Predictors of prolonged hospitalization in modified sternoplasty following postoperative mediastinitis.

BACKGROUND AND AIM: Deep sternal wound infection (DSWI) is a serious complication following cardiac surgery, and demands early intervention as any delay in diagnosis and management may lead to increased morbidity and mortality. DSWI is associated with increased length of hospitalization (LOH) and economic burden in this patient population. The aim of this study was to determine predictors for increased length of hospitalization in patients who underwent the Modified Sternoplasty technique for deep sternal wound infection following cardiac surgery. METHODS: A retrospective study was undertaken on data from patients who underwent the Modified Sternoplasty surgery for DSWI between September 2010 and January 2020. Patients' characteristics that were recorded included medical history, type of the original heart surgery, length of hospitalizations, and risk factors including hyperlipidemia, diabetes mellitus and hypertension, and morbidity and mortality rates following the Modified Sternoplasty. RESULTS: Sixty-eight patients underwent the Modified Sternoplasty surgery with an average length of hospitalization of 24.63 + 22.09 days. Multivariable analysis showed that only gender was considered a predictor of length of hospitalization when controlling for comorbidities, with average length of hospitalization longer for women than men (35.4 vs. 20.9, p = .04). CONCLUSION: The Modified Sternoplasty surgery is a novel surgical technique for managing DSWI complicated by sternal dehiscence with exposed heart and great vessels. Female gender was associated with increased length of hospitalization in our patient cohort, with average length of hospitalization for women almost twice that of males.

Clinical factors and pre-surgical depression scores predict pain intensity in cardiac surgery patients.

BACKGROUND: Severe pain is prevalent in cardiac surgery patients and can increase cardiac complications, morbidity and mortality. The objectives of the study were to assess perioperative pain intensity and to assess predictors of pain post-cardiac surgery, including clinical characteristics and depression. METHODS: A total of 98 cardiac surgery patients were included in the study. Pain intensity was assessed using a Numerical Rating System. Pain was measured one day pre-operatively and recorded daily from Post-operative Day 2 to Day 7. Clinical data were recorded and depression scores were assessed using the Center for Epidemiological Study of Depression (CES-D). RESULTS: Pain intensity increased significantly during hospitalization from pre-operative levels, surging at 2 days post-operatively. Predictors of high pain intensity were high pre-operative CES-D scores, female gender, cardiac function, smoking and high body mass index (BMI). Significantly higher pre-operative CES-D scores were found in patients with severe pain compared to patients with no pain to moderate pain (18.23 ± 1.80 vs 12.84 ± 1.22, p = 0.01 pre-operatively). Patients with severe pain (NRS 7-10) had significantly higher levels of white blood cells (WBC) compared to patients with no pain-moderate pain (NRS 0-6), (p = 0.01). However, CES-D scores were only weakly correlated maximum WBC levels perioperatively. CONCLUSION: Pain intensity significantly increased following surgery, and was associated with depressive symptoms, female sex, cardiac function, BMI, and smoking. These factors may serve as a basis for identification and intervention to help prevent the transition from acute pain to chronic pain.

The routine use of preoperative non-contrast chest computerized tomography and carotid arteries Doppler prior to cardiac surgery.

INTRODUCTION: There is no consensus as to which patients should undergo Non-Contrast Chest Computerized Tomography (NCCCT) and carotid arteries Doppler (CD) prior to cardiac surgery. The objective of this study was to examine whether preoperative imaging modalities provide clinical benefits and a change in surgical strategy. METHODS: We routinely performed NCCCT and CD in all non-urgent cardiac surgery patients. Major NCCCT/CD findings related to cardiovascular findings (aortic calcification/atherosclerosis, carotid artery plaque/stenosis), or other incidental findings (lung kidney, thyroid, adrenal, gastrointestinal sites etc.) were documented. The results were divided into 3 categories: (A) findings requiring both changes in surgical strategy and post-operative evaluation/treatment; (B) findings requiring changes in surgical strategy, but not requiring a specific post-operative evaluation/treatment; (C) findings not requiring changes in surgical strategy but requiring post-operative evaluation/treatment. RESULTS: In this cohort, 93 (18.6%) out of 500 patients had significant cardiac and extra-cardiac findings on NCCCT and/or CD. Among the 93 patients with significant findings, 33.33% (31 patients, 6.2% of all patients) were in group A, 7.5% (7 patients, 1.4% of all patients) were in group B, and 59.14% (55 patients, 11% of all patients) were in group C. Change in surgical strategies included, for example, switching from planned on-pump Coronary Artery Bypass Graft surgery (CABG) to off-pump CABG and performing additional procedures to the originally planned heart surgery. CONCLUSION: Routine preoperative NCCCT and CD evaluation in all non-urgent cardiac surgical patients is an effective measure for uncovering cardiac and extra-cardiac findings prior to surgery.

