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The bleeding from the upper gastrointestinal tract represent a significant medical but also socio-economic problem.A special group of patients et increased risk consists of critically ill patients in intensive care units. Particularly significant cause of bleeding in intensive care unit patients is bleeding resulting from the stress ulcers caused by damage of themucosa of the stomach and duodenum. The purpose of this review is to present current experience in prevention of upper gastrointestinal tract bleeding using proton pump inhibitors in intensive care units. Combination of endoscopic hemostatic methods and proton pump inhibitors represents golden standard in most cases. Despite some adverse effects treatment with proton pump blockers is essential when upper gastrointestinal tract bleeding appears in critically ill patients in intensive care units. Proton pump inhibitors are more effective in acid suppression, as well as in the prevention of recurrent bleeding after endoscopic hemostasis than histamine 2 receptor blockers. The efficacy of proton pump blockers is higher in the case of a continuous intravenous infusion than in the intermittent mode of administration of the drug. The need for highly elaborate strategy for the prophylaxis of bleeding from the upper parts of gastrointestinal tract in intensive care units is essential, because when it occurs in intensive care units, mortality is high, and therapeutic options become narrow.

Mucocele of the apendix is a rare clinical and pathological entity with a higher incidence in the female population, and non-specific symptomatology that includes more diagnoses including neoplastic and non-neoplastic causes of the apendix dilation and mucin proliferation. With obtained numerous variations in symptomatology, clinical picture, intraoperative presentation, surgical treatment and histopathological findings, the aim of this paper is an inspection into current knowledge of this disease, its histopathological characteristics, differential diagnosis and current treatment modalities. We present a patient with a clinical picture of the acute abdomen and numerous comorbidities. Ultrasound diagnostics indicated the presence of thin-walled dilatation of the small intestine, especially in the lower right quadrant, as well as the presence of free fluid in the peritoneal cavity. Apendectomy and removal of the mucocele and resection of the gangrenous sigmoid colon according to Hartmann were done. A definitive histopathological finding suggests ischemic colitis and retention mucocele of the apendix with normal mucosa. Histopathologically, four types of mucocele apendixes are distinguished, namely the retention mucinous cyst, mucosal hyperplasia, mucinous cystadenoma and mucinous cystadenocarcinoma. Surgical treatment is the method of choice in treating these tumors, either open or laparoscopic. Imperative is the preservation of the integrity of the entire mucocele, due to the possible dissemination of contents of the cyst and the subsequent development of pseudomyxoma peritonei.

Chemotherapy combined with immunotherapy has improved the treatment of certain solid tumors, but effective regimens remain elusive for pancreatic ductal adenocarcinoma (PDAC). We conducted a randomized phase 2 trial evaluating the efficacy of nivolumab (nivo; anti-PD-1) and/or sotigalimab (sotiga; CD40 agonistic antibody) with gemcitabine/nab-paclitaxel (chemotherapy) in patients with first-line metastatic PDAC (NCT03214250). In 105 patients analyzed for efficacy, the primary endpoint of 1-year overall survival (OS) was met for nivo/chemo (57.7%, P = 0.006 compared to historical 1-year OS of 35%, n = 34) but was not met for sotiga/chemo (48.1%, P = 0.062, n = 36) or sotiga/nivo/chemo (41.3%, P = 0.223, n = 35). Secondary endpoints were progression-free survival, objective response rate, disease control rate, duration of response and safety. Treatment-related adverse event rates were similar across arms. Multi-omic circulating and tumor biomarker analyses identified distinct immune signatures associated with survival for nivo/chemo and sotiga/chemo. Survival after nivo/chemo correlated with a less suppressive tumor microenvironment and higher numbers of activated, antigen-experienced circulating T cells at baseline. Survival after sotiga/chemo correlated with greater intratumoral CD4 T cell infiltration and circulating differentiated CD4 T cells and antigen-presenting cells. A patient subset benefitting from sotiga/nivo/chemo was not identified. Collectively, these analyses suggest potential treatment-specific correlates of efficacy and may enable biomarker-selected patient populations in subsequent PDAC chemoimmunotherapy trials.

