Features of Ductular Reaction in Rats with Extrahepatic Cholestasis

Ductular reaction develops during liver regeneration, fibrosis, and carcinogenesis. However, the types, stages of formation, and topography of ductular profiles in various pathologies remain insufficiently studied. Using the model of common bile duct occlusion, we showed that the number and topography of ductular profiles are closely related to the duration of biliary obstruction. The ductular profiles can be located inside the portal tract, along the existing bile ducts, and/or intramurally, around the portal vein, periportally, inside the lobules, in the portocaval fibrous connections, in the adventitia of the hepatic veins, in the septs connecting the portal tracts, and also in the "portal plate" of the liver. The ductular profiles can be formed as a result of expansion of existing bile ducts, cholangiocyte proliferation, as well as transdifferentiation of hepatocytes and activation of mesenchymal stem cells.

Porta-caval fibrous connections — the lesser-known structure of intrahepatic connective-tissue framework: A unified view of liver extracellular matrix

Knowledge about the connective-tissue framework of the liver is not systematized, the terminology is inconsistent and some perspectives on the construction of the hepatic matrix components are contradictory. In addition, until the last two decades of the 20^th century, the connective-tissue sheaths of the portal tracts and the hepatic veins were considered to be independent from each other in the liver and that they do not make contact with each other. The results of the research carried out by Professor Shalva Toidze and his colleagues started in the 1970s in the Department of Operative Surgery and Topographic Anatomy at the Tbilisi State Medical Institute have changed this perception. In particular, Chanukvadze I showed that in some regions where they intersect with each other, the connective tissue sheaths of the large portal complexes and hepatic veins fuse. The areas of such fusion are called porta-caval fibrous connections (PCFCs). This opinion review aims to promote a systematic understanding of the hepatic connective-tissue skeleton and to demonstrate the hitherto underappreciated PCFC as a genuine structure with high biological and clinical significance. The components of the liver connective-tissue framework — the capsules, plates, sheaths, covers — are described, and their intercommunication is discussed. The analysis of the essence of the PCFC and a description of its various forms are provided. It is also mentioned that analogs of different forms of PCFC are found in different mammals.

Spatial architecture of biliary tree in mammals: Fractal and Euclidean geometric features

The study of the fractal architecture of various organs and structures expanded the possibilities for determining the ranges of their functioning and structural arrangement, which, as a result, was reflected in the development of new approaches to diagnostics and therapeutic impacts. The architecture of the excretory duct systems, similar to the hemo- and lymph- circulatory beds and the bronchial tree, is considered fractal. At the same time, information about hitherto unknown structures of the biliary tree continues to appear in the literature. We aimed to study the features of the spatial geometry of the biliary tree and assess the significance of both its fractal and Euclidean characteristics for the development of approaches that facilitate comprehensive description of intrahepatic biliary tract architecture. We investigated the architecture of the biliary trees of six men, seven male canines, and seven male Wistar rats using the corrosion casting method. Corrosion casts were prepared by injecting solidifying latexes into the bile ducts. The preparations were studied using a light stereomicroscope and a scanning electron microscope. Biliary tree branching is of various types. In addition, the correlation between variations in the caliber and length of the bile ducts and their order is not significant. Therefore, the biliary tree should not be considered as a classical fractal and it consists of the main modules, represented by the network of the bile canaliculi (first nonfractal module) and a biliary tree with a fractal branching (second module) that drains the bile canaliculi mesh and the additional modules represented by the mucosal biliary glands (in mammals with the gallbladder) or the periportal biliary plexus (in mammals without a gallbladder) and the aberrant biliary ducts. Such a configuration of the biliary bed should optimally ensure the smooth implementation of the physiological function of the liver, as well as its adaptation to different pathologies accompanied by biliary hypertension. It also might be considered in the diagnosis and assessment of ductular reaction, biliary regeneration, and/or carcinogenesis.

Spatial Organization of the Transport of Interstitial Fluid and Lymph in Rat Liver (Scanning Electron Microscopy of Injection Replicas)

Using the method of scanning electron microscopy of injection replicas, we studied the movement of a new injection mass between the blood microcirculation system, interstitial space, lymphatic system, and bile transport system in rat liver under normal conditions and 3 days after the occlusion of the common bile duct. The casts of the perisinusoidal spaces of Disse's after injection of the injection mass through the portal vein and common bile duct were obtained. Their direct transition not only in "leakages" structurally related to lymphatic capillaries in interlobular spaces, but also in perivascular spaces around the portal and hepatic veins. The flow of the injection mass through the perivascular spaces leads to the formation of peculiar "sheaths" around hepatic veins and components of the portal complex. The proposed approach allows effective visualization of the structural basis of interaction of various compartments of the fluid microcirculation in the liver under normal and pathological conditions.

