Influence of regular reporting on local Pseudomonas aeruginosa and Acinetobacter spp. sensitivity to antibiotics on consumption of antibiotics and resistance patterns.

WHAT IS KNOWN AND OBJECTIVE: Regular surveillance of antimicrobial resistance is an important component of multifaceted interventions directed at the problem with resistance of bacteria causing healthcare-associated infections (HAIs) in intensive care units (ICUs). Our aim was to analyse antimicrobial consumption and resistance among isolates of Pseudomonas aeruginosa and Acinetobacter spp. causing HAIs, before and after the introduction of mandatory reporting of resistance patterns to prescribers. METHODS: A retrospective observational study was conducted between January 2011 and December 2015, at an interdisciplinary ICU of the Clinical Centre Kragujevac, Serbia. The intervention consisted of continuous resistance monitoring of all bacterial isolates from ICU patients and biannual reporting of results per isolate to prescribers across the hospital. Both utilization of antibiotics and density of resistant isolates of P. aeruginosa and Acinetobacter spp. were followed within the ICU. RESULTS AND DISCUSSION: Resistance densities of P. aeruginosa to all tested antimicrobials were lower in 2015, in comparison with 2011. Although isolates of Acinetobacter spp. had lower resistance density in 2015 than in 2011 to the majority of investigated antibiotics, a statistically significant decrease was noted only for piperacillin/tazobactam. Statistically significant decreasing trends of consumption were recorded for third-generation cephalosporins, aminoglycosides and fluoroquinolones, whereas for the piperacillin/tazobactam, ampicillin/sulbactam and carbapenems, utilization trends were decreasing, but without statistical significance. In the same period, increasing trends of consumption were observed for tigecycline and colistin. WHAT IS NEW AND CONCLUSION: Regular monitoring of resistance of bacterial isolates in ICUs and reporting of summary results to prescribers may lead to a significant decrease in utilization of some antibiotics and slow restoration of P. aeruginosa and Acinetobacter spp. susceptibility.

[Endometriosis in cesarean section surgical scar].

INTRODUCTION: Endometriosis is the presence of endometrial glands and stroma outside of uterine cavity. It may occur in the abdominal wall scar after the operation in which uterus was opened. In cesarean section scar it occurs in 0.4%. It is in 2/3 patients characterised with triad of: tumor, periodic pain associated with menses and history of cesarean section. The mechanism of endometriosis occuring in the cesarean scar is felt to be secondary to iatrogenic transplantation of endometrium or extrauterine decidual tissue into the incision during the cesarean section. CASE OUTLINE: Forty years old patient with tumor 4,5x4 cm that appeared in abdominal wall scar one year after second cesarean section, followed by periodic pain and macroscopic changes associated with menses. First diagnosis was granuloma in the surgical scar, but as she had periodic simptoms, diferential diagnosis was endometriosis. Hormonal therapy with contraceptiv drugs was ordered. As it was no improvement she was operated. The surgical excision of the tumor including fascia and muscle tissue was done. Sample revealed endometrium after histopathologic examination. Patient was complitely recoverd and without relepse of simptoms during followup to date. CONCLUSION: When there is a tumor in the cesarean section scar or scar after the operation in which uterus or ovarial tube was opened, followed with periodical pain and macroscopic changes associated with menses, endometriosis should be considered. Surgical excision of the tumor is sufficient and patohistological examination confirms diagnosis.

[Assessment of the degree of maturity in the wall of pancreatic pseudocysts in relation to choice of surgical procedure].

The aim of this study is to present our experience in the diagnosis and treatment of pancreatic pseudocysts. A pancreatic pseudocyst is an incapsulated collection of pancreatic juice, enclosed by nonepithelial elements, containing a high concentration of pancreatic enzymes, bicarbonates and necrotic detritus. It is a common complication of acute pancreatitis and trauma of the pancreas. In the period between 1996 and 2001, 53 surgical procedures were performed for pancreatic pseudocyst at the Institute for Digestive Diseases (First Surgical University Hospital), 35 male patients (67%) and 17 female patients (33%) underwent surgery. In 39 (75%) patients the method of choice was cystojejunostomy by Roux. In 4 cases distal pancreatectomy for pseudocysts localized within the pancreatic tail was performed, complete pseudocyst excision only was performed in one case and complete pseudocyst excision combined with cystojejunostomy was also performed in one case. Cystogastrostomy and drainage in one case and partial cystectomy and drainage also in one case. Surgical internal drainage is the method of choice for the treatment of pancreatic pseudocysts, involving low morbidity and mortality rates.