Introduction: Hemangiopericytoma is a rare tumor arised from the pericytes, contractile spindle cells that surround the capillaries and post-capillary venules. The tumor was found equally among males and females. Case report: We report a case of a 63-year-old female who presented a giant painful mass on her right shoulder that occurred one year before admission. Limited range of motion and a sense of tingling along the affected arm was present also. An irregular, oval-shaped mass, colored dark-red, with signs of necrosis was the maximal diameter of 14cm. Routine laboratory analyzes showed results within the range of referenced values. Lung X-ray and ultrasonographic examination of the abdomen showed no signs of secondary tumor deposits, and no osteo-muscular lesions in the affected region. Ultrasonographic examination of the neck and right axillary region showed no signs of regional metastases. The surgical excision of the entire tumor was performed, with the associated subcutaneous tissue and a part of fascia underneath. Results of the histopathological analysis confirmed the diagnosis of hemangiopericytoma. The specimen showed no signs or elements of the neoplastic tissue on the edges of the resection lines. 3 years after the operation, there was found no signs of tumor relapses, regional or systemic metastases. Conclusion: Considering that there are no official clinical guides and protocols for hemangiopericytoma management, as well as the occurrence of cutaneous and subcutaneous hemangiopericytomas is exceptionally rare, more extensive research in this field and more described cases are need to gain a better understanding of that issue.

Background: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal system and it accounts for between 1-3% of all gastrointestinal malignancies. GIST arises most commonly from the stomach in 60 – 70% of cases. The clinical presentation of acute abdomen, due to GIST perforation, was a particularly rare described complication of this disease. Our case report aimed to present a case of acute abdomen in an elderly female patient, due to jejunal GIST perforation. Case presentation: A 76-year-old female patient presented with acute abdomen to the emergency surgical unit University Clinical Center of Kragujevac. Computed tomography (CT) scan with intravenous contrast showed pneumoperitoneum, the presence of a 75 x 35 mm irregular fluid collection in the left lower quadrant of the abdomen with air inclusions and signs of small intestine perforations. The patient underwent an emergency laparotomy. Intraoperative findings showed the acute inflammatory reaction of the peritoneum with free bowel contents in the abdominal cavity due to jejunal tumor perforation. Partial resection of the small intestine with tumor was performed followed by intestine anastomosis. Histopathological examination of a specimen revealed a completed resected jejunal gastrointestinal stromal tumor. CONCLUSIONS: GIST arises from the small intestine in 25-30% of cases, and jejunum in 10% of cases. Perforation of GIST and acute diffuse peritoneal inflammation was rare complication of the disease. Emergency laparotomy and complete resection of tumors are essential.

Colluvisols represent an important part of the soil cover, occupying concave slope elements especially in landscapes with undulating relief. Their development reacts to changes in land use or climate, manifested by intense erosion activity or longer resting periods with predominantly in-situ pedogenesis. In climatically, pedologically and historically different regions, diverse colluvial profiles can be encountered. In this study, we investigated deep colluvial profiles in three agricultural plots in Czechia with different soil cover, climatic and geological conditions in order to identify differences in the depositional pattern and erosion history of the areas. In each of the plots, two profiles (depths ranging from 200 to 400 cm) were opened in the toe-slope and side valley areas. Individual layers were investigated by various methods, including optically stimulated luminescence dating, 137Cs activity, concentration of vertically stable geochemical tracers (organochlorine pesticides, nutrients) or micromorphology and clay mineralogy, allowing the layers to be linked to periods of human activity. In all study areas, a significant difference in the colluvial deposition mechanism was found in the toe-slope and side valley areas. While the positions in the side valleys were mainly composed of older material with a minimum concentration of human-bound substances, the profiles in the toe-slopes are characterized by a significant deposition of recently accumulated material. The most pronounced redistribution of material was recorded in the Chernozem area on loess. In the toe-slope area, maxima of 137Cs, DDT (up to 350 µg/kg) and phosphorus were found at 100-140 cm, indicating the very low age of this layer (from the mid-20th century). The mineralogical and chemical composition of this layer and the layer below (140-220 cm) shows considerable similarities to the substrate material, indicating severe truncation of the source soils and accumulation of ploughed parent material. In contrast, in the side valley, this new material was found only in the topsoil, with approximately 3 m of older, humus-rich material beneath. This area is therefore not an area of recent deposition, but rather of material transport. The original buried Chernozem was found in both cases at a depth of about 300-350 cm. In the Cambisol area, the combination of rill and sheet erosion led to the formation of a highly stratified profile with a large variation in texture or humus content. The maximum of human-bound substances (137Cs, HCB, DDT) was found at a depth of 1 m, underlain by older material with signs of post-depositional pedogenesis (weathering and redox processes). The area of side valley was, as in the previous area, almost unaffected by recent sedimentation. In Luvisol area, the concentration on human-bound substances was generally lower and affected only the upper, humus-rich layer (ca 80 cm) of the Colluvisols, both at the toe-slope and the side valley. Below this layer, the profiles are characterised by relatively pronounced pedogenesis in the sedimentary material (clay coatings visible at the thin sections), indicating slower sedimentation and a longer period of sedimentary quiescence.Study was supported by grant nr. 21-11879S of the Czech science foundation and MEYS CR project nr. CZ.02.1.01/0.0/0.0/16_019/0000845.

