Ovarian Torsion in Adolescent with Chronic Immune Thrombocytopenia

Ovarian torsions in adolescence are rarity, particularly bilateral, with mostly unknown etiology. Enlargement of the ovary contributes to torsion. Young girl presenting with abdominal pains, nausea and vomiting was for two days suspected and observed as gastroenteritis. By exclusion of gastroenteritis she was admitted for gynecological work-up. Ultrasound showed significantly enlarged right ovary, with tumor-like appearance. At the laparotomy, gynecologist found torsioned, necrotic ovary and ovariectomy was performed. Histology showed massive stromal bleeding (haemorrhage). Asymptomatic enlargement of remaining ovary occurred nine months after the ovariectomy. This enlargement was accompanied with platelets’ fall and the possibility of repeated torsion impended. Thrombocytopenia was suspected from the first moment, but diagnosed after the surgery. Thrombocytopenia in adolescence requires additional attention as possible cause of intra-ovarian bleeding with consecutive enlargement and may lead to torsion. Oral contraceptives regulate dysfunctional bleeding, decrease ovarian volume and by so, may minimize risk of torsion. This strategy proved effective in the case we present

Clostridial gas gangrene after laparoscopic cholecystectomy: the role of SARS-CoV-2 virus – a case report and review of literature

Klostridijska plinska gangrena je brzo šireća nekrotična infekcija mekog tkiva s visokim smrtnim ishodom. Rijetka je komplikacija laparoskopske kolecistektomije. Predstavljamo 68-godišnju bolesnicu koja je razvila klostridijsku plinsku gangrenu nakon laparoskopske kolecistektomije. Bolesnica je prethodno bila bez komorbiditeta osim što je 14 dana ranije imala SARS CoV-2 infekciju s blagim respiratornim simptomima. Klostridijska infekcija je nastala neposredno nakon operacije uzrokujući gangrenu trbušne stijenke, septički šok i multiorgansko zatajenje. Unatoč pravovaljanoj i pravodobnoj antibiotskoj terapiji, kirurškom debridementu i ostalim mjerama intenzivnog liječenja, ishod bolesti bio je letalan. Postavljamo si dva pitanja: je li virus SARS CoV-2 mogao biti inicijator letalne kaskade u ove bolesnice i bismo li promijenili ishod da smo odgodili operaciju?Clostridium gas gangrene is fast-spreading necrotic infection of soft tissue relevant to high mortality rates. It is a rare complication after laparoscopic cholecystectomy. We present a case of a 68-year old woman who developed clostridial gas gangrene after laparoscopic cholecystectomy. The patient didn’t have have any comorbidity except SARS CoV-2 infection with mild respiratory symptoms 14 days ago. The infection developed immediately after the operation causing gangrene of the abdominal wall, septic shock and multi-organ failure. Although the patient was treated with appropriate and prompt antibiotic therapy and thorough surgical debridement and with other supportive measures, outcome was lethal. Based on this case we ask ourselves: Could the SARS CoV-2 virus initiate lethal cascade and should we change the outcome if we postponed the operation

Influence of postconditioning with isoflurane on histological differences in the healing of cardiac infarction in rats

