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Challenges and Variables Affecting the Success of Sentinel Lymph Node Biospy in Malignant Melanoma a 4-Year Analysis of Clinical Results

Summary

In the last 15 years, sentinel lymph node biopsy (SLNB) for patients with malignant melanoma (MM) has been introduced into the clinical practice. Our aim was to make a retrospective analysis of clinical results in order to assess the success ratio of SLNB and the variables affecting it in MM patients, treated in the Oncology Center at the University Hospital “Dr George Stranski” - Pleven, Bulgaria for a 4-year period. A research index card was used to process the oncologic files of 82 out of 102 patients with MM, treated and monitored at the Oncology centre between 01.01.2008 and 31.12.2011. TNM-stages, Breslow and Clark levels, location, characteristics of the skin lesion, diagnostic excision, type of lymph node dissection, number of SLN, localization of SLN, etc. were registered in the index card. SLNB staging was carried out in 28 patients. Sentinel lymph nodes were found in 22 of them. The success ratio of the method was 78.6%. Histologically, metastatic SLN were found in 4 cases. The Patent Blue Dye method was used in 22 of the cases (78%). A combined radiocolloid and dye method was used in 5 cases (18%). A radiocolloid method was used in 1 case (4%) only. Our research showed that more therapeutic lymph node dissections were performed in cases of locally advanced MM, which in turn worsened the clinical results. According to our research, the SLNB success ratio depends on the precision of diagnostic excision (p=0.019), lesion location (p=0.015), Clark level (p=0.0229), mapping method (p=0.08) and the type of melanoma (p=0.088).

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Evaluation of Recovery of Activities of Daily Living in Patients with Sequelae from Cerebral Vascular Disease

Summary

Bulgaria ranks first in the world in incidence, morbidity and death associated with cerebrovascular disease. The aim of the study was to investigate, follow-up and register recovery of activities of daily living (using the toilet and maintaining personal hygiene) in patients with sequelae from cerebrovascular disease in a subacute stage, who underwent physiotherapy and rehabilitation. Sixty-one patients were included and followed up. They were given tailored physiotherapy and rehabilitation. This included kinesitherapy, occupational therapy and electrotherapy. All the patients filled in self-assessment questionnaires before and after the rehabilitation course. Major parameters were assessed, irrespective of the limb affected -dominant or non-dominant. Results were analyzed using the Wilcoxon rank test. At the end of the rehabilitation course, the Wilcoxon curves were driven to the right, confirming improvement concerning independence, irrespective of involvement of dominant or non-dominant limb.

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Internal Incarceration of Left Paraduodenal Hernia with Necrosis of Proximal Jejunum and Atypical Reconstruction of the Passage: A Case Report

Summary

Internal hernias are rare and most of them are diagnosed intraoperatively. We present a case of a 53-year-old man with proximal intestinal obstruction, caused by incarcerated internal hernia. During the operation, a proximal portion of 40 cm of the jejunum was found herniated and strangulated in the lesser sac through an opening of the transverse mesocolon. The jejunum was necrotic and local purulent peritonitis was present. After resection of the proximal 40 cm of the jejunum, the passage was restored using an unconventional approach. The distal duodenum was closed and, to protect the stump, the duodenum was ligated between its second and third parts. A latero-lateral anastomosis was made between the first part of duodenum and the jejunum. Anatomical, clinical and radiological findings, diagnosis and treatment of paraduodenal hernias are discussed in brief.

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Popliteal Aneurysms as a Cause for Arterial Insufficiency

Summary

Clinical manifestations, possibilities for accurate diagnosis of popliteal aneurysms, and operative approaches applied depending on their location are presented, as well as results from treatment over a four-year period. Popliteal artery aneurysms accounted for 5.63% of all 266 cases of acute arterial insufficiency. The mean age of the patients was 68.8 years, and the male:female ratio – 4:1. In five patients (33.33%), the localization of aneurysm was unilateral. In 80% of the cases with bilateral popliteal aneurysms, the aneurysms were combined with aneurysms of other locations. The surgical technique applied was posterior approach with resection of the aneurysm and interposition of a polytetrafluoroethylene (PTFE) prosthesis. The early patency rate of the reconstructed segment was 100%. Late patency rate of the reconstructed segment was 90.9%. Despite the better late results in femoropopliteal reconstruction, we think that a posterior approach with prosthesis implantation is better because it saves the great saphenous vein. The presence of multiple aneurysms in the patients studied (80%) determined the low survival at 5 and 10 years, which makes it comparable to the results from applying the two surgical methods.

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Postoperative Outcomes of Elective Pancreatic Surgery in a Low-Volume Academic Surgical Clinic

Summary

According to the volume-outcome concept the postoperative outcome after major pancreatic surgery in high-volume institutions compares favorably to low- volume centers. However, it is not clear whether this is applicable to all low-volume institutions nowadays. The aim of the study was to evaluate the postoperative outcome after major elective pancreatic surgery in a low- volume academic surgical clinic. All consecutive elective major pancreatic cases operated within a 10-year period till October 2013 have been retrospectively reviewed. During the studied period, 36 patients (15 females, 21 males, mean age 54 years, age range 37-76) were scheduled for elective pancreatic surgery and underwent pancreatic resection (n=31, 18 proximal and 13 distal pancreatic resections) or complete pancreatic duct drainage procedure (n=5). Eleven patients had chronic pancreatitis and 25 patients had malignant or benign tumors. Vascular or adjacent organ resection was performed in 9 patients (29% of resections). The overall postoperative morbidity was 36% (n=13), and complications requiring re-operation occurred in 5 patients (14%). The median postoperative hospital stay was 11 days for patients without complications vs. 25 days for patients with any complication. There was no 60- day postoperative mortality or hospital readmission. Major elective pancreatic surgery can be safely performed today in a low-volume academic general surgical clinic, with postoperative outcomes similar to those reported by high-volume centers.

