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Studies have documented various effects of circadian rhythm and daytime variations on the cardiovascular and immune system as well as wound healing. From June to December 2016, n  = 367 cardiac surgery patients were enrolled. Microbiological swabs from the mediastinum and subcutaneous wound were taken before sternal closure. Patients were assigned to groups based on operation start: morning ( n  = 219) or afternoon ( n  = 135). Bacterial contamination and wound infections were studied in relation to circadian rhythm and daytime variation. We did not observe any difference in mortality (morning: 3.7%, afternoon: 3.0%, p  > 0.99) and major adverse events (morning: 8.2%, afternoon: 5.9%, p  = 0.53). In 27.7% of the morning group, at least one positive intraoperative swab was observed, similar to the afternoon group (25.6%, p  = 0.71). The incidence of positive presternal swabs was 15.6% in the morning compared to 9.1% in the afternoon ( p  = 0.18). About 90% of the germs detected were part of the natural skin flora (e.g., Cutibacterium acnes and Staphylococcus epidermidis). The incidence of sternal wound infections was 7.3% (morning) and 3.0% (afternoon) ( p  = 0.18). We did not find differences in the incidence of intraoperative bacterial sternal contamination, nor postoperative infections, between patients who underwent cardiac surgery in the morning or afternoon.

Introduction Heart surgery is associated with a sternotomy in most patients. Low serum calcidiol level below 80 nmol/l carries the risk of bone loss as a risk factor in sternotomy healing. Objectives The primary objective was to compare postoperative complications of sternotomy healing in two groups of patients treated with cholecalciferol or placebo. Secondary objectives were focused on the degree of sternal healing, length of hospitalization, number of days spent in ICU and mechanical ventilation, and number of repeated hospitalizations for sternotomy complications. Methodology Monocentric, randomized, double-blind, placebo-controlled, prospective study was conducted from September 2016 to December 2020 at Na Homolce Hospital. Of the 216 originally recruited and randomized subjects, 141 completed the study. Seventy-two subjects were enrolled in the cholecalciferol arm, and sixty-nine subjects in the placebo arm. The detailed methodology has been published previously. The results are presented as a comparison between two groups: calcidiol above 80 nmol/l (saturated subjects) and the calcidiol lower or equal to 80 nmol/l (unsaturated subjects). Results Statistics include 141 subjects. After a 6-month follow-up, CT imaging and calcidiol levels were performed. Primary objective: postoperative complications in sternotomy were not among the population under or above 80 nmol/l statistical difference ( p  = 0.907). Secondary objectives: monitored parameters did not differ between individual arms. But the key was the state of saturation with calcidiol (> 80 nmol/l), which was associated with a significantly lower risk of complete non-healed sternotomy ( p  = 0.008). Conclusion Optimal calcidiol level (> 80 nmol/l) indicates a positive trend towards greater sternal healing. Cholecalciferol oral administration can be considered as a safe method how to achieve the required calcidiol concentration. Trial registration EU Clinical Trials Register, EUDRA CT No: 2016–002606-39.

Background and ObjectivesUnipolar sternocleidomastoid release with myectomy (USRM) for correction of congenital muscular torticollis in pediatric patients produces moderate to severe postoperative pain. The objective of this trial was to examine the effect of ultrasound-guided intermediate cervical plexus block on postoperative pain after USRM.MethodsThirty-two patients (1–7 years old) were enrolled in this parallel-group, patient- and observer-blinded, randomized controlled trial. In the block group, 0.25% ropivacaine (0.2 mL/kg) was injected into the interfascial plane between the sternocleidomastoid muscle and the prevertebral fascia under ultrasound guidance at the fourth to fifth cervical vertebral level. The primary outcome measure was the face, legs, activity, cry, and consolability (FLACC) score at 5 minutes after entering the postanesthesia care unit (PACU), and secondary outcome measures were the FLACC score at discharge from the PACU and 3, 6, and 24 hours after operation and the use of rescue analgesic in the PACU and ward.ResultsThe FLACC score at 5 minutes after admission to the PACU was significantly reduced (3 vs 8; median difference, 4; 95% confidence interval, 1–7; P = 0.044), and the fentanyl dose and the number of patients requiring rescue analgesics in the PACU were significantly lower (0.0 vs 0.5 μg/kg, P = 0.014; 5 [29.4%] vs 12 [75.0%], P = 0.032) in the block than in the control group. However, after discharge from PACU, there was no difference in FLACC scores and use of rescue analgesics between groups.ConclusionsUltrasound-guided intermediate cervical plexus block decreased immediate postoperative pain and opioid requirements in the PACU in pediatric patients who underwent USRM.Clinical Trial RegistrationThis study was registered at ClinicalTrials.gov, identifier NCT02651311.

The incidence of sternal wound complications, such as dehiscences, infections, and sternocutaneous fistulas, can reach 10%. Sternocutaneous fistulas are extremely rare, and the only definite therapy is surgical repair. Our experience taught us that combining a traditional approach with an extracellular matrix patch might be a step forward in therapy. We described three examples of surgically reconstructing sternocutaneous fistulas with an extracellular matrix patch (ProxiCor®).

Background Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB). Methods Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www.clinicaltrials.gov ( https://clinicaltrials.gov/ ) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18–80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects. Results The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients’ intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients. Conclusions In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area.

To describe a new technique of sternal closure, modified from the conventional figure-of-eight approach, which can provide a secure closure and prevent sternal complications. The modified technique is based on the intercalation of the caudal portion of each steel wire passed along the sternum. This is a retrospective analysis of patients operated with this modified technique at our institution between January 2014 and December 2016. One hundred and forty-three patients underwent sternal closure with the modified technique. In-hospital mortality rate was 1.4% (n=2). No sternal instability was observed at 30 days postoperatively. Two patients developed mediastinitis that required extraction of the wires. Short-term results have shown that the modified sternal closure technique can be used safely and effectively, with complications rates being consistent with worldwide experience.

A 59-year-old man was brought to the emergency department after a motor vehicle collision. Paradoxical movement of a segment of his chest wall during respiration was noted on examination (shown in a video).

Objectives Recently a biocompatible bone adhesive was introduced in addition to the sternal wires to expedite sternal union and improve patient recovery. In this study we aim to objectively assess the biomarker of pain in patient who received the biocompatible bone adhesive. Methods A total of 62 patients who underwent sternotomy were prospectively randomised to receive either conventional wire closure (CWC); 32 patients or adhesive enhanced closure in addition to sternal wire (AEC); 30 patients. Patients were monitored postoperatively at certain time intervals for incisional pain, serum Interleukin-6 (IL-6) level, analgesia used and postoperative complications. All patients were followed up for 4 weeks. Results The post-operative pain scores with coughing were significantly higher in the CWC group at 24 hours and 48 hours. The postoperative IL 6 levels were significantly higher in the CWC group in comparison with the AEC group at 6 hours, 24 hours, and 48 hours. There were no significant differences in term of additional analgesia used. No adverse events from adhesive bone cement were observed during follow up. Conclusions Adhesive-enhanced sternal closure resulted in modest reduction of pain confirmed by reduction of pain biomarker. Justification of its routine use requires larger multicentre study.

Background Primary malignant or metastatic sternal tumors are uncommon. A subtotal or total sternectomy can offer a radical form of treatment. The issue is to restore the structural integrity of the chest wall. Case presentation We report the implantation of an individualized 3D–printed titanium sternum in a patient with a sternal tumor. Conclusions We believe that tridimensional print technologies may also change the strategy of chest wall reconstruction.

Background Unstable steel wire cerclage following open heart surgery may result in increased pain, sternal cut-through, non-union, or dehiscence. These complications lead to longer hospital stays, increased cost, higher morbidity, and patient dissatisfaction. The Figure 8 FlatWire Sternal Closure System is a new construct which is a simple, intuitive, and inexpensive alternative for primary sternal repair following open heart surgery. Prior bench-top testing of FlatWire has demonstrated superior strength and stiffness compared to traditional steel wire. We present our initial experience in a prospective, randomized, single blinded pilot study utilizing this FDA approved system. Methods Sixty-three patients undergoing elective complete sternotomies at a single institution were randomly assigned to receive either the Figure 8 FlatWire or standard steel wire cerclage. All surgeries were performed by a single board certified cardiothoracic surgeon. Data collected included: Age, BMI, pump time, off pump to surgical stop time, length of hospital stay after surgery, cost from time of surgery to discharge, and pain on a visual analog pain scale on the day of discharge, day 30, and day 60. Results The groups were well matched. Patients receiving the Figure 8 FlatWire (33) had a reduction in length of stay compared to patients receiving steel wire circlage (30), but it was not statistically significant (6.8 vs. 7.8 days respectively, p < 0.093). Additionally those with the FlatWire reported significantly decreased pain at day of discharge (3.07 vs. 4.92 points on pain scale, p < 0.0066), with similar pain scores at 30 and 60 days. Off pump to surgery stop time was increased by 15.9 minutes in patients receiving the FlatWire vs. steel wires (55.7 vs. 71.6 minutes, p = 0.00025). Mean cost from surgery until discharge was $87,820.98 in the FlatWire group vs. $91,930.29 in the steel wire group (p < 0.3082). Conclusion Early clinical results suggest that Figure 8 FlatWire provides excellent stability, which resulted in significantly diminished postoperative pain at discharge. Although not significant there was a trend toward decreased length of stay, and reduced cost. Further clinical research is warranted to expand upon these initial trends and validate long term outcomes.