Uvidom u literaturu nalazim da je prvi put u nekom istraživanju za ishemijsko-reperfuzijsku ozljedu srca korišten transdijafragmalni pristup koji omogućuje bolji prikaz ishemičkog područja te manju varijabilnost rezultata. Istraživanje je po prvi put dokazalo utjecaj postkondicioniranja izofluranom na veličinu infarkta tijekom subakutne i kronične faze cijeljenja ishemijsko-reperfuzijske ozljede. Utjecaj postkondicioniranja na smanjenje infarkta je tijekom vremena rastao što se može objasniti povoljnim učinkom na stvaranje granulacijskog tkiva (sa 56-59% na 64-68% ovisno o načinu mjerenja veličine infarkta). Naime, postkondicioniranje izofluranom izazvalo je stvaranje značajno većeg broja krvnih žila i miofibroblasta u granulacijskom tkivu tijekom subakutne faze cijeljenja ozljede. Navedeno ima bitan utjecaj na cijeljenje ozljedom zahvaćenog područja, koje je bolje opskrbljeno krvlju i nutrijentima te se bolje kontrahira. U procesu stvaranja kvalitetnijeg granulacijskog tkiva važnu ulogu su imali povećanje izražaja VEGF-a te povećana regenerativna sposobnost infarciranog područja u štakora postkondicioniranih izofluranom. Naime, u navedenoj skupini štakora utvrđen je značajno veći broj nestin pozitivnih progenitornih stanica tijekom proliferacijske faze cijeljenja infarkta. Za pretpostaviti je da su se iz progenitornih stanica razvile subpopulacije stanica koje su omogućile stvaranje kvalitetnijeg granulacijskog tkiva. Navedeno je potvrđeno na primjeru endotelnih progenitornih stanica i krvnih žila koje su se iz njih razvile. Dakle, u granulacijskom tkivu štakora nađen je veći broj krvih žila nastalih angiogenezom i vaskulogenezom. Zbog navedenih učinaka, infarcirana područja štakora postkondicioniranih izofluranom kvalitetnije su i brže cijelila. Stoga u kroničnoj fazi cijeljenja ishemijsko-reperfuzijske ozljede kod izofluranske skupine štakora nalazimo manje nezrelog granulacijskog tkiva te više zrelih αSMA pozitivnih krvnih žila. 14. dan nakon ozljede broj nezrelih kardiomiocita veći je kod životinja postkondicioniranih izofluranom, što također ide u prilog tezi o bržem cijeljenju područja oštećenog ishemijom i reperfuzijom, u kojem dolazi do zamjene odumrlog srčanog mišića. Istraživanje naglašava važnost primjene inhalacijskih anestetika tijekom ishemijsko-reperfuzijske ozljede srca te navodi na razmišljanja o kliničkim studijama gdje bi se isti mogli primjenjivati. Jedna od mogućnosti je primjena u reperfuziji nakon perkutane koronarne intervencije (sa dilatacijom koronarne arterije balonom ili postavljanjem „stenta“).The result of detailed literature search is a finding that this is the first time that an original diaphragmectomy-based approach to produce ischemia-reperfusion model of myocardial damage offers not only better visualization of the heart but also decreases variability of results. Also, for the first time it was shown that isoflurane postconditioning has a positive influence on the size of infarct in both subacute and chronic phase of healing following the ischemia-reperfusion model of injury. The positive influence of postconditioning increased with the duration of recovery probably through an increase of formation of mature fibrous tissue (from 56-59% to 64-68% depending on methodology of assessment of infarct size). Postconditioning led to formation of significantly greater number of blood vessels and myofibroblasts in scar tissue during subacute phase of healing. This has an important influence on the process of healing of the entire affected area via better blood/nutrient supply leading to more efficient contractility. Also, better quality of scar tissue was a result of increased expression of VEGF leading to an increase of regenerative capacity of posconditioned animals. In addition to this, the increased number of nestin positive progenitor cells led to development of mature cells responsible for the process of healing, which in turn led to better and faster recovery. This has been confirmed when both endothelial progenitor cells and blood vessels were taken into account. Hence, in the chronic model of isoflourane postconditioning we found smaller quantity of immature scar tissue and more mature αSMA positive vessels than in acute model. 14 days after injury, the number of mature cardiomyocites was greater in animals with postconditioning which is an additional proof of faster and more efficient healing which includes replacement of myocites. This research has also clinical repercussions and implies a possibility of application of volatile anesthetics in situations like percutaneous coronary interventions (with dilatation of the arterial lumen by a balloon or by inserting a stent)

Influence of postconditioning with isoflurane on histological differences in the healing of cardiac infarction in rats

