Infective Endocarditis of a Rare Etiology of Streptococcus alactolyticus: A Case Report and Literature Review.

Streptococcus alactolyticus is a non-motile Gram-positive, catalase-negative cocci, a part of group D Streptococci. In the literature, S. alactolyticus is documented as a causative agent of infective endocarditis, demonstrated by blood cultures in only four other cases, representing an extremely rare circumstance. Here, we describe a case of infective endocarditis due to S. alactolyticus in a young patient known with a bicuspid aortic valve and associated with a sigmoid precancerous polyp. The patient was also known to have blood hypertension and type II diabetes. Symptoms at the debut appeared insidiously and were non-specific: fatigue, loss of appetite, weight loss, night sweats, and fever. They lasted for the entire period of the illness with transient improvement during the courses of antibiotics. He followed more antibiotic courses prescribed for various clinical diagnoses. Each round of antibiotic treatment transitorily alleviated the symptoms, which reappeared each time after the cessation. The correct diagnosis was made only about three months after the appearance of the first clinical manifestations. This was based on ultrasound criteria (presence of vegetation and lesions of aortic cusps) and microbiological criteria (isolation of S. alactolyticus in blood cultures). A course of six weeks of ceftriaxone was considered the opportune antibiotic therapy. Similar to all other cases described in the literature, our patient presented important damage to the valvular tissue and required cardiac surgery to re-establish the normal function of the valve. The surgery consisted of the excision of the severely affected natural aortic valve and her replacement with a mechanical prosthetic valve. Following medical and surgical treatment, the patient is completely healed and has a normal life. Our case is noteworthy because of the scarcity of the involvement of S. alactolyticus in the pathogeny of infective endocarditis. This is the fifth published case with this etiology, and an overview of all five cases is provided in the article.

The Role of CT Imaging in a Fractured Coronary Stent with Pseudoaneurysm Formation.

We report a case of a 63-year-old male patient with multiple cardiovascular risk factors and previous myocardial infarction who was referred to the emergency department on September 2023 with symptoms and clinical and biological data consistent with an acute coronary event. A coronary angiography revealed severe ostial stenosis of the left anterior descending artery (LAD) and intrastent thrombotic occlusion in the first two segments of the LAD. Two drug-eluting stents were implanted and the patient was discharged when hemodynamically stable; however, three weeks later, he returned to the emergency department complaining of fever, anterior chest pain, dyspnea at rest, and high blood pressure values at home. High levels of troponin T, C-reactive protein, and NT-proBNP were detected and blood cultures showed methicillin-resistant Staphylococcus aureus. The computed tomography (CT) examination showed a saccular dilatation had developed between two fragments of a stent mounted at the level of the LAD, surrounded by a hematic pericardial accumulation. LAD pseudoaneurysm ablation and a double aortocoronary bypass with inverted saphenous vein autograft were performed and the patient showed a favorable postoperative evolution. In this case, surgical revascularization was proven to be the appropriate treatment strategy, demonstrating the need to choose an individualized therapeutic option depending on case-specific factors.

Suspension of the penis - dissection, anatomical description and highlighting of anatomical risks in sectioning the suspensory ligaments.

BACKGROUND: The suspension of the penis is provided by two ligaments: fundiform and suspensory. These ligaments are sectioned during some augmentative surgical procedures. The structure, the relations and the variability of these ligaments have been demonstrated. The penile neurovascular bundle and its relationships have also been emphasized. A clear knowledge of these details should ensure a reduction of the risk of surgical injury during augmentation procedures. RESULTS: We dissected the ligaments providing the suspension of the penis in 7 formalized corpses. We identified, for each of the ligaments, the origin, the insertion and the relations. The dissection pieces were photographed and the images obtained were discussed upon. We described the variability of the anatomical distribution and highlighted the relations with the vascular and nervous structures for each of these ligaments. The anatomical variability of the fascia and the relations with the base of the penis were also emphasized. For the suspensory ligament, we identified three groups of fibers through which it is attached to the penile body. CONCLUSIONS: The dissections were conducted in layers, corresponding to the operative steps for the penile augmentation procedures. We believe that our study highlights the anatomical basis necessary to safely perform these surgeries. The study contributes to the description of the anatomical variability of the ligaments and logically presents details that contribute to preventing most surgical incidents.

