Risk factors for methicillin-resistant Staphylococcus aureus and extended-spectrum ß-lactamase producing Enterobacterales in patients with diabetic foot infections requiring hospital admission.

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum ß-lactamase-producing Enterobacterales (ESBL-E) may complicate the treatment of diabetic foot infections (DFIs). The aim of this study was to determine the risk factors for these pathogens in DFIs. METHODS: This was a prospective observational study of 167 consecutive adult patients with DFIs. The diagnosis and severity of DFIs were based on the Infectious Disease Society of America (IDSA) classification system. Multivariate analyses were performed in order to identify risk factors for MRSA and ESBL-E infections. RESULTS: S. aureus was the most isolated pathogen (n=82, 37.9 %) followed by Escherichia coli (n= 40, 18.5%). MRSA accounted for 57.3% of all S. aureus and 70% of Klebsiella pneumoniae and 25% of E. coli were ESBL producers, respectively. Deep ulcer [OR 8,563; 95% CI (1,068-4,727)], previous use of fluoroquinolones [OR 2,78; 95% CI (1,156-6,685)] and peripheral vasculopathy [OR 2,47; 95% CI (1.068-4.727)] were the independent predictors for MRSA infections; and osteomyelitis [OR 6,351; 95% CI (1,609-25,068)] and previous use of cephalosporins [OR 5,824; 95% CI (1,517-22,361)] for ESBL-E infections. CONCLUSIONS: MRSA and ESBL-E have adquired a great clinical relevance in DFIs. The availability of their risk factors is very convenient to choose the empirical treatment in severe forms.

Versatilidad del colgajo en hacha para reconstrucción de lesiones en punta de dedo / Versatility of the hatchet flap for reconstruction of fingertip injuries

El colgajo en hacha descrito por Emmet, ha sido recientemente aplicado por Tuncali et al. en amputaciones de punta de dedo. Este sencillo colgajo triangular puede ser utilizado tanto n amputaciones transversas como oblicuas. El objetivo del estudio es presentar nuestra experiencia con este versátil colgajo en la reconstrucción de punta de dedo. Incluimos en el estudio 5 pacientes que completaron un periodo de seguimiento de un año. El nivel de amputación fue considerado de acuerdo con la clasificación de Ishikawa. Los pacientes fueron preguntados por la existencia de intolerancia al frío, hipersensibilidad y dolor. Empleamos diferentes diseños del colgajo en hacha que se aplicaron en pacientes pediátricos y adultos con amputaciones múltiples, lesiones del primer dedo del pie o de la mano, de dedos largos y en reconstrucciones con doble colgajo. La media de tamaño del defecto fue 2,2 x 1,4 cm. En todos los pacientes el colgajo aportó almohadillado protector y resultados estéticos. Se observó rigidez articular en un paciente debido a la combinación con un colgajo de dedo cruzado. El objetivo de toda reconstrucción de punta de dedo es proveer cobertura pulpar suficiente al hueso para evitar inestabilidad y pérdida de sensibilidad como consecuencia de la reconstrucción. El colgajo en hacha es una opción versátil y segura para la reconstrucción de punta de dedo. Los diferentes diseños pueden ser usados conforme a nuestras necesidades (AU)

The hatchet flap described by Emmet, has been recently applied by Tuncali et al. in fingertip amputations. This single triangular flap can be used in different types of injuries, as transverse and lateral oblique amputations. The aim of our study was to present the authors´ experience with this versatile flap in fingertip reconstruction. Five patients who have completed their 1-year follow-upperiod were included in the study. The level of amputation was categorized according Ishikawa classification. The patients were queried about the existence of cold intolerance, hypersensitivity and pain. Different designs of the hatchet flap were used. The authors applied this flap in adult an pediatric patients, with single or multiple amputations, toe, thumb and long finger lessions, or reconstructions with double flap. The average defect size was2,2 x 1,4 cm. In all the patients the flap has provided protective padding and aesthetic results. Joint stiffness was observed in one patient because the combination with a cross-finger flap. The concern with all reconstructions of the fingertip is to provide adequate pulp cover of the bone, to avoid bone tip tenderness and to avoid loss of sensibility as a result of the reconstruction. The hatchet flap is a versatile and safe alternative for fingertip reconstruction. Different designs can be used in accordance with our necessities (AU)

