloproctology of Great Britain and Ireland.)

Purpose: Stapled anastomotic techniques to the distal rectum have gained widespread acceptance due to their procedural advantages. Various modifications in the stapling techniques have evolved since their inception. The triple-staple technique utilizing stapled closure of both the proximal colon and distal rectal stump provides a rapid and secure colorectal anastomosis. The aims of this study were to determine the safety and efficacy of the triple-staple technique and to compare the clinical outcomes with a historical control group for which the conventional double-staple technique had been performed., Methods: One hundred consecutive patients operated on by a single surgeon were included in the study; 50 patients who underwent a double-staple (DSA) procedure and 50 patients undergoing triple-staple anastomosis (TSA)., Results: The most common indication for surgery in both groups was rectal cancer followed by diverticular disease and distal sigmoid cancer. There was no significant difference in number of patients requiring loop ileostomy formation in the groups (TSA, 56.0% vs. DSA, 68.0%; P = 0.621). The mean operating time for the TSA group was significantly shorter compared to that of the DSA group (TSA, 242.8 minutes vs. DSA, 306.1 minutes; P = 0.001). There was no significant difference in complication rate (TSA, 40% vs. DSA, 50%; P = 0.315) or length of hospital stay between the two groups (TSA, 11.3 days vs. DSA, 13.0 days; P = 0.246). Postoperative complications included anastomotic leak, prolonged ileus, bleeding, wound infection, and pelvic collection., Conclusion: The triple-staple technique is a safe alternative to double-staple anastomosis after anterior resection and effectively shortens operating time.

The intestinal T-cell lymphomas are a rare group of lymphatic malignancies arising from the gastrointestinal tract. They frequently manifest with non-specific clinical and radiographic findings that may mimic several other disease processes. The most common subtype is linked with refractory coeliac disease and commonly affects the small intestine. We report a case where the diagnosis was uncovered endoscopically in a patient presenting with colonic perforation on a background of long-standing ulcerative colitis. Surgical source control was required prior to considering chemotherapy, which is the usual treatment option in lymphatic malignancies. The case highlights the importance endoscopic evaluation in inflammatory conditions of the colon.

Protein ubiquitination is involved in virtually all cellular processes. Enrichment strategies employing antibodies targeting ubiquitin-derived diGly remnants combined with mass spectrometry (MS) have enabled investigations of ubiquitin signaling at a large scale. However, so far the power of data independent acquisition (DIA) with regards to sensitivity in single run analysis and data completeness have not yet been explored. Here, we develop a sensitive workflow combining diGly antibody-based enrichment and optimized Orbitrap-based DIA with comprehensive spectral libraries together containing more than 90,000 diGly peptides. This approach identifies 35,000 diGly peptides in single measurements of proteasome inhibitor-treated cells - double the number and quantitative accuracy of data dependent acquisition. Applied to TNF signaling, the workflow comprehensively captures known sites while adding many novel ones. An in-depth, systems-wide investigation of ubiquitination across the circadian cycle uncovers hundreds of cycling ubiquitination sites and dozens of cycling ubiquitin clusters within individual membrane protein receptors and transporters, highlighting new connections between metabolism and circadian regulation.

Recent advances in mass spectrometry (MS)-based quantitative proteomics now allow the identification and quantification of deep proteomes and post-translational modifications (PTMs) in relatively short times. Therefore, in the last few years, this technology has proven successful in the circadian field to characterize temporal oscillations of the proteome and more recently PTMs in cellular systems and in tissues. In this chapter, we describe a robust and simple protocol, based on the EasyPhos workflow, to enable preparation of large number of proteomes and phosphoproteomes from mouse tissues for MS-based quantitative analysis. We additionally discuss computational methods to analyze proteome and phosphoproteome time series to determine circadian oscillations.

