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The dispersal of Homo sapiens across Eurasia during MIS 3 in the Late Pleistocene is marked by technological shifts and other behavioral changes, known in the archaeological record under the term of Initial Upper Paleolithic (IUP). Bacho Kiro Cave in north Bulgaria, re-excavated by us from 2015 to 2021, is one of the reference sites for this phenomenon. The newly excavated lithic assemblages dated by radiocarbon between 45,040 and 43,280 cal BP and attributed to Homo sapiens encompass more than two thousand lithic artifacts. The lithics, primarily from Layer N1-I, exist amid diverse fauna remains, human fossils, pierced animal teeth pendants, and sediment with high organic content. This article focuses on the technological aspects of the IUP lithics, covering raw material origin and use-life, blank production, on-site knapping activities, re-flaking of lithic implements, and the state of retouched lithic components. We apply petrography for the identification of silicites and other used stones. We employ chaîne opératoire and reduction sequence approaches to profile the lithics techno-typologically and explore the lithic economy, particularly blade production methods, knapping techniques, and artifact curation. Raw material analysis reveals Lower Cretaceous flints from Ludogorie and Upper Cretaceous flints from the Danube region, up to 190 km and 130 km, respectively, from Bacho Kiro Cave, indicating long-distance mobility and finished products transport. Imported lithic implements, were a result of unidirectional and bidirectional non-Levallois laminar technology, likely of volumetric concept. Systematic on-anvil techniques (bipolar knapping) and tool segmentation indicate re-flaking and reshaping of lithic implements, reflecting on-site curation and multifaceted lithic economy. A limited comparison with other IUP sites reveals certain shared features and also regional variations. Bacho Kiro Cave significantly contributes to understanding the technological and behavioral evolution of early Homo sapiens in western Eurasia., Competing Interests: NO authors have competing interests., (Copyright: © 2024 Tsanova et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The expansion of Homo sapiens and our interaction with local environments, including the replacement or absorption of local populations, is a key component in understanding the evolution of our species. Of special interest are artifacts made from hard animal tissues from layers at Bacho Kiro Cave (Bulgaria) that have been attributed to the Initial Upper Paleolithic. The Initial Upper Paleolithic is characterized by Levallois-like blade technologies that can co-occur with bone tools and ornaments and likely represents the dispersal of H. sapiens into several regions throughout Eurasia starting by 45 ka or possibly earlier. Osseous artifacts from the Initial Upper Paleolithic are important components of this record and have the potential to contribute to our understanding of group interactions and population movements. Here, we present a zooarchaeological, technological, and functional analysis of the diverse and sizable osseous artifact collection from Bacho Kiro Cave. Animal raw material sources are consistent with taxa found within the faunal assemblage including cervids, large bovids, and cave bears. A variety of bone tool morphologies, both formal and informal, indicate a diverse technological approach for conducting various on-site activities, many of which were focused on the processing of animal skins, likely for cold weather clothing. Technological flexibility is also evident in the manufacture of personal ornaments, which were made primarily from carnivore teeth, especially cave bear, though herbivore teeth and small beads are also represented. The osseous artifacts from Bacho Kiro Cave provide a series of insights into the bone technology and indirectly on the social aspects of these humans in southeast Europe, and when placed within the broader Initial Upper Paleolithic context, both regional and shared behaviors are evidently indicating widespread innovation and complexity. This is especially significant given the location and chronology of the site in the context of H. sapiens dispersals., Competing Interests: Conflicts of interest The authors declare that there is no conflict of interest., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

To understand the ways in which past stone knappers controlled the morphology of the flakes they produced, archaeologists have focused on examining the effects of striking platform attributes on flake size and shape. Among the variables commonly considered, platform width has routinely been noted to correlate with flake size and hence used to explain past knapping behaviors. Yet, the influence of platform width on flake variation remains equivocal due to the fact that the attribute is not under the direct control of the knapper. Instead, platform width tends to be treated as a by-product of other independent knapping parameters, such as platform depth. In this study, we hypothesize that platform width acts as an intermediary that intervenes the effect of other independent variables on flake attributes. By analyzing experimental flakes produced under both controlled and replicative settings, the results support the hypothesis that platform width mediates the effect of platform depth on flake width, such that flakes with relatively larger platform widths are generally wider but no longer. This finding provides a way to incorporate platform width into discussions of the interrelationships among knapping variables, and highlights the importance of platform width for investigating how past knappers controlled flake production through platform manipulation., Competing Interests: The authors have declared that no competing interests exist.