RéSUMé: CONTEXTE: La suspension du pénis est assurée par deux ligaments: fundiforme et suspenseur. Ces ligaments sont sectionnés lors de certaines interventions chirurgicales d'agrandissement pénien. La structure, les relations, et la variabilité de ces ligaments ont été démontrées. Le faisceau neurovasculaire pénien et ses relations ont également été soulignés. Une connaissance claire de ces détails devrait assurer une réduction du risque de blessure chirurgicale pendant les procédures d'augmentation. RéSULTATS: Nous avons disséqué les ligaments assurant la suspension du pénis sur 7 cadavres standardisés. Nous avons identifié, pour chacun des ligaments, l'origine, l'insertion et les relations. Les pièces de dissection ont été photographiées et les images obtenues ont été discutées. Nous avons décrit la variabilité de la distribution anatomique, et mis en évidence les relations avec les structures vasculaires et nerveuses pour chacun de ces ligaments. La variabilité anatomique du fascia et les relations avec la base du pénis ont également été soulignées. Pour le ligament suspenseur, nous avons identifié trois groupes de fibres par lesquelles il est attaché au corps pénien. CONCLUSIONS: Les dissections ont été effectuées en couches, correspondant aux étapes opératoires des procédures d'augmentation du pénis. Nous pensons que notre étude met en évidence la base anatomique nécessaire pour effectuer ces chirurgies en toute sécurité. L'étude contribue à la description de la variabilité anatomique des ligaments et présente logiquement des détails qui contribuent à prévenir la plupart des incidents chirurgicaux.

The Pelvic and Sacral Splanchnic Nerves - Identification by Dissection, Trajectory.

The modern principles in pelvic surgery imply the preservation of the nervous structures that are involved in the physiological functioning of the pelvic and genital organs. The main pelvic nervous element is represented by the inferior hypogastric plexus. This plexus receives sympathetic afferent fibres from the hypogastric nerve, parasympathetic afferent fibres from the pelvic splanchnic nerves and also sympathetic afferent fibres coming from the sympathetic sacral chain via the sacral splanchnic nerves. We aimed to demonstrate the anatomy of these structures through dissection and we exposed the origins, pathway and manner of distribution of the splanchnic nerves of the pelvis. We managed to clarify the main anatomical relations of these nerves, among which we highlighted the relation to the branches of the internal iliac artery. The parasympathetic fibres reach the pelvis by running through the anterior rami of the spinal nerves, which are the origin of the sacral plexus. We managed to exhibit the way in which the parasympathetic fibres emerge from the sacral nerves and form the pelvic splanchnic nerves. Pelvic surgery nowadays is focused on nerve-sparing, which essentially means the conservation of the integrity of splanchnic nerves, hypogastric nerves and inferior hypogastric plexuses in order to maintain the normal functioning of the anatomical sphincters and genital organs. In this respect, it is crucial for the surgeon who performs pelvic procedures to be more than well-acquainted to the anatomy of the pelvic splanchnic nerves, which are considered to be the erectile nerves, and to that of the sacral splanchnic nerves.

The distribution of the inferior hypogastric plexus in female pelvis.

Elements that comprise the inferior hypogastric plexus are difficult to expose, intricate, and highly variable and can easily be damaged during local surgical procedures. We aimed to highlight, through dissection, the origin, formation, and distribution of the hypogastric nervous structures and follow them in the female pelvis. We performed detailed dissections on 7 female formalin-fixed cadavers, focusing on structures surrounding the pelvic organs. For each hemipelvis, we removed the peritoneum from the pelvic floor, and after we identified the hypogastric nerves, we continued our dissection towards the inferior hypogastric plexuses, following the branches of the latter. Laterorectally, the hypogastric nerves form the inferior hypogastric plexus, a variable structure - nervous lamina, neuronal network (more frequently), or sometimes a combination of them. We identified three components of the inferior hypogastric plexus. The anterior bundle travels towards the base of the urinary bladder, the middle part innervates the uterus and the vagina, and the posterior segment provides the innervation of the rectum. The plexus can be identified after removing the pelvic peritoneum and the subperitoneal adipose tissue. Intraoperatively, the structures can be preserved by using an immediately-subperitoneal dissection plane. The variable branches are relatively well-organized around the pelvic vessels, supplying the urinary bladder, the genital organs, and the rectum. The ureter is surrounded by some branches, especially in its last segment, and it also receives innervation directly from the hypogastric nerve. Close to the viscera, the nerves enter neurovascular plexuses, making the intraoperative separation of the nerves and the vessels virtually impossible.

