Surgery - Journal for students and young doctors by Surgery - Journal for students and young doctors

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Honourable president: Prof. Maya Gulubova, PhD, MD

Students' Organizing Comittee Chairperson: Ivan Mindov Secretary: Kaloyan Georgiev

Members: Mihaela Doychinova Polina Panayotova Filis Kazalieva Emil Enchev Darina Ivanova

Scientific Comittee

Chairperson: Assoc.prof. Dimiter Sivriev, PhD, MD Secretary: Assist.prof. Julian Ananiev, PhD, MD Members: assoc.prof. Hristo Stoyanov, PhD, MD assoc.prof. Krasimira Kalinova, PhD, MD assist.prof. Borislava Chakarova, PhD, MD assist.prof. Stefan Valkanov, PhD, MD assist.prof.Dimo Dimov, PhD, MD assist.prof. Bozhidar Petrov, MD

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Management of Hydatidosis in Children Georgiev K1, Mindov I1, Naydenov K1, Hristova H1, Kalinova K2 1-Students in Medicine, Faculty of Medicine, Trakia University - Stara Zagora 2-Dept.of General and Operative Surgery,Special Surgerym Urology, Neurosurgery and Paediatric-Surgery, Faculty of Medicine, Trakia University, UMHAT „Prof.Dr.Stoyan Kirkovich“

Until 2007, 6287 patients underwent surgery in Bulgaria because of cystic echinococcosis caused by Echinococcus granulosus. 10.6% were children aged < 15 years and 5.25% adolescents aged 15-19 years, giving annual incidences of 1.25 and 2.03/100,000 inhabitants, respectively. This retrospective study present our experience in the management of hydatidosis in children and define the criteria for the most effective model of treatment. Material and methods :The anatomical location of the parasite was as follows: liver 90 children(119 cysts), lung -56 cases (70 cysts), spleen- 4 children(5 cysts), mesentery -2, kidneys -5 children(6 cysts) and pelvic floor -1 case Echinococcal cysts in hepar

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Echinococcal cysts in lung

Echinococcosis in mesenterium

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

The incidence of surgical treatment for echinococcosis was higher in males than females in all but the youngest subjects (< 5 years) and adults (> 19 years). It was also higher in rural populations than in urban populations.Cysts were found more frequently in the livers of children than lungs (51.8% v. 38.3% of the patients). Open surgical procedures were classified as radical forany type of resection and cystectomy. Partialcystectomy with either tube drainage, capitonnage, oromentoplasty were considered conservative approachesas described elsewhere.For cysts located deeper in the liver parenchyma, simple external drainage and partial cystectomy was performed. The residual cavity was soaked with a scolicidal agent: hypertonic saline solution (initially 3% and lately 10–15%), H2O2 or povidone iodine.Omentoplasty was performed for packing of the residual cavity after inspection for remaining living hydatid tissue or bile leakage. Pulmonary hydatid cysts in children we treat successfully by cystotomy and capitonnage or only cystotomy.After the operation, the patients received chemotherapy (albendazole 10 mg/kg/day -1,5 months) for preventing the recurrences. Enucleation was performed for superficial and small cysts,cystotomy for those deep inside the parenchyma.Theresidual cavity and lung were treated by conservativemethods (such as pericystectomy, which is alwaysassociated with suturing of bronchial fistulas and capitonnageof the cavity) or by adapted lung resections (such aswedge resection, segmentectomy and lobectomy). CONCLUSIONS: - Radical interventions such as totalcystectomy and liver resection can be done safely withminimal morbidity and mortality for suitable cases. - Laparoscopic surgery is effective and safe with low morbidity and recurrence ratesfor type I– IIcysts. - PAIR (puncion, aspiration, injection and reaspiration(ne znamdali se pisehe taka) is an effective and safe procedure and a good alternative to surgery for selected cases. Cystectomy and omentoplasty should be the standard surgical procedure - safe, simple, and effective and meets all criteria of surgical treatment for liver hydatid disease. Pericystectomy should be used for peripherally located cysts that are surrounded by parenchyma only partially.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Hernia in children Georgiev K1, Mindov I1, Naydenov K1, Hristova H1, Kalinova K2 1-Students in Medicine, Faculty of Medicine, Trakia University - Stara Zagora 2-Dept.of General and Operative Surgery,Special Surgerym Urology, Neurosurgery and Paediatric-Surgery, Faculty of Medicine, Trakia University, UMHAT „Prof.Dr.Stoyan Kirkovich“

A hernia is a sac formed by the lining of the abdominal cavity (peritoneum). The sac comes through a hole or weak area in the strong layer of the belly wall that surrounds the muscle. This layer is called the fascia. Hernias in kids can be treated ( hernia repair is the one of the most common surgeries performed on children), but it's important to recognize their symptoms so that you can get your child the appropriate medical care..

Which type of hernia you have depends on where it is:     

Femoral hernia is a bulge in the upper thigh, just below the groin. This type is more common in women than men. Hiatal hernia occurs in the upper part of the stomach. Part of the upper stomach pushes into the chest. Incisional hernia can occur through a scar if you have had abdominal surgery in the past. Umbilical hernia appears as a bulge around the belly button. It occurs when the muscle around the belly button doesn't close completely. Inguinal hernia is a bulge in the groin. It is more common in men. It may go all the way down into the scrotum.

Causes Usually, there is no obvious cause of a hernia. Sometimes hernias occur with heavy lifting, straining while using the toilet, or any activity that raises the pressure inside the belly area. Hernias may be present at birth, but the bulge may not be noticeable until later in life. Some patients may have a family history of hernias.Babies and children can get hernias. It happens when there is weakness in the belly wall. About 5 out of 100 children have inguinal hernias. They are more common in boys. Some children may not have symptoms until they are adults.Any activity or medical problem that increases pressure on the tissue in the belly wall and muscles may lead to a hernia, including:            

Chronic constipation and pushing hard (straining) to have a bowel movement Chronic cough Cystic fibrosis Enlarged prostate, straining to urinate Extra weight Fluid in the abdomen (ascites) Heavy lifting Peritoneal dialysis Poor nutrition Smoking Overexertion Undescended testicles 15

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Symptoms There are usually no symptoms. Some people have discomfort or pain. The discomfort may be worse when you stand, strain, or lift heavy objects. In time, most people will complain about a bump that is sore and growing. If a hernia gets bigger, it may get stuck inside the hole and lose its blood supply. This is called "strangulation." If this occurs, you will need urgent surgery.

Exams and Tests Your doctor or nurse can usually see or feel a hernia when they examine you. You may be asked to cough, bend, push, or lift. The hernia may get bigger when you do this.The hernia (bulge) may not be easily seen in infants and children, except when the child is crying or coughing. Ultrasound or CT scans may be done to look for a hernia.If you may have a blockage in your bowel, you will need an x-ray of the abdomen.

Treatment Surgery is the only treatment that can permanently fix a hernia. Surgery may be more risky for patients with serious

medical problems. Surgery secures the weakened abdominal wall tissue (fascia) and closes any holes. Today, most hernias are closed with cloth patches to plug up the holes.An umbilical hernia that does not heal on its own by the time your child is 5 years old may be repaired.Emergency surgery is sometimes needed. The sac containing the intestine or other tissue may become stuck in the hole in the abdominal wall. If it cannot be pushed back through, this can lead to a strangulated loop of intestine. If left untreated, this portion of the intestine dies because it loses its blood supply.Today, hernias can be fixed by open surgery or with the use of a laparoscope (camera). The advantages of using a camera include smaller surgical cuts, faster recovery, and less pain after the procedure.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Prevention

Use proper lifting techniques. Lose weight if you are overweight. Relieve or avoid constipation by eating plenty of fiber, drinking lots of fluid, going to the bathroom as soon as you have the urge, and exercising regularly.  Men should see their health care provider if they strain with urination. This may be a symptom of an enlarged prostate.   