Introduction. Marjolin?s ulcer is a skin malignancy that occurs on a scar or chronic wound. It most commonly occurs on a burn scar. Squamous cell carcinoma is the most common type of this tumor in more than 90% of cases. The rate of this rare malignant transformation is 1?2%. Marjolin?s ulcer is more aggressive than other skin cancers. Wide excision is the treatment of choice. Recurrences are common. We present a large exophytic carcinoma of the lower leg as a rare form of this tumor ac-cording to the size and type together with reconstruction results. Case report. A 52-year-old man was presented with a large exophytic tumor on the left lower leg. The tumor was located at the site of the previous gunshot in-jury. The latent period was 22 years. Tumor size was 14 ? 12 cm. Wide excision was performed (2-cm surgical margin), including the deep fascia, and the defect was closed by a split-thickness skin graft from the opposite thigh. Histology showed well-differentiated squamous cell carcinoma. There were no regional or distant metastases. One year after surgery, there was no recurrence of the tumor. Conclusion. Early diagnosis of Marjolin?s ulcer and wide excision are mandatory. Surgical margins for excision should be 2 cm, and excision should include deep fascia. Multiple and repeated biopsies of chronic wounds are advised. There is no consensus on the staging of Marjolin?s ulcer and lymph node dissection.

Phyllodes tumors of the breast can be benign, malignant, or borderline. Benign and borderline tumors are rare tumor types that have a positive outlook and high survival rate, while the risk of recurrence is typical for malignant breast tumors. Giant phyllodes tumors are larger than 10 cm in diameter and demand a serious diagnostic and treatment approach. In this study we present a case of a female patient treated for an exulcerated breast carcinoma- a giant borderline phyllodes tumor of the breast. The patient presented to the department for the right breast lump with ulcerated skin and nipple abnormalities. The core biopsy was performed and the patient was diagnosed with a benign tumor. Simple mastectomy was performed and final histopathological report revealed a borderline phyllodes tumor. Diagnosis and treatment of a giant phyllodes tumor remain a great challenge for the surgeons. Establishing the preoperative diagnosis based on histopathological findings is imperative to disease management. Surgery is the mainstay of treatment and mastectomy has been the traditional procedure; in cases where suspicious findings in the axilla are revealed, radical mastectomy is performed and the axilla is to be dissected.

The quality of life and patient survival rate in terminal chronic renal insufficiency depends on the duration of vascular approaches. Dialysis catheters are used to establish an adequate vascular approach when emergency hemodialysis is indicated and when all approaches are exhausted. Complications of CVC can be classified into three categories: mechanical (hematoma, arterial puncture, pneumothorax, hemothorax, catheter misplacement, and stenosis), infectious (insertion site infection, CVC colonization, and bloodstream infection) and thrombotic (deep vein thrombosis). Despite the increasing prevalence of haemodialysis patients with complex access issues, there remains no consensus on the definition of vascular access failure or end-stage vascular access. The dilema in these cases remains whether the generalized vascular insufficiency is the cause or a complication of exhausted vascular accesses. This case report is one of the examples of combined complications with generalized vascular access insufficiency. During the year and a half of the chronic dialysis program, the patient had several changes of vascular approaches, and each approach became dysfunctional in certain time due to various causes. After six months of successful hemodialysis, the patient was admitted with signs of infection and during hospitalization was again subjected to multiple changes of the vascular approach due to infection, thrombosis, and vascular access failure.

