Management of thoracoabdominal gunshot injuries by using minimally invasive surgery at role 2 deployed field hospitals in Ukraine.

The Russia-Ukraine war is associated with critical and severe thoracoabdominal injuries. A more specific approach to treating patients with thoracoabdominal injury should also include minimally invasive technologies. It remains unclear about the utility of using video-assisted thoracoscopic surgery (VATS) and laparoscopy in patients with thoracoabdominal injury. The aim of this study was to investigate and evaluate the utility of video-assisted thoracoscopic surgery, laparoscopy as well as magnetic tool applications for the management of severe thoracoabdominal injury in combat patients injured in the ongoing war in Ukraine and treated in the Role 2 deployed hospital. Patients and methods 36 male combat patients thoracoabdominal injury were identified for the study during the first 100 days from February, 24 2022. These individuals were diagnosed with thoracoabdominal GSW in the Role 2 hospital (i.e. deployed military hospital) of the Armed Forces of Ukraine. Video-assisted thoracoscopy surgery (VATS) and laparoscopy with application of surgical magnetic tools were applied with regards to the damage control resuscitation and damage control surgery. Results In 10 (28%) patients, VATS was applied to remove the metal foreign body fragments. Both thoracotomy and laparotomy were performed in 20 (56%) hemodynamically unstable patients. Of these 20 patients, the suturing of the liver was performed in 8 (22%) patients, whereas peri-hepatic gauze packing in 12 (33%) patients. Massive injury to the liver and PI 2.0-3.0 were diagnosed in 2 (6%) patients. Lethal outcome was in 1 (2.8%) patient. Conclusions Thoracoabdominal gunshot injuries might be managed at Role 2 hospitals by using video-assisted thoracoscopy (VATS) and laparoscopy accompanied by surgical magnetic tools. Damage control surgery and damage control resuscitation must be applied for patients in critical and severe conditions.

Gunshot injury to the colon by expanding bullets in combat patients wounded in hybrid period of the Russian-Ukrainian war during 2014-2020.

BACKGROUND: A gunshot wound to the colon is a frequent injury in armed conflicts. An example of a high-energy modern weapon is hollow-point bullets, which is associated with increased tissue damage and lethal outcome. The aim of this study was to evaluate gunshot injuries to the colon in combat patients and to assess the difference in clinical features of patients with colon injuries by hollow-point versus shape-stable bullets. PATIENTS AND METHODS: Analyses of clinical data were performed on 374 male soldiers from the Armed Forces of Ukraine with gunshot abdominal wounds with injury to the colon in East Ukraine between 2014 and 2020. Out of 374 injured, 112 (29.9%) patients were diagnosed with penetrating gunshot bullet wounds: 69/112 (61.6%) were injured by shape-stable bullets, and the hollow-point bullets injured 43/112 (38.4%) patients. RESULTS: More severe hemorrhagic shock stages were in patients injured by hollow-point bullets: shock stages III-IV was in 25 (58.1%) patients injured by the hollow-point bullets vs. 17 (24.6%) patients injured by shape-stable bullets (p = 0.0004). Left colon parts were more frequently injured as compared to the right colon side or transverse colon: 21 (48.8%) patients were injured by the hollow-point bullets (p < 0.0001), and 41 (59.4%) patients were injured by the shape-stable bullets (p = 0.032). A significant difference was identified for the frequent injury to the middle colon within the entire cohort (p = 0.023). Patients injured by the hollow-point bullets demonstrated a higher frequency of 3-5 areas of colon gunshot defects, which was detected in 18 (41.8%) patients injured by hollow-point bullets and none with shape-stable bullets injury (p = 0.0001). Colon Injury Scale (CIS) IV was detected in 7 (16.3%) patients injured by the hollow-point bullets as compared to 2 (2.9%) patients injured by shape-stable bullets (p = 0.011). Colostomy was performed in 14 (69%) patients injured by shape-stable bullets and in 12 (27.9%) patients injured by hollow-point bullets (p > 0.05). 15 (35%) patients died after injury by the hollow-point bullet, whereas 9 (13%) patients after damage by the shape-stable bullets (p = 0.0089). CONCLUSIONS: All patients should be suspected to have an injury by bullet with expanding properties in case of penetrating abdominal injury (absent of outlet wound) and careful revision of the abdomen must be performed to identify possible multiorgan injury as well as multiple gunshot defects of the intestine.