Background: Neoadjuvant chemoradiotherapy plays a key role in reducing local recurrence rates for locally advanced rectal cancer. Pelvic magnetic resonance imaging (pMRI) is the gold standard for local clinical staging which allows clinicians to decide the treatment patients receive. A more advanced tumour or the presence of high-risk features on pMRI mean that neoadjuvant therapy will be offered to these patients. Understanding the accuracy of pMRI in local staging for rectal cancer is therefore crucial., Methods: A retrospective cohort analysis of the accuracy of pMRI staging in a subgroup of patients who had primary rectal cancer surgery without neoadjuvant therapy was performed. Specificity and sensitivity for T-staging, N-staging and presence of high-risk features (threatened circumferential resection margin and extramural venous invasion) were calculated. Patients who had previous pelvic surgery, previous pelvic radiotherapy and previous surgery for continence were excluded., Results: A total of 114 patients were included in the analysis. MRI accurately predicts T-stage in 56.6% and N-stage in 55.8%. Prediction of extramural disease was accurate in 51%. A negative circumferential resection margin was accurately predicted in 98.6% of patients. Overall adherence to reporting proforma was 15.8%., Conclusion: Overall, this study provided valuable information about the clinical staging of patients with rectal cancer who are at an early stage within a large regional catchment area in Australia with pMRI. These results allow us to assess the accuracy of our local staging with ramifications to the clinical decisions being made in the context of the more recent trials which questioned the need for neoadjuvant chemo-radiotherapy in all node positive patients., (© 2020 Royal Australasian College of Surgeons.)

Background: Parastomal hernia (PSH) management poses difficulties due to significant rates of recurrence and morbidity after repair. This study aims to describe a practical approach for PSH, particularly with onlay mesh repair using a lateral peristomal incision., Methods: This is a retrospective review of consecutive patients who underwent PSH repair between 2001 and 2018., Results: Seventy-six consecutive PSH with a mean follow-up of 93.1 months were reviewed. Repair was carried out for end colostomy (40%), end ileostomy (25%), ileal conduit (21%), loop colostomy (6.5%) end-loop colostomy (5%) and loop ileostomy (2.5%). The repair was performed either with a lateral peristomal incision (59%) or a midline incision (41%). Polypropylene mesh (86%), biologic mesh (8%) and composite mesh (6%) were used. Stoma relocation was done in 9 patients (12%). Eight patients (11%) developed postoperative wound complications. Recurrence occurred in 16 patients (21%) with a mean time to recurrence at 29.4 months. No significant difference in wound complication and recurrence was observed based on the type of stoma, incision used, type of mesh used, and whether or not the stoma was repaired on the same site or relocated., Conclusion: Onlay mesh repair of PSH remains a practical and safe approach and could be an advantageous technique for high-risk patients. It can be performed using a lateral peristomal incision with low morbidity and an acceptable recurrence rate. However, for patients with significant adhesions and very large PSH, a midline approach with stoma relocation may also be considered.

We describe a practical approach to the management of complex anal fistula in an immunocompromised patient. We define our treatment motifs: to close the internal opening, maintain external drainage until internal opening and tract healed; minimize sphincter damage. We hope other authors can build on this case technique to improve fistula surgery outcomes., (© 2020 Royal Australasian College of Surgeons.)

A straightforward, systematic and reproducible framework for junior registrars to adopt when learning the handsewn ileostomy closure technique., (© 2020 Royal Australasian College of Surgeons.)

