Laparo-endoscopic Approach for Large Ovarian Cyst in the Morbidly Obese: Case Report

We report a successful case of laparo-endoscopic single site total hysterectomy and bilateral salpingo-oophorectomy (LESS THBSO) using conventional laparoscopic instruments for a large ovarian cyst in a morbidly obese woman. A 58-year-old female with a BMI of 46kg/m2 complaint of abdominal distension. A pelvic ultrasound revealed a left ovarian cyst measuring 21.3 x 15.2 x 20.8 cm. The IOTA score is 3.5% and the RMI score was 51, suggesting a benign pathology. LESS THBSO was performed and the final histology was a benign ovarian mucinous cystadenoma. The patient recovered well with no postoperative complications. This case demonstrates that LESS is feasible for large ovarian cysts even in morbidly obese patients when appropriate cases are selected and when the patient is managed in a multi-disciplinary team.

Atypical Presentation of Aortic Dissection: A Case Report

Background: Aortic dissection (AD) is considered to be one of the life-threatening diseases. Quick diagnosis has great significance so that a one-hour delay in treatment leads to a 1-2% increase in mortality. Case Report: The 55-year old obese woman with epigastric pain and right upper quadrant pain referred to the emergency department of our hospital. The acute coronary syndrome was our initial diagnosis but an image similar to a Perl in one cut and a crescent in another cut of computed tomography (CT) drew our attention in the mediastinal view of CT without intravenous contrast that was performed to rule out coronavirus disease-19 (COVID-19). Finally, CT-angiography was requested and AD diagnosis was approved accordingly. Conclusion: The presence of calcification on a non-contrast chest CT in the middle of the aorta or away from the artery wall can be a sign of AD. Thus, special attention should be paid to the atypical symptoms of AD.

Estrogen Receptor Beta (ERβ) Maintains Mitochondrial Network Regulating Invasiveness in an Obesity-Related Inflammation Condition in Breast Cancer

Obesity, a physiological situation where different proinflammatory cytokines and hormones are secreted, is a major risk factor for breast cancer. Mitochondrial functionality exhibits a relevant role in the tumorigenic potential of a cancer cell. In the present study, it has been examined the influence of an obesity-related inflammation ELIT treatment (17β-estradiol, leptin, IL-6, and TNFα), which aims to stimulate the hormonal conditions of a postmenopausal obese woman on the mitochondrial functionality and invasiveness of MCF7 and T47D breast cancer cell lines, which display a different ratio of both estrogen receptor isoforms, ERα and ERβ. The results showed a decrease in mitochondrial functionality, with an increase in oxidative stress and invasiveness and motility, in the MCF7 cell line (high ERα/ERβ ratio) compared to a maintained status in the T47D cell line (low ERα/ERβ ratio) after ELIT treatment. In addition, breast cancer biopsies were analyzed, showing that breast tumors of obese patients present a high positive correlation between IL-6 receptor and ERβ and have an increased expression of cytokines, antioxidant enzymes, and mitochondrial biogenesis and dynamics genes. Altogether, giving special importance to ERβ in the pathology of obese patients with breast cancer is necessary, approaching to personalized medicine.

Diagnosis and Management of Obesity Hypoventilation Syndrome during Labor

Obesity hypoventilation syndrome (OHS) is a disorder in which patients with a body mass index ≥30 kg/m2 develop awake hypercapnia with a partial pressure of carbon dioxide ≥45 mm Hg, in the absence of other diseases that may produce alveolar hypoventilation. Additional clinical features include sleep disordered breathing, restrictive lung disease, polycythemia, hypoxemia, and an increased serum bicarbonate concentration (≥27 mEq/L). Anesthesia providers should be familiar with OHS because it is often undiagnosed, it is associated with a higher mortality rate than obstructive sleep apnea, and it is projected to increase in prevalence along with the obesity epidemic. In this case, a 33-year-old obese woman with presumed OHS developed respiratory acidosis during induction of labor. Continuous positive airway pressure treatment was initiated, but the patient continued to have hypercapnia. A cesarean delivery was recommended. The patient had baseline orthopnea due to her body habitus; thus, despite adequate labor analgesia, a cesarean delivery was completed with general endotracheal anesthesia. We believe this patient had OHS despite a serum bicarbonate <27 mEq/L, a partial pressure of oxygen >70 mm Hg, and a hemoglobin <16 g/dL, which would typically rule out OHS. Pregnant women experience a decrease in serum bicarbonate concentration due to progesterone-mediated hyperventilation, an increase in arterial oxygenation from increased minute ventilation and higher cardiac output, and a decrease in hemoglobin due to the physiologic anemia of pregnancy. Thus, OHS may be defined differently in pregnant than in non-pregnant patients.

