Inhaled Nitric Oxide in Acute Severe Pulmonary Hypertension and Severe Acute Respiratory Distress Syndrome Secondary to COVID-19 Pneumonia: A Case Report.

BACKGROUND Inhaled nitric oxide (iNO) is used as a treatment for pulmonary arterial hypertension (PAH). Severe hypoxia with hypoxic vasoconstriction caused by severe acute respiratory distress syndrome (ARDS) can induce pulmonary hypertension with hemodynamic implications, mainly secondary to right ventricle (RV) systolic function impairment. We report the case of the use of iNO in a critically ill patient with bilateral SARS-CoV-2 pneumonia and severe ARDS and hypoxemia leading to acute severe PAH, causing a ventilation/perfusion mismatch, RV pressure overload, and RV systolic dysfunction. CASE REPORT A 36-year-old woman was admitted to the Intensive Care Unit with a severe ARDS associated with SARS-CoV-2 pneumonia requiring invasive mechanical ventilation. Severe hypoxia and hypoxic vasoconstriction developed, leading to an acute increase in pulmonary vascular resistance, severe to moderate tricuspid regurgitation, RV pressure overload, RV systolic function impairment, and RV dilatation. Following 24 h of treatment with iNO at 15 ppm, significant oxygenation and hemodynamic improvement were noted, allowing vasopressors to be stopped. After 24 h of iNO treatment, echocardiography showed very mild tricuspid regurgitation, a non-dilated RV, no impairment of transverse free wall contractility, and no paradoxical septal motion. iNO was maintained for 7 days. The dose of iNO was progressively decreased with no adverse effects and maintaining an improvement of oxygenation and hemodynamic status, allowing respiratory weaning. CONCLUSIONS Sustained acute hypoxia in ARDS secondary to SARS-CoV-2 pneumonia can lead to PAH, causing a ventilation/perfusion mismatch and RV systolic impairment. iNO can be considered in patients with significant PAH causing hypoxemia and RV dysfunction.

Reproductive ecology of the Amaral's blind snake trilepida koppesi in an area of Cerrado in south-eastern Brazil

Studies on reproductive biology have largely contributed to the understanding of snake ecology. However, detailed reproductive data are scarce for many groups, particularly blind snakes. Here, we describe the reproductive biology of Trilepida koppesi (Leptotyphlopidae), a widely distributed species in the savannas of south-central Brazil. We describe its macro- and microscopic reproductive anatomy, female reproductive cycle, potential clutch size, seasonal activity, and sexual dimorphism of a population from south-eastern Brazil. Males have plurilobulated testes. Spermiogenesis occurs in early spring (October), when gonads and kidneys show a textured surface, the sexual segment of the kidney is hypertrophied, and the ductus deferentia are opaque and packed with sperm. Females have only the right oviduct, which shows developed epithelium and uterine glands in spring. Mating likely occurs in spring (October–December), and females store sperm in infundibular receptacles until ovulation between late spring and early summer. Potential clutch size ranges from three to five eggs. Females grow larger than males. The synchrony between spermiogenesis and mating defines the male cycle as prenuptial, which is considered the ancestral state of Squamata. These results agree with the hypothesis of conservative parameters for the group.

Composition and natural history of a snake community from the southern Cerrado, southeastern Brazil.

The natural history of a cerrado snake community in a protected area in southeastern Brazil (Santa Bárbara Ecological Station; SBES) is described. A visual guide and an identification key are also provided to assist researchers and local people in identifying snakes in that region. Sampling was performed through pitfall traps, time-constrained search, accidental encounters, and observations by local people for two years, which corresponded to 240 days of sampling. Among the 388 individuals found in the field, 33 snake species belonging to 21 genera of seven families were recorded. Most species were restricted or found at least once in non-forest vegetation types (campo sujo, campo cerrado, and cerrado sensu stricto) and a few were restricted to forest habitats (cerradão). Our results show that most species (1) occupy open areas; (2) present both diurnal and nocturnal activity; (3) are primarily terrestrial; (4) include lizards, mammals and/or anurans in the diet; (5) present seasonal reproductive activity; and (6) use mainly visually oriented defensive tactics. Despite its small size (3,154 ha), the SBES harbours preserved habitats and a rich and typical Cerrado snake fauna, including threatened species. Furthermore, most of the SBES snakes occur in non-forest environments (54%) and some species are sensitive to habitat disturbance.

Genetic Determinants for Prediction of Outcome of Patients with Papillary Thyroid Carcinoma.

