Successful management of evisceration occurred after exploratory laparotomy for bilateral ovarian micropapillary serous borderline tumors

Micropapillary serous borderline tumor of the ovary is characterized by a more frequent association with extraovarian, especially invasive, implants. The aim of this study was to report the clinicopathological findings of a rare case of micropapillary serous borderline tumor of the ovary since there are less than 100 similar cases in the published literature. Additionally, the successful management of evisceration that complicated the postoperative stay of the patient is analyzed. The incidence of this severe complication is estimated between 0.29-2.3%. There are four main causes: suture tearing through the fascia, knot failure, suture failure, and extrusion of abdominal contents between sutures placed too far apart. At least 50% of the cases are due to technical error with a potentially lethal result.

Alveolite

A etiologia da alveolite é desconhecida. Considera-se não haver uma causa específica, mas sim uma associação de factores inerentes ao seu aparecimento. O diagnóstico é realizado, geralmente, entre o 2º e 5º dia após exodontia, sendo bastante claro. Manifesta-se por uma dor aguda e pulsátil, mal controlada com analgésicos, e de apresentação clínica uma inflamação da mucosa em torno do alvéolo, com parcial ou total perda do coágulo, apresentando-se este vazio ou com tecido necrótico e/ou restos alimentares. Pode ainda haver uma exposição óssea. Diversas são as taxas de incidência, variando consoante os factores de risco predisponentes da doença. São estes a idade, género, ciclo menstrual e toma de contraceptivos orais (nas mulheres), trauma cirúrgico e experiência do médico, a indicação da extração, bem como características do dente a ser extraído, ainda as técnicas e anestesia usadas, bem como remanescentes ósseos e/ou radiculares, uso de retalhos e suturas, patologias sistémicas, medicação e cuidados pós-operatórios do doente. Todos estes podem ter impacto no desenvolvimento desta condição, devendo o médico dentista eliminá-los e reduzi-los ao máximo. A prevenção aplica-se a medidas não farmacológicas, como redução de factores de risco, em combinação a terapia farmacológica, de modo a favorecer uma correta cicatrização. Recurso a soluções antissépticas, medicação tópica (intra-alveolar) e prescrição sistémica de antibióticos e anti-inflamatórios não esteroides são algumas dessas medidas. Ao nível do tratamento, vários métodos e materiais estão disponíveis no mercado. Por ser uma condição que o próprio organismo “combate”, o objectivo terapêutico passa basicamente pela redução dos sintomas debilitantes do paciente e controlo bacteriano. A opção é individual, uma vez que não existe nenhum tratamento com características ideais, sendo os resultados na literatura bastante discrepantes. Limpeza do alvéolo, medicação intra-alveolar (tópica) e/ou sistémica, bem como terapia com laser de baixa intensidade, são algumas opções. A administração antibiótica deve ser reservada para casos especiais, não devendo ser abordada como método de rotina. Analgésicos são uma opção, podendo ser aconselhada consoante o quadro clínico doloroso. Também o reforço para uma higiene oral rigorosa, com irrigação do alvéolo para evitar detritos e impactação alimentar (no caso de não existirem obtundantes intra-alveolares) devem ser preocupação do médico dentista. Deve haver um seguimento regular do paciente, especialmente se aplicados medicamentos tópicos, para avaliação e renovação (se necessário) do curativo até recuperação. O médico dentista deve saber identificar um caso de alveolite, encontrando-se informado e consciente das várias opções preventivas e terapêuticas. Estudos mais claros e objectivos são necessários na procura de critérios de diagnóstico genéricos da doença, bem como terapêuticas preventivas e de tratamentos com taxas de sucesso altas e suportadas por evidência científica. Para que, desta forma, seja elaborado um protocolo universal a seguir na prática clínica.

