Search

Introduction: Lemierre syndrome (LS) is a rare condition with a high mortality risk. It is well described in older children and young adults involving bacteremia, thrombophlebitis, and metastatic abscess commonly due to Fusobacterium infections. Young, pre-verbal children are also susceptible to LS; thus, careful attention must be given to their pattern of symptoms and history to identify this condition in the emergency department (ED). Case Report: A 12-month-old previously healthy boy with a recent diagnosis of acute otitis media and viral illness presented to the ED with a complaint of fever. Additional symptoms developed at the head and neck and were noted on subsequent ED visits. Advanced imaging revealed significant lymphadenopathy and deep space inflammation extending to the mediastinum. Subsequent imaging confirmed extensive sinus and deep vein thromboses, consistent with LS. Methicillin-resistant Staphylococcus aureus (MRSA) was the only organism identified. After surgical debridement, appropriate intravenous antibiotics, and heparin anticoagulation therapy, the patient experienced full recovery after prolonged hospitalization.Conclusion: A febrile infant with multiple acute care visits and development of lymphadenopathy, decreased oral intake, decreased cervical range of motion, and sepsis should raise suspicion for Lemierre syndrome. The medical evaluation of deep neck spaces and deep veins should be similar to that of older children and adults with LS, including advanced imaging of the head and neck. However, medical management should particularly target MRSA due to its emerging prevalence among infantile LS cases. Further research is necessary to determine the optimal management strategies of LS for this age group.

We report a case of descending necrotizing mediastinitis (DNM) in a 68-year-old male who presented in acute respiratory distress accompanied with anterior cervical neck swelling and pain with swallowing. Contrast enhanced computed tomography (CECT) of the neck demonstrated a large, peripherally enhancing retropharyngeal fluid and air collection that appeared to communicate with a fluid and air collection within the mediastinum. CECT of the chest demonstrated punctate foci of air and fat stranding along the anterior and superior mediastinum. Radiological evidence and the presence of necrosis on surgical debridement of the retropharyngeal abscess established the diagnosis of DNM. This case emphasizes the role of computed tomography (CT) in the diagnosis of DNM and demonstrates the utility of chest imaging in a high-risk patient who presents with a retropharyngeal abscess.

We report a case of descending necrotizing mediastinitis (DNM) in a 68-year-old male who presented in acute respiratory distress accompanied with anterior cervical neck swelling and pain with swallowing. Contrast enhanced computed tomography (CECT) of the neck demonstrated a large, peripherally enhancing retropharyngeal fluid and air collection that appeared to communicate with a fluid and air collection within the mediastinum. CECT of the chest demonstrated punctate foci of air and fat stranding along the anterior and superior mediastinum. Radiological evidence and the presence of necrosis on surgical debridement of the retropharyngeal abscess established the diagnosis of DNM. This case emphasizes the role of computed tomography (CT) in the diagnosis of DNM and demonstrates the utility of chest imaging in a high-risk patient who presents with a retropharyngeal abscess.

International guidelines establish EUS-guided sampling as safe and accurate for the evaluation of mediastinal solid lesions, such as lymphadenopathies of unknown origin, and point out an increased risk of severe infectious complications induced by needle puncture in mediastinal cystic lesions. A retrospective case series and a systematic review documented an increased risk of mediastinal abscess formation after EUS-guided lymph nodes sampling in patients with sarcoidosis. The authors describe a case of a 38-year-old male patient with a final diagnosis of sarcoidosis, who developed a large mediastinal abscess after EUS-guided fine-needle biopsy of mediastinal lymphadenopathies. Endoscopists should be aware of the potential increased risk of severe infectious complications when sampling mediastinal lymph nodes in suspected sarcoidosis, and a strategy to minimize such risk should be pursued., SCOPUS: ar.j, info:eu-repo/semantics/published

Objectives: The occurrence of mediastinitis after cardiac surgery remains a rare and severe complication associated with poor outcomes. Whereas bacterial mediastinitis have been largely described, little is known about their fungal etiologies. We report incidence, characteristics and outcome of post-cardiac surgery fungal mediastinitis. Methods: Multicenter retrospective study among 10 intensive care units (ICU) in France and Belgium of proven cases of fungal mediastinitis after cardiac surgery (2009–2019). Results: Among 73,688 cardiac surgery procedures, 40 patients developed fungal mediastinitis. Five were supported with left ventricular assist device and five with veno-arterial extracorporeal membrane oxygenation before initial surgery. Twelve patients received prior heart transplantation. Interval between initial surgery and mediastinitis was 38 [17–61] days. Only half of the patients showed local signs of infection. Septic shock was uncommon at diagnosis (12.5%). Forty-three fungal strains were identified: Candida spp. (34 patients), Trichosporon spp. (5 patients) and Aspergillus spp. (4 patients). Hospital mortality was 58%. Survivors were younger (59 [43–65] vs. 65 [61–73] yo; p = 0.013), had lower body mass index (24 [20–26] vs. 30 [24–32] kg/m2; p = 0.028) and lower Simplified Acute Physiology Score II score at ICU admission (37 [28–40] vs. 54 [34–61]; p = 0.012). Conclusion: Fungal mediastinitis is a very rare complication after cardiac surgery, associated with a high mortality rate. This entity should be suspected in patients with a smoldering infectious postoperative course, especially those supported with short- or long-term invasive cardiac support devices, or following heart transplantation., SCOPUS: ar.j, info:eu-repo/semantics/published

