Surgical management of giant skin tumor - A case report.

INTRODUCTION: Malignant non-melanoma skin cancers (NMSC) are of two main types: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). In rare occasions, some of the malignant skin lesions show histopathological characteristics of both BCC and SCC and are known as basosquamous carcinomas (BSC). In some cases of large tumors, extensive reconstructive surgery might be needed to correct the skin defect after the primary excision. PRESENTATION OF CASE: We report a case of a 76-year-old Bulgarian male patient who presented with a neglected giant cutaneous tumor with more than a 15-year history of a growing mass in the right deltoid area. On physical exam an enormous exophytic ulcerated and crusted skin lesion measuring around 11×11cm was found. Wide local excision of the lesion with 10-mm resection margins and partial resection of the underlying deltoid muscle were performed due to signs of infiltration. A full-thickness total skin graft from the left inguinal area was harvested to cover the skin defect. Final histopathological examination showed metatypical carcinoma with mixed characteristics of SCC and BCC - BSC, with infiltration of the fatty tissue, deltoid muscle and clear margins of resection, staged as T4R0. Two and a half years after surgery there are no signs of upper arm motor dysfunction and no evidence of local recurrence and distant metastasis on a follow-up PET/CT. DISCUSSION: Following current National Comprehensive Cancer Network's guidelines for primary treatment of BCC, surgical candidates should undergo standard excision with wider surgical margins, postoperative margin assessment and second intention healing, linear repair, or skin graft. Therapeutic strategy for non-operable cases includes administration of radiotherapy or system therapy in the face of Hedgehog pathway inhibitors and programmed cell death protein 1 inhibitor. They can provide an alternative solution to unresectable or difficult-to-treat locally advanced cases of BSC. CONCLUSION: Similarly to BCC and SCC, the first-line treatment option for BCS is surgical excision, but surgical margins should be wider than those for low-risk BCC due to the infiltrative growth pattern of this tumor. Favorable esthetic outcome requires precise planning of the reconstructive technique.

[SUCCESSFUL LAPAROSCOPIC TREATMENT OF HETEROTOPIC PREGNANCY AFTER ICSI / FREEZE EMBRYO TRANSFER - A CASE REPORT.]

The coexistence of extrauterine and intrauterine or haeterotopic pregnancy (HP) is a rare condition with reported incidence of 1 in 8000 to 1 in 30 000 pregnancies in natural conceived pregnancies, but with the widespread application of assisted reproductive technologies (ART) the incidence of HP in women with ART has risen to about 0.09% to 1.00%. We have reported a case of a 36 old woman, pregnant in 9 gestation week, gravidity 2, 0 para, who have achieved a pregnancy after in-vitro fertilization - embryo-transfer of two freeze embryos, developed after an ICSI procedure with donor eggs. The patient attended our clinic because of acute abdominal pain. She was evaluated by trans-vaginal sonography and coexistence of ectopic tubal and intrauterine pregnancy has been confirmed. Emergency laparoscopy was carried out. Left tubal ectopic pregnancy and hemoperitoneum (1200 ml) were diagnosed. Left salpingectomy was performed. At present, the patient is at 24 gestation week and the pregnancy is developing in a proper manner. We report such a case due to the increase of the awareness to the condition and the possibility of a successful treatment by a laparoscopic surgery. Intrauterine pregnancy does not exclude extrauterine pregnancy especially in cases after in-vitro fertilization.

[CLINICAL IMPLEMENTATION OF CELL-FREE DNA ANALYSIS IN MATERNAL BLOOD IN SCREENING FOR ANEUPLOIDIES IN SINGLETON PREGNANCIES].

