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.

[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.

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.

[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.

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.

[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.

[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.