Investigation of the morphometry of the pre-lacrimal recess of the maxillary sinus for the pre-lacrimal approach of the maxillary sinus and paramedian skull base. A computed-tomography study.

The pre-lacrimal recess approach is modernly used for lesions of the anterior maxillary wall and for reaching paramedian cranial base regions. In this computed-tomography study, we assessed the pre-lacrimal recess types as well as the angles between the anterior and medial maxillary walls and between the anterior maxillary wall and the lateral margin of the nasolacrimal canal to show the feasibility of the pre-lacrimal recess approach in reaching lesions of the infratemporal and pterygopalatine fossae, using 30 computed-tomography studies (60 sides). A type I pre-lacrimal recess was identified in 22 cases (35%), type II was identified in 31 cases (53.30%), and type III in 7 cases (11.66%). We found that angle 1 (the angle between the anterior maxillary wall and the medial maxillary wall) had a mean value of 80.8° (minimum 75.5°, maximum 85.8°), while angle 2 (the angle between the anterior maxillary wall and the lateral margin of the nasolacrimal canal) had a mean value of 59.1° (minimum 57.6°, maximum 60.1°). We consider the pre-lacrimal recess approach a very good option for the anterior maxillary wall, the alveolar recess, and in reaching the infratemporal fossa and lateral part of the pterygopalatine fossa. In cases where direct visualization of the medial part of the pterygopalatine fossa is needed, the pre-lacrimal recess approach could not be the perfect option.

The pterygopalatine ganglion, palatine nerves and vessels: dissection and pathway / El ganglio pterigopalatino, nervios palatinos y vasos: disección y trayecto

SUMMARY: Background and Objectives: The palatine nerves and vessels cross the pterygopalatine fossa, the palatine canals, the palatine foramina and the submucosal space, at the level of the hard palate and the palatine recess of the maxillary sinus. Their trajectory is long, complicated and difficult to highlight on a single dissection piece. In the literature that we studied, we did not find clear images that fully highlight the real configuration of the pterygopalatine ganglion and nerves and of the palatine vessels. Our aim was to provide a clear and representative dissection of the pterygopalatine ganglion and of the palatine neurovascular bundle throughout its pathway in a simple, coherent and useful presentation for the practitioners interested in the regional pathology. We resected the posterior and inferomedial osseous walls of the maxillary sinus and highlighted the neurovascular structures in the pterygopalatine fossa and the wall of the maxillary sinus. We photographed the dissection fields and detailed the important relations. The images that we obtained are clear, simple and easy to interpret and use. We successfully highlighted the aspect and the main relations of the pterygopalatine ganglion and the pathway and distribution of the palatine nerves and vessels, from their origin to the terminal plexuses. There is a broad spectrum of clinical procedures or situations that require a proper knowledge and understanding of the anatomical pathway and relations of the palatine neurovascular elements. This includes the various types of regional anesthesia, tumor resection surgery, flaps of the palatine mucosa, the LeFort osteotomy etc. Demonstration of the pterygopalatine ganglion and its relations is useful in endoscopic interventions at the level of the pterygopalatine fossa.

