São Camilo Hospital

Introduction: The pes anserinus corresponds to the conjoined insertion of the sartorius, gracilis, and semitendinosus muscle tendons on the anteromedial aspect of the proximal tibia. These tendons are widely used as autologous grafts in anterior cruciate ligament (ACL) reconstruction procedures. However, anatomical variations and insufficient knowledge of this region may contribute to surgical complications and graft harvesting failures. Objective: To provide detailed knowledge of this medial knee region in fetuses and the possible anatomical variations of the tendons to assist in reducing surgical complications. Methodology: Forty lower limbs from 20 human fetal cadavers (20 right limbs and 20 left limbs), with an average gestational age of 27.94 weeks, were dissected. Morphometric measurements of the muscle bellies and tendons forming the pes anserinus were obtained. Results: Measurement of the muscles forming the pes anserinus revealed that the sartorius muscle presented the largest mean value for the muscle belly (66.10 mm), while the semitendinosus muscle tendon demonstrated the greatest mean length (31.70 mm). In 5% of cases (n=2), a common tendinous attachment for the gracilis and semitendinosus muscles was observed. Additionally, accessory tendinous attachments were found in 52.5% (n=21) of cases, restricted to the gracilis and semitendinosus muscles. Conclusion: The detailed anatomical and morphometric data provided by this study contributes to a better understanding of the fetal development of the pes anserinus and may help reduce technical failures during the harvesting of autologous grafts in ligament reconstruction procedures.

Resumen El tumor del seno endodérmico (TSE), también denominado tumor del saco vitelino (TSV), corresponde a una neoplasia maligna poco frecuente de origen germinal, que afecta predominantemente a mujeres jóvenes en edad reproductiva. Representa aproximadamente el 20% de los tumores malignos de células germinales ováricos (TCGO) y se caracteriza por su alta agresividad, rápido crecimiento, diseminación temprana y marcada elevación de la alfa-fetoproteína (AFP), biomarcador esencial para el diagnóstico, seguimiento terapéutico y detección de recurrencias. El presente manuscrito describe el caso de una paciente de 15 años que consultó por dolor y distensión abdominal. Los estudios clínicos, de laboratorio e imagenológicos revelaron una masa anexial izquierda con características compatibles con TSV, destacando una lesión sólido-quística con vascularización y un nivel de AFP sérica de 1000 UI/mL. Se realizó laparotomía exploradora con anexectomía ipsilateral izquierda y biopsia intraoperatoria, confirmándose el diagnóstico mediante biopsia diferida como TSV estadio IA (limitado al ovario). La paciente cursó un postoperatorio favorable y se encuentra actualmente en tratamiento quimioterápico con seguimiento oncológico especializado. Se enfatiza la importancia del diagnóstico diferencial de masas anexiales en adolescentes, considerando tanto neoplasias benignas como malignas, ginecológicas y no ginecológicas. Se destaca el rol de los marcadores tumorales y el estudio imagenológico en la orientación diagnóstica. El diagnóstico definitivo es histopatológico, y el tratamiento incluye cirugía conservadora con preservación de fertilidad y quimioterapia adyuvante, dado que se trata de una neoplasia altamente quimiosensible. Este caso resalta la importancia de un diagnóstico precoz y manejo multidisciplinario en adolescentes con sintomatología abdominal inespecífica, lo cual permite optimizar el pronóstico oncológico y conservar la función reproductiva. Palabras clave: Tumor del seno endodérmico, Tumor del saco vitelino, Ovario, Adolescente, Diagnóstico precoz. Abstract Endodermal sinus tumors (ESTs), also known as yolk sac tumors (YSTs), are a rare malignant neoplasm of germ cell origin that predominantly affects young women of reproductive age. They represent approximately 20% of ovarian germ cell tumors (OGCTs) and are characterized by high aggressiveness, rapid growth, early dissemination, and marked elevation of alpha-fetoprotein (AFP), an essential biomarker for diagnosis, therapeutic monitoring, and detection of recurrence. This manuscript describes the case of a 15-year-old female patient who presented with abdominal pain and distension. Clinical, laboratory, and imaging studies revealed a left adnexal mass with characteristics consistent with YST, highlighting a vascularized solid-cystic lesion and a serum AFP level of 1000 IU/mL. Exploratory laparotomy with left ipsilateral adnexectomy and intraoperative biopsy was performed, confirming the diagnosis by delayed biopsy as stage IA YST (limited to the ovary). The patient had a favorable postoperative course and is currently undergoing chemotherapy with specialized oncology follow-up. Emphasis is placed on the importance of differential diagnosis of adnexal masses in adolescents, considering both benign and malignant, gynecological and non-gynecological neoplasms. The role of tumor markers and imaging studies in diagnostic guidance is highlighted. The definitive diagnosis is histopathological, and treatment includes conservative surgery with fertility preservation and adjuvant chemotherapy, as this is a highly chemosensitive neoplasm. This case highlights the importance of early diagnosis and multidisciplinary management in adolescents with nonspecific abdominal symptoms, which allows for optimizing the oncological prognosis and preserving reproductive function. Key words: Endodermal Sinus Tumor, Yolk Sac Tumor, Ovary, Adolescent, Early Diagnosis.