One of the most intriguing problems in modern esophageal surgery is the acquired short esophagus. While some authors recognize this entity, others deny its existence. There is a consensus about types of the short esophagus, its etiology and pathophysiology. Definitive diagnosis can be established only intraoperatively. There are a few surgical procedures for this problem, and most frequently is used Collis gastroplasty with fundoplication. In this review we emphasize recent literature data and further perspectives of the Collis procedure.

Background: Appendiceal mucoceles represent neoplastic and non-neoplastic, dilatated, mucus filled appendix vermiformix. Appendectomy is obligatory due to a possible malignancy. It is crucially important to avoid rupturing of the mucocele because it can result in pseudomyxoma peritonei, with high morbidity and mortality. Case Report: We presented a 52-year-old man with pain and palpable mass in the lower right quadrant of the abdomen. The mucocele was removed without a rupture, and the patient was discharged from the surgical department one day after the surgery without a complication. Discussion: The resection must be done very carefully, because the rupture of a mucocele can cause pseudomyxoma peritonei, a very dangerous and often lethal condition. Due to the concern of rupture, we performed the classical resection through laparotomy. Conclusion: It is very important, especially for young, inexperienced surgeons to be aware of this rare diagnosis and perform a surgical intervention according to the guidelines of good clinical practice.

4010 Background: Preclinical and small clinical studies of chemoimmunotherapy for metastatic pancreatic ductal adenocarcinoma (mPDAC) point to a yet unrealized potential of clinically significant immune activation. In our phase II study of the CD40 agonist antibody sotigalimab (sotiga) and/or nivolumab (nivo) with gemcitabine and nab-paclitaxel (chemo), we observed promising improvements in overall survival (OS) in 105 patients with newly diagnosed mPDAC (NCT03214250); the primary endpoint of 1-year OS rate was 57.7% (p = 0.006) in the nivo/chemo arm, 48.1% (p = 0.062) in the sotiga/chemo arm and 41.3% (p = 0.233) in the nivo/sotiga/chemo arm (O’Hara, ASCO 2021) as compared to a historical control of 35%. Here, we report results of multi-omic translational analyses designed to identify signatures predictive of OS benefit. Methods: Longitudinal blood and tumor tissue samples were collected for immune and tumor biomarker analysis. Tumor samples underwent RNA sequencing and multiplex immunofluorescence (mIF). Peripheral blood was analyzed by mass cytometry time of flight (CyTOF), high parameter flow cytometry, and proteomics. Machine learning (ML) algorithms were applied to the data to identify biosignatures related to OS in each arm. Results: Comprehensive multi-omic, multi-parameter immune and tumor biomarker analyses identified distinct pretreatment immune signatures predictive of longer OS specific to nivo/chemo or sotiga/chemo (Table, representative examples). Because patients in each arm received chemotherapy, these and other arm-unique biomarkers suggest a relationship to the immunotherapy rather than chemotherapy in this randomized study. There was evidence of immune exhaustion in the sotiga/nivo/chemo arm that may explain the lack of survival benefit. Conclusions: From in-depth translational and ML analyses of randomized phase II trial of first-line chemoimmunotherapy in mPDAC patients, we identified novel biomarkers that associated with OS distinctly in each arm. Clinical trials in first-line mPDAC exploiting these previously unappreciated biomarkers and aiming to enrich patients for response, are warranted to further advance chemoimmunotherapy in this disease. Clinical trial information: NCT03214250. [Table: see text]

Short esophagus is well known complication of a long term gastroesophageal disease. There are several ways to solve this problem intraoperatively. One of the first steps is extensive esophageal mobilisation. In this review we emphasize different approaches and types of this procedure, with their advantages and disadvantages.