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Acute abdomen in neonates Georgiev K1, Mindov I1, Naydenov K1, Hristova H1, Kalinova K2 1-Students in Medicine, Faculty of Medicine, Trakia University - Stara Zagora 2-Dept.of General and Operative Surgery,Special Surgerym Urology, Neurosurgery and Paediatric-Surgery, Faculty of Medicine, Trakia University, UMHAT „Prof.Dr.Stoyan Kirkovich“

Features: A group of excessive undergoing abdominal and others deseases which put the neonate in a critical state and require emergent medicial intervention and emergent surgical treatment. Anatomical features of the neonate: Abdomen – the biggest anatomical area in the body of the neonate. Abdominal organs – different topography and syntopy. Abdominal cavity – specific and different volume and structure Physiological features of the neonates: 1. Physiological overload of gastrointestinal tract. 2. Functional immaturity of the gastrointestinal tract. 3. Dynamic and age-determined changes in all organs and systems, related to the development of the child. Disease – in order, frequency and level of lasting : Incarcerated inguinal hearnia, invagination membrane and Led syndrome, complications of Meckel’s diverticulum, spontaneous perforations of the “hollow”organs of the gastrointestinal tract, and others. Accompanying inguinal hearnia conditions(they predispose to complications): maceration of the scrotum’s skin; - skin in the inguinal folds; - skin of the perineum -

Difficulties in: - miction; - defecation; movements of the lower extremities; - interference of the nutrition.

Incarceration is never random – always for a reason! 1. Nutrition mistakes of the neonate – rhythm of nutrition, kind and quantity of the food. 2. Medications received with or without a reason. 3. Preceeded and accompanied deseases and conditions. 4. The way of raising the child. 5. Curiosities 18

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Deseases predispose to incarceration: 1. Deseases in the abdominal cavity, with high intraabdominal pressure. 2. Extraabdominal deseases leading to high intraabdominal pressure. Incarcerated inguinal hearnia – diagnostic signs of the complication(s) -Changes in the haernia determine the diagnose of the complication. The changes in the status praesens – the delay of the diagnosis. Anamnestic data: 1. Pain syndrome – primary and leading in all the stages of the complication. The pain in the area of the hearnia and- and fixed in time. 2. Dispeptic syndrome – follows the Pain syndrome with differences in its manifestation. Objective examination of the patient: 1. Inspectious characteristics of the hearnia swelling – increased volume, changed shape and color. 2. Palpable characteristics of the hearnia – hard consistency and painful. 3. Neighbouring anatomical areas. Characteristics of the Pain syndrome – the pain is an indispensable symptom of the incarceration . The pain is an initial symptom of every incarceration. Also, it is a leading and dominating symptom, during the incarceration. The pain is changeable, but it never disappears at all. It could be related to other symptoms and changes in the general and local condition. Dynamic of the changes in general and local status Local status – changes ( very fast – in a minutes) – data of the mechanism of the incarceration. General status – changes (in hours) – sing for the quality of the undergoing treatment. Incarcerated inguinal hearnia (diagnosis and way of proceeding) – -In 99%- obviously (diagnosed “at first sight”); -In 1% - intraoperative, incarcerated hearnia ->active behavior ->emergent direction to the surgical clinic. Tactics of the therapeutical acts: Absolute indication for emergent hospitalization-↓ attempt to replace or emergent operative treatment. The attempt of the replacement is a risky manipulation. (acceptable only after hospitalization and under certain circumstances). Attempt of replacement – risky manipulation (possible iatrogenic damage) Traumatic replacement of the hearnia with rupture of the heanial sack and reposition of the haernial content in preperitoneal space of the anterior abdominal wall.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Iatrogen taxis Traumatic placement with rupture of the haernial sack and reposition of the hearnial content in the perineal area. The increted haernial content is moved out of the abdominal cavity, but stays increted.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Tactics and strategy in the treatment of the desease The strategical change in the treatment of the hearnias and their complications, is possible only in cases of changing the way of thinking of the medics.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Squamous cell carcinoma of the trachea Mindov I1, Naydenov K1, Alcheva J1, Georgiev K1, Ananiev J2 1-

Students in medicine, Faculty of Medicine, Trakia University – Stara Zagora, Bulgaria

Dept. of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Trakia University – Stara Zagora, Bulgaria

The trachea connects the pharynx and larynx to the lungs, allowing the air flows into the lungs.. It is extremely rare - developing tumor of the trachea (primary tracheal tumors), as well as the bronchi[1]. Some of the tumors occur as the result of metastasizing to the trachea or bronchi - metastatic disease. Malignant tracheal tumors are more common in adults – in children, in most of the cases they are benign[1]. Types of malignant tracheal and bronchial tumors are:  Squamous cell carcinoma, adenoid cystic carcinoma,carcinoid tumors; Squamous cell carcinoma is the most common type of all tracheal tumors. It is a tumor arising in the lower portion of the trachea, and it could be extremely fast-growing. Also, growing on, squamous cell carcinoma could penetrate the mucosal lining of the airway, and as result of that - ulceration and bleeding could occur. It’s been proven that squamous cell carcinoma is more common in men than in women and that there’s a relation between smoking. It is said that smoking is one of the main risk factors. [1] Looking-alike other cancers, there isn’t a particular cause and it is said it is unknown. However, statistics showed that it affects men and women equally with prevalence between the ages of 40 and 60[3]. Symptoms: A dry coughing Coughing up blood Breathlessness Fevers, chills and often chest infections Difficult breathing Stridor, appears when breathing in caused by a blockage in the throat or larynx(a high-pitched musical sound as it like a voice box)  Wheezing  Dysphagia and hoarness(pointing out that the cancer had been spread beyond the trachea.      

Diagnostic tests: 

CT scan (CAT scan). Visualizes the exact location and extent of a tumor. The information gathered is crucical in determining whether the patient is able for surgery or to undergoes other treatments.



Laryngoscopy. An endoscope (narrow, flexible tube)with installed camera on the tip is into the trachea to examine the upper portion of the airway. 22

Surgery (Vol. 1, yr.6., february 2014)   

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Bronchoscopy. A special endoscope for the airway is inserted into the trachea to examine it. It could be a rigid or flexible one. It could be used with diagnostic and therapeutical purposes. Biopsy. A small sample of tissue is being cut microscope.

with a bronchoscope of the lining epithelium

Tumours like these tend to be diagnosed late. Symptoms like haemoptysis, dyspnoea, cough, hoarseness, stridor (as the most common); when patients do not report for present blood in the sputum, the initial diagnosis is thought to be bronchial asthma; in many cases, suffocation occurs before surgical treatment[2].

Squamous cell carcinoma of the trachea - differentiation in the malignant cells, is manifest by the squamous pearl and distinct intercellular bridges.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Staging and grading of the tracheal cancer Staging is used to express the size and whether the tumor has spread or not beyond its original area of formation. By knowing this, lets the doctor precisely to decide the way of therapeutical ways. TNM Staging   

T – related to size/position of the primary tumour. N – related to lymph nodes involved, if any. M – related to whether or not the cancer has spread to other part of the body(metastases).