Uvidom u literaturu nalazim da je prvi put u nekom istraživanju za ishemijsko-reperfuzijsku ozljedu srca korišten transdijafragmalni pristup koji omogućuje bolji prikaz ishemičkog područja te manju varijabilnost rezultata. Istraživanje je po prvi put dokazalo utjecaj postkondicioniranja izofluranom na veličinu infarkta tijekom subakutne i kronične faze cijeljenja ishemijsko-reperfuzijske ozljede. Utjecaj postkondicioniranja na smanjenje infarkta je tijekom vremena rastao što se može objasniti povoljnim učinkom na stvaranje granulacijskog tkiva (sa 56-59% na 64-68% ovisno o načinu mjerenja veličine infarkta). Naime, postkondicioniranje izofluranom izazvalo je stvaranje značajno većeg broja krvnih žila i miofibroblasta u granulacijskom tkivu tijekom subakutne faze cijeljenja ozljede. Navedeno ima bitan utjecaj na cijeljenje ozljedom zahvaćenog područja, koje je bolje opskrbljeno krvlju i nutrijentima te se bolje kontrahira. U procesu stvaranja kvalitetnijeg granulacijskog tkiva važnu ulogu su imali povećanje izražaja VEGF-a te povećana regenerativna sposobnost infarciranog područja u štakora postkondicioniranih izofluranom. Naime, u navedenoj skupini štakora utvrđen je značajno veći broj nestin pozitivnih progenitornih stanica tijekom proliferacijske faze cijeljenja infarkta. Za pretpostaviti je da su se iz progenitornih stanica razvile subpopulacije stanica koje su omogućile stvaranje kvalitetnijeg granulacijskog tkiva. Navedeno je potvrđeno na primjeru endotelnih progenitornih stanica i krvnih žila koje su se iz njih razvile. Dakle, u granulacijskom tkivu štakora nađen je veći broj krvih žila nastalih angiogenezom i vaskulogenezom. Zbog navedenih učinaka, infarcirana područja štakora postkondicioniranih izofluranom kvalitetnije su i brže cijelila. Stoga u kroničnoj fazi cijeljenja ishemijsko-reperfuzijske ozljede kod izofluranske skupine štakora nalazimo manje nezrelog granulacijskog tkiva te više zrelih αSMA pozitivnih krvnih žila. 14. dan nakon ozljede broj nezrelih kardiomiocita veći je kod životinja postkondicioniranih izofluranom, što također ide u prilog tezi o bržem cijeljenju područja oštećenog ishemijom i reperfuzijom, u kojem dolazi do zamjene odumrlog srčanog mišića. Istraživanje naglašava važnost primjene inhalacijskih anestetika tijekom ishemijsko-reperfuzijske ozljede srca te navodi na razmišljanja o kliničkim studijama gdje bi se isti mogli primjenjivati. Jedna od mogućnosti je primjena u reperfuziji nakon perkutane koronarne intervencije (sa dilatacijom koronarne arterije balonom ili postavljanjem „stenta“).The result of detailed literature search is a finding that this is the first time that an original diaphragmectomy-based approach to produce ischemia-reperfusion model of myocardial damage offers not only better visualization of the heart but also decreases variability of results. Also, for the first time it was shown that isoflurane postconditioning has a positive influence on the size of infarct in both subacute and chronic phase of healing following the ischemia-reperfusion model of injury. The positive influence of postconditioning increased with the duration of recovery probably through an increase of formation of mature fibrous tissue (from 56-59% to 64-68% depending on methodology of assessment of infarct size). Postconditioning led to formation of significantly greater number of blood vessels and myofibroblasts in scar tissue during subacute phase of healing. This has an important influence on the process of healing of the entire affected area via better blood/nutrient supply leading to more efficient contractility. Also, better quality of scar tissue was a result of increased expression of VEGF leading to an increase of regenerative capacity of posconditioned animals. In addition to this, the increased number of nestin positive progenitor cells led to development of mature cells responsible for the process of healing, which in turn led to better and faster recovery. This has been confirmed when both endothelial progenitor cells and blood vessels were taken into account. Hence, in the chronic model of isoflourane postconditioning we found smaller quantity of immature scar tissue and more mature αSMA positive vessels than in acute model. 14 days after injury, the number of mature cardiomyocites was greater in animals with postconditioning which is an additional proof of faster and more efficient healing which includes replacement of myocites. This research has also clinical repercussions and implies a possibility of application of volatile anesthetics in situations like percutaneous coronary interventions (with dilatation of the arterial lumen by a balloon or by inserting a stent)

Influence of postconditioning with isoflurane on histological differences in the healing of cardiac infarction in rats