STRUCTURAL CHANGES IN RATS' LIVER DURING THE FIRST 2 WEEKS FOLLOWING 2/3 PARTIAL HEPATECTOMY

Aim of study - Investigation of changes in hepatocyte size and shape and architecture of the sinusoidal network in 2-week dynamics after resection 2/3 of the liver. The experiments were performed on 16 adult male Wistar rats weighing 190-200 grams who underwent 2/3 resection of liver, while a resected portion of the liver of the same rat was considered as a control. We examined liver tissue by histological, immunohistochemical, morphometrical methods, and the architecture of the sinusoidal capillary network by electron microscopy of corrosion casts. The study was conducted in 24 hours, 48 hours, 96 hours, 1 week, and 2 weeks after surgery. The shape and size of the hepatocytes in the first and third zones of the liver acinus change with the term of the experiment. With changes in the shape and size of hepatocytes, new intercellular connections are formed, including with the involvement of atypical membrane protrusions of deformed neighboring hepatocytes. One week after regeneration, electron microscopic examination of corrosion casts reveals a network of sinusoids that spatially define lobules of different shapes and sizes, including those that appear to be a combination of two "normal" lobules. Superficial sinusoids are often markedly dilated (up to 25 μm). In addition, small-diameter (6-7μm) sinusoidal casts with a rough surface and small bud-shaped protrusions are observed in some areas, giving the line of this a zigzag shape. The existence of hepatic vein tributaries and associated with them large sinusoids, found In single areas, reveals the characteristic feature of vascular sprouting. Based on the data obtained, it can be assumed that despite the recovery of liver mass, the regeneration process is not complete. Regenerated liver undergoes a permanent process of transformation of hepatocytes' shape and size, as well as the transformation of the vascular network, which is the basis for changes in the spatial architecture of the liver lobules.

Challenges and perspectives of surgical treatment of liver failure. Current status and last achievements in Georgia

Liver transplantation is considered to be the last hope of treatment for irreversible liver failure caused by different diffuse and/or space-occupying lesions of this organ. The strict limitation of the donor organs stipulates for development of alternative approaches for the solving this problem. The presented review of literature and our experience aims to discuss the modern aspects of management of different hepatic pathologies causing liver failure with the view of creation of the auxiliary, bioengineer-based functional tissues and/or organs and innovative surgical interventions allowing to conduct the operations in cases, which were up to date considered as inoperable. There are highlighted the last achievements of the experimental and translational studies performed in four University research centers of Georgia, which, on the one hand, provoke the specific professional interest, and on the other hand, require the international cooperation and collaboration for further progress and advances in this field of surgery. KEY WORDS: Artificial liver, Bio-Artificial organs, Liver failure, Innovative surgery, Tissue engineering.

LIVER EXTRACELLULAR MATRIX PECULIARITIES IN MAMMALS AND AVIANS

Analysis of liver matrix studies makes it obvious that knowledge about the connective tissue skeleton of the liver is not systematized, the terminology is contradictory, and the question of the construction of some components sometimes causes controversy. We set a goal to study the features of the construction of the connective tissue matrix of the liver of various mammals and birds in order to identify and systematize general and specific patterns of this structure. The liver of mammals with a gallbladder (pigs, sheep) and without a gallbladder (rats) and birds (domestic chickens with a gallbladder) was studied by the methods of anatomical preparation, histology, histochemistry, histotopography, immunohistochemistry, scanning electron microscopy of corrosion replicas and fluorescence microscopy. In the liver of mammals and birds, connective tissue membranes of various thicknesses and compositions around the portal tracts and hepatic veins are revealed. These membranes are connected in various ways with each other, the liver capsule and the intralobular network of connective tissue and form an extracellular matrix, which strengthens the structure of the liver tissue and helps the organ maintain its integrity in various pathological conditions.