The details of the T, N and M depend on the type of cancer. Most of the times – T, N, M have number next to. Which described the exact tissue and number of organs involved[3]. Number staging system Stage 1 describes a an early phase usually small in size and hasn’t spread. Therefore, stage 4 describes cancer at advanced stage - usually spread to other parts of the body. Stages 2 and 3 are in between these stages. The number stages are type of modification of the different combinations of the TNM stages, e.g. a stage 1 cancer in TNM is described as either T1, N0, M0 or T2, N0, M0. Number stages could be subdivided and giving more information. For example, a stage 3 cancer - subdivided into stage 3a, stage 3b and stage 3c. A stage 3b - might differ from a stage 3a cancer in size or if it has spread to lymph nodes. GRADING

Grading relates to finding cancer cells under the microscope and it could points out how the cancer may possibly behave. Low-grade means the cancer cells are almost similar to normal cells. High-grade means cells seemed a bit abnormal. A low-grade tumour usually grows more slowly and it is less likely to spread than a high-gradeone[4]. Treatment of tracheal cancer Treatment is based on general health of the patient, the exact position and size of the tumor, whether it has spread or not. The two main therapeutical way are surgery and radiotherapy. Surgery In early stages (a small tumor in size, without spreading) – it is possible to remove the cancer completely. During the removal of the cancer, surgeon remove some part of the normal tissue, this is needed to check if there are any cancer cells there. If there are – another operation must be scheduled to remove more tissue. Postoperatively – the length of the trachea could be slightly shorter than previously, so that it is recommendable for the patient not to stretch his/her head and neck back [4]. This is just for while, shortly after the surgery. 24

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Radiotherapy Radiotherapy is recommended after the surgery. It is a precaution – to reduce the chances of return of the tumor(adjuvant radiotherapy) [3]. Using high energy X-rays to destroy the cancer cells, and to affect as less as possible normal cells. It is used for people, who a inoperable – in these cases, radiotherapy is used to relieve the symptoms(palliative radiotherapy).

Side effects of radiotherapy:  Trouble swallowing (due to inflammation, caused to the oesophagus) 

Skin changes



Tiredness



Hair loss



Nausea

Chemotherapy Using cytotoxic cells to destroy the cancer (anti-cancer cells). Also could be used to control the symptoms. Possible chemotherepeautic drug – cisplatin and carboplatin

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

References: 1. Tracheal cancer, 800-MD-SINAI (800-637-4624) - Center for Head and Neck Cancer 2. A primary squamous cell carcinoma of the trachea: Case report and review of the literature,G.ABBATE,A.LANCELLA,R.CONTINI,andA.SCOTTI (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3008146/) 3. Macchiarini P. Primary tracheal tumours. Lancet Oncology. 2006. 7: 83-91. 4. Myers, et al. Cancer of the head and neck. 4th edition. 2003. WB Saunders.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Abdominal pain in patient with Echinococcus granulosum in liver Georgiev K1, Kalinova K2, Mindov I1, Naydenov K1, Hristova H1 1- Students in Medicine, Faculty of Medicine, Trakia University – Stara Zagora, Bulgaria 2- Dept.of General and Operative Surgery, Special Surgery, Neurosurgery, Pediatric Surgery and Urology, Faculty of Medicine, Trakia University – Stara Zagora, Bulgaria

Abstract Case presentation An otherwise well 46-year-old woman presented to her general practitioner with intermittent abdominal pain that had been present for several months. The only abnormality found at the initial consultation was moderate tenderness in the right upper abdomen. The laboratory tests that were ordered showed elevated parameters of inflammation. Sonography suggested the presence of an echinococcal cyst in segment VIII of the liver. Computed tomography confirmed this finding and showed no other cysts. On the basis of serological tests and the clinical findings, a diagnosis of Echinococcus granulosus infection was made. The patient was therefore admitted to hospital for surgical removal of the cyst. Her postoperative recovery was without complication and she remained free of symptoms. Conclusion Echinococcus granulosus infections are rare. The sonographic appearances are generally characteristic and permit diagnosis. Treatment is pharmacological (albendazole, mebendazole) and surgical. It is curative in the vast majority of cases. The possibility of echinococcal infection should be considered in patients, especially immigrants, with abdominal pain. Introduction Abdominal pain is a common cause of presentation to general practitioners. The present case report refers to a cause of abdominal pain which, though relatively rare, must be considered by general practitioners in the differential diagnosis of abdominal pain. Case presentation A 46-year-old womanhad always been healthy and had never been under the care of a general practitioner. In November she visited a general practitioner complaining of right upper abdominal pain with no radiation. The pain, which was described as pressing in character, had been present for about three months and was intermittent. There was no nausea, vomiting, weight loss, melaena, change in bowel habit, urinary symptoms, or fever. The patient denied alcohol abuse and said that she was a nonsmoker and took no regular medication. Blood pressure 140/80 mmHg, weight 75 kg, height 170 cm. Heart and lungs normal to percussion and auscultation. No lymph node enlargement. Abdomen slightly obese and soft. Tenderness present in the right upper abdomen. Bowel sounds normal. Renal angles clear. The clinical findings did not indicate a need for immediate hospital admission. On the basis of the history and the findings at the initial consultation, a series of laboratory tests and an ultrasound scan of the abdomen were ordered. Relevant abnormal laboratory test results: C-reactive protein 108 mg/l (normal range < 5 mg/l), erythrocyte sedimentation rate 91 mm after two hours (normal range < 20 mm). The following values were within normal limits: blood count, aspartate aminotransferase, alanine aminotransferase, gammaglutamyltransferase, alkaline phosphatase, creatinine, bilirubin, serum electrolytes. Sonography showed an irregularly echogenic, partially calcified septate cystic structure in segment VIII of the liver (Fig. 1). 27

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

No other abnormalities were apparent. In view of the sonographic findings, the radiologist arranged for the immediate performance of a contrast-enhanced computed tomographic scan of the abdomen. This showed a circumscribed rounded lesion measuring 5.8 × 4.7 × 5 cm in hepatic segment VIII (Fig. 2). The lesion showed a thick rim of calcification and a suggestion of fine septa with no affinity for contrast medium. The liver was otherwise homogeneous and of normal appearance. The other parenchymal abdominal organs appeared normal and there were no enlarged lymph nodes.

Figure 1. Sonographic appearance of the echinococcal cyst in hepatic segment VIII.

Figure 2. Computed tomographic appearance of the echinococcal cyst in hepatic segment VIII. Additional laboratory tests showed an antibody titre of 1:512 for E. granulosus and the presence of anti-E. multilocularis IgG. A western blot analysis was positive for Echinococcus granulosus and negative for Echinococcus multilocularis. After being informed about possible treatment options, the patient was referred to the university hospital. There she underwent hepatic segmental resection and cholecystectomy. Histological preparation of the material removed at operation showed caseating necrosis with a moderately severe, partly giant-cell, inflammatory reaction at the margin of an echinococcal cyst. There was no evidence of malignancy. The histological appearance was consistent with Echinococcus granulosus infection. Moderately severe chronic cholecystitis with moderate fibrosis of the gallbladder wall and cholecystolithiasis were also present. 28

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

The skin sutures were removed on the tenth postoperative day. As a result of wound dehiscence, the wound healed partly by second intention. The patient was free of symptoms. Follow-up treatment with Eskazole® 400 mg (active ingredient: albendazole) b.i.d. was given. The patient's subsequent progress was without complication . Discussion Upper abdominal pain is a common cause of presentation to general practitioners. Provided that the problem is new and that the clinical findings do not indicate a need for immediate hospitalisation, the cause of the pain can be satisfactorily established by history-taking and physical examination, where necessary supplemented by laboratory tests and imaging investigations (sonography) [1]. The SESAM-2 study found the most common diagnoses in patients presenting to general practitioners with abdominal pain to be gastritis and duodenitis (24.5%), while other infectious bowel diseases (7.5%) and cholecystolithiasis and cholecystitis (6.1%) occupied positions four and five in terms of frequency of diagnosis. Echinococcal disease is a rare cause of abdominal pain in Central Europe. In Germany the Robert Koch Institute has received reports of approximately 100 cases of echinococcal disease (60 cases of Echinococcus granulosus, 20 of Echinococcus alveolaris, and 20 unspecified; oral communication from the Robert Koch Institute) per year over the past few years. The incidence of this notifiable disease is thus approximately 1:1,000,000. The pattern of occurrence of Echinococcus granulosus infection in Central Europe is sporadic, whereas in parts of the former Soviet Union it is highly endemic [2]. In the case described here echinococcal infection was diagnosed with the aid of sonography. The distinction between cystic and alveolar echinococcosis is fundamental for treatment and prognosis. Along with imaging investigations, serological testing is essential. Serological screening is based on the use of only slightly purified antigens of E. granulosus or E. multilocularis and therefore often yields nonspecific results due to cross-reactivity [3]. In the present case the inconclusive serological result was therefore supplemented by western blot analysis for positive identification of the parasite. In conjunction with the computed tomographic findings, this established the diagnosis of a cyst due to Echinococcus granulosus. This disease is generally asymptomatic at first. Provided that their diameter remains less than 5 cm, the cysts rarely become symptomatic [4]. The case described here is typical in this respect. The infection gives rise to nonspecific symptoms (abdominal pain, digestive disturbances, nausea, vomiting, weight loss, fever, jaundice) and secondary complications (cyst rupture, anaphylaxis) [4,5]. Asymptomatic calcified echinococcal cysts require no treatment. If symptoms develop, operative treatment is the method of choice [3]. Pre- and postoperative anthelmintic therapy is recommended [4], since it reduces the risk of recurrence and of intraperitoneal dissemination of the infection after rupture or intraoperative damage to the cyst [6]. In the present case albendazole (in the form of Eskazole®) was used in accordance with WHO recommendations. A daily dose of 10 to 15 mg of this drug per kilogram bodyweight is taken in two individual doses after meals for a period of up to several months [5]. Conclusion In the case described here abdominal pain, a common reason for presentation to general practitioners, was found to be due to a rare condition. Especially in immigrants, the possibility of echinococcosis must be considered in the differential diagnosis of abdominal pain.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

