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One of the most common stressors is so-called "occupational stress." It is defined as the sum of physical, mental and physiological responses to work in situations where the workload or stress associated with it intensifies for an extended period of time. It is a gradual process in which individual cognitive assessments of occupational stressors generate adverse health events and may lead to burnout. Since it has become a major problem in the medical field, studying, measuring and limiting it have been set as goals for the future.

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Background and Objectives: Esophageal stenting with self-expandable metallic stents (SEMS), for both benign and malignant reasons, has been widely practiced for decades, but migration still remains the most common complication of the procedure. In this report we aim to review our experience and results in stent fixation with clips. Materials and Methods: We present 18 patients who underwent esophageal stenting for both benign and malignant reasons. The SEMSs used were partially covered and were fixated with two to four through the scope hemostatic clips in the proximal end of the prothesis. The procedure was performed only on patients with a high risk of migration of the stent. Results: Migration occurred in only one of the above-mentioned patients and was treated with stent repositioning. The other adverse events that occurred were related to tumor growth in patients with malignant diseases. Conclusions: Clip fixation of an esophageal self-expandable metallic stent in cases considered high-risk for migration is a safe procedure. It reduces the migration rate significantly for both benign and malignant indications.

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Portal hypertension (PH) and esophageal varices (EVs) are a matter of extensive research. According to current Baveno VII guidelines, in patients with compensated advanced chronic liver disease (cACLD), liver stiffness measurement (LSM) < 15 kPa and PLT count > 150 × 109/L, upper endoscopy (UE) is not mandatory, and the emphasis should be set on non-invasive methods for evaluation of clinically significant portal hypertension (CSPH). The aim of this study is to establish whether liver stiffness (LS) measured by 2D-SWE could be used as a predictor for the presence and severity of EVs in cirrhotic patients. In total, 86 patients of whom 32 with compensated liver cirrhosis (cLC) and 54 with decompensated liver cirrhosis (dLC) were examined in the Gastroenterology clinic of University hospital "Kaspela", Plovdiv, Bulgaria. Each patient underwent LS assessment by 2D-SWE and EVs grading by UE. EVs were detected in 47 (54.7%) patients, 23 (49%) of them were stage 4-high-risk EVs (HREV). The cut-off value for LS that differentiates HREV from the rest was set at 2.49 m/s with 100% sensitivity and 100% specificity (AUC 1.000, CI 0.925). Conclusions: 2D-SWE can be used as a non-invasive method in the assessment of only high-grade esophageal varices. For the other grades, upper endoscopy remains the method of choice.

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The epiphrenic esophageal diverticulum is a rare non-malignant condition that is commonly associated with motility disorders. It would normally be treated surgically, but with the advancement of endoscopy techniques, peroral endoscopic myotomy with septotomy (D-POEM) has shown its benefits in coping with the symptoms. We present a case of a 71-year-old woman with increasing symptoms of dysphagia, weight loss and imaging data showing a large epiphrenic diverticulum. We treated her using peroral endoscopic myotomy combined with septotomy of the diverticular septum. The procedure showed excellent results with reducing the amount of contrast materials retained in it, improving the quality of life of the patient, and increasing her weight. There were minimal adverse events and no perforations or severe adverse effects occurred. D-POEM is a new and rapidly evolving procedure that is proving to be a safe and effective method of treating epiphrenic esophageal diverticulum.

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INTRODUCTION: A variety of imaging techniques exists for the diagnosis of pancreatic disorders. None of the broadly applied diagnostic methods utilizes elasticity as an indicator of tissue damage. A well-known fact is that both chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDA) are associated with the development of prominent fibrosis (increased tissue stiffness). PURPOSE: To prospectively assess the accuracy of point shear wave elastography (pSWE) in differentiating between benign and malignant pancreatic diseases, establish a cut-off value for the diagnosis of PDA, and evaluate the influence of certain variables on the obtained results. MATERIALS AND METHODS: The present study included 78 patients who were admitted at the Department of Gastroenterology at the university hospital "Kaspela" between December 2017 and August 2021 for diagnosis and/or treatment of pancreatic disorders. Based on the clinical criteria, diagnostic imaging, and histological findings, patients were divided into the CP and PDA group. The ultrasound based pSWE technique was applied and shear wave velocity (SWV) was measured. The depth of region of interest (ROI) and successful measurement rate were also recorded. RESULTS: The mean ± SD SWV values established through pSWE were 1.75 ± 0.34 m/s and 2.93 ± 0.91 m/s for the CP and PDA, respectively. With a cut-off value of 2.09 m/s, we calculated the sensitivity (Se), specificity (Sp), and accuracy for differentiating between CP and PDA of 89.47%, 91.20%, and 88.60%, respectively. Of the examined variables, BMI and depth of ROI in the CP group and sex in the PDA group showed a statistically significant influence on the obtained results. CONCLUSIONS: pSWE may be utilized as a differential diagnostic modality in patients with suspected CP or PDA.