Abstract Machine learning is a powerful data-driven technology for regression and classification tasks in numerous branches of science and technology. With probabilistic machine learning, we can approximate the probability density function of a given digital data set, unlocking the sampling of new and realistic data. We implement probabilistic machine learning as a statistical-based data augmentation tool to effectively improve the performance of a classifier on scarce data sets. Limited data are the norm in most practical situations, as is the case with core samples retrieved from unconventional oil and gas reservoirs. Obtaining and properly labeling rock sample images is a manual and time-consuming task. This leads to scarce data sets that make the lithologic classification of rock samples challenging. We illustrate the technology on images taken from well cores from the Argentinean Neuquén and Austral Basins, where by introducing generated samples in the training stage of a machine-learning classifier, we achieve a 5% higher accuracy with respect to the baseline obtained using the same number of samples from the original data set. We reach these results by proposing a lightweight workflow that can be run on very limited hardware. Our workflow is an alternative to classical data augmentation strategies for dealing with incomplete information, such as geometric transformations.

Abstract Background In obstructive hypertrophic cardiomyopathy (HOCM) medical intervention becomes necessary when symptoms coexist, whereas invasive septal reduction therapy (SRT) is indicated in presence of NYHA class >II, although optimized medical therapy. Thus, if SRT is avoided by medical therapy patient should be considered responder. However, due to inconsistency on definition of responders, effectiveness of medical therapy among data are conflicting. In addition, only short follow-up (FU) is available for analyses. Purpose To address this, we conducted a retrospective analysis in two HCM centers, both defining responders based on guidelines recommendations. Methods 62 symptomatic HOCM patients (43% women, age 52±14 years) with LVOTG ≥50 mmHg at rest or during provocation, were recruited from two HCM Italian centers. Disopyramide was added as second-line therapy. Responders were those reaching at least NYHA class II, if >II at baseline and those reaching NYHA class I or with stabilization of symptoms if in NYHA II class at baseline. Results At FU, (mean 4.4 years, IQR 1.1-6.6 years), 47 patients (76%) were responders, whereas 15(24%) patients were no-responders. Changes in NYHA class from baseline to follow-up are reported in the Figure. There were no differences at baseline of clinical and echocardiographic data between responders and no-responders, whereas at FU responders showed a significant lower LVOTG than no-responders (43 ±32 vs 66 ±28 mmHg, respectively, p=0.013), with LVOTG <50 mmHg more represented in responders than in no-responders (75% vs 25%, respectively; p=0.004) (Figure). No side effects indicating discontinuation of the therapy were recorded. Conclusion Patients treated with disopyramide as second-line therapy showed a reduction in symptoms in a quite long-follow-up, avoiding SRT in up to 70% of them. Patients who might benefit the most from the therapy are those who reached LVOTG <50 mmHg during treatment.