Papillary thyroid carcinoma (PTC) usually presents an excellent prognosis, but some patients present with aggressive metastatic disease. BRAF, RAS, and TERT promoter (TERTp) genes are altered in PTC, and their impact on patient outcomes remains controversial. We aimed to determine the role of genetic alterations in PTC patient outcomes (recurrent/persistent disease, structural disease, and disease-specific mortality (DSM)). The series included 241 PTC patients submitted to surgery, between 2002-2015, in a single hospital. DNA was extracted from tissue samples of 287 lesions (primary tumors and metastases). Molecular alterations were detected by Sanger sequencing. Primary tumors presented 143 BRAF, 16 TERTp, and 13 RAS mutations. Isolated TERTpmut showed increased risk of structural disease (HR = 7.0, p < 0.001) and DSM (HR = 10.1, p = 0.001). Combined genotypes, BRAFwt/TERTpmut (HR = 6.8, p = 0.003), BRAFmut/TERTpmut (HR = 3.2, p = 0.056) and BRAFmut/TERTpwt (HR = 2.2, p = 0.023) showed increased risk of recurrent/persistent disease. Patients with tumors BRAFwt/TERTpmut (HR = 24.2, p < 0.001) and BRAFmut/TERTpmut (HR = 11.5, p = 0.002) showed increased risk of structural disease. DSM was significantly increased in patients with TERTpmut regardless of BRAF status (BRAFmut/TERTpmut, log-rank p < 0.001; BRAFwt/TERTpmut, log-rank p < 0.001). Our results indicate that molecular markers may have a role in predicting PTC patients' outcome. BRAFmut/TERTpwt tumors were prone to associate with local aggressiveness (recurrent/persistent disease), whereas TERTpmut tumors were predisposed to recurrent structural disease and DSM.

Clinicopathological Features as Prognostic Predictors of Poor Outcome in Papillary Thyroid Carcinoma.

Papillary thyroid cancer (PTC) has an indolent nature and usually excellent prognosis. Some PTC clinicopathological features may contribute to the development of aggressive metastatic disease. In this work, we want to evaluate PTC clinicopathological features that are presurgical prognostic predictors of patients' outcomes and find which indicators are more adequate for tailoring surgical procedures and follow-up. We studied a series of 241 PTC patients submitted to surgery. All patients' files and histological tumor samples were reviewed. The 8th edition AJCC/UICC (American Joint Committee on Cancer/Union for International Cancer) Controlstaging system and the 2015 American Thyroid Association risk stratification system were used. Total thyroidectomy was performed in 228 patients, lymphadenectomy in 28 patients. Gross extrathyroidal extension (ETE) was present in 10 patients and 31 tumor resection margins were incomplete. Cervical lymph node metastases (LNMs) were present in 34 patients and distant metastases at diagnosis in four patients. In multivariate analysis, male gender (OR = 15.4, p = 0.015), venous invasion (OR = 16.7, p = 0.022), and lateral compartment LNM (OR = 26.7, p = 0.004) were predictors of mortality; psammoma bodies (PBs) (OR = 4.5, p = 0.008), lymph vessel invasion (OR = 6.9, p < 0.001), and gross ETE (OR = 16.1, p = 0.001) were predictors of structural disease status; male gender (OR = 2.9, p = 0.011), lymph vessel invasion (OR = 2.8, p = 0.006), and incomplete resection margins (OR = 4.6, p < 0.001) were predictors of recurrent/persistent disease. Our study supports that the factors helping to tailor patient's surgery are male gender, presence of PBs, gross ETE, and lateral compartment LNM. Together with pathological factors, lymph vessel invasion, venous invasion, necrosis, and incomplete surgical resection, should be taken into consideration regarding treatment and follow-up of patients.