OBJECTIVE: Clinical implementation of cell free(cf) DNA testing in maternal blood for aneuploidies in singleton pregnancies. METHODS: This is a retrospective study conducted in two centers for fetal medicine in Sofia, Bulgaria, between October 2013 and August 2015. We examined the clinical implementation of cf DNA testing in the routine practice for trisomies 21, 18 and13 after the performance of the first trimester combined test, second trimester biochemical test and/or the combination between first and second trimester integrated test. RESULTS: Cell-free DNA testing was performed in 170 singleton pregnancies with a median maternal age of 35 (range 22-46) years. The primary risk assessment for aneuploidies was derived from 95 cases after the first trimester combined screening test, 39 cases after the second trimester biochemical screening test, 16 cases after the integrated screening test and 20 cases there were no screening test performed. The results from the first line screening test were : 8 pregnancies with risk for trisomy 21 > 1: 100; 23 pregnancies with risk for trisomy 21 from 1:100 to 1: 300; 43 pregnancies with risk for trisomy 21 from 1:300 to 1:1000 and 76 pregnancies with risk for trisomy 21 < 1: 1000. No pregnancies with high risk for T13/T18 were identified. The analysis of cf DNA in the maternal blood reported 3 cases with T21 and no cases with T18 or T13. There was only one case of T21 in the group with risk >1:100 identified by the cf DNA analysis which was also identified by the first trimester combined screening test. The positive results were confirmed with invasive testing: CVS in the first trimester (one case) and Amniocentesis in the second trimester (two cases). CONCLUSION: Clinical implementation of cell-free DNA analysis in the contingent policy for screening could improve the detection rate for T21 and could reduce the rate of invasive procedures.

[LAPAROSCOPIC TREATMENT OF PRIMARY ABDOMINAL PREGNANCY: A CASE REPORT AND REVIEW OF THE LITERATURE].

Abdominal pregnancies are 1.4% of all ectopic pregnancies. They are mostly complicated and usually managed by laparotomy, but laparoscopy is an alternative method which some surgeons perform instead of laparotomy, especially in early pregnancy. We reported a 29 year old woman with supra pubic pain and vaginal bleeding. After sonographic evaluations, ectopic pregnancy was diagnosed and the patient underwent laparoscopic surgery for termination of pregnancy. Laparoscopy is a successful alternative method of surgery for abdominal pregnancies in first trimester.

[Ultrasound Examination and Management of Twin Pregnancy.]

Twin pregnancies are found in about 3 % of all pregnancies and 2/3 are dizygotic and 1/3 are monozygotic. In the last 30 years after the introduction of assisted conception and increasing maternal age the rate of twin pregnancies dramatically increased. Compared to singletons, twins have more complications such as intrauterine demise, intrauterine selective fetal growth reStriction, congenital anomalies, miscarriage and preterm labour. Monochorionic twins are at high risk for unique complications because of blood exchange through vascular communications in the shared placenta. Twin pregnancies should be considered as a high risk pregnancies and the well-being of the two fetuses should be taken into account with a strict protocol for follow up and management options. CONCLUSION: Ultrasound examination olavs a maior role in fetal surveillance.

[THE VALUE OF COLPOSCOPY EXAMINATION IN DIAGNOSIS OF PRECANCEROUS AND CANCEROUS DISEASES OF THE CERVIX].

The aim of this study is to present the value of colposcopy examination in diagnosis of precancerous and cancerous diseases of the cenvix. A retrospective study analyze 127 patients at SA GBAL" Dr. Shterev Hospital" that undenNent, firstly cervical smear test and secondly a colposcopic punch biopsy The patients are divided in two groups--one group of cytologically non-signaled patients with results from the Pap test I-II and one group with cytologically -signaled patients with results from the Pap test III-IV The data shows a correlation between the cytological and histological results of the second group and absence of such a correlation in the first group. In the non-signaled group the mild precancerous lesions to Thvasive cen'ical cancer were left undiagnosed. The conduct of a routine colposcopy during preventive gynecological examination will reduce the deficiencies of the cytological method and by amplifying it, it will lead to better results of the diagnosis and treatment of the precanceroses and the cervical cancer.

[Norms for determination of the physical development of the newborn Bulgarian children in the town of Plovdiv].

In the compound complex of factors, influencing the physical development, a significant role plays the ethnical belonging. The aim of the study is to work out norms for assessment of the physical development of the newborn Bulgarian children. In the period 01.01-01.12.2008 the primary information for the physical development of the newborn 789 children was registered at the Obstetric-Gynecological Clinic of Medical University-Plovdiv. One of the most precise methods for individual assessment--the Method of the percentiles was used. The extent of the excerpt gives a reason to consider that the norms for assessment of height, weight, head and chest measurement of the newborn children with Bulgarian origin are stable and statistically reliable and can be used by the obstetricians and micropediatricians for assessment of the physical development of the children in the next 8-10 years.

[Standards for determining the physical development of newborn children of Roma origin in city of Plovdiv].