Pelvifemoral external fixation for the treatment of open fractures of the proximal femur caused by firearms.

Seventeen patients with open fractures of the upper third of the femur were treated using a pelvifemoral external fixation device. All of them had grade III open fractures resulting from high-velocity missile and explosive injuries with massive foreign body contamination. Sciatic nerve injury was present in five (29.4%); abdominal viscera and thoracic wall injuries were present in two patients (11.8%). There were no major arterial injuries. Full weight bearing was allowed after clinical and radiological bone healing (average 11.5 months). Chronic osteitis with fistula and sequestra developed in two (11.8%) patients. There were no nonunions and no refractures. Minor painless limitation of hip motion persisted in all patients. Upper-third femoral open fractures due to firearms are a unique type of open fractures. They are usually highly comminuted; therefore, stable fixation is difficult or impossible to achieve using external fixation with transfixation of the fracture site. On the other hand, the risk of infection is high following intramedullary nailing. Pelvifemoral external fixation allows adequate management of the soft tissue wounds, provides stable bone fixation and allows early patient mobilization.

[Autotransplantation of the spleen]. / Autotransplantacija slezine.

Auto transplantation of the spleen can be performed in the patients with traumatic rupture of the spleen, in whom spleen could not be conserved in the other way. The right indication for this method is isolated rupture of the spleen (concvasation or complete devascularisation). This method is not recommended in the endangered patients, patients with previous disease of the spleen as well as in the patients with the perforation of the other abdominal organs at the same time. Auto transplantation was performed in 12 patients with isolated splenic rupture and hematoperitoneum, 11 men and one woman. The majority of patients are younger. In 8 patients, autotransplant was placed into big omentum, in three into lipomatous tissue surrounding left kidney, and in one into anterior abdominal wall. In all the patients from this group, following analysis were taken: MCV (middle volume of erythrocytes), HTC, Hb, Le, Glucose, urea, creatinin, sodium, potassium, alkali phosphatasis, target cells, Howell Jolly's bodies, Heinz's bodies, IgG, IgA, IgM, C3, C4, T3, T4, T8, B, segmentated, eosinophiles, lymphocytes, reticulocytes, thrombocytes, fibrinogen, PT, APTT, aggregation of thrombocytes and aggregation of thrombocytes on collagen. The same parameters were taken in 12 patients with surgery similar to splenectomy and in 12 after splenectomy. After splenectomy, there was decrease of the immunologic defending abilities of the organism because of the loss of the childrens function of the spleen, decreased level of the opsonines and tutsin, which leads to the impaired phagocytosis, decreased concentration of IgM and T and B lymphocytes, while in patients after auto transplantation the results were physiological. The most important thing in the assessment of the function of the autotransplanted spleen is scintigraphic investigation using 99mTc-denaturated red blood cells. In our study, auto transplant function was assessed in 10/12 patients by scintigraphy. Five years after surgery, no one patient was proved to have postsplenectomic sepsis.

[Pseudoarthrosis of the scaphoid bone associated with carpal collapse: factors in choice of surgical approach]. / Pseudoartroze skafoidne kosti udruzene s kolapsom rucja: faktori od znacaja za izbor operacionog postupka.