OVARIAN CANCER TREATMENT OPTIMIZATION: THE COMPLEX ANALYSIS OF THE RESULTS OF CYTOREDUCTIVE SURGERY, MICROSCOPIC MALIGNANCY AND T-LYMPHOCYTIC INFILTRATION OF THE TUMOR

The paper discusses 64 cases of ovarian cancer (observed in 2016-2019). Patients underwent cytoreductive surgery. Both Shimizu/Silverberg system and the "Two-tier" system were used to grade the tumor differentiation of serous carcinomas. The grade of the differentiation was specified by expression of oncoprotein p53. The tumor infiltrating lymphocytes (TILs) labeled with immunohistochemical markers - CD2, CD3, CD4, CD8 - were evaluated for the intensity of expression in both - the ovarian tumor parenchyma and stroma. Quantitative assessment of expression was performed by a computer program ImageJ. The survival of patients with ovarian cancer was examined by using the Kaplan-Meier curves and calculations of Cox Hazard Ratio (HR). Multiple regression analyses of factors influencing surgical intervention was performed by a logarithmic regression method. According to the obtained data, the carcinogenesis of high-grade and low-grade serous ovarian carcinoma is different: low-grade forms are always preceded by serous cystadenoma and/or serous cystadenofibroma, which progresses to borderline serous carcinomas and then to low-grade invasive carcinoma; high-grade serous carcinomas are not developed from the progression of low-grade invasive carcinomas and are the product of the de novo formation. p53 may be used as an additional molecular-biological feature for specifying the grade of microscopic malignancy of the tumor in the cases, when the moderate differentiation is established by Shimizu/Silverberg system. The antineoplastic and/or prognostic role of the tumor-infiltrating T lymphocytes is not fully evident and needs further investigation. High-grade (G3) of ovarian carcinoma and the neoadjuvant chemotherapy are the factors having a significant impact in defining the effectiveness of the surgical treatment of ovarian cancer.

RELATIONSHIP BETWEEN ORAL SQUAMOUS CELL CARCINOMA AND IMPLANTS (REVIEW)

In this review, we have discussed the relationships between oral squamous cell carcinoma (OSCC) and dental implants. In the last decade, dental implants have been widely used for the treatment of complete or partial edentulism. Despite the fact that they have seen incredible success and the use of dental implants increases, concerns over safety and efficiency is rising as well. The literature analysis has shown that the number of reported cases when the OSCC development is associated with peri implantitis is gradually increasing. The possibility of squamous cell carcinoma development must be considered when evaluating the peri-implantitis. We highly recommend periodic oral and radiographic examination after the implant placement. The patients with peri-implantitis that do not respond to conventional treatment methods, and the patients who have a severe or rapid progression of peri-implantitis require biopsy. The histopathological examination will aid with the differential diagnosis between peri-implantitis and OSCC, and hence, provide the correct diagnosis.

Papillary thyroid carcinoma in Struma Ovarii

Struma Ovarii is one of the types of mature teratoma, with predominant thyroid tissue (>50%). It occurs in 1% of all cases of ovarian tumors and in 2.7% of dermoid tumors. There are no specific clinical, radiological or serum markers for this rare pathology. Rarely it may be accompanied by ascites and the increased level of CA-125. In general Stuma Ovarii is clinically defined as an ovarian malignancy. It is diagnosed only by histopathological examination of the surgical material. Diagnosis of Struma Ovarii dictates the need for advanced research of the thyroid. Struma Ovarii is mostly benign. Its malignant transformation occurs in only 5% of all cases, That leads to further management planning analogous to the treatment of thyroid cancer. The case of malignant Struma Ovarii of the 50-year-old woman, which led to total thyroidectomy and radioactive iodine therapy - is described.

Liver structural transformation after partial hepatectomy and repeated partial hepatectomy in rats: A renewed view on liver regeneration

BACKGROUND

The phenomenon of liver regeneration after partial hepatectomy (PH) is still a subject of considerable interest due to the increasing frequency of half liver transplantation on the one hand, and on the other hand, new surgical approaches which allow removal of massive space-occupying hepatic tumors, which earlier was considered as inoperable. Interestingly, the mechanisms of liver regeneration are extensively studied after PH but less attention is paid to the architectonics of the regenerated organ. Because of this, the question “How does the structure of regenerated liver differ from normal, regular liver?” has not been fully answered yet. Furthermore, almost without any attention is left the liver's structural transformation after repeated hepatectomy (of the re-regenereted liver).