Abstract Background The left ventricular (LV) force, also known as elastance, serves as a load-independent indicator of contractility and can be noninvasively assessed through echocardiography. In hypertrophic cardiomyopathy (HCM), the heightened presence of the active state of myosin heads results in an increased LV force. Purpose To assess the prognostic value of increased LV elastance at rest in patients with HCM. Methods We enrolled 1420 HCM patients (age 50±16 years, 907 males, 64%) with ejection fraction (EF) ≥50%, referred for rest transthoracic echocardiography (TTE) in 10 quality-controlled labs from 7 countries. TTE assessment included peak left ventricular outflow tract gradient (LVOTG), EF, and LV force (systolic blood pressure + LVOTG/LV end-systolic volume assessed with 2-D, mmHg/mL). All patients were followed up. All-cause death was the outcome measure. Results At a median follow-up of 83 months, 150 deaths occurred (Group 1). At study entry, Group 1 patients had the same ESC-Sudden cardiac death score compared to survivors (Group 2). In Group 1 compared to Group 2, TTE showed higher values of MR severity, E/e’ , left atrial volume index, estimated systolic pulmonary artery pressure, and force (see table). At multivariable Cox analysis, only age (HR =1.08, 95% CI=1.03-1.14, p=0.001) and force > median value of 5.3 mmHg/mL (HR = 2.14, 95% CI 1.53-2.99, p=0.020) were independent predictors of mortality. Ten-year survival was 95% in the pooled first (<3.8 mmHg/mL) and second (3.8-5.2 mmHg/mL) quartiles vs 80% in the pooled third (5.3-7.8 mmHg/mL) and fourth quartiles (>7.8 mmHg/mL), see figure. Conclusion HCM patients with higher values of resting LV elastance show a worse survival, highlighting the dark prognostic side of an excess of force in these patients. Table Legends E/e’, early mitral inflow to early mitral annulus motion ratio, EF, left ventricular ejection fraction, LAVI, left atrial volume index; LVOTG, left ventricular outflow tract peak gradient, MR, mitral regurgitation; MWT, maximal wall thickness, NYHA, New York Heart Association classification, RWT, relative wall thickness; SCD risk, risk score for sudden cardiac death in hypertrophic cardiomyopathy, SPAP, systolic pulmonary arterial pressure.Table.Clinical and TTE findingsFigure.Survival in the force quartiles

Case Presentation: We present the case of a 64-year-old woman, with essential hypertension, referred to our hospital for investigation of refractory epilepsy. She had a history of prolonged inpatient treatment in another hospital due to several complications of her state: bronchoaspiration, pneumonia, and hyponatremia of hard control. The patient had already received a loading dose of phenobarbital followed by phenytoin due to long-duration seizures. Upon admission, the patient exhibited decreased mental status, diurnal excessive somnolence, episodes of hyponatremia, and seizures characterized by fasciobrachial dystonias. Discussion: While the seizures were initially controlled, the patient progressed to a non-convulsive status epilepticus, necessitating a loading dose of levetiracetam for management. Suspecting autoimmune encephalitis, we conducted thorough laboratory investigations and a lumbar puncture, initially yielding no remarkable results. Consequently, the patient received pulse therapy with methylprednisolone (1 g daily for 5 days), followed by maintenance treatment with prednisone (50 mg daily). Subsequent improvement in the patient's condition was observed, with resolution of seizures and hyponatremia, and gradual improvement in mental status. Analysis of the autoimmune panel of the cerebrospinal fluid revealed positivity for anti-LGI1 antibodies, confirming the diagnosis of autoimmune limbic encephalitis. Autoimmune encephalitis, particularly the anti-LGI1 subtype, is often underdiagnosed despite its significant clinical manifestations, including seizures, hyponatremia, and fasciobrachial dystonic seizures. The treatment primarily involves pulsed corticosteroid therapy followed by maintenance with prednisone. Our patient exhibited an excellent response to corticosteroids, allowing for gradual tapering of prednisone dosage. Final Comments: This case underscores the importance of considering autoimmune encephalitis in patients presenting with refractory seizures and associated clinical features. Prompt diagnosis and initiation of appropriate treatment are essential for favorable outcomes in these patients.