INTRODUCTION: The most common fracture involving the wrist is a fracture of the scaphoid bone [1], and only 5% to 10% of these fractures proceed to nonunion. Although not symptomatic initially, most (if not all) nonunions later produce a painful wrist with impaired function, clinically significant loss of motion, increased weakness and degenerative arthritis. Nonunion of the scaphoid bone should be treated by open reduction and internal fixation. Many surgical procedures have been advocated to achieve union. Most widely used technique for the treatment of scaphoid nonunion was described by Russe [2], but this method may overcome the flexion deformity of the scaphoid and carpal deformities. The ununited scaphoid usually undergoes resorption of the fractures surfaces, principally over the anterolateral aspect of the fracture, so that the scaphoid becomes misshapen. The restoration of the exact length and form is enabled by insertion of a tight-fitting trapezoidal corticocancellous graft, a technique described by Fernandez [11]. AIM: We analysed the results of treatment of scaphoid nonunion utilized by two bone-grafting techniques and pointed out the need of choice of the best operative method. METHODS: From 1977 to 1993, at the Institute of Orthopaedic Surgery and Traumatology in Belgrade, 40 patients were surgically treated for symptomatic nonunion of the scaphoid bone. The mean duration of follow-up was 10.2 years (range, from 6 to 22 years). Eighteen (45%) patients were operated by Fernandez technique and 22 (55%) patients were operated using Russe's technique. Volar approach and Kirschner's wire fixation were performed in both operative methods. We used two rating scales proposed by Cooney [13] to evaluate the results. Objective scale (Table 1a) included the radiographic appearance of the wrist, the range of motion and grip strength. Subjective scale (Table 1b) comprised function, pain perception of a decrease in performance because of limited motion or strength, and satisfaction. These scales were used to compare the objective and subjective results in patients who had postoperatively carpal collapse with the results in patients who had not such deformity. RESULTS: The union rate was 92.5% in both methods. Russe's technique resulted in union in 20 (91%) of 22 cases with two ununited. Fernandez technique achieved union in 17 (94%) of 18 cases. Fracture union was determined by both clinical and roentgenographic examinations. Correction of the lateral interscaphoid angle was obtained in 14 (82%) patients operated by Fernandez technique and 9 (45%) patients operated by Russe's technique. Correction of dorsal tilt of the lunate were achieved in 6 (30%) patients operated by Russe's technique, and 13 (76.6%) patients operated by Fernandez technique. There was a highly significant correlation (p < 0.01) between increased deformity of the scaphoid and extent of carpal collapse (Graph 1). Also, there was significant difference between two operative techniques regarding correction of lateral interscaphoid angle (p < 0.05). Arthrosis of the wrist was present in all patients. We could not demonstrate a significant difference (p > 0.05) between intensity of degenerative changes and increase of lateral interscaphoid angle, but obviously, the large flexion deformity of the scaphoid the worse intensity of degenerative changes (Graph 2). The grip strength significantly increased after Fernandez technique (p > 0.05) (Graph 3), but wrist motion changed a little. The average objective score was 71 points for the patients in whom the lateral interscaphoid angle was 45 degrees or less, and 63 points for those in whom the angle was more than 45 degrees. This difference was significant (p < 0.05), but we could not demonstrate a significant difference between the two groups in terms of the average subjective score. DISCUSSION: In our series, both procedures provided a high union rate [2]. In cases with severe scaphoid shortening and flexion deformity, Russe's procedure has proved to be insufficient to restore anatomic length and correction of carpal alignment [6, 11, 17]. Previous authors have reported that the progression in degenerative changes was slower in patients who had a lateral interscaphoid angle less than 45 degrees [13]. Also, grip strength and range of motion increased in patients in whom flexion deformity of the scaphoid had been corrected [2, 4, 6, 16, 17]. Our study supports these findings, except results regarding the movement. We believe that this was due to postoperative scarring. Discrepancy between the subjective and objective results may have been due to postoperative relief of pain obtained by increased carpal stability or decreased range of motion of the carpal joints due to postoperative scarring. If pain is relieved, patients readily adapt to the functional deficit of decreased range of motion. We concluded that angulatory collapse of the scaphoid resulted in nonunion as well as malunion with secondary functional loss. Recognition and avoidance in acute fractures were important. When recognised late, volar wedge grafting appeared to be a satisfactory method of treatment.

Role of autologous fibrin tissue adhesive in abdominal surgery.

Fibrin tissue adhesive (FTA) is an agent developed for achieving better hemostasis and adhesion of living tissue. FTA appears to have no tissue toxicity, promotes a firm seal in seconds to minutes, is reabsorbed in days to weeks following application, and appears to promote local tissue growth and repair. It can be used in various surgical procedures. It has been used preoperatively, perioperatively and postoperatively in abdominal surgical procedures. There were no side effects. Improvement of surgical hemostasis was obvious in all patients. Anastomotic leakages were closed in a shorter time without surgical intervention. Sero-lymphatic drainage after surgical procedures that include extensive lymph node dissections was less. Use of FTA in treatment of fistula in ano was successful. The data would indicate that use of FTA may be a good alternative in solving various conditions in every day clinical practice, although a bigger randomized series, and longer follow up is needed.

Absorbable suture technique: solution to the growth problem in pediatric pacing with endocardial leads.

Endocardial pacing system implantation has been performed in 15 children of mean age 37 months (ranging from 1 day to 89 months). Endocardial lead fixation was performed by means of slowly resorbable suture (Dexon) to allow spontaneous lead migration as the child grows. During a mean follow-up period of 61 months (range 17-108 months), none of the patients needed reintervention for correcting the lead length to allow growth.

[Application of LNNB in patients with closed brain injury]. / Primena neuropsiholoskog upitnika Lurija Nebraska kod bolesnika sa zatvorenom povredom mozga.