AIM

To compare the architectonics of the lobules and circulatory bed of normal, re-generated and re-regenerated livers.

METHODS

The livers of 40 adult, male, albino Wistar rats were studied. 14 rats were subjected to PH - the 1^st study group (SG1); 10 rats underwent repeated PH – the 2^nd study group (SG2); 16 rats were subjected to sham operation - control group (CG); The livers were studied after 9 months from PH, and after 6 months from repeated PH. Cytological (Schiff reaction for the determination of DNA concen-tration), histological (H&E, Masson trichrome, CK8 Immunohistochemical marker, transparent slides after Indian Ink injection, ), morphometrical (hepatocytes areas, perimeters and ploidy) and Electron Microscopical (Scanning Electron Microscopy of corrosion casts) methods were used.

RESULTS

In the SG1 and SG2, the area of hepatocytes and their perimeter are increased compared to the CG (P < 0.05). However, the areas and perimeters of the hepatocytes of the SG₁ and SG₂ groups reveal a lesser difference. In regenerated (SG₁) and re-regenerated (SG₂) livers, the hepatocytes form the remodeled lobules, which size (300-1200 µm) exceeds the sizes of the lobules from CG (300-600 µm). The remodeled lobules (especially the “mega-lobules” with the sizes 1000-1200 µm) contain the transformed meshworks of the sinusoids, the part of which is dilated asymmetrically. This meshwork might have originated from the several portal venules (interlobular and/or inlet). The boundaries between the adjacent lobules (including mega-lobules) are widened and filled by connective tissue fibers, which gives the liver parenchyma a nodular look. In SG₂ the unevenness of sinusoid diameters, as well as the boundaries between the lobules (including the mega-lobules) are more vividly expressed in comparison with SG₁. The liver tissue of both SG₁ and SG₂ is featured by the slightly expressed ductular reaction.

CONCLUSION

Regenerated and re-regenerated livers in comparison with normal liver contain hypertrophied hepatocytes with increased ploidy which together with transformed sinusoidal and biliary meshworks form the remodeled lobulli.

New corrosion cast media and its ability for SEM and light microscope investigation

SEM of corrosion casts (CC) provides the opportunities to study the vessels and ducts in the phyllogenetic and ontogenetic (age-related) settings, as well as the pathogenesis, compensation, and sanogenesis in different diseases and experimental models. Along with the refinement of SEM CC, the requirements toward casting media (CM) as nontoxicity, low viscosity, quick polymerization, resistance to corrosion solutions, availability, and so on, gradually has developed. We aimed to adapt the sets widely used in dental practice toward the modern requirements to the CC. The following ratio of the components of Protacryl-M and Aycryl-C sets were used for the preparation CM-0.25 g MAYCRYL Powder +0.08 g Benzoyl Peroxide +5.0 ml Protacryl-M liquid component +0.2 Redont Colour (dye concentrate). The obtained solidifying mass was injected in the blood vessels and biliary ducts of the adult Wistar white rats. The SEM of CC of different organs' vascular networks, as well as a biliary tract, reveals that offered CM excellently replicates the forms and branching features of studied tubular structures of all sizes and gives the adequate imprinting of their luminal surfaces. Besides, CM may provide the replication of perivascular spaces and give the casts having no analogous in the appropriate literature. The CM prepared by us perfectly reproduces all possibilities of famous rubbers widely used for the casting of different vascular-ductular structures. Besides, it presents the new implications, which should be implemented in the profound research of the connective-tissue skeleton of different organs.