The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis.

Deep sternal wound infection (DSWI) is one of the most complex and devastating complications post cardiac surgery. We present here the modified sternoplasty, a novel surgical technique for treating DSWI post cardiac surgery. The modified sternoplasty includes debridement and sternal refixation via bilateral longitudinal stainless-steel wires that are placed parasternally along the ribs at the midclavicular or anterior axillary line, followed by six to eight horizontal stainless-steel wires that are anchored laterally and directly into the ribs. On top of that solid structure, wound reconstruction is performed by the use of bilateral pectoralis muscle flaps followed by subcutaneous tissue and skin closure. We reported mortality rates and length of hospitalization of patients who underwent the modified sternoplasty. In total, 68 patients underwent the modified sternoplasty. Two of these critically ill patients died (2.9%). The average length of hospitalization from the diagnosis of DSWI was 24.63 ± 22.09 days. The modified sternoplasty for treating DSWI is a more complex surgery compared with other conventional sternoplasty techniques. However, this technique was demonstrated to be more effective, having a lower rate of mortality, and having a length of hospitalization lower than or comparable to other techniques previously reported in the literature.

Clinical, Surgical, and Sociopsychological Factors and Depression After Cardiothoracic Surgery.

BACKGROUND: Depression is highly prevalent in cardiac surgical patients and is associated with mortality. The objectives of the study were to evaluate depression scores longitudinally pre- and postoperatively and to examine the association between postoperative depression scores and clinical, surgical, and sociopsychological factors. METHODS: Depression scores were assessed using the Center for Epidemiological Study of Depression (CES-D) in 100 cardiac surgical patients who underwent cardiac surgery preoperatively, during hospitalization, and at 2 and 6 week after discharge. Clinical, surgical, and sociopsychological predictors of depression scores were recorded. RESULTS: The average depression scores significantly increased from preoperative levels (14.9 ± 1.07) to during hospitalization (21.5 ± 1.05) and decreased at both 2 weeks (15.8 ± 1.07) and 6 weeks after discharge (14.0 ± 1.06), as compared with scores during hospitalization (P < .001). The percentage of patients who scored CES-D > 16 increased significantly from preoperative (39%) to hospitalization (71%) and decreased gradually at 2 weeks (45%) and 6 weeks (37%) after discharge (P < .001). Significant predictors of high postoperative CES-D scores were female gender, ejection fraction < 50%, and high preoperative CES-D scores. CONCLUSIONS: High depression scores after cardiac surgery suggest that perioperative screening and management of depression after surgery are necessary and may improve outcomes of these patients who are at high risk for depression. Further understanding of the factors that contribute to high depression scores is required to facilitate clinical intervention.

Improving characterization and diagnosis quality of myofascial pain syndrome: a systematic review of the clinical and biomarker overlap with delayed onset muscle soreness.

INTRODUCTION: Myofascial pain syndrome (MPS) is one of the most common conditions of chronic musculoskeletal pain, yet its mechanisms are still poorly understood. Delayed Onset Muscle Soreness (DOMS) is also a regional pain syndrome that has clinical similarities to MPS, but has been better investigated. Emerging research suggests that DOMS may be a valid experimental model for studying MPS; however, a comparison of the similarities and differences of these two conditions has previously not been performed. Herein, we aimed to identify the similarities and differences in the clinical features and biomarkers between DOMS and MPS in order to better define MPS and identify future areas of (DOMS-informed) MPS research. EVIDENCE ACQUISITION: In order to identify similarities and differences in the clinical manifestation and biomarkers of DOMS and MPS, scoping literature searches were performed using Medline (1965-2019), Embase (1966-2019) and Central (1966-2019) databases. Fifty-three full-text articles were reviewed out of the 2836 articles retrieved in the search. EVIDENCE SYNTHESIS: A scoping review of the literature demonstrated that DOMS and MPS similarly present as conditions of musculoskeletal pain that are associated with decreased strength and limited range of motion. However, while taut bands and discrete tender spots were described in DOMS, none of the studies reviewed have characterized whether these tender points represent the classic myofascial trigger point phenomenon observed in MPS. Certain systemic circulation biomarkers, including inflammatory cytokines and growth factors, were commonly elevated in MPS and DOMS; further research is needed to determine if other biomarkers that are currently characterized in DOMS are useful to enhance the clinical evaluation of MPS. CONCLUSIONS: DOMS and MPS share clinical and biomarker similarities suggesting that DOMS may be a useful model for studying MPS.