Revisión clínica de diez técnicas tradicionales para cobertura de lesiones en punta de dedo / Clinical review of ten traditional techniques for finger tip injuries coverage

Las amputaciones de punta de dedo son lesiones muy comunes para las que se han descrito numerosas técnicas reconstructivas. El manejo de estas heridas supone, con frecuencia, un problema difícil para el cirujano que no dispone de medios para la realización de intervenciones microquirúrgicas. En estos casos, las técnicas convencionales de cobertura, que han probado su eficacia y sencillez, pueden aportar soluciones adecuadas a cada paciente si son correctamente empleadas. Los injertos de piel, colgajos de avance V-Y, las diferentes modalidades de colgajos de dedos cruzados, los colgajos inguinales, colgajos homodigitales de pedículo retrógrado y anterógrado, son algunas de las técnicas desarrolladas en este estudio. El correcto manejo de las técnicas tradicionales, cuyo empleo sigue hoy vigente en muchos Servicios de Urgencias del mundo, se presenta como un recurso eficaz para resolver las más diversas lesiones de punta de dedo (AU)

Fingertip amputations are very common injuries and a lot of reconstructive methods have been described to treat them. The management of these wounds frequently supposes a complex problem for surgeons without resources for microsurgical applications. In these cases, conventional coverage techniques, that have proven their effectiveness and simplicity, can be appropriate solutions to each patient if they are correctly employed. Skin grafts, advancement V-Y flaps, different modalities of cross-finger flaps, groin flaps, homodigital direct and reverse pedicle flaps, are some of the techniques developed in this study. Correct management of these traditional techniques, are today effective in many Emergency Services all over the world, and represent an effective resource to solve most of finger tip injuries (AU)

[Portal-splenic-mesenteric venous thrombosis secondary to a mutation of the prothrombin gene]. / Trombosis venosa portoesplenomesaraica secundaria a mutación del gen de la protrombina.

Thrombosis of the portal-mesenteric axis is an infrequent cause of intestinal ischemia or infarction. In addition to the multiple acquired factors that contribute to the development of this entity, hereditary risk factors, especially the factor V Leiden mutation and the G20210A mutation of the prothrombin gene, have been implicated. The G20210A mutation of the prothrombin gene is found in up to 40% of patients with splenic-portal-mesenteric thrombosis. The present case illustrates the unusual and nonspecific presentation of this mutation in the form of diarrhea and images of thrombosis of the superior mesenteric-portal vein and cavernous transformation of the portal vein. Delayed diagnosis is highly frequent since the clinical signs, laboratory investigations and radiological tests do not suggest the diagnosis. The patient received anticoagulant treatment and showed clinical improvement with complete portal-mesenteric recanalization. Currently the diagnostic technique of choice is magnetic resonance angiography or computerized tomography angiography and treatment consists of indefinite anticoagulation. This case illustrates that an unusual or atypical localization of venous thrombosis may be a manifestation of thrombophilia, emphasizing the importance of genetic screening in these cases.

Trombosis venosa portoesplenomesaraica secundaria a mutación del gen de la protrombina / Portal-Splenic-Mesenteric venous thrombosis secondary to a mutation of the prothrombin gene

La trombosis del eje portomesaraico es una causa infrecuente de isquemia o infarto intestinal. Además de múltiples factores adquiridos que contribuyen al desarrollo de este cuadro, recientemente se han implicado factores de riesgo hereditario, especialmente la mutación del factor V de Leiden y la mutación G20210A del gen de la protrombina. La mutación G20210A del gen de la protrombina se encuentra hasta en el 40% de los pacientes con trombosis portoesplenomesaraica. El presente caso ilustra la presentación inusual e inespecífica de dicha mutación, en forma de diarreas e imágenes de trombosis de la vena mesentérica superior y porta y cavernomatosis portal. Es muy frecuente el retraso en el diagnóstico ya que los signos clínicos, analíticos y la radiología no apuntan el diagnóstico. El paciente recibió tratamiento anticoagulante y mejoró clínicamente, con una repermeabilización completa portomesaraica. En la actualidad la técnica diagnóstica de elección es la angiorresonancia magnética o la angiotomografía computarizada, y el tratamiento, la anticoagulación de manera indefinida. Nuestro caso ilustra que una localización inusual o atípica de trombosis venosa puede ser la manifestación de una trombofilia, lo que recalca la importancia del cribado genético en estos casos