MORPHOLOGICAL CHANGES IN THE LIVER AFTER 8 HOURS OF PRESERVATION BY MACHINE PERFUSION

Patients with refractory cardiac arrest, who have undergone Extracorporeal Life Support (ECLS) for resuscitation, but have not achieved cardiac recovery, can be considered as potential donors (Cardiac Death Donors). In such cases, it takes time to notify and obtain the principle consent of the relatives and finalize the clinical and legal documents. During this time, prior to obtaining consent for the removal of organs, ECLS can be extended. In this case, the extracorporeal circulation implies organ preservation "in situ" until the ethical, religious and organizational problems should be decided. Correspondingly, the identification of safe time terms during which the donor organs do not suffer by the changes not compatible with transplantation is extremely important. We aimed to study the morphological changes in the liver after 8 hours of extracorporeal circulation in experiments. The investigation was performed on 6 sheep with simulated cardiac arrest and undergone 8-hours extracorporeal circulation with own blood by using of new portable perfusion apparatus, made on the basis of a universal volumetric blood pump of our own design. The device was connected to the body through the femoral artery and vein with special cannulas. The biopsy of the liver was performed before the starting of perfusion, and on 4 and 8 hours of the experiment. The histological slices were stained by H&E and were assessed by standard criteria: level of steatosis (large-droplet macrovesicular steatosis [ld-MaS] and/or small-droplet macrovesicular steatosis [sd-MaS]); mononuclear portal inflammatory cell infiltrates; bile ductular proliferation; cholestasis; venous congestion; hepatocellular necrosis. Before the perfusion, no venous congestion, hepatocellular necrosis or ld-MaS were observed; Less than 3% of cells were suffered by sd-MaS; mononuclear portal inflammatory cell infiltrates were found only in several areas. Mild mixed ld-MaS and sd-MaS was found in less than 5 % and 10% of the cells accordingly on the 4 and 8 hours after in vivo Machine perfusion. Similarly the mild venous congestion was present in 1 out of 6 livers after 4-hours perfusion and in 2 out of 6 livers after 8-hours Perfusion. The number of necrotic hepatocytes and portal triads infiltrated with mononuclear cells did not exceed 10% and 15% accordingly. However, there were no differences in the degree of biliary damage - cholestasis or ductular proliferation - correlating with the terms of the experiment. Taking into the consideration all internationally accepted criteria of donor liver histological assessment, 8-hour in vivo perfusion of the liver in Cardiac Death Donors by using of the machine of own design providing the pulsatile blood flow guarantees the satisfactory preservation of liver making it useful for successful transplantation.

PERCEPTION OF ORAL PROBLEMS IN PATIENTS WITH ADVANCED CANCER

The results of the previous research, aimed to study the per-ception of and attitude to the end-of-life in the incurable cancer patients as well as the elderly aged 85 and older, revealed that independently from the cause of the life limitation, perceptions of and attitudes to the end-of-life are mainly similar. Moreover, it must be highlighted that the complaints on oral cavity were stated only by the single patients from the sample. We aimed to verify if the less attention from the sides of pa-tients towards the oral cavity symptoms/complaints were caused by the "poor" format of semi-structured interviews that were not focused on the oral status. The sample of the research included 50 advanced cancer pa-tients aged 20 to 75, under integrated palliative treatment (care). We applied for two-part questionnaire in the first part of which the patients had to choose one out of the alternative answers to the concrete questions related to oral cavity problems. The sec-ond part of the questionnaire was filled by the researcher/dentist based on the information obtained through examination of the patient's oral cavity. Based on the results of the data processing it was concluded that conditions recorded by a dentist were more severe and seri-ous in comparison to what the patients stated. Furthermore, it must be taken into consideration that the con-ditions and pathologies of oral cavity registered during our re-search are subject to improvement and treatment and, relevant-ly, their correct management has potential to improve the quality of life for incurable cancer patients.

ON THE TOPIC OF SURGICAL DEBULKING OF EPITHELIAL OVARIAN CANCER (REVIEW)

Surgical debulking is a relatively new and promising treatment for epithelial ovarian cancer. The aim of the study was to analyze current literature data to identify the best algorithms in order to promote the wider adoption of cytoreductive treatment based on the principles of evidence-based medicine. Such an analysis is important, since different studies contain contradictory results and their authors often point out the need for additional data to develop reliable recommendations. The review is based on articles published in journals indexed in PubMed, Web of Science (Clarivate Analytics) and Scopus, with an impact factor (IF)> 1, H-index> 50 and Q1 or Q2 category (according to Scimago Journal & Country Ranking). The data is classified according to the National Comprehensive Cancer Network (NCCN) principles.

DUCTULAR REACTION AT THE EARLY AND LATE STAGES OF BILIARY OBSTRUCTION: IS THE MECHANISM THE SAME?

