Late results of treatment of anal fistulas.

OBJECTIVE: The aim of this paper was to analyse the results of treatment of anal fistulas retrospectively. METHODS: Between 1992 and 2004, 407 patients were operated on for perianal fistula. In the follow-up period, 107 patients were lost, so 300 patients were analysed in the study. The mean follow-up time was 4.2 years. Analysed parameters included: types of surgical procedures in different kinds of fistulas and postoperative complications. Various types of surgical procedures and their effectiveness were described. Late results were assessed taking into account healing time, duration of sick leave, recurrence rate and incidence of anal sphincter dysfunction. Severity of gas and stool incontinence was assessed according to the Cleveland Clinic Incontinence Score. RESULTS: In our study, subcutaneous fistula was diagnosed in 23.3%, inter-sphincteric in 18%, trans-sphincteric in 37.7%, supra-sphincteric in 16% and extra-sphincteric in 5% of patients. Single-tract fistulas were present in 88.7% and multi-tract fistulas were present in 11.3%. Overall, 242 patients had primary fistulas and 58 patients had recurrent fistulas. The most frequently performed procedures were cutting seton (139 patients) and radical fistulectomy (104 patients). Recurrent fistulas developed in 14.3%. Postoperative gas and/or stool incontinence was noticed in 10.7%. The recurrence rate was 5.4% in patients with primary fistula and in 51.7% patients presenting with a recurrent fistula. Gas and stool incontinence developed in 3.7% of patients with primary fistulas and in 39.7% of patients presenting with recurrent fistulas. Recurrence rate was 12% in the patients of single-tract fistulas and 32.4% in the patients of multi-tract fistulas. Postoperative gas and/or stool incontinence occurred in 8.3% of patients of single-tract fistulas and in 29.4% of patients of multi-tract fistulas. CONCLUSIONS: The complication rate was 10-fold higher in patients presenting with a recurrent fistula than in those with primary fistulas and threefold higher in patients with multi-tract fistulas than in those with single-tract fistulas.

Downregulation of N1 gene expression inhibits the initial heartbeating and heart development in axolotls.

Recessive mutant gene c in the axolotl results in a failure of affected embryos to develop contracting hearts. This abnormality can be corrected by treating the mutant heart with RNA isolated from normal anterior endoderm or from endoderm conditioned medium. A cDNA library was constructed from the total conditioned medium RNA using a random priming technique in a pcDNAII vector. We have previously identified a clone (designated as N1) from the constructed axolotl cDNA library, which has a unique nucleotide sequence. We have also discovered that the N1 gene product is related to heart development in the Mexican axolotl [Cell Mol. Biol. Res. 41 (1995) 117]. In the present studies, we further investigate the role of N1 on heartbeating and heart development in axolotls. N1 mRNA expression has been determined by using semi-quantitative RT-PCR with specifically designed primers. Normal embryonic hearts (at stages 30-31) have been transfected with anti-sense oligonucleotides against N1 to determine if downregulation of N1 gene expression has any effect on normal heart development. Our results show that cardiac N1 mRNA expression is partially blocked in the hearts transfected with anti-sense nucleotides and the downregulation of N1 gene expression results in a decrease of heartbeating in normal embryos, although the hearts remain alive as indicated by calcium spike movement throughout the hearts. Confocal microscopy data indicate some myofibril disorganization in the hearts transfected with the anti-sense N1 oligonucleotides. Interestingly, we also find that N1 gene expression is significantly decreased in the mutant axolotl hearts. Our results suggest that N1 is a novel gene in Mexican axolotls and it probably plays an important role in myofibrillogenesis and in the initiation of heartbeating during heart development.

Relationship between cardiac protein tyrosine phosphorylation and myofibrillogenesis during axolotl heart development.

The axolotl, Ambystoma mexicanum, is a useful system for studying embryogenesis and cardiogenesis. To understand the role of protein tyrosine phosphorylation during heart development in normal and cardiac mutant axolotl embryonic hearts, we have investigated the state of protein tyrosine residues (phosphotyrosine, P-Tyr) and the relationship between P-Tyr and the development of organized sarcomeric myofibrils by using confocal microscopy, two-dimensional isoelectric focusing (IEF)/SDS-polyacrylamide gel electrophoresis (PAGE) and immunoblotting analyses. Western blot analyses of normal embryonic hearts indicate that several proteins were significantly tyrosine phosphorylated after the initial heartbeat stage (stage 35). Mutant hearts at stages 40-41 showed less tyrosine phosphorylated staining as compared to the normal group. Two-dimensional gel electrophoresis revealed that most of the proteins from mutant hearts had a lower content of phosphorylated amino acids. Confocal microscopy of stage 35 normal hearts using phosphotyrosine monoclonal antibodies demonstrated that P-Tyr staining gradually increased being localized primarily at cell-cell boundaries and cell-extracellular matrix boundaries. In contrast, mutant embryonic hearts showed a marked decrease in the level of P-Tyr staining, especially at sites of cell-cell and cell-matrix junctions. We also delivered an anti-phosphotyrosine antibody (PY 20) into normal hearts by using a liposome-mediated delivery method, which resulted in a disruption of the existing cardiac myofibrils and reduced heartbeat rates. Our results suggest that protein tyrosine phosphorylation is critical during myofibrillogenesis and embryonic heart development in axolotls.