Simple Summary This study confirmed the overall safety of endosonography and guided bronchoscopy, even in a cohort of patients with multiple comorbidities and a high prevalence of advanced cancer. However, it suggested that implementing a 30-day follow-up in routine clinical practice would also help identify and treat clinically relevant late complications promptly while establishing a more realistic rate of adverse events for these procedures.Abstract Background and objective: Limited data exist regarding the adverse events of advanced diagnostic bronchoscopy, with most of the available information derived from retrospective datasets that primarily focus on early complications. Methods: We conducted a 15-month prospective cohort study among consecutive patients undergoing endosonography and/or guided bronchoscopy under general anesthesia. We evaluated the 30-day incidence of severe complications, any complication, unplanned hospital encounters, and deaths. Additionally, we analyzed the time of onset (immediate, within 1 h of the procedure; early, 1 h-24 h; late, 24 h-30 days) and identified risk factors associated with these events. Results: Thirty-day data were available for 697 out of 701 (99.4%) enrolled patients, with 85.6% having suspected malignancy and multiple comorbidities (median Charlson Comorbidity Index (IQR): 4 (2-5)). Severe complications occurred in only 17 (2.4%) patients, but among them, 10 (58.8%) had unplanned hospital encounters and 2 (11.7%) died within 30 days. A significant proportion of procedure-related severe complications (8/17, 47.1%); unplanned hospital encounters (8/11, 72.7%); and the two deaths occurred days or weeks after the procedure. Low-dose attenuation in the biopsy site on computed tomography was independently associated with any complication (OR: 1.87; 95% CI 1.13-3.09); unplanned hospital encounters (OR: 2.17; 95% CI 1.10-4.30); and mortality (OR: 4.19; 95% CI 1.74-10.11). Conclusions: Severe complications arising from endo

Introduction: The use of peripherally inserted central catheters (PICC) has been integral to the advancement of medical care in both in-patient and out-patient arenas.1 However, our knowledge of PICC line complications remains incomplete, particularly in regard to venous perforation and extraluminal migration. Utilization of displaced catheters harbors lethal complications and is an infrequently reported phenomenon, with traumatic etiologies only referenced as possible mechanisms; however, to date no formal cases have been reported.5,6 Case Report: We report a case of a fall associated with extraluminal PICC migration and perforation causing mediastinitis and severe sepsis after total parenteral nutrition (TPN) infusion in a 54-year-old woman. Our patient required a right-sided PICC for long-term home TPN due to severe malnutrition following gastric bypass surgery. During a routine home care visit our patient was found tachypneic, hypoxic, and short of breath. Computed topography imaging in the emergency department (ED) identified the injury, likely related to the recent fall. The patient experienced a complicated hospital course after removal of the PICC. Although rare, PICC line migrations and perforations cause serious complications that should be considered by emergency physicians evaluating patients with chronic indwelling vascular access. Conclusion: Given the efficacy and widespread use of PICC lines, we present this case as a rarely reported but life-threatening complication that requires particular attention. Emergency physicians should be aware of such PICC line complications when encountering patients with chronic indwelling vascular access.

OBJECTIVES: Deep sternal wound infection (DSWI) is a serious complication after open-heart surgery. We investigated the association between DSWI and short- and long-term all-cause mortality in a large well-defined nationwide population. METHODS: A retrospective, nationwide cohort study, which included 114676 consecutive patients who underwent coronary artery bypass grafting (CABG) and/or valve surgery from 1997 to 2015 in Sweden. Short- and long-term mortality was compared between DSWI patients and non-DSWI patients using propensity score inverse probability weighting adjustment based on patient characteristics and comorbidities. Median follow-up was 8.0 years (range 0-18.9). RESULTS: Altogether, 1516 patients (1.3%) developed DSWI, most commonly in patients undergoing combined CABG and valve surgery (2.1%). DSWI patients were older and had more disease burden than non-DSWI patients. The unadjusted cumulative mortality was higher in the DSWI group compared with the non-DSWI group at 90 days (7.9% vs 3.0%, P < 0.001) and at 1 year (12.8% vs 4.5%, P < 0.001). The adjusted absolute difference in risk of death was 2.3% [95% confidence interval (CI): 0.8-3.9] at 90 days and 4.7% (95% CI: 2.6-6.7) at 1 year. DSWI was independently associated with 90-day [adjusted relative risk (aRR) 1.89 (95% CI: 1.38-2.59)], 1-year [aRR 2.13 (95% CI: 1.68-2.71)] and long-term all-cause mortality [adjusted hazard ratio 1.56 (95% CI: 1.30-1.88)]. CONCLUSIONS: Both short- and long-term mortality risks are higher in DSWI patients compared to non-DSWI patients. These results stress the importance of preventing these infections and careful postoperative monitoring of DSWI patients.