RESUMEN: Los nervios y vasos palatinos atraviesan la fosa pterigopalatina, además de los canales palatinos, los forámenes palatinos y el espacio submucoso a nivel del paladar duro y el receso palatino del seno maxilar. Su trayectoria es larga, complicada y difícil de destacar en una sola pieza de disección. En la literatura que estudiamos, no encontramos imágenes claras que resalten completamente la configuración real del ganglio y los nervios pterigopalatinos y de los vasos palatinos. Nuestro objetivo fue proporcionar una disección clara y representativa del ganglio pterigopalatino y del haz neurovascular palatino a lo largo de su trayecto en una presentación simple, coherente y útil para los médicos interesados en la patología regional. Resecamos las paredes óseas posterior e inferomedial del seno maxilar y resaltamos las estructuras neurovasculares en la fosa pterigopalatina y la pared del seno maxilar. Fotografiamos los campos de disección y detallamos las relaciones importantes. Las imágenes que obtuvimos son claras, sencillas y de fácil interpretación. Resaltamos con éxito el aspecto y las principales relaciones del ganglio pterigopalatino y el trayecto y distribución de los nervios y vasos palatinos, desde su origen hasta los plexos terminales. En conclusion, existe un amplio espectro de procedimientos o situaciones clínicas que requieren un adecuado conocimiento y comprensión del trayecto anatómico y las relaciones de los elementos neurovasculares palatinos. Esto incluye los distintos tipos de anestesia regional, cirugía de resección tumoral, colgajos de mucosa palatina, osteotomía de LeFort, etc. La demostración del ganglio pterigopalatino y sus relaciones es útil en intervenciones endoscópicas a nivel de la fosa pterigopalatina.

Overview of the anatomical basis of the piriformis syndrome-dissection with magnetic resonance correlation.

The piriformis syndrome is one of the most commonly misdiagnosed causes of lower back and gluteal pain caused by the compression of the sciatic nerve and the internal pudendal neurovascular bundle by the piriformis muscle. Although this syndrome was first suggested over 90 years ago, its diagnosis still represents a challenge for clinicians. In the present study, dissection was used to determine the intra- and extrapelvic anatomical course of the internal pudendal nerve and the data were compared with the information obtainable through MRI examination, in order to identify the piriformis syndrome and to differentiate it from other causes of internal pudendal neuralgia. Thorough dissections of the pelvis and deep gluteal region were conducted on female cadavers, which were correlated with MRI scans, in order to describe the course of the internal pudendal nerve in contact with the piriformis muscle. The dissection findings and MRI scans obtained allowed us to describe and demonstrate the compression points along the course of the sciatic nerve and the internal pudendal bundle, the anatomical correlations between the piriformis muscle and the nervous structures around it, emphasizing the areas most susceptible to possible nerve impingement syndromes. In the anatomic trajectory of the sciatic nerve and the internal pudendal bundle there are multiple contact points with anatomical structures that may lead to compression of the nerve structures, generating symptoms that comprise the piriformis syndrome. The present study sought to establish clear osseous landmarks that may help evaluate these associations and possible nerve compressions on pelvic MRI examination.

The Assessment of the Anatomical Risk in the Perioral Region.

Introduction:Safe and effective procedures in the perioral region rely on a clear understanding of the facial anatomy, as insufficient knowledge of this aspect can lead to severe complications. Materials and methods:We performed thorough layer-by-layer dissections of the perioral region on 11 freshly formalinized cadaver heads. Dissections were performed between 2020 and 2022 in the dissection laboratory of the Anatomy Department, where the ethical conducts were regulated by "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania, and fall under its jurisdiction. Dissections were digitally photographed and edited without altering the scientific content. By performing minute dissections, a considerable amount of attention has been paid to the trajectory and diameter of the superior and inferior labial arteries and their relations with the surrounding structures. Results:We demonstrated the presence of the fibro-muscular compartment above the philtrum, where the superior labial artery passes and gives off the columellar and septal branches, and where it can be compressed in case of either the migration of the filler or quick bolus injections of substance. We also emphasized the importance of the labial salivary glands as risk elements in the perioral region. The depth of the inferior labial artery varied between 4.1-5.4 mm and that of the superior labial artery between 4.8-5.6 mm. Discussion: Safe and complication-free procedures require an exact knowledge of the anatomy of the main neurovascular bundle of each facial region and their anatomical variability should be highlighted. Conclusion:The clinically relevant anatomical observations and descriptions of landmarks presented in our research serves as crucial information for plastic, reconstructive and aesthetic surgeons and dentists. Doppler ultrasound imaging has a considerable potential for both diminishing the risk and facilitating the prompt treatment of complications, especially because it is an affordable, repeatable, quick and reliable procedure. Cadaveric dissection for anatomy training provides an unparalleled opportunity to precisely understand the structure of actual human tissue and the clinical and structural relationships between the multitude of anatomical risk elements.