Impact on sexual function of surgical treatment in rectal cancer

ABSTRACT Introduction The development of new surgical techniques and medical devices, like therapeutical multimodal approaches has allowed for better outcomes on patients with rectal cancer (RCa). Owing to that, an increased awareness and investment towards better outcomes regarding patients' sexual and urinary function has been recently observed. Aim Evaluate and characterize the sexual dysfunction of patients submitted to surgical treatment for RCa. Materials and Methods An observational retrospective study including all male patients who underwent a surgical treatment for RCa between January 2011 December 2014 (n=43) was performed, complemented with an inquiry questionnaire to every patient about its sexual habits and level of function before and after surgery. Discussion All patients were male, with an average of 64yo. (range 42-83yo.). The surgical procedure was a rectum anterior resection (RAR) in 22 patients (56%) and an abdominoperineal resection (APR) in 19(44%). Sixty three percent described their sexual life as important/very important. Sexual function worsening was observed in 76% (65% with complains on erectile function, and 27% on ejaculation). Fourteen patients (38%) didn't resume sexual activity after surgery. Increased age (p=0.007), surgery performed (APR) (p=0.03) and the presence of a stoma (p=0.03) were predictors of ED after surgery. A secondary analysis found that the type of surgery (APR) (p=0.04), lower third tumor's location (p=0.03) and presence of comorbidities (p=0.013) (namely, smokers and diabetic patients) were predictors of de novo ED after surgery. Conclusions This study demonstrated the clear negative impact in sexual function of patients submitted to a surgical treatment for RCa. Since it is a valued feature for patients, it becomes essential to correctly evaluate/identify these cases in order to offer an adequate therapeutical option.

Impact on sexual function of surgical treatment in rectal cancer.

INTRODUCTION: The development of new surgical techniques and medical devices, like therapeutical multimodal approaches has allowed for better outcomes on patients with rectal cancer (RCa). Owing to that, an increased awareness and investment towards better outcomes regarding patients' sexual and urinary function has been recently observed. AIM: Evaluate and characterize the sexual dysfunction of patients submitted to surgical treatment for RCa. MATERIALS AND METHODS: An observational retrospective study including all male patients who underwent a surgical treatment for RCa between January 2011 December 2014 (n=43) was performed, complemented with an inquiry questionnaire to every patient about its sexual habits and level of function before and after surgery. DISCUSSION: All patients were male, with an average of 64yo. (range 42-83yo.). The surgical procedure was a rectum anterior resection (RAR) in 22 patients (56%) and an abdominoperineal resection (APR) in 19(44%). Sixty three percent described their sexual life as important/very important. Sexual function worsening was observed in 76% (65% with complains on erectile function, and 27% on ejaculation). Fourteen patients (38%) didn't resume sexual activity after surgery. Increased age (p=0.007), surgery performed (APR) (p=0.03) and the presence of a stoma (p=0.03) were predictors of ED after surgery. A secondary analysis found that the type of surgery (APR) (p=0.04), lower third tumor's location (p=0.03) and presence of comorbidities (p=0.013) (namely, smokers and diabetic patients) were predictors of de novo ED after surgery. CONCLUSIONS: This study demonstrated the clear negative impact in sexual function of patients submitted to a surgical treatment for RCa. Since it is a valued feature for patients, it becomes essential to correctly evaluate/identify these cases in order to offer an adequate therapeutical option.

Endoscopic management of non-iatrogenic gastrointestinal perforations - A case series / Manejo endoscópico de perforaciones gastrointestinales no iatrogénicas

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Hemosuccus pancreaticus: a rare complication of chronic pancreatitis.

Hemosuccus pancreaticus is a very rare cause of gastrointestinal bleeding and it should be considered in every patient with history of chronic pancreatitis who presents with acute or intermittent gastrointestinal haemorrhage. A 54-year-old man with a history of chronic alcoholic pancreatitis was admitted to hospital for an acute exacerbation. During hospital stay, he presented with haematemesis and haemodynamic instability. Upper gastrointestinal endoscopy revealed a blood clot on Vater papilla. CT investigation showed a 4 cm cephalopancreatic pseudocyst and angiography identified a large pseudoaneurysm of the right gastroepiploic artery, bleeding into the pseudocyst-hemosuccus pancreaticus. Microcoil transcatheter embolisation was performed with success.

Conventional clinical and pathological features fail to accurately predict recurrence in patients with gastric cancer staged N0.

INTRODUCTION: Despite the medical-surgical advances, even after R0 gastric resections, some patients without apparent metastatic disease develop cancer recurrence and eventually die. AIMS: We aimed to define recurrence in patients with node-negative gastric adenocarcinoma and to determine whether any clinicopathological features are predictive for recurrence. MATERIALS AND METHODS: This was a retrospective cohort study on patients with gastric adenocarcinoma, consecutively diagnosed at our institution, staged as N0M0 between January 2000 and December 2008. RESULTS: We recruited 129 patients; 53% were men and 56% were older than 60 years. A total of 22% of the patients developed recurrence, with a mortality rate of 93%. Overall, 71% of the patients, N0, with recurrence presented lymphatic permeation. In univariate analysis, on comparing recurrent patients with those with no recurrence, age, size, T status, lymphatic, and venous permeation were factors that were associated significantly with recurrence, but in multivariate analysis, only age (odds ratio:19.5; 95% confidence interval: 2.3-168; P=0.008) and venous permeation (odds ratio: 6.34; 95% confidence interval: 1.8-22.8; P=0.005) were associated with recurrence. On the basis of only these two factors, the proportion of missed recurrent patients by age and venous permeation was 13 and 39%, respectively. CONCLUSION: A total of 22% of patients, N0, developed recurrence of their disease. Age and venous permeation were independent risk factors for recurrence, but on the basis of these factors, up to 40% of patients may be missed for recurrence. New methods to predict recurrence are needed.