Lime soil stabilization is a well-known and often used method. One of the methods of landslide stability improvement is changing soil with materials that have better physical and mechanical characteristics. In most of the methods for determining slope stability, the main input data are internal friction angle and cohesion. The main objective of this paper was to find out if the sampled silty clay soil was suitable for lime stabilization, and to get the values of shear strength parameters from soil samples with and without added lime. The results showed that by increasing lime content, internal friction angle rises, while cohesion values decrease, as well as deformations, all the way to 15% of lime by mass. The changes in internal friction angle, cohesion and deformations were most noticeable between 0 and 5% of added lime. Samples that endured the largest pressures were those containing 10% of lime.

Introduction. Asymptomatic Bochdalek hernia in adults is a rarity. The aim of this paper is to present a rare case of Bochdalek hernia among adults and to point out to significance of clinical suspicion and important role of imaging techniques in reaching the exact diagnosis of this abnormality. Case report. A patient, aged 68 years, came to the Clinic of Pulmonology complaining of constant dyspnea, coughing and fatigue. Computed tomography (CT) findings were dominated by the large rear right diaphragmatic hernia with the hernial sac that reached the carina trachea and urged the principal bronchi. The stomach, duodenum and proximal part of jejunal winds, as well as a greater amount of omental and mesenteric adipose tissue were localized in hernial sac. Radiography of gastroduodenum showed: entry of the esophagus into the cardia was in the level of the right main bronchus. Stomach was mainly located in the chest (cardia, upper corpus half - to the level of the right main bronchus). Operation was indicated. First, we made right thoracotomy and the hernia sac was separated from the right lung and then we performed median laparotomy and the contents of the hernia sac were returned to the abdominal cavity; diaphragm defect was reconstructed with prolen mesh. Conclusion. We presented a rare case of right sided Bochdalek hernia which was discovered at late age and surgically treated with success.

Introduction. Malignant fibrous histiocytoma is a fast spreading pleomorphic sarcoma with a high malignant potential. Its spreading is characterized with local invasion and distant metastazes with early onset. Most common localisations of development are extremities, trunk and retroperitoneum. Given the line of rare case and specimen, lack of a clear etiology and mechanisms of this disease, as well as adequate histopathologic findings and intraoperative documentation, we presented current status, discuss putative etiology, histopathology with variant morphology, differential diagnosis and treatment modalities. Case report. We presented a 56-years-old female Serbian with tumor in the thigh that clinically resembles incapsulated hematoma. Computed tomography revealed intramuscular tumor with a heterodense structure and compression on surround tissue. Ex tempore biopsy specimen showed malignant potential of the tumor. Wide and radical excision of the nodule has been done, and definitive histopathological verification revealed malignant fibrous histiocytoma. Conclusion. Malignant fibrous histiocytoma is a most common type of soft tissue sarcomas in adults. Frequent localization is on lower extremities, and every rapidly enlarging nodule in this localization that on computed tomography is like incapsulated hematoma with necrotic zone should alert suspicion on presence of this type of sarcoma. [Project of the Serbian Ministry of Education, Science and Technological Development, Grant no. III41007 and Grant no. III41010]

