Histopathologic Changes in Congenital Corneal Stromal Dystrophy: Report of 4 Cases in 2 Families.

Corneal dystrophies are hereditary diseases affecting the corneal tissue; they are bilateral, symmetrical and unrelated to environmental or systemic conditions. Congenital corneal stromal dystrophy is a very rare autosomal dominant dystrophy that is caused by a mutation in the DCN gene that encodes decorin (a proteoglycan of the extracellular matrix). We herein report 4 cases of congenital stromal corneal dystrophy in 2 families, highlighting the previously undescribed histopathologic features, the possible differential diagnosis of this entity and the key role played by decorin staining in its diagnosis.

Histological artifacts associated with laser and electroscalpel gingivectomy: Case series / Artefactos histológicos asociados a gingivectomía con láser y electrobisturí: serie de casos

Introduction. Over time, efforts have been invested in the design of new instruments that overcome the disadvantages of the gold standard instrument in surgery, the scalpel. As a result, electronic equipment has emerged such as the electric scalpel and laser devices. The available evidence on these instruments suggests that the tissue response is related to each instrument's physical and biological cutting principles. Objective. To compare the histological changes in gingiva samples associated with surgical cutting performed with a 940 nm diode laser, a 2780 nm erbium, chromium: yttriumscandium-gallium-garnet (Er,Cr:YSGG) laser, and an electric scalpel, by presenting a series of cases. Case presentation. We present three cases of healthy patients undergoing cosmetic surgery. The clinical examination revealed exposure of a keratinized gingiva band greater than 4 mm, normal color and texture in gingival tissue, with a firm consistency and no bleeding on periodontal probing. Gingivectomy was indicated with the following protocols: Diode laser of 940 nm at 1 W, in continuous mode; Er,Cr:YSGG laser of 2780 nm at 2.5 W, 75 Hz, H mode, air 20, water 40, gold tip MT4); and electric scalpel in cutting mode at power level four. Gingival tissue samples were taken and stored in 10% formaldehyde for histological analysis. Conclusion. All the evaluated cutting instruments generated histological changes produced by the thermal effect, the main ones being collagen coagulation and carbonization. The depth of thermal damage caused by the 2780 nm Er,Cr:YSGG laser was much lesser than that induced by the electric scalpel and the 940 nm diode laser.

Introducción. Históricamente se ha invertido esfuerzo en el diseño de nuevos instrumentos que superen las desventajas del estándar de referencia en cirugía, el bisturí. Como consecuencia de esto, han surgido equipos electrónicos como el electrobisturí y los diferentes dispositivos de tecnología láser. La información disponible sobre estos instrumentos sugiere que la respuesta del tejido intervenido está influenciada por los principios físicos y biológicos de corte del instrumento. Objetivo. Comparar los cambios histológicos en muestras de encía asociados al corte quirúrgico realizado con láser de diodo de 940 nm, láser de erbio, cromo: itrio-escandio-galio-granate (Er,Cr:YSGG) (2780nm) y electrobisturí mediante una presentación de serie de casos. Presentación de los casos. Se presentan tres casos de pacientes sanos sometidos a cirugía estética. El examen clínico reveló la exposición de una banda gingival queratinizada mayor de 4 mm, tejido gingival de color y textura normales, de consistencia firme y sin sangrado al sondaje periodontal. Se indicó gingivectomía con los siguientes protocolos: láser de diodo de 940 nm a 1 W, en modo continuo; láser de Er,Cr:YSGG de 2780 nm a 2,5 W, 75 Hz, modo H, aire 20, agua 40, punta de oro MT4; y bisturí eléctrico en modo de corte, a nivel de potencia cuatro. Se tomaron muestras de tejido gingival y se almacenaron en formaldehído al 10 % para su análisis histológico. Conclusión. Los tres instrumentos de corte generaron cambios histológicos producidos por el efecto térmico; los principales fueron coagulación del colágeno y carbonización. La profundización del daño térmico causada por el láser de Er,Cr:YSGG de 2780 nm fue mucho menor que la generada por el electrobisturí y por el láser de diodo de 940 nm.