Uvidom u literaturu nalazim da je prvi put u nekom istraživanju za ishemijsko-reperfuzijsku ozljedu srca korišten transdijafragmalni pristup koji omogućuje bolji prikaz ishemičkog područja te manju varijabilnost rezultata. Istraživanje je po prvi put dokazalo utjecaj postkondicioniranja izofluranom na veličinu infarkta tijekom subakutne i kronične faze cijeljenja ishemijsko-reperfuzijske ozljede. Utjecaj postkondicioniranja na smanjenje infarkta je tijekom vremena rastao što se može objasniti povoljnim učinkom na stvaranje granulacijskog tkiva (sa 56-59% na 64-68% ovisno o načinu mjerenja veličine infarkta). Naime, postkondicioniranje izofluranom izazvalo je stvaranje značajno većeg broja krvnih žila i miofibroblasta u granulacijskom tkivu tijekom subakutne faze cijeljenja ozljede. Navedeno ima bitan utjecaj na cijeljenje ozljedom zahvaćenog područja, koje je bolje opskrbljeno krvlju i nutrijentima te se bolje kontrahira. U procesu stvaranja kvalitetnijeg granulacijskog tkiva važnu ulogu su imali povećanje izražaja VEGF-a te povećana regenerativna sposobnost infarciranog područja u štakora postkondicioniranih izofluranom. Naime, u navedenoj skupini štakora utvrđen je značajno veći broj nestin pozitivnih progenitornih stanica tijekom proliferacijske faze cijeljenja infarkta. Za pretpostaviti je da su se iz progenitornih stanica razvile subpopulacije stanica koje su omogućile stvaranje kvalitetnijeg granulacijskog tkiva. Navedeno je potvrđeno na primjeru endotelnih progenitornih stanica i krvnih žila koje su se iz njih razvile. Dakle, u granulacijskom tkivu štakora nađen je veći broj krvih žila nastalih angiogenezom i vaskulogenezom. Zbog navedenih učinaka, infarcirana područja štakora postkondicioniranih izofluranom kvalitetnije su i brže cijelila. Stoga u kroničnoj fazi cijeljenja ishemijsko-reperfuzijske ozljede kod izofluranske skupine štakora nalazimo manje nezrelog granulacijskog tkiva te više zrelih αSMA pozitivnih krvnih žila. 14. dan nakon ozljede broj nezrelih kardiomiocita veći je kod životinja postkondicioniranih izofluranom, što također ide u prilog tezi o bržem cijeljenju područja oštećenog ishemijom i reperfuzijom, u kojem dolazi do zamjene odumrlog srčanog mišića. Istraživanje naglašava važnost primjene inhalacijskih anestetika tijekom ishemijsko-reperfuzijske ozljede srca te navodi na razmišljanja o kliničkim studijama gdje bi se isti mogli primjenjivati. Jedna od mogućnosti je primjena u reperfuziji nakon perkutane koronarne intervencije (sa dilatacijom koronarne arterije balonom ili postavljanjem „stenta“).The result of detailed literature search is a finding that this is the first time that an original diaphragmectomy-based approach to produce ischemia-reperfusion model of myocardial damage offers not only better visualization of the heart but also decreases variability of results. Also, for the first time it was shown that isoflurane postconditioning has a positive influence on the size of infarct in both subacute and chronic phase of healing following the ischemia-reperfusion model of injury. The positive influence of postconditioning increased with the duration of recovery probably through an increase of formation of mature fibrous tissue (from 56-59% to 64-68% depending on methodology of assessment of infarct size). Postconditioning led to formation of significantly greater number of blood vessels and myofibroblasts in scar tissue during subacute phase of healing. This has an important influence on the process of healing of the entire affected area via better blood/nutrient supply leading to more efficient contractility. Also, better quality of scar tissue was a result of increased expression of VEGF leading to an increase of regenerative capacity of posconditioned animals. In addition to this, the increased number of nestin positive progenitor cells led to development of mature cells responsible for the process of healing, which in turn led to better and faster recovery. This has been confirmed when both endothelial progenitor cells and blood vessels were taken into account. Hence, in the chronic model of isoflourane postconditioning we found smaller quantity of immature scar tissue and more mature αSMA positive vessels than in acute model. 14 days after injury, the number of mature cardiomyocites was greater in animals with postconditioning which is an additional proof of faster and more efficient healing which includes replacement of myocites. This research has also clinical repercussions and implies a possibility of application of volatile anesthetics in situations like percutaneous coronary interventions (with dilatation of the arterial lumen by a balloon or by inserting a stent)

Isoflurane post-conditioning stimulates the proliferative phase of myocardial recovery in an ischemia-reperfusion model of heart injury in rats

