We report a patient with a verrucous keratotic variant of melanoma visiting the policlinic of Medical Institute of Ministry of Interior (MVR-Sofia), Department of Dermatology and Dermatologic surgery, with a keratotic verrucous lesion, located on the right thigh, partially deeply pigmented at upper right quadrant. The lesion had appeared three years ago before her presentation in the policlinic, and it had gradually enlarged and become darker in the last twelve months. The surface of the lesion was covered with thick hyperkeratotic lobules. The histologic evaluation revealed verrucous melanoma with a tumour thickness of 3 mm and Clark Level IV and focal ulceration. The tumour was staged as stage IIB (T3bN0M0). Sentinel lymph node biopsy was planned. Verrucous-keratotic forms of malignant melanoma occur more commonly in women and favour the extremities, but may be found on any anatomic site. Seventy-one percent of this melanoma type are situated on the upper and lower extremities. Although two-thirds of these neoplasms can be can be histologically graded according to the classification of Clark, one-third of these melanomas with marked verrucous hyperplasia and hyperkeratosis of the epidermis do not fit into his classification. Histological classification of patients with a verrucous keratotic type of melanoma may sometimes be extremely difficult. The marked papilliferous architecture of these lesions made an assessment of Breslow depth difficult. The presented case highlights the clinical existence and features of such benign-looking melanomas. It is therefore important for surgical pathologists to recognise this unusual variant of malignant melanoma, as it may be confused both clinically and pathologically with benign lesions.

Objective: to evaluate the effect of golimumab (GLM) on the receptor activator of NF-κB ligand (RANKL)/osteoprotegerin (OPG) transmembrane molecular system and arterial stiffness in patients with rheumatoid arthritis (RA).Subjects and methods. Thirty-six patients with RA were examined and randomized into 2 groups based on disease duration (less than or more than 2 years). The serum levels of OPG, and RANKL, were investigated. Dual-energy X-ray absorptiometry and pulse wave contour analysis were performed before and 52 weeks after GLM treatment.Results and discussion. Group 1 patients demonstrated increased serum OPG levels that were on average 3.6 times higher than in the controls (р=0.005) and 2.1 times higher than in Group 2 (р=0.01). In Group 2 patients, the RANKL concentration was 9-fold higher than that in the controls (p=0.001) and 30.6% higher than in Group 1 (p=0.01). The examinees were found to be diagnosed with subclinical damage to the great arteries (increases in augmentation index (AIp), stiffness index (SI), and reflection (RI) index), which progressed with a longer RA duration. After GLM treatment, serum OPG and RANKL levels decreased in Group 1 patients by 2.1- (p<0.001) and 1.7-fold (p<0.01), respectively. In Group 2, the level of RANKL dropped by 32.2% (p<0.01), without significant OPG concentration changes. After GLM treatment, the pulse wave contour analysis parameters in Group 1 did not differ from those in the controls; Group 2 showed significant decreases in AIp by an average of 1.8 times (p<0.01), in SI by 1.2 times (p<0.01), and in RI by 1.6 times (p<0.01).Conclusion. GLM treatment in RA patients is accompanied by a lower imbalance in the RANKL/OPG transmembrane molecular system and exerts a vasoprotective effect on the large elastic vessels (reductions in AIp and SI) and small muscular arteries (a decrease in RI).

Optimization of joint syndrome treatment methods, including those based on the intra- and periarticular drug administration and invasive diagnostic techniques, remains high on the agenda of modern clinical rheumatology. The implementation and quite widely spread use of ultrasonographic visualization has been an impetus to the development of this type of treatment for joint diseases. Without any doubt, the quality of intraarticular injection performance mainly depends on the professional level of the specialist and his/hers procedural skills. However, here comes a predictable question: are these conditions sufficient to enable maximal precision, safety, and efficacy of intraarticular interventions? From this perspective, it is interesting to study the possibilities to improve the results of local treatments for the joint syndrome by means of the ultrasound navigation technique. Based on data presented in the literature review, we compared a “blind” invasive treatment method to the ultrasound navigation-guided intra- and periarticular interventions in patients with skeletomuscular and connective tissue disorders. The authors of the studies published point to higher safety, efficacy, procedure precision, and diagnostic quality of the information obtained by the ultrasound navigation. Its important advantages include wider possibilities and availability of this method in outpatient settings, due to its rather low costs and patients' safety. The information from the current literature review reflects an initial stage of studies on the evaluation of the role, significance, determination of potential of the ultrasound navigation to enhance the quality of diagnosis and invasive treatment in patients with joint syndromes of various origins and to minimize adverse effects.

Objective: to evaluate the effect of golimumab (GLM) on endothelial vasomotor function and arterial stiffness in patients with ankylosing spondylitis (AS).Subjects and methods. A total of 42 patients with advanced-stage AS, who were older than 18 years and met the 1984 modified New York criteria with a disease duration of ≤5 years, were examined. The investigators visualized carotid arteries to determine local vascular wall stiffness, studied regional arterial stiffness to assess a pulse wave contour analysis, and a reactive hyperemia test before and after 104-week therapy.Results and discussion. RA patients without cardiovascular comorbidity were found to have signs of subclinical great artery involvement accompanied by endothelial vasoregulatory dysfunction in both the small resistance and large muscular arteries; by increases in common carotid artery (CCA) intima-media thickness (IMT) and stiffness index (SI); by rises in peripheral augmentation index (AIp), SI and reflection index (RI), the intensity of a change in which correlated with disease duration and activity assessed by ASDAS; as well as with the modified Schober test value, cervical rotation, and tragus-to-wall distance. In addition to a decrease in the Ankylosing Spondylitis Disease Activity Score (ASDAS), GML treatment in patients with AS caused a statistically significant increase in the amplitude occlusion index to the control values and a rise in the phase shift between the channels by an average of 2 times (p<0.01) as compared to the baseline values; a decrease in CCA IMT by an average by 20% (p=0.01) and in the local stiffness of the (carotid) vascular bed by 31% (p=0.01). The pulse wave contour analysis after 104-week GLM therapy revealed that AIp, SI and RI decreased by an average of 5 (р<0.001), 1.3 (р<0.01), and 2 (p<0.05) times, respectively, with the remaining statistically significant differences from the control values.Conclusion. In addition to the effectively reduced inflammatory activity, GLM therapy in patients with AS provides restoration of endothelial function in both the small resistance vessels (an increase in the amplitude occlusion index) and the large muscular arteries (a rise in the phase shift between the channels) and also has a vasoprotective effect on the wall of large elastic vessels (reductions in CCA IMT, SI, AIp, and SI) and small muscular arteries (a decrease in RI).