References 1.Sandholzer H: [Diagnostic work-up of abdominal pain by the family doctor: an avertable potentially threatening situation must be excluded].MMW Fortschr Med 2006, 148:30.32-34, 36-37 2.Eckert J, Deplazes P: Biological, epidemiological, and clinical aspects of echinococcosis, a zoonosis of increasing concern.Clin Microbiol Rev 2004, 17:107-135. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL 3.Liance M, Janin V, Bresson-Hadni S, Vuitton DA, Houin R, Piarroux R: Immunodiagnosis of Echinococcus infections: confirmatory testing and species differentiation by a new commercial Western Blot.J Clin Microbiol 2000, 38:3718-3721. PubMed Abstract | PubMed Central Full Text OpenURL 4.Goksoy E, Saklak M, Saribeyoglu K, Schumpelick V: [Surgery for Echinococcus cysts in the liver].Chirurg 2008, 79:729-737. PubMed Abstract | Publisher Full Text OpenURL 5.Ceballos L, Elissondo C, Moreno L, Dopchiz M, Sanchez Bruni S, Denegri G, Alvarez L, Lanusse C: Albendazole treatment in cystic echinococcosis: pharmacokinetics and clinical efficacy of two different aqueous formulations.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicineâ&#x20AC;&#x2122;Studentsâ&#x20AC;&#x2122;Council, Trakia University â&#x20AC;&#x201C; Stara Zagora

Factors influencing medical students' choice of future specialization in medical sciences Kalinova Kr1, Georgiev K2, Mindov I2, Hristova H1, Alcheva J2 1-Faculty of Medicine, Trakia University - Stara Zagora 2-Students in medicine, Faculty of Medicine, Trakia University - Stara Zagora

Abstract Background: In future, increase in the number of healthcare professionals is dependent on the career interest among present undergraduate medical students. Based on their interest to pursue their specialty, the availability of medical doctors in each specialty could be done. Aims: This study was to find out future career interest and factors that influence undergraduate medical students to choose their future specialization. Materials and Methods: The study was carried out among first-year medical students from five countries. The students were asked to complete an 8-item questionnaire. Two thousand one hundred fifty three participants were enrolled in the study. Data were analyzed in Microsoft-Excel and Statistical Package for the Social Sciences. Results: Of the 553 participants, only 470 responded. Among the 470 participants, 169 participants were excluded due to the ambiguity in responses, finally making it to 301participants. Among them, Anatomy (49.3%) followed by Biochemistry (26.7%) and Physiology (24%) were the most preferred subjects. Conclusions: Anatomy was the most preferred basic science subject among the other subjects and the students were interested to pursuing surgery in future. Furthermore, the most preferred future specialties were surgery, internal medicine and pediatrics with gender variations; males preferring surgery and females in obstetrics and gynecology. Keywords: First year medical students, Bulgaria, Medical Education Introduction The projection for future health professionals can be met based on the career interest of the present undergraduate medical students who are pursuing their MBBS degree. [1] Based on the students' interest in pursuing their specialty and super-specialty subjects, the availability of medical professionals could be projected in each specialty. If the factors which influence the medical students to choose specific specialty are identified during their training period of the pre- and para-clinical modules, can be modified to stimulate interest in choices that are not preferred by them. [2] The major motive of most of the medical students is to choose specialty which would be lucrative in future. [3] Career options for medical students in choosing postgraduate (PG) subjects of choice are wide due to the availability of more PG seats in private medical colleges. Also the financial status of their parents and educational loans from banks do not create any financial burden, which is required to pay up high fees for their postgraduate specialties. [4] In most cases, it is observed that students never wishes to take up basic science specialty, as their knowledge and skills become limited to teaching and learning activities and is very restricted. [5] To suffice the needs of basic medical science teachers, medical colleges have started master and doctorate programs in medical streams especially in Anatomy, Physiology, Biochemistry, Microbiology, and Pharmacology. These programs have fulfilled the need of basic science teachers to some extent in medical colleges.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