Clostridium haemolyticum Infection: A Cause of Hemolytic Anemia in a Patient with Bone Marrow Necrosis

Clostridium haemolyticum is a sporulating Gram-positive anaerobic rod that is considered to be one of the most fastidious and oxygen-sensitive anaerobes. It is a well-known animal pathogen and the cause of bacillary hemoglobinuria primarily in cattle. To date, human infections caused by C. haemolyticum have been reported in three patients with malignant underlying diseases. We present herein the case of a 30-year-old obese woman with no significant past medical history who developed bacteremia caused by C. haemolyticum with massive intravascular hemolysis associated with bone marrow necrosis and acute renal failure. Because of subculture failure, the diagnosis was made on the basis of 16S rDNA sequencing and next-generation sequencing. The patient, who had been afebrile for 20 days after a 17-day-course of antibiotics, experienced a second bacteremic episode caused by C. haemolyticum. After having been successfully treated for 42 days with clindamycin and amoxicillin-clavulanic acid, the patient developed acute myeloid leukemia as a result of bone marrow regeneration. Although uncommon in humans, infections caused by C. haemolyticum are severe and should be considered in a febrile patient who has severe hemolytic anemia. This case also highlights the importance of using molecular techniques for the identification of this fastidious anaerobic organism.

Death from COVID-19 in a Hispanic postpartum woman and review of the literature

There is still much we do not know about the impact of COVID-19 on the health of pregnant and postpartum women and pregnancy outcomes. Current evidence suggests that there is biological plausibility for worse outcomes among this population. This case report details the clinical care given to a postpartum Hispanic and obese woman diagnosed with COVID-19 in April 2020. We report the care she and her newborn received and her progression through the virus. We discuss the current knowledge surrounding COVID-19 among pregnant and postpartum women. While research supports COVID-19 outcomes being comparable to the general population, there is limited research in this area. Clinical trials, acting on the side of caution, have tended to exclude pregnant women from participation. Therefore, there is a need for further research that can inform evidence-based policy decisions related to COVID-19 in pregnant and postpartum women.

Morbidly obese patient with endometrial cancer treated by bariatric surgery to enable cancer treatment

The case demonstrates the use of bariatric surgery to improve a patient’s candidacy for surgical treatment for endometrial cancer (EC). A 50-year-old morbidly obese woman with early-stage EC was initially treated with levonorgestrel-releasing intrauterine system (52 mg) . She had to reduce her body mass index (BMI) to become eligible for definite EC treatment. Using conservative methods, she was unable to lose weight effectively. She then underwent bariatric surgery that reduced her BMI from 71.3 to 54.3 kg/m2. She maintained her weight and was eligible for total hysterectomy and bilateral salpingo-oopherectomy. Her procedure was successful and had no complications. She has 6-monthly follow-ups, and the most recent review showed no evidence of recurrence.

Case Report: Pink Urine Syndrome Following Exposure to Propofol: A Rare, Impressive but Benign Complication

Drug-induced changes in urine color induced by drugs may have clinical significance. Pink urine syndrome (PUS), which has been associated with urinary uric acid (UA) disorders, is most frequently reported in patients with morbid obesity undergoing gastric bypass surgery and/or from propofol anesthesia use in those who potentially have preexisting UA metabolism disorders. However, PUS has rarely occurred following exposure to propofol in non-obese patients, and literature on long-term follow-up after PUS is scarce. We report a case of PUS induced by propofol in a previously healthy non-obese woman after undergoing thoracoscopic wedge resection of pulmonary nodules under general anesthesia using propofol. The patient suddenly developed pink urine 4 h after surgery. A pink sediment rapidly precipitated at the bottom of the test tube following centrifugation of the urine. Amorphous, colorless UA-like crystals were identified under a polarizing microscope. The diagnosis of PUS was confirmed by examining the urinary UA concentration. The patient recovered and as followed-up for 1 month, during which she did not experience any urinary complications. To our knowledge, this is the first report to describe in detail a case of PUS caused by propofol in a non-obese patient with follow-up. PUS is usually benign and can resolve by rapidly on administering lactated Ringer’s solution; however, the potential risk of urinary complications, particularly UA lithiasis, should be fully realized.

Review Article: Obesity and Infertility

Obesity is a main health problem, that affects people all over the world. According to recent articles, obese patients should be denied any therapy to aim improving ovulation rates and achieving pregnancy until their BMI is reduced. We believe that this approach does not solve the issue, but rather exacerbates the maternal and perinatal complications linked to fertility clinics. Obesity independent of polycystic ovary syndrome (PCOS) is related with anovulation, and a weight loss alone is an effective treatment for inducing ovulation in both obese women with or not PCOS. As a result, weight-loss lifestyle programs should be considered an ovulation induction therapy, with due consideration for a possible pregnancy in an obese woman. Obesity has been linked to menstrual irregularities and infertility, Despite the fact that a critical mass of adipose tissue is needed for development female reproductive function. The severity of fat tissue distribution and obesity are important factors that affect the female reproductive system. The mechanisms of pathogenetic that link them aren't well understood. Insulin resistance and hyperinsulinemia are common in obese, especially those women with upper obesity of body, as are hyperandrogenemia, increased peripheral aromatization of androgens to oestrogens, altered secretion of gonadotrophin, and reduced (SHBG), decreased growth hormone (GH) , insulin like growth factor binding proteins (IGFBPs), elevated level of leptin and changed neuroregulation of the hypothalamic‐pituitary‐gonadal axis.