Ultrafast track versus conventional fast track in patients undergoing cardiac surgery: a propensity score-matched analysis.

OBJECTIVES: We aimed at comparing the risk of major adverse events and length of stay between patients undergoing ultrafast track and conventional fast track. METHODS: Retrospective cohort study adjusted by propensity score matching, including patients operated on between March 2020 and December 2022 of any of the following: coronary, valve surgery or ascending aorta surgery. Patients were divided into 2 groups: ultrafast track: extubation in the operating room and fast track: extubation attempted in the first 6 postoperative hours. The primary objective was to compare the risk of the combined event death, lung respiratory outcomes (reintubation, mechanical ventilation longer than 24 h or pneumonia), or acute renal failure. RESULTS: A total of 1126 patients were included. A total of 579 (51.4%) were extubated in the operating room. A total of 331 pairs were available after matching by propensity score. The risk of the primary outcome was 11.8% (n = 39) in the fast-track group and 6.3% (n = 21) in the ultrafast-track group (P = 0.013), mostly driven by lung adverse events (6.9% vs 2.4%, P = 0.011) while no significant differences were detected in the risk of death (2.4% vs 1.8%, P = 0.77) or acute renal failure (8% vs 6.3%, P = 0.56). The risk of myocardial infarction was higher in the fast-track group (2.7% vs 0%, P = 0.039). The median length of stay in the postoperative intensive care unit was longer in the fast-track group [24.7 h (interquartile range 21.5; 62.9) vs 23.5 h (interquartile range 22; 46), P = 0.015]. CONCLUSIONS: In patients undergoing cardiac surgery, extubation in the operating room is associated to a lower risk of postoperative complications (mostly driven by lung adverse events) and length of stay in intensive care unit as compared to fast track.

Evaluation of Composites Reinforced by Processed and Unprocessed Coconut Husk Powder.

Engineering activities aim to satisfy the demands of society. Not only should the economic and technological aspects be considered, but also the socio-environmental impact. In this sense, the development of composites with the incorporation of waste has been highlighted, aiming not only for better and/or cheaper materials, but also optimizing the use of natural resources. To obtain better results using industrial agro waste, we need to treat this waste to incorporate engineered composites and obtain the optimal results for each application desired. The objective of this work is to compare the effect of processing coconut husk particulates on the mechanical and thermal behavior of epoxy matrix composites, since we will need a smooth composite in the near future to be applied by brushes and sprayers with a high quality surface finish. This processing was carried out in a ball mill for 24 h. The matrix was a Bisphenol A diglycidyl ether (DGEBA)/triethylenetetramine (TETA) epoxy system. The tests that were performed were resistance to impact and compression, as well as the linear expansion test. Through this work, it can be observed that the processing of coconut husk powder was beneficial, allowing not only positive improvements to the properties of the composite, but also a better workability and wettability of the particulates, which was attributed to the change in the average size and shape of particulates. That means that the composites with processed coconut husk powders have improved impact strength (46 up to 51%) and compressive strength (88 up to 334%), in comparison with unprocessed particles.

A needle in a haystack: A new metabarcoding approach to survey diversity at the species level of Arcellinida (Amoebozoa: Tubulinea).