Open access
Predisposition to Thrombophilia and Hypofibrinolysis in Pulmonary Embolism: Analysis of Inherited Factors

Summary

Pulmonary embolism (PE) is a relatively common cardiovascular emergency, though its exact incidence is difficult to assess. Accurate diagnosis is critical because of the high 30-day mortality in patients in whom the diagnosis is missed on admission. Doubt for PE is often raised by the presence of risk factors for venous thromboembolism (VTE), which are categorized into inherited and acquired. Among these, the importance of inherited/genetic thrombophilic factors is increasingly recognized. The most frequent markers of inherited thrombophilia are Factor V Leiden (FVL) and G2021OA prothrombin gene mutation. Among the inherited factors causal to thrombophilia, the C677T variant in methylentetrahydrofolate reductase (MTHFR) gene as well as factors like P1A1/P1A2 polymorphism in platelet glycoprotein Ilb/IIIa (P1A2) and hypofibrinolytic polymorphism 4G/4G in PAI-1 gene are discussed with controversial results. In our study, thrombophilic and hypofibrinolytic genetic variants were identified in 54.2% of 115 patients with PE. The most common significant genetic defects were FVL- 16.5% in patients versus 6.2% in controls (OR=3.102; p=0.05), G20210A PT 5.7% versus 2.1% (OR=2.983; p>0.05). P1A2 was found in 27.3% patients versus 19.9% in controls (OR= 1.523, p>0.05) and PAM 27.8% versus 22.6% (OR =1.501 p>0.05). MTHFR C677T carriage was inverse: 6.7% in patients versus 13.4% in controls. (OR=0.461 p=0.05). Of all the patients studied, 15.65% had a history of recurrent embolic incidents. The risk of recurrence was higher for the carriers of FVL and G20210A prothrombin gene mutation. The association between carriage of thrombophilic genetic factor and the early onset of the first embolic episode was found in the patients with PE. The awareness of risk factors and risk stratification is a critical issue in treatment and prevention policy. Preventive measures should be taken in particular medical conditions.

Open access
Rare Case of Human Visceral Linguatuliasis in Bulgaria Diagnosed on Biopsy Specimen

Summary

We report a rare case of visceral linguatuliasis in a 9-year-old boy. The diagnosis was made incidentally on a biopsy specimen obtained during laparotomy on account of an acute appendicitis. An encysted parasite was found in a mesenteric lymph node and diagnosed as Linguatula serrata larva mainly based on its typical appearance. The vermiform appendix showed only lymphoid hyperplasia and no features of inflammation. The patient made an uneventful recovery after the operation and was discharged. He is being followed up. To our knowledge this is the first officially reported case of human linguatuliasis in Bulgaria.

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A Rare Case of Subtentorial Arterio-Venous Malformation Case Report

Summary

The majority - over 80%, of arteriovenous malformations (AVMs) are supratentorial. The infratentorial AVM are uncommon and different from other intracranial AVMs in terms of history, diagnosis, treatment, prognosis, and follow up. The authors present a case of an intracranial hemorrhage, caused by rupture of an AVM in the posterior cranial fossa. Native (unenhanced) CT and computed tomography angiography (CTA) images of this rare location of AVM are presented.

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Risk Factors for Coronary Artery Diseases: A Study Among Patients With Ischemic Heart Disease in India (Kerala)

Summary

Coronary artery disease (CAD) is a condition that develops due to accumulation of atherosclerotic plaque in the epicardial coronary arteries, leading to myocardial ischemia. It is the leading cause of death worldwide and is a common complex disease. A study was carried out in a group of 496 patients with acute coronary syndrome or with angiographic or stress test evidence for coronary artery disease, admitted to the Department of Cardiology at Lourdes Heart Institute and Neuro Centre during the period June-August 2012. The risk factors studied were hypertension, diabetes mellitus, dyslipidemia, body mass index, smoking and family history of CAD. The results demonstrated that in both males and females of the Indian population studies, diabetes and dyslipidemia were major risk factors for CAD, while hypertension was not a major risk factor. Therefore, early detection and treatment of diabetes mellitus and dyslipidemia play a vital role in prevention of CAD in Indian population.

Open access
Study of the Carrier State for Five BRCA1/BRCA2 Deleterious Mutations in Bulgarian Women with Breast Cancer

Summary

Genetic testing for BRCA 1/2 mutation is a well recognized medical management tool. Identification of healthy carriers of such mutations allows effective risk reduction procedures to be performed. There is no data reported on the founder mutations in the Bulgarian population. To evaluate the contribution of genetic factors to breast cancer (BC), we investigated the carrier state of Bulgarian women with BC for five common (according to BIC database) deleterious BRCA1/2 mutations. The list of patients diagnosed with BC between January 2011 and April 2012 was obtained from the Cancer Registry of University Hospital, Pleven. Eighty-two women with BC were interviewed and a pedigree was constructed of each of them. The patients were classified into seven categories, according to personal, disease and family history. Based on the preliminary prepared selection criteria and the personal family history, we defined a target group of 33 Bulgarian women with BC. They were screened for five deleterious mutations: 5382insC in BRCA1 and 6174delT, 6079del4, 8138del5, 5946delCT in BRCA2, by DNA sequencing. The genetic analysis detected none of the tested mutations. Two polymorphic variants were found in BRCA2 gene: c.5744C>T (rs4987117, SNP database) in exonl 1E in one patient and c.7806-14T>C (rs9534262, SNP database) in exonl7 in 22 patients. In conclusion, without basic information on the founder mutations in the population, the genetic screening for the specific mutations in a small group of tested patients is ineffective.

Open access