Background: Management of radiation proctitis presents a treatment challenge. Limited data exist on the management of symptomatic hemorrhoids in radiated patients. This study aims to present a practical approach to the management of radiation proctitis, particularly in patients with synchronous hemorrhoids., Methods: A total of 52 consecutive cases of radiation proctitis managed between September 1999 and October 2017 were retrospectively reviewed. The primary treatment was formalin application, plus rubber band ligation in conjunction with formalin when hemorrhoids were a significant component of bleeding, and occasionally argon plasma coagulation., Results: The primary indication for radiotherapy was for the treatment of prostate cancer (71%), anal squamous cell carcinoma (10%), and gynecological malignancies (18%). More than half of the patients (52%) presented with radiation proctitis and concomitant internal hemorrhoids. The hemorrhoids were managed with rubber band ligation (56%) and stapled hemorrhoidectomy (7%), at the same procedure as formalin application. At a median follow-up of 12 months, no recurrent rectal bleeding occurred, and no further treatment was needed for most patients. One patient experienced a short period of perianal pain, which was treated with analgesics., Conclusion: Formalin application has consistently demonstrated an excellent cure rate and safety profile comparable with the published results as a primary treatment for radiation proctitis. The prolapse of irradiated mucosa over the internal hemorrhoids appears to exacerbate bleeding. Local hemorrhoid treatment is often required as an adjunct in the management of these patients.

The circadian clock drives daily changes of physiology, including sleep-wake cycles, through regulation of transcription, protein abundance, and function. Circadian phosphorylation controls cellular processes in peripheral organs, but little is known about its role in brain function and synaptic activity. We applied advanced quantitative phosphoproteomics to mouse forebrain synaptoneurosomes isolated across 24 hours, accurately quantifying almost 8000 phosphopeptides. Half of the synaptic phosphoproteins, including numerous kinases, had large-amplitude rhythms peaking at rest-activity and activity-rest transitions. Bioinformatic analyses revealed global temporal control of synaptic function through phosphorylation, including synaptic transmission, cytoskeleton reorganization, and excitatory/inhibitory balance. Sleep deprivation abolished 98% of all phosphorylation cycles in synaptoneurosomes, indicating that sleep-wake cycles rather than circadian signals are main drivers of synaptic phosphorylation, responding to both sleep and wake pressures., (Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Neurons have adapted mechanisms to traffic RNA and protein into distant dendritic and axonal arbors. Taking a biochemical approach, we reveal that forebrain synaptic transcript accumulation shows overwhelmingly daily rhythms, with two-thirds of synaptic transcripts showing time-of-day-dependent abundance independent of oscillations in the soma. These transcripts formed two sharp temporal and functional clusters, with transcripts preceding dawn related to metabolism and translation and those anticipating dusk related to synaptic transmission. Characterization of the synaptic proteome around the clock demonstrates the functional relevance of temporal gating for synaptic processes and energy homeostasis. Unexpectedly, sleep deprivation completely abolished proteome but not transcript oscillations. Altogether, the emerging picture is one of a circadian anticipation of messenger RNA needs in the synapse followed by translation as demanded by sleep-wake cycles., (Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Forensic series on fatal anaphylaxis are scarce, probably because the diagnosis of anaphylaxis is often complex and the incidence is low. We report on the medicolegal, demographic and histopathological characteristics of a series of sudden deaths which were investigated for anaphylaxis at the Spanish National Institute of Toxicology and Forensic Sciences (INTCF) over a 17-year period (1998-2015). A total of 122 undetermined sudden deaths from a high percentage of Spanish regions (81.5% of the total population) were sent to the INTCF with anaphylaxis as the suspected cause of death for histological, biochemical, and medicolegal investigation. Two certified allergists confirmed that 46 of the 122 cases were fatal anaphylaxis. The results indicated a median age of 51 years (IQR = 29) and a male predominance (76%). The main causes of anaphylaxis were drugs (41%), hymenoptera stings (33%), and food (13%). A previous allergic event had been reported in both food anaphylaxis (67%) and drug anaphylaxis (53%). The deaths occurred in health care settings (37%), at home (22%), and outside the home (26.09%). Histopathology data were available for 40 individuals. The most frequent autopsy findings were angioedema of the upper airways (50%), pulmonary edema (47.5%), atheromatosis of coronary vessels (32.5%), and pulmonary congestion (27.5%). Our findings for fatal anaphylaxis indicated a predominance of men, older age (≥50 years) and death in a health care setting (one-third of cases). Previous episodes had occurred in two-thirds of cases of food-induced anaphylaxis and in half of the cases of drug-induced anaphylaxis.