Heparin-induced bleeding treatment in microsurgery

Microsurgery is associated with prolonged surgical times with an increased risk of deep vein thrombosis, pulmonary embolism and myocardial infarction. The use of antithrombotic means is a commonly employed tactic to prevent vascular thrombosis after microvascular free flap surgery. Flap loss is a devastating complication of microsurgical procedures that leads to detrimental outcomes. A 32-year-old male patient has a ruptured calcaneal tendon. He underwent 5 surgical cleanings with multiple failed sequential attempts at wound closure. Traumatology department in its microsurgery division where it is proposed to perform neo-tendon with graft of palmaris longus of the right thoracic extemity and radial antebrachial microvascular flap. The neo tendon was performed in addition to the micro surgical coverage with the radial antebrachial flap.When having vascular control with micro-clamps, 6000 U of unfractionated heparin was initiated, approximately 20 minutes after the end of the microvascular anastomosis, there was incoercible bleeding, which is initially treated with spray fibrin. Continued bleeding after 3 hours, so it was decided to reverse the effect of heparin with transfusion of fresh frozen plasma, 10 mg of vitamin K and fibrinogen. The effect of heparin was reversed without having thrombotic complications of microvascular anastomoses. The flap was not reexplored since they showed no signs of vascular compromise. If anticoagulants have been used and an incoercible hemorrhage is found, the effect of heparin must be reversed. In the transfer of tissues with microsurgery, the recommended and safe anticoagulation are prophylactic doses and not therapeutic doses

Pelvic limb reconstruction failed by propeller flap resolved with microsurgery

Reconstruction of lower limb defects is a constant challenge for surgeons, the etiology of the defect can be very variable from diabetic ulcers, traffic accidents, fall from height, oncological resections and many others. Free flaps have always been an important option because it has great results in complex reconstructions in lower limbs, it is a microvascular technique, so it has a higher level of complexity. This technique is usually reserved for extensive perilesional wide defects. On the other hand, the propeller flap, which is considered less invasive and easier as it does not involve microvascular surgery. An 18-year-old patient who had a fracture of the right tibial pylon due to a 7-meter drop, who after orthopedic treatment had a defect with exposure of ostesynthesis material of 3 cm in circumference in the medial malleolus. This defect was first managed with a propeller flap complicated with necrosis at 48 hours which was treated with sub atmospheric pressure system for 5 days and later with an ultra-thin anterolateral flap of the pelvic limb. Complete pedicled propeller flap failure is very rare but, because necrosis develops distally, even partial necrosis can expose bone, tendons, or other tissue. Some surgeons consider that propeller flap placement is risky in this location, especially the distal third of the lower leg a prefer to use free flaps. Whenever any pelvic member reconstruction plan fails in the distal third, the best and safest is the use of microsurgery even with the failure of a previous micro vascular flap

Antimicrobial stewardship programs in seven Latin American countries: facing the challenges

