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CURRENT ISSUE /2-2013

ANTEROGRADE FACIAL-SUBMENTAL ARTERY ISLAND FLAP FOR PALATE REPAIR AFTER CARCINOMA ABLATION – A CASE REPORT
Y. Yordanov(1), A. Shef(2) and J. M. Lasso(3)
(1)Unit of Plastic Surgery and Burns, Military Medical Academy, Sofia
(2)Department of Dermatovenereology and Allergology, Military Medical Academy, Sofia
(3)Unit of Plastic Reconstructive and Aesthetic Surgery, University Hospital Gregorio Marañón, Madrid, Spain

Summary. The submental island flap is a reliable alternative in the armamentarium of the plastic surgery for reconstruction of various head and neck defects including those affecting the oral mucosa and the palate. Since it was first described, it has been affirmed as a safe, rapid and easy reconstruction method with minimal to missing donor site morbidity.We present a clinical case of complete reconstruction of soft palate using an anterograde pattern submental flap. We believe this flap to be safer than the reverse-flow one that has been typically used for defects located in this region. The surgical technique is described.
Key words: anterograde submental flap, flap harvest technique, soft palate reconstruction

 

STERNAL WOUND RECONSTRUCTION WITH PORCINE ACELLULAR DERMAL MATRIX (STRATTICE) FOR POSTSTERNOTOMY MEDIASTINITIS
Y. Yordanov(1), A. Shef(2), V. Vaseva(3) and J. M. Lasso(4)
(1)Unit of Plastic Surgery and Burns, Military Medical Academy, Sofia
(2)Department of Dermatovenereology and Allergology, Military Medical Academy, Sofia
(3)Military Medical Academy, Sofia
(4)Unit of Plastic Reconstructive and Aesthetic Surgery, University Hospital Gregorio Marañón, Madrid, Spain

Summary. Sternal reconstruction could be a complex and challenging procedure. Common indications are defects after heart surgery, infections, tumour ablation, radiation necrosis, congenital deformities and trauma. Aloplastic materials are often used for sternal stabilization and regional flaps are applied to provide well vascularized soft tissue coverage. Although numerous materials are available, acellular dermal matrice have some advantage that could be of benefit in the repair of the anterior mediastinum and chest wall. We present a case of a 72-year-old male patient whit mediastinitis and sternal dehiscence after triple-vessel coronary artery bypass grafting and failure of the initial chest wall closure. After conservative treatment and VAC-therapy, titanium plates were used to restore the sternal continuity. Porcine acellular dermal matrix (Strattice™ Tissue Matrix) was applied for wrapping the fixation plates and reinforcing the pectoralis muscle flaps used for soft tissue coverage. Due to its ability to become incorporated and vascularized, to resist wound infections and to provide stability, Strattice seems to be a promising, although probably not enough efficient alternative of the synthetic materials. To our knowledge, this is the first report in the Bulgarian scientific literature of sternal reconstruction by using a porcine acellular dermal matrix (Strattice).
Key words: sternal reconstruction, mediastinitis, porcine acellular dermal matrix, Strattice

 

ONCOGENIC BALANITIS
G. Tchernev(1), J. Ananiev(2), J. C. Cardoso(3), S. Philipov4 and U. Wollina(5)
(1)Polyclinic for Dermatology and Venerology, University Hospital Lozenetz, “Saint Kliment Ohridski” University, Sofia, Bulgaria
(2)Department of General and Clinical Pathology, Medical Faculty, Trakia University, Stara Zagora, Bulgaria
(3)Dermatology Department, University Hospital of Coimbra, Coimbra, Portugal
(4)Department of General and Clinical Pathology, Medical Faculty, “Saint Kliment Ohridski” University, Sofia, Bulgaria
(5)Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany

Summary. The so-called „oncogenic balanitis“ is a not so rare nosological entity, whose pathogenesis is related in most cases to infection with oncogenic strains of the human papilloma viruses (HPVs). In the early stages of the disease the clinical presentation of the infection with some oncogenic or high risk human HPVs is often non-specific, contributing to its persistance for a long time, often misdiagnosed as a candidous or bacterial balanitis. Clinically the lesions may also be confused with lichen planus or lichen sclerosus, as well as penile eczema or psoriasis. Local and/or systemic therapy with corticosteroids can lead to unmasking of the symptoms and rapid progression of the disease, with potential risk of malignant transformation. Additionally, some patients decline a biopsy, further hampering the confirmation of the diagnosis. In all these problematic cases a diagnostic PCR examination of material taken from lesional skin could be of help for the diagnosis of Bowen’s disease, erythroplasia Queyrat, consequently preventing its progression to invasive squamous cell carcinoma. We present a rare case of erosive and partially verrucous balanitis, in which HPV 56 strains were identifed by PCR in repeated samples from lesional skin. Additionaly, HPV 16 was also identified in the second sample. The clinical findings were entirely consistent with erythroplasia of Queyrat but histopathological examination was not possible. A local therapy with imiquimod was started. After complete clinical recovery a vaccination with Gardasil was additionaly planned with the hope that the patient would be protected from possible recurrence due to the generation of cross-immunity against HPV 56. Due to the risk of malignant transformation into squamous cell carcinoma of the penis, HPV-associated “oncogenic balanitis” is a disease portending a potentially unfavorable prognosis. In patients with longstanding genital lesions unresponsive to topical treatments usually used for balanitis, the possibility of HPV-induced “oncogenic balanitis” should be a strong consideration. PCR testing from lesional skin is probably one of the most sensitive, accurate, and reliable methods that help the clinician identify oncogenic and nononcogenic HPV-strains in problematic patients who refuse invasive and semi-invasive diagnostic options such as biopsy and cytological examination. Subsequent therapy should be complemented by regular clinical follow-up due to the possibility of relapse.
Key words: oncogenic balanitis, HPV infection, erythroplasia of Queyrat, penile intraepithelial neoplasia

 

A RARE CASE OF A PATIENT WITH A METATYPICAL BASAL CELL CARCINOMA OF THE FOREHEAD TREATED SUCCESSFULLY
WITH ELLIPTICAL EXCISION

G. Tchernev(1), J. Ananiev(2) and J. C. Cardoso(3)
(1)Polyclinic for Dermatology and Venerology, University Hospital Lozenetz, “Saint Kliment Ohridski” University, Sofia, Bulgaria
(2)Department of General and Clinical Pathology, Medical Faculty, Trakia University, Stara Zagora, Bulgaria
(3)Dermatology Department, University Hospital of Coimbra, Coimbra, Portugal

Summary. We present a rare case of a 72-year-old patient with an ulcerative lesion localized to the left forehead, appearing 3 months prior to clinical presentation. Biopsy revealed a metatypical basal cell carcinoma. Treatment consisted of wide local excision. There was no sign of recurrence or metastasis after a 12-month follow-up period. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) make up 95% of the most common type of cancer in the world, the non-melanoma skin cancer.  BCC is known for its potential to be locally invasive, while SCC for its potential to metastasize in lymph nodes. Metatypical basal cell carcinoma (MTBC) is a rare tumor that combines clinical and histopathological features of both BCC and SCC. The gold standard for diagnosis lies in the histopathologic examination. Clinical examination alone does not suffice.
Key words: metatypical, basal cell carcinoma, histopathology, basosquamous carcinoma, surgery


ARTHROGRYPOSIS MULTIPLEX CONGENITA, EPILEPTIC SEIZURES AND CORTICAL DYSPLASIA: A CASE REPORT
E. Viteva
Department of Neurology, University of Medicine – Plovdiv, Bulgaria

Summary. We have presented a case of a 22-year-old patient having a rare variety of arthrogryposis multiplex congenita – arthrogryposis with epileptic seizures and defect in neural migration. We have described the patient’s disease history, the clinical, and laboratory data by giving prominence to the lack of mental retardation and the late onset of the generalized tonic-clonic seizures, despite the present cortical dysplasia. We have also discussed cases reported by other investigators. We consider that our case report is a contribution to the knowledge about the clinical manifestations, the possible results from neuroimaging and electrophysiological methods, and the progression of arthrogryposis multiplex congenita.
Key words: arthrogryposis, epilepsy, cortical dysplasia


ROLE OF LEPTIN IN OXIDATIVE STRESS AND SURVIVAL OF HUMAN GRANULOSA LUTEINIZED CELLS IN VITRO
J. Dineva(1), I. Vangelov(1), I. Rangelov(2), G. Stamenov(2) and T. Fartsova(3)
(1)Institute of Biology and Immunology of Reproduction “Acad. K. Bratanov”, BAS
(2)Centre of Reproductive Health “Nadezhda”
(3)Medical Center “Viara”

Summary. The aim of this study was to investigate the effect of leptin on oxidative status and survival of human granulosa luteinized cells (GLCs) in vitro. The human GLCs were isolated from follicular fluids of women undergoing IVF procedure and cultured in DMEM /HAM F12 with 10% FCS for 24 h. To study the oxidative status and survival of GLCs, after a 24-hour culture period, the cells were supplemented with 0, 1, 10, 100 ng/ml leptin in DMEM/ HAM F12 plus 1% FCS and cultured for another 24 h. The level of malondialdehyde (MDA), formed during the decomposition of lipid peroxidation products in cells, was measured by TBARS Assay Kit. Using the specific substrate (AcDEVD-PNA), the caspase-3 activity was measured as an indicative marker for apoptosis. Treatment with a physiological dose of leptin (10 ng/ml) decreased MDA level, while the higher dose of leptin (100 ng/ml) resulted in increased MDA level, compared to control cells (p < 0.05). Moreover, the treatment of GLCs with 100 ng/ml of leptin led to a significant increase in caspase-3 activity compared to control cells or cells treated with 10 ng/ml leptin (p < 0.05). The higher concentration of MDA was related to higher caspase-3 activity (R = 0.5789, p = 0.049). In conclusion, leptin plays an important role in oxidative metabolism and survival of human granulosa luteinized cells.
Key words: apoptosis, human granulosa luteinized cells, leptin, oxidative stress


IN VITRO COMPARISON OF FOUR DENTINE EXCAVATION METHODS IN PERMANENT TEETH
K. Peycheva(1) and D. Krastev(2)
(1)Department Conservative Dentistry, Faculty of Dental Medicine, Medical University – Sofia
(2)Medical College “Jordanka Filaretova”, Medical University – Sofia

Summary. The modern concept of minimal invasive technique inquires to keep maximum healthy structure and demineralized dentine during excavation. The study was primarily aimed at comparing the effectiveness of round steel burs and polymer burs (Smart burs II, USA) and evaluating the abilities of different methods to control the dentin excavation, using the visual-tactile method with mirror and probe as a clinical method on one hand, and modern devices based on light-induced fluorescence such as SoproLife (Acteon, France) in “treatment mode”, chemical substances (caries indicators) and self-limiting polymer burs (Smart burs II) for paraclinical evaluation on the other. Materials and methods: Forty extracted, non-devitalized teeth with initial carious lesions were divided into 4 groups according to the method of controlling the level of excavation: 1st group – visual-tactile (VT) control, 2nd group – control by means of caries indicator, 3rd group – control with SoproLife, and 4th group – control with polymer burs. All groups were clinically followed-up with mirror and probe (VT) and paraclinically with SoproLife (Acteon, France). Results and conclusions: The steel burs removed the carious mass more efficiently than the polymer ones, but a tendency for over excavation and danger of removing healthy dentine was observed. Polymer burs surely preserved healthy dentine, but were risky in removing infected dentine. The most accurate and sparing method was SoproLife, followed by caries indicator, polymer burs and visual examination as the least accurate.
Key words: excavation, polymer burs, light-induced fluorescence


MAIN LEGISLATIVE CHANGES IN HEALTHCARE SYSTEM IN BULGARIA DURING 1997-2012
M. Marcheva(1), L. Tosheva-Konteva(1) and G. Petrova(2)
(1)GlaxoSmithKline Bulgaria
(2)Faculty of Pharmacy, Medical University of Sofia

Summary. After the social and economic changes in Eastern Europe since 1990s, substantial changes were made in the health care systems in the countries. Most of them moved from centralized Semashko to decentralized health insurance systems of Bismark type. The latter also have an impact on the pharmaceutical systems and mostly on the way of financing, pricing and reimbursement of medicines. There is no historical overview of the basic changes in the health and pharmaceutical system in Bulgaria till now that stimulated out interest towards the topic. This paper presents a historical legislation analysis of the main health care and pharmaceuticals regulatory acts. The Healthy and Safe Conditions of Labour Act, Health Act, Health Insurance Act, Medicinal Products in Human Medicine Act were analysed, as well as the main regulations endorsed in the field. The analysis focused on the main changes that influenced the future of the health care and pharmaceutical system. The reforms in the sphere of health care are radical and substantial. They lead to regulation and protection of the rights in respect of the healthcare system, the rights of the patients, the rights of the citizens in relation to medical treatments, provided by the health institutions, as well as the rights of the health specialists when providing medical help and healthcare. These acts regulate the structure, activity, organization and management of the medical and pharmaceutical areas and their financing. The regulation of the pricing and reimbursement in Bulgaria was discussed. However, this paper was produced before the recent establishment of the National Council on Pricing and Reimbursement of Medicines which is expected to make the process more transparent, controlled and visible for the general public.
Key words: health policy, health legislation, pharmaceutical legislation

 

IMPACT OF BODY MASS INDEX ON INSULIN SENSITIVITY/RESISTANCE IN PREGNANT WOMEN WITH AND WITHOUT
GESTATIONAL DIABETES MELLITUS

M. Genova(1), K. Todorova-Ananieva(2) and K. Tzatchev(1)
(1)Department of Clinical Laboratory and Clinical Immunology, University Hospital “Alexandrovska”, Medical University, Sofia, Bulgaria
(2)University Clinic of Endocrinology, Medical University, Pleven, Bulgaria

Summary. The aim of the present study was to evaluate the impact of body mass index (BMI) on homeostasis model assessment (HOMA) and insulin sensitivity, using the quantitative insulin sensitivity check index (QUICKI), and homeostasis model assessment value for insulin sensitivity (HOMA-S) in pregnant women with normal glucose tolerance (NGT) and gestational diabetes mellitus (GDM). A total of 102 pregnant women between 24-28 gestational weeks (53 with GDM and 49 with NGT) were included in the study. Age, body mass index (BMI), week of GDM diagnosis, fasting plasma glucose and insulin concentrations were measured in all women. HOMA indexes (insulin resistance – HOMA-IR and HOMA-B), QUICKI and HOMA-S indexes were calculated from fasting glucose and insulin concentrations. BMI was significantly higher in GDM patients (32.6 ± 4,39) compared to their NGT (26.83 ± 5.54) weight-matched group (p < 0.011). HOMA-IR in women with GDM was significantly higher than those in women with NGT (p < 0.0001). QUICKI-IS and HOMA-S were significantly lower in GDM group (p = 0.001; p = 0.002, respectively). The correlation between BMI and HOMA-IR were r = 0.594; r = 0.485, p < 0.0001 for GDM and NGT, between BMI and QUIСKI (r = -0.603; r = -0.458); between BMI and HOMA-S (r = -0.679; r = -0.467 for GDM and NGT pregnant women). In our study, compared BMI of pregnant with NGT and GDM demonstrated that the OR of developing GDM was 1.099 (95% CI, 1.028-1.176, p = 0.006). According to our results, insulin sensitivities determined by QUICKI and HOMA-S are lower in GDM than NGT group, but GDM pregnant women have statistically higher HOMA-IR. We found higher positive correlation between BMI and HOMA-IR, and markedly negative correlation between BMI, QUICKI-IS and HOMA-S in pregnant women with GDM in comparison to NGT. Moreover, we observed that higher BMI decreasеd insulin sensitivity, increased insulin resistance and contributed to development of GDM.
Key words: body mass index, gestational diabetes mellitus, homeostasis model assessment, quantitative insulin sensitivity check index

 
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