20.09.2014

What is the treatment for bone cancer 5k

Science, Technology and Medicine open access publisher.Publish, read and share novel research. Current Challenges in the Treatment of Deep Sternal Wound Infection Following Cardiac SurgeryMartin Simek1, Martin Molitor1, Martin Kalab2, Patrick Tobbia3 and Vladimir Lonsky1[1] Department of Cardiac Surgery, University Hospital Olomouc, Olomouc, Czech Republic[2] Department of Plastic Surgery, University Hospital Bulovka, Prague, Czech Republic[3] Department of Medicine, Cone Health, University of North Carolina, Greensboro, NC, USA1. Accepted risk factors: diabetes, obesity, immunosupressive therapy intakeIn 1997, Obdeijin et al described the first application of NPWT for treatment of DSWI in 3 consecutive patients [112].
A shoulder sprain is stretching or partial tearing of the ligaments and capsule that support the shoulder, specifically, the glenohumeral joint. Shoulder instability is a condition in which the upper-end of the humerus (the upper arm bone) slides partially or completely out of the shoulder socket. A shoulder dislocation occurs when the head of the humerus (upper arm bone) pops out of the shallow shoulder socket of the scapula (called the glenoid). The material on this web site is provided for educational purposes only, and is not to be used for medical advice, diagnosis or treatment.
The band, which originally was formed in 1990, will play five shows in five cities in November to mark the 25th anniversary of the band’s first and only album, Temple of the Dog. The group was formed from the ashes of Mother Love Bone, which dissolved upon the death of lead singer Andrew Wood. Temple of the Dog is being given the deluxe reissue treatment by UMe. The reissue, which will hit stores September 30, will be available as four-disc Super Deluxe, double LP, two CD Deluxe and single CD sets. GA’s Ultimate Luxury Products Guide: We present the best in fine food, exquisite autos, exotic vacations, impeccable audio reproduction and sartorial superiority. Cadaveric calva bone allograft in large bone defect repair and CT reconstruction showing the bone re-union9.3. IntroductionMedian sternotomy due to its technical simplicity and excellent exposure of the heart, great vessels and pulmonary hila is the most common incision performed in cardiothoracic surgery worldwide [1].
Although more than two dozen factors were obtained for uni-, and multivariable analyses, only obesity and diabetes mellitus were constantly proven in published studies [6-18,21,22]. They found that physical therapy contracted the wound, provided sufficient chest stability, and allowed patients to be extubated.
The rotator cuff is made up of muscles and four separate tendons that fuse together to surround the shoulder joint. This can happen when a strong force pulls the shoulder upward or outward, or from an extreme external rotation of the humerus. Chris Cornell wrote numerous songs in tribute to Wood, his longtime friend, and decided to record them with Ament, Gossard and McCready, who had formed the bulk of Mother Love Bone. Getty Images reserves the right to pursue unauthorized users of this image or clip, and to seek damages for copyright violations. Originally described by Julian more than 100 years ago and re-induced by Milton in 1957, median sternotomy replaced gradually thoracotomy or bilateral transverse sternothoracotomy (clamshell incision) for routine access to the heart [2,3]. Catarino et al reported the first retrospective comparison between NPWT and closed chest irrigation in 2000. The glenohumeral joint is the meeting of the upper arm bone, humerus, and the cup of the shoulder blade.
Even though median sternotomy is still considered to be the gold standard, efforts remain ongoing to use less invasive methods such as partial sternotomy or small thoracotomy to influence the risk of wound healing complications, patient’s satisfaction and better quality of life [4].2. Even though BMI does not correlate closely with body fat, there is a step-wise relationship between BMI and the risk of major surgical infection in cardiac surgery [7,15,24]. The proportion of individual strains of Staphylococcus and their methicillin-sensitivity varies between countries and institutions, reflecting their long-term hygienic and antibiotic policies [35]. In comparing 9 versus 10 patients, they found superiority of NPWT in length of in-hospital stay (15 vs. It is caused not only through technical obesity-related problems, but also through less effective penetration of antibiotics into the fat tissue [24]. Although surgical site infections are typically perceived to be an exogenous problem related to exposure to healthcare workers, the most causative pathogens are endogenous from patient’s own skin or mucosal flora [36,37].
Although, DSWI can be described from many perspectives, the definition according to the Center for Disease Control and Prevention (CDC), is used for distinguishing DSWI from others types of sternal wound infections (SWIs), and is respected by most authors (Table 1) [5]. Undoubtedly, diabetics are at a higher risk of developing DSWI, making the role of perioperative glycemic control crucial. Nasal carriage of SA has been identified as a potential risk factor for DSWI [38], and genetically identical SA from nasal flora have been cultivated from sternotomy wounds [39]. The first calculation of cost originated from the Loop et al paper, published in the late 1980?s, and found a 2.8 times increase in cost [6].