In a complex set of factors affecting the physical development plays an important role and ethnicity. Purpose of the study was the development of standards for assessing the physical development of newborn children from the Roma ethnos. The information is registered in the Obstetric Clinic of Medical University Plovdiv and includes 338 newborns Roma children. Norms are made using one of the most accurate methods for individual assessment--method of percentile. The size of the sample gives reason to believe that the norms for evaluation of height, body mass and size of the head and breasts of newborn children of Roma origin are stable and statistically reliable and can be used by gynecologists, micro-pediatricians to assess physical development of children in the next 80-10 years.

Review: Early life predisposing factors for biting in pigs.

The pig industry faces many animal welfare issues. Among these, biting behaviour has a high incidence. It is indicative of an existing problem in biters and is a source of physical damage and psychological stress for the victims. We categorize this behaviour into aggressive and non-aggressive biting, the latter often being directed towards the tail. This review focusses specifically on predisposing factors in early life, comprising the prenatal and postnatal periods up to weaning, for the expression of aggressive and non-aggressive biting later in life. The influence of personality and coping style has been examined in a few studies. It varies according to these studies and, thus, further evaluation is needed. Regarding the effect of environmental factors, the number of scientific papers is low (less than five papers for most factors). No clear influence of prenatal factors has been identified to date. Aggressive biting is reduced by undernutrition, cross-fostering and socialization before weaning. Non-aggressive biting is increased by undernutrition, social stress due to competition and cross-fostering. These latter three factors are highly dependent on litter size at birth. The use of familiar odours may contribute to reducing biting when pigs are moved from one environment to another by alleviating the level of stress associated with novelty. Even though the current environment in which pigs are expressing biting behaviours is of major importance, the pre-weaning environment should be optimized to reduce the likelihood of this problem.

Spiral T1 Spin-Echo for Routine Postcontrast Brain MRI Exams: A Multicenter Multireader Clinical Evaluation.

BACKGROUND AND PURPOSE: Spiral MR imaging has several advantages compared with Cartesian MR imaging that can be leveraged for added clinical value. A multicenter multireader study was designed to compare spiral with standard-of-care Cartesian postcontrast structural brain MR imaging on the basis of relative performance in 10 metrics of image quality, artifact prevalence, and diagnostic benefit. MATERIALS AND METHODS: Seven clinical sites acquired 88 total subjects. For each subject, sites acquired 2 postcontrast MR imaging scans: a spiral 2D T1 spin-echo, and 1 of 4 routine Cartesian 2D T1 spin-echo/TSE scans (fully sampled spin-echo at 3T, 1.5T, partial Fourier, TSE). The spiral acquisition matched the Cartesian scan for scan time, geometry, and contrast. Nine neuroradiologists independently reviewed each subject, with the matching pair of spiral and Cartesian scans compared side-by-side, and scored on 10 image-quality metrics (5-point Likert scale) focused on intracranial assessment. The Wilcoxon signed rank test evaluated relative performance of spiral versus Cartesian, while the Kruskal-Wallis test assessed interprotocol differences. RESULTS: Spiral was superior to Cartesian in 7 of 10 metrics (flow artifact mitigation, SNR, GM/WM contrast, image sharpness, lesion conspicuity, preference for diagnosing abnormal enhancement, and overall intracranial image quality), comparable in 1 of 10 metrics (motion artifacts), and inferior in 2 of 10 metrics (susceptibility artifacts, overall extracranial image quality) related to magnetic susceptibility (P < .05). Interprotocol comparison confirmed relatively higher SNR and GM/WM contrast for partial Fourier and TSE protocol groups, respectively (P < .05). CONCLUSIONS: Spiral 2D T1 spin-echo for routine structural brain MR imaging is feasible in the clinic with conventional scanners and was preferred by neuroradiologists for overall postcontrast intracranial evaluation.

A study of nanosize Fe3O4 deposited on carbon matrix.

Nanosized crystalline Fe3O4 (with an average particle size of 16 nm) was successfully synthesized on a carbon matrix surface. The prepared sample was heat-treated in the temperature range 300 degrees C - 750 degrees C to remove residual impurities and to obtain a final product with a 77:23 ratio between magnetite and the carbon support. The sample was subjected to physicochemical and electrochemical tests. The purity of the phase and the particles size was determined by X-ray diffraction analysis and confirmed by field emission scanning electron micrographs. The specific surface area of the sample measured by the B.E.T method was 120 m2 g(-1). A series of electrochemical tests including EIS, CV and long-term constant current cycling have been performed. The obtained reversible capacity within 15 cycles was in the range 400-550 mA h x g(-1). The electrochemical behavior of the test sample and its possible practical use as an anode material in lithium secondary batteries are discussed.

