Grave thoraco-intestinal complication secondary to an undetected traumatic rupture of the diaphragm: a case report.

BACKGROUND: Diaphragmatic lesions as a result of blunt or penetrating trauma are challenging to detect in the initial trauma setting. This is especially true when diaphragmatic trauma is part of a polytrauma. Complications of undetected diaphragmatic defects with incarcerating bowel are rare, but as in our patient can be serious. CASE PRESENTATION: A 57-year-old female presented to the Emergency Room of our Hospital in a critical condition with 3 days of increasing abdominal pain. The initial clinical examination showed peritonism with tinkling peristaltic bowel sounds of mechanical obstruction. A thoraco-abdominal CT scan demonstrated colon prolapsed through the left diaphragmatic center with a large sero-pneumothorax under tension. As the patient was hemodynamically increasingly unstable with developing septic shock, an emergency laparotomy was performed. After retraction of the left colon, which had herniated through a defect of the tendinous center of the left diaphragm and was perforated due to transmural ischemia, large amounts of feces and gas discharged from the left thorax. A left hemicolectomy resulting in a Hartmann-type procedure was performed. A fully established pleural empyema required meticulous debridement and lavage conducted via the 7-10 cm in diameter phrenic opening followed by a diaphragmatic defect reconstruction. Due to pneumonia and recurring pleural empyema redo-debridement of the left pleural space via thoracotomy were required. The patient was discharged on day 56. A thorough history of possible trauma revealed a bicycle-fall trauma 7 months prior to this hospitalization with a surgically stabilized fracture of the left femur and conservatively treated fractures of ribs 3-9 on the left side. CONCLUSION: This is the first report on a primarily established empyema at the time of first surgical intervention for feco-pneumothorax secondary to delayed diagnosed diaphragmatic rupture following abdomino-thoracic blunt trauma with colic perforation into the pleural space, requiring repetitive surgical debridement in order to control local and systemic sepsis. Thorough investigation should always be undertaken in cases of blunt abdominal and thoracic trauma to exclude diaphragmatic injury in order to avoid post-traumatic complications.

Hepatic Vasculopathy and Regenerative Responses of the Liver in Fatal Cases of COVID-19.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infects the nasopharynx and lungs and causes coronavirus disease-2019 (COVID-19). It may impact the heart, brain, kidney, and liver.1 Although functional impairment of the liver has been correlated with worse clinical outcomes, little is known about the pathophysiology of hepatic injury and repair in COVID-19.2,3 Histologic evaluation has been limited to small numbers of COVID-19 cases with no control subjects2,4 and demonstrated largely heterogeneous patterns of pathology.2,3.

A Systematic Review on Extracellular Vesicles-Enriched Fat Grafting: A Shifting Paradigm.

BACKGROUND: Recent evidence confirms that mesenchymal stem cells (MSCs) facilitate angiogenesis mainly through paracrine function. Extracellular vesicles (EVs) are regarded as key components of the cell secretome, possessing functional properties of their source cells. Subsequently, MSC-EVs have emerged as a novel cell-free approach to improve fat graft retention rate. OBJECTIVES: The authors sought to provide a systematic review of all studies reporting the utilization of MSC-EVs to improve graft retention rate. METHODS: A systematic search was undertaken employing the Embase, PubMed, and Cochrane Central Register of Controlled Trials databases. Outcome measures included donor/receptor organism of the fat graft, study model, intervention groups, evaluation intervals, EV research data, and in vitro and in vivo results. RESULTS: Of the total 1717 articles, 62 full texts were screened. Seven studies reporting on 294 mice were included. Overall, EV-treated groups showed higher graft retention rates compared with untreated groups. Notably, retention rate was similar following EV and MSC treatment. In addition to reduced inflammation, graft enrichment with EVs resulted in early revascularization and better graft integrity. Interestingly, hypoxic preconditioning of MSCs improved their beneficial paracrine effects and led to a more proangiogenic EV population, as observed by both in vitro and in vivo results. CONCLUSIONS: MSC-EVs appear to offer an interesting cell-free alternative to improve fat graft survival. Although their clinical relevance remains to be determined, it is clear that not the cells but rather their secretome is essential for graft survival. Thus, a paradigm shift from cell-assisted lipotransfer towards "secretome-assisted lipotransfer" is well on its way.

Expanding Clinical Indications of Mechanically Isolated Stromal Vascular Fraction: A Systematic Review.

BACKGROUND: Mechanically isolated stromal vascular fraction (tSVF, tissue SVF) is a potent regenerative solution, increasingly used as a therapeutic modality for a variety of pathologies. With recent evidence conclusively favoring mechanical isolation over enzymatic alternatives, the therapeutic share and indications of tSVF are expected to grow even further. OBJECTIVES: The aim of this study was to provide a systematic review of all studies reporting on the use of tSVF. METHODS: A systematic search was undertaken of the Embase, PubMed, Web of Science, and Cochrane Central Register of Controlled Trials databases. Outcome measures included clinical indications, such as recipient area, adverse events, clinical results recipient area, method of application, follow-up duration and evaluation methods. RESULTS: Of the total of 4505 articles identified, 186 full-texts were screened. Thirty-four studies, reporting on 1443 patients were included. tSVF-based therapy was observed for 10 different pathologies, including aged skin (8 studies), scars (5), wounds (6), osteoarthritis (6), tendinopathy (2), temporomandibular joint disorders (1), androgenic alopecia (1), perianal fistula (3), migraine (1), and vocal fold scarring (1). Across all studies, tSVF-based therapy resulted in favorable clinical results. Overall, 50 (3.43%) minor and one (0.07%) major adverse events were observed, mainly related to the liposuction procedure. CONCLUSIONS: tSVF offers a safe, easy and legal treatment modality for a range of indications. Future research is indicated to identify the optimal isolation protocol, dose and timing. In addition, basic research remains crucial to identify the mechanism of action of SVF within different pathologies.