2573 Background: Immune checkpoint inhibitors (ICIs) have demonstrated durable clinical responses and improved survival in patients (pts) across numerous indications. Despite this progress, the benefit of ICIs is limited to a minority of overall metastatic cancer patients. There is a critical need for biomarkers agnostic of tumor type to inform which pts will benefit from nivo alone versus ipi/nivo combination treatment. Both pre-treatment tumoral CD8 + cells and recruitment of CD8+ T cells in response to ICIs are associated with improved clinical outcomes in patients treated with anti-PD-1 therapy. 1,2,3,4 Here we report the final results of a prospective clinical study in which pts with varying advanced solid tumors were assigned to nivo, with or without ipi, based on the percentage of tumoral CD8 cells at the time of treatment. Methods: We performed a prospective, non-randomized, open-label, multicenter study in which pts with tumoral CD8+ cells ≥ 15% (CD8+ high) received nivo 360mg IV Q3W, followed by nivo maintenance 480mg Q4W. Pts with tumoral CD8+ cells < 15% (CD8+ low) received nivo 360 mg IV Q3W, and ipi at 1 mg/kg IV Q3W for 2 doses and then Q6W for 2 doses, followed by nivo maintenance 480 mg IV Q4W until PD or intolerable toxicity. Primary endpoints were Disease Control Rate (DCR: CR, PR, or SD ≥ 6 months) and CD8 low to high conversion (< 15% to ≥ 15%). Baseline and on-treatment tumor, blood and stool samples were collected for multiomic biomarker analyses. This study was not powered for formal statistical analysis. Up to 200 pts could be enrolled to allow for adaptive exploration of response and CD8 changes. Results: N = 79 pts were enrolled:7 in CD8+ high arm (nivo) and 72 in CD8+ low arm (ipi/nivo). The study enrolled a wide variety of primary solid tumors; the most common were gynecological (n = 15), prostate (12), and head and neck (7). DCR was 14% (1/7; 95% CI 1 - 44) and 24% (17/72; 95% CI 15 - 34) in the CD8 high and CD8 low arms, respectively. Of 39 pts in CD8 low arm with an on-treatment biopsy, 14 (36%; 95% CI 22 - 51) had CD8 conversion; 7/14 pts (50%) who converted had DCR. Immune-related AEs (irAEs) were consistent with known safety profile of both drugs. Conclusions: Ipi/nivo demonstrated clinical responses and increased CD8% in a range of “cold” tumors with low tumoral CD8 cells. There may be an association between increasing CD8% and response. Baseline high CD8% alone does not appear to be sufficient as a pan-cancer predictive biomarker of response to nivo monotherapy. CD8 conversion, response, and irAEs associated with circulating and stool-based biomarkers are under evaluation as composite biomarkers may improve their predictive value. Clinical trial information: 03651271.

Accessory auricle is a rare anomaly with an estimated incidence rate of 0.2-0.5%. The most common form of this malformation is the accessory tragus. It may be a sign of other syndromes, such as oculo-auriculo-vertebral dysplasia (Goldenhar’s syndrome). In this paper, we describe two cases of accessory auricle with a focus on diagnosis and surgical treatment.

Introduction. Chylothorax is an accumulation of chyle in the pleural cavity due to a disruption of the thoracic duct. Traumatic chylothoraces are usually a result of a penetrating trauma and disruption of the thoracic duct, but blunt traumatic chylothorax is a rare condition. The aim of this paper is to present a rare case of traumatic chylothorax after blunt thoracic trauma. Case Outline. We present a case of traumatic chylothorax after blunt thoracic trauma in a patient injured in a motor vehicle accident. The patient had a right-sided fracture of rib XI, hydropneumothorax, lung contusion, and signs of pneumomediastinum. We performed thoracic drainage, but a few days later, according to the increase of amount of the fluid daily drained, and the confirmation of laboratory findings of the analyzed fluid, we made a diagnosis of chylothorax and the patient underwent a thoracotomy, where we sutured the thoracic duct. Conclusion. Chylothorax should be considered in patients after chest trauma if they develop a milky pleural effusion. Analysis of pleural fluid and level of triglycerides is important for the diagnosis and treatment of chylothorax. [Project of the Serbian Ministry of Education, Science and Technological Development, Grant no. III41007]