Unsatisfactory preoperative glycemic control is considered to be an important risk factor for development of DSWI [25,26].
Unlike SA which caused a more aggressive presentation, CONS infection accompanied with bacteremia as observed in 50-60% of cases [34, 40] had a rather indolent course, clinically manifested later, and was more prone to recurrence [41, 42]. Patients who died of DSWI consequences consumed 60,500 USD more, making the total cost of these patients approximately 80,000 USD compared with 11,000 USD an uncomplicated CABG patient cost, as showed by Hollenbeak et al [11].
Furthermore, Gustafsson et al and Fleck et al, from the two most active European centers (Lund and Vienna), reported similar in-hospital and 30-day or 90-day mortality of DSWI patients, with 60% of all cases having class III according to El Oakley and Wright [114,115].
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It could be perceived that the numerous advances in cardiac surgery, post-operative care and employment of preventive measurements may have played a role in reducing the incidence of DSWI in the last 10 years.
Internal mammary artery (IMA) harvesting, particularly in the pedicled fashion, has been found to have a higher incidence of DSWI in a CABG cohort compared with valvular procedures [7,8].
DSWI is diagnosed in 40-70% of patients post-discharge, thus post-discharge surveillance of up to 90 days is recommended [43]. Consequently, the Lund group reported survival data from 1,3, and 5 year follow-up which showed comparable survival (92.9%, 89%, 89%) with patients without DSWI after CABG (96%,92%, 86%) and showed potential survival benefit of NPWT therapy unlike data known from conventional therapy [18].


Today surgically treated patients’ cohorts are different than patients operated on 20 years ago in terms of advanced age, co-morbidities, and surgical complexity. Furthermore, this risk becomes stronger when both IMA are used for revascularization or in the diabetic population, but this effect might be attenuated when both IMA are taken down in a skeletonized fashion, even in diabetics [10,27,28]. Gram negative strains contribute less commonly in the pathogenesis of DSWI and mostly translocate from other host site infections, such as pneumonia, urinary or abdominal infections [34].
In other words, the relatively steady status of DSWI incidence over the last three decades might be considered a satisfactory result [23]. Chronic obstructive pulmonary disease (COPD) or smoking increases the risk of infectious complications, prolonged post-operative ventilation, and jeopardizes sternal stability from excessive coughing [6,12,15]. Finally, no significant difference in mortality was observed between DSWI infections caused by CoNS, when compared to SA, or Gram-negative pathogens [34]. The majority of the increased cost is spent on repeat surgical and ICU service, and extension of in-hospital stay [11,51,52]. The mean length of application of NPWT was 8 to 14 days with a mean number of 4 to 6 dressing changes [116-119]. In looking for cost-effectiveness of treatment strategies, NPWT does not seem to be a more expensive treatment in comparison with the conventional therapy for DSWI, as calculated in the Swedish healthcare system by Mokhari et al [52]. The amount of dressing used by centers has only minor variability in first-line application protocol, with the only differences reported being the materials used for interface dressing and the timing of wound closure [116-119]. Historically, a strong relationship between early tracheostomy and DSWI has not been confirmed; but tracheostomy is known to reduce the need for mechanical ventilation and thereby may limit risk of pulmonary infection and ICU stay [32]. Outcomes and cost of DSWIUnsurprisingly, DSWI negatively affected outcomes in cardiac surgery. Atkins et al reported lower NPWT costs than Medicare charges for conventional therapy (152,000 vs. Furthermore, re-exploration for bleeding has been analyzed as an independent risk factor for DSWI in several studies [11,12]. Even with the adoption of modern treatment strategies, the reported in-hospital mortality for DSWI varies from 1.1 to 19% [6-9,11,16,45]. Since the introduction of NPWT, its comparison with conventional therapy, closed chest irrigation or sternal resection and flap have been studied. Although the mortality rate is similar to data reported from the 1980s, it appears that implementation of negative pressure wound therapy (NPWT) may improve long-term survival of patients [18,20,46].
Strategies preventing DSWIAs mentioned previously, diabetes mellitus is a strong independent risk factor for development of DSWI, and concomitant obesity doubles the risk of further infection [24]. So far, we have data only from retrospective comparative studies, with the compared arms being heterogeneous in number of patients, time periods and type of DSWI based on El Oakley classification.
Other factors traditionally associated with an increased risk of DSWI are inconsistently seen in analyses of retrospective studies including advanced age, emergency surgery, hemodynamic instability, low ejection fraction, duration of surgery and CPB time, and renal failure [6-22]. Regardless of treatment strategy, in-hospital stay of DSWI patients is at least two weeks longer compared to patients with an uncomplicated post-operative course [6,10,11].
It was suggested that NPWT positively influenced the risk of primary therapy failure and survival of patients at short and long-term follow-up [18,46,121-138]. Incidence and risk factors based on multivariable analysis from larger retrospective studies are summarized in Table 2. DSWI-related morbidity was repeatedly reported in relation to prolonged mechanical ventilation, renal impairment, atrial and ventricular arrhythmias, cerebrovascular accidents, need for hemodynamic support, and healing-related complications [20,47].
Outcomes of NPWT are DSWI causative pathogen independent, even comparing therapeutic response to MRSA and MSSA caused DSWI [139]. The cause of death in the early post-operative period is mostly multiple organ failure initiated by sepsis or specific DSWI-related complications such as serious bleeding [6-8,16,18,20].
From multivariable analyses, obesity, renal failure and sepsis were calculated as independent risk factors of NPWT failure [128,129]. Predictors of a poor outcome in DSWI patients that have been reported include length of intensive care unit (ICU) stay, late indication for surgical revision, bacteremia, hemodynamic instability, and prolonged mechanical ventilation [47,48]. As Staphylococcal stains are a major causative pathogen, beta-lactam antiobiotics are recommended for prophylaxis, particularly first or second generation cephalosporins [57].
Loop et al presented the worse survival data of DSWI in patients operated on during the 1980s in comparison with a standard CABG population within a 3-year follow-up after surgery [6].
The use of glycopeptides, which are highly effective against MRSA, has not been linked with a reduction in sternal wound infection rates compared to standard prophylaxis, with one study suggesting higher SSI?s rate (3.7 vs. Survival analyses published in the last decade consistently confirm long-term complications of patients with mid-, and long term survival rates who were successfully treated for DSWI (Table 3) [8,11,12,14,15,18,22,46]. Local application of a gentamicin soaked-collagen sponge between the sternal lamella was suggested to reduce all SWI?s, particularly DSWI. Risnes et al reported significantly higher cardiac-related deaths in the post-DSWI group (34.6 vs. In contrast with this data, Sjoegren et al and Bailot et al showed unimpaired long-term survival of DSWI patients in comparison with patients who had uncomplicated surgery once NPWT was used [18,46]. Although SA caused DSWI might be reduced by locally applied gentamicin, primarily gentamicin-resistant strains such a CONS may overgrow [62].Another prophylactic issue is patient decontamination before surgery. As Staphylococci colonization is seen in a majority of DSWI, skin and nasopharyngeal decontamination became popular [38,39]. The use of chlorhexidine for skin care before surgery showed a significant reduction in the microbial count including SA [63]. In comparison to general surgery where reduction of SSI?s due to skin decontamination was confirmed [64], data for cardiac surgery is lacking, nevertheless, protocols involving chlorhexidine or a different skin cleanser are already widely accepted.
Locally applied ointment containing mupirocin is 80 to 90% effective in eradicating all types of SA from the nasopharyngeal mucosa [65]. A randomized controlled trial published by Konvalinka et al did not confirm a reduced DSWI rate from the use of nasal mupirocin ointment (0.8 vs.


Careful handling of skin and pre-sternal soft tissue, mid-lined sternal incision and avoidance of bone wax are essential, in addition to keeping scrub protocol, checking for glove injury, changing gloves after sternotomy and after sternal wiring, and leaving the closed wound primarily covered for at least 48 hours [68].It has been proposed that the method of IMA harvesting affects the incidence of DSWI, particularly when both IMA (BIMA?s) are demanded for revascularization [7,8,10,27,28].
A recent meta-analysis published by Saso et al showed a reduced risk of SWI?s once IMA or BIMA?s were harvested in a skeletonized fashion compared with a pedicled graft. Besides harvesting methods of BIMA?s in diabetics, as was mentioned above, tight long-term glycemic control influenced the risk of DSWI. Even through diabetic patients may have a comparable risk of developing DSWI when IMA in skeletonized fashion is taken down, the BIMA?s harvesting need is to be considered carefully because additional risk factors such an obesity and COPD are commonly presented in this cohort [24,70].The crucial point in preventing DSWI is achievement of stable sternal approximation.
Facing poor sternal quality, sternal fracture, or increased traction forces in obese or COPD patients, some modifications of this technique were proposed. Parasternal wire reinforcement, described originally by Robicsek and modified by Sharma, proved to reduce the risk of sternal wound complications [72,73]. Friberg et al reported that the use of more than 6 or 7 simple wires may also reduce DSWI rates (0.4% vs.