There is need to find out what motivates the students to take up certain specialty of their choice so that the balance in medical doctors among various specialties is maintained. Research studies conducted in India observed that educational loans and life style factors may be the determining factors for the choice of specialty by the students. [6] Similarly, in Malaysia and China, government sanctions scholarship to those students who are interested to pursue MBBS based on their merits. Based on the above facts, our objectives of undertaken study was to understand, the possibilities of variable backgrounds in opting their future specialization. Also, the results generated from the current study would help the medical councils of the respective countries to modify and plan an alternative to increase the medical doctors in the various specialties including basic sciences. Materials and Methods The study was carried out among the first year medical students from five countries, namely China, Sri Lanka, Nepal, India and Malaysia during the month of March 2011-April 2012. A total of 2153 participants took part in the study. In the initial stage of the study, the questionnaire was pre-tested among ten medical students of first and second semesters from each medical school of five countries and the data generated were not included in the study. Initially, we distributed the questionnaires to 2153 medical students of which only 470 responded to the questionnaires. Non-respondents were excluded in the first stage. We found an ambiguity in their responses of 169 students among the 1470 students, since they marked more than one choice and hence we excluded 169 responded from the study. Thus of the 2153 medical students, only 1301 medical students were selected and those data were analyzed. Questionnaire design The students were asked to complete 8-item questionnaire, which consisted of three parts. The first part collected demographic and other relevant information about the medical students. The sex and nationality, the parents' qualifications and professions were also included in the questionnaire. The questionnaire used in the study is shown in the Appendix-I.[Additional file 1] The questionnaire was pre-tested in ten medical students from each institution but their data was not taken up for further analysis. The second part of the questionnaire consisted of 2-item question, which questions about their interest in pursuing post-graduate studies and why. The third part of the questionnaire was also a 2-item question, which enquired about the opinions of the students regarding the teaching and learning interest during their embarkation of the MBBS program, and the methodology of teaching they liked the most. They were also asked to give two suggestions to improve the teaching and learning. These were analyzed and the most frequently made suggestions were noted down to obtain an idea about emerging trends. Data collection The data were collected and entered in MS Excel for further analysis. Sample size calculation For 95% confidence interval and, significance level α = 1%, P = 70%, Q = 30%, allowable error = 10%, required sample size was 218. P = percentage of students selected their PG as medicine and surgery from the pilot study of 10 students from each country.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Explanatory variables The demographic characteristics and reason for opting factors were defined at individual level. Factors at individual level were age, country (China, India, Malaysia, Nepal and Sri Lanka), gender (Male, Female), location (Rural, Urban), fathers and mother's professions and qualification (Medical, Non-Medical), interesting subjects (physiology, biochemistry and anatomy) and reasons for opting future post-graduation studies (intellectual, interests, good quality of life and early experience). Ethical committee approval Prior to the study, ethical committee approval was taken from the concerned Institute, where the study was conducted among the medical schools of Malaysia, China and some of the SAARC countries. The ethical approval numbers of the concerned Institute were DERC/11/34, NSMRC/10/22, MERC/3/45, IMSERC/22/13, and NSFERC/11/21 Statistical analysis Descriptive statistics and testing of hypothesis were used for the analysis. The data collected was analyzed using Statistical Package for the Social Sciences (SPSS) for Windows Version16.0 (SPSS Inc; Chicago, IL, USA) and EPI Info 3.5.1 Windows Version. The associations between the different variables were tested using the Chi-square test. A P value less than 0.05 were considered statistically significant. Results Response rates and demographic characteristics. One thousand three hundred one respondents were analyzed for the study. Median age of the students was 21 years (inter quartile range 20, 22 years). Surgery was the most opted subject for post-graduation (37.1%) and least was pediatrics (1.1%) [Table 1]. Analysis based on country-wise response of participants in the study observed that medical students from Malaysia mostly opted for surgery (242 of 497) in their post-graduation followed by China (58 of 182), Nepal (67 of 217), Sri Lanka (58 of 194) and India (58 of 211). Obstetrics and gynecology were the most preferred post-graduate subjects (70 of 211) amongst Indian medical students and it was least opted among Malaysians (80 of 497). Of all the medical students, the inclination to choose basic medical science subjects were very minimal when compared to choosing clinical subjects [Table 1]. Table 1: Overall representation of fi ve countries in choosing post-graduate subjects and its analysis Gender-wise analysis revealed that males had their career choice in internal medicine (122 of 441) and surgery (319 of 441), whereas females opted for obstetrics and gynecology (313 of 860) followed by surgery (164 of 860), general practice (157 of 860) and internal medicine (156 of 860) [Table 2]. The study observed that the career choice for basic medical science subjects were minimal (56 of 860) for females of all the choices and none of the male medical students opted for it. Table 2: Gender-wise analysis in choosing subjects in Post-Graduation Analysis based on geographical location of the medical students revealed that most of the participants were from urban areas (1239 of 1301) and only (62 of 1301) participants were from rural areas [Table 3]. Among the students who were from urban area, the majority opted subject for post-graduate study in surgery (478 of 1239) followed by obstetrics and gynecology (282 of 1239), internal medicine (256 of 1239) and general practice (157 of 1239). Among the students who hailed from rural areas, obstetrics and gynecology were their major preference (30 of 62) followed by internal medicine (22 of 62) [Table 3]. It was observed that the preference of choosing basic science subjects were very minimal (5 of 62; 58 of 1239) among both the groups of medical students [Table 3]. 33

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicineâ&#x20AC;&#x2122;Studentsâ&#x20AC;&#x2122;Council, Trakia University â&#x20AC;&#x201C; Stara Zagora

The influence of family background was analyzed taking into consideration that students whose parents were from medical profession would also opt for medicine as a career of choice, but the current study revealed more medical students from parents of non-medical profession. Surgery and general practice were the most opted postgraduate subjects (157 of 363; 148 of 159) among the medical students in case of medical professional parents, whereas in case of non-medical professional parents, surgery (326 of 938; 473 of 1142) was the most opted subject for post-graduation. The current study also analyzed whether there in any influence of basic science subjects in choosing specialty in clinical sciences. The study observed that the first-year students mostly preferring anatomy are (642 of 1301) participants, followed by biochemistry (347 of 1301) and physiology (312 of 1301). Of those medical students, whose interest lies in anatomy preferred to choose surgery (321 of 1301), followed by obstetrics and gynecology (312 of 1301) [Table 5]. Those who had interest in biochemistry had future choice of general practice and those who had interest in physiology, preferred to take Internal medicine (156 of 312) as a career choice in future. Further, it was noticed that only those medical students who liked biochemistry in their first year had preferred post-graduate in basic medical sciences (156 of 347) [Table 5]. The study also intended to know the reason for choosing various post-graduate specialties from respondents. Off all the respondents, most of them (750 of 1301) chose their specialty for early experience in medicine [Table 6]. Surgery was opted (155 of 1301) for good quality of life in future whereas obstetrics and gynecology (159 of 1301) was of the choice of medical students, as they found it interesting and focused on intellectuality [Table 6]. Discussion The current study was conducted across five countries and the participants included in the study were pursuing their first year of MBBS degree program. Country wise analysis Among the countries, the maximum participants were from Malaysia (497 of 1301) and least was from China (182 of 1301). Off all the students selected from different countries, surgery was the most preferred postgraduate specialty (483 of 1301) followed by obstetrics and gynecology (OBG) (313 of 1301). The medical students from China, Sri Lanka, Malaysia and Nepal mostly preferred surgery for the post-graduation but Indian medical students opted for OBG. Only 14 of 1301 respondents opted pediatrics from Malaysia. The reasons for not opting for pediatrics from other countries need to be unrevealed. Off all the medical students, we observed Basic Medical Science subjects were least preferred (57 of 1301) among the students of all the countries. The reasons could be due to limited opportunities in basic sciences, which are restricted to teachings, research and diagnostic laboratories [Table 1]. It could be possible that students, who choose these subjects, are out of compulsion even though they may not have much passion for, or commitment to the subject, resulting in mediocrity and frustration. Career choices are dynamic and likely to change overtime as the students understand better as they move from first to final semester; however, if the disinclination towards these subjects persists, there is likely to be a scarcity of teachers in pre- and para-clinical departments. Moreover, the number of private medical schools across the globe is on the rise and those students who cannot secure seats in government medical schools have no other choice than to take up MBBS program in private sector. It is obvious that the high demand of medical seats makes an avenue for the private medical school to take heavy capitation fees to embark in medicine. Several banks provide loan for higher and professional studies. [7] Due to high fees structure for MBBS program, the medical students develop a tendency to earn money [8],[9],[10] , which becomes a matter of preference for clinical science subjects in post-graduate and earn more through private practice and repay back the loan for which they are indebted. [11] Study conducted by Bhat et al. [12] reported that the career of choice for most of the medical undergraduate students (95.3%, n = 250) was of clinical specialty with the most preferred ones were medicine, surgery, OBG and pediatrics. 34

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicineâ&#x20AC;&#x2122;Studentsâ&#x20AC;&#x2122;Council, Trakia University â&#x20AC;&#x201C; Stara Zagora

