ABSTRACT
Usage of negative pressure wound therapy (NPWT) in the management of acute and chronic wounds has grown exponentially in the past decade. Hundreds of studies have been published regarding ...outcomes and methods of therapy used for adult wounds. This treatment is increasingly being used to manage difficult‐to‐treat paediatric wounds arising from congenital defects, trauma, infection, tumour, burns, pressure ulceration and postsurgical complications in children, although relatively few studies have been aimed at this population. Given the anatomical and physiological differences between adults and children, a multidisciplinary expert advisory panel was convened to determine appropriate use of NPWT with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum Assisted Closure® (V.A.C.® Therapy, KCI Licensing, Inc., San Antonio, TX) for the treatment of paediatric wounds.
The primary objectives of the expert advisory panel were to exchange state‐of‐practice information on paediatric wound care, review the published data regarding the use of NPWT/ROCF in paediatric wounds, evaluate the strength of the existing data and establish guidelines on best practices with NPWT/ROCF for the paediatric population. The proposed paediatrics‐specific clinical practice guidelines are meant to provide practitioners an evidence base from which decisions could be made regarding the safe and efficacious selection of pressure settings, foam type, dressing change frequency and use of interposing contact layer selections. The guidelines reflect the state of knowledge on effective and appropriate wound care at the time of publication. They are the result of consensus reached by expert advisory panel members based on their individual clinical and published experiences related to the use of NPWT/ROCF in treating paediatric wounds. Best practices are described herein for novice and advanced users of NPWT/ROCF. Recommendations by the expert panel may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the collaborating medical team, including the surgeon and wound care specialist based on available resources, individual patient circumstances and experience with the V.A.C.® Therapy System.
Abstract
Objective: Integrin-linked kinase (ILK) is a cell membrane-bound molecule implicated in the metastatic progression of many tumour types. It phosphorylates the downstream target AKT ...(phosphorylated AKT, pAKT), and, by doing this, it activates anti-apoptotic pathways. We have recently shown ILK expression in malignant pleural mesothelioma (MPM). To determine whether ILK expression in MPM is connected with pAKT expression, and whether ILK and pAKT expression have any influence on the patient's prognosis, we correlated ILK and pAKT expression, as assessed by immunohistochemistry, with disease-related survival in a retrospective cohort of 80 MPM patients. Material and methods: The paraffin specimens of 80 MPM cases treated from 1990 to 2006 (52 surgical cases, 28 conservative cases) have been retrieved from the archive. The median (range) patients' age was 62 (28-83 years) years; the male-to-female ratio was 3:1. Fifty percent of the patients had an epitheloid subtype. The samples have been stained with anti-ILK as well as with anti-pAKT and scored by two independent pathologists. Intensity of ILK and pAKT expression has been correlated with disease-related survival. Results: In total, 73 of 80 (91%) MPM samples expressed ILK; 65 of 74 (88%) MPM samples expressed pAKT. Comparing the 5-year disease-related survival according to ILK or pAKT expression, no statistically significant difference could be found between ILK and pAKT expressing or non-expressing patients. However, in the subgroup of conservatively treated MPM patients, those with strong ILK expression had a longer 5-year disease-related survival (p ≪ 0.0001). In total, the only prognostic factor across all ILK, pAKT and therapy subgroups was the histological subtype (p = 0.01). The prognostic significance of the histological subtype has been confirmed in multivariate analysis (p = 0.005). Conclusion: The expression of ILK in MPM is connected with the expression of the downstream target pAKT, but neither ILK nor pAKT expression has a measurable influence on the patient's prognosis, except for certain subgroups of MPM. However, to shed light on the true prognostic impact of ILK and pAKT expression in MPM, prospective trials are needed.
Post-operative atrial fibrillation (POAF) is postulated as a complex interaction of different pathogenic factors, suggesting inflammatory processes as a main trigger of this particular type of atrial ...fibrillation. Therefore, the study sought to assess the impact of cellular immunity on the development of POAF. Comparing patients developing POAF to individuals free of POAF the fraction of CD4
CD28
T Lymphocytes was significantly higher in individuals developing POAF (11.1% POAF vs. 1.9% non-POAF; p < 0.001). CD4
CD28
cells were independently associated with the development of POAF with an adjusted odds ratio per one standard deviation of 4.89 (95% CI: 2.68-8.97; p < 0.001). Compared to N-terminal Pro-Brain Natriuretic Peptide, the fraction of CD4
CD28
cells demonstrated an increased discriminatory power for the development of POAF (NRI: 87.9%, p < 0.001; IDI: 30.9%, p < 0.001). Interestingly, a pre-operative statin-therapy was associated with a lower fraction of CD4
CD28
cells (p < 0.001) and showed an inverse association with POAF (p < 0.001). CD4
CD28
cells proved to be predictive for the development of POAF after cardiac surgery. Our results potentially indicate an auto-immune impact of this preexisting, highly cytotoxic T cell subset in the pathogenesis of POAF, which might be modified via the anti-inflammatory potential of a pre-operative statin-therapy.
a Department of Cardiothoracic Surgery, Medical University of Vienna, AKH Vienna, Leitstelle 20A, Währinger Gürtel 18-20, 1090 Vienna, Austria
b Department of Cardiothoracic and Vascular Anaesthesia, ...Medical University of Vienna, Austria
*Corresponding author. Tel.: +43 40400 5620. E-mail address : wilfried.wisser{at}meduniwien.ac.at (W. Wisser).
Surgical treatment of myasthenia gravis should include the complete resection of the thymus with the whole fatty tissue adherent to the pericardium for immunologic as well as oncologic reasons. The aim of the current study was to investigate the efficacy and safety of robotic approach. A total of 18 patients with myasthenia gravis (mean age 44 years) have been operated robotically via a left-sided approach. Preoperative MGFA (Myasthenia Gravis Foundation of America) classification was: Class I n =4, Class IIa n =4, Class IIb n =5, and Class IIIa n =3, IIIb n =2. Total endoscopic resection was feasible in 17/18 patients. One patient had to be converted due to bleeding. In the remaining patients, operative time was 175 min, intensive care unit (ICU) one day, hospital stay four days. In all patients it was possible to perform an extended thymic resection. MGFA post-intervention status after a mean of 18 months follow-up showed complete stable remission n =5, pharmacologic remission n =4, minimal manifestations n =5, unchanged n =1. Complete endoscopic thymus surgery with the da Vinci surgical system enables a complete and extended resection of all thymic tissue in the mediastinum. Due to the minimal trauma, patients can return to full activity within a short time.
Key Words: Myasthenia gravis; Thymectomy; Robotics; Outcomes; Minimal invasive surgery
a Department of Cardiothoracic Surgery, Leitstelle 20A, AKH Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
b Department of Pediatrics, PICU, Medical University of ...Vienna, AKH Vienna, 1090 Vienna, Austria
*Corresponding author. Tel.: +43-1-404005620; fax: +43-1-404005640. E-mail address : tatjana.fleck{at}meduniwien.ac.at (T. Fleck).
Sternal wound infections occur with an incidence between 0.4 and 5% in the adult as well as the pediatric population. However, in contrast to the adults, established treatment options do not exist in the pediatric population. We evaluated our preliminary results with 3 neonates, respectively, small infants (mean age 20.3±6 days) who underwent vacuum assisted closure (VAC) therapy for the treatment of sternal wound infections with the intention to enable secondary closure and preservation of the sternal bone. The mean VAC duration was 11.3 days, ranging from 10 to 12 days. After three dressing changes (every 48 to 72 h) the infection resolved and a secondary closure was feasible in all three patients. Isolated specimens were Candida albicans, Staphylococcus aureus and MRSA, respectively. These preliminary results show that VAC therapy is a promising alternative to the current treatment options available to neonates. Especially, the preservation of the sternal bone which enables normal thoracic cage stability and growth, is a clear advantage over the currently used muscle flaps.
Key Words: Sternal wound infection; Vacuum assisted closure; Small infant; Cardiac congenital surgery
a Department of Cardiothoracic Surgery, Medical University of Vienna, AKH Vienna, Leitstelle 20A, Währinger Gürtel 18-20, 1090 Vienna, Austria
b Department of Cardiothoracic and Vascular Surgery, KH ...Hietzing, Vienna, Austria
*Corresponding author. Tel.: +43-140-4005620; fax: +43-140-4005640. E-mail address : tatjana.fleck{at}meduniwien.ac.at (T. Fleck).
The management of open chest with the vacuum assisted closure (VAC) system was evaluated in terms of impact on cardiac hemodynamics, respiratory parameters, complications, incidence of wound infection, overall handling and outcome in 22 patients during 2005 and 2008 after cardiac surgery. The decision to leave the sternum open was made electively in all patients at the time of primary operation or reexploration. In four patients the VAC was implanted during the primary operation. In the remainder the VAC was implanted after a mean of five days after the primary operation. The overall mortality rate was 45% (10/22). None of the patients developed a sternal wound infection, nor were there any VAC related complications. Management of open chest with the VAC system can be considered as an alternative to sterile draping. The VAC has no negative impact on cardiac hemodynamics as well as respiratory mechanics. The feared complication of right ventricular rupture and massive bleeding can be effectively prevented. Through the stabilizing of the thoracic cage, the patient can be easily moved and mobilized for nursing reasons and pneumonia prevention. Furthermore, the VAC effectively prevents the contamination of the wound and the mediastinum with potential subsequent infection.
Key Words: Mediastinal infection; Hemodynamics; Wound closure
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