Multidrug-Resistant Bacteria in Surgical Intensive Care Units: Antibiotic Susceptibility and ß-Lactamase Characterization.

Multidrug-resistant (MDR) bacteria of the utmost importance are extended-spectrum ß-lactamase (ESBL) and carbapenemase-producing Enterobacterales (CRE), carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Pseudomonas aeruginosa (CRPA), methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus spp. (VRE). In this study, an evaluation of MDR bacteria in surgical intensive care units in a tertiary referral hospital was conducted. The study aimed to characterize ß-lactamases and other resistance traits of Gram-negative bacteria isolated in surgical intensive care units (ICUs). Disk diffusion and the broth dilution method were used for antibiotic susceptibility testing, whereas ESBL screening was performed through a double disk synergy test and an inhibitor-based test with clavulanic acid. A total of 119 MDR bacterial isolates were analysed. ESBL production was observed in half of the Proteus mirabilis, 90% of the Klebsiella pneumoniae and all of the Enterobacter cloacae and Escherichia coli isolates. OXA-48 carbapenemase, carried by the L plasmid, was detected in 34 K. pneumoniae and one E. coli and Enterobacter cloacae complex isolates, whereas NDM occurred sporadically and was identified in three K. pneumoniae isolates. OXA-48 positive isolates coharboured ESBLs belonging to the CTX-M family in all but one isolate. OXA-23 carbapenemase was confirmed in all A. baumannii isolates. The findings of this study provide valuable insight of resistance determinants of Enterobacterales and A. baumannii which will enhance surveillance and intervention strategies that are necessary to curb the ever-growing carbapenem resistance rates.

PSEUDOCYST FORMATION AFTER ABDOMINOPLASTY: A CASE REPORT.

Abdominoplasty is one of the most popular aesthetic body contouring procedures. Seroma formation is the most common early complication after abdominoplasty. Usually, it resolves with punctions and seroma evacuation. Chronic seroma and pseudocyst formation is a rare complication and it demands surgical intervention. Based on our experience from the described case, the pseudocyst needs to be radically extirpated and a combination of quilting sutures, fibrin glue, three weeks of suction drainage, and compressive garments should be used to prevent recurrence.

THE EFFECT OF REGIONAL VS. GENERAL ANESTHESIA ON THE IMMUNE RESPONSE IN BREAST CANCER SURGERY: A NARRATIVE REVIEW OF THE LITERATURE.

For breast cancer patients, surgery remains the cornerstone in treatment. Perioperative and postoperative period is associated with impaired immune function that can have profound implications for cancer patients in terms of tumor recurrence and metastases. The three main factors include surgery and related neuroendocrine stress response, anesthetic drugs, including opioid analgesics and postoperative pain. The most investigated immune cells are natural killer (NK) cells that are affected by both anesthesia and surgery. It has been demonstrated that ketamine, thiopental, volatile anesthetics, fentanyl and morphine, but not propofol, remifentanil or tramadol reduce the number of circulating NK cells and depress their toxicity. The level of NK cells' cytotoxicity is inversely proportional to the stage and spread of cancer. Regional anesthesia and its potential beneficial effects on the perioperative immune response and long-term outcome after surgery has been investigated as an alternative to general anesthesia in patients undergoing breast cancer surgery. In this paper, we present a review of literature aimed to assess the impact of regional anesthesia techniques on the immune response in patients undergoing breast cancer surgery and how it compares to general anesthesia.

The Acceptance of Cosmetic Surgery Scale (Acss) and Its Correlations with Psychological Characteristics among the Croatian Population.

BACKGROUND: This study aimed to examine the results of Acceptance of Cosmetic Surgery Scale among the Croatian population and its correlations with other scales and demographic data. SUBJECT AND METHODS: The sample consisted of 420 people who voluntarily filled out an online questionnaire. They completed demographic questions and four scales: Acceptance of Cosmetic Surgery Scale (ACSS), Rosenberg Self-Esteem Scale (RSES), Satisfaction With Life Scale (SWLS), and Body Appreciation Scale-2 (BAS-2). RESULTS: ACSS scale showed five statistically significant differences between genders and a higher overall score in women, but no significant differences were recorded in three ACSS subscales and the overall ACSS score. In contrast to men, women respondents recorded a significant negative correlation between ACSS subscales score (Social, Consider) and BAS-2 and Satisfaction with life score, while a positive correlation was recorded with BMI. CONCLUSION: The ACSS score among the Croatian population was higher than the results among the Italian and Serbian population, and similar to the original American study, which tells us that the Croatian population accepts and considers cosmetic surgery a lot. Furthermore, our results are important for practitioners and patients because they revealed correlations between ACSS scores and the self-thinking scale.