Ruptured jejunal artery aneurysm.

Visceral artery aneurysms (VAAs), unlike aortic aneurysms, are very rare, but are also a potentially lethal vascular disease. Jejunal artery aneurysms only account for less than 3% of VAAs, but have a 30% risk of rupture, with 20% death rate, presenting with only few and vague symptoms. We report the case of a 76-year-old man presenting at the emergency department (ED) with a crampy epigastric pain and vomiting. An ultrasound performed diagnosed free abdominal fluid and immediate CT scan diagnosed jejunal artery aneurysm spontaneously rupturing, followed by hypovolaemic shock. Emergent surgery was undertaken, and aneurysmectomy, followed by partial enterectomy with primary anastomosis were performed, because of segmentary jejunal ischaemia. The patient's recovery was unremarkable. High level of suspicion, rapid diagnosis capability and prompt surgical or endovascular intervention, as well as an effective teamwork in the ED are critical to avoid the devastating consequences of ruptured VAAs.

Analysis of clinicopathologic characteristics and prognosis of gastric cancer in young and older patients.

BACKGROUND: The worldwide incidence of gastric cancer is gradually declining, however it remains the fourth highest in cancer incidence and the second leading cause of cancer death. Gastric cancer in young people is a disturbing problem and the routine screening does not include people less than 35 years. The clinicopathological features of gastric carcinoma are said to differ between young and elderly patients and it is thought that the prognosis of this disease is worse for younger patients. It is also suggested that the diagnosis is usually made later or have a more aggressive behaviour. Although, others report that tumor staging and prognosis for young patients is similar to older patients and depends on whether the patients undergo a curative resection. All these data need more investigation and studies. Although Portugal has a high incidence of gastric cancer, no studies have yet been performed comparing the clinicopathologic features and prognosis of young and elderly patients with gastric cancer. AIMS: This study intend to assess whether the clinicopathological features and prognosis of gastric cancer in young patients (YGC) is similar to older ones (OGC). METHODS: Between 2000 and 2005, 406 patients with histological diagnosis of primary gastric cancer, treated in the Departments of Surgery and Oncology at the Centro Hospitalar of Vila Nova de Gaia / Espinho, were regularly followed at least for five years after surgery. These were reviewed retrospectively. Several variables were analyzed in young patients and compared with the elder ones. We used the chi-square and Fisher to evaluate the statistical association between categorical variables and t-test for numeric variables. Survival was estimated by the Kaplan-Meier method and used the log-rank test to assess differences in survival among different subgroups of patients. The criteria for statistical significance was p < 0.05. Data analysis was performed using the SPSS 18. RESULTS AND CONCLUSIONS: With regard to resectability, 78 % of the tumors were resected in the group of younger patients, the surgery more frequently achieved was total gastrectomy with anastomosis in Y of Roux. In the elder group, about 62 % of the tumors were resected and BII gastrectomy was the most frequent surgery. The diffuse adenocarcinoma was the most frequent histological type in younger patients, whereas in older patients was intestinal adenocarcinoma. With regard to the stage in the first group there was a predominance of stages: IA and IV (26.1 %) in the second: IV (25.8 %). The survival for stage III e IV was significantly worst in YGC compared with OGC.

Breast angiosarcoma secondary to phyllodes tumour.

Angiosarcomas are rare malignant tumours that arise from endothelial cells lining vascular channels, representing 0.04% of malignant neoplasms of the breast. Breast angiosarcomas (BAs) were first described by Schmidt in 1887, and may be primary or secondary to the pre-existing conditions. Primary BAs are more common in young women and present as a palpable mass. Secondary BAs arise in older patients, frequently 5-6 years after radiotherapy, and present as a rash.The authors describe the case of an 83-year-old woman with no history of thoracic radiotherapy or surgery. She had been observed for a breast nodule where biopsy revealed phyllodes tumour. The patient refused surgery and returned 2 years later because of an impressive increase in tumour volume and skin ulceration. She underwent mastectomy with local skin flaps. Histopathological result revealed high-grade angiosarcoma of 15×12 cm. There was follow-up without evidence of recurrence, after radiotherapy.