Amplification of 2p as a genomic marker for transformation in lymphoma.

To outline further genetic mechanisms of transformation from follicular lymphoma (FL) to diffuse large B-cell lymphoma (DLBCL), we have performed whole genome array-CGH in 81 tumors from 60 patients [29 de novo DLBCL (dnDLBCL), 31 transformed DLBCL (tDLBCL), and 21 antecedent FL]. In 15 patients, paired tumor samples (primary FL and a subsequent tDLBCL) were available, among which three possessed more than two subsequent tumors, allowing us to follow specific genetic alterations acquired before, during, and after the transformation. Gain of 2p15-16.1 encompassing, among others, the REL, BCL11A, USP34, COMMD1, and OTX1 genes was found to be more common in the tDLBCL compared with dnDLBCL (P < 0.001). Furthermore, a high-level amplification of 2p15-16.1 was also detected in the FL stage prior to transformation, indicating its importance during the transformation event. Quantitative real-time PCR showed a higher level of amplification of REL, USP34, and COMMD1 (all involved in the NFκΒ-pathway) compared with BCL11A, which indicates that the altered genes disrupting the NFκΒ pathway may be the driver genes of transformation rather than the previously suggested BCL11A. Moreover, a 17q21.33 amplification was exclusively found in tDLBCL, never in FL (P < 0.04) or dnDLBCL, indicating an upregulation of genes of importance during the later phase of transformation. Taken together, our study demonstrates potential genomic markers for disease progression to clinically more aggressive forms. We also confirm the importance of the TP53-, CDKN2A-, and NFκΒ-pathways for the transformation from FL to DLBCL.

Spontaneous longitudinal rupture of the thyroid cartilage: A management of the rare clinical case.

INTRODUCTION AND IMPORTANCE: Non-traumatic rupture or other injuries to the larynx are very rare disorder. According to the published series, there are only 15 cases reported with such kind of injury to the larynx. Despite the rarity of the non-traumatic larynx fracture, it is important to elucidate adequate management for the patients with such emergency. The aim of the study is to demonstrate the features of clinical manifestations, examination, and surgical treatment of a case of spontaneous longitudinal rupture of the thyroid cartilage. PRESENTATION OF CASE: A 54-year-old male patient presented with chief complaints of pain in the front surface of the neck, difficulty swallowing and breathing during physical exertion, hyperemia of the skin on the front surface of the neck, and the presence of subcutaneous emphysema. 20 h after the onset of the symptoms, the patient reported breathing difficulties that appeared during physical exertion, and the patient walked to the hospital. Computed tomography revealed a longitudinal rupture of the thyroid cartilage, emphysema of the neck, and the presence of air in the anterior-upper mediastinum. The defect of the ruptured thyroid cartilage was treated by suturing as well as by myoplasty using sternocleidomastoid muscle. CLINICAL DISCUSSION: Our case report is in line with others, showing that patient with spontaneous rupture of the thyroid cartilage is the surgical emergency. Our approach of using myoplasty was not presented before. CONCLUSION: This case report adds evidence and knowledge about such rare disorders as spontaneous rupture the thyroid cartilage rupture. It is useful to apply the technique of myoplasty with sternocleidomastoid muscle flaps, ensuring reliable sealing of the damaged area reducing the risk of failure, and inflammatory complications, and supporting neck functions in the postoperative period.

A rare case of endoscopic removal of the metal fragment from the segmental bronchus after gunshot injury to the chest in combat patient injured in the war in Ukraine.