Creation of chimeric mutant axolotls: a model to study early embryonic heart development in Mexican axolotls.

The Mexican axolotl (Ambystoma mexicanum) provides an excellent model for studying heart development since it carries a cardiac lethal mutation in gene c that results in failure of contraction of mutant embryonic myocardium. In cardiac mutant axolotls (c/c) the hearts do not beat, apparently because of an absence of organized myofibrils. To date, there has been no way to analyze the genotypes of embryos from heterozygous spawnings (+/c x +/c) until stage 35 when the normal (+/c or +/+) embryos first begin to have beating hearts; mutant (c/c) embryos fail to develop normal heartbeats. In the present study, we created chimeric axolotls by using microsurgical techniques. The general approach was to transect tailbud embryos and join the anterior and posterior halves of two different individuals. The chimeric axolotl is composed of a normal head and heart region (+/+), permitting survival and a mutant body containing mutant gonads (c/c) that permits the production of c/c mutant offspring: 100% c/c offspring were obtained by mating c/c chimeras (c/c x c/c). The mutant phenotypes were confirmed by the absence of beating hearts and death at stage 41 in 100% of the embryos. Examination of the mutant hearts with electron microscopy and comfocal microscopy after immunofluorescent staining for tropomyosin showed identical images to those described previously in naturally-occurring c/c mutant axolotls (i.e., lacking organized sarcomeric myofibrils). These "c/c chimeric" axolotls provide a useful and unique way to investigate early embryonic heart development in cardiac mutant Mexican axolotls.

Expression of HoxA5 in the heart is upregulated during thyroxin-induced metamorphosis of the Mexican axolotl (Ambystoma mexicanum).

Widespread external and internal changes in body morphology have long been known to be hallmarks of the process of metamorphosis. However, more subtle changes, particularly at the molecular level, are only now beginning to be understood. A number of transcription factors have recently been shown to alter expression either in levels of message or in isoforms expressed. In this article, we describe a dramatic increase in the expression of the homeobox gene HoxA5 in the heart and aorta of the Mexican axolotl Ambystoma mexicanum during the process of thyroxin-induced metamorphosis. Immunohistochemical analysis with anti-HoxA5 antibody in thyroxin-induced metamorphosing animals showed a pattern of expression of HoxA5 comparable to that in spontaneously metamorphosing animals. Further, by in situ hybridization, we were able to show significant qualitative differences in the expression of this gene within the heart. Maximum HoxA5 expression occurred at the midpoint of metamorphosis in the myocardium, whereas the hearts of completely metamorphosed animals had the highest levels of expression in the epicardium and endocardium. In the aorta, smooth-muscle cells of the tunica media as well as cells of the tunica adventitia had an increase in expression of HoxA5 with thyroxin-induced metamorphosis. HoxA5 expression significantly changed in cells of the aorta and ventricle with treatment by thyroid hormone. HoxA5, a positive regulator of p53, may be involved with the apoptotic pathway in heart remodeling during amphibian metamorphosis.

Alteration of cardiac myofibrillogenesis by liposome-mediated delivery of exogenous proteins and nucleic acids into whole embryonic hearts.