Environmental DNA-based diversity studies have increased in popularity with the development of high throughput sequencing technologies. This permits the potential simultaneous retrieval of vast amounts of molecular data from many different organisms and species, thus contributing to a wide range of biological disciplines. Environmental DNA protocols designed for protists often focused on the highly conserved small subunit of the ribosome gene, that does not permit species-level assignments. On the other hand, eDNA protocols aiming at species-level assignments allow a fine level ecological resolution and reproducible results. These protocols are currently applied to organisms living in marine and shallow lotic freshwater ecosystems, often in a bioindication purpose. Therefore, in this study, we present a species-level eDNA protocol designed to explore diversity of Arcellinida (Amoebozoa: Tubulinea) testate amoebae taxa that is based on mitochondrial cytochrome oxidase subunit I (COI). These organisms are widespread in lentic water bodies and soil ecosystems. We applied this protocol to 42 samples from peatlands, estuaries and soil environments, recovering all the infraorders in Glutinoconcha (with COI data), except for Hyalospheniformes. Our results revealed an unsuspected diversity in morphologically homogeneous groups such as Cylindrothecina, Excentrostoma or Sphaerothecina. With this protocol we expect to revolutionize the design of modern distributional Arcellinida surveys. Our approach involves a rapid and cost-effective analysis of testate amoeba diversity living in contrasted ecosystems. Therefore, the order Arcellinida has the potential to be established as a model group for a wide range of theoretical and applied studies.

Co-Management Reduces Mortality in Post-Sternotomy Mediastinitis.

Background: Post-sternotomy mediastinitis (PSM) is one of the most feared complications of cardiac surgery. The impact of a multidisciplinary management approach on this pathology is yet unknown. Patients and Methods: A multidisciplinary approach based on a co-management model (CMM) of care was initiated in January 2018 because of the incorporation of a hospitalist unit on a cardiac surgery department. An observational retrospective cohort study was designed to evaluate the impact of the CMM of care compared to the standard model (SM) of care in patients diagnosed with PSM. Our primary and secondary outcomes were survival time and treatment failure rate (two or more surgical procedures needed to solve PSM or PSM-related death), respectively. Data related to patient death date were collected from the Spanish National Death Index. A multivariable Cox regression model was created using those variables believed to be clinically relevant. Results: Ninety-one patients developed PSM from January 2010 to June 2020. Regarding the pre-operative clinical status, surgical procedure, and PSM severity, both groups had similar baseline characteristics. Patients were followed for a mean of 27.54 ± 30.5 months. A total of 60.3% of the SM group and 11.1% of the CMM group (p < 0.001) died. Treatment failure occurred in 53 patients (72.6%) in the SM group versus 7 (38.6%) in the CMM group (p = 0.007). The CMM independently reduced overall mortality (hazard ratio [HR], 0.11; 95% confidence interval [CI]. 0.01-0.83) and treatment failure rate (HR, 0.01; 95% CI, 0.001-0.183). Gram-positive bacterial infection (HR, 3.73; 95% CI, .6-8.3), and complete osteosynthesis material removal (HR, 0.47; 95% CI, 0.24-0.91) also influenced mortality in our model. Conclusions: A co-management care model reduced overall mortality in patients diagnosed with post-sternotomy mediastinitis.

TRANSALUD: A qualitative study of the healthcare experiences of transgender people in Barcelona (Spain).

Transgender identities are still considered a psychiatric pathology in many countries according to the prevailing biomedical model. However, in recent years, this pathologizing vision has begun to shift towards a perspective that focuses on the diversity of transgender peoples' experiences. However, some transgender people still face denial of services, discrimination, harassment, and even violence by healthcare professionals, causing them to avoid seeking ongoing or preventive healthcare. This article describes the health experiences of transgender people in Barcelona regarding their access and use of non-specialized health services. Semi-structured interviews were conducted using a descriptive phenomenological approach with sixteen transgender people between December 2018 and July 2019. The data were analyzed descriptively and thematically following the method proposed by Colaizzi with the help of the Atlas.ti8 software. Transgender people care experiences were divided into three categories: overcoming obstacles, training queries, and coping strategies. Participants identified negative experiences and difficulties with the health system due to healthcare providers' lack of competence. Discriminatory, authoritarian, and paternalist behaviors are still present and hinder the therapeutic relationship, care, and access to healthcare services. There is a fundamental need for the depathologization of transgender reality and training for healthcare professionals in the field of sexual diversity. Training in sexual and gender diversity must be included in the curricula of university courses in the health sciences.