Thrombosis of the portal-mesenteric axis is an infrequent cause of intestinal ischemia or infarction. In addition to the multiple acquired factors that contribute to the development of this entity, hereditary risk factors, especially the factor V Leiden mutation and the G20210A mutation of the prothrombin gene, have been implicated. The G20210A mutation of the prothrombin gene is found in up to 40% of patients with splenic-portal-mesenteric thrombosis. The present case illustrates the unusual and nonspecific presentation of this mutation in the form of diarrhea and images of thrombosis of the superior mesenteric-portal vein and cavernous transformation of the portal vein. Delayed diagnosis is highly frequent since the clinical signs, laboratory investigations and radiological tests do not suggest the diagnosis. The patient received anticoagulant treatment and showed clinical improvement with complete portal-mesenteric recanalization. Currently the diagnostic technique of choice is magnetic resonance angiography or computerized tomography angiography and treatment consists of indefinite anticoagulation. This case illustrates that an unusual or atypical localization of venous thrombosis may be a manifestation of thrombophilia, emphasizing the importance of genetic screening in these cases

[Multiple angiodysplasia of the small intestine. A diagnostic and therapeutic challenge]. / Angiodisplasia múltiple de intestino delgado. Un reto diagnóstico y terapéutico.

Small bowel bleeding is infrequent and presents a challenge to the clinician. Approximately 30-40% of gastrointestinal bleeding localized in the small bowel is due to angiodysplasia, a vascular malformation. We present the case of a patient with multiple angiodysplasia of the small bowel who required push enteroscopy and capsule endoscopy to establish the diagnosis. Treatment with subcutaneous octreotide was successful. In conclusion, in doubtful cases or in patients with persistent hemorrhage, capsule endoscopy can improve the diagnostic yield of enteroscopy in bleeding gastrointestinal vascular lesions such as angiodysplasia. Endoscopic treatment (laser coagulation) and drug therapy (somatostatin or analogs) are valid alternatives in inoperable or non-resectable cases.

[Superior vena cava syndrome caused by multinodular goiter]. / Síndrome de vena cava superior por bocio multinodular.

Currently, the vena cava superior syndrome (VCSS) is mainly of oncologic origin. We report here four cases of this syndrome caused by intrathoracic multinodular goiter. All patients had compressive symptoms, particularly of the oesophagus and trachea. Axial CT was the imaging technique that delineated the intrathoracic multinodular goiter compressing brachiocephalic vessels. Surgery (total thyroidectomy) was used and all compressive symptoms resolved.

Manifestaciones clínicas de las fracturas de órbita / The clinic demostrations of the orbit fractures

Se revisan fas manifestaciones clínicas de fas fracturas presentadas por 326 pacientes que fueron atendidos en servicio de Cirugía Maxilolacial del H.U. Virgen de la Arrixaca entre 1977 y 1992. Las manifestaciones clínicas de fas fracturas de órbita son muy variadas, van desde las lesiones de los párpados que son la primera estructura defensiva de la órbita y del globo ocular, hasta las graves alteraciones del sistema nervioso central. Las manifestaciones clínicas se han ordenado siguiendo de la siguiente forma: lesiones de los párpados, alteraciones ele posición del globo ocular, lesiones oculares, alteraciones de la agudeza visual, alteraciones de los nervios periféricos, alteraciones neurológicas. Las fracturas más frecuentes fueron fas del complejo órbitomalar causadas por los accidentes de tráfico, más de un tercio de fas fracturas se asociaban a fracturas craneofaciales y se intervinieron más del 80 por ciento, lo que indica fa gravedad de los accidentes. En cuanto a las manifestaciones clínicas hay que destacar en nuestra serie los trece pacientes (4 por ciento) que presentaban a su ingreso pérdida de globo ocular (AU)

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Síndrome de vena cava superior por bocio multinodular / Superior vena cava syndrome caused by multinodular goiter

El síndrome de vena cava superior (SVCS) es hoy un problema principalmente oncológico. En este trabajo presentamos cuatro casos de este síndrome causado por bocio multinodular intratorácico. Todos los pacientes presentaban otros síndromes compresivos, sobre todo esofágico y traqueal. La tomografía axial computadorizada (TAC) fue la técnica de imagen que objetivó el bocio multinodular intratorácico comprimiendo los troncos braquiocefálicos. El tratamiento fue quirúrgico (tiroidectomía total), revirtiendo todos los síntomas compresivos. (AU)