Lateral root growth in Arabidopsis is controlled by short and long distance signaling through the LRR RLKs XIP1/CEPR1 and CEPR2.

Plants rely on lateral roots to explore their soil environment and to maximize their uptake of essential minerals and water. Here we present evidence that the receptor kinases XIP1/CEPR1 and CEPR2 regulate both the initiation of lateral root primordia and emergence of lateral roots locally in the root, while also controlling lateral root extension in response to shoot-derived sucrose in Arabidopsis plants. In addition, mutation of both of these receptors prevents seedlings from responding to sucrose in the media, resulting in longer lateral roots. These results, combined with previous data, establish XIP1/CEPR1 and CEPR2-dependent roles in short- and long-distance pathways regulating different stages of lateral root growth.

Approaches to assess IgE mediated allergy risks (sensitization and cross-reactivity) from new or modified dietary proteins.

The development and introduction of new dietary protein sources has the potential to improve food supply sustainability. Understanding the potential allergenicity of these new or modified proteins is crucial to ensure protection of public health. Exposure to new proteins may result in de novo sensitization, with or without clinical allergy, or clinical reactions through cross-reactivity. In this paper we review the potential of current methodologies (in silico, in vitro degradation, in vitro IgE binding, animal models and clinical studies) to address these outcomes for risk assessment purposes for new proteins, and especially to identify and characterise the risk of sensitization for IgE mediated allergy from oral exposure. Existing tools and tests are capable of assessing potential crossreactivity. However, there are few possibilities to assess the hazard due to de novo sensitization. The only methods available are in vivo models, but many limitations exist to use them for assessing risk. We conclude that there is a need to understand which criteria adequately define allergenicity for risk assessment purposes, and from these criteria develop a more suitable battery of tests to distinguish between proteins of high and low allergenicity, which can then be applied to assess new proteins with unknown risks.

Peak effect in polycrystalline vortex matter.

We report a study of the peak-effect phase diagram of a strongly disordered type-II superconductor V-21 at. %Ti using ac magnetic susceptibility and small-angle neutron scattering (SANS). In this system, the peak effect appears only at fields higher than 3.4 T. The sample is characterized by strong atomic disorder. Vortex states with field-cooled thermal histories show that both deep in the mixed state, as well as close to the peak effect, there exist no long-range orientationally ordered vortex lattices. The SANS scattering radial widths reveal vortex states ordered in the sub-mum scale. We conjecture that the peak effect in this system is a remnant of the Bragg glass disordering transition, but occurs on submicron length scales due to the presence of strong atomic disorder on larger length scales.

Hypergravity as a crystallization tool.

The centrifugal increase of concentration is nondestructive, rapid, and simple technology. Therefore it is used to create a higher supersaturation that is required for crystal nucleation, as the one that is appropriate for the subsequent growth. Crystal nucleation is evoked in glass capillary tubes filled with protein solutions. The couple ferritin/ apoferritin is used as model proteins in the present article. Although differing in their masses the two (quasi) spherical molecules have exactly the same size and surface properties. Together with the temperature-independent solubility this makes them very convenient for our investigations. Decoupling nucleation and growth, for example, by means of hypergravity makes it possible to grow quasi-equidimensional crystals. The use of monodisperse crystalline forms of therapeutic agents can ensure constant time-release of protein-based medications.

[Inguinal endometriosis: two case reports and literature review].

Endometriosis is a common gynecological disease that is characterized by the presence of endometrial glands and stroma outside the uterus. Ectopic endometrial tissue can be localized in all organs of the human body, but it affects most often organs in the pelvis. The localization in the inguinal canal is extremely rare - 0.3% -0.6% of all cases of endometriosis. We report two cases of inguinal endometriosis in patients with a history of previous surgery in the pelvis. Both patients is formation in the inguinal region of increasing volume, accompanied by severe pain especially in the premenstrual period. The diagnosis was based on an exact medical history and histological examination. The main methods of treatment of inguinal endometriosis is radical surgical excision of the lesion. We recommend hormone therapy as an adjunct to treatment.

Intermolecular dipole-dipole relaxation of (129)Xe dissolved in water.