Summary. The application of isoflurane in a postconditioning manner, during early reperfusion following a period of coronary occlusion, has numerous beneficial effects on the ischemic myocardium, including reduction of infarct size. It does so by stimulating a sequence of well studied anti-apoptotic pro-survival mechanisms in a similar manner to various ‘ischemic’ pre-/postconditioning approaches which achieve their cardio protective effects in both laboratory and clinical situations. Proliferation of newly formed blood vessels, resulting in formation of highly vascularized granulation tissue, is an essential stage of infarct healing. It can be evaluated by detecting various angiogenic factors, including vascular endothelial growth factor (VEGF) and platelet endothelial cell adhesion molecule-1 (PECAM-1/CD31) or by quantification of expression of vascular smooth muscle progenitors, such as Nestin. Expression of these three markers was used to evaluate the effect of early isoflurane post-conditioning in ischemia-reperfusion type cardiac injury. A large reduction in infarct size (59.3% of control), and marked increase of expression of VEGF (43.4%), PECAM1/CD31 (136%) and Nestin (77.9%) was found in experimental animals when compared to control animals that did not receive isoflurane treatment. Hence, based on our results, we can emphasize two morphologically detectable benefits of isoflurane post-conditioning: a marked reduction in infarct size and much better organization/vascularization of necrotic tissue

Klostridijska plinska gangrena nakon laparoskopske kolecistektomije: uloga SARS-CoV-2 virusa – prikaz bolesnice s pregledom literature

Klostridijska plinska gangrena je brzo šireća nekrotična infekcija mekog tkiva s visokim smrtnim ishodom. Rijetka je komplikacija laparoskopske kolecistektomije. Predstavljamo 68-godišnju bolesnicu koja je razvila klostridijsku plinsku gangrenu nakon laparoskopske kolecistektomije. Bolesnica je prethodno bila bez komorbiditeta osim što je 14 dana ranije imala SARS CoV-2 infekciju s blagim respiratornim simptomima. Klostridijska infekcija je nastala neposredno nakon operacije uzrokujući gangrenu trbušne stijenke, septički šok i multiorgansko zatajenje. Unatoč pravovaljanoj i pravodobnoj antibiotskoj terapiji, kirurškom debridementu i ostalim mjerama intenzivnog liječenja, ishod bolesti bio je letalan. Postavljamo si dva pitanja: je li virus SARS CoV-2 mogao biti inicijator letalne kaskade u ove bolesnice i bismo li promijenili ishod da smo odgodili operaciju

Nonelective surgery at night and in-hospital mortality - Prospective observational data from the European Surgical Outcomes Study

BACKGROUND Evidence suggests that sleep deprivation associated with night-time working may adversely affect performance resulting in a reduction in the safety of surgery and anaesthesia. OBJECTIVE Our primary objective was to evaluate an association between nonelective night-time surgery and in-hospital mortality. We hypothesised that urgent surgery performed during the night was associated with higher in-hospital mortality and also an increase in the duration of hospital stay and the number of admissions to critical care. DESIGN A prospective cohort study. This is a secondary analysis of a large database related to perioperative care and outcome (European Surgical Outcome Study). SETTING Four hundred and ninety-eight hospitals in 28 European countries. PATIENTS Men and women older than 16 years who underwent nonelective, noncardiac surgery were included according to time of the procedure. INTERVENTION None. MAIN OUTCOME MEASURES Primary outcome was in-hospital mortality; the secondary outcome was the duration of hospital stay and critical care admission. RESULTS Eleven thousand two hundred and ninety patients undergoing urgent surgery were included in the analysis with 636 in-hospital deaths (5.6%). Crude mortality odds ratios (ORs) increased sequentially from daytime [426 deaths (5.3%)] to evening [150 deaths (6.0%), OR 1.14; 95% confidence interval 0.94 to 1.38] to night-time [60 deaths (8.3%), OR 1.62; 95% confidence interval 1.22 to 2.14]. Following adjustment for confounding factors, surgery during the evening (OR 1.09; 95% confidence interval 0.91 to 1.31) and night (OR 1.20; 95% confidence interval 0.9 to 1.6) was not associated with an increased risk of postoperative death. Admittance rate to an ICU increased sequentially from daytime [891 (11.1%)], to evening [347 (13.8%)] to night time [149 (20.6%)]. CONCLUSION In patients undergoing nonelective urgent noncardiac surgery, in-hospital mortality was associated with well known risk factors related to patients and surgery, but we did not identify any relationship with the time of day at which the procedure was performed