Hypocalcemia: A possible risk factor for anastomotic leak in digestive surgery.

Anastomotic leaks (ALs) remain the most severe complication in digestive surgery, as well as the most consumptive in terms of human and financial resources. There is an abundance of international research which has focused on identifying and correcting risk factors, and on individualized surgical management as well. The most frequent risk factors are male sex, obesity, diabetes, advanced malignant disease, ASA score, perioperative blood loss or perioperative transfusion, long operation time, emergency operation and altered nutritional status. The aim of the present study was to measure the preoperative serum calcium level and to find a possible correlation between calcium levels and the risk of AL occurrence. A retrospective analysis of medical records for 122 patients who underwent surgical gut resection with anastomosis for different pathologies was carried out. Preoperative serum calcium level and the occurrence of AL was noted. The results revealed that the average value of total blood calcium was 8.78 mg/dl, without a significant difference in sex groups. Hypocalcemia was identified in 44 patients (36.1%). AL was identified in 8 patients (6.6%), with a statistically insignificant difference between male and female patients. The average value of blood calcium in the AL patient group was 8.07 mg/dl, while in patients without AL the average value was 8.83 mg/dl. Hypocalcemia, defined as a serum calcium level below 8.5 mg/dl, was observed in 7 of the 8 patients presenting with AL (87.5%) and 37 patients who did not present with AL (32.5%), a significant difference with which to consider and include hypocalcemia in the group of risk factors for AL (P=0.001). In conclusion, preoperative low serum calcium level can represent a risk factor for AL in digestive surgery.

Impact of adipose tissue in chronic kidney disease development (Review).

Obesity is a worldwide pandemic health issue. Obesity is associated with the pathogenesis of type 2 diabetes, hypertension, dyslipidemia, cardiovascular diseases, cancer, and kidney diseases. This systemic disease can affect the kidneys by two mechanisms: Indirectly through diabetes mellitus (DM) and hypertension and directly through adipokines secreted by adipose tissue. Obesity is a risk factor for chronic kidney disease (CKD), which is associated with an increased risk of morbidity and mortality among the adult population. Increased visceral adipose tissue leads to renal glomerular hyperfiltration and hyperperfusion, which may lead to glomerular hypertrophy, proteinuria, and CKD development. Adipokines are hormones produced by fat tissue. They are involved in energy homeostasis, sugar and fat metabolism, reproduction, immunity, and thermogenesis control. Hormones and cytokines secreted by adipose tissue contribute to the development and progression of CKD. Decreased serum or urinary adiponectin levels are specific in diabetic and non-diabetic CKD patients, while leptin presents increased levels, and both are associated with the development of glomerulopathy. Excessive adipose tissue is associated with inflammation, oxidative stress (OS), insulin resistance and activation of the renin angiotensin-aldosterone system (RAAS). Therefore, adipose tissue dysfunction plays an important role in the development of CKD.

PI3K/AKT/mTOR signalling pathway involvement in renal cell carcinoma pathogenesis (Review).

Renal cell carcinoma (RCC) accounts for over 90% of all renal malignancies, and mainly affects the male population. Obesity and smoking are involved in the pathogenesis of several systemic cancers including RCC. The phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) signalling pathway regulates cell growth, differentiation, migration, survival, angiogenesis, and metabolism. Growth factors, hormones, cytokine and many extracellular cues activate PI3K/AKT/mTOR. Dysregulation of this molecular pathway is frequently reported in human cancers including RCC and is associated with aggressive development and poor survival rate. mTOR is the master regulator of cell metabolism and growth, and is activated in many pathological processes such as tumour formation, insulin resistance and angiogenesis. mTOR inhibitors are used at present as drug therapy for RCC to inhibit cell proliferation, growth, survival, and the cell cycle. Temsirolimus and everolimus are two mTOR inhibitors that are currently used for the treatment of RCC. Drugs targeting the PI3K/AKT/mTOR signalling pathway may be one of the best therapeutic options for RCC.

