Giant conjunctival melanoma treated with excision and primary reconstruction using a partial thickness skin graft.

Conjunctival melanoma is a rare type of malignancy of ocular surface tissue with a high recurrence rate, sight, and life-threatening malignancy. In this paper, we report a case of giant conjunctival melanoma in an 86-year-old woman, localized on her left eye. The pigmented tumor lesion was de novo occurred and treated by local wide excision and reconstruction of the presented defect by partial thickness skin from the inside parts of the forearm. The eye itself was not damaged, and the first-line lymph nodes showed no malignant activity. In the three years of follow-up, no signs of recurrence have been observed. The treatment approach with local excision and subsequent reconstruction with the partial thickness skin graft or excision with adjuvant therapy has given a good clinical outcome.

The Regenerative Potential of Donkey and Human Milk on the Redox-Sensitive and Proliferative Signaling Pathways of Skin Fibroblasts.

The influence of milk bioactive peptides on skin regenerative potential and rejuvenation is very often limited because of allergic reactions. The current study is aimed at exploring the influence of donkey colostrum and mature milk, human colostrum and mature milk, and ß-casein and ß-casomorphine-7, on the growth and inflammatory response of the culture of cultured skin fibroblasts exposed to these conditions for twenty-four hours. Their effects on the growth-regulatory kinases and redox-sensitive, proinflammatory transcriptional factor NF-κB were detected by using specific primary antibodies against NF-κB p65, Akt-1, phospho-Akt-1, Erk-1, phospho-Erk-1, JNK, phospho-JNK, phospho-STAT-1, and CD26, while logarithmic integrated fluorescence intensity patterns were recorded by flow cytometry. The downregulation of NF-κB p65 was observed after the exposure of skin fibroblasts to donkey milk and human colostrum, while ß-casein and ß-casomorphine-7 exerted the opposite effect, which suggests that noncasein bioactive peptides of donkey and human milk may be responsible for anti-inflammatory properties. The exposure to all milk species examined and ß-casein leads to the activation of growth-regulatory kinases (Akt1/2/3 kinase, Erk kinase, JNK kinase, and Stat-1 kinase), especially for the p-Erk pathway, which suggests that essential amino acids of casein may be responsible for Erk-induced cell cycle activation and proliferation. The opposite effect was observed when cells were exposed to ß-casomorphine-7, which may affect the skin fibroblast survival and their proliferative and regenerative potential. Donkey milk did not significantly change the CD26 antigen expression. In conclusion, our results suggest that among cell signaling molecules, the most sensitive but nonspecific downstream effector is p-Erk kinase, which may point to donkey milk usefulness in wound healing, regenerative, and aesthetic dermatology. The noncasein bioactive peptides of donkey milk may be responsible for the anti-inflammatory property of donkey milk and colostrum, which may indicate the usefulness in the treatment of inflammatory skin diseases.

Peptidomics of an in vitro digested α-Gal carrying protein revealed IgE-reactive peptides.

The mammalian carbohydrate galactose-α1,3-galactose (α-Gal) causes a novel form of food allergy, red meat allergy, where patients experience severe allergic reactions several hours after red meat consumption. Here we explored gastric digestion of α-Gal glycoproteins using an in vitro model. Bovine thyroglobulin (BTG), a typical α-Gal carrying glycoprotein, was digested with pepsin. The resulting peptides were characterised by SDS PAGE, immunoblot and ImmunoCAP using sera from 20 red meat allergic patients. During pepsinolysis of BTG, a wide range of peptide bands was observed of which 14 to 17 kDa peptides remained stable throughout the gastric phase. The presence of the α-Gal epitope on the obtained peptides was demonstrated by an anti-α-Gal antibody and IgE from red meat allergic patients. The α-Gal digests were able to inhibit up to 86% of IgE reactivity to BTG. Importantly, basophil activation test demonstrated that the allergenic activity of BTG was retained after digestion in all four tested patients. Mass spectrometry-based peptidomics revealed that these peptides represent mostly internal and C-terminal parts of the protein, where the most potent IgE-binding α-Gal residues were identified at Asn1756, Asn1850 and Asn2231. Thus allergenic α-Gal epitopes are stable to pepsinolysis, reinforcing their role as clinically relevant food allergens.

Peanut protein structure, polyphenol content and immune response to peanut proteins in vivo are modulated by laccase.

Food texture can be improved by enzyme-mediated covalent cross-linking of different food components, such as proteins and carbohydrates. Cross-linking changes the biological and immunological properties of proteins and may change the sensitizing potential of food allergens. In this study we applied a microbial polyphenol oxidase, laccase, to cross-link peanut proteins. The size and morphology of the obtained cross-linked proteins were analyzed by electrophoresis and electron microscopy. Structural changes in proteins were analyzed by CD spectroscopy and by using specific antibodies to major peanut allergens. The bioavailability of peanut proteins was analyzed using a Caco-2 epithelial cell model. The in vivo sensitizing potential of laccase-treated peanut proteins was analyzed using a mouse model of food allergy. Finally, peanut polyphenols were analyzed by UHPLC-MS/MS, before and after the enzymatic reaction with laccase. Laccase treatment of peanut proteins yielded a covalently cross-linked material, with the modified tertiary structure of peanut proteins, improved bioavailability of Ara h 2 (by 70 fold, p < 0.05) and modulated allergic immune response in vivo. The modulation of the immune response was related to the increased production of IgG2a antibodies 11 fold (p < 0.05) and reduced IL-13 secretion in in vitro cultured splenocytes 7 fold (p < 0.05). Analysis of the peanut polyphenol content and profile by HPLC-MS/MS revealed that laccase treatment depleted the peanut extract of polyphenol compounds leaving mostly isorhamnetin derivatives and procyanidin dimer B-type in detectable amounts. Treatment of complex food extracts rich in polyphenols with laccase results in both protein cross-linking and modification of polyphenol compounds. These extensively cross-linked proteins have unchanged potency to induce allergic sensitization in vivo, but certain immunomodulatory changes were observed.

KLF4 expression and apoptosis-related markers in gastric cancer.

PURPOSE: To correlate the expression of Kruppel-like factor 4 (KLF4) with clinicopathological properties of gastric cancer (GC) and to evaluate any possible correlation between KLF4 expression and the expression of apoptosis-related markers p53, Fas, Bcl-2, survivin and FLICE inhibitory protein (Flip-l). METHODS: Formalin-fixed, paraffin-embedded tissue specimens obtained from 96 patients with GC who had undergone gastric surgery were analyzed for pathological parameters, while KLF4, p53, Fas, Bcl-2, survivin and Flip-l expression was assessed by immunohistochemistry. RESULTS: TKLF4 immunohistochemical staining was noted in 78.1% of the cases. Strong positivity was found in 15.6% and weak in 62.5% of the samples. Positive expression of p53, Fas, Bcl-2, survivin, Flip-l was found in 56.2%, 44.8%, 15.6%, 41.7% and 38.5% of the samples, respectively. KLF4 expression was significantly associated with p53 nuclear staining and Fas immunoreactivity. p53-positive tumors demonstrated more often high KLF4 staining compared to p53-negative tumors. Fas-positive tumors were associated with decreased KLF4 expression. Logistic regression analysis of apoptosis-related markers to KLF4 expression revealed that Fas positivity significantly decreased the probability of strong KLF4 expression, and inversely, Bcl-2 expression improved the prediction of KLF4 staining. When all 5 predictive variables were considered together (p53, Fas, survivin, Bcl-2, Flip-l) they significantly predicted the type of KLF4 expression in GC cells (p=0.019). CONCLUSION: Our results suggest that the decrease or loss of KLF4 expression correlates with diffuse-type GC and immunoreactivity to Fas, and are inversely linked with p53 nuclear accumulation. The significance of KLF4 in GC requires further studies and should be more thoroughly investigated for potential use in the evaluation and better stratification of GC patients.

Maternal mortality in Serbia.

Maternal mortality related to obstetric events is still high today. The main components of reproductive health are evaluated. Early diagnosis of the obstetric risks can significantly reduce maternal mortality.

Endoscopic ultrasound for differential diagnosis of duodenal lesions.