Antecedentes: Diversos estudios han demostrado que más del 50% de los antibióticos utilizados en los hospitales son innecesarios o inadecuados y que la resistencia a los antimicrobianos puede suponer cada año hasta 20.000 millones de dólares de sobrecostes médicos. Por otro lado, los programas de administración de antimicrobianos (PEA) reducen significativamente el uso inadecuado de antimicrobianos, la aparición de resistencias a los antimicrobianos, las infecciones asociadas a la atención sanitaria y los costes en el ámbito hospitalario. Objetivo: Evaluar el desarrollo de ASP y el ahorro de antibióticos en 7 hospitales latinoamericanos utilizando indicadores cuantitativos estandarizados en todas las instituciones de salud participantes. Métodos: Se realizó un estudio de intervención, donde se realizaron evaluaciones pre y post utilizando una herramienta de puntuación estandarizada adaptada de los estándares de acreditación de la Joint Commission International y, del Instituto Colombiano de Normas Técnicas y Certificación. Se evaluó ASP de 7 hospitales latinoamericanos entre 2019 y 2020. Se realizó una evaluación pre-intervención en cada hospital para cuantificar el grado de desarrollo de la ASP (ASP Development score). Con base en estos resultados, se implementó una capacitación in situ adaptada en cada hospital, seguida de una evaluación posterior a la intervención para cuantificar la mejora de los indicadores de desarrollo de ASP. Además, se estimó el ahorro monetario en antimicrobianos derivado de la intervención del PEA. Resultados: En la evaluación previa a la intervención, la puntuación media de desarrollo del PEA en las 7 instituciones fue del 65,8% (40-94,3%). Los puntos con la puntuación más baja fueron los relacionados con el seguimiento y la comunicación de los progresos y el éxito del PEA. Para la evaluación posterior a la intervención, 2 instituciones no pudieron participar debido a la presión impuesta por la pandemia COVID-19. Para los 5/7 hospitales restantes, la puntuación media del desarrollo del PEA fue del 82,3%, con un aumento del 12,0% en comparación con la medición previa a la intervención de las mismas instituciones (puntuación media previa a la intervención 70,3% (48,2%-94,3%) Los puntos con un aumento significativo fueron los indicadores clave de rendimiento, la educación de los AMS y la formación de los prescriptores. Tres de los siete (3/7) hospitales informaron de ahorros monetarios en antibióticos asociados a la intervención ASP. Conclusiones: El uso de la herramienta descrita demostró ser útil para evaluar áreas específicas del desarrollo del PEA que eran deficientes y adaptar las intervenciones para los hospitales participantes, en consecuencia, ayudó a mejorar el desarrollo del PEA en las instituciones que se sometieron al análisis previo y posterior a la intervención. Además, las estrategias mostraron ahorros monetarios en los costes antimicrobianos cuando se midieron. © 2023, Los autores.Background: Studies have shown that more than 50% of the antibiotics used in hospitals are unnecessary or inappropriate and, that antimicrobial resistance may cost up to 20 billion USD in excess medical costs each year. On the other hand, Antimicrobial Stewardship Programs (ASP) significantly reduce inappropriate antimicrobial use, emergence of antimicrobial resistance, healthcare associated infections, and costs in hospital settings. Objective: To evaluate the development of ASP and antibiotic savings in 7 Latin American hospitals using standardized quantitative indicators in all the participating health care institutions. Methods: An interventional study was conducted, where pre- and post- evaluations were performed using a standardized score tool adapted from the Joint Commission International accreditation standards and, the Colombian Institute of Technical Standards and Certification. We evaluated ASP from 7 Latin American hospitals between 2019 and 2020. A pre-intervention evaluation was done in each hospital to quantify the degree of development of the ASP (ASP Development score). Based on these results, tailored on-site training was implemented in each hospital, followed by a post-intervention evaluation to quantify improvement of ASP-development indicators. In addition, monetary savings in antimicrobials derived from the ASP intervention were estimated. Results: In the pre-intervention evaluation, the average ASP development score for the 7 institutions was 65.8% (40-94.3%). The items with the lowest development score were those related to monitoring and communicating the ASP progress and success. For the post-intervention evaluation, 2 institutions couldn’t participate due to the pressure imposed by the COVID-19 pandemic. For the remaining 5/7 hospitals, the average ASP development score was 82.3% with an increase of 12.0% when compared to the pre-intervention measurement of the same institutions (average pre-intervention score 70.3% (48.2%-94.3%) The items with a significant increase were key performance indicators, AMS education and training of the prescribers. Three of the seven (3/7) hospitals reported antibiotic monetary savings associated to the ASP intervention. Conclusions: The use of the tool described shown to be useful to evaluate specific areas of ASP-development that were lacking and tailor interventions for the participating hospitals, consequently, it helped improve ASP-development in the institutions that underwent pre- intervention and post-intervention analysis. In addition, the strategies showed monetary savings on antimicrobial costs when measured. © 2023, The Author(s)

Microsurgery in complex trauma of pelvic limb in a pediatric patient: case report

