• No results found

Incidental appendiceal mucinous neoplasm mimicking a left adnexal mass: A case report

N/A
N/A
Protected

Academic year: 2021

Share "Incidental appendiceal mucinous neoplasm mimicking a left adnexal mass: A case report"

Copied!
4
0
0

Full text

(1)

CASE

REPORT

OPEN

ACCESS

InternationalJournalofSurgeryCaseReports74(2020)132–135

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

jo u r n al ho me p a g e :w w w . c a s e r e p o r t s . c o m

Incidental

appendiceal

mucinous

neoplasm

mimicking

a

left

adnexal

mass:

A

case

report

Ammar

Aleter

a

,

Walid

El

Ansari

b,c,d,∗ aDepartmentofGeneralSurgery,HamadGeneralHospital,Doha,Qatar bDepartmentofSurgery,HamadGeneralHospital,Doha,Qatar cCollegeofMedicine,QatarUniversity,Doha,Qatar

dSchoolofHealthandEducation,UniversityofSk¨ovde,Sk¨ovde,Sweden

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received1July2020

Receivedinrevisedform30July2020 Accepted30July2020

Availableonline12August2020

Keywords:

Appendicealmucinousneoplasm Appendix

Mucocele

Mimickingovariantumor Misdiagnose

Casereport

Pelvicultrasonography

a

b

s

t

r

a

c

t

INTRODUCTION:Appendicealmucinousneoplasmisararetypeofappendicealtumorswhichcanpresent

inavarietyofsymptomsandisdifficulttodiagnose.Preoperativediagnosisdependsmainlyondiagnostic

imagingsuchasultrasonographyandcomputerizedtomography(CT)scan.Thisuncommoncasereport

discussesanappendicealmucinousneoplasmmimickingaleftadnexalmassonpresentation,physical

examinationanddiagnosticimagingfindings.

PRESENTATIONOFCASE:Thisisa61-year-oldfemalefoundtohavealargeleftadnexalmassduringfollow

upultrasonography.Thepatientrefusedfurtherimaging,andduringlaparotomy,shewasfoundtohave

anappendicularmucocelewithnormalleftandrightovaries.

DISCUSSION:Appendectomywasdoneandthefinalpathologycameasappendicealmucinousneoplasm.

Herpost-operativecourseand3yearsfollowupwereuneventful.

CONCLUSIONS:Theequivocalsignsandsymptomsalongwiththeanatomicalpositionofappendiceal

mucocelemakesitdifficulttodiagnoseandcanmimicothertypesoftumors.Therefore,itshouldbe

consideredinthedeferentialdiagnosisoflowerabdominalandpelvicmasses.

©2020TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen

accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Appendicealmucoceledescribestheprogressivedilatationof thevermiformappendixduetoabnormalmucusaccumulationin thelumen[1].Mucusisretainedasaresultoflumenobstruction orhyperproductiondue tobenign(fecaliths,postinflammatory fibrosis,hyperplasticpolyps,serratedadenomas)ormalignant(low orhigh-gradeappendicealmucinousneoplasm,carcinoidtumors, mucinousadenocarcinomas)pathologies[2].Appendiceal muco-celesformedduetoappendicealmucinousneoplasms(AMNs)are exceptionallyrare,withanincidenceof0.12casesper1million individualsperyear[3,4].

AMNsareoccasionallyfoundincidentally,duringfollowupor atthetimeofsurgeryforothercauses,andfrequentlydiagnosed inthelatestages[5].ThesymptomsofAMNvarysignificantly,and itisasymptomaticin25%ofcases[6].Hence,awiderangeof dif-ferentialdiagnosesshouldbeconsidered,toincludeappendicitis, mesentericorduplicationcyst,oradnexalmass[7].

∗ Correspondingauthorat:DepartmentofGeneralSurgery,HamadGeneral Hos-pital,Doha,Qatar.

E-mailaddress:welansari9@gmail.com(W.ElAnsari).