Recently, a large multicenter prospective study conducted by Schimmer et al comparing the Robicsek technique with standard cerclage failed to reduce the risk of SWI and sternal dehiscence [75]. Primary plating, mirroring the experience in maxillofacial surgery, was proposed for patients at high risk of sternal non-union [76]. Plates could be anchored only into the sternal bone (SternaLock system™,Biomet Microfixation Inc, Jacksonville, US) or into the ribs (Titanium Sternal Fixation system™, Syntes, Switzeland). Raman et al reported better chest bone healing after primary plating than rewiring at 6-month follow up (70 vs. Others systems are used for sternal approximation including, thermoreactive nitinol clips (Flexigrip™, Praesidia SRL, Bologna, Italy), titanium locked staples (Sternal Talon™, KLS Martin Group, US), and Poly-Ether-Ether-Ketone tapes (Sternal ZipFix system™, Syntes, Switzeland), all designed for parasteral fixation. Snyder et al reported 5 years of experience with the SternaLock system™ for primary plating in high risk patients. Superiority of plate over wires was seen in the incidence of early presentation (<30 days) of SWI (0% vs. A pilot study published by Bennett-Guerrero et al showed insignificantly higher spirometry volume in the SternalTalon™ arm (67% ± 32%) versus the wire arm (58% ± 24%). Antonio, USA) is used, with skin preservation through a semipermeable membrane that has contact with foam, and one proposal pump system with reservoir is added [81].
Limited clinical experience has shown a decreased risk of wound hematoma, seroma and SSI [82]. Other positive effects from wound application of NPWT might include promotion of microvascular flow and decreased tissue edema and myofibroblast activation [83].
Colli and Atkins et al reported no wound healing complications in patients at high risk for sternal wound infections after cardiac surgery, but both studies were retrospective and done on smaller cohort of patients, 10 and 57, respectively [84,85].6. Treatment strategies for DSWIEven though treatment of DSWI has considerably evolved, a generally accepted treatment strategy remains controversial. Robicsek postulated three valid principles addressing this issue: first, that the infectious process should be brought under control within the shortest possible time, secondly, that adequate debridement and drainage of the infected area should occur, and third that sternal stability should be assured [86]. Until the 1960s, patients suffering from DSWI were treated conservatively with antibiotic therapy, limited drainage, or exposure of the sternotomy wound until closure with granulation tissue occurred [87]. Mortality rates then reached over 50% and survivors’ quality of life was limited due to significant morbidity [87]. In 1964, Shumacker and Mandelbaum reported their experience with single-stage technique of wound debridement, primary sternal re-wiring and continuous antibiotic irrigation [88].
Their original method was consequently modified in terms of the type of antibiotic or antiseptic solution used including its amount, or the setting of indwelling drains for irrigation and suction [89-90]. Lee et al proposed in 1976 the use of an omental flap for covering infected sternotomy wounds [93].
It was suggested that well-vascularized omentum fulfills dead spaces, ensures high antibiotic levels, and yielded angiogenic and absorptive capacity [13,93]. Jurkiewicz et al first reported the use of muscle flaps, preferably the pectoralis flap, and radical sternal debridement in the treatment of DSWI in 1980 [94].
This approach has received many modifications regarding the timing of wound closure, choice of flap, and type of advancement, with reported mortality ranging from 0% to 19% [96,97]. Comparing the omental to the pectoralis flap, Milano et al reported that the omental flap had lower mortality (4.8% vs. El Oakley and Wright suggested classification of DSWI based on the time of presentation, presence of risk factors such as obesity, diabetes or immunosuppressive therapy, and number of failed therapeutic attempts in 1996 (Table 3) [99].
The identification of five subtypes of DSWI seemed to be a relevant tool for choice of therapeutic method and patient prognosis. Adjusted to the El Oakley and Wright classification, closed chest irrigation has comparable mortality data for type I and II DSWI compared with radical sternal resection and concomitant flap, but with lower flap-related associated morbidity [100-102]. Ringelman et al noted that at 48 month follow-up, 51% of patients had pain or discomfort, 44% had numbness, 42% complained of sternal instability, and 33% claimed to have shoulder weakness, when pectoral flap was used for reconstruction [103]. Closed chest irrigation carries a higher rate of therapy failure when used for type III, and particularly type IV and V El Oakley and Wright classification [104-107]. Thus, these patients might have benefit from more radical sternal debridement and employment of well-vascularized tissue to replenish residual defects.
Flap-related morbidity may be addressed with less invasive techniques such as a laparoscopic greater omentum harvesting [108]. Atkins et al recently reported on the influence of sternal repair choice (pectoral, omental flap, or secondary closure) on long-term survival [109].There is limited data evaluating hyperbaric oxygen (HBO) therapy in the treatment of SWI, despite theoretical advantages, availability of HTO close to the cardiac surgical unit impedes its routine use [110].
Siondalski et al reported successful healing of 55 DSWI patients with no mortality, nevertheless therapy required 20-40 HBO sessions after surgical revision.



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