The behavioral dynamics underlying the expansion of Homo sapiens into Europe remains a crucial topic in human evolution. Owing to poor bone preservation, past studies have strongly focused on the Initial Upper Paleolithic (IUP) stone tool record. Recent excavations and extensive radiocarbon dating at Bacho Kiro Cave (Bulgaria) pushed back the arrival of IUP H. sapiens into Europe to ca. 45,000 years ago. This site has exceptional bone preservation, and we present the study of 7431 faunal remains from across two IUP layers (I and J) and one Middle Paleolithic layer (K). We identified a shift in site use and occupation intensity through time, marked by increased find density and human modifications in Layer I. Alongside a decrease in carnivore presence and seasonality data demonstrating human presence in all seasons, this indicates a more frequent or prolonged occupation of the site by IUP groups. Contrarily, the dietary focus across the IUP and Middle Paleolithic layers is similar, centered on the exploitation of species from a range of habitats including Bos/Bison, Cervidae, Equidae, and Caprinae. While body parts of large herbivores were selectively transported into the site, the bear remains suggest that these animals died in the cave itself. A distinct aspect of the IUP occupation is an increase in carnivore remains with human modifications, including these cave bears but also smaller taxa (e.g., Canis lupus, Vulpes vulpes). This can be correlated with their exploitation for pendants, and potentially for skins and furs. At a broader scale, we identified similarities in subsistence behavior across IUP sites in Europe and western Asia. It appears that the first IUP occupations were less intense with find densities and human modifications increasing in succeeding IUP layers. Moreover, the exploitation of small game appears to be limited across IUP sites, while carnivore exploitation seems a recurrent strategy., Competing Interests: Conflict of interest The authors declare that there is no conflict of interest., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The expansion of Homo sapiens across Eurasia marked a major milestone in human evolution that would eventually lead to our species being found across every continent. Current models propose that these expansions occurred only during episodes of warm climate, based on age correlations between archaeological and climatic records. Here, we obtain direct evidence for the temperatures faced by some of these humans through the oxygen isotope analysis of faunal remains from Bacho Kiro Cave, Bulgaria, the earliest clear record of H. sapiens in Europe. The results indicate that humans ∼45,000 years ago experienced subarctic climates with far colder climatic conditions than previously suggested. This demonstrates that the early presence of H. sapiens in Europe was not contingent on warm climates. Our results necessitate the revision of key models of human expansion and highlight the need for a less deterministic role of climate in the study of our evolutionary history.

Modern humans appeared in Europe by at least 45,000 years ago 1-5 , but the extent of their interactions with Neanderthals, who disappeared by about 40,000 years ago 6 , and their relationship to the broader expansion of modern humans outside Africa are poorly understood. Here we present genome-wide data from three individuals dated to between 45,930 and 42,580 years ago from Bacho Kiro Cave, Bulgaria 1,2 . They are the earliest Late Pleistocene modern humans known to have been recovered in Europe so far, and were found in association with an Initial Upper Palaeolithic artefact assemblage. Unlike two previously studied individuals of similar ages from Romania 7 and Siberia 8 who did not contribute detectably to later populations, these individuals are more closely related to present-day and ancient populations in East Asia and the Americas than to later west Eurasian populations. This indicates that they belonged to a modern human migration into Europe that was not previously known from the genetic record, and provides evidence that there was at least some continuity between the earliest modern humans in Europe and later people in Eurasia. Moreover, we find that all three individuals had Neanderthal ancestors a few generations back in their family history, confirming that the first European modern humans mixed with Neanderthals and suggesting that such mixing could have been common.