A precise organization of contractile proteins is essential for contraction of heart muscle. Without a necessary stoichiometry of proteins, beating is not possible. Disruption of this organization can be seen in diseases such as familial hypertrophic cardiomyopathy and also in acquired diseases. In addition, isoform diversity may affect contractile properties in such functional adaptations as cardiac hypertrophy. The Mexican axolotl provides an uncommon model in which to examine specific proteins involved with myofibril formation in the heart. Cardiac mutant embryos lack organized myofibrils and have altered expression of contractile proteins. In order to replicate the disruption of myofibril formation seen in mutant hearts, we have developed procedures for the introduction of contractile protein antibodies into normal hearts. Oligonucleotides specific to axolotl tropomyosin isoforms (ATmC-1 and ATmC-3), were also successfully introduced into the normal hearts. The antisense ATmC-3 oligonucleotide disrupted myofibril formation and beating, while the sense strands did not. A fluorescein-tagged sense oligonucleotide clearly showed that the oligonucleotide is introduced within the cells of the intact hearts. In contrast, ATmC-1 anti-sense oligonucleotide did not cause a disruption of the myofibrillar organization. Specifically, tropomyosin expression can be disrupted in normal hearts with a lack of organized myofibrils. In a broader approach, these procedures for whole hearts are important for studying myofibril formation in normal hearts at the DNA, RNA, and/or protein levels and can complement the studies of the cardiac mutant phenotype. All of these tools taken together present a powerful approach to the elucidation of myofibrillogenesis and show that embryonic heart cells can incorporate a wide variety of molecules with cationic liposomes.

The cardiac mutant Mexican axolotl is a unique animal model for evaluation of cardiac myofibrillogenesis.

Hearts from cardiac mutant Mexican axolotl, Ambystoma mexicanum, do not form organized myofibrils and fail to beat. Though previous biochemical and immunohistochemical experiments showed a possible reduction of cardiac tropomyosin it was not clear that this caused the lack of organized myofibrils in mutant hearts. We used cationic liposomes to introduce both rabbit and chicken tropomyosin protein into whole hearts of embryonic axolotls in whole heart organ cultures. The mutant hearts had a striking increase in the number of well-organized sarcomeric myofibrils when treated with rabbit or chicken tropomyosin. FITC-labeled rabbit tropomyosin was used to examine the kinetics of incorporation of the exogenous protein into mutant hearts and confirmed the uptake of exogenous protein by the cells of live hearts in culture. By 4 h of transfection, both normal and mutant hearts were found to incorporate FITC-labeled tropomyosin into myofibrils. We also delivered an anti-tropomyosin antibody (CH 1) into normal hearts to disrupt the existing cardiac myofibrils which also resulted in reduced heartbeat rates. CH1 antibody was detected within the hearts and disorganization of the myofibrils was apparent when compared to normal controls. Introduction of a C-protein monoclonal antibody (ALD 66) did not result in a disruption of organized myofibrils. The results show clearly that chicken or rabbit tropomyosin could be incorporated by the mutant hearts and that it was sufficient to overcome the factors causing a lack of myofibril formation in the mutant. This finding also suggests that a lack of organized myofibrils is caused primarily by either inadequate levels of tropomyosin or endogenous tropomyosin in mutant hearts is unsuitable for myofibril formation, which we were able to duplicate with the introduction of tropomyosin antibody. Furthermore, incorporation of a specific exogenous protein or antibody into normal and mutant hearts of the Mexican axolotl in whole heart organ culture offers an unique model to evaluate functionalroles of contractile proteins necessary for cardiac development and differentiation.

Ectopic expression of tropomyosin promotes myofibrillogenesis in mutant axolotl hearts.

Expression of tropomyosin protein, an essential component of the thin filament, has been found to be drastically reduced in cardiac mutant hearts of the Mexican axolotl (Ambystoma mexicanum) with no formation of sarcomeric myofibrils. Therefore, this naturally occurring cardiac mutation is an appropriate model to examine the effects of delivering tropomyosin protein or tropomyosin cDNA into the deficient tissue. In this study, we describe the replacement of tropomyosin by using a cationic liposome transfection technique applied to whole hearts in vitro. When mouse alpha-tropomyosin cDNA under the control of a cardiac-specific alpha-myosin heavy chain promoter was transfected into the mutant hearts, tropomyosin expression was enhanced resulting in the formation of well-organized sarcomeric myofibrils. Transfection of a beta-tropomyosin construct under control of the same promoter did not result in enhanced organization of the myofibrils. Transfection of a beta-galactosidase reporter gene did not result in the formation of organized myofibrils or increased tropomyosin expression. These results demonstrate the importance of alpha-tropomyosin to the phenotype of this mutation and to normal myofibril formation. Moreover, we have shown that a crucial contractile protein can be ectopically expressed in cardiac muscle that is deficient in this protein, with the resulting formation of organized sarcomeres.

[Rheumatoid arthritis in a patient with osteopoikilosis]. / Reumatoidalne zapalenie stawów u chorej z osteopoikilia.

57-years old woman with spotted bones was reported, with concomitant rheumatoid arthritis. It was great concern because of low incidence of osteopoikilia and diagnosis obstacles concerning coexistence of this two pathologies.