Intermolecular (129)Xe-(1)H nuclear Overhauser effects and (129)Xe longitudinal relaxation time measurements were used to demonstrate that the dipole-dipole coupling is the dominant relaxation mechanism for (129)Xe in water, at room temperature. (129)Xe-(1)H cross-relaxation rates were derived to be sigma(XeH) approximately 3.2 +/- 0.3 x 10(-3) s(-1), independent of xenon pressure (in the range of 1-10 bar) and of the presence of oxygen. Corresponding xenon-proton internuclear distances were calculated to be 2.69 +/- 0.12 A. Using the magnitude of the dipole-dipole coupling and the spin density ratio between dissolved xenon and bulk water, it is estimated that (129)Xe-(1)H spin polarization-induced nuclear Overhauser effects would yield little net proton signal enhancement in water.

An MR imaging method for simultaneous measurement of gaseous diffusion constant and longitudinal relaxation time.

A magnetic resonance imaging method for simultaneous and accurate determination of gaseous diffusion constant and longitudinal relaxation time is presented. The method is based on direct observation of diffusive motion. Initially, a slice-selective saturation of helium-3 (3He) spins was performed on a 3He/O2 phantom (9 atm/2 atm). A time-delay interval was introduced after saturation, allowing spins to diffuse in and out of the labeled slice. Following the delay interval a one-dimensional (1-D) projection image of the phantom was acquired. A series of 21 images was collected, each subsequent image having been acquired with an increased delay interval. Gradual spreading of the slice boundaries due to diffusion was thus observed. The projection profiles were fit to a solution of the Bloch equation corrected for diffusive motion. The fitting procedure yielded a value of D3He = 0.1562+/-0.0013 cm2/s, in good agreement with a measurement obtained with a modified version of the standard pulsed-field gradient technique. The method also enabled us to accurately measure the longitudinal relaxation of 3He spins by fitting the change of the total area under the projection profiles to an exponential. A value of T1 = 1.67 s (2 T field) was recorded, in excellent agreement with an inversion recovery measurement.

Cerebellopontine angle meningiomas. Clinical features and surgical treatment.

AIM: The aim of this study is to present the clinical picture of patients with cerebellopontine angle meningiomas and analyze the results of their operative treatment. METHODS: A retrospective study of patients with cerebellopontine angle meningiomas operated consecutively in our department over an 11-year period has been carried out. Data regarding their clinical features, surgical treatment, morbidity, mortality and outcome have been analyzed. Forty-four patients with cerebellopontine angle meningiomas were operated during the period 1991-2001 (intervention: tumor removal via the retrosigmoid suboccipital approach). MAIN OUTCOME MEASURES: clinical condition, MRI/ CT imaging. RESULTS: The median duration of symptoms prior to diagnosis was 44.5 months. The most frequent initial complaints were hearing loss, tinnitus and headache. Most frequent symptoms and signs at presentation were cerebellar, followed by hearing loss and trigeminal nerve symptoms. In 98% of the cases the operative approach used was the retrosigmoidal suboccipital. Total tumor removal was achieved in 55%. After total tumor removal no recurrences have been observed. The mortality rate was 2%. CONCLUSION: The application of different classification schemes complicates the comparison between published series. The outcome depends on their location, consistency, size and relation to the surrounding neurovascular structures. In our experience the retrosigmoid suboccipital approach is most appropriate for their surgical treatment. It offers the possibility to remove completely even large meningiomas and avoids the risk of recurrences.

Totally chlorine-free bleaching of flax pulp.

Alkaline-sulphite Tamlin flax mill pulp of 34-41% brightness has been bleached with different totally chlorine-free (TCF) sequences (oxygen delignification, pressurised peroxide, peroxide without and with activator (TAED, tetraacetylethylenediamine) and with and without pre-treatment with ultrasound to 82% ISO brightness of the mill conventional CEH bleaching. Although the best results after oxygen delignification were obtained with pressurised peroxide, activated peroxide caused lower cellulose degradation and gave a higher pulp strength. The effects of temperature, retention time, chemical charge, TAED/peroxide ratio and alkalinity have been studied in order to maximise the brightness gain at lower viscosity loss. The chemistry and flexibility of TAED made it possible to activate the peroxide under conditions for which the peroxide alone is ineffective as a bleach, such as low alkalinity or low temperature. The presence of shives hindered the bleaching, but the bleached non-screened pulp was stronger than the screened one. Pre-treatment with ultrasound for 4 min of 1% pulp consistency gave 3-4% gain in ISO brightness for non-screened pulp and 2% for screened pulp and facilitated further delignification and peroxide bleaching.