Sporadic exophytic hepatic angiomyolipoma.

Angiomyolipomas are rare mesenchymal tumours consisting of smooth muscle, blood vessels and adipocytes in variable proportions. These tumours are more usually seen in kidneys (incidence 0.3-3%), and the extrarenal location is rare. Since its initial description by Ishak in 1976, only about 200 cases of hepatic angiomyolipomas have been reported. We describe the case of a 59-year-old woman, without tuberous sclerosis, with a 6 cm tumour in hepatic segments II and III, gallbladder with parietal calcification and lithiasis. She was proposed to bisegmentectomy (II and III) and cholecystectomy, which were performed without complications. The pathological examination confirmed the diagnosis of hepatic angiomyolipoma (positive for HMB45 and focally positive for HHF35) and chronic cholecystitis. Although typically benign, the emergence of cases with malignant behaviour--recurrence or distant metastasis--led to a change in attitude towards these lesions, from clinical surveillance to surgical excision, with few exceptions.

Neuroendocrine breast cancer.

Neuroendocrine breast cancer is thought to account for about 1% of all breast cancers. This rare type of breast malignancy is more common in older women and presents as a low-grade, slow-growing cancer. The most definitive markers that indicate neuroendocrine carcinoma are the presence of chromogranin, synaptophysin or neuron-specific enolase, in at least 50% of malignant tumour cells. The authors present a case report of an 83-year-old woman, admitted to their institution with right breast lump. Physical examination, mammography and ultrasonography showed a 2.4 cm nodule, probably a benign lesion (BI-RADS 3). A fine needle aspiration biopsy was performed and revealed proliferative epithelial papillary lesion. She was submitted to excisional biopsy and histology showed endocrine breast cancer well differentiated (G1). Immunohistochemically, tumour cells were positive for synaptophysin. These breast cancers are characterised for their excellent prognosis and conservative treatment is almost always enough to obtain patient cure.

Gastric GIST with synchronous neuroendocrine tumour of the pancreas in a patient without neurofibromatosis type 1.

The gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract. These are rare tumours with an incidence of 15 new cases per million per year. The occurrence of neuroendocrine tumours of the pancreas is rare, representing 1-5% of pancreatic cancers, and it is estimated that its incidence does not exceed five to one million. GISTs are common in patients with neurofibromatosis type 1 (NF1); there are few reported cases of synchronous neuroendocrine tumours in these patients and most are pheochromocytomas. The case reports a 64-year-old woman referred to the General Surgery Outpatient for incidental finding of gastric and pancreatic tumours. She underwent a radical subtotal pancreatectomy + partial gastrectomy with jejunal transposition. The pathological examination revealed: gastric GISTs and a well-differentiated neuroendocrine carcinoma of the pancreas. This is the second case published so far of a patient with both tumours and without NF1. Posterior studies must be performed to evaluate if some other genetic disorder is involved in these patients without NF1.

[Bariatric surgery: epidemic of the XXI century]. / Cirurgia bariátrica: do passado ao século XXI.

Obesity is a chronic and endemic disease in developed countries, there is an inverse relationship between the socio-economic level and the prevalence of this disease. Their costs are responsible from 2 to 7% of the total health costs. The prevalence of obesity in the world is so high that the World Health Organization considered this disease as the global epidemic of the XXI century. In Portugal it's estimated that around 16.5% of the population aged over 18 years, has obesity, and due to the morbidity and mortality associated with this pathology, this constitutes a serious public health issue. There are several ancient references to obesity and its consequences, with descriptions of different therapeutic attitudes. But only in 1965 the term bariatric was introduced and consequently the term bariatric surgery. Mason, the father of bariatric surgery, started its history in 1966. Several surgical techniques were subsequently developed, but currently the most used are the gastric bandoplastia, a restrictive surgery, and the gastric bypass, a combined surgery. Today, the bariatric surgery is not limited to the treatment of obesity, but the treatment of a syndrome associated with obesity, allowing a significant improvement in Quality of life of these patients. Thus, it's licit to think that the surgery that allows addressing the epidemic of the XXI century is the surgery of the century, with curative rates, of obesity and their comorbidities, which were never achieved by any other pharmacological treatment.