Cáncer tiroideo en el hipertiroidismo: una asociación no tan excepcional / Thyroid cancer in hyperthyroidism: not such an uncommon association

Objetivo. Analizar la tasa de asociación entre hipertiroi dismo y cáncer tiroideo en nuestra experiencia, así como la que existe con los distintos tipos de enfermedades tiroideas que cursan con hipertiroidismo. Pacientes y métodos. Se han estudiado, de forma retrospectiva, las piezas quirúrgicas y los historiales clínicos de aquellos pacientes intervenidos por hipertiroidismo y en los que se detectó un cáncer tiroideo en el estudio anatomopatológico. Los pacientes fueron agrupados según presentaran enfermedad de Graves-Basedow, bocio multinodular o adenoma tóxico. Resultados. En 10 casos de 265 pacientes se detectó un cáncer tiroideo asociado (3,8 por ciento). Fueron mayoría los pacientes con enfermedad de Graves (63 por ciento), aunque sólo el 3,5 por ciento de éstos presentaron asociación con cáncer, frente al 5,5 por ciento de los bocios multinodulares. No se encontró ningún caso en los pacientes con adenoma tóxico. Todos los casos de tumor correspondieron a cáncer papilar. En 3 casos se encontró multicentricidad del tumor en el mismo lóbulo. Conclusiones. Debe realizarse un estudio detallado de las piezas quirúrgicas en los pacientes intervenidos por hipertiroidismo y considerar siempre la posibilidad de esta asociación al planificar el tratamiento de estos pacientes (AU)

Multivariate analysis of histopathological features as prognostic factors in patients with papillary thyroid carcinoma.

A retrospective analysis of 121 papillary thyroid carcinomas was made to assess prognostic factors including histological variants which might be related to survival. The mean follow-up period was 10 years and clinical, surgical and histopathological data were studied. The survival curves were analysed by the Kaplan-Meier method and the multivariate analysis used Cox's regression model. Eighty-seven patients had well differentiated papillary cancers. The survival rate for papillary thyroid cancer was 86 per cent at 5 years and 72 per cent at 10 years. Factors showing prognostic significance for survival were tumour size, extrathyroid extension and histological type. Disease-free survival was influenced by sex, existence of a capsule and nodal metastases. Factors showing a favourable prognosis were: age under 45 years, size less than 4 cm, no extrathyroid extension and well differentiated histological type (P < 0.001). Histological subtype was one of the most important prognostic factors.

Prognostic value of the tall cell variety of papillary cancer of the thyroid.

We analyse a new variety of papillary carcinoma of the thyroid, known as the tall cell variant. The lesion is characterized by a papillary cancer (PCT) in which more than 30% of the tumour is made up of a population of tall columnar cells over twice as tall as their width. Of a population of 158 differentiated thyroid carcinomas we found five cases of this rare variant. We studied their clinico-pathological features, the importance of an early diagnosis and their prognostic implications. The data were compared with those of Well-Differentiated or Classical PCT (WDPC), the most important features of which were: (a) later age of appearance; (b) greater predilection for males; (c) greater frequency of extrathyroid tumor extensions; (d) greater frequency of recurrences; and (e) a shorter survival or disease-free interval. The prognostic importance involved in recognizing this variant is based on the need to give patients a more aggressive treatment and more exhaustive follow-up.

[Does the ingestion of caustics produce irreversible motor changes in the esophagus? Manometric study of 17 cases]. / Produce la ingesta de cáusticos alteraciones motoras esofágicas irreversibles? Estudio manométrico de 17 casos.

During the acute period of caustic esophagitis, important alterations in esophageal motor function appear. However, it is not known if these alterations persist later. To determine whether motor disorders persist (after the aggression) in the esophagus that has suffered caustic aggression, a manometric study was made in two groups of patients classified as mild (9 cases) or severe esophagitis (8 cases), and results were compared with those of a control group. Patients who had developed stenosis or suffered the caustic aggression less than a year earlier were excluded. The probable existence of motor anomalies could determine the appearance of dysphagia or reduce the effectiveness of motor clearance of the esophageal body, thus conditioning a situation of esophageal defenselessness against physiological or eventual abnormal episodes of gastroesophageal reflux (RGE). Our results indicate that in a variable percentage of cases some peristaltic dysfunctions can persist in the esophageal body in relation to the severity of the initial lesion.