Analysis of the Effects of Melanin Depigmentation on Immunohistochemical Staining.

Heavily pigmented lesions are difficult to evaluate histologically, as melanin obscures cellular details. Several classic laboratory techniques aim to clear melanin and allow evaluation. Most of them are old and appeared before immunohistochemistry (IHC) use. Many laboratories perform IHC with aminoethylcarbazole instead of diaminobenzidine (DAB) in heavily pigmented lesions, as red-stained is easy to interpret despite pigmentation. Nevertheless, many laboratories lack alternatives to DAB. The aim of this study is to compare 6 different tissue bleaching techniques and evaluate which is the best for immunohistochemical staining with DAB. In the present study we have selected a case with gross pigmentation because of the high grade of melanin deposition. We have performed 6 different bleaching techniques and subsequently performed 2 different IHC stains, frequently used in melanoma: SOX10 (nuclear) and Melan-A (cytoplasmic). Five different pathologists, 2 of them with expertise in dermatopathology, have blindly reviewed and scored the staining quality. Our results indicate a high grade of interobserver concordance in the evaluation of IHC results between pathologists. All the bleaching techniques that included a sulfuric acid led to tissue detachment from the slide. The best method for SOX10 was that based in potassium permanganate, with a high quality of staining (4 over 5), while the best method for Melan-A was the 1 based in peroxide hydrogen (4 over 5). We consider this study can be quite useful for those laboratories lacking aminoethylcarbazole for IHC techniques, allowing the use of DAB for IHC of heavily pigmented lesions.

Cyphoderia ampulla (Cyphoderiidae: Rhizaria), a tale of freshwater sailors: The causes and consequences of ecological transitions through the salinity barrier in a family of benthic protists.

The salinity barrier that separates marine and freshwater biomes is probably the most important division in biodiversity on Earth. Those organisms that successfully performed this transition had access to new ecosystems while undergoing changes in selective pressure, which often led to major shifts in diversification rates. While these transitions have been extensively investigated in animals, the tempo, mode, and outcome of crossing the salinity barrier have been scarcely studied in other eukaryotes. Here, we reconstructed the evolutionary history of the species complex Cyphoderia ampulla (Euglyphida: Cercozoa: Rhizaria) based on DNA sequences from the nuclear SSU rRNA gene and the mitochondrial cytochrome oxidase subunit I gene, obtained from publicly available environmental DNA data (GeneBank, EukBank) and isolated organisms. A tree calibrated with euglyphid fossils showed that four independent transitions towards freshwater systems occurred from the mid-Miocene onwards, coincident with important fluctuations in sea level. Ancestral trait reconstructions indicated that the whole family Cyphoderiidae had a marine origin and suggest that ancestors of the freshwater forms were euryhaline and lived in environments with fluctuating salinity. Diversification rates did not show any obvious increase concomitant with ecological transitions, but morphometric analyses indicated that species increased in size and homogenized their morphology after colonizing the new environments. This suggests adaptation to changes in selective pressure exerted by life in freshwater sediments.

GXP: Analyze and Plot Plant Omics Data in Web Browsers.

Next-generation sequencing and metabolomics have become very cost and work efficient and are integrated into an ever-growing number of life science research projects. Typically, established software pipelines analyze raw data and produce quantitative data informing about gene expression or concentrations of metabolites. These results need to be visualized and further analyzed in order to support scientific hypothesis building and identification of underlying biological patterns. Some of these tools already exist, but require installation or manual programming. We developed "Gene Expression Plotter" (GXP), an RNAseq and Metabolomics data visualization and analysis tool entirely running in the user's web browser, thus not needing any custom installation, manual programming or uploading of confidential data to third party servers. Consequently, upon receiving the bioinformatic raw data analysis of RNAseq or other omics results, GXP immediately enables the user to interact with the data according to biological questions by performing knowledge-driven, in-depth data analyses and candidate identification via visualization and data exploration. Thereby, GXP can support and accelerate complex interdisciplinary omics projects and downstream analyses. GXP offers an easy way to publish data, plots, and analysis results either as a simple exported file or as a custom website. GXP is freely available on GitHub (see introduction).