Inthecurrentcasereport,wepresentanincidentalappendiceal mucinousneoplasmmimickingaleftadnexalmass.Weusethe AmericanJointCommitteeonCancer(AJCC)8thedition[8]forthe classification,prognosisandtreatmentofAMNs,andthecaseis reportedinlinewiththeupdatedconsensus-basedsurgicalcase report(SCARE)guidelines[9].

2. Casepresentation

A61yearoldJordanianfemalewasreferredtotheobstetricsand gynecologyclinicatourinstitutionfromhealthcenterdueto sus-pectedlargeleftovarianmassdiscoveredbypelvicultrasound(US). Thepatientwaspostmenopausal(gravida7,para6,1abortion).Her lastchildbirthwas25yearsbackandpasthistoryrevealedthatshe underwenthysteroscopyandpolypectomyofanendometrialpolyp 3yearsago.Thenewlydiscoveredmasswasfoundduringher reg-ularfollowup.Uponthisincidentalfinding,thepatientwasnot complainingofanygynecologicalsymptoms.Shewasmenopausal since20years,withnocomplaintsofabdominalpainormass, vagi-nalbleedingordischarge,orweightorappetitelossduringthepast months.Therewerenoothergastrointestinalorurologic symp-toms,andtherestofhersystemicexaminationwasunremarkable. Herfamilyhistorywasnegativeforgynecologicalor gastroenterol-ogycancers,but thepatienthad comorbiditiesincludingtype2

https://doi.org/10.1016/j.ijscr.2020.07.081

2210-2612/©2020TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

(2)

CASE

REPORT

OPEN

ACCESS

A.Aleter,W.ElAnsari/InternationalJournalofSurgeryCaseReports74(2020)132–135 133

Fig.1. Pelvicultrasoundshowinglargeleftadnexalmass:rightovarycouldnotbe seenattimeofscanduetooverlyingbowelgas.

Fig.2.Pelvicultrasoundshowinglargeleftadnexalmass(10.0×4.2cm)with cal-cifications.

diabetesmellitus,hypertensionandhyperlipidemiawhichwere controlledbyoralmedications.

Examinationofthepatientrevealedthatshewasvitally sta-blewithunremarkableabdominalorgynecologicalfindings,and nomasscouldbepalpatedinthelowerabdomen.Investigations showedthatherlaboratorytestswereunremarkableexceptfor irondeficiencyanemiaand mildlyelevatedcancerantigen19-9 (CA19-9)(40U/mL).Othertumormarkersforovarianandother solidintraperitonealorganswerewithinthenormalrange:cancer antigen125(CA125),cancerantigen15-3(CA15-3)and alpha-fetoprotein(AFP)were9U/mL,13U/mLand2Ng/mLrespectively. HerpelvicUS(Figs.1and2)showedlargeleftadnexalovalshaped heterogeneoussolidmasslesion(10.4×4cm),containingareasof calcification,andtheleftovarycouldnotbeseen.Boththeright ovary(2.9×2cm)andtheuteruswereunremarkable.Nofreefluid wasfoundinthepelvis.ThepatientwasreferredforMRIabdomen andpelvis,butsherefusedtoproceedwithanyfurtherimaging. Theconditionwasdiscussedthoroughlywiththepatientanddue toahighsuspicionofovarianmalignancy,thedecisionwasmade toproceedwithsurgery.Wedidnotstartwithlaparoscopydue tolargetumorsize(10.4×4cm),asexploringthepelvicregion, resectingthetumoranddeliveringitwouldhavebeenvery dif-ficultandcouldexposethepatienttofurthercomplications.The patientwaspostedforexploratorylaparotomywithorwithout totalabdominalhysterectomywithsalpingo-oophorectomy.