INTRODUCTION AND IMPORTANCе: Russo-Ukrainian war is associated with severe injuries to the chest. Isolated chest injuries are associated with high mortality or advanced invalidization due to the severity of the trauma. The aim of the study was to demonstrate the experience and the challenges in diagnosis and management of the combat patient with gunshot injury to the lungs with subsequent migration of the shrapnel projectile to the segmental bronchus and its bronchoscopic removal by using forceps. CASE PRESENTATION: A male patient 44 years of age was injured at an artillery strike in East Ukraine. The patient was evacuated to the Forward Surgical Team (Role 1) facility within one hour after the injury. The bronchoscopy was performed and to our surprise, the metal fragment in the lumen of the right segmental S2 bronchi was visualized at bronchoscopy, indicating its migration from the first place. The decision was made to attempt to remove the metal fragment endoscopically. At bronchoscopy, the metal fragment was caught by the endoscopic forceps and therefore removed endoscopically. The time of endoscopic removal of the metal fragment was 8 min. CLINICAL DISCUSSION: Removal of a foreign body (metal fragment) of gunshot origin from the lumen of a segmental bronchus by using bronchoscopy with endoscopic forceps is a rare phenomenon. CONCLUSIONS: The use of minimally invasive technologies in the treatment of gunshot blind penetrating wounds of the chest contributes to the reduction of operative trauma and shortens the time of operative treatment.

Management of gunshot injury to the abdominal aorta and inferior vena cava: a case report of a combat patient wounded in the Russo-Ukrainian war.

BACKGROUND: Russo-Ukrainian war is associated with severe traumas, including injuries to the major vessels. Penetrating aortic injury remains one of the most difficult injuries; the mortality rate is 90-100% in case of gunshot wounds, associated with frequent lethal outcomes due to uncontrolled bleeding. Of the three main abdominal veins, the inferior vena cava (IVC) is the most frequently damaged, which is required quick and appropriate surgical decisions to be made. Little is known about the management of gunshot injuries to such major vessels as the aorta and IVC. It is also worth mentioning about the importance to share our practical experience from the ongoing war for better understanding and future considerations by war surgeons of the vascular trauma management. The aim of the study was to demonstrate the specific features of the diagnosis and management of a gunshot shrapnel blind penetrating wound to the abdomen with injury to the aortic bifurcation level and the infrarenal section of the inferior vena cava. CASE PRESENTATION: A 44-year-old male soldier of the Armed Forces of Ukraine received a gunshot injury to the abdomen from a mortars' explosive shelling. The patient was evacuated to the Forward Surgical Team (Role 1) and received primary surgical treatment within one hour after the injury according to the "golden hour" principle. Then, evacuated was performed to the Role 3 hospital in Kharkiv. At the Role 3 hospital, the patient underwent second-look surgery as well as damage control surgery. At revision, no active bleeding was observed, and the surgical pads (packed previously by the Forward Surgical Team) were removed. Further revision showed a metal projectile within the aortic wall at the level of aortic bifurcation and wall defects were also detected for inferior vena cava. This metal projectile was removed by using the multifunctional surgical magnetic tool followed by suturing of the aortic wall defect as well as defects of the inferior vena cava. CONCLUSIONS: Application of Damage Control Surgery is a useful approach in the management of severe vascular injury as well as useful to stop abdominal contamination by intestinal contents. The application of a surgical magnetic tool for the searching and removal of ferromagnetic foreign bodies reduces operative trauma and reduces the time for identification of foreign bodies.

Management of severe defects of humerus in combat patients injured in Russo-Ukrainian war.

INTRODUCTION: Russo-Ukrainian war is associated with application of high-energy weapon, causing severe multifragmental injuries to the bones an associating with severe bone defects. The aim of the study was to evaluate various methods to treat combat patients with severe defects of humerus and to demonstrate the experience of orthopedic war surgeons in managing gunshot injuries to the humerus defects in the ongoing war. PATIENTS AND METHODS: A 24 patients were active-duty military personnel of Armed Forces of Ukraine. These patients were diagnosed with severe humerus defects due to gunshot injury in battlefield zone in various areas of Ukraine. Data was collected within period between February, 24th 2022 till January, 01st 2023. The following approaches were applied to replace bone defect: preoperative 3D printing with polyetheretherketone (PEEK) as orthobiological material; closed reduction, percutaneous lag screw and Ilizarov external fixation; vascularized fibula grafting. RESULTS: Data analyses of the segmental defects of humerus showed 5 cm defect in 3 (13 %) patients, from 5 to 10 cm in 4 (17 %) patients, over 10 cm in 17 (71 %) patients. Analyses were performed in these 17 (71 %) patients, showing 5 patients treated with 3D-printed PEEK implants, 6 patients with vascular-pedicle graft of fibula, 6 patients with closed reduction, percutaneous lag screw, Ilizarov external fixation. Osteomyelitis was diagnosed in one case (20 %) after the use of PEEK implants, requiring to remove both PEEK implant and metal implants followed by application of the antibiotic joint spacers and Ex-Fix fragments of the humerus. In our opinion, the osteomyelitis happened due to inadequate debridement of the wound and non-compliance with the conversion criteria (replacement of the fixation method). The mean length of hospital stay was 5.5 months for patients treated with 3D-printed PEEK implants. CONCLUSIONS: Closed reduction, percutaneous lag screw and Ilizarov external fixation as well as vascularized fibula grafting are associated with good outcomes in management of the patients with severe humerus defect due to gunshot injury. 3D printing and PEEK implants could also be considered for the reconstructions of the humerus multifragmental fractures with a bone defect over 10 cm associated with gunshot injury due to high-energy weapon in the war settings.