Selection of AmpC ß-Lactamase Variants and Metallo-ß-Lactamases Leading to Ceftolozane/Tazobactam and Ceftazidime/Avibactam Resistance during Treatment of MDR/XDR Pseudomonas aeruginosa Infections.

Infections caused by ceftolozane-tazobactam and ceftazidime-avibactam-resistant P. aeruginosa infections are an emerging concern. We aimed to analyze the underlying ceftolozane-tazobactam and ceftazidime-avibactam resistance mechanisms in all multidrug-resistant or extensively drug-resistant (MDR/XDR) P. aeruginosa isolates recovered during 1 year (2020) from patients with a documented P. aeruginosa infection. Fifteen isolates showing ceftolozane-tazobactam and ceftazidime-avibactam resistance were evaluated. Clinical conditions, previous positive cultures, and ß-lactams received in the previous month were reviewed for each patient. MICs were determined by broth microdilution. Multilocus sequence types (MLSTs) and resistance mechanisms were determined using short- and long-read whole-genome sequencing (WGS). The impact of Pseudomonas-derived cephalosporinases (PDCs) on ß-lactam resistance was demonstrated by cloning into an ampC-deficient PAO1 derivative (PAOΔC) and construction of 3D models. Genetic support of acquired ß-lactamases was determined in silico from high-quality hybrid assemblies. In most cases, the isolates were recovered after treatment with ceftolozane-tazobactam or ceftazidime-avibactam. Seven isolates from different sequence types (STs) owed their ß-lactam resistance to chromosomal mutations and all displayed specific substitutions in PDC: Phe121Leu and Gly222Ser, Pro154Leu, Ala201Thr, Gly214Arg, ΔGly203-Glu219, and Glu219Lys. In the other eight isolates, the ST175 clone was overrepresented (6 isolates) and associated with IMP-28 and IMP-13, whereas two ST1284 isolates produced VIM-2. The cloned PDCs conferred enhanced cephalosporin resistance. The 3D PDC models revealed rearrangements affecting residues involved in cephalosporin hydrolysis. Carbapenemases were chromosomal (VIM-2) or plasmid-borne (IMP-28, IMP-13) and associated with class-1 integrons located in Tn402-like transposition modules. Our findings highlighted that cephalosporin/ß-lactamase inhibitors are potential selectors of MDR/XDR P. aeruginosa strains producing PDC variants or metallo-ß-lactamases. Judicious use of these agents is encouraged.

Nonuniversal large-size asymptotics of the Lyapunov exponent in turbulent globally coupled maps.

Globally coupled maps (GCMs) are prototypical examples of high-dimensional dynamical systems. Interestingly, GCMs formed by an ensemble of weakly coupled identical chaotic units generically exhibit a hyperchaotic "turbulent" state. A decade ago, Takeuchi et al. [Phys. Rev. Lett. 107, 124101 (2011)PRLTAO0031-900710.1103/PhysRevLett.107.124101] theorized that in turbulent GCMs the largest Lyapunov exponent (LE), λ(N), depends logarithmically on the system size N: λ_{∞}-λ(N)≃c/lnN. We revisit the problem and analyze, by means of analytical and numerical techniques, turbulent GCMs with positive multipliers to show that there is a remarkable lack of universality, in conflict with the previous prediction. In fact, we find a power-law scaling λ_{∞}-λ(N)≃c/N^{γ}, where γ is a parameter-dependent exponent in the range 0<γ≤1. However, for strongly dissimilar multipliers, the LE varies with N in a slower fashion, which is here numerically explored. Although our analysis is only valid for GCMs with positive multipliers, it suggests that a universal convergence law for the LE cannot be taken for granted in general GCMs.

