[A hard subcutaneous swelling: not always as malignant as it seems]. / Een harde onderhuidse bult.

BACKGROUND: Nodular fasciitis is a rare, benign soft tissue tumor in young adults on the arms or trunk. CASE DESCRIPTION: A 24-year-old woman with previous pretibial melanoma in situ presented with a painless, rapidly growing subcutaneous hard swelling on the right forearm since two weeks. Ultrasound showed a subcutaneous, irregularly shaped, vascularized mass, suspicious for malignancy. Three days later, the swelling had subsided spontaneously. A new ultrasound showed a smaller, oval, sharply demarcated lesion with an inflammatory aspect. Histopathological-immunohistochemical examination of a biopsy showed a spindle cell lesion consisting of (myo)fibroblasts with some erythrocyte extravasation, consistent with nodular fasciitis. Three months later the nodule was resolved spontaneously without treatment. CONCLUSION: Nodular fasciitis should be included in the differential diagnosis in case of hard, fast-growing, subcutaneous bumps in young adults. By ultrasound, it is difficult to differentiate from a malignant soft tissue tumor. A biopsy is necessary to confirm the diagnosis with certainty.

[A man with Covid-19 and abdominal pain]. / Een man met luchtwegklachten en pijn in de bovenbuik.

A 53-year-old man, diagnosed with Covid19, experienced pain in the left flank. Imaging results showed multiple spleen infarction. While thrombotic events are common complications in Covid19, diagnosing and imaging a spleen infarction is rather rare. There is no clear loss of contrast in the picture, which suggests local inflammation and coagulation in capillary vessels as physiological mechanism. Conflict of interest and financial support: none declared.

Impact of hernia volume on pulmonary complications following complex hernia repair.

BACKGROUND: Despite a multitude of evidence-based prediction models and risk factors for postoperative complications after ventral hernia repair, estimating a patient's risk of postoperative complications after ventral hernia repair remains challenging. In an attempt to improve the preoperative assessment of complex hernia patients, some studies have examined pulmonary changes after hernia repair hypothesizing that large hernias lead to pulmonary changes and increased pulmonary complication rates. Some studies have described a correlation between hernia volume and pulmonary changes, although none provided compelling evidence to identify hernia volume as a risk factor for pulmonary complications. This study evaluates the relationship between hernia volume and postoperative pulmonary complications using computed tomography (CT)-based volume measurements. MATERIALS AND METHODS: Analysis of a prospectively maintained database of consecutive complex hernia patients from 2011 to 2014 undergoing endoscopic (ECST) or open component separation technique (CST) for a hernia defect with a minimum width of 6 cm and visual protrusion of the hernia sac ventral of the rectus abdominis muscles in supine position was performed. Hernia volume was calculated using multiple plane reconstruction of a standard abdominal CT-scan. Noted endpoints were pulmonary complications. RESULTS: Thirty-five patients underwent ECST (n = 20) or CST (n = 15) with a median defect volume of 474 cm3 (range, 114-2086 cm3). Observed complications were pneumonia (n = 4), pulmonary infiltrate (n = 3), aspiration pneumonia (n = 2), and acute respiratory distress syndrome (n = 1). Univariate and multivariate analyses showed that pulmonary complications were associated with "hernia volume" (P = 0.045; 95% CI: 1.008-1.910). CONCLUSIONS: Hernia volume is a promising risk factor for postoperative pulmonary complications and can be calculated using a standard abdominal CT-scan.

Malformations of the axial skeleton in the museum Vrolik: II: craniosynostoses and suture-related conditions.

The Museum Vrolik collection of anatomical specimens in Amsterdam, The Netherlands, comprises over 5,000 specimens of human and animal anatomy, embryology, pathology, and congenital anomalies. Recently, we rediagnosed a subset of the collection comprising dried infantile, juvenile, and adult human skulls with congenital and acquired conditions. On external examination and additional radiography, we found 58 skulls with craniosynostosis (CS) involving one or more sutures and 40 skulls with a presumed suture related condition. Most of these were part of the material collected and described by Louis Bolk (1866-1930). Analysis of his observations suggests that skull deformation because of premature suture closure depends not only on the identity of the sutures involved but also on the timing and progression of their closure and the extent of their involvement. Moreover, premature closure of the sagittal suture after 3-6 years of age appeared to be much more common than expected because it is not accompanied by skull deformation. Many of the skulls with single-suture CS were microcephalic, which may be the cause of the premature synostosis. By contrast, microcephaly may be a resulting phenomenon in multi-suture CS. We noticed that the quotient between height of the cranial vault (vertex-porion distance) and head circumference, multiplied by 100, was 26 or higher only in those CS cases with multi-suture involvement. We therefore consider this parameter, which we named "acrocephalic index", to be an indicator of multi-suture involvement in individual CS cases. In two adult skulls, the skull had a quadrangular shape, which we assumed to be correlated to the presence of an unusually interdigitated open metopic suture. We propose to name this anomaly: tetragonocephaly. Another presumed suture-related condition, bathrocephaly, was found concomitantly with basilar invagination in several cases. We hypothesize that the chronically raised intracranial pressure in these cases caused the still open lambdoidal sutures to distend and the occipital bone to protrude.