A traditional surgical knot (H2H1s) occasionally opens with little force and thus is potentially dangerous. Safe knots are H2H2 and H3H2 combinations, a sequence of 5 half hitches with 3 blocking sequences, and H2H1s together with 2 blocking half hitches.

In elderly patients, numerous factors subsidize the diagnostic challenge and high incidence of complications in this specific population, taking gangrenous cholecystitis as a critical example. The aim of this work is to report an unusual case of gangrenous choleystitis in an elderly diabetic women and its atypical clinical presentation. A 79-year-old female patient came to our observation; her medical history showed nausea and vomiting of about 2 hours which rapidly ended with symptomatic therapy, without recurrence, and a 3-week history of intermittent fever associated with productive cough. No abdominal discomfort was declared. Physical examination of the abdomen was negative. Laboratory analysis revealed leukocytosis with the remaining criteria within the normal range. After 2 days, she started with a mildabdominal pain in the epigastric region that rapidly progressed to the right upper quadrant, right flank and right iliac fossa, without nausea, vomiting or fever. Abdominal computer tomography findings revealed thickness of the gall-bladder and important densification of the vascular bed. Acute cholecystitis was diagnosed. The patient was then submitted to a laparoscopic cholecystectomy under general anaesthesia with findings suggestive of gangrenous acute cholecystitis confirmed by histologic examination of the specimen. Delays in diagnosing acute cholecystitis in specific populations, such as elderly diabetics, result in a higher prevalence of morbidity and mortality due to potentially serious complications as gangrenous cholecystitis. Consequently, the diagnosis should be measured and investigated promptly in order to prevent poor outcomes.

The diagnosis and management of blood culture-negative endocarditis constitute a real clinical challenge and a systemic approach is necessary for a successful outcome. The authors report a case of a female patient aged 26, with previous clinical history of valve disease and heart failure NYHA class II, with decompensation of co-morbidities associated with fever, productive cough, nonselective anorexia and unquantified weight loss with one month of evolution with negative blood cultures. Transesophageal echocardiography revealed the presence of severe pulmonary hypertension and mitral valve vegetations in the context of positive serology for Q fever. Herein, the authors report a case of blood culture-negative endocarditis and present a brief review on the management of this medical condition. We highlighted the diagnostic difficulties of blood culturenegative endocarditis and subacute clinical presentation, which sometimes present with fever of unknown origin and complaints of deterioration of cardiac function, thus creating a challenging differential diagnosis.

Lung cancer is a leading cause of death due to malignancy worldwide. Diaphragmatic metastasis secondary to primary lung cancer is rare. In the literature, only a few cases have been described as the majority of cases of diaphragmatic metastasis which are secondary to gastrointestinal neoplasia. The authors report a rare case of diaphragmmatic metastasis from a primary adenocarcinoma of the lung in a 76-year-old female patient with no history of active or passive smoking with progressive worsening fatigue, asthenia, malaise, and unquantified weight loss with three months of evolution, associated with pleuritic chest pain and edema of the lower limbs for fifteen days previous to hospital admission. Chest X-ray showed elevation of the right hemi-diaphragm and thoracic-abdominal-pelvic computed tomography revealed a complex multilobuled mass with neoformative characteristics intersecting the diaphragm and invading the dome liver and the right lung region. Biopsy of the mass was performed whose histological examination was consistent with moderately differentiated adenocarcinoma. Immunohistochemical examination was positive for cytokeratin 7 and negative forcytokeratin 20, suggesting primary lung tumor. A positron emission tomography was performed without uptake in other locations. Diagnosis of adenocarcinoma with diaphragmatic metastasis was then admitted and the patient started chemotherapy with carboplatin and gemcitabine. The patient died six months after the diagnosis. The authors also present a brief theoretical discussion based on the current and scarce literature on this rare entity.

A 9-year-old, 5.5-kg (12.12-lb) spayed female Poodle was evaluated due to recurrent seizures and possible diabetes. The dog also had a history of anorexia, polyuria and polydipsia. Serum biochemistry results revealed increases in pancreatic amylase and glucose associated with decreased protein levels. Abdominal ultrasound suggested acute pancreatitis and/or a pancreatic tumor with intense peripancreatic vascularization. The clinical condition of the dog worsened despite medical treatment, and death occurred shortly thereafter. At necropsy, blood clots were found in the stomach and in the intestinal lumen, which was filled with undigested blood. The pancreas was moderately increased in size with an irregular surface and multifocal yellow firm areas. In the cranial portion of the pancreas, a single nodule, approximately 2 cm in diameter, was found. Histologic evaluation of the pancreas revealed chronic and acute lesions characterized by lymphohistiocytic pancreatitis, periductal fibrosis, degeneration of pancreatic islets and necrotizing and fibrinopurulent pancreatitis. The nodule was diagnosed as pancreatic adenocarcinoma. These clinical, imaging, and histopathologic findings were compatible with Hemosuccus pancreaticus. To the authors' knowledge, this is the first report of Hemosuccus pancreaticus in a dog and it should be considered as a differential diagnosis for dogs with pancreatic disease and gastrointestinal bleeding.