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Magnetic resonance imaging (MRI) of the breast has been increasingly used for the detailed evaluation of breast lesions. Diffusion-weighted imaging (DWI) gives additional information for the lesions based on tissue cellularity. The aim of our study was to evaluate the possibilities of DWI, apparent diffusion coefficient (ADC) value and ADC ratio (the ratio between the ADC of the lesion and the ADC of normal glandular tissue) to differentiate benign from malignant breast lesions. MATERIALS AND METHODS: Eighty-seven patients with solid breast lesions (52 malignant and 35 benign) were examined on a 1.5 T MR scanner before histopathological evaluation. ADC values and ADC ratios were calculated. RESULTS: The ADC values in the group with malignant tumors were significantly lower (mean 0.88 ± 0.15 × 10-3 mm2/s) in comparison with the group with benign lesions (mean 1.52 ± 0.23 × 10-3 mm2/s). A significantly lower ADC ratio was observed in the patients with malignant tumors (mean 0.66 ± 0.13) versus the patients with benign lesions (mean 1.12 ± 0.23). The cut-off point of the ADC value for differentiating malignant from benign breast tumors was 1.11 × 10-3 mm2/s with a sensitivity of 94.23%, specificity of 94.29%, and diagnostic accuracy of 98%, and an ADC ratio of ≤0.87 with a sensitivity of 94.23%, specificity of 91.43%, and a diagnostic accuracy of 95%. CONCLUSION: According to the results from our study DWI, ADC values and ADC ratio proved to be valuable additional techniques with high sensitivity and specificity for distinguishing benign from malignant breast lesions.

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INTRODUCTION: Based on many previous studies, liver cirrhosis is traditionally associated with cardiac dysfunction. The main clinical features of cirrhotic cardiomyopathy include attenuated systolic contractility in response to physiologic or pharmacologic strain, diastolic dysfunction, electrical conductance abnormalities, and chronotropic incompetence. Previous studies have found that the levels of brain natriuretic peptide (BNP) and its precursor the N-terminal pro B-type natriuretic peptide (NT-proBNP) are elevated in cirrhosis with systolic as well as diastolic dysfunction.

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Achalasia is a rare motility disorder with unknown etiology that results in failure of relaxation of the lower esophageal sphincter (LES). As there is no etiological treatment, different pharmacological agents and invasive techniques have been used for relieving the symptoms. For the past decade, peroral endoscopic myotomy (POEM) has proven to have excellent results.

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AIM: The aim of this study was to identify the incidence of and the risk factors for poor bowel preparation in elderly patients. PATIENTS AND METHODS: We enrolled 240 patients over 60 years of age, hospitalized in the Clinic of Gastroenterology, Kaspela University Hospital between October 2016 and May 2017 and scheduled them for colonoscopy. We recorded patients' demographics data, clinical characteristics and the rate of bowel preparation. Factors associated with poor bowel preparation were identified by multivariate logistical regression analysis. RESULTS: The rate of poor bowel preparation was 33.6%. Factors associated with poor bowel preparation were a history of abdominal surgery (OR, 2.617, CI, 1.324-5.174), chronic constipation (OR, 3.307; CI, 1.551-7.054), non-compliance with dietary instructions (OR, 2.239, CI, 1.122-4.471), noncompliance with polyethylene glycol (PEG) dosage (OR, 4.576, CI, 1.855-11.287), walking less than 30 min during preparation (OR, 2.474; CI, 1.261-4.855), interval between PEG ingestion and the onset of bowel activity (OR, 1.025, CI, 1.010-1.040), the latest stool that was not clear and watery (OR, 4.191; CI, 1.529-11.485). CONCLUSIONS: Elderly patients tend to have suboptimal preparation for colonoscopy. Walking less than 30 min. during the PEG ingestion period may be a surrogate for bowel preparation failure. Future studies should identify patients at risk for poor bowel preparation. Methods and interventions should be developed to improve outcomes.

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Lower gastrointestinal bleeding is a rare condition in childhood pathology. The incidence of this disorder in the general population of Bulgarian children is unknown. We report a case of a 7-year-old child with diagnosed hemophilia A and high titer of factor VIII inhibitor; the patient was admitted into the Department of Pediatrics and Medical Genetics for rectorrhagia after falling onto his buttocks while playing. Colonoscopy showed submucosal hematoma 25 cm from the anocutaneous line occluding the intestinal lumen with a lesion of the overlying mucosa as long as 20 mm. If a patient presents with rectorrhagia, timely and carefully planned colonoscopy could identify the source of bleeding, determine the severity of bleeding and the size of hematoma, and assess the need for surgical intervention. The reported case supports the modern view that patients with inhibitor hemophilia should not be denied interventional procedure or surgical intervention for fear of uncontrolled bleeding.