Biochemical markers for prediction of the first half pregnancy losses: a review.

Objective: 26% of all pregnancies end in miscarriage, and up to 10% of clinically diagnosed pregnancies, and recurrent pregnancy loss is 5% among couples of childbearing ages. Although there are several known causes of pregnancy loss in the first half, including recurrent pregnancy loss, including parental chromosomal abnormalities, uterine malformations, endocrinological disorders, and immunological abnormalities, about half of the cases of pregnancy loss in its first half remain unexplained. Methods: The review includes observational controlled studies (case-control or cohort, longitudinal studies, reviews, meta-analyses), which include the study of biochemical factors for predicting pregnancy losses in the first half, in singlet pregnancy. The Newcastle-Ottawa Scale (NOS) was used to assess the research quality. Results: Finally, 27 studies were included in the review, which has 134904 examined patients. The results of the review include estimates of ß-human chorionic gonadotropin, progesterone, pregnancy-associated protein - A, angiogenic vascular factors, estradiol, α-fetoprotein, homocysteine and CA-125 as a predictors or markers of the first half pregnancy losses. Conclusion: It may be concluded that to date, research data indicate the unavailability of any reliable biochemical marker for predicting pregnancy losses in its first half and require either a combination of them or comparison with clinical evidence. A fairly new model shall be considered for the assessment of α-fetoprotein in vaginal blood, which may have great prospects in predicting spontaneous miscarriages.

Penetrating gunshot wounds to the penis: a case report of combat patient injured in the war in Ukraine.

BACKGROUND: The current war in Ukraine is associated with frequent applications of multiple-launch rocket systems and cruise missiles as well as other various high-energy weapons to cause severe injuries in military personnel including abdomen wounds, vascular injury, and limb amputations as well as genitourinary trauma. The aim of this report is to demonstrate a case of successful penile salvage by restoring its function in a combat patient with gunshot genitourinary trauma in conditions of an interrupted supply of medical equipment. CASE PRESENTATION: We describe a case of a 48-year-old male patient with a combined shrapnel gunshot wound to the penis with damage to the urethra and combined injury to the soft tissues of the left thigh. Several hours after the injury, the patient underwent primary surgical debridement of the left thigh, ligation of the great saphenous vein of the thigh, primary sutures on the penile urethra and navicular fossa, suturing of the rupture of the head and penis, drainage of the wound, catheterization of the bladder, and epicystostomy. An artificial erection was performed intraoperatively. The urethral catheter was removed 3 weeks after urethral suturing (May 4, 2022). The epicystostomy was removed 5 months after the injury (August 4, 2022) and 2 days after the restoration of spontaneous urination. At the follow-up of 7 months after the injury, the patient has normal urination with minor urinary dribbling, sufficient erection, and ejaculation. CONCLUSIONS: We have shown that in a case of gunshot wounds to the penis and hanging part of the urethra, even in the presence of combined severe purulent lesions of non-urological localizations, it is possible to perform a primary reconstruction of urogenital injuries using a primary urethral suture and applying a negative pressure device. Findings from this case report shed new light on the management of penile gunshot injury in ongoing warfare as well as provide evidence of the possibility to perform adequate management for penile injury in conditions of limited medical resources, violation of international humanitarian law, and under frequent strikes of high-energy weapons.

Temporary arterial shunts in combat patient with vascular injuries to extremities wounded in Russian-Ukrainian war: A case report.

INTRODUCTION AND IMPORTANCE: Vascular injuries to extremities are common in armed conflicts. Such kind of injury is associated with a high risk of critical ischemia, limb amputation, and high morbidity. There is a clinical challenge for the management of vascular injuries to extremities in ongoing warfare due to limited medical resources. PRESENTATION OF CASE: A 34 years old male received a gunshot injury to both low extremities on March, 23rd 2022 in a battlefield area 30 km away from Kyiv city. CAT tourniquet was applied to stop the bleeding and the patient was transported to Level II by ambulance 40 min after the injury. The patient was diagnosed with a gunshot injury to the left superficial femoral artery (SFA) followed by primary surgical debridement and temporary arterial shunting at Level II hospital. Then the patient was evacuated to Level IV hospital, diagnosed with an injury to the right popliteal artery, and underwent vascular reconstruction. CLINICAL DISCUSSION: Arterial shunting is a well-known approach to prevent critical ischemia and limb amputations of injured extremities in both combat and civilian patients. This case report provides evidence for the utility of temporary arterial shunting in combat conditions, which is supported by data from the larger cohorts. We consider temporary vascular shunting as a damage control measure to be associated with high chances of limb salvage in ongoing warfare. CONCLUSION: Our study demonstrated the utility of temporary arterial shunting in combat patients with gunshot wounds in ongoing warfare, which could be performed even in case of limited medical resources.

Retrieval of ferromagnetic fragments from the lung using video-assisted thoracoscopic surgery and magnetic tool: a case report of combat patient injured in the war in Ukraine.

BACKGROUND: Gunshot wounds injury to the thorax is common in armed conflicts or war, including the war of Russia against Ukraine. Injury to the chest is associated with a high mortality or physical disability due to damage to the lungs, heart, and major vessels. The aim of this report is to demonstrate a case of successful management of severe gunshot injury to the lungs using video-assisted thoracoscopic surgery and magnetic tool for a combat patient injured in the war in Ukraine. CASE PRESENTATION: A 51-year-old soldier of the Armed Forces of Ukraine received a gunshot injury due to shelling from artillery strikes in the Donbas battlefield area. After evacuation to Level II, a forward surgical team performed primary surgical debridement. Two hours after the injury, the patient was evacuated to the Level IV of medical care (Kharkiv). At Level IV, a CT scan showed penetrating gunshot wounds to the left part of the chest with injury to the upper lobe of the left lung with the presence of the 2 metal fragments of the artillery projectile with the size of 2.5 × 2.0 cm and 1.0 × 1.0 cm. These two fragments were removed by using video-assisted thoracoscopic surgery (VATS) using the inlet gunshot hole in the left lateral chest area, as well as the assistance of a magnetic tool. CONCLUSIONS: VATS and magnetic technologies should be considered for hemodynamically stable combat patients with a gunshot injury to the lungs in the ongoing war. Each combat patient could be treated by individualized approach such as using the wound canal as a scope port after primary surgical debridement of the wound and antibiotic prophylaxis.

A new approach for reconstruction of the gunshot defect of the flexor surface of the ungual (distal) phalanx by the proper transverse branch of the digital artery: a case report of combat patient injured in the Russo-Ukrainian war.

BACKGROUND: Gunshot injury to the hand is severe trauma, requiring complicated reconstruction surgery for the damaged anatomic site to restore all the hand functions. The aim of this study was to show the example of the distal phalanx reconstruction by using a flap with distal transverse digital artery (DTDA) blood supply as well as to demonstrate the utility of the audio Doppler application at the reconstruction stage in the combat patient injured in the Russo-Ukrainian war. CASE PRESENTATION: In this report, we present a case of a 26-year-old service member of the Ukrainian Armed Forces delivered to the Military Medical Clinical Centre on the fourth day after the gunshot gutter shrapnel wound of the distal flexor of the 2nd digit with a gunshot fracture of the ungula (distal) and middle phalanges of the 2nd digit of the right hand along with a bone deficiency of the osseous structure of the distal and middle phalanges, volar soft tissues. The dorsal metacarpal artery (DMCA) flap is a universal variant among the tools of the reconstructive plastic surgeon engaged in reconstructing defects of the digital dorsum and flexors with a limited range of flaps. We consider this to be a key that conforms with the majority of the reconstructive principles, such as 'analog replacement', and which is simple, adequate, and easy for operating with a minimal sequela of the donor site. CONCLUSIONS: The distal transverse digital artery (DTDA) could be considered for hand reconstructive surgery for repairing defects of the flexor surface of the digit injury and hands after severe gunshot injury.

Challenges of Differential Diagnosis Between Primary Hyperparathyroidism and Bone Metastases of Breast Cancer.

Breast cancer might be complicated by distant metastases accompanied by hypercalcemia, but hyperparathyroidism is not commonly considered in the differential diagnosis. We present a case of 38 years old female patient who was diagnosed with ductal breast carcinoma. Eight months after the initial diagnosis the patient was diagnosed with distant bone metastases. However, this diagnosis was reconsidered at follow up, because we identified elevation of PTH 137.2 pg/ml, Ca2+ 1.19 mmol/l, albumin corrected calcium 2.42 mmol/l, 25(OH)D 39.4 nmol/l, indicating hyperparathyroidism. Scintigraphy with 99mTC-sestamibi confirmed parathyroid adenoma. Postoperative histopathology confirmed 1.2 g chief-cell PTA. Two months after the operation both PTH and Ca2+ levels were within the normal ranges. This study emphasizes the importance of considering possible hyperparathyroidism in patients with breast cancer and hypercalcemia. Routine evaluation of PTH is considered as a reasonable test in patients with breast cancer accompanied by bone lesions.

Retained bullet in the neck after gunshot wounds to the chest and arm in combat patient injured in the war in Ukraine: A case report.

INTRODUCTION AND IMPORTANCE: A gunshot wound is the most common injury in armed conflicts, resulting in severe trauma and increased morbidity usually due to damage to major vessels. Gunshot injury could be associated with the projectile location in one anatomical area, but the initial inlet place in another. PRESENTATION OF CASE: A 33-years old male patient received gunshot injuries to the left axillary area of the chest and left upper extremity in the battlefield area near Kyiv (Ukraine). The patient was diagnosed with multiple gunshot injuries, as judged from the presence of inlet and outlet holes in the chest and left upper arm. Without having any major complaints, the patient was examined by chest X-ray, showing a metal density fragment in the area of the first left rib, behind the left clavicle and adjacent to the left common carotid artery (CCA) and internal jugular vein (IJV). Surgery revealed 25 mm retained bullet in the area between CCA and IJV. CLINICAL DISCUSSION: Our case report is in line with others, showing that identification of the bullet or projectile fragment in unexpected locations was made by chance or due to routine application of protocols for the clinical evaluation of combat patients, including those without clinical signs or specific complaints. CONCLUSION: A gunshot injury could be associated with an unusual bullet trajectory. A routine whole-body CT scan or chest and abdominal X-ray should be performed for all patients with gunshot injury of any localization for early detection of a possible retained bullet.

Application of Damage Control Tactics and Transpapillary Biliary Decompression for Organ-Preserving Surgical Management of Liver Injury in Combat Patient.

The combat penetrating gunshot injury is frequently associated with damage to the liver. Bile leak and external biliary fistula (EBF) are common complications. Biliary decompression is commonly applied for the management of EBF. Also, little is known about the features of combat trauma and its management in ongoing hybrid warfare in East Ukraine. A 23-year-old male was diagnosed with thoracoabdominal penetrating gunshot wound (GSW) by a high-energy multiple metal projectile. Damage control tactics were applied at all four levels of military medical care. Biliary decompression was achieved by endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and the placement of biliary stents. Occlusion of the stent was treated by stent replacement, and scheduled ERCP was performed. Partial EBF was diagnosed from the main wound defect of the liver and closed without surgical interventions on the 34th day after the injury. A combination of operative and nonoperative techniques for the management of the combat GSW to the liver is effective along with the application of damage control tactics. A scheduled ERCP application is an effective approach for the management of EBF, and liver resection could be avoided. A successful biliary decompression was achieved by the transpapillary intervention with the installation of stents. Stent occlusion could be diagnosed in the early post-traumatic period, which is effectively managed by scheduled ERCP as well as stent replacement with a large diameter as close as possible to the place of bile leak.