Background/Aim. Acute pancreatitis is an inflammatory condition having the significant mortality rate in the case of severe forms of the disease. The aim of this study was to investigate putative factors of increased mortality in patients with acute pancreatitis with contradictory prior evidence, and to reveal factors that were insufficiently explored previously. Methods. This prospective cohort study with nested case/control design included all adult patients treated for acute pancreatitis in the Clinical Center of Kragujevac, Serbia, during the 3-year period (from October 2011 to December 2014). The cases (n = 19) were patients who died, while the controls (n = 113) were patients who survived. The associations between putative risk factors and the study outcomes were tested by univariate and multivariate logistic regressions, and expressed as crude and adjusted odds ratios (OR) with corresponding 95% confidence intervals (CI). Results. Significant association with the lethal outcome in acute pancreatitis was found for advanced age (adjusted OR 1.12, 95%CI 1.02?1.23), presence of significant comorbidities (adjusted OR 10.62, 95%CI 1.01?111.39), higher interleukin- 8 (IL-8) value on third day from onset of symptoms (adjusted OR 1.05, 95%CI 1.02?1.08), use of tramadol and/or morphine (adjusted OR 47.34, 95%CI 3.21?699.08), the Bedside index for severity in acute pancreatitis (BISAP) score ? 3 in the first 24 hours (adjusted OR 48.11, 95%CI 3.14?736.29), and prophylactic use of antibiotics (adjusted OR 0.07, 95%CI 0.01?0.85). Conclusion. Advanced age, significant comorbidities, use of tramadol and/or morphine and more severe disease as assessed by BISAP score can increase the risk of death in acute pancreatitis, while prophylactic use of antibiotics may have a protective role.

Introduction. Management of a polytraumatized patient is a problem that requires a multidisciplinary approach, in order to optimise patient’s outcome. The purpose of this study is to show the approach in the treatment of a patient with a severe life-threatening polytrauma, including a personalized healthcare approach, after the inadequate initial treatment with the positive outcome. Case report. We present a case of a young polytraumatized patient with trauma as a result of road traffic accident. The patient had chest injuries, abdominal injuries and right arm injuries. He was diagnosed of hepatic rupture with conquasation and retroperitoneal hematoma and the patient underwent liver tamponade. Chest trauma was treated by chest drainage. After the adequate multidisciplinary interventions for the patient, the patient was discharged. Conclusion. This case report is of great importance since it shows that severe polytraumatized patients with bad initial prognosis can successfully receive a life - saving treatment.

OBJECTIVE Superior semicircular canal dehiscence (SSCD) is a rare disorder characterized by the formation of a third opening in the inner ear between the superior semicircular canal and the middle cranial fossa. Aberrant communication through this opening causes a syndrome of hearing loss, pulsatile tinnitus, disequilibrium, and autophony. This study analyzed the clinical outcomes of a single-institution series of patients with SSCD undergoing surgical repair by the same otolaryngologist and neurosurgeon. METHODS All patients who underwent SSCD repair at the University of California, Los Angeles, between March 2011 and November 2014 were included. All patients had their SSCD repaired via middle fossa craniotomy by the same otolaryngologist and neurosurgeon. Outcomes were analyzed with Fisher's exact test. RESULTS A total of 18 patients with a mean age of 56.2 years (range 27–84 years) and an average follow-up of 5.0 months (range 0.2–21.8 months) underwent 21 cases of SSCD repair. Following treatment, all patients (100%) reported resolution in ≥ 1 symptom associated with SSCD. Autophony (p = 0.0005), tinnitus (p = 0.0059), and sound- and/or pressure-induced dizziness (p = 0.0437) showed significant symptomatic resolution. Following treatment, 29% (2/7) of patients developed imbalance, 20% (1/5) of patients developed sound- and/or pressure-induced dizziness, and 18% (2/11) of patients developed aural fullness. Among patients with improved symptoms following surgical repair, none reported recurrence of symptoms at subsequent follow-up visits. CONCLUSIONS SSCD remains an underdiagnosed and undertreated condition. Surgical repair of SSCD using a middle fossa craniotomy is associated with a high rate of symptom resolution. Continued investigation using a larger patient cohort and longer-term follow-up could further demonstrate the effectiveness of using middle fossa craniotomy for SSCD repair.

Differentiation of proinflammatory CD4(+) conventional T cells (T(conv)) are critical for productive antitumor responses yet their elicitation remains poorly understood. We exhaustively characterized myeloid cells in tumor draining lymph nodes (tdLN) of mice and identified two subsets of conventional type-2 dendritic cells (cDC2) that traffic from tumor to tdLN and present tumor-derived antigens to CD4(+) T(conv), but then fail to support antitumor CD4(+) T(conv) differentiation. Regulatory T cell (T(reg)) depletion enhanced their capacity to elicit strong CD4(+) T(conv) responses and ensuing antitumor protection. Analogous cDC2 populations were identified in patients, and as in mice their abundance relative to T(reg) predicts protective ICOS(+) PD-1(lo) CD4(+) T(conv) phenotypes and survival. Further, in melanoma patients with low T(reg) abundance, intratumoral cDC2 density alone correlates with abundant CD4(+) T(conv) and with responsiveness to anti-PD-1 therapy. Together, this highlights a pathway which restrains cDC2, and whose reversal enhances CD4(+) T(conv) abundance and controls tumor growth.

Summary The aim of the paper was to determine the factors related to the initial therapy that may contribute to death from severe necrotizing acute pancreatitis and to analyze their clinical importance as well as possible additive effects. A retrospective case-control study included all adult patients treated for severe necrotizing acute pancreatitis in the Clinical Center of Kragujevac, Serbia, during the five-year period (2006-2010.). The cases (n = 41) were patients who died, while the controls (n = 69) were participants who survived. In order to estimate the relationship between potential risk factors and observed outcome, crude and adjusted odds ratios (OR) with 95 % confidence intervals (CI) were calculated in logistic regression models. Significant association with observed outcome was shown for the use of gelatin and/or hydroxyethyl starch (adjusted OR 12.555; 95 % CI 1.150-137.005), use of albumin (adjusted OR 27.973; 95 % CI 1.741-449.373), use of octreotide (adjusted OR 16.069; 95 % CI 1.072-240.821) and avoiding of enteral feeding (adjusted OR 3.933; 95 % CI 1.118-13.829), while the use of nonsteroidal anti-inflammatory drugs had protective role (adjusted OR 0.057; 95 % CI 0.004-0.805). The risk of death in patients with predicted severe necrotizing acute pancreatitis could be reduced with avoidance of treatment with colloid solutions, albumin and octreotide, as well as with an early introduction of oral/enteral nutrition and use of nonsteroidal anti-inflammatory drugs.

The number of patient imaging studies has increased because of precautious physicians ordering scans when a vague symptom is presented; subsequently, the number of incidental meningiomas detected has increased as well. These brain tumors do not present with related symptoms and are usually small. MRI and computed tomographic scans most frequently capture incidental meningiomas. Incidental meningiomas are managed with observation, radiation, and surgical resection. Ultimately, a conservative approach is recommended, such as observing an incidental meningioma and then only radiating if the tumor displays growth, whereas a surgical approach is to be used only when proven necessary.

Hyperhomocysteinemia is one of the unconventional risk factors of cardiovascular morbidity - it is causally associated in both directions with oxidative stress, endothelial dysfunction, mechanisms of cell signaling and apoptosis. Numerous clinical and experimental studies have explained the mechanisms and clinical expression of atherosclerotic and prothrombotic effects of homocysteine. The main pathological substrate, previous therapy, and surgical procedure-intervention itself are associated with the state of oxidative stress and endothelial dysfunction, which is one of important factors for elevated plasma homocysteine levels. Recent studies point to the possibility of a successful correction of hyperhomocysteinemia, especially secondary one.

New findings on the activity of myeloperoxidase in the course of an inflammatory process associated with infections and vascular lesions indicate its role in the state of oxidative stress and endothelial dysfunction as well as its predictive value for cardiovascular insults. The products of actions by myeloperoxidase represent an integrative mechanism connecting the tissue lesions, infectious, inflammatory processes, oxidative stress, endothelial dysfunction and the development of vascular insult (the most common are the arterial and venous thrombosis and consecutive embolism). The most common complications of an operative surgical treatment are vascular. Seen from a conservative standpoint the most common are arterial and venous thrombosis, but more broadly suture dehiscence could be considered as a consequence of the impaired microcirculation. Operational procedures as well as the underlying pathology lead to the activation of inflammatory cascade with the activation of myeloid lineage cells whereby a release and activation of myeloperoxidase, which in addition to antimicrobial exerts multiple vascular operations. Increased concentrations of myeloperoxidase in the plasma up to three months before the clinical expression of vascular insult indicates its predictive value. Current research portrays the possibility of adjusting the successful result of the action of myeloperoxidase and prevention of vascular complications.