Closed brain injury (CBI) has become epidemiological problem with important neuropsychological consequences that, although often not obvious without formal testing, are of great influence on cognitive and social functioning of these patients. We applied Luria Nebrasca Neuropsychological Battery (LNNB) to 24 victims of moderate and severe CVI after they regained proper orientation for time and place, and 75 to 180 days later. There were 18 male and 6 female patients, age from 16 to 55 years. The most impaired functions on first testing were rhythm perception, which can be taken as a measure of attention, memory, Intellectual processes, visual function and arithmetics (in the descending order of scores). On retesting we noted significant recovery in rhythm perception, visual functions, intellectual processes, motor functions, receptive speech and arithmetics. Disorders of attention and concentration showed widespread influence on other neuropsychological functions as a nonspecific factor, especially in spontaneous recovery that stresses the importance of specific rehabilitation measures for attention and concentration. LNNB showed great opportunities for assessment of wide spectrum of neuropsychological functions both in initial and later phases, and also in planning of cognitive and social rehabilitation.

The evaluation of tumor markers levels in determination of surgical procedure in patients with gallbladder carcinoma.

In purpose of early diagnosis of gallbladder carcinoma, the serum levels of tumor markers CA 72-4, CA 19-9, CEA, AFP, Ferritin and beta HCG were determined in 124 patients with benign and malign diseases of gallbladder, before and 10 days after the operation. The most important clinical significance have CA 72-4 and CA 19-9, which are increased in Ca in situ and carcinoma of the first stage. These early stages of carcinoma cannot be diagnostified by preoperative echotomography, but radical operation is possible with recover by all means. These two tumor markers should be attended in risk group of patients for rising gallbladder carcinoma: calculosis and polyposis. The rest of tumor markers are increased in progressive carcinoma with infiltration of surrounding tissue and metastases.

[Extradural hematomas with delayed clinical manifestations]. / Ekstraduralni hematomi sa odlozenim klinickim manifestacijama.

Extradural haematomas are usually characterized by a rapidly progressing clinical course within several hours. However, an extradural haematoma may have a lucid interval lasting days or weeks. These haematomas are known as chronic or delayed extradural haematomas. Nevertheless, there is little agreement among authors as to when an extradural haematoma should be called chronic. From the practical standpoint they can be divided into a subacute (between the 3rd and 14th day) or a chronic (two weeks or more) group. The authors report a study of 39 extradural haematomas with delayed onset of clinical manifestations treated at the University Neurosurgical Department in Belgrade from 1976 to 1987.

Results of our 15-year study into the biological effects of microwave exposure.

The results obtained during 15 years of clinical and experimental examinations of biological microwave exposure effects are briefly surveyed. Some important results are reported. Based on their experience, the authors present their attitudes concerning harmful microwave effects on living matter. They consider that microwave effects, either direct or indirect, are the results of hyperthermia. Exposure of the living body to irradiation intensities not causing thermal effects do not induce important pathological alterations in the irradiated organisms. Also, it has been pointed out that the term "injury" is more suitable than the term "microwave sickness" when harmful effects of microwaves to the living organism are concerned. According to the authors, the term "microwave sickness" is not acceptable as a synonym for professional diseases of persons working with sources of microwave energy, since it refers to the complex of insufficiently defined symptoms of uncertain etiology.

A study of the health status of radar workers.

The health status was examined of 322 radar workers with a history of occupational exposure in a microwave field from 5-10 years. The clinical findings were compared with a control group of 220 persons. There were no statistically significant differences in clinical and laboratory findings between exposed and control group. Only some subjective complaints were found more frequently in the exposed group than in the control. The authors' feeling is that subjective complaints in radar workers could not be ascribed only to the influence of microwaves because they could be due to other nonspecific harmful occupational factors. On the basis of the results of this work, the authors concluded that it is unlikely to expect marked harmful effects from microwaves in radar workers in normal working conditions.

Surgical treatment of craniopharyngiomas in children.

This paper sets out the surgical difficulties and the results of treatment in 50 cases of craniopharyngiomas in children up to the age of 13. During surgery, 10 patients were in a sub-comatose state, while 4 had respiratory arrest. Two-thirds of the children under 10 were given an A-V shunt implant. Radical excisions were attempted in 20 cases but were executed in only 13. Three of these died. Separation of the upper and posterior part of the capsule from the hypothalamus had to be interrupted in seven cases. The object of the operation was the radical removal of the capsule. We failed in one-third of our cases. Tumour excision is always attempted unilaterally. When this proves impossible, a second operation is undertaken on the opposite side when the hypothalamic disturbance subsides. If repeated surgery is indicated, it is always performed on the opposite side of the primary operation.