Duringlowermidlinelaparotomybyanexperiencedsurgeon andafterfullinspectionofthepelvicorgansincludingrightandleft adnexaalongwiththeuterusandsigmoidcolon,thepatientwas unexpectedlyfoundtohavealargeappendicealmassatthe ter-minalportionofherappendixapproximately15cm(long)×5cm (wide).Theappendixwasintactwithnospillageorperforation, andnoperitonealnoduleswerefound(Fig.3).Theuterusandboth ovarieswerenormal.Appendectomywithexcisionalbiopsyofthe

Fig.3.Appendicularmucocelepostresection:appendixwasremovedintact with-outspillage.Arrowpointstosurgicalknotneartheproximalresectionmarginwhich wasfoundtobefreeofmalignancy.

Fig.4. Villousandflatproliferationofmucinousepithelialcellsliningthe appen-dicealmucosainLAMN,HX&E,x4.

Fig.5.Flatproliferationofmucinousepithelialcellswithlowgradenuclearatypia inLAMN,HX&E,x20.

omentumthatwasattachedtotheappendixwashenceperformed. Thepost-operativeperiodwasunremarkable,withnocomplaints orcomplications,thepatientwasstablevitallyandstarteddieton day1.Shewasfollowedforthenext2daysthendischarged.

Herhistopathologyresultsindicatedadiagnosisoflowgrade appendicealmucinousneoplasm(LAMN,17×3cm).Figs.4–6show villousandflatproliferationofmucinousepithelialcellsliningthe appendicealmucosawithlowgradenuclearatypia.Theacellular

(3)

CASE

REPORT

OPEN

ACCESS

134 A.Aleter,W.ElAnsari/InternationalJournalofSurgeryCaseReports74(2020)132–135

Fig.6. AcellularmucindissectthemuscularispropriaoftheappendixinLAMN, HX&E,x10.

mucinouscellshadinvadedintothemuscularispropria,the proxi-malandmesentericmarginswereuninvolvedbytumor,andthere werenoidentifiabletumordeposits,lymphovascularorperineural invasion.Nolymphnodeswherefoundinthesubmittedspecimen andthepathologicalclassificationwaspT2,pNx[10].Staging com-puterizedtomography(CT)scanofthechestandabdomeninorder todetectanydistantmetastasiswerenegative.Thepatientwas referredand discussedatourgastro-intestinalmultidisciplinary (MDT)meeting,andtheplanwastofollowherupintheGeneral surgeryoutpatientclinicwithnoneedforfurtherinterventionor completionsurgery.Thepatientwasfollowedforthenext3years withnosignsofrecurrence.Shewassatisfiedwiththeoutcome. 3. Discussion

AMNis a very raredisease withheterogeneousclinical fea-tures[11]. Tothebestofourknowledge,thecurrentcasecould bethesecondcasereporteddescribinganAMNmimickingaleft ovarian tumor,the first beingfrom United States [12], despite thatmanycasereportsdescribedAMNmimickingarightovarian tumor[13,14]. Accurate preoperative diagnosis of AMNis usu-allydifficultdue to itsdiverseclinical features, lackof specific tumorbiomarkers, and susceptibilityof appendiceal neoplasms toinvolve/ metastasizetotheovarieshencemimicking ovarian tumors[11,15].

Intermsofdemographics,thecurrentpatientwasafemaleaged 61years, inagreementwithotherreports suggestingthat AMN tendstohaveaslightfemaleprevalenceandistypicallyfoundin patientsintheir5thand6thdecades;although,itmayoccuratany age[6,16].

As for presentation, the possible symptoms of appendiceal mucocelerangefromlowerabdominalorpelvicpain,fever, nau-sea,andvomitingtoasymptomaticpresentation[16,17].Ourcase representsaclassicexampleofthelackofsymptomsanddifficulty indiagnosisasthepatientwasactuallyasymptomaticandthemass wasfoundincidentallyduringroutineUSfollowup.