Tattoo Pigment within Regional Lymph Nodes Mimicking Cutaneous Melanoma Metastasis.

Dear Editor, The diagnosis of malignant melanoma accounts for 1-2% of all cancer diagnoses, around 4% of all malignant skin diseases, and 80% of all skin cancer deaths (1). The prognosis depends on several factors including tumor size, Clark level, Breslow thickness, location, ulceration, and presence of metastases. Detection of lymph node metastasis is initially accomplished by clinical examination and by operative evaluation for occult metastasis using sentinel lymph node biopsy (SLNB) when indicated (2). Lymph nodes (LN) with melanoma metastasis may appear normal in early stages, but eventually they become dark, firm, and enlarged (3). In 2017, a 32-year-old female patient was referred to our ward by a dermatologist following a biopsy excision of a nevus under her right breast that tested positive for a cutaneous melanoma grade T2aNx with a Breslow thickness of 1.9 mm, with no sign of ulceration and no history of previous illnesses or chronic diseases. Based on the American Joint Committee on Cancer (AJCC) guidelines, wide excision with a sentinel lymph node (SLN) biopsy was indicated (4). The patient was injected with 0.4 mL CiTc 99m Nanocoll in all four quadrants around the primary scar. A 2 cm wide elliptical excision was performed circumferentially around the scar and to the depth of the muscular fascia of the thorax. With the aid of a gamma probe, a single radioisotope positive lymph node was located in the ipsilateral axilla, but 5 dark pigmented lymph nodes situated behind the SLN were visualized during manual dissection and thought to be consistent with metastatic disease (Figure 1). Due to this new finding, an excisional biopsy of all pigmented nodes was performed. Histology of the excised skin did not demonstrate any further cancerous cells. The size of the SLN was 15 mm, and immunohistochemistry for Melan A was negative for metastatic melanoma. Histological analysis of the darkly pigmented nodes was negative for metastatic melanoma as the pigment was demonstrated to originate from the dermal tattoo on the patient's back that had been removed by dermabrasion 3 years before melanoma development (Figure 2, Figure 3). Dermal tattooing results in initial sloughing of the overlying epidermis, variable dermal inflammation, and gradual assimilation of pigment into macrophages. Much of the pigment is rapidly carried into regional draining LN, which was shown in 2010 on a SKH-1a mouse model, and causes lymphadenopathy which is thought to be a result of local inflammation (6). Importantly, even after removal of the offending cutaneous tattoo the tattoo pigment can persist in draining or distant nodes visible to the naked eye (7). In such cases, LN can mimic metastatic malignant melanoma and may prompt the surgeon to proceed with radical lymph node dissection which may not be necessary. Despite clear guidelines for melanoma treatment in the general population, there are several questions that need to be addressed: firstly, how should a physician approach a patient with unknown history of tattoo removal, a diagnosis of melanoma, and intraoperative darkly pigmented lymph nodes? Secondly, due to the lack of scientific data and treatment protocol, if the SLN is normally colored while other regional nodes are darkly pigmented, what should the treatment plan entail?

Changes in total body surface area and the distribution of skin surfaces in relation to body mass index.

BACKGROUND: A correct estimation of total burn surface area is important since it is used for determining fluid resuscitation volumes, nutritional estimates and hospital admission criteria. Wallace's rule of nines is the most commonly used methods for this purpose. However, fat distribution is non-uniform and the total body surface area changes with obesity. The aim of this study was to determine if the rule of nines applies to all body mass index groups. METHODS: A total of 217 individuals were included in the study. The patients were divided into 4 groups according to their BMI (18.5-25kg/m2 (60 persons)), 25-29.9kg/m2 (61 individuals)), 30-34.9kg/m2 (55 persons)), >35kg/m2 (41 persons)). Each patient underwent a complete duel-energy X-ray absorptiometry body scan to determine the surface area (cm2) of the various regions of the body. RESULTS: We found no statistically significant variations between the Wallace body percentage distributions and our results in the men for all BMI ranges (head p=0.331, arms p=0.861, legs p=0.282, trunk p=0.696). In contrast, among women we found a statistically significant change in body surface area percentage distribution between the BMI groups and specific body regions (head p=0.000, legs p=0.000 and trunk p=0.001). CONCLUSION: The Wallace rule of nines is a quick and acceptable method for estimating the total burn surface area percentage in men of all BMI ranges. However, for women, a more accurate method of burn area estimation is required as proposed by our BMI adjusted charts.