Early Initiation of a Standardized Open Abdomen Treatment With Vacuum Assisted Mesh-Mediated Fascial Traction Achieves Best Results.

Background: The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Complete fascial closure is an essential treatment objective and can be achieved by the use of different dynamic closure techniques. Both surgical technique and-decision making are essential for optimal patient outcome in terms of fascial closure. The aim of this study was to analyse patients' outcome after the use of mesh-mediated fascial traction (MMFT) associated with negative pressure wound therapy (NPWT) and identify important factors that negatively influenced final fascial closure. Methods: A single center ambispective analysis was performed including all patients treated for an open abdomen in a tertiary referral center from 3/2011 till 2/2020. All patients with a minimum survival >24 h after initiation of treatment were analyzed. The data concerning patient management was collected and entered into the Open Abdomen Route of the European Hernia Society (EHS). Patient basic characteristics considering OA indication, primary fascial closure, as well as important features in surgical technique including time after index procedure to start mesh mediated fascial traction, surgical closure techniques and patients' long-term outcomes were analyzed. Results: Data were obtained from 152 patients who underwent open abdomen therapy (OAT) in a single center study. Indications for OAT as per-protocol analysis were sepsis (33.3%), abdominal compartment syndrome (31.6%), followed by peritonitis (24.2%), abdominal trauma (8.3%) and burst abdomen (2.4%). Overall fascial closure rate was 80% as in the per-protocol analysis. When patients that started OA management with MMFT and NPWT from the initial surgery a significantly better fascial closure rate was achieved compared to patients that started 3 or more days later (p < 0.001). An incisional hernia developed in 35.8% of patients alive with a median follow-up of 49 months (range 6-96 months). Conclusion: Our main findings emphasize the importance of a standardized treatment plan, initiated early on during management of the OA. The use of vacuum assisted closure in combination with MMFT showed high rates of fascial closure. Absence of initial intraperitoneal NPWT as well as delayed start of MMFT were risk factors for non-fascial closure. Initiation of OA with VACM should not be unnecessary delayed.

High concentrations of trimethylamines in slime glands inhibit skein unraveling in Pacific hagfish.

Hagfish defend themselves from fish predators by producing large volumes of gill-clogging slime when they are attacked. The slime consists of seawater and two major components that are ejected from the slime glands: mucus and threads. The threads are produced within specialized cells and packaged into intricately coiled bundles called skeins. Skeins are kept from unraveling via a protein adhesive that dissolves when the skeins are ejected from the slime glands. Previous work revealed that hagfish slime glands have high concentrations of methylamines including trimethylamine N-oxide (TMAO), trimethylglycine (betaine) and dimethylglycine (DMG); however, the function of these compounds in the slime glands is unknown. We hypothesized that methylamines have stabilizing effects on the skeins that prevent premature unraveling in the gland. To test this hypothesis, we quantified the effect of methylamines on skein unraveling in Pacific hagfish and found that TMAO and betaine have inhibitory effects on skein unraveling in vitro Furthermore, we found that TMAO is a more effective inhibitor of unraveling than betaine, but the presence of TMAO synergistically boosts the inhibitory action of betaine. Glycine and DMG were far less effective inhibitors of unraveling at natural concentrations. Our results support the hypothesis that high levels of trimethylamines in the slime glands may act to hold the coiled thread skeins together within gland thread cells, and they may do so by stabilizing adhesive proteins. These results advance our knowledge of skein stabilization and deployment and provide yet another example of trimethylamines functioning to stabilize proteins in a marine organism.

Giant fibroadenoma with massive infarction masquerading as malignancy: a case report.

Fibroadenoma is a common benign breast lesion that usually affects women in their second and third decade of life and usually present as small mobile painless lump. However, it is important to recognize that a small percentage have been shown to progress to giant fibroadenomas. Giant fibroadenomas can undergo infarction leading to significant morbidity and difficulty to distinguish from the more aggressive phyllodes tumors or carcinoma. We report an interesting case of giant fibroadenoma (17 × 11 × 7 cm) with massive infarction during lactation, further complicated by lactational mastitis with close resemblance to cystosarcoma phyllodes. Detailed clinical evaluation and proper investigation in the form of USG breast and PET-CT scan helped us to delineate the nature of pathology. Simple excision of lesion with curvilinear incision was done with excellent cosmetic outcome. Histopathologic features were consistent with fibroadenoma (giant) with large areas of infarction. Fibroadenoma breast has varied clinical presentations. The course of disease may be complicated by pregnancy, lactation and inflammatory processes. Massive infarction may make the picture more dubious and masquerade with malignant transformation altering our treatment decision. The presence of necrosis on core biopsy or intra-operative finding should be cautiously interpreted and is not itself a sign of malignancy. Detailed clinical evaluation and comprehensive workup should be done before embarking on radical treatment.