Complex trauma is defined as the condition secondary to the exchange of kinetic energy of two or more tissues in one limb. This entity is a surgical emergency that can have many sequelae and can even result in limb loss. An 11-year-old female patient presents complex pelvic limb trauma secondary to contuse injury caused by a helicopter’s rotor blades.  Pelvic limb reconstruction was performed with iliac crest bone graft, the fracture was stabilized with an external fixator and the skin defect was covered with an anterolateral microvascular thigh flap (ALT). There was an adequate integration of the bone graft with adequate skin coverage thanks to the ALT thigh flap. The patient presented discreet limb shortening as consequence.  Currently, microsurgery is the only medical option that meets the objectives of limb reconstruction. Microsurgical techniques can be used in pediatric and adult patients. The success of any recovery from complex trauma is vigorous surgical cleaning, avoiding sequential and/or multiple washes

Mecanismos Moleculares de Resistencia a Ceftazidima/Avibactam en Aislados Clínicos de Enterobacterales y Pseudomonas aeruginosa en Hospitales Latinoamericanos

Ceftazidima-avibactam (CZA) es la combinación de una cefalosporina de tercera generación y un nuevo inhibidor de β-lactamasas no β-lactámico capaz de inactivar β-lactamasas de clase A, C y algunas D. A partir de una colección de 2.727 aislamientos clínicos de Enterobacterales (n = 2.235) y P. aeruginosa (n = 492) que se recogieron entre 2016 y 2017 de cinco países latinoamericanos, investigamos los mecanismos moleculares de resistencia a CZA de 127 (18/2.235 [0,8%] Enterobacterales y 109/492 [22,1%] P. aeruginosa). En primer lugar, mediante qPCR para detectar la presencia de genes que codifican las carbapenemasas KPC, NDM, VIM, IMP, OXA-48-like y SPM-1, y en segundo lugar, mediante secuenciación del genoma completo (WGS). De los aislados resistentes a la CZA, se detectaron genes codificadores de MBL en los 18 Enterobacterales y los 42/109 aislados de P. aeruginosa, lo que explica su fenotipo resistente. Los aislados resistentes que dieron un resultado negativo en la qPCR para cualquiera de los genes codificadores de MBL se sometieron a WGS. El análisis WGS de los 67 aislados de P. aeruginosa restantes mostró mutaciones en genes previamente asociados con una susceptibilidad reducida a la CZA, como los implicados en la bomba de eflujo MexAB-OprM y la hiperproducción de AmpC (PDC), PoxB (blaOXA-50-like), FtsI (PBP3), DacB (PBP4) y OprD. Los resultados aquí presentados ofrecen una instantánea del panorama epidemiológico molecular para la resistencia a CZA antes de la introducción de este antibiótico en el mercado latinoamericano. Por lo tanto, estos resultados sirven como una valiosa herramienta de comparación para rastrear la evolución de la resistencia a CZA en esta región geográfica endémica de carbapenemasas.Ceftazidime-avibactam (CZA) is the combination of a third-generation cephalosporin and a new non-β-lactam β-lactamase inhibitor capable of inactivating class A, C, and some D β-lactamases. From a collection of 2,727 clinical isolates of Enterobacterales (n = 2,235) and P. aeruginosa (n = 492) that were collected between 2016 and 2017 from five Latin American countries, we investigated the molecular resistance mechanisms to CZA of 127 (18/2,235 [0.8%] Enterobacterales and 109/492 [22.1%] P. aeruginosa). First, by qPCR for the presence of genes encoding KPC, NDM, VIM, IMP, OXA-48-like, and SPM-1 carbapenemases, and second, by whole-genome sequencing (WGS). From the CZA-resistant isolates, MBL-encoding genes were detected in all 18 Enterobacterales and 42/109 P. aeruginosa isolates, explaining their resistant phenotype. Resistant isolates that yielded a negative qPCR result for any of the MBL encoding genes were subjected to WGS. The WGS analysis of the 67 remaining P. aeruginosa isolates showed mutations in genes previously associated with reduced susceptibility to CZA, such as those involved in the MexAB-OprM efflux pump and AmpC (PDC) hyperproduction, PoxB (blaOXA-50-like), FtsI (PBP3), DacB (PBP4), and OprD. The results presented here offer a snapshot of the molecular epidemiological landscape for CZA resistance before the introduction of this antibiotic into the Latin American market. Therefore, these results serve as a valuable comparison tool to trace the evolution of the resistance to CZA in this carbapenemase-endemic geographical region