Variablity of Mechanical or Tissue Valve Implantation in Patients Undergoing Surgical Aortic Valve Replacement in Spain: National Retrospective Analysis from 2007 to 2018.

BACKGROUND: There is no robust evidence regarding the types of valves implanted among patients undergoing surgical aortic valve replacement (SAVR) in Spain. METHODS: All cases of patients undergoing SAVR ± coronary artery bypass grafting from January 2007 to December 2018 in the public Spanish National Health System were included. We analyzed the trends of SAVR volume, risk profile and type of implanted valve across time and place. Using multivariable logistic regression, we identified factors associated with biological SAVR. RESULTS: In total, 62,870 episodes of SAVR in 15 Spanish territories were included. In 35,693 (56.8%), a tissue valve was implanted. The annual volume of procedures increased from 107.3/million (2007) to 128.6 (2017). In 2018, it fell to 108.5. Age increased and Charlson's comorbity index worsened throughout the study period. Tissue valve implantation increased in most regions. After adjusting for other covariates, we observed a high variability in aortic valve implantation across different regions, with differences of as much as 20-fold in the use of tissue valves. CONCLUSIONS: Between 2007 and 2018, we detected a significant increase in the use of bioprostheses in patients undergoing SAVR in Spain, and a great variability in the types of valve between the Spanish territories, which was not explained by the different risk profiles of patients.

Serial disparity in the carnivoran backbone unveils a complex adaptive role in metameric evolution.

Organisms comprise multiple interacting parts, but few quantitative studies have analysed multi-element systems, limiting understanding of phenotypic evolution. We investigate how disparity of vertebral morphology varies along the axial column of mammalian carnivores - a chain of 27 subunits - and the extent to which morphological variation have been structured by evolutionary constraints and locomotory adaptation. We find that lumbars and posterior thoracics exhibit high individual disparity but low serial differentiation. They are pervasively recruited into locomotory functions and exhibit relaxed evolutionary constraint. More anterior vertebrae also show signals of locomotory adaptation, but nevertheless have low individual disparity and constrained patterns of evolution, characterised by low-dimensional shape changes. Our findings demonstrate the importance of the thoracolumbar region as an innovation enabling evolutionary versatility of mammalian locomotion. Moreover, they underscore the complexity of phenotypic macroevolution of multi-element systems and that the strength of ecomorphological signal does not have a predictable influence on macroevolutionary outcomes.

Phenotypic integration in the carnivoran backbone and the evolution of functional differentiation in metameric structures.

Explaining the origin and evolution of a vertebral column with anatomically distinct regions that characterizes the tetrapod body plan provides understanding of how metameric structures become repeated and how they acquire the ability to perform different functions. However, despite many decades of inquiry, the advantages and costs of vertebral column regionalization in anatomically distinct blocks, their functional specialization, and how they channel new evolutionary outcomes are poorly understood. Here, we investigate morphological integration (and how this integration is structured [modularity]) between all the presacral vertebrae of mammalian carnivorans to provide a better understanding of how regionalization in metameric structures evolves. Our results demonstrate that the subunits of the presacral column are highly integrated. However, underlying to this general pattern, three sets of vertebrae are recognized as presacral modules-the cervical module, the anterodorsal module, and the posterodorsal module-as well as one weakly integrated vertebra (diaphragmatic) that forms a transition between both dorsal modules. We hypothesize that the strength of integration organizing the axial system into modules may be associated with motion capability. The highly integrated anterior dorsal module coincides with a region with motion constraints to avoid compromising ventilation, whereas for the posterior dorsal region motion constraints avoid exceeding extension of the posterior back. On the other hand, the weakly integrated diaphragmatic vertebra belongs to the "Diaphragmatic joint complex"-a key region of the mammalian column of exceedingly permissive motion. Our results also demonstrate that these modules do not match with the traditional morphological regions, and we propose natural selection as the main factor shaping this pattern to stabilize some regions and to allow coordinate movements in others.