Gewebeansatz-Strukturen auf pyritisierten Steinkernen von Ammonoideen

3400 pyritized internal moulds of Upper Devonian, Triassic, Jurassic and Lower Cretaceous ammonoids show various soft tissue attachment structures. They are preserved as regularly distributed black patterns on the moulds. All structures can be interpreted as attachment areas of muscles, ligaments and intracameral membranes. Paired structures are developed along the umbilicus and on the flanks of the moulds, unpaired ones appear on the middle of their dorsal and ventral sides. Strong lateral muscles cause paired twin lines on the flanks of the phragmocone and of the body chamber. A ventral muscle is deduced from small rounded or crescent shaped spots in front of each septum on the ventral side. These spots are often connected, forming a band-like structure. Broad dark external bands on the ventral side of the phragmocone, ventral preseptal areas in the posterior part of the living chamber, small twin lines or oval shaped areas on the ventral side of the living chamber represent paired or unpaired attachment areas of the hyponome muscle. A middorsal muscle is documented by small roughened areas in front of each dorsal lobe. Dark spots along the umbilicus, often connected and thus forming a band-like structure (tracking band), are remains of a pair of small dorsolateral muscles at the posterior end of the soft body. Dark bands, lines and rows of small crescent shaped structures behind the tips of sutural lobes are due to spotlike fixation places of the posterior part of the mantle and their translocation before subsequent septal secretion. Devonian goniatites had a paired system of lateral and ventrolateral muscles preserved on the moulds as black or incised lines on the flanks of the living chamber and as dark preseptal areas, ventrally indented. These structures represent the attachment areas of paired lateral cephalic and paired ventral hyponome retractors. Fine black lines on the phragmocone situated parallel to the sutures (pseudosutures) represent a rhythmical secretion of camera! membranes during softbody translocation. Goniatites had a paired system of lateral and ventrolateral muscles, whilst Neoammonoids have a paired lateral and dorsolateral system, and, additionally, an unpaired system on the ventral and on the dorsal side. Mesoammonoids show only a paired lateral and an unpaired dorsal one. Fine black lines situated parallel to the saddles and behind the lobes of the suture line can be interpreted as structures left during softbody translocation and a temporary attachment of rhythmical secreted cameral membranes. Cameral membranes had supported the efficiency of the phragmocone. Only some of the observed structures are also present in recent Nautilus. Differences in the form and position of attachment sites between ammonoids and recent Nautilus indicate different soft body organizations between ammonoids and nautiloids. The attachment structures of goniatites especially of tornoceratids can be compared with those of Nautilus which indicates Richter - Gewebeansatz-Strukturen bei Ammonoideen 3 a comparable mode of life. Differences in the form and position of attachment structures between goniatites and ammonites may indicate an increasing differentiation of the muscular system in the phylogeny of this group. Different soft body organization may depend on shell morphology and on a different mode of life. On the modification or reduction of distinct muscle systems ammonoids can be assigned to different ecotypes. Based on shell morphology and the attachment areas of cephalic and hyponome retractor muscles two groups can be subdivided: - Depressed, evolute morphotypes with longidome body-chambers show only small ventral hyponome retractor muscles. Lateral cephalic retractors are not developed. These morphotypes are adapted to a demersal mode of life. Without strong cephalic retractor muscles no efficient jet propulsion can be produced. These groups represent vertical migrants with efficient phragmocone properties (multilobate sutures, cameral membranes, narrow septal spacing). - Compressed, involute moiphotypes with brevidome body-chambers show strong cephalic and hyponome retractor muscles and represent a group of active swimmers. These morphotypes were able to live at different depths, in the free water column or/and near the seafloor. They are not confined only to one habitat. Most of the examined genera and species belong to this group. Changes of the attachment structures in the course of ontogeny confirm that juveniles of Amaltheus and Quenstedtoceras lived as passive planche drifters in upper and intermediate parts of the free water column after hatching. At the end of the juvenile stage with a shell diameter of 0,3 - 0,5 cm cephalic retractor muscles developed. With the beginning of an active swimming mode of life (neanic stage) the subadult animals left the free water column and moved into shallow water habitats. Fuciniceras showed no marked changes in the attachment structures during ontogeny. This indicates that there occur no differences in the mode of life between juvenile and adult growth stages. Based on attachment structures and shell morphology of Devonian goniatites their relation to the systematic position permits statements about probable phylogenetic relationships between the Cheiloceratidae and Tornoceratidae. In some cases attachment structures of ammonites permit statements about phylogenetic relationships on family and genus level.

Minimally invasive repair of Morgagni hernia - A multicenter case series

Children may benefit from minimally invasive surgery (MIS) in the correction of Morgagni hernia (MH). The present study aims to evaluate the outcome of MIS through a multicenter study. National institutions that use MIS in the treatment of MH were included. Demographic, clinical and operative data were analyzed. Thirteen patients with MH (6 males) were operated using similar MIS technique (percutaneous stitches) at a mean age of 22.2±18.3 months. Six patients had chromosomopathies (46%), five with Down syndrome (39%). Respiratory complaints were the most common presentation (54%). Surgery lasted 95±23min. In none of the patients was the hernia sac removed; prosthesis was never used. In the immediate post-operative period, 4 patients (36%) were admitted to intensive care unit (all with Down syndrome); all patients started enteral feeds within the first 24h. With a mean follow-up of 56±16.6 months, there were two recurrences (18%) at the same institution, one of which was repaired with an absorbable suture; both with Down syndrome. The application of MIS in the MH repair is effective even in the presence of comorbidities such as Down syndrome; the latter influences the immediate postoperative recovery and possibly the recurrence rate. Removal of hernia sac does not seem necessary. Non-absorbable sutures may be more appropriate.