Study conducted in Israel reported both male and female medical students opted for clinical subjects as they specialty and none opted for basic medical sciences. [13] Another study that reported from India, [12] observed male medical students choosing internal medicine and surgery as their specialization, compared to females choosing OBG and pediatrics. Earlier study conducted by Subba et al.[14] showed that male medical students opt for surgery and females opt for OBG and internal medicine which concurred with our study. From the above findings, there is a continued decline in the number of students intending to pursue a postgraduate career in basic science subjects and this calls for more proactive steps to address this as shown by the example of Kathmandu University, the first private University in Nepal, that have started enrolling Bachelor of Dental Surgery graduates for MD program in basic science subjects. The study observed that the career choice for basic medical sciences subjects were minimal (56 of 860) for females, it is possible that shorter work time, flexibility etc could have been responsible for the choice of females in the basic sciences bearing in mind the family commitments. Association of geographical location The current study observed more urban participants compared to rural. Of the total number of students participated in the study, we observed 95.2% of students hailed from urban setup and only 4.8% were from the rural background. This shows that people living in urban cities have more access to medical course compared to rural. Even the students from cities have more access to coaching classes for medical entrance examinations. Thus, we found more students from urban areas compared to rural ones. Association of parent's profession We presumed more medical students areof parents who are professionally and medically qualified, but was just the opposite. The current study observed the predominance of medical students (79.9%; n = 2080) from non-medical professional against medical professional parents (20%; n = 522). Surgery was the most opted subject by medical students for post-graduation among non-medical background parents. The changing trends in medical education can be noticed in our study. Association of first year subject in choosing their specialty in post-graduate Students from the both first and second semesters were asked about their opinion regarding the subjects taught in first year of MBBS program. Of all the students 642 (49.3%) of students chose anatomy as their most interesting subject followed by biochemistry 347 (26.7%) and physiology (24%). Among the students who liked anatomy showed their future interest in surgery (50%) followed by OBG (48.6%). Those students whose interest was in biochemistry preferred general practice (45%) followed by internal medicine (32.9%) for their career prospects. Similarly, those who were interested in physiology were more inclined towards internal medicine (50%) followed by surgery (49%). The medical students in their first year might have felt and learnt from their senior or teachers that if they study anatomy in more detail it would be easy for them to understand surgery, and they knew surgery is the most income generating subject in medical sciences, and that is why they embarked in MBBS program and they liked anatomy which is pre-requisite for surgery. Similarly, those who liked biochemistry and physiology, are interested to pursue their future career in internal medicine or general practice as they would be able to understand the biochemical basis of disorders, which would help them to apply their knowledge in these subjects. Approximately 57.6% of the medical students' main reason for opting their choice of subject in various specialties was to have an early experience and good quality of life. Study reported from India [12] also reported the factors influencing the specialty choice were job satisfaction, income, lifestyle friendliness and career prospects.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Conclusions Anatomy was the most interesting subject among the first year medical students and they were interested in pursuing surgery as their future career prospects. General practice and internal medicine were the career of choice for those who liked Biochemistry among the first year medical students. Similarly, internal medicine was the most opted subject of choice for those interested in physiology. Furthermore, our study also reveals that the most preferred specialties of the students were surgery, internal medicine and pediatrics with gender variations; males preferring surgical specialties and females opting OBG. Factors that had the most influence on their choices for post-graduation career were their interest in the specialty leading to good quality of life. Of all specialties, the inclination to choose basic science subjects as specialty was not generally preferred by them.

References 1. Rowson M, Smith A, Hughes R, Johnson O, Maini A, Martin S, et al. The evolution of global health teaching in undergraduate medical curricula. Global Health 2012;8:35. Back to cited text no. 1 2. Jantschi L, Bolboaca SD. Interactive Web Application for Evidence-Based Medicine Training. 11 th world Congress on Internet in Medicine. MEDNET 2006. Back to cited text no. 2 3. Arnold JL, Dickinson G, Tsai MC, Han D. A survey of emergency medicine in 36 countries. CJEM 2001;3:109-18. Back to cited text no. 3 4.Fordtran JS, Armstrong WM, Emmett M, Kitchens LW Jr, Merrick BA. The history of internal medicine at Baylor University Medical Center, Part 1.Proc (BaylUniv Med Cent) 2004;17:9-22. Back to cited text no. 4 5.Elstein AS. On the origins and development of evidence-based medicine and medical decision making.Inflamm Res 2004;53Suppl 2:S184-9. Back to cited text no. 5 6.Why Do Doctors Make So Much Money? (Accessed September 23, 2013, at http://www.wisegeek.org/why-do-doctors-make-so-muchmoney.htm). 7.Altbach PG, Reisberg L, Rumbley LE. Trends in Global Higher Education: Tracking an Academic Revolution. A report prepared for the UNESCO 2009 World Conference on Higher Education. 2009. p. 6779. Back to cited text no. 7

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Immunological Follow-up of Hydatid Cyst Cases Kr.Kalinova1, K.Halacheva2, K.Georgiev3, I.Mindov3, H.Hristova3 1-Department of Pediatric surgery,Medical Faculty, Thracian University- Stara Zagora,Bulgaria 2-Department of Molecular biology, Immunology and Medical genetics, Faculty of Medicine, Trakia University – Stara Zagora 3-Students in medicine, Faculty of Medicine, Trakia University-Stara Zagora

Abstract Hydatid disease is caused by Echinococcus granulosus. In this study, we aimed to investigate the benefit of monitoring cases with hydatid cyst by means of immune components in patients in a long-term follow-up after surgery. Twenty-one preoperative and postoperative serum samples from 21 cases undergoing surgery for hydatid disease were evaluated in terms of immune parameters, such as total and specific IgE, IgG, IgM, IgA and complement. Total and specific IgE were determined by ELISA. Specific IgG levels were measured by indirect hemaglutination.Total IgG, IgM, IgA and complement (C3 and C4) were detected by nephelometry. Imaging studies were also carried out during the follow-up. In none of the patients hydatid cysts were detected during the follow-up. Total IgE levels in the sera of the patients decreased to normal six months after surgery. Although specific IgE against echinococcal antigens decreased one year after operation, levels were still significantly high. There were no changes in the levels of anti-Echinococcus IgG and total IgG in follow-up period. Additionally, other parameters, such as IgA, IgM, C3 and C4, were not affected. Keywords: hydatid cyst - immune system Hydatid cysts of E. granulosus develop in internal organs (mainly the liver and lungs) of humans and intermediate hosts (herbivores such as sheep, horses, cattle, pigs, goats and camels) as unilocular fluid-filled bladders . These consist of two parasite-derived layers, an inner nucleated germinal layer and an outer acellular laminated layer surrounded by a host-produced fibrous capsule. Brood capsules and protoscoleces (PSC) bud off from the germinal membrane. Definitive hosts are carnivores such as dogs, wolves, and foxes. Sexual maturity of adult E. granulosus occurs in the host small intestine within 4 to 5 weeks after the host ingests offal containing viable PSC. Gravid proglottids or released eggs are shed in the feces, and following their ingestion by a human or ungulate host, an oncosphere larva is released that penetrates the intestinal epithelium and enters the lamina propria. The larva is then transported passively through the blood or lymph to the target organs, where it develops into a hydatid cyst. Since the life cycle relies on carnivores eating infected herbivores, humans are usually a dead end for the parasite. Hydatid disease is caused by Echinococcusgranulosus in the liver, the spleen and the lungs. Many cases are asymptomatic, and physical examination is not useful, unless the cyst enlarges and pressures on surrounding tissues and vascular structures. Due to antigens in cystic fluid, antibody production can be induced in the host. Cassoni reaction is a skin test that is not in use because of 20% false negative and 30% false positive results (Imren 1997). Weinberg test is complicated to be performed and was replaced with serological tests. Quantitative determination of specific IgE antibodies to E. granulosus and total IgE levels in sera, using ELISA, might be a useful tool not only in diagnosis, but also in follow-up period after surgical applications in order to monitor remaining or relapsing hydatid cysts (Dessaint et al. 1975). The outcome of a study in surgically confirmed cases, showed that ELISA is a good screening test with 88.2% sensitivity, 88.8% specificity and 88.5% diagnostic efficacy (Kaddah et al. 1992).