Morphological evolution of the carnivoran sacrum.

The sacrum is a key piece of the vertebrate skeleton, since it connects the caudal region with the presacral region of the vertebral column and the hind limbs through the pelvis. Therefore, understanding its form and function is of great relevance in vertebrate ecomorphology. However, it is striking that morphometric studies that quantify its morphological evolution in relation to function are scarce. The main goal of this study is to investigate the morphological evolution of the sacrum in relation to its function in the mammalian order Carnivora, using three-dimensional (3D) geometric morphometrics. Principal component analysis under a phylogenetic background indicated that changes in sacrum morphology are mainly focused on the joint areas where it articulates with other parts of the skeleton allowing resistance to stress at these joints caused by increasing muscle loadings. In addition, we demonstrated that sacrum morphology is related to both the length of the tail relativised to the length of the body, and the length of the body relativised to body mass. We conclude that the sacrum in carnivores has evolved in response to the locomotor requirements of the species analysed, but in locomotion, each family has followed alternative morphological solutions to address the same functional demands.

Barriers and Facilitators to Intraoperative Alternatives to Opioids: Examining CRNA Perspectives and Practices.

Opioids are the mainstay of intraoperative pain control, but they have several deleterious effects. Alternative medications and strategies to opioids, while effective in producing intraoperative analgesia, are underutilized by anesthesia providers. The purpose of this study was to examine and describe Certified Registered Nurse Anesthetists' perspectives and practices on administering opioids vs nonopioid or opioid-sparing strategies ("opioid alternatives") to treat intraoperative pain. A qualitative study design using semistructured interviews was conducted (N = 12). Study participants described their perspectives and practices on treating intraoperative pain. Two key themes emerged: (1) barriers to intraoperative opioid-alternative administration and (2) facilitators to intraoperative opioid-alternative administration. Barriers expressed by study participants included opioid superiority, inconsistent analgesic effects of intraoperative opioid alternatives, limited experience with opioid alternatives, limited resources on opioid alternatives, negative experiences with intraoperative opioid-alternative administration, and patient comorbidities. Facilitators expressed by study participants included the adverse effects of opioids, institutional policy and procedures, positive experiences with opioid-alternative administration, and regional anesthesia superiority. This study highlights the importance of improving education, training, and institutional policies in support of opioid-alternative medications and strategies to treat intraoperative pain and better prevent opioid addiction and abuse.

Adenomioepitelioma de mama: descripción de cuatro casos y revisión de la literatura / Adenomyoepithelioma of the breast: report of four cases and literature review

Los adenomioepiteliomas (AME) mamarios son tumores muy poco frecuentes, de histología variable, que pueden simular otras lesiones epiteliales, mioepiteliales y bifásicas de la mama. En el presente estudio analizamos los hallazgos clínico-patológicos de 4 casos de AME diagnosticados en el Hospital Clínico San Carlos en el periodo 2005-2015. La media de edad fue de 57años. Eran nódulos sólidos de bordes irregulares localizados en todos los casos en cuadrantes superiores (3 en mama derecha y uno en mama izquierda), con tamaño medio de 13mm. Microscópicamente 2 de ellos eran variante tubular y 2, lobulada. Se observaron cambios hialinos, áreas mixoides, quísticas, pseudoinfiltración periférica y nódulos satélite en algunos de los casos. Las células mioepiteliales eran fusiformes y fueron positivas para actina, calponina, p63, S100 y CD10 y negativas para CKAE1-AE3, con CK34BE12 y CK5/6 variables. En todos los casos la tumorectomía fue curativa, sin recurrencias ni transformación maligna (AU)