Ductular reaction (DR) is one of the classical features of biliary obstruction in humans as well as in experimental models. It is the histological phenomenon expressed by the increased number of ductular profiles (DPs), which is especially intensively studied in rodents' model of common bile duct ligation (CBDL). However, some issues related with DR in long-term CBDL are not clear enough. The liver tissue of male Wistar rats (150-200 g) subjected to CBDL were studied histologically (H&E). The architectonics of the biliary tract was studied by investigation of the corrosion casts obtained by retrograde injection (trough CBD) the solidified mass prepared on the basis of "Protacryl M" widely implemented in orthopedic dentistry. The casts were investigated by electro-optic device ProScope-HR with magnification X10, X50 and X200. DR accompanying CBDO is featured by the development of new DPs, the number of which is permanently increased in association with the prolongation of the terms of Cholestasis. DPs continue to develop in all areas of liver lobules - from portal/periportal region up to the regions containing central veins (hepatic veins tributaries of small calibers). The part of DPs has wide lumens, while the lumens of another part of DPs are hardly notable. In spite of evident ductular metaplasia of hepatic tissue, the small groups of normal by form and structure hepatocytes forming the separate small islets could be revealed. Histological features of these hepatocytes support the proposition that these cells maintain the functional activity on the 4th-5th weeks after CBDO. The results of investigations of biliary corrosion casts on the 4th and 5th weeks of CBDO show that solidifying mass cannot reach the small ducts/ductules and especially bile canaliculi. This fact confirms the interruption of ductular-canalicular junctions (IDCJ). We propose that due to IDCJ the increased pressure in preserved bile canaliculi should stipulate the mitotic activity and biliary trans-differentiation of hepatocytes on the late terms of CBDO and support the generation of ductal-like structures and appearance of new DPs. These ductules generally are not drained into the entire biliary tree.

The Attitudes, Needs, and Requirements at End of Life in the Republic of Georgia (Comparative Analysis of Groups of Patients With Cancer and Elders)

INTRODUCTION

In developing a model of palliative care, the attitudes, needs, and requirements of its beneficiaries recognizing the limited remaining life expectancy need to be met. We aimed to map and compare these issues at the end of life in the groups of patients with advanced cancer and elderly individuals.

MATERIALS AND METHODS

The prospective study based on the analysis of semistructured interviews was conducted. Fifty individuals aged older than 85 and 50 incurable patients with advanced cancer were studied. Transcripts of interviews were analyzed qualitatively (the interviews were divided into logically completed themes, and the compliance of each with one of the levels of Abraham Maslow pyramid was determined) and quantitatively (data comparisons of 2 groups were tested in bivariate analysis using Pearson χ² or Fisher exact test. Two-sided significance tests were used; P value of <.05 was deemed significant).

RESULTS

It was assumed that 120 themes were relevant to a certain level of Maslow pyramid. Their comparison showed small differences in the narratives of the patients with advanced cancer and elderly individuals aged 85 and older-concerning the past, present, and future terms of lives. In studied themes explicitly prevail the stories that are consistent with satisfaction of the upper levels of the hierarchy of needs and demands of Maslow: social relation (belonging), love, esteem, and transcendence.

CONCLUSION

The attitudes, needs, and requirements at the end of life of the people are basically similar, regardless of what determined the sense of limitation of the remaining life-incurable disease or advanced age.

Impact of Ambiguous and Restrictive Regulations on Opioid-Prescribing Practice in Georgia

CONTEXT

Chronic pain management with opioids in incurable patients remains a challenge of modern medicine regardless of the evidence-based effectiveness of opioids and recommendations of authorities such as the World Health Organization and International Narcotics Control Board. Many countries, including Georgia, maintain overly restrictive regulations that contribute to inadequate pain management.

OBJECTIVE

To identify barriers to pain management in Georgia caused by legislation, administrative issues, and physicians' lack of knowledge and understanding of legislative aspects governing opioid use, and their impact on opioid-prescribing practice.

METHODS

We conducted a survey among 550 primary health care physicians. In total, 302 physicians completed the questionnaire. Overall, 289 questionnaires were analyzed statistically with SPSS version 20 (Armonk, NY: IBM Corp.).

RESULTS

We found that 38% of the physicians avoid prescribing opioids and only one-third of the physicians make an independent decision to treat the patients with opioids. About one-third of the physicians know the updated liberalized legislation and even fewer follow it. Those who apply more liberal legislation and have better medical practice are investigated three to five times more by legal authorities for prescribing morphine to incurable patients than those who do not.

CONCLUSION

Ambiguous legislation negatively influences opioid-prescribing practice. Most of the physicians believe that the legislation is restrictive. Physicians who have better medical and legal knowledge and understanding are controlled and investigated more because of their opioid-prescribing practice. Physicians who are concerned that they might be investigated are less inclined to prescribe opioids or use liberalized regulations.

The Contribution of the International Pain Policy Fellowship in Improving Opioid Availability in Georgia

In the Republic of Georgia, the incidence and prevalence of cancer are increasing, signifying a growing need for palliative care and pain relief, including with controlled opioid medicines. As a signatory to the Single Convention, the Georgian government has a responsibility to ensure the adequate availability of controlled medicines for medical purposes; however, the consumption of morphine is very low, suggesting a high occurrence of unrelieved pain. In Georgia, palliative care development began in the 2000s including the adoption of a policy document in 2005, the creation of the National Palliative Care Coordinator in 2006, and important changes in Georgian legislation in 2007 and 2008, which served to lay a foundation for improving opioid availability. In 2008, a neurologist from the Sarajishvili Institute of Neurology and Neurosurgery in Tbilisi, and member of the Georgia National Association for Palliative Care, was selected to be an International Pain Policy Fellow to focus on improving opioid availability. Working with colleagues, government officials, and international experts, the Fellow contributed to several improvements to opioid availability, such as 1) positive changes to opioid prescribing legislation, 2) clarification of legislative terminology regarding dependence syndrome, 3) initiating the importation of both sustained-release and immediate-release oral morphine, and 4) improvements in the availability of sustained-release morphine. Despite these varied achievements, morphine consumption remains low in Georgia relative to the estimated amounts needed. The Fellow is continuing to study and understand the barriers that are impeding physician's prescription of opioids and patient's acceptance of them.

INFLUENCE OF TESTOSTERONE ON MORPHOLOGICAL CHANGES IN PANCREATIC ISLETS AND LIVER TISSUE OF RATS WITH ALLOXAN-INDUCED DIABETES

The role of exogenous testosterone (methyltrienolone) in the repair of damaged pancreatic islet and liver cells during alloxan diabetes was studied. Modeling of diabetes was performed through single intraperitoneal injection of Alloxan, with the dose 2 mg per 10 g of body weight. Pancreatic and liver tissues were investigated microscopically using 3-4 µm slices embedded in paraffin and stained with hematoxylin and eosin. Software Adobe Photoshop was used to measure the areas of pancreatic islets as well as areas of necrotic foci in these islets of animals with Alloxan-induced experimental diabetes. The degree of liver damage was assessed by a 5-score "visual scale". The animals with diabetes revealed degenerative changes of pancreatic islets and liver tissue, the intensity of which correlates with the time-period passed since diabetic modeling. These changes correspond to the metabolic abnormalities described for various experimental models or clinical cases of diabetes. The study revealed that treatment of Alloxan-induced diabetes with testosterone (methyltrienolone) restores not only the biochemical disorders (as previously described) but also supports to reverse the pathological changes in pancreatic and liver tissues.

Hepatitis C virus seroprevalence in the general female population of 9 countries in Europe, Asia and Africa

BACKGROUND

New oral treatments with very high cure rates have the potential to revolutionize global management of hepatitis C virus (HCV), but population-based data on HCV infection are missing in many low and middle-income countries (LMIC).

METHODS

Between 2004 and 2009, dried blood spots were collected from age-stratified female population samples of 9 countries: China, Mongolia, Poland, Guinea, Nepal, Pakistan, Algeria, Georgia and Iran. HCV antibodies were detected by a multiplex serology assay using bead-based technology.

RESULTS

Crude HCV prevalence ranged from 17.4% in Mongolia to 0.0% in Iran. In a pooled model adjusted by age and country, in which associations with risk factors were not statistically heterogeneous across countries, the only significant determinants of HCV positivity were age (prevalence ratio for ≥45 versus <35 years = 2.84, 95%CI 2.18-3.71) and parity (parous versus nulliparous = 1.73, 95%CI 1.02-2.93). Statistically significant increases in HCV positivity by age, but not parity, were seen in each of the three countries with the highest number of HCV infections: Mongolia, Pakistan, China. There were no associations with sexual partners nor HPV infection. HCV prevalence in women aged ≥45 years correlated well with recent estimates of female HCV-related liver cancer incidence, with the slight exception of Pakistan, which showed a higher HCV prevalence (5.2%) than expected.

CONCLUSIONS

HCV prevalence varies enormously in women worldwide. Medical interventions/hospitalizations linked to childbirth may have represented a route of HCV transmission, but not sexual intercourse. Combining dried blood spot collection with high-throughput HCV assays can facilitate seroepidemiological studies in LMIC where data is otherwise scarce.

Mismatch between physicians and family members views on communications about patients with chronic incurable diseases receiving care in critical and intensive care settings in Georgia: a quantitative observational survey

BACKGROUND

Physicians working in critical and intensive care settings encounter death of chronic incurable patients on a daily basis; however they have scant skills on how to communicate with the patients and their family members. The aim of the present survey is to examine communication of critical and intensive care physicians with patients' family members receiving treatment due to chronic incurable diseases/conditions and to compare the views of families with physicians working in critical and intensive care settings.

METHODS

The survey was conducted in four cities of Georgia (Tbilisi, Kutaisi, Batumi and Telavi) in 2014. Physicians working in critical and intensive care settings and family members were asked to fill in separate questionnaires, covering various aspects of communication including patients' prognosis, ways of death occurrence, treatment plans and religion. Participants ranked their responses on a scale ranging from "0" to "10", where "0" represented "never" and "10"-"always". After data collection, responses were recoded into three categories: 0-3 = never/rarely, 4-7 = somewhat and 8-10 = often/always. Differences were tested using Pearson's chi-square or Fisher's exact test as appropriate. P value of < 0.05 was considered as significant.

RESULTS

Sixty-five physicians and 59 patients' family members participated in this cross-sectional study. Majority of their responses was statistically significantly different. Only one quarter (23.7 %) of family members of patients receiving medical aid in critical and intensive care settings were satisfied with the communication level. In contrast, 78.5 % of physicians considered their communication with families as positive (p < 0.0001).

CONCLUSIONS

The survey revealed the mismatch between the views on communication of critical and intensive care settings physicians and family members of the patients with chronic incurable diseases receiving care in critical and intensive care settings. In order to provide the best care for chronic incurable patients and their family members, physicians working in critical and intensive care settings must have relevant clinical knowledge and ability to provide effective communication. Present results reflect important potential targets for educational interventions including critical and intensive care physicians training through online modules.

BILIARY ATRESIA: CURRENT CONCEPTS AND FUTURE PROSPECTS (REVIEW)

Treatment of biliary atresia is a major challenge in pediatric surgery. Early diagnosis and availability of Kasai procedure with its modern modifications improve outcome of biliary atresia treatment. But Kasai procedure does not fully restore anatomical integrity of biliary tract, because Oddi sphincter is not included in reconstructed system. Constant reflux of intestinal content into the biliary tree is a cause of recurrent cholangitis and change in biliary epithelium that, which is a predisposing factor for cholangiocarcinoma. Various methods have been developed to improve Kasai procedure and prevent the reflux (anti-reflux valve, different enteric conduits, etc.). Many authors used biological grafts made from artery, vein, appendix, urether as well as synthetic materials to restore hepaticocholedochus. Although, neither of these methods were implemented in clinical practice. Nowadays, huge attention is paid to organ and tissue bioengineering. Present advances of tissue bioengineering may assist to create bile duct equivalent, which can be used to restore biliary tract in patients with biliary atresia.

[THEORETICAL BACKGROUND OF FINDING ORGANS FOR TRANSPLANTATION AMONG NON-HEART BEATING DONORS UNDER UNSUCCESSFUL EXTRACORPOREAL RESUSCITATION (LITERATURE REVIEW)]

The number of patients who are in the "Transplant Waiting List" is increasing each year. At the same time, as a result of the significant shortage of donor organs, part of the patients dies without waiting till surgery. According to the Maastricht classification for non-heart beating donors, the patients, who had cardiac arrest outside the hospital (in the uncontrolled by medical staff conditions) should be considered as a potential donors of category II. For these patients, the most effective resuscitation is recommended. The extracorporeal life support (ECLS) considers the connection to a special artificial perfusion system for the restoration of blood circulation out-of-hospital with further transportation to the hospital. If restoration of independent cardiac activity does not occur, in spite of the full range of resuscitative measures, these patients may be regarded as potential donors. The final decision should be received in the hospital, by the council of physicians, lawyers and patient's family members. Until the final decision, the prolongation of ECLS and maintaining adequate systemic and organic circulation is recommended.