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Franjo Rudman,1 Davor Barić,2 Daniel Unić2 1Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital “Dubrava”, 2Department of Cardiac and Transplant Surgery, University Hospital “Dubrava”, Zagreb, CroatiaWe read with great interest the report by Dr Spindler and coworkers about the utilization of omentoplasty as salvage procedure in deep sternal wound infection.1 First of all, we congratulate the authors on the excellent results. Mortality rates in this high-risk cohort of patients can be attributed to advanced age, comorbidities, and other complications, but neither the timing nor the type of reconstruction performed.View the original paper by Spindler and colleagues.

We report a case of necrotizing fasciitis of the leg caused by Vibrio cholerae O8 in a 63-year-old immunocompetent man after he had been fishing in a lake on a Croatian island. The strain was cytotoxic, invasive and adhesive and contained a fragment of the gene for El Tor-like hemolysin (El Tor hlyA). After surgical and antibiotic treatment, the patient fully recovered.

Purpose: To determine platelet serotonin (5-HT) concentrations and genotype and allele frequencies of serotonergic type 2A receptor gene (HTR2A) and 5-HT transporter gene (SLC6A4) in women with pre-eclampsia, gestational hypertension without proteinuria (PIH) and in control normotensive pregnant women., Methods: The study included 96 control women, 131 women with PIH and 84 women with pre-eclampsia (ICD-10 criteria) in the last trimester of pregnancy. Variants of the HTR2A T102C (rs6313) and SLC6A4 (5-HTTLPR and rs25531) were determined by the PCR and real-time PCR procedures. Platelet 5-HT concentrations were analyzed by the spectrofluorimetric method., Results: The frequency of the 5HTTLPR and of HTR2A T102C genotypes or alleles was similar between three groups of pregnant women and was not associated with low platelet 5-HT concentrations observed in pregnant women with PIH or pre-eclampsia., Conclusions: The results confirm alterations in the peripheral 5-HT system in pregnancy-induced hypertension. Low platelet 5-HT concentration is a common feature of both PIH and pre-eclampsia. The results did not support the hypothesis that hypertension in pregnancy is a trait associated with polymorphic variants of the HTR2A and SLC6A4 or that they have a role in the predisposition to hypertensive disorders in pregnancy. The further studies are necessary to elucidate the role of 5-HT and genetic factors in the development of hypertensive disorders in pregnancy.

Skin and nipple-areola complex sparing mastectomy (SNSM) and primary reconstruction have been popular for breast cancer treatment in the last decade. An advantage of the SNSM technique is the removal of all breast tissue as a radical surgical procedure while preserving native breast integrity, nipple-areola complex (NAC), and submammary fold. This retrospective 15-year clinical study analyzes medical records from our breast surgery database collected at our department between 1997 and 2012. A total number of 3757 patients were treated for breast cancer; 411 (10.9%) patients had a skin-sparing mastectomy with the median (range) length follow-up of 63 months. This is the longest follow-up for SNSM in breast cancer patients; 3.7% of patients who underwent SNSM developed disease local recurrence, whereas occult NAC involvement with cancer occurred in 7.7% and local recurrence in the NAC in 1.2%. Partial necrosis of the NAC developed in 9.4% and total necrosis in 0.7% of operated breasts. All disease recurrences occurred in the first 10 years of the follow-up period. Local recurrence developed as first recurrence event has longer median cancer-specific survival time of 70 months than those with only distant metastases with 50 months and locoregional plus distant metastases with 35.5 months. The "Omega" pattern incision combines an oncological radical procedure with a lower incidence of skin flap necrosis. Patients reconstructed with autologous tissue were the group most satisfied. SNSM is an oncological safe procedure for breast cancer treatment with low recurrence in properly selected patients.

A modern approach to breast cancer treatment after mastectomy includes immediate breast reconstruction (performed simultaneously with the mastectomy). The understanding of factors that influence women's decisions and appreciation of their satisfaction is as important as the knowledge of medical efficiency of the selected treatment. The influence of women's age on opinion making for immediate breast reconstruction was researched in a monocentric prospective study (N = 102). Methods included questionnaires, interviews and medical documentation reviews. Women comply breast reconstruction with silicone implants and autologous tissue equally. Analyzing age distribution it is evident that women age 35-50 and older than 65 would agree to reconstruction with silicone implants more often. This can be explained by the fact that younger women expect to have better shaped breasts after reconstruction then prior to the same, while older women tend to avoid breast reconstruction using muscle flaps because they are more demanding and also require longer hospitalization.

Objective: The status of the axilla is the single most important prognostic indicator of overall survival in patients with breast cancer. Sentinel-node biopsy has false-negative rates of 5-10%. The aim of this study was to assess the importance of tumor and breast volume ratio as a predictive factor for axillary lymph node metastases in patients with T1c ductal invasive breast cancer., Methods: This study included 136 consecutive patients with T1c ductal invasive breast cancer. Three tumor diameters were measured. Tumor volume was calculated by the formula for ellipse. Breast volume was measured preoperatively. Tumor and breast volume ratio was calculated and shown per thousand., Results: Tumor and breast volume ratio is a new independent predictive factor for axillary lymph node metastase in T1c ductal invasive breast cancer., Conclusions: This predictive factor could help to define a subgroup of patients who will be at a higher risk for axillary lymph node metastase and would benefit from additional close follow up or axillary lymph node dissection.

Pyoderma chronica vegetans is a rare condition clinically characterized by large verrucous plaques with elevated borders and multiple pustules. Although the etiology is unknown, it is generally believed that vegetating reaction is due to an immune system dysfunction or immunosuppressive state. We report on a 72-year-old man with pyoderma chronica of the buttocks. The lesion on the left buttock worsened two years before with gradual onset of fistulas, scarring and verrucous plaques. Laboratory test revealed medium high erythrocyte sedimentation rate, anemia, shift to left in differential white blood cell count, and polyclonal hyperglobulinemia. Streptococcus species and Escherichia coli were detected in tissue samples. T-cell functional tests for mitogens were decreased. Flow cytometry analysis of phagocytic capability of monocytes and granulocytes by was normal. Inflammatory bowel diseases were excluded with clinical and radiological examination. Anti-HIV test was negative. Histology revealed hyperplasia and irregular acanthosis of the epidermis, sinus and abscess formation, fibrosis and diffuse infiltration of inflammatory cells such as plasma cells, lymphocytes, histiocytes, eosinophils and neutrophils. Surgery was chosen as a therapeutic option as conservative treatment proved ineffective. Therefore, complete excision of the lesion was performed and skin grafting was required to close the defect because of extensity of the lesions. The skin-graft donor site was normal skin. Good postoperative result was achieved, without recurrence of the pyodermatic process.

The aim of our study is to evaluate results of treating war injuries of colon and rectum, after 10 years. During the war in Croatia, 21 wounded, with colon (19) and rectum (2) injuries, were treated in the Department of Surgery at Nova Gradiska General Hospital from August 1991 to April 1992. Bullet wounds accounted for 57% of the injuries. All patients had other associated injuries. Primary repair and proximal derivation was possible in 2 cases (9.5%), while primary resection with intraperitoneal anastomosis was performed in 3 (14.3%) patients. In 2 (9.5%) patients sustained intraperitoneal and extraperitoneal rectal penetrating injury rectum was resected and closed performing temporary sigmoidostomy. When multiple perforations or crush injury of the colon were found, in 8 (38.1%) injured persons resection of the involved segment was combined with proximal end colostomy and aboral mucous fistula. Exteriorization of injured segment of the colon and creating colostomy incorporating the injured colon as the stoma was performed in 6 (28.5%) wounded patients. Four of the wounded (19.0%) died two of them during the operative procedure due to hemorrhagic shock. One injured died after eight days due to pulmonary embolism, and one patient died after thirty days due to sepsis. Reoperation was necessary in two (9.5%) injured due to bowel obstruction four days following initial surgery because of adhesions. Three (14.3%) of the injured had wound infection, one of them died 30 days after injury due to sepsis, and two (9.5%) consequently developed ventral hernia that was operated after 4 and 5 years respectively. Four (19.0%) of the injured are still occasionally experiencing occasional abdominal pain.

Radiation-induced osteosarcoma is a rare complication of radiation therapy for breast cancer. The authors present a 60-year-old patient in whom osteosarcoma of the chest wall developed 5 years after modified radical mastectomy and radiation therapy for breast cancer. One year after resection of the chest osteosarcoma, metastasis to the contralateral axillary lymph nodes developed and these were removed. Radiation-induced osteosarcoma is difficult to treat and has a poor prognosis, thus early diagnosis is necessary for optimal treatment.