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AIM: To present a chronological overview of the most important events and actors that have marked the history of anaesthesiology and intensive treatment in R. Macedonia since its beginnings in the 1950s. METHOD: Retrospective study based on archive materials, published literature and jubilee publications, as well as the memories of individuals who have worked in the field of anaesthesiology in the past period. RESULTS: Between the two World Wars the first anaesthesia procedures were handled by surgeons. After World War II, the development of anaesthesia in R. Macedonia could be divided into two periods: before 1965 and after 1965. Before 1965 anaesthesia was mainly given by technicians trained on courses, and after this year anaesthesiology was taken over by anaesthesiologists who had specialized at the Faculty of Medicine in Skopje. In 1985 the number of anaesthesiologists was 100, and today it exceeds 250. The most important figures in the history of Macedonian anaesthesiology are: Dr. Risto Ivanovski, who worked from 1954-78, and Prof. Dr. Vladimir Andonov, who worked as an anaesthesiologist from 1965-99. Both of them are doyens who contributed a lot to the development of the anaesthesiology service and education of anaesthesiologists in R. Macedonia. Intensive treatment had started in 1955, but in real terms it has been performed since 1966, when artificial ventilators were introduced. The modern Intensive Care Department was opened at the Surgical Clinic in 1995 and it was followed in other hospitals in the state. The Department of Anaesthesiology has existed since 1975, and it has made a huge contribution to the education of professionals who apply modern principles in emergency medicine and intensive care. CONCLUSION: From modest beginnings in the 1950s, anaesthesiology today in R. Macedonia has developed well organized activity that successfully follow the trends of modern medicine in the field of anesthesiology, resuscitation, intensive care and pain treatment.

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UNLABELLED: The great many hormones released by the endocrine cells of the glands and lining epithelium of gastric mucosa determine its significance for the processes in the gastrointestinal tract. One of these hormones, serotonin, plays an important role in the regulation of the motility, secretion and sensation in the gastrointestinal tract. The aim of the present study was to conduct immunohistochemical and electron microscopic studies of serotonin-producing EC cell of gastric mucosa. MATERIAL AND METHODS: Gastric mucosa biopsies were obtained and studied immunihistochemically for serotonin expression in the mucosa endocrine cells. Electron microscopic study was performed to specify the processes of synthesis, accumulation and release of secretory product by those cells. RESULTS: The immunohistochemical study revealed a considerable number of serotonin-containing EC cells scattered in the lining epithelium and between the glands in the corpus and pyloric region of the stomach. The electron microscopic study followed the stages of formation of the secretory granules from the initial accumulation of granular substance, its membrane packing and formation of mature granules to their disintegration in the secretory process. CONCLUSIONS: Serotonin as a neurotransmitter and gastrointestinal hormone appears to be a key to understanding a number of symptoms of gastrointestinal disorders like nausea, vomiting, pain, diarrhea and constipation. A detailed study of serotonin functions in the gastrointestinal tract realised through different types of receptors, and of the development of specific antagonists and agonists to these receptors would open up new opportunities for a more efficient treatment of gastrointestinal disorders.

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UNLABELLED: The gastrointestinal tract in the early prenatal development is an endoblastic mesenchyme-lined tube. The endoblast differentiates and gives origin to all epithelial structures (covering epithelium, glands). The mesenchyme develops into connective tissue, blood vessels, the smooth muscle cells of lamina muscularis mucosae and muscular tunic. Neuroectoblast cells participate in these processes--individual cells with future endocrine function, nerve cells and fibers that form nerve plexuses and vegetative ganglia. AIM OF THE PRESENT STUDY: To trace the changes in the small intestine development during the prenatal period in rat embryos and fetuses, and during the postnatal period in newborn rats. We specifically studied the beta-actin expression in the cytoskeletal structures of the covering epithelium and in the contractile elements of the differentiating smooth muscle cells. The presence and localization of the enteroendocrine EC cell was studied using the immunohistochemical expression of serotonin in them. MATERIAL AND METHODS: Material from rat embryos and fetuses aged 8-11, 12-15, 16-20 days of gestation and small intestine fragments from newborn rats was studied using routine hematoxylin-eosin staining, enzymohistochemically for succinate dehydrogenase and immunohistochemically for beta-actin and serotonin. RESULTS: In the early embryogenesis (8-11 day of gestation), the primitive gut of rat embryos is an endoblastic tube of 2-3 layers of cuboidal cells covered with a thin layer of mesenchyme. In the subsequent stages of embryonic and fetal development the processes of differentiation run at different rates in the different tissues. The maturation process in the small intestine wall of one-day-old newborn rats is incomplete. The mucosa presents with shallow crypts and loosely set villi. Differentiated resorptive and enteroendocrine EC cells are found in the lining epithelium. CONCLUSION: The changes we found in the beta-actin expression in the contractile elements of the differentiating smooth muscle cells and the cytoskeletal structures of the lining epithelium probably reflect the induction interference between the derivatives of the mesenchyme and endoblast.

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