Intermsofimaging,diagnosisofappendicealmucoceleoften dependsondiagnosticimaging, anda main featurethat distin-guishesappendicealmucocelefromuncomplicatedappendicitisby USisthelackofappendicealwallthickeningof>6mm[18,19].We wereunabletoconfirmthepresenceorabsenceofappendiceal wallthickeningastheappendixcouldnotbeseparatelyidentified inrightiliacfossaduetoobscuringbowelgasandlargepelvicmass. SeveralUSappearancesspecificforappendicealmucocelemight beencounterede.g.abottle-likeshapedsolidappendicularmass slidingovertheuterusandovaries[19,20]orthehighlyspecific “onionskinsign”(concentricechogeniclayerswithseptaandfine

echoes)[21,22]canhelptodistinguishappendicealmucocelefrom anovariancyst.Unfortunately,suchdiagnosticappearanceswere notevidentintheUSweundertook.Otherssuggestedthatthe pres-enceoftheonionskinsignwithinacysticmassintherightlower abdominalquadrant,withanormalrightovary,couldbespecific forthediagnosisofappendicealmucocele[22].

Colonoscopy,MRI,andcomputedtomography(CT)areall valu-ableinvestigationsthatcanaidinreachinganaccuratediagnosis [23].Colonoscopicfindingse.g.“volcanosign”(appendicealorifice seeninthecenterofa firmmoundcoveredbynormal mucosa) and a bulbous submucosal lesion of the cecum, establish pre-cisediagnosisand areusefulfor themanagement [24].In MRI, appendicealmucocelelesionsarewellencapsulatedcysticmasses, hyperintenseonT2-weightedsequences,andhypo-orisointense onT1-weightedsequences[25].ThetypicalCTappearanceofan appendicealmucoceleisalargeandwell-encapsulatedcysticmass intheexpectedregionoftheappendix;calcificationsofthecyst wallareveryspecifictoappendicealmucoceleandarevaluable tocharacterizethemucocelefromanabscesscollection[25,26]. AlthoughCTisconsideredthemostinformativeimagingtechnique, thediagnosisismoredifficultintheabsenceofcysticcalcifications andfailuretoidentifytheorganoforigin[27].Unfortunately,the currentpatientrefusedtoprovideconsenttoproceedwithany fur-therimaging (eitherCT abdomenorMRIabdomen)asasecond modalityofdiagnosis.

Althoughalltheimaging techniquesand related signs high-lightedabovecanhelptodifferentiateanappendicealmucocele fromprimaryovariantumors,aprimaryAMNisrarelydiagnosed beforeoperationand histopathologicalexaminationwhen com-paredwithothermorefrequenttypesofappendicealorcolonic tumors[15].Hence,recentviewsadvocateconsideringAMNinthe differentialdiagnosisofanypelvicmassinelderlyfemalepatients, andnottorelymainlyonpreoperativeimagingtools[13–15].

Inourcase, thepre-operativemisdiagnosiswaspossiblydue to:a)thespecific‘onionskin’signwasnotevidentonUS;and,b) althoughcalcificationswithinthemassandthewallwerepresent, therightovarywasnotrecognizedduetoobscuringbowelgas,and themasswasmimickingaleftadnexalmass(Fig.2).Findingofa largeleftadnexalmassoccupyingthepelvicregionusuallyprompts additionaldiagnosticimagingtofurtheroutlinetheanatomybefore intervention,butthepatientrefusedfurtherMRIimaging.Others havereportedamisdiagnosedovarianmassduringpreoperative evaluationwhichturnedouttobeappendicealmucoceleduring surgicalexploration,andattributesuchmisdiagnosistothe mim-ickingsymptoms, nearbysurgicalanatomy and invasion ofthe neoplasmtothesurroundingovariesanduterus[13].

Asfortheprocedure,upondirectvisualizationofthelesionat thetimeofsurgery,thesurgeonrecognizedthispathologicalentity andperformedasimpleappendicectomythatwasneeded,andthe patientwasreferred forlongtermfollow-upafterdiscussionat ourgastrointestinalMDTmeeting.Thepatientwasrecentlyseen attheclinicafter3yearsoffollowupand wasrecurrence-free, usingtumormarkers(noelevation),colonoscopy,andimaging.

4. Conclusions

Thesymptomsofappendicealmucocelevarysignificantlyand arerelativelysimilartoovariantumors.Thesesimilarsignsand symptoms,alongwiththeanatomicalpositionoftheappendiceal mucocele,rendersitdifficulttodiagnoseappendicealmucoceleas itcanmimicothertypesoftumors,particularlyovariantumors. Althoughmultiplediagnosticimagingtechniquescanaidin reach-inganaccuratediagnosis,aprimaryAMNisrarelydiagnosedbefore operationandhistopathologicalexamination.Hence,high

(4)

suspi-CASE

REPORT

OPEN

ACCESS

A.Aleter,W.ElAnsari/InternationalJournalofSurgeryCaseReports74(2020)132–135 135 cionisrequired,andrecentviewsadvocateconsideringAMNinthe

differentialdiagnosisforanypelvicmassinelderlyfemalepatients.

DeclarationofCompetingInterest

Theauthorsreportnodeclarationsofinterest.

Sourcesoffunding

Nothingtodeclare.

Ethicalapproval

ApprovedbytheMedicalResearchCenter(IRB),HamadMedical Corporation,referencenumber(MRC-04-20-133).

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Author’scontribution

AmmarAleter:datacollection,interpretation,writingthepaper, editingthepaper.WalidElAnsari:studyconcept,data interpreta-tion,writingthepaper,editingthepaper.Allauthorsreviewedand agreedonthefinalversionofthepaper.

Registrationofresearchstudies

NotfirstinMan.

Guarantor

WalidElAnsari:welansari9@gmail.com. Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed. References

[1]A.Mastoraki,G.Sakorafas,P.Vassiliu,etal.,Mucoceleoftheappendix:

dilemmasindifferentialdiagnosisandtherapeuticmanagement,IndianJ.

Surg.Oncol.7(1)(2016)86–90.

[2]N.J.Carr,T.D.Cecil,F.Mohamed,etal.,Aconsensusforclassificationand

pathologicreportingofpseudomyxomaperitoneiandassociatedappendiceal

neoplasia:theresultsoftheperitonealsurfaceoncologygroupinternational

(PSOGI)modifiedDelphiprocess,Am.J.Surg.Pathol.40(2016)14–26.

[3]W.L.Shaib,M.Goodman,Z.Chen,S.Kim,etal.,Incidenceandsurvivalof

appendicealmucinousneoplasms:aSEERanalysis,Am.J.Clin.Oncol.40(6)

(2017)569–573.

[4]C.Bartlett,M.Manoharan,A.Jackson,Mucoceleoftheappendix—adiagnostic

dilemma:acasereport,J.Med.CaseRep.1(2007)183.

[5]H.H.Gonzalez,K.Herard,M.C.Mijares,Ararecaseoflow-gradeappendiceal

mucinousneoplasm:acasereport,Cureus11(1)(2019)e3980.

[6]E.Kalu,C.Croucher,Appendicealmucocele:araredifferentialdiagnosisofa

cysticrightadnexalmass,Arch.Gynecol.Obstet.271(1)(2005)86–88.

[7]A.H.Omari,M.R.Khammash,G.R.Qasaimeh,A.K.Shammari,M.K.Yaseen,S.K.

Hammori,Acuteappendicitisintheelderly:riskfactorsforperforation,

WorldJ.Emerg.Surg.9(1)(2014)6.

[8]M.J.Overman,E.A.Asare,C.C.Compton,etal.,in:M.B.Amin,S.B.Edge,F.L.

Greene,etal.(Eds.),AJCCCancerStagingManual,8thedition,Springer,

Chicago,IL,2017.

[9]R.A.Agha,M.R.Borrelli,R.Farwana,K.Koshy,A.Fowler,D.P.Orgill,Forthe

SCAREGroup,TheSCARE2018statement:updatingconsensusSurgicalCAse

REport(SCARE)guidelines,Int.J.Surg.60(2018)132–136.

[10]S.E.Edge,D.R.Byrd,C.C.Compton,etal.,AJCCCancerStagingManual,7th

edition,Springer,NewYork,NY,USA,2009.

[11]A.M.Mehta,M.B.Bignell,S.Alves,etal.,Riskofovarianinvolvementin

advancedcolorectalorappendicealtumorsinvolvingtheperitoneum,Dis.

ColonRectum60(2017),691e6.

[12]A.Hajiran,K.Baker,P.Jain,M.Hashmi,Caseofanappendicealmucinous

adenocarcinomapresentingasaleftadnexalmass,Int.J.Surg.CaseRep.5(3)

(2014)172–174.

[13]O.Balci,S.Ozdemir,A.S.Mahmoud,Appendicealmucocelemimickingacystic

rightadnexalmass,Taiwan.J.Obstet.Gynecol.48(4)(2009)412–414.

[14]P.Panagopoulos,T.Tsokaki,E.Misiakos,V.Domi,etal.,Low-grade

appendicealmucinousneoplasmpresentingasanadnexalmass,CaseRep.

Obstet.Gynecol.2017(2017),7165321.

[15]W.Zhang,C.Tan,M.Xu,X.Wu,Appendicealmucinousneoplasmmimics

ovariantumors:challengesforpreoperativeandintraoperativediagnosisand

clinicalimplication,Eur.J.Surg.Oncol.45(11)(2019)2120–2125.

[16]J.Ruiz-Tovar,D.G.Teruel,V.M.Castineiras,A.S.Dehesa,P.L.Quindos,E.M.

Molina,Mucoceleoftheappendix,WorldJ.Surg.31(3)(2007)542–548.

[17]W.L.Shaib,R.Assi,A.Shamseddine,etal.,Appendicealmucinousneoplasms:

diagnosisandmanagement,Oncologist22(9)(2017)1107–1116.

[18]W.C.Lien,S.P.Huang,C.L.Chi,etal.,Appendicealouterdiameterasan

indicatorfordifferentiatingappendicealmucocelefromappendicitis,Am.J.

Emerg.Med.24(7)(2006)801–805.

[19]S.Degani,I.Shapiro,Z.Leibovitz,G.Ohel,Sonographicappearanceof

appendicealmucocele,UltrasoundObstet.Gynecol.19(1)(2002)99–101.

[20]C.Malave,G.Wynn,M.S.Nussbaum,A.M.Kaunitz,Incidentaldiagnosisof

appendicealmucocelewithvaginalultrasonographyandcomputed

tomography,Obstet.Gynecol.117(2)(2011)479–481.

[21]R.K.Demirci,M.Habibi,B.R.Karakas¸,H.Bulus¸,etal.,Appendixmucocele

mimickingacomplexovariancyst,Ulus.CerrahiDerg.31(1)(2015)58–60.

[22]B.Caspi,E.Cassif,R.Auslender,A.Herman,Z.Hagay,Z.Appelman,Theonion

skinsign:aspecificsonographicmarkerofappendicealmucocele,J.

UltrasoundMed.23(1)(2004)117–123.

[23]Y.O.Tanaka,Y.Takazawa,M.Matsuura,K.Omatsu,N.Takeshima,K.

Matsueda,MRimagingofsecondarymassiveovarianedemacausedby

ovarianmetastasisfromAppendicealAdenocarcinoma,Magn.Reson.Med.

Sci.18(2)(2019)111–112.

[24]M.Shiihara,T.Ohki,M.Yamamoto,Preoperativediagnosisandsurgical

approachofappendicealmucinouscystadenoma:usefulnessofvolcanosign,

CaseRep.Gastroenterol.11(3)(2017)539–544.

[25]M.Puvaneswary,A.Proietto,Mucoceleoftheappendixwithmagnetic

resonanceimagingfindings,Australas.Radiol.50(1)(2006)71–74.

[26]S.A.Laalim,I.Toughai,B.Benjelloun,K.H.Majdoub,K.Mazaz,Appendiceal

intussusceptiontothececumcausedbymucoceleoftheappendix:

laparoscopicapproach,Int.J.Surg.CaseRep.3(9)(2012)445–447.

[27]G.L.Bennett,T.P.Tanpitukpongse,M.Macari,K.C.Cho,J.S.Babb,CTdiagnosis

ofmucoceleoftheappendixinpatientswithacuteappendicitis,Am.J.

Roentgenol.192(3)(2009)103–110.

OpenAccess

ThisarticleispublishedOpenAccessatsciencedirect.com.ItisdistributedundertheIJSCRSupplementaltermsandconditions,which permitsunrestrictednoncommercialuse,distribution,andreproductioninanymedium,providedtheoriginalauthorsandsourceare credited.

References

Related documents

Both Brazil and Sweden have made bilateral cooperation in areas of technology and innovation a top priority. It has been formalized in a series of agreements and made explicit

The increasing availability of data and attention to services has increased the understanding of the contribution of services to innovation and productivity in

For more detailed summaries of the in- terviews please see my Masters dissertation: Olausson, J, Christianity, Is- lam, Malawian Traditional Religion and the Malawian Culture:

Treating cells with β-cyclodextrin (β-CD) results in cholesterol depletion of the membrane and flattening of the caveolae invaginations [135, 140]. In rat adipocytes the

In the case of both passage 1 scores, the number of respondents whose comprehension could be classified as independent was relatively small, with the majority of

Solution depth is the maximum depth in the Configuration Tree the solution will be found; one (1) means that the search is done for an Atomic service as the end-2-end service required

I rapporten kommer utvalda begrepp återkommande att finnas med, begreppen kommer att vara Transparens; vilket är synonymt med genomskinlighet och insyn i verksamhet,

These kind of methods transform the low-resolution observations to the frequency domain where, in a combined image registration and reconstruction step, the high-resolution image

FÖRSVARSHÖGSKOLAN 01-06-18 19 100:1058 ChP T 99-01 Sida 8 79 Mj Martin Nylander Det finns ytterligare två underliggande syften med denna uppsats, dessa är dels ett intresse

Att socialarbetare arbetar inom en bred och många gånger svårhanterbar profession är känt sedan länge (Brigid, 2013). Det låg därmed i vårt intresse att

As an incentive to decrease the use of interior space and hence the environmental impact of activities and utilities, this paper suggests that total GHG (greenhouse gas)

The goal of the current study was threefold: (1) evalu- ate the distribution of glioma-related seizures at the time of tumor diagnosis with respect to tumor- and patient-related

The learning activity is divided into four phases whereas the first phase is accomplished by using an interactive multimedia scenario to present a problem by

The teacher at the primary school explained the school’s involvement with teaching sign language and providing visual images in order for all children at the

The main conclusions of the study are that: Primary education is not free in Tanzania, as there are significant costs involved to send a child to primary school,

Currently, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is standard treatment for patients with PM originating from colorectal cancer,

The project area Bloemendal is situated in the outskirts of Port Elizabeth in South Africa and was fi rst developed for coloured people during the apartheid regime.. The planning

Därmed bör 8 § lagen (2001:82) om svenskt medborgarskap strykas, vilket innebär att alla personer över 18 år får en likvärdig prövning där kriminellt leverne blir ett vik-

The purpose of this thesis is to investigate the favorable dynamic effects of increased mass, increased stiffness, and viscoelastic damping systems in tall

Factory Kind of Water: Description of Sample: Source of Water: ANALYSIS Silica SiO, Iron Fe Calcium Ca Magnesium Mg Sodium Na Chlorine Cl.. Sulphuric Acid

Finns det skillnad i subjektivt välbefinnande mellan individer som anser att social kompetens är viktigt respektive mindre viktigt, mellan individer med låg respektive hög

The guide poses more questions like “How can we know baking soda is not acid?” “What do you think if we put lemon juice and baking soda together?” With the scaffolding of the

In study III (n=89), a cross sectional study, we examined various scales for measuring dyspnea [i.e., Visual Analogue Scale (VAS), Verbal Rating Scale (VRS), modified Medical