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Additionally, complement cascade activation and immune complex deposition due to antibodies in patients with hydatid cyst have been reported (Ali Khan & Rausch 1987, DAmelio et al. 1989). In this study, we aimed to investigate the presence of immunoglobulins and complement, in a long-term follow-up after surgery. Fourteen cases (mean of ages: 34±7) with hydatid cyst disease were enrolled in the study. Diagnosis of the patients was established by ultrasound, CT and serological tests and confirmed by parasitological examination of cystic fluid after surgery. All cases underwent surgery for hydatid disease. Partial cystectomy plus drainage were performed on ten patients and complete cystotomy plus drainage on remaining four patients. Prior to and after surgical approach (1 day, 1 week, 1 month, 6 months and 1 year), 15 ml of venous blood from each case were obtained. Serum was separated by centrifugation. Eighty-four preoperative and postoperative serum samples were evaluated for specific IgE and IgG, and total IgE, IgG, IgM, IgA and complement factors. Total and specific IgE were determined by ELISA (Bioclone, Marrickville, Australia and DrFook, Neuss, Germany, respectively). Specific IgG levels were measured by indirect hemaglutination (International-Immuno Diagnostics, CA, USA). Total IgG, IgM, IgA and complements (C3 and C4) were detected by using nephelometry (Beckman Array 360, CA, USA). Imaging studies were also carried out during the follow-up. As a control group, 32 healthy voluntaries were enrolled to the study (mean age: 34±7). Statistical analysis was performed by Kruskal-Wallis (nonparametric one-way ANOVA), Student's t test between groups showing normal Gauss distribution, Mann-Whitney U test between groups not showing normal Gauss distribution, correlation analysis (Spearman) in SPSS 7.0.5 for Windows 95. p values below 0.05 were accepted as statistically significant. RESULTS In none of the patients cysts were detected during the follow-up. Total IgE levels decreased gradually to normal six months after surgery (Fig. 1). Although specific IgE against echinococcal antigens also decreased, its levels were still significantly high (Fig. 2). There was no alteration in the levels of anti-EchinococcusIgG and total IgG in follow-up period (Tables I, II). Additionally, other parameters, such as IgA, IgM, C3 and C4, were not affected (Tables I, II). IgA and IgG levels in the patients with hydatid cyst were found to be slightly higher than in healthy individuals (Table I) but with no statistical significance. There was no difference among time point measurements of C3 and C4 levels (Table III). DISCUSSION In the study, a highly significant correlation was obtained between levels of total serum IgE and specific IgE antibodies (rs=0.289, p<0.001). This finding is in agreement with the report of Dessaint et al. (1975). While total IgE levels declined to normal values six months after surgery, specific IgE levels maintained their high levels longer than six months. This is most likely due to polyclonal activation of B lymphocytes by E. granulosus antigens, such as antigen 5, Em 16, Em 18 and antigen B, also present in E. alveolaris (Ayadi et al. 1995, Abdel et al. 1996, Nirmalan& Craig 1997). There is no information that evaluates half-lives of specific IgE against these antigens. We examined the patients in order to exclude echinococcosis in other tissues, including the lungs, performing chest X-rays. The commercial antigen used for detecting specific IgE in the system is obtained from cyst fluid by crude extraction and purification by chromatography. Probably, specific IgE against E. granulosus has a long half-life or there is antigenic exposure after surgery in spite of no relapse of the disease.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

We could not find any alteration in complement levels (C3 and C4) in a quantitative manner. Assesing total complement activity by using Complement Hemolytic Activity (CH50) assays might give more useful information. During the follow-up period, IgA and IgM levels did not change, as well, and no patients in the study presented clinical manifestations indicating immune-complex patterns. When compared with the levels of healthy individuals, IgA and IgG levels in the cases were slightly higher prior to and after surgical operation. However, there was no statistical significance (p>0.05).

REFERENCES 1.Abdel Aal TM, al-Hady HM, Youssef FG, Fahmi IA, Abou-el-Saoud SM, Ramadan NI 1996. Studies on the most reactive purified antigen for immuno-diagnosis of hydatid disease. J Egypt SocParasitol 26: 297303. 2.Ali Khan Z, Rausch RL 1987. Demonstration of amyloid and immune complex deposits in renal and hepatic parenchyma of Alaskan alveolar hydatid disease patients. Ann Trop Med Parasitol 81: 381-392. 3.Ayadi A, Dutoit E, Sendid B, Camus D 1995. Specific diagnostic antigens of Echinococcusgranulosus detected by western blot. Parasite 2: 119-123. 4.D'Amelio R, De Rosa F, Pontesilli O, Dayal R, Brighouse G, Teggi A, Barnet M, Lambert PH 1989. Hydatid disease: analysis of parasite antigens in circulating immune complexes and in preformed hydatid antigen-antibody complexes. Med MicrobiolImmunol 178: 177-186. 5.Dessaint JP, Bout D, Wattre P, Capron A 1975. Quantitative determination of specific IgE antibodies to Echinococcusgranulosus and IgE levels in sera from patients with hydatid disease. Immunology 29: 813-823. 6.Imren AH 1997. Laboratory in Clinical Diagnosis, Mentes Publication, Istanbul, p. 571-572. 7.Kaddah MH, Maher KM, Hassanein HI, Farrag AI, Shaker ZA, Khalafallah AM 1992. Evaluation of different immunodiagnostic techniques for diagnosis of hydatidosis in Egypt. J Egypt SocParasitol 22: 653665. 8.Nirmalan N, Craig PS 1997. Immunoblot evaluation of the species-specificity of EM 18 and EM 16 antigens for serodiagnosis of human alveolar echinococcosis. Trans R Soc Trop Med Hyg 91: 484-486.

Fig. 1: total IgE levels (IU/l) of 21 cases were shown. Results are expressed as mean±SEM bars. Standard of the laboratory, in which the study was carried out, was obtained from a group of healthy individuals in quality control procedures (n:30); *: p<0.01; **: p<0.001 39

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

RISK FACTORS OF DEVELOPMENT OF EOSINOPHILIC PHENOTYPE OF BRONCHIAL ASTMA IN SCHOOL AGE CHILDREN Ortemenka Ye.P., Gorbatuk I.B. Scientific adviser: PHD, MD, professor E.K. Koloskova Bukovinian State Medical University Department of Pediatrics and pediatric infectious diseases (chief of department: PHD, MD, professor E.K. Koloskova) Chernivtsi, Ukraine

Introduction. Currently, bronchial asthma (BA) in children is considered as a disease characterized by chronic inflammation of the airways, in development of which many different cells and cellular elements play the role. It is believed that under the antigenic stimulation, the primary effectors cells (epithelial cells of the respiratory tract, mast cells, and macrophages), associated with immunoglobulin E, release inflammatory mediators, causing a development of inflammatory reaction both immediate and late types. Concurrently, an inefficiency of standard anti-relapse basic therapy of BA in children is associated with phenotypic polymorphism of disease. Sputum induction by inhalations of hypertonic (3%, 5%, 7%) solutions of sodium chloride, used for identification of type of bronchial inflammation in children is limited and, unfortunately, available mainly in older children. Aim. To study the clinical and anamnestic risk factors of eosinophilic BA in school age children. Methods. Eosinophilic asthma phenotype was diagnosed in 66 patients (56.9%) in the presence of ≥ 3% eosinophils in cell’s sediment of induced sputum. Estimates were presented as an Relative Risk (RR), Attributive Risk (AR) and Odds Ratio (OR) with their 95% CI. Results. Eosinophilic asthma phenotype have been often associated with: patients’ overweight (body mass index ≥19,0 kg/m2) (RR=1.5; 95% CI 0,9-2,5, OR=2.7; 95% CI 1,3-5,98, AR=24%), concomitant atopic dermatitis (AR=33%, RR=1.6; 95% CI 0,2-12,6, OR=5.8; 95% CI 0,7-48,9), more severe course of disease (AR= 9%, RR= 1.6; 95% CI 0,7-3,6, OR=3.7; 95% CI 1,4-9,9) and infectious index >1 (RR=1.3, 95% CI 0,5-3,1, OR=2.0; 95% CI 0,7-5,6, AR=16%). It appeared that major provocative factors for this asthma phenotype were: physical activity (RR=1.5; 95% CI 0,9-2,3, OR=2.6; 95% CI 1,2-5,5, AR=22%), food and inhaled allergens (RR=1.3; 95% CI 0,6-2,9,OR=1.9; 95% CI 0,7-5,1, AR=15%), and smoking (RR=1.4; 95% CI 0,36,4, OR=2.4; 95% CI 0,5-12,4, AR=19%). Conclusions. For eosinophilic bronchial asthma more common: increased body weight; more severe course of the disease, the presence of a atopic dermatitis and higher infection index, the prevalence of such triggers as food and inhaled allergens, physical activity, and smoking. 41

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

THE PROVISION OF MICROELEMENTS IN THE RATION OF STUDENTS Filippova O.V. Scientific advisor: k.med.n, associate O. L. Tarinskaya National O. O. Bogomolets Medical University Department of Pediatrics ¹ 3 (Chief of department: DMSc professor Y.V. Maryshko) Kyiv, Ukraine Actuality of problem. People get microelements from food, water and air. Microelements are exogenous chemical factors that play a significant role in vital processes such as growth, reproduction, hematopoiesis, cell respiration, metabolism, and other trace elements form the proteins of an organism-specific organometallic complexes, which are regulators of biochemical reactions. In the case of the anomalous content or content infringement or violation of the ratio of trace elements in the environment in the human body can develop disorders with characteristic clinical symptoms, mainly due to the dysfunction of the enzymes in which they are incorporated or activate. As a result of malfunction of one or more enzyme systems caused by some etiologic factor, blocking the normal course of metabolic processes. Balanced diet – a factor contributing to the development of the child’s body and maintain its health. Currently in Ukraine nutrition is not fully balanced, which can lead to a deficiency of trace elements in the body of the child and to the development of various diseases. Purpose of study. Set features deviations microelement status indicators and their relation to rational and balanced nutrition of the student. Materials and methods. We at the department of pediatrics¹ 3 of the National O.O. Bogomolets Medical University were examined 90 students, including 51 boys and 39 girls, living in Kiev. All students surveyed trace element content in hair. Determination of trace elements (Cr, Se, Cu, Zn, Fe, Ca,) in the hair of children was studied by X-ray fluorescence spectrometry apparatus “ElvaX – med”. Results and discussion. In the clinical study investigated trace element status of students/ By X-ray fluorescence spectroscopy revealed that 44.6% of children are deficient in zinc, in 48.9% – iron, in 25.3% – copper, in 51.8% – selenium at 71.9% – the calcium in 34.6% – chrome. Profiles of students found that daily diet – is carbohydrate and have the micronutrient deficiency. Students don’t consume such foods as beef (it contains a lot of Zn, Fe), marine products (Zn), figs and raisins (Fe), legumes (Cu), garlic (Se), dairy products (Ca), shrimp (Cr).

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Conclusions. Microelements – a group of chemicals that are contained in the body of humans in very small amounts. Microelements are chemical factors that play an important role in vital processes.The analysis nutrition of students showed that daily diet of the most them – inconsistency accepted standards, which may lead to a deficiency of trace elements in the body of the student and the emergence of various diseases.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

WHITE MISTLETOE EXTRACT (VISCUM ALBUM) TESTED ON EXPERIMENTAL ANIMALS AS THERAPY FOR CANCER Field of medicine:Oncology Author(s): ANGJEL STOJANOVSKI, I.Milev, B.Panov, B.Panova, N.Velickova, L. Nikolovska Supervisor(s): Prof. D-r Gordana Panova, B.Sc. Pharm. Spec. Biljana Nastova Sci Country: Macedonia Faculty: Faculty Of Medicine Shtip Introduction: Despite the efforts made to achieve early detection,effective and successful treatment of malignant diseases,adjuvant therapy has become increasingly popular to provide better results and reduction the mortality rates from cancer. In Europe extracts from Viscum album, the European white-berry mistletoe,are widely used as alternative treatment for patients with cancer. On the whole mixture of active components in the aqueous solution of white mistletoe,antineoplastic strongest potential has lectin. Aim: The purpose of this paper is to prove the antitumor effect of lectin from mistletoe extract on white Wistar rats with stimulation of immune system by increasing the number and activity of varios types of white blood cells. Material and methodology: The three groups of mice (5 mice / group) was placed on the 4 day semi- synthetic diet. All mice were treated subcutaneously with melanoma cells (B16F10 cells). One group served as placebo control group,that is not treated with lectins and the rest were treated with ML-1 with a daily dose of lectin to 1,0 ng/kg (this is experimental number becose we have aqueous solution of plant).The examination is worked over 9 days Results: After 72 hours of treatment with lectin cytotoxicity of NK cells doubles and the number of granulated lymphocytes increased three times compared with the untreated control group. Conclusion: From the analysis and results we can conclude that the lectin acts stimulating the immune system, perform stabilization of DNA in white blood cells,stimulate an increase in the number and activity of certain types of leukocytes.Lektin induces macrophage cytotoxicity,phagocytosis,then increasing cytokine secretion in vivo. Key words: Cancer 44

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

Surgery – Journal for students and young doctors PUBLICATION REQUIREMENTS 1. Articles are published in English.. 2. Age of the author, whose name stands first, should not exceed 35 years. 3. The author’s original consists of two copies printed on one side of A4 white paper, and the electronic version of the material on the 3,5-inch diskette or CD-R, typed in Microsoft Word (any version), typeface “Times New Roman”, font size 12, without tabulators, with 1,5 line spacing, with all the margins of 20 mm. The text and titles should not contain words, typed in capital letters. To ensure reliable preservation of materials, please, submit two copies of materials on a single electronic carrier. Diskette or CD-R should be sent in a solid envelope. 4. The structure of the main text of the article should correspond the generally assepted structure of scientific articles. The volume should not exceed: article – up to 9 p.; review, problematic article – up to 12 p., short information – up to 3 p. Attention! The decision about publication of lengthy articles in the journal is taken individually if, in the opinion of the editorial board, it is of particular interest for readers. 5. Articles, containing the results of experimental researches, including PhD-theses, consist of the following parts: “Introduction,” “Objective”, “Materials and Methods”, “Results and Discussion”, “Conclusions”. These publications should include the following elements: formulation of the problem in general and its connection with important scientific or practical tasks; analysis of recent researches and publications, in which the discussion of the problem is initiated and on which the author relies, distinguifhing previously unsolved aspects of the general problem which the article focuses on; definition of the objectives of the article; presentation of the basic research material with the full justification of the obtained scientific results; conclusions of the study and the prospects for further researches in this area. 6. The abstract should supplement the language of the article (for example, if the article is written. 7. On the 1-st page of the text indicate: 1) the UDC identifier and the title of the article; 2) the names and initials of the authors; 3) an institution where the authors work, city, country (for foreigners); 4) keywords – 5 – 10 words or phrases revealing the content of the article. 8. On the last page of the text place: 1) the handwritten signatures of all authors; 2) the stamp and signature of the responsible person from the institution submitting the material; 3) name, surname, postal address, telephone numbers (work and home) of the author, with whom the Editorial Board has to communicate. 9. Tables should be made in the typeface “Times New Roman”, 10 points, without service mark symbols inside. Publications containing tables, which are made with the help of a tabulator, will not be considered. The names of drugs/medical products should be written from small letter. 10. All measures are indicated in units of SI.

Surgery (Vol. 1, yr.6., february 2014)

Faculty of Medicine’Students’Council, Trakia University – Stara Zagora

11. References should be given on separate pages. Literature sources are presented in alphabetical order (foreign ones – separately) or in order of their citation in the text. Their total number should not exceed 50, with 50% of them published not more than five years ago. References in the text are indicated by figures in square brackets (for example [7]). The list of reference sources should be arranged according the State Standarts 7.1:2006 “System of informational, library and publishing standards. Bibliographic record. Bibliographic description. General requirements and rules.” 12. The article should be accompanied by the review of an expert in the appropriate field, as a rule, Doctor of Science, and the referral to printing, stamped by the institution, where the work has been performed. 13. Authors are responsible for the scientific and literary editing of the presented material, quotations and references, but the editors reserve the right to correct the article or refuse in its publication, if the submitted text materials do not correspond in their form or content to the above mentioned requirements. 14. Materials, which do not correspond to the above mentioned requirements of publication in the journal, are not considered and not returned by the editors. 15. Diskettes or CD-R, manuscripts, pictures, photographs and other materials, sent to the editorial board, are not returned.