Intraoperative detection of parathyroid glands by autofluorescence identification using image-based system: report of 15 cases.

BACKGROUND: A detection of parathyroid glands by the evaluation of their autofluorescence in the near-infrared spectrum is considered as a promising tool in addition to their visual verification. The aim of this study was to evaluate the role of near-infrared autofluorescence application by using two different image-based systems for the identification of parathyroid glands during surgery of thyroid and parathyroid benign and malignant lesions. METHODS: Evaluation of near-infrared autofluorescence was performed in 15 patients by using two different image-based systems equipped with a near-infrared laser camera. Intravenous injection of fluorophore indocyanine green was used for the enhancement of near-infrared autofluorescence signal. RESULTS: Normal parathyroid glands were identified and mobilized after visual inspection in 12 (80%) patients, which was confirmed by near-infrared autofluorescence evaluation. Confident recognition of parathyroid glands by near-infrared autofluorescence signal and their subsequent distinction from lymph nodes was achieved in two (13%) patients with prior surgery for papillary thyroid carcinoma. In one (7%) case, parathyroid gland was identified as fragments of tissue within the postoperative scarring area by near-infrared autofluorescence evaluation, but not by visual inspection. A less intensive near-infrared autofluorescence signal was detected in the parathyroid gland owing to unintentional excision in one (7%) case. Better signal intensity from parathyroid glands was noticed after changes of the near-infrared camera in Fluobeam 800 image-based system in position to an angle of approximately 45-65° in relation to area of interest in all cases as compared with holding straight on the parathyroid gland. Fluobeam LX demonstrated a good near-infrared autofluorescence signal without any specific changes in the camera angle. Thyroid carcinoma demonstrated low-intensity signal in the case of invasion to thyroid capsule. No fluorescent signal was identified from metastatic, or from normal, lymph nodes. CONCLUSIONS: The application of near-infrared autofluorescence imaging is considered as a useful, but additional, tool for the visual assessment of parathyroid gland in the case of primary neck exploration. The utility of near-infrared autofluorescence imaging for parathyroid detection is increased in the case of repeated surgical intervention owing to increased risk of unintentional parathyroid removal as well as for discrimination of parathyroids from the lymph nodes in cases of thyroid malignancy.

Prognostic role of increased serum homocysteine concentration in preeclampsia.

Objective: To assess homocysteine (Hcy) concentration in women with preeclampsia (PE).Methods: Hcy concentrations were detected by ELISA in 305 pregnancies.Results: Hcy concentration in patients with PE was 16.07 umol/L at 10-14 weeks as compared to 7.19 umol/L in normotensive pregnancies (p < 0.0001). Optimal cutoff level for Hcy in the first trimester of pregnancy was >9.55 umol/L with area under curve of 0.859, sensitivity of 91.67%, specificity of 72.24%.Conclusion: Assessment of serum Hcy concentration may be used as a predictor of PE, with the highest diagnostic utility in the first trimester of pregnancy.

Non-Operative Management of Bronchobiliary Fistula Due to Proximal Migration of Biliary Stent in a Patient With Unresectable Klatskin Tumor.

INTRODUCTION: One of the methods for the biliary tree decompression in the case of Klatskin tumor is transpapillary stenting, which could be completed by stent migration in 4% to 10% of cases. Approximately half of the stent migrations are in the proximal direction. In this study, we reported a rare case of proximal trans-diaphragmatic stent migration to the lower lobe of the right lung with the formation of a biliary-bronchial fistula (BBF). CASE PRESENTATION: A 60-year-old woman was diagnosed with hilar cholangiocarcinoma (type 3B by Bismuth-Corlette) complicated by posthepatic jaundice. To relieve jaundice there were performed endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, endobiliary stent placement (10 Fr, 150 mm). A restenting (11.5 Fr, 130 mm) was performed in 2.5 months due to endobiliary tube occlusion. In the next 2 months, coughing attacks and biliptysis have appeared in the patient. A CT scan showed penetration of the liver, diaphragm, and lower lobe of the right lung with the proximal part of the stent and caused BBF formation. Anti-inflammatory and antibacterial therapy was administrated for 14 days and BBF was closed. Stent retrieval from the right hemithorax and endobiliary restenting was performed in 9 months after primary stenting. During follow-up, appropriate positioning and functioning of the stent were observed. CONCLUSION: BBF formation is a rare complication of endobiliary stenting, which can be successfully treated by anti-inflammatory and antibiotic therapy, followed by transpapillary stent retrieval.