Defect Reconstruction of an Infected Diabetic Foot Using Split- and Full-thickness Skin Grafts With Adjuvant Negative Pressure Wound Therapy: A Case Report and Review of the Literature.

INTRODUCTION: Any alteration or impairment to normal wound healing can result in the development of chronic wounds, which may lead to serious complications such as infection and loss of body fluid and proteins. Primary closure alone may not be sufficient to fulfill the criteria of successful defect reconstruction. Therefore, additional procedures such as skin grafting must be considered as an option. CASE REPORT: The case of a 43-year-old woman with diabetes who was admitted to the University Hospital Rebro (Zagreb, Croatia) due to an infected, nonhealing wound on her left foot. Skin grafts combined with negative pressure wound therapy (NPWT) before and after graft application improved wound healing in this patient. CONCLUSIONS: In this patient, the combination of skin grafts with NPWT before and after graft application reduced the comorbidities and complications often seen in the diabetic patient population. Herein, the authors utilized a quicker, cost-efficient, and safer technique of wound closure compared with traditional nonsurgical methods.

Management of a Complex Lower Limb Open Fracture in a Teenage Patient: A Case Report.

The challenges of managing Gustilo IIIB tibial fractures (ie, high energy trauma with a contaminated wound >10 cm in length, severe comminution ["crumbling"] or segmental fractures, and periosteal stripping) in children are unique in part because no clear guidelines exist and the injuries may cause short-term and long-term complications. Repeated wound debridement and secondary reconstruction are required in approximately 20% of these cases in both adults and children. A 13-year-old girl presented with severe polytrauma including an open Gustilo type IIIB fracture of the left lower leg. The patient declined limb amputation; a multidisciplinary team (plastic, pediatric, orthopedic-trauma surgeons, pediatrician, psychiatrist, clinical pharmacologist, anesthesiologist, physiotherapist, nurses) was assembled in order to give the patient the best chance of a successful outcome. Multiple limb salvage and reconstructive procedures including wound debridements, necrectomies, long-term negative pressure wound therapy, soft tissue reconstructions, external bone fixation, bone osteosynthesis, multiple skin grafts, and free-flap reconstruction were provided over a period of 6 months with great success. The patient is doing well 3 years after initial injury and is walking without complications. A multidisciplinary approach and structured treatment plan are important to minimize complications, avoid unnecessary delays in treatment, decrease morbidity, and provide the patient with the best result possible. Studies examining optimal treatment strategies for children and adolescents with these complicated fractures are needed.

Analysis of pulmonary surfactant by Fourier transform infrared spectroscopy after exposure to sevoflurane and isoflurane.

Pulmonary surfactant, consisting primarily of phospholipids and four surfactant-specific proteins, is among the first structures that is exposed to inhalation anesthetics. Consequently, changes of pulmonary surfactant due to this exposure could cause respiratory complications after long anesthetic procedures. Fourier transform infrared (FTIR) spectroscopy was used to explore the effects of two inhalation anesthetics, sevoflurane and isoflurane, on a commercially available pulmonary surfactant. The research was primarily focused on the effect of anesthetics on the lipid component of the surfactant. Four different concentrations of anesthetics were added, and the doses were higher from the low clinical doses typically used. Recorded spectra were analyzed using principal component analysis, and the Student's t-test was performed to confirm the results. The exposure to both anesthetics induced similar changes, consistent with the increase of the anesthetic concentration. The most pronounced effect was on the hydrophilic head group of phospholipids, which is in agreement with the disruption of the hydrogen bond, caused by the anesthetics. A change in the band intensities of CH2 stretching vibrations, indicative of a disordering effect of anesthetics on the hydrophobic tails of phospholipids, was also observed. Changes induced by isoflurane appear to be more pronounced than those induced by sevoflurane. Furthermore, our results suggest that FTIR spectroscopy is a promising tool in studying anesthetic effects on pulmonary surfactant.