Kidney aging process and the management of the elderly patient with renal impairment (Review).

As life expectancy increases, a rise in the number of chronically ill patients is observed due to the aging population. Among the various diseases, chronic kidney disease is at present one of the main causes of morbidity and, due to its typical complications, it is also one of the most important causes of mortality in the general population. For these reasons, the understanding of the kidney aging process, its consequences and its adequate management are essential. The judicious use of certain types of drugs, the prevention of episodes of renal injury either by toxic mechanisms or by dehydration are important aspects and are part of the apropriate approach for elderly patients. The most effective treatment of various types of conditions with a negative impact on renal function and for which an increased incidence is known as we age should also be considered. Thus, in the case of elderly patients, in order to protect the kidneys, an integrative approach is recommended, one that includes both elements of prevention and the appropriate treatment of existing diseases.

Management of acute intradialytic cardiovascular complications: Updated overview (Review).

An increasing number of patients require renal replacement therapy through dialysis and renal transplantation. Chronic kidney disease (CKD) affects a large percentage of the world's population and has evolved into a major public health concern. Diabetes mellitus, high blood pressure and a family history of kidney failure are all major risk factors for CKD. Patients in advanced stages of CKD have varying degrees of cardiovascular damage. Comorbidities of these patients, include, on the one hand, hypertension, hyperlipidemia, hyperglycemia, hyperuricemia and, on the other hand, the presence of mineral-bone disorders associated with CKD and chronic inflammation, which contribute to cardiovascular involvement. Acute complications occur quite frequently during dialysis. Among these, the most important are cardiovascular complications, which influence the morbidity and mortality rates of this group of patients. Chronic hemodialysis patients manifest acute cardiovascular complications such as intradialytic hypotension, intradialytic hypertension, arrhythmias, acute coronary syndromes and sudden death. Thus, proper management is extremely important.

Dyselectrolytemia-management and implications in hemodialysis (Review).

Hemodialysis is a method for the renal replacement therapy followed by series of acute and chronic complications. Dyselectrolytemia appears in patients undergoing dialysis through mechanisms related to the chronic kidney disease and/or to the dialysis therapy and for this group of patients it is associated with an increase of morbidity and mortality. The dialysate has a standard composition, which can be modified according to the patient's characteristics. During hemodialysis patients are exposed to 18,000-36.000 litres of water/year, and the water purity along with the biochemical composition of the dialysate are essential. The individualization of the dialysis prescription is recommended for each patient and it has an important role in preventing the occurrence of dyselectrolyemia. The individualization of the treatment prescription according to the blood constants of each patient is the prerogative of the nephrologist and the association of the electrolyte imbalances with the patients cardiovascular mortality explains the importance of paying special attention to them.

Primary Hepatic Marginal Zone Lymphoma in a Patient with Chronic Hepatitis C.

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) is a low-grade malignant lymphoma that appears frequently in the stomach, but other sites can also be involved: the intestinal tract, lungs, head, neck, skin, thyroid, breasts and liver. Recently, epidemiological evidences support the idea that there is an association between hepatitis C and B-cell non-Hodgkin lymphomas (that include MALT as a subtype). Primary non-Hodgkin lymphomas confi ned only to the liver are very rare (only 0.016% of all cases of all non-Hodgkin's lymphomas) and MALT is not the most frequent type. We present the case of a male patient, age 62, known with chronic hepatitis C, previously relapser a" er a 72 week treatment with peg-interferon alfa and ribavirin that was diagnosed at three years a" er the relapse with multiple focal liver lesions. One of the tumors was surgically removed and the histological exam performed demonstrated an extranodal marginal zone lymphoma with small B-cell with plasmacytoid diff erentiation confi ned only to the liver. Direct acting antiviral (DAA) therapy was started, but the virologic clearance was not obtained by week 10, leading to a change of DAA regimen at week 12. The antiviral therapy was continued until week 24. Imaging showed an increase in number and size of the focal lesions until week 12. At week 12 chemo- and immune-therapy was started with bendamustine and rituximab. A" erwards the evolution was favorable, the patient being now in complete remission and with undetectable viral load.