Comparative study between the effects of hyaluronic acid and acid galactan purified from eggs of the mollusk Pomacea sp in wound healing

To compare the effect of hyaluronic acid (HA) and of AG on the healing of intestine wounds. Methods: The semi-purified extract of the eggs of the mollusc was obtained by fractionation with ammonium sulfate and purification for ion-exchange chromatography. The obtained galactans were eluted in water (neutral galactan) and in 0.1 and 0.2M NaCl (acidic galactans). The in vivo study was performed with 45 “Wistar” rats, separated in three groups (n=15). Solutions containing HA 1%, GA 1% or saline solution 0,9%, was placed topically on the sutures of wounds in the small intestine of the rats. After 05, 10 and 21 days the animals were sacrificed and biopsy of the healing tissue was done. Results: The hystologic grading was more significant for HA and AG groups when compared to the group C. AG stimulated the appearance of macrophages, giant cells and increase in the concentration of collagen in the area of the wound when compared to HA. Conclusion: The topical use of GA in intestinal wounds promoted the anticipation of events that are important in the wound healing

Surgical infection and malnutrition

Background: Malnutrition in surgical patients is associated with delayed recovery, higher rates of morbidity and mortality, prolonged hospital stay, increased healthcare costs and a higher early re-admission rate. Methods: Data synthesis after review of pertinent literature. Results: The aetiology of malnutrition is multifactorial. In cancer patients, there is an abnormal peripheral glucose disposal, gluconeogenesis, and whole-body glucose turnover. Malnourished cancer patients undergoing major operations are at significant risk from perioperative complications such as infectious complications. Surgical aggression generates an inflammatory response which worsens intermediary metabolism. Conclusions: Nutritional evaluation and nutritional support must be performed in all surgical patients, in order to minimize infectious complications. Enteral nutrition early in the postoperative period is effective and well tolerated reducing infectious complications, improving wound healing and reducing length of hospital stay. Pharmaconutrition is indicated in those patients, who benefit from enteral administration of arginine, omega 3 and RNA, as well as parenteral glutamine supplementation. When proximal sutures are used, tubes allowing early jejunal feeding should be used.

Flexor Digitorum Superficialis and Flexor Digitorum Profundus with separated sheaths, a new normal variation in human

Case description: A 25 years old man presented with a laceration on radial side of proximal phalanx of 4th finger (zone II flexor) which was due to cut with glass. Clinical findings: The sheaths of Tendons of flexor digitorum sperficialis and profundus were not the same and each tendon had a separate sheath. Treatment and outcome: The tendons were reconstructed by modified Kessler sutures, after 15 months the patient had a 30 degrees of extension lag even after physiotherapy courses. Clinical relevance: This is the first reported of such normal variation in human hand tendon anatomy.

Tectonic evolution of Variscan Iberia: Gondwana–Laurussia

An integrated interpretation of the late Paleozoic structural and geochronological record of the Iberian Massif is presented and discussed under the perspective of a Gondwana-Laurussia collision giving way to the Variscan orogen. Compressional and extensional structures developed during the building of the Variscan orogenic crust of Iberia are linked together into major tectonic events operating at lithosphere scale. A review of the tectonometamorphic and magmatic evolution of the IberianMassif reveals backs and forths in the overall conver- gence between Gondwana and Laurussia during theamalgamation of Pangea in late Paleozoic times. Stages dom- inated by lithosphere compression are characterized by subduction, both oceanic and continental, development of magmatic arcs, (over- and under-) thrusting of continental lithosphere, and folding. Variscan convergence re- sulted in the eventual transference of a large allochthonous set of peri-Gondwanan terranes, the Iberian Allochthon, onto the Gondwana mainland. The Iberian Allochthon bears the imprint of previous interaction be- tween Gondwana and Laurussia, including their juxtaposition after the closure of the Rheic Ocean in Lower De- vonian times. Stages governed by lithosphere extension are featured by the opening of two short-lived oceanic basins that dissected previous Variscan orogenic crust, first in the Lower-Middle Devonian, following the closure of the Rheic Ocean, and then in the early Carboniferous, following the emplacement of the peri-Gondwanan allochthon. An additional, major intra-orogenic extensional event in the early-middle Carboniferous dismem- bered the Iberian Allochthon into individual thrust stacks separated by extensional faults and domes. Lateral tec- tonics played an important role through the Variscan orogenesis, especially during the creation of new tectonic blocks separated by intracontinental strike-slip shear zones in the late stages of continental convergence.