Reverse-flow anterolateral thigh flap for knee soft-tissue reconstruction: case report

The reconstruction of the injured tissue around the knee is a complex procedure for the plastic and orthopaedic surgeon. The objective is to provide an acceptable function and aesthetic result. Successful wound management includes meticulous debridement, planning and proper execution of the surgical procedure. An 11-year-old male patient with a right patellar fracture using an anterolateral thigh flap with reverse flow to cover the skin defect. For such purposes, the reverse flow anterolateral flap is an effective, trustworthy and well-documented option. The correct obtaining and implantation of the flap reduces the morbidity of the donor site, offers options in size and design, an adequate length of the pedicle and the possible combination with the fascia lata in case it is required. The versatility of the reverse flow anterolateral flap makes it a possible therapeutic alternative in reconstructive surgery since it is aesthetic and functional for the reconstruction of tissue near the knee joint

Automated Testing of Mobile Applications: A Systematic Map and Review

Context: Software testing is a costly and time-consuming activity. Automated testing of mobile applications is considered complex and difficult. Indeed, several factors such as a variety of inputs (user, context, and environment) that a mobile application normally requires, and the heterogeneity of the technologies make automated testing not a trivial task. Two of the major challenges for automated testing are creation of the appropriate test cases scenarios and to decide in which devices to perform the testing. Objective: This paper reports on a systematic map and review. Automated testing approaches for mobile applications, testing techniques, and empirical assessment are identified, mapped, and characterized. We investigate the major challenges in automated testing of mobile applications. An analysis and synthesis of these studies is conducted. Method: A systematic mapping and systematic literature review research method has been conducted for identifying and aggregating evidence about automated testing of mobile applications. Results: A total 83 studies were identified. The results were tabulated and synthesized to provide recommendations to practitioners about automated testing of mobile applications. The main approaches identified were model-based testing (30%), capture/replay (15.5%), model-learning testing (10%), systematic testing (7.5%), fuzz testing (7.5%), random testing (5%) and scripted based testing (2.5%). Conclusions: In recent years, the number of proposals for automated software testing of mobile applications has increased. In 40% of the studies, the testing techniques use GUI-based models of the application. Further research is needed, in order to improve the creation of effective and efficient models for automated testing of mobile applications.Ministerio de Ciencia, Tecnología y Telecomunicaciones/[]/MICITT/Costa RicaUCR::Vicerrectoría de Docencia::Ingeniería::Facultad de Ingeniería::Escuela de Ciencias de la Computación e InformáticaUCR::Vicerrectoría de Investigación::Unidades de Investigación::Ingeniería::Centro de Investigaciones en Tecnologías de Información y Comunicación (CITIC

Holocene multiproxy records of Laguna Meseta, Chile (46.5º S): XRF-elements, magnetic susceptibility, bulk chemistry and grain size

A 3 m-long continuous sediment record recovered from Laguna Meseta (LME), one of the lakes located on Meseta Chile Chico, Central Patagonia, Chile. Its radiocarbon chronology documents sediments of the last ~10,000 years indicating a minimum age for postglacial ice-free lacustrine conditions due to a westward retreat of the Large Patagonian Ice sheet. At this time, lacustrine productivity reached its maximum and decreased afterwards. Between 5,500 and 4,600 cal yr BP, a major shift towards allochthonous sediment accumulation occurred, caused by an abrupt increase in clastic deposition from basaltic lithologies of the Meseta Chile Chico. This episode correlates with the precipitation-driven Mid-Holocene glacier advance of Patagonian glaciers, suggesting a persisting glacial influence on the Meseta Chile Chico. After 4,600 cal yr BP wetter climate conditions returned to feed LME with fluvial sediments until a stepped decrease around 1,000 cal yr BP. Thereupon, lacustrine productivity distinctly increased and stabilized around 300 cal yr BP. Our reconstructions and comparisons with other regional paleoenvironmental studies indicate that environmental conditions of LME were mainly controlled by humidity changes on the Meseta Chile Chico and reflect Holocene climate variability