PURPOSE: Duodenal tumors are rare and require a different management from that of esophagogastric neoplasia. The present study retrospectively analyses the endoscopic ultrasound (EUS) features of duodenal tumors of both epithelial and subepithelial origin. MATERIALS AND METHODS: During a 12 year period, all duodenal tumors with histologic confirmation by surgery or biopsy were collected including endoscopic and endosonographic images. EUS images were analyzed for specific features (echogenicity, wall layer structure and relation, outer margins) to possibly distinguish epithelial (polyps and carcinoma versus lymphoma) and subepithelial (tumor type) tumors. RESULTS: 53/80 cases had histologic confirmation (mean age 53.1 ±â€Š11.4 years, m:f = 33:20), 31 were epithelial (13 adenomas, 12 carcinomas, 6 lymphomas) and 22 subepithelial (11 GISTs, 7 Brunneromas, 1 lipoma, 3 NETs). EUS did not recognize carcinomas in 2/13 adenomas. EUS features suggesting carcinoma were loss of wall layers and irregular margins. 5/6 lymphomas showed inhomogeneous thickening with layers partially recognizable. Tumor type of subepithelial lesions correlated with echogenicity: GIST tumors were mostly (62.5 %) hypocheoic with the 3 malignant cases being characterized by heterogeneous echopattern with irregular outer margins. Of the hyperechoic lesions, lipomas had a homogeneous whitish appearance, while NET and Brunneromas were less hyperechoic. In the latter, the endoscopic aspect was also helpful for differential diagnosis. Accuracy of combined endoscopic/EUS imaging for all duodenal lesions was 84.9 % (45/53). No procedural complications occurred among all patients that received EUS examinations. CONCLUSION: EUS contributes to the differential diagnosis of epithelial lesions known to be malignant; in subepithelial tumors, tissue confirmation is still required.

Gastrointestinal and liver tumours and public health in Europe.

STATE OF THE ART: Europe comprises only one eighth of the total world population but has around one quarter of the global total of cancer cases--some 3.2 million new patients per year. While the disproportionate cancer burden is readily apparent, the disease patterns in Europe cannot simply be generalized--overall cancer incidence and mortality rates vary at least two-fold between European countries and the differences are often far greater for specific cancers. With 1.7 million deaths each year, cancer currently represents the second most important cause of death in Europe. The range of survival rates is similarly wide. For individual cancers, the variation across Europe is even greater. This reflects a wide range of social and epidemiological factors in different countries: cancer prevention programmes; screening programmes; cancer control plans; individual lifestyles and occupational exposures; the existence and accessibility of health-care facilities and technological infrastructure; and the availability of human, financial and material resources for health and economic development. Europe has some of the richest countries in the world, but also some of the poorest. In 2002, 168 million people were living below the poverty line, about 46% of the European population. The time trends in cancer risk also vary between European countries and some cancers show different trends between men and women, or young and old, or poor and rich. The public health profile of cancer in Europe is complex. Trends in the incidence and mortality rates are also influenced by successes in health promotion (e.g. tobacco control), efficient screening (e.g. breast, bowel, cervix) and better treatment. These have been reflected in lower incidence, reduced mortality, higher survival, improved life expectancy and a better quality of life for cancer survivors. CONCLUSIONS: Cancer of the gastrointestinal (GI) tract is the most common cancer in Europe. More than half of GI cancer cases arise from the colon. They can remain asymptomatic until late in the natural history of the disease, and as this is the stage at which they can be cured, screening has been advocated for well members of the population and surveillance for those with conditions predisposing to cancer.

Triple-way therapeutic approach for paraganglioma-dependent erythrocytosis: drugs and surgery plus "multi-manner" apheresis.

Paragangliomas are tumors arising from the extra-adrenal paragangliar neural crest cells. The sympathoadrenal neuroendocrine system consists of extra-adrenal paragangliar cellular layer along the paravertebral and para-aortic axis, and the adrenal medullae. Paraganglioma should be included in the differential diagnosis of secondary erythrocytosis due to its possible ectopic erythropoietin (EPO) secretion. Thus, in this report we present a 24-year-old female patient with onset of unregulated ectopic EPO secretion, and consecutive erythrocytosis followed by hypertension, secondary to paraganglioma of multifocal retroperitoneal localization. Clinical, laboratory, and radiological investigations confirmed both an elevated EPO level and the presence of multiple paraganglioma. This paraneoplastic-mediated medical condition with high risk of cellular hyperviscosity syndrome (CHVS) requires prompt diagnosis and rapid therapeutic interventions. Initially, simple phlebotomy procedures were used; following that, tumors were surgically removed. In the course of the disease, this tumor relapsed, and urgent apheresis, as a treatment of life-threatening state, was used. The therapy performed resulted in a rapid blood viscosity depletion and a significant (P < 0.01) serum EPO reduction, as well as the general clinical benefit. Therefore, we conclude that the use of our own "multi-manner" apheresis (erythrocythapheresis plus plasma exchange), for long-time interval (until further causative therapy), effectively cross-bridged the possible hazards of EPO-dependent CHVS.

[Occurrence and risk factor for development of pancreatitis and asymptomatic hyperamylasemia following endoscopic retrograde cholangiopancreatography--our experiences].

INTRODUCTION: Chronic pancreatitis is defined as chronic inflammatory lesion of pancreatic parenchyma leading to destruction and fibrosis of exocrine pancreas. Endoscopic retrograde cholangiopancreatography (ERCP) is the most sensitive and specific method for detection of morphological alterations in chronic pancreatitis. ERCP is inevitably associated to post-ERCP acute pancreatitis, as well as hyperamilasemia. STUDY AIM: This study aims to determine frequency of post-ERPC pancreatitis and asymptomatic hyperamilasemia. STUDY METHODS: We have studied 160 patients who underwent ERCP in Institute of Digestive Diseases, Clinical Centre of Serbia in Belgrade. Data regarding cholecystectomy, papillotomy, peripapillary diverticulosis, Oddi's sphincter hypertension, choledoch canulation and diameter, Wirsung duct canulation, minor duodenal papilla patency, anomalies of BP junction, as well as chronic pancreatitis has been analysed and correlated with eventual development of post-ERCP pancreatitis and asymptomatic hyperamilasemia. RESULTS: Asymptomatic hyperamilasemia was determined in 51 subjects (31.9%), while pancreatitis has been developed in 5 patients (3.1%) subsequent to ERCP. It has been proofed that Wirsung duct canulation plays significant role in development of post-ERCP complications. CONCLUSION: Although numerous factors may potentially contribute to development of post-ERCP pancreatitis, none of them, with the exception of Wirsung duct canulation, has been determined to play significant role in development of these complications.

[Medicolegal aspects in gastroenterology].

INTRODUCTION: Medical practice is under continual public scrutiny. There are increasing concerns on medical malpractice and its consequences - further deterioration of health and death. Public criticism of medical practice very often outrageous, but sometimes medical negligence is obvious. AIM OF THE STUDY: We are presenting basic medicolegal analysis of causation in cases of medical malpractice with subsequent fatal outcome. CASE STUDY: We are reporting on two cases from archives of Institute of Forensic Medicine. The selected cases (biliary ileus and pseudomembranous colitis subsequent to elective cholecistectomy) may reflect common gastroenterological pathology. The analysis of medical practice and its consequences, i.e. analyse of causation has been presented and commented in regard to the pertinent legislation. CONCLUSION: Doctors ought to be familiar with medicolegal aspects of their practice. This might affect them to improve the quality of health care, and to increase protection, both of health care personal and patients.

[Aute upper gastrointestinal bleeding--erosive gastropathy].

AIMS: Acute upper gastrointestinal bleeding is the commonest emergency managed by gastroenterologist. Our aim was to assess the frequency of erosive gastropathy as a cause of upper GI bleeding as well as its relation to age. gender and known risk factors. MATERIAL AND METHODS: We conducted retrospective observational analysis of emergency endoscopy reports from the files of Emergency Department of Clinic of Gastroenterology and Hepatology, Clinical Center of Serbia, during the period from 2000-2005. Data consisted of patients' demographics, endoscopic findings and potential risk factors. RESULTS: During the period 2000-2005. Three thousand-nine hundred and fifty four emergency tipper endoscopies were performed for acute bleeding. In one quarter of cases acute gastric erosions were the actual cause of bleeding. One half of them were associated with excessive consumption of salicilates and NSAIDs. In most of the examined cases bleeding stopped spontaneously, while in 7.6%) of the cases required endoscopic intervention. CONCLUSION: Erosive gastropathy represents significant cause of upper gastrointestinal bleeding count up to one quarter of all cases required emergency endoscopy during the 5-year period. Consumption of NSAIDs and salicilates was associated with erosive gastropathy in almost one half of cases (46%) leading us with a conclusion that we must explore other causes of erosive gastropathy more thoroughly.

[The role of wireless capsule endoscopy in the evaluation of patients with suspected small bowel bleeding: a single center experience].

BACKGROUND: Capsule endoscopy (CE) is a new diagnostic tool for the study of patients with suspected small bowel pathology. The aim of the study was to clarify the usefulness of CE in the group of patients with obscure (overt / occult) gastrointestinal (GI) bleeding. PATIENTS AND METHODS: Thirty patients (14 men, 16 women, mean age 50 years, range 9 -79 years) were enrolled in the study. All of them undergone non-diagnostic esophagogastroduodenoscopy, colonoscopy and barium follow-through of the small bowel. All patients underwent capsule endoscopy. Fourteen patients had overt and sixteen occult bleeding. The single senior endoscopist interpreted CE findings in an unblinded manner. RESULTS: CE identified a source of bleeding in 14/30 patients (46.6%). Lesions identified were: tumors in five pts, vascular lesions, Crohnzs disease and Meckelzs diverticulum in two pts and fresh bleeding, segmental celiac disease and colonic diverticulosis in one patient each. CE identified a source of bleeding in 9/14 (64.3%) of patients with ongoing overt bleeding and in only 5/16 (31.3%) of patients with occult bleeding. The positive suspicious findings were seen in 6/30 (20%) of patients (2/14 with overt bleeding and 4/16 with occult bleeding. In 3/14 (21.4%) with overt and 7/16 (43.7%) with occult bleeding findings on CE were negative. All patients with negative findings on follow-up remained asymptomatic for one year. Capsule retention because of unsuspected stenosis occurred in a single patient and required surgery, which resolved the problem. CONCLUSION: CE is an effective diagnostic tool for patients with obscure GI bleeding. It is safe and painless technique which can diagnose the bleeding site beyond the reach of conventional endoscopy. The best candidates for the procedure are those with ongoing and overt bleeding.

[Role of Helicobacter pylori infection and use of NSAIDs in the etiopathogenesis of upper gastrointestinal bleeding].

INTRODUCTION: Non-steroid antiinflammatory drugs (NSAIDs) and Helicobacter pylori (Hp) infection are two most important independent risk factors involved in the etiopathogenesis of gastroduodenal mucosal injury with a clear and critical role in both uncomplicated and complicated peptic ulcer disease. It is estimated that upto 90% of all peptic ulcers result from the effect of one or both of these factors. AIM: To determine the frequency of NSAIDs use and Hp infection in patients with acute upper gastrointestinal bleeding. PATIENTS AND METHODS: Study evaluated data from 500 patients in whom esophagogastroduodenoscopy was performed following presentation in emergency unit with acute upper gastrointestinal bleeding. Anamnestic data was collected together with detailed information on previous salicilates and/or NSAIDs use. Hp status was determined and anatomic localisation of bleeding lesion was also registered. RESULTS: Acute upper GIT bleading was caused solely by NSAIDs in 55 (11%), by aspirin in 66 (13.2%), while combined NSAID/aspirin therapy was identified in 19 (3.8%) of patients. In total NSAID and/or aspirin use were diagnosed in 139 (27.8%). while in 122 (24.4%) only Hp infection was diagnosed. Both risk factors were identified in 144 (28.8%) patients (Hp+NSAIDs in 12.2%, Hp+aspirin in 10.8% and Hp+aspirin+NSAIDs in 5.8%). In 19.8% of the cases (14% of males and 27% of females) neither NSAID/aspirin use nor presence of Hp infection was noted. Out of 500 patients enrolled, 63% were mails. In females, bleeding lesion was most frequently localized in gastric mucosa, while males had equal chance of bleeding from either gastric or duodenal mucosa. Fortunatelly, only 5 to 7% of patients were bleeding from both gastric and duodenal lesion. CONCLUSION: Prevention of acute upper gastrointestinal bleeding can be achieved trough strict and limited use of aspirin and NSAIDs, eradication of Hp infection and use of gastroprotective therapy in well-defined risk patients that need chronic NSAIDs and/or aspirin therapy. In all patients starting long-term NSAID and/or aspirin therapy and all patients already on long-term aspirin therapy test and treat strategy for Hp infection should be used. On the other hand, only in high risk patients (more than 65 years, history of peptic ulcer disease, concomitant corticosteroid, aspirin, clopidogrel or warfarin therapy) already on chronic NSAID therapy long-term PPI therapy should be prescribed after testing and treating of Hp infection.

[Myeloproliferative diseases as causative agents of portal and hepatic veins thrombosis].

Thrombosis of portal and hepatic veins is one of the most severe complications and most important causes of death of patients with chronic myeloproliferative diseases. Based on results of the past studies, myeloproliferative diseases were the causes of hepatic veins thrombosis in 30% and portal vein thrombosis in 20% of patients. The study presented 4 patients with myeloproliferative diseases complicated by thrombosis of splanchnic veins, aiming at the illustration of issue complexity in diagnostics and therapy. Two patients with portal vein thrombosis and recurring hemorrhage from esophageal varicosity were described. The first case was planned for shunting, while another case sustained bleeding on what account his anticoagulant therapy was discontinued, but it caused mesenterial thrombosis resulting in lethal outcome. Another two patients had hepatic veins thrombosis. Due to frequent, life-threatening bleeding from the esophageal and gastric varices, a patient with chronic Budd-Chiari syndrome and lineal vein thrombosis underwent mesocaval shunting. An immediate postoperative period was manifested by multiple thrombosis and hemorrhages that ended in his death. A patient with the acute Budd-Chiari syndrome was administered myelosuppressants and anticoagulants on time so reperfusion was restored. In myeloproliferative diseases, thrombosis of portal and hepatic veins gives rise to excessive portal hypertension with profuse hemorrhage from the esophageal and gastric varicosity which is difficult to manage because of complex coagulation disorders.

[Acute upper gastrointestinal nonvariceal bleeding--how to determine low risk patients for rebleeding and mortality after endoscopic sclerotherapy?].

INTRODUCTION: Successful endoscopic sclerotherapy is effective in securing hemostasis for bleeding lesions and remains the first line and only needed therapy for most of the patients (pts), but bleeding reoccurs in 10% to 30% pts, and 4% to 14% of the pts die after acute nonvariceal upper gastrointestinal bleeding (UGIB). The need for hospitalization and its duration for all the bleeding pts is still a controversial question. AIM: To create the simple scoring system able to determine low risk pts for rebleeding and mortality by establishing the relative importance of risk factors for rebleeding and mortality after successful endoscopic sclerotherapy of acute nonvariceal UGIB. PATIENTS AND METHODS: Prospective study included 3 15 pts who where admitted to hospital because of acute nonvariceal UGIB. All of them underwent gastroscopy with successful sclerotherapy within 12 hours after the admission. We investigated the episode of rebleeding and death during the initial hospitalization, and analyzed the following parameters: age, gender, drug intake, shock, bleeding stigmata, location of bleeding lesion and comorbidity. RESULTS: Rebleeding occurred in 53 pts (16.8%) and was determined by shock, bleeding stigmata and comorbidity. Eleven pts (3.5%) died and shock, rebleeding and comorbidity were all independent, statistically significant predictors of pts' mortality. The numerical scores for determination of pts with different risk levels for rebleeding and mortality have been developed using the significant predictors of rebleeding and death. The score values for rebleeding ranged from 3 to 9 and pts with values < or = 4 had low risk of rebleeding. We identified 59 pts (18.7% of all) with score for rebleeding < or = 4. Score values for mortality risk ranged from 3 to 8 and the values < 5 revealed negligible risk of death. In our group we found 290 pts (92.1% of all) with low mortality score values. CONCLUSION: Following the successful initial endoscopic sclerotherapy, these scores can help to identify pts with low risk of rebleeding and negligible risk of death, so they can be treated as outpatients.