Adenomyoepitheliomas of the breast are infrequent tumors with a variable histological appearance, and they can mimic several epithelial, myoepithelial and biphasic lesions of the breast. We have reviewed four cases of adenomyoepithelioma of the breast diagnosed between 2005 and 2015 in our institution (Hospital Clínico San Carlos). Mean age was 57years. All lesions were solid irregular masses located in the upper quadrants (3 of them in the right breast and one in the left), with an average size of 13mm. Microscopically 2 of them were tubular and the remaining 2 were lobulated subtypes. Hyaline, myxoid and cystic areas, peripheral pseudoinfiltration and satellite nodules were occasionally seen. Myoepithelial cells were fusiform and immunohistochemically they were actin, calponin, p63, S100 and CD10 positive and CKAE1-AE3 negative, with variable CK23BE12 and CK5/6 staining. In all cases lumpectomy was curative, no recurrences or malignant degeneration were observed (AU)

[Adenomyoepithelioma of the breast: Report of four cases and literature review]. / Adenomioepitelioma de mama: descripción de cuatro casos y revisión de la literatura.

Adenomyoepitheliomas of the breast are infrequent tumors with a variable histological appearance, and they can mimic several epithelial, myoepithelial and biphasic lesions of the breast. We have reviewed four cases of adenomyoepithelioma of the breast diagnosed between 2005 and 2015 in our institution (Hospital Clínico San Carlos). Mean age was 57years. All lesions were solid irregular masses located in the upper quadrants (3 of them in the right breast and one in the left), with an average size of 13mm. Microscopically 2 of them were tubular and the remaining 2 were lobulated subtypes. Hyaline, myxoid and cystic areas, peripheral pseudoinfiltration and satellite nodules were occasionally seen. Myoepithelial cells were fusiform and immunohistochemically they were actin, calponin, p63, S100 and CD10 positive and CKAE1-AE3 negative, with variable CK23BE12 and CK5/6 staining. In all cases lumpectomy was curative, no recurrences or malignant degeneration were observed.

Apoplejía hipofisaria en posoperatorio inmediato de cirugía cardiaca: a propósito de un caso / Postoperative pituitary apoplexy: case report after a cardiac surgery

Pituitary apoplexy is caused by ischemia or hemorrhage and is considered a medical emergency. A percentage of undiagnosed pituitary adenomas may be diagnosed in the postoperative period of cardiac surgery. The clinical picture is a consequence of the increase in pressure which causes compression on cerebral structures (optic chiasm, cranial nerves) and hormonal deficit. We present a clinical case of a 69-year-old Caucasian male, who debuted with a clinical syndrome of the left cavernous sinus in the immediate postoperative period of cardiac surgery. Clinical and imaging studies (MRI) confirmed the diagnosis of pituitary apoplexy. The condition was solved satisfactorily with replacement therapy. She underwent urgery sixth days later due to persistence of visual symptoms.

La apoplejía hipofisaria se produce por un infarto o una hemorragia en dicha glándula y se considera una emergencia médica. Un porcentaje de adenomas hipofisarios no diagnosticados debutan clínicamente así, pudiéndose producir en el postoperatorio de cirugía cardiaca. El cuadro clínico es consecuencia del aumento de presión y volumen en el interior de la silla turca, lo que origina compresión de las estructuras cerebrales colindantes (quiasma óptico, silla turca, nervios craneales, etc.) y déficit hormonal. Presentamos un caso clínico de un varón de raza caucásica de 69 años, el cual debuta con un síndrome clínico de seno cavernoso izquierdo en el posoperatorio inmediato de una cirugía cardiaca. La clínica y los estudios de imagen (RMN) confirmaron el diagnóstico de apoplejía hipofisaria. El cuadro se resolvió satisfactoriamente con tratamiento esteroideo sustitutivo y cirugía al sexto día del inicio de los síntomas por persistencia de los síntomas visuales.