Biochemical markers for prediction of the first half pregnancy losses: a review

Abstract Objective 26% of all pregnancies end in miscarriage, and up to 10% of clinically diagnosed pregnancies, and recurrent pregnancy loss is 5% among couples of childbearing ages. Although there are several known causes of pregnancy loss in the first half, including recurrent pregnancy loss, including parental chromosomal abnormalities, uterine malformations, endocrinological disorders, and immunological abnormalities, about half of the cases of pregnancy loss in its first half remain unexplained. Methods The review includes observational controlled studies (case-control or cohort, longitudinal studies, reviews, meta-analyses), which include the study of biochemical factors for predicting pregnancy losses in the first half, in singlet pregnancy. The Newcastle-Ottawa Scale (NOS) was used to assess the research quality. Results Finally, 27 studies were included in the review, which has 134904 examined patients. The results of the review include estimates of β-human chorionic gonadotropin, progesterone, pregnancy-associated protein - A, angiogenic vascular factors, estradiol, α-fetoprotein, homocysteine and CA-125 as a predictors or markers of the first half pregnancy losses. Conclusion It may be concluded that to date, research data indicate the unavailability of any reliable biochemical marker for predicting pregnancy losses in its first half and require either a combination of them or comparison with clinical evidence. A fairly new model shall be considered for the assessment of α-fetoprotein in vaginal blood, which may have great prospects in predicting spontaneous miscarriages.

Unexpected Routes of the Mutagenic Tautomerization of the T Nucleobase in the Classical A·T DNA Base Pairs: A QM/QTAIM Comprehensive View.

In this paper using quantum-mechanical (QM) calculations in combination with Bader's quantum theory of "Atoms in Molecules" (QTAIM) in the continuum with ε = 1, we have theoretically demonstrated for the first time that revealed recently highly-energetic conformers of the classical A·T DNA base pairs - Watson-Crick [A·T(wWC)], reverse Watson-Crick [A·T(wrWC)], Hoogsteen [A·T(wH)] and reverse Hoogsteen [A·T(wrH)] - act as intermediates of the intrapair mutagenic tautomerization of the T nucleobase owing to the novel tautomerisation pathways: A·T(wWC)↔A·T*(w⊥ WC); A·T(wrWC)↔A· T O 2 * (w⊥ rWC); A·T(wH)↔A·T*(w⊥ H); A·T(wrH)↔A· T O 2 * (w⊥ rH). All of them occur via the transition states as tight ion pairs (A+, protonated by the N6H2 amino group)·(T-, deprotonated by the N3H group) with quasi-orthogonal geometry, which are stabilized by the participation of the strong (A)N6+H···O4-/O2-(T) and (A)N6+H···N3-(T) H-bonds. Established tautomerizations proceed through a two-step mechanism of the protons moving in the opposite directions along the intermolecular H-bonds. Initially, proton moves from the N3H imino group of T to the N6H2 amino group of A and then subsequently from the protonated N6+H3 amino group of A to the O4/O2 oxygen atom of T, leading to the products - A·T*(w⊥ WC), A· T O 2 * (w⊥ rWC), A·T*(w⊥ H), and A· T O 2 * (w⊥ rH), which are substantially non-planar, conformationally-labile complexes. These mispairs are stabilized by the participation of the (A)N6H/N6H'···N3(T) and (T)O2H/O4H···N6(A) H-bonds, for which the pyramidalized amino group of A is their donor and acceptor. The Gibbs free energy of activation of these mutagenic tautomerizations lies in the range of 27.8-29.8 kcal·mol-1 at T = 298.15 K in the continuum with ε = 1.