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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-up period 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 was 2,2 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. [ABSTRACT FROM AUTHOR]

Background: Retroperitoneal lipomas are extremely rare tumors that must be differentiated from well-differentiated liposarcomas (WD-LPS)., Objectives: To summarize the evidence about giant retroperitoneal lipomas or liposarcomas; and to elaborate recommendations for their management., Data Sources: A systematic literature search from January 1985 to December 2019 and a review of our own cases was performed., Results: Our series comprises four patients, two females and two males. The diagnosis was incidental in two cases. The medium size was 26 cm, being two cases located exclusively in the retroperitoneum, one in the inguinal region and one in the buttock via pelvic space. All cases were surgically removed being confirmed the initial diagnosis of retroperitoneal lipomas in two cases, as the rest two cases were classified as WD_LPS after MDM2/CDK4 genetic analysis. The review of the available literature plus our own cases revealed 30 cases, of which 58% were woman. Only two cases were asymptomatic. The main symptom was abdominal mass (53%) followed by abdominal pain (40,6%). The median size of the lesions was 24,9 cm with a median weight of 4.576,3 g. All cases were surgically removed, being necessary to remove contiguous organs in only four cases (12,5%)., Conclusions: Retroperitoneal lipoma is a rare tumor which must be differentiated from WD-LPS. This is a very difficult task, being necessary to determinate MDM2 status (by FISH or MLPA), present in liposarcoma but not in lipomas, for its correct diagnosis. The treatment must be based on a complete surgical resection with negative margins., (Copyright © 2020 Sociedad Española de Anatomía Patológica. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: Methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum β-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., (©The Author 2020. Published by Sociedad Española de Quimioterapia. This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).)

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.

Background: Frozen-section examination (FSE) has traditionally been used for the intraoperative diagnosis of thyroid cancer. However, the utility of the technique is now controversial, especially in multinodular goiter (MNG), on which there are few studies. The aim of this study was to analyze the utility of FSE for ruling out malignancy in patients undergoing surgery for MNG., Patients and Methods: FSE was performed in 197 patients with MNGs undergoing surgery for suspected malignancy, either preoperatively (n = 145; 74%) or intraoperatively (n = 52; 26%), and where the preoperatively planned surgical technique was partial resectional surgery. The FSE diagnosis was classified as benign, suggestive of malignancy, or malignant. The following FSE parameters were calculated for diagnosing MNG-associated carcinoma: true- and false-positives and true- and false-negatives, sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy. The chi2 and Student's t tests were applied., Results: The FSE revealed benignity in 191 cases (97%), suggested malignancy in 3 (1.5%), and were malignant in the remaining 3. The final histology revealed 16 carcinomas (8%), of which only 3 were detected by FSE. Only tumor size was a factor significantly associated with FSE carcinoma detection (p = 0.0012). The sensitivity of the technique for detecting carcinoma was 19%, specificity, 100%; positive predictive value, 100%; negative predictive value, 93%; and diagnostic accuracy, 93%., Conclusions: FSE should not be used routinely in the management of MNG, and considering its low rate of sensitivity for detecting malignancy, the decision on the extent of the thyroidectomy should be based on other factors and explorations.

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.

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.

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.

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.