One of the greatest difficulties with evolutionary approaches in the study of stone tools (lithics) has been finding a mechanism for tying culture and biology in a way that preserves human agency and operates at scales that are visible in the archaeological record. The concept of niche construction, whereby organisms actively construct their environments and change the conditions for selection, could provide a solution to this problem. In this review, we evaluate the utility of niche construction theory (NCT) for stone tool archaeology. We apply NCT to lithics both as part of the "extended phenotype" and as residuals or precipitates of other niche-constructing activities, suggesting ways in which archaeologists can employ niche construction feedbacks to generate testable hypotheses about stone tool use. Finally, we conclude that, as far as its applicability to lithic archaeology, NCT compares favorably to other prominent evolutionary approaches, such as human behavioral ecology and dual-inheritance theory., (© 2021 The Authors. Evolutionary Anthropology: Issues, News, and Reviews published by Wiley Periodicals LLC.)

Four ways archaeologists have tried to gain insights into how flintknapping creates lithic variability are fracture mechanics, controlled experimentation, replication and attribute studies of lithic assemblages. Fracture mechanics has the advantage of drawing more directly on first principles derived from physics and material sciences, but its relevance to controlled experimentation, replication and lithic studies more generally has been limited. Controlled experiments have the advantage of being able to isolate and quantify the contribution of individual variables to knapping outcomes, and the results of these experiments have provided models of flake formation that when applied to the archaeological record of flintknapping have provided insights into past behavior. Here we develop a linkage between fracture mechanics and the results of previous controlled experiments to increase their combined explanatory and predictive power. We do this by documenting the influence of Herztian cone formation, a constant in fracture mechanics, on flake platforms. We find that the platform width is a function of the Hertzian cone constant angle and the geometry of the platform edge. This finding strengthens the foundation of one of the more influential models emerging from the controlled experiments. With additional work, this should make it possible to merge more of the experimental results into a more comprehensive model of flake formation., Competing Interests: The authors have declared that no competing interests exist.

The stratigraphy at Bacho Kiro Cave, Bulgaria, spans the Middle to Upper Palaeolithic transition, including an Initial Upper Palaeolithic (IUP) assemblage argued to represent the earliest arrival of Upper Palaeolithic Homo sapiens in Europe. We applied the latest techniques in 14 C dating to an extensive dataset of newly excavated animal and human bones to produce a robust, high-precision radiocarbon chronology for the site. At the base of the stratigraphy, the Middle Palaeolithic (MP) occupation dates to >51,000 yr BP. A chronological gap of over 3,000 years separates the MP occupation from the occupation of the cave by H. sapiens, which extends to 34,000 cal BP. The extensive IUP assemblage, now associated with directly dated H. sapiens fossils at this site, securely dates to 45,820-43,650 cal BP (95.4% probability), probably beginning from 46,940 cal BP (95.4% probability). The results provide chronological context for the early occupation of Europe by Upper Palaeolithic H. sapiens.

The Middle to Upper Palaeolithic transition in Europe witnessed the replacement and partial absorption of local Neanderthal populations by Homo sapiens populations of African origin 1 . However, this process probably varied across regions and its details remain largely unknown. In particular, the duration of chronological overlap between the two groups is much debated, as are the implications of this overlap for the nature of the biological and cultural interactions between Neanderthals and H. sapiens. Here we report the discovery and direct dating of human remains found in association with Initial Upper Palaeolithic artefacts 2 , from excavations at Bacho Kiro Cave (Bulgaria). Morphological analysis of a tooth and mitochondrial DNA from several hominin bone fragments, identified through proteomic screening, assign these finds to H. sapiens and link the expansion of Initial Upper Palaeolithic technologies with the spread of H. sapiens into the mid-latitudes of Eurasia before 45 thousand years ago 3 . The excavations yielded a wealth of bone artefacts, including pendants manufactured from cave bear teeth that are reminiscent of those later produced by the last Neanderthals of western Europe 4-6 . These finds are consistent with models based on the arrival of multiple waves of H. sapiens into Europe coming into contact with declining Neanderthal populations 7,8 .