Introduction: The use of peripherally inserted central catheters (PICC) has been integral to the advancement of medical care in both in-patient and out-patient arenas.1 However, our knowledge of PICC line complications remains incomplete, particularly in regard to venous perforation and extraluminal migration. Utilization of displaced catheters harbors lethal complications and is an infrequently reported phenomenon, with traumatic etiologies only referenced as possible mechanisms; however, to date no formal cases have been reported.5,6 Case Report: We report a case of a fall associated with extraluminal PICC migration and perforation causing mediastinitis and severe sepsis after total parenteral nutrition (TPN) infusion in a 54-year-old woman. Our patient required a right-sided PICC for long-term home TPN due to severe malnutrition following gastric bypass surgery. During a routine home care visit our patient was found tachypneic, hypoxic, and short of breath. Computed topography imaging in the emergency department (ED) identified the injury, likely related to the recent fall. The patient experienced a complicated hospital course after removal of the PICC. Although rare, PICC line migrations and perforations cause serious complications that should be considered by emergency physicians evaluating patients with chronic indwelling vascular access. Conclusion: Given the efficacy and widespread use of PICC lines, we present this case as a rarely reported but life-threatening complication that requires particular attention. Emergency physicians should be aware of such PICC line complications when encountering patients with chronic indwelling vascular access.

[EN] Introduction Mediastinitis is an infrequent but serious complication of cardiac surgery. Antimicrobial treatment guidelines are not well established. The aim was to describe the efficacy of sequential intravenous to oral therapy in selected post-surgical mediastinitis patients. Methods A retrospective observational study including cases of mediastinitis after cardiac surgery, defined according to CDC criteria, at a third-level university hospital between January 2002 and December 2016. Sequential antimicrobial therapy was proposed in clinically stable patients. Rates of cure, relapse, and hospital stay were compared between patients who received sequential intravenous to oral therapy and those who received therapy exclusively by the intravenous route. Results Eighty-one cases were included. Sequential intravenous to oral therapy was performed in 48 (59.3%) patients on median day 15. No differences in baseline characteristics or causal microorganisms were found between the two cohorts. The average duration of antibiotic therapy was 41.2 ± 10.09 days. The most commonly used drugs in sequential therapy were quinolones in 31 (64.6%) cases and rifampicin, always in association with another antibiotic, in 25 (52.1%). Hospital stay was shorter in the sequential therapy group (57.57 ± 34.03 vs. 84.35 ± 45.67; P = 0.007). Cure was achieved in 77 (92.8%) patients. Overall in-hospital mortality was less frequent in the group that received sequential therapy (2.1% vs. 15.2%; P = 0.039). There were no differences in relapse between the two cohorts (4.2% vs 9.1%; P = 0.366). Conclusion Sequential antimicrobial treatment in selected patients with post-surgical mediastinitis may be as effective as exclusively intravenous treatment, reducing risks, hospital stay and associated costs., [ES] Introducción La mediastinitis es una complicación grave pero infrecuente de la cirugía cardiaca. Las pautas de tratamiento antimicrobiano no han sido bien definidas. El objetivo es describir la eficacia del tratamiento antimicrobiano secuencial, de intravenoso a oral, en pacientes seleccionados con mediastinitis. Método Estudio observacional retrospectivo en el que se incluyeron los casos de mediastinitis relacionados con la cirugía cardiaca, según criterios del CDC, en un hospital universitario entre enero de 2002 y diciembre de 2016. Una vez estabilizados los pacientes, se propuso completar el tratamiento antimicrobiano de forma secuencial, pasando de la vía intravenosa a la oral. Se compararon las tasas de curación, las recidivas y la estancia hospitalaria entre los pacientes que recibieron ambos regímenes. Resultados Se incluyeron 81 casos. El tratamiento antimicrobiano secuencial se utilizó en 48 (59,3%) pacientes, en una media de 15 días. No se encontraron diferencias respecto a las características basales y microorganismos causales en ambos grupos. La duración media del tratamiento antibiótico fue de 41,2 ± 10,09 días. Los antimