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Tennis is an athletic complex game that places great demands on tennis players and their motor skills. Agility is an important component that they must possess. In order to be successful in rallies, players must perform quick, multi-directional movements in response to the high speed of the ball and/or the opponent's position. The aim of the study is to establish the current state of motor quality 'agility' of students from Sofia University participating in tennis classes. Methods: For the purposes of the study, we used field testing, analyticalsynthetic and mathematical-statistical methods (variation analysis, sigma method). Results: The data from the study are based on the results of three tests - "Fan", "Compass" and "Pair of compasses". The totality of the variation analysis provides information on the state of agility in the movement of the subjects studied. Conclusions: The standard tables for assessing the motor quality 'agility' will serve sports specialists and teachers to assess the quality of skills acquired by student-tennis players in the learning process. In sports practice, agility is a component related to the coordination and motor abilities of tennis players in mastering the basic technical elements in tennis. That's why we recommend periodic control of the different manifestations of agility, which is essential for tennis training of students as well as in their sports training activity. [ABSTRACT FROM AUTHOR]

Background/Aim. Resuscitation and surgical medical aid are the most important medical procedures in disaster relief operations. The limited time frame available for life-saving activities in such circumstances demands that resuscitation and surgical medical teams be established and trained for timely reaction and disaster medical support prior to disaster occurrence. The aim of the study was to analyze the awareness among the hospital medical staff in the Plovdiv Region of the hospital response plan in case of disaster, which concerns surgical and resuscitation team composition and tasks for disaster medical support. Methods. An anonymous survey, consisting of 55 questions about hospital staff awareness of the medical activities described in the hospital disaster medical support plan, was conducted between July and September 2019 among 295 hospital medical professionals in the Plovdiv Region, Bulgaria. Descriptive statistics and Pearson’s χ2 test were used in the statistical analysis of results. Results. The survey showed that the majority of medical staff demonstrated complete ignorance regarding the presence, number, and tasks of the specialized medical teams planned for hospital disaster response. Employees of multidisciplinary hospitals for active treatment were more familiar with the aforementioned plans than their colleagues from the university multidisciplinary hospitals. Conclusion. Insufficient awareness about human resources foreseen for disaster medical support negatively impacts the hospital surge capacity, leading to inadequate medical assistance in such cases. Hospital tactical disaster preparedness must be ameliorated by conducting a more rigorous training program among medical staff related to the planned hospital activities in case of disastrous events, especially for those working in emergency departments, intensive care units, and surgical departments.

Background/Aim. In the event of a disaster, it is necessary for medical personnel to demonstrate the operational component of disaster resilience, which requires certain knowledge and skills regarding disaster medical response algorithms. The aim of this study was to analyze the preparedness of hospital’s healthcare staff for maintaining hospital disaster resilience. Methods. An anonymous survey was conducted from July to September 2019 among 295 medical staff employed in hospitals in the territory of the city of Plovdiv, Bulgaria. Pearson’s Chisquare test, Student’s t-test, and graphical analysis were used in the statistical analysis. Results. Most of the medical staff, i.e., 85.8%, believed that disaster drills are not held regularly in hospitals, 30.8% thought that the training period was shorter than two years, and the majority, i.e., 86.1%, did not participate in exercises. Conclusion. Due to the irregular implementation of exercises and the small number of participants in them, the level of preparedness for responding to disasters is not maintained at a high level in hospitals in the Plovdiv region. Therefore, it is necessary to introduce a specific training program and exercise once a year, which should have a beneficial effect on increasing the preparedness of the medical staff for disasters and improving the operational resilience of the hospital.

This publication presents analysis of actual data regarding the development level for some of the most significant motor skills in age 12-14 alpine skiers representing a variety of Bulgarian ski clubs. Alpine skiing is a strongly athletic power-speed sport setting higher and higher requirements regarding the skiers' physical fitness. The research's aim is documenting the current physical state of the tested skiers' group and, based on the data, elaborating evaluation standards for their motor skills. Methods: For the needs of this research we used onsite testing, analytical synthetics and mathematical statistics (variation analysis, sigma methodology). Results: The obtained and aggregated data from the variation analysis present information in regards to the motor skills state of the persons, while the values are with average or close to the average distribution, and applying sigma methodology we derived an evaluation standards table. Conclusions: Motor skills evaluation standards of skiers (adolescents) could assist sports professionals in making quality estimation of the current state of their contestants. We recommend the framing and approbation into the practice of tables for all age groups aiming to achieve better quality control and training process management. [ABSTRACT FROM AUTHOR]

Objectives: In the last few years an increasing frequency of diagnosed cases of HEV infections has been reported from various European countries. In recent years sporadic cases of HEV infections have emerged also in Bulgaria. METHOD‟s: In this retrospective study, 21 patients with acute viral hepatitis type E were included. To describe the clinical and demographic characteristic, we used information from cases recorded at the Clinic of Infectious Diseases, Military Medical Academy - Sofia, from January 2008 to December 2012. The diagnosis of HEV infection was confirmed by the finding of anti-HEV antibodies of class IgG and IgM (ELISA) in acute phase, and by disappearing of IgM anti-HEV in the convalescent period. Statistical analysis was performed using the chi-square test. RESULT‟s: Acute viral hepatitis E composes 5.8% of all acute viral hepatitis treated in Clinic of infectious diseases, MMA - Sofia. The mean age of the patients was 52.4 and 57.1% were males. The most frequent clinical signs were mild to moderate upper gastric symptoms (65%) and liver enlargement (91%). One of the patients was with coinfection HEV+HBV with signs of threatening acute hepatic failure. Another patient was a probable case of chronic HEV infection. The cholestasis enzymes (ALP and GGT) were elevated by most of the patients, but without clinical evidence of cholestasis. CONCLUSION‟S: Acute hepatitis E in Bulgaria emerges as an autochthonous infection with a low incidence rate. Most of the patients were with mild clinical form of acute viral hepatitis E. Patients with severe form have a history of chronic liver disease or co-infections. The question of probable chronic form of HEV infection was discussed. [ABSTRACT FROM AUTHOR]

BACKGROUND: In time of Global economic crisis it is necessary to estimate very precisely the cost for patient treatment so to avoid eventual losses for hospital. According to leading authors drug costs are evaluated between 10-40%. This imposes the necessity of using large range of economic and mathematical instruments for drugs cost control. OBJECTIVE: To assess the need of reducing drugs cost and on this base to propose computer model, adapted to HIS. MATERIAL AND METHODS: Data from Hospital Information System are used to calculate drugs expenditure in the most resource consuming unit in MMA - Anaesthesiology and Intensive Care Department for 5 year period. Statistic methods were used for extracting trends and evaluation. Questionnaire survey was conducted among 50 physicians in MMA, aimed to determine the main problems in drugs prescription. RESULTS: At the beginning of the studied period drugs cost was about 80% of the patient treatment and in the last year after introduced manager control it was reduced to 57%. Among the main reasons for high cost according to the survey are the lack of knowledge and ignorance of drugs prices by physicians. Using the capacity of HIS as an instrument for drugs cost control results in cost reducing up to 30%. CONCLUSIONS: Hospital Information System can play an important role in the reducing drugs costs, and it can help managers to control the process of prescription [ABSTRACT FROM AUTHOR]

INTRODUCTION: The frequency of skin and soft tissue infections (SSTIs) has increased over the last decade due to increased predispositions to those illnesses - diabetes, malignant diseases, obesity, varices, dermatomycosis, etc. MATERIALS and METHOD‟s: In this retrospective study we analyzed 368 military personnel with SSTIs, hospitalized in Clinic of infectious diseases of Military Medical Academy, Sofia for the period January 2006 - December 2012. The study population was grouped according to: gender, age, location of the exanthema, underlying comorbidities, immunodeficiency, risk factors, complications and recurrences. RESULT‟s and DISCUSSION: Of the 368 patients, 317 (86.1%) were male and 51 (13.9%) female, with mean age 32±6. The most common skin and soft tissue infections were erysipelas 198 (53.8%) followed by impetigo 82 (22.3%), cellulitis 44 (11.9%), post-operative wound infections 39 (10.6%) and necrotizing fasciitis 5 (1.4%). Most frequently was affected shank (63.3%), thigh (10.1%), face (10.6%), arm (8.5%), abdomen (4.8%) and chest (2.7%). Diagnosis was based on epidemiological, clinical, hystopatological and microbiological data. Among the isolates tested 185 (50.3%) were beta-hemolytic Streptococcus group A, followed by Staphylococcus aureus - 102 (27.7%); Streptococcus viridians 42 (11.4%); E. faecalis - 14 (3.9%); Haemophilus influenzae 11 (2.9%); P. vulgaris - 7 (1.9%); Ps. aeruginosa - 5 (1.4%) and B. cereus - 2 (0.5%). The approach of treatment has been guided by the microbiological type of SSTIs and the severity of clinical presentation. Given the increasing number of methicillinresistant Staphylococcus aureus, beta-lactam antibiotics are no longer reliable empiric therapy for SSTIs. As an alternative etiological therapy we used Vancomycin, Clindamycin, Rifampin, Meropenem, Linezolid, Daptomycin, Tigecyclime, Telavancin and Quinupristindalfopristin. Surgical treatment included incision, drainage and debridement applied in 24 (6.5%) patients. CONCLUSION‟s: The main problem was patients with SSTIs in age group 30-40, with obesity, metabolic disorders, heart diseases and frequent traumatism. There was statistically significant difference in clinical improvement between patients treated with beta-lactam antibiotics and those treated with Daptomycin, Tigecyclin and Telavancin. They can be alternative in parenteral treatment of patients with multiple predisposing SSTIs factors, complications, multiple recurrences and isolated Grampositive cocci. [ABSTRACT FROM AUTHOR]

Introduction  Multivisceral resections (MVRs) in gastric cancer are potentially curable in selected patients in whom clear resection margins are possible. However, there are still uncertain data on their feasibility and safety considering short- and long-term results. The study compares survival, morbidity, mortality, and other secondary outcomes between standard and MVRs for gastric cancer. Materials and Methods  A monocentric retrospective study in patients with gastric adenocarcinoma, covering 2004 to 2020. Of the 336 operable cases, 101 patients underwent MVRs. The remaining 235 underwent standard gastric resections (SGRs), of which 173 patients were in stage T3/T4. To compare survival, a control group of 101 patients with palliative procedures was used-bypass anastomosis or exploration. Results  MVR had a lower survival rate than the SGR but significantly higher than the palliative procedures. The predominant gender in MVR was male (72.3%), with a mean age of 61 years. The perioperative mortality was 3.96% ( n  = 4), and the overall median survival was 28.1 months. The most frequently resected organs were the spleen (67.3%), followed by the pancreas (32.7%) and the liver (20.8%). In 56.4% of the cases two organs were resected, in 28.7% three organs, and in 13.9% four organs. The main complication was bleeding (9.9%). The major postoperative complications in the MVR were 14.85%, and in the SGR 6.4% ( p  < 0.05). Better long-term results were observed in patients who underwent R0 resections compared with R1. Conclusion  Multiorgan resections are characterized by poorer survival and a higher complication rate than gastrectomies. On the other hand, they have better long-term outcomes than palliative procedures. However, MVRs are admissible when performed by an experienced surgical team in high-volume centers., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ).)

We report the transmission of acute myeloid leukemia (AML) undetected at donation from a deceased organ donor to two kidneys and one liver recipients. We reviewed the medical records, and performed molecular analyses and whole exome sequencing (WES) to ascertain AML donor origin and its molecular evolution. The liver recipient was diagnosed 11 months after transplantation and died from complications 2 months later. The two kidney recipients (R1 and R2) were diagnosed 19 and 20 months after transplantation and both received treatment for leukemia. R1 died of complications 11 months after diagnosis, while R2 went into complete remission for 44 months, before relapsing. R2 died 10 months later of complications from allogenic bone marrow transplantation. Microsatellite analysis demonstrated donor chimerism in circulating cells from both kidney recipients. Targeted molecular analyses and medical records revealed NPM1 mutation present in the donor and recipients, while FLT3 was mutated only in R1. These findings were confirmed by WES, which revealed additional founder and clonal mutations, and HLA genomic loss in R2. In conclusion, we report the first in-depth genomic analysis of AML transmission following solid organ transplantation, revealing distinct clonal evolution, and providing a potential molecular explanation for tumor escape., (© 2022 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Abstract., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Hemobilia is an extremely rare cause of upper gastrointestinal bleeding. It often has intermittent manifestation, which may lead to significant diagnostic delay. In 65% of the cases, the causes are iatrogenic, in 7% the cause is malignancy, in 5% - gallstones, in 8% it is inflammation (cholecystitis, parasites, reflux cholangitis), vascular abnormality is the cause in 7% (most commonly pseudoaneurysm of the hepatic artery), and pancreatic pseudocyst causes hemobilia in 1%. In almost all cases, the bleeding originates from intrahepatic or extrahepatic bile ducts, and rarely from the pancreas., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: We present a comparative analysis of survival, complications and major risk factors in patients who underwent surgery for pancreatic head carcinoma. Methods: This is a single-centre retrospective study aimed to evaluate clinical, surgical and pathoanatomical features of 467 patients who underwent radical surgery for pancreatic head carcinoma between September 2004 and October 2019. The series includes 88 patients (18.8%) with venous resections for borderline resectable pancreatic adenocarcinoma. Results: The estimated median survival rates were statistically significant with 19.3 months in pancreatoduodenal venous resections (VR) and 26.9 months in pancreatoduodenal resections (PDR), respectively (p=0.047). On the other hand, one, three, and five-year survival rates of 46.6%, 17.6% and 8.3% in VR, and 53.6%, 20.8%, 14.9% in PDR were not statistically significant (p=0.13, 0.5 and 0.11 respectively). Survival rates comparison in PDR, VR, and palliative procedures (PP) between the three groups showed statistical significance (p 0.05). The clinically relevant postoperative complications in venous resections (13.6%) vs. 14.8% in PDR were not statistically significant (p=0.77). Postoperative bleeding and reoperation (p 0.05) are independent prognostic factors for worse outcomes. There was no statistically significant relationship between survival and presence of vascular invasion (p=0.581). Conclusions: When performed by experienced surgeons at specialized high-volume centres, pancreatoduodenal resections combined with venous resection and reconstruction are reliable and safe surgical procedures., (Celsius.)

Background: Tumours involving the supra-renal segment of IVC have dismal prognosis if left untreated. Currently, aggressive surgical management is the only potentially curative treatment but is associated with relatively high morbidity and mortality. This study aims to evaluate perioperative factors, associated with adverse postoperative outcomes, based on the perioperative characteristics and type of IVC reconstruction., Methods: We identified 44 consecutive patients, who underwent supra-renal IVC resection with a mean age of 57.3 years. Isolated resection of IVC was performed in four patients, concomitant liver resection was performed in 27 patients and other associated resection in 13 patients. Total vascular exclusion was applied in 21 patients, isolated IVC occlusion in 11 patients. Neither venovenous bypass (VVB) nor hypothermic perfusion was used in any of the cases., Results: The mean operative time was 205 min (150-324 min) and the mean estimated blood loss was 755 ml (230-4500 ml). Overall morbidity was 59% and major complications (Dindo-Clavien ≥ III) occurred in 11 patients (25%). The 90-day mortality was 11% (5pts). Intraoperative haemotransfusion was significantly associated with postoperative general complications (p < 0,001). With a mean follow-up of 26.2 months, the actuarial 1-, 3- and 5-year survival is 69%, 34%, and 16%, respectively., Conclusions: IVC resection and reconstruction in the aspect of aggressive surgical management of malignant disease confers a survival advantage in patients, often considered unresectable. When performed in experienced centres it is associated with acceptable morbidity and mortality.

Purpose: Treatment failure from drug resistance is the primary reason for relapse in acute lymphoblastic leukemia (ALL). Improving outcomes by targeting mechanisms of drug resistance is a potential solution., Patients and Methods: We report results investigating the epigenetic modulators decitabine and vorinostat with vincristine, dexamethasone, mitoxantrone, and PEG-asparaginase for pediatric patients with relapsed or refractory B-cell ALL (B-ALL). Twenty-three patients, median age 12 years (range, 1-21) were treated in this trial., Results: The most common grade 3-4 toxicities included hypokalemia (65%), anemia (78%), febrile neutropenia (57%), hypophosphatemia (43%), leukopenia (61%), hyperbilirubinemia (39%), thrombocytopenia (87%), neutropenia (91%), and hypocalcemia (39%). Three subjects experienced dose-limiting toxicities, which included cholestasis, steatosis, and hyperbilirubinemia ( n = 1); seizure, somnolence, and delirium ( n = 1); and pneumonitis, hypoxia, and hyperbilirubinemia ( n = 1). Infectious complications were common with 17 of 23 (74%) subjects experiencing grade ≥3 infections including invasive fungal infections in 35% (8/23). Nine subjects (39%) achieved a complete response (CR + CR without platelet recovery + CR without neutrophil recovery) and five had stable disease (22%). Nine (39%) subjects were not evaluable for response, primarily due to treatment-related toxicities. Correlative pharmacodynamics demonstrated potent in vivo modulation of epigenetic marks, and modulation of biologic pathways associated with functional antileukemic effects., Conclusions: Despite encouraging response rates and pharmacodynamics, the combination of decitabine and vorinostat on this intensive chemotherapy backbone was determined not feasible in B-ALL due to the high incidence of significant infectious toxicities. This study is registered at http://www.clinicaltrials.gov as NCT01483690., (©2020 American Association for Cancer Research.)

Despite decades of research and an enormity of resultant data, cancer remains a significant public health problem. New tools and fresh perspectives are needed to obtain fundamental insights, to develop better prognostic and predictive tools, and to identify improved therapeutic interventions. With increasingly common genome-scale data, one suite of algorithms and concepts with potential to shed light on cancer biology is phylogenetics, a scientific discipline used in diverse fields. From grouping subsets of cancer samples to tracing subclonal evolution during cancer progression and metastasis, the use of phylogenetics is a powerful systems biology approach. Well-developed phylogenetic applications provide fast, robust approaches to analyze high-dimensional, heterogeneous cancer data sets. This article is part of a Special Issue entitled: Evolutionary principles - heterogeneity in cancer?, edited by Dr. Robert A. Gatenby., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Mutations detected in cancers are often divided into "drivers" and "passengers." We suggest that this classification is potentially misleading for purposes of early detection and prevention. Specifically, some mutations are frequent in tumors and thus appear to be drivers, but are poor predictors of cancer; other mutations are individually rare and thus appear to be passengers, but may collectively explain a large proportion of risk. The assumptions bundled into the terms "driver" and "passenger" can lead to misunderstandings of neoplastic progression, with unintended consequences including overdiagnosis, overtreatment, and failure to identify the true sources of risk. We argue that samples from healthy, benign, or neoplastic tissues are critical for evaluating the risk of future cancer posed by mutations in a given gene. Cancer Prev Res; 9(5); 335-8. ©2016 AACR., (©2016 American Association for Cancer Research.)

When multiple samples are taken from the neoplastic tissues of a single patient, it is natural to compare their mutation content. This is often done by bulk genotyping of whole biopsies, but the chance that a mutation will be detected in bulk genotyping depends on its local frequency in the sample. When the underlying mutation count per cell is equal, homogenous biopsies will have more high-frequency mutations, and thus more detectable mutations, than heterogeneous ones. Using simulations, we show that bulk genotyping of data simulated under a neutral model of somatic evolution generates strong spurious evidence for non-neutrality, because the pattern of tissue growth systematically generates differences in biopsy heterogeneity. Any experiment which compares mutation content across bulk-genotyped biopsies may therefore suggest mutation rate or selection intensity variation even when these forces are absent. We discuss computational and experimental approaches for resolving this problem.

Immunosuppression for solid organ transplantation increases lymphoproliferative disease risk. While central nervous system (CNS) involvement is more rare, we noticed an increase in primary CNS (PCNS) disease. To investigate a potential association with the immunosuppressive regimen we identified all post-transplant lymphoproliferative disease (PTLD) cases diagnosed over a 28-year period at our institution (174 total, 29 PCNS) and all similar cases recorded in a United Network for Organ Sharing-Organ Procurement and Transplant Network (UNOS-OPTN) datafile. While no PCNS cases were diagnosed at our institution between 1986 and 1997, they comprised 37% of PTLD cases diagnosed from 2011-2014. PCNS disease was more often associated with renal vs. other organ transplant, Epstein-Barr virus, large B-cell morphology and mycophenolate mofetil (MMF) as compared to PTLD that did not involve the CNS. Calcineurin inhibitors were protective against PCNS disease when given alone or in combination with MMF. A multivariate analysis of a larger UNOS-OPTN dataset confirmed these findings, where both MMF and lack of calcineurin inhibitor usage were independently associated with risk for development of PCNS PTLD. These findings have significant implications for the transplant community, particularly given the introduction of new regimens lacking calcineurin inhibitors. Further investigation into these associations is warranted.

Barrett's esophagus is a condition in which the normal stratified squamous epithelium of the distal esophagus is replaced by intestinal metaplasia. For more than three decades, the prevailing clinical paradigm has been that Barrett's esophagus is a complication of symptomatic reflux disease that predisposes to esophageal adenocarcinoma. However, no clinical strategy for cancer prevention or early detection based on this paradigm has been proven to reduce esophageal adenocarcinoma mortality in a randomized clinical trial in part because only about 5% to 10% of individuals with Barrett's esophagus develop esophageal adenocarcinoma. Recent research indicates that Barrett's metaplasia is an adaptation for mucosal defense in response to chronic reflux in most individuals. The risk of progressing to esophageal adenocarcinoma is determined by development of genomic instability and dynamic clonal evolution in the distal esophagus modulated by host and environmental risk and protective factors, including inherited genotype. The challenge for investigators of Barrett's esophagus lies in integrating knowledge about genomic instability and clonal evolution into clinical management to increase the lifespan and quality of life of individuals with this condition., (©2011 AACR.)

Barrett's esophagus (BE) is a premalignant intermediate to esophageal adenocarcinoma, which develops in the context of chronic inflammation and exposure to bile and acid. We asked whether there might be common genomic alterations that could be identified as potential clinical biomarker(s) for BE by whole genome profiling. We detected copy number alterations and/or loss of heterozygosity at 56 fragile sites in 20 patients with premalignant BE. Chromosomal fragile sites are particularly sensitive to DNA breaks and are frequent sites of rearrangement or loss in many human cancers. Seventy-eight percent of all genomic alterations detected by array-CGH were associated with fragile sites. Copy number losses in early BE were observed at particularly high frequency at FRA3B (81%), FRA9A/C (71.4%), FRA5E (52.4%), and FRA 4D (52.4%), and at lower frequencies in other fragile sites, including FRA1K (42.9%), FRAXC (42.9%), FRA 12B (33.3%), and FRA16D (33.3%). Due to the consistency of the region of copy number loss, we were able to verify these results by quantitative PCR, which detected the loss of FRA3B and FRA16D, in 83% and 40% of early molecular stage BE patients, respectively. Loss of heterozygosity in these cases was confirmed through pyrosequencing at FRA3B and FRA16D (75% and 70%, respectively). Deletion and genomic instability at FRA3B and other fragile sites could thus be a biomarker of genetic damage in BE patients and a potential biomarker of cancer risk.