North Africa is quickly emerging as one of the more important regions yielding information on the origins of modern Homo sapiens. Associated with significant fossil hominin remains are two stone tool industries, the Aterian and Mousterian, which have been differentiated, respectively, primarily on the basis of the presence and absence of tanged, or stemmed, stone tools. Largely because of historical reasons, these two industries have been attributed to the western Eurasian Middle Paleolithic rather than the African Middle Stone Age. In this paper, drawing on our recent excavation of Contrebandiers Cave and other published data, we show that, aside from the presence or absence of tanged pieces, there are no other distinctions between these two industries in terms of either lithic attributes or chronology. Together, these results demonstrate that these two 'industries' are instead variants of the same entity. Moreover, several additional characteristics of these assemblages, such as distinctive stone implements and the manufacture and use of bone tools and possible shell ornaments, suggest a closer affinity to other Late Pleistocene African Middle Stone Age industries rather than to the Middle Paleolithic of western Eurasia., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Interbody fusion has become a mainstay of surgical management for lumbar fractures, tumors, spondylosis, spondylolisthesis and deformities. Over the years, it has undergone a number of metamorphoses, as novel instrumentation and approaches have arisen to reduce complications and enhance outcomes. Interbody fusion procedures are common and successful, complications are rare and most often do not involve the interbody device itself. We present here a patient who underwent an anterior L4 corpectomy with Harms cage placement and who later developed a fracture of the lumbar titanium mesh cage (TMC). This report details the presentation and management of this rare complication, as well as discusses the biomechanics underlying this rare instrumentation failure.

Aims: The purpose of this prospective randomized study was to evaluate the safety and efficacy of transvenous pacemaker and implantable cardioverter-defibrillator (ICD) lead extraction with an electrosurgical dissection sheath (EDS) system in a single-centre experience. Methods Over 10 years, 462 patients have undergone transvenous lead extraction in our institution. From these, 120 consecutive patients (with 161 leads) were randomized to either radiofrequency (RF) current supported extraction or standard countertraction lead removal (60 patients in each arm, 96 men and 24 women). The mean age of randomized patients was 62.7 +/- 9.6 years. In 16 patients, we explanted 17 ICD leads. The average time from the date of implantation to the extraction procedure was 73.4 +/- 15.7 months. The most common reason for lead extraction was infection (95.6%). Results The complete extraction of 78 leads (93%) was achieved in the RF group and 56 leads (73%) with the standard transvenous lead extraction system by counter-traction (P < 0.01). Among these leads, we successfully removed nine of 10 ICD leads (90%) in the RF group and only four of seven ICD leads (57%) in the standard group. We also observed a significant reduction in the time taken for the successful removal of pacemaker and ICD leads using the RF system (9.6 +/- 6.2 min versus 21 +/- 9 min, P < 0.01). Partial success was achieved in six patients with the RF system and in 11 with standard sheaths. In those cases where we failed to remove the lead from the body we sent all but one patient to cardiac surgery. Serious complications were associated with the standard system in two patients, both of whom developed septic pulmonary embolization. Serious bleeding occurred in three patients, one with standard and two with the EDS lead extraction system., Conclusion: The EDS extraction system is significantly more effective and quicker. However, the standard counter-traction method is still an effective alternative when used in a highly experienced centre.

The presented work is only a minor contribution to the extensively elaborated method of surgical treatment of subrenal aneurysms of the abdominal aorta, informing on the unusual pattern of important anatomical structures in the surgical field involving the retroaortal localization of the left renal artery which runs closely dorsally behind the proximal neck of the aneurysm. The incidence of major venous anomalies which are associated with the aortal section and which include in particular the circumaortal left renal vein (circumaortal annulus) left-sided transposition of the lower vena cava or its duplicity and preaortal connection of iliac veins amounts according to data in the literature to 5.6% [1], a left renal vein 2% [18] and the incidence of these anomalies in surgery of the abdominal aorta is 0.8% [3]. The presence of the anomaly we encountered was detected already before surgery due to the careful evaluation of the spiral CT and called for a change of the usual surgical technique because of the risk of injury of the renal vein during construction of the proximal anastomosis by the usual inclusion technique from the inside of the aneurysm. A more extensive release of the proximal cervix of the aneurysm was necessary with isolation of the adjacent ventral portion of the left renal vein, complete transverse severing of the aorta at the level of the proximal cervix and direct end to end suture of the proximal anastomosis. This case-history draws attention to the possibility of venous malformations which may make the course of surgery on the abdominal aorta difficult and draws attention to the importance of CT examination during elective operations of aneurysms of the abdominal aorta.

The author presents a review of the approach of vascular surgeons to penetrating injuries of the extremities from the initial period of development of the discipline when surgical exploration was preferred and performed as a matter of routine, across the sixties, seventies and eighties characterized by universal use of angiography, up to the last decade and the present time when specialists accept the necessity of selective indication of angiography derived from the clinical picture. Certain persisting differences in views pertain only to some aspects of the clinical finding. Some authors were for instance concerned with investigation of the probable risk of arterial injuries with regard to the site of penetration, from their conclusion ensues in the great majority the recommendation to perform angiography in injuries of the medial side of the thigh and arm, popliteal area, leg and forearm, incl. asymptomatic ones. Other investigations sought a relationship between the incidence of injuries and the presence of some clinical symptoms and recommend to indicate angiography in injuries associated with at least one "hard" symptom (pulse or neurological ischaemic deficiency) or at least two "soft" symptoms (haematoma, haemorrhage, hypotension, malleobrachial index smaller than 1). The author presents also his own attitude to the problem and emphasizes expert comprehensive clinical examination, taking into account the site of penetration, character and mechanism of injury, character of clinical symptoms, their intensity in relation to the general state of the circulation and its possible changes, in selected cases supplementation of the clinical finding by sonographic examination.

In the clinical 4W study patients with newly diagnosed multiple myeloma are included where the state of the disease calls for treatment, while high dose chemotherapy is not contraindicated. Treatment according to protocol 4W comprises induction chemotherapy VAD, mobilization of haematopoietic cells (cyclophosphamide 5 g/m2). This is followed by autologous transplantation (as a conditioning regime melfalan 200 mg/m2 is administered). The patients are randomized into two groups, the first one is given interferon alpha as maintenance treatment, in the second group alternates cyclically interferon alpha and dexamethasone treatment. So far between 1996 and Aug. 31 2000 in the 4W clinical study 167 patients were included. 113 patients after transplantation were evaluated incl. 13 (12%) who achieved complete remission of the disease (absence of paraprotein, negative immunofixation), 63 patients (56%) with remission of the disease (decline of paraprotein, by more than 75%). Another 24 patients (21%) achieved partial remission (decline of paraprotein by more than 50% but less than 75%). The peritransplantation mortality is 2.67%. So far there is no significant difference between the two groups on maintenance treatment as regards the mean period before a relapse of the disease (p = 0.567). The median of the mean survival was not reached so far. The authors describe the results of the internal analysis of data incl. statistical processing.

The author presents his experience with the technique of alternative plastic closure of longitudinal arteriotomy of the internal carotid artery (ACI) using an autoarterial graft from the ipsilateral arteria thyroidea superior (ATS) [1]. Autoarterial plastic operations were sued so far in eight patients, in six instances endarterectomy of a primary ACI stenosis with a narrow lumen was involved, and in this group in two instances a peripheral intimal step was involved. In two instances an autoarterial patch was used after resection of kinking of the thin ACI. The graft is collected from an incision commonly used in plastic operations of carotid endarterectomy and takes roughly 10 minutes. In all instances ATS provided enough material, although in two instances it had a rather thin lumen. The described plastic operation is rapid, effective, limited to one surgical field and easily performed. The favourable results of subsequent sonographic controls of the patency of the reconstructed ACI, implemented so far 1-2 years after surgery confirm that this technical solution is suitable.

The author presents a case-history of a late infection of a bilateral aortofemoral bypass by a coagulase-negative staphylococcus and the definite solution by substitution of the contaminated vascular prosthesis by an anatomical autogenous bilateral bypass made from popliteal and superficial femoral veins. From the technical aspect the operation was very satisfactory without marked peroperative difficulties, the early postoperative course was also favourable, with readily palpable peripheral pulsations, without marked manifestations of venostasis on the lower extremities. From the third postoperative day onwards however progressive manifestations of multiorgan failure developed associated with septic shock and leading to a fatal outcome. Despite this the author considers in patients with a reasonable surgical risk this method of substitution of an infected vascular prosthesis in the aortofemoral region feasible with regard to its resistance to infection and long-term patency, though the operation is technically pretentious but easy to implement.

The author describes a technical 8-shaped variation of continuous suture of longitudinal arteriotomy. He describes the technical details of implementation of the suture which by crossing of the thread between the margins of the arteriotomy prevents overlapping of the margins and thus narrowing the arterial lumen. Practical aspects of the use of the suture are described, incl. evaluation of conditions and local findings where this continuous suture can, due to its functional effect, replace autovenous or prosthetic plastic surgery of the artery.

The author presents the case-history of a typical clinical picture of a rare vascular affection--cystic degeneration of the adventitia of the popliteal artery in a young man. The diagnostic conclusion was reached by means of duplex sonography and angiography of the extremity, the condition was treated by reconstruction surgery. With regard to its long-term effect the author prefers it to some non-surgical procedures which include in particular transluminal angioplasty or sonographically assisted needle aspiration of the cyst.

We report our results with high-dose chemotherapy in previously untreated multiple myeloma patients (4 courses of VAD chemotherapy, collection of PBSC after priming with cyclophosphamide, 5 g/m2, high-dose chemotherapy with melphalan, 200 mg/m2). Second transplantation was indicated only for patients who did not achieve remission after the first high-dose therapy (paraprotein lower than 25% of the pretreatment value). For the second transplantation melphalan (200 mg/m2) with methylprednisolone (1.5 g for 5 days) were used as conditioning regimen. After high-dose therapy all patients were randomized into two arms of maintenance therapy: interferon alpha-2b or sequential maintenance therapy (interferon alpha-2b for 3 months followed after 4 week pause by 40 mg of dexamethasone days 1-4, 10-13 and 20-23. The administration of interferon alpha was resumed four weeks after the last dexamethasone for next three months. The maintenance therapy continued for 48 months or until the progression. Fifty-five patients were enrolled in the study from January 1996 to August 1997. Thirty-five patients have undergone the first transplantation and 57% of them reached complete remission. There were 10% of non-responders after the first high-dose regimen. The mean time to reach white blood cell count above 1 x 10(9)/L after the application of high dose melphalan and platelets more than 50 x 10(9)/L were 12.2 (range 6-16 days) and 12.4 (range 0-25 days), respectively. Grade 4 mucositis according to SWOG classification requiring total parenteral nutrition was presented in 40% of the patients. The mean number of 1 unit of platelets and 2 units of packed red blood cells transfusions were given within the posttransplant period. Early transplant related mortality was 3%. This paper describes the response and tolerance of each particular step of therapy. The follow-up has been too short to evaluate event-free and overall survivals.

The author describes the case-history of an injury of the common femoral and external pelvic vein. He describes the method of replacement of the loss using an autovenous graft formed from the trunk of the vena saphena magna which was split longitudinally and then sutured in a spiral fashion. The applied reconstruction method can be evaluated as reliable, technically feasible. The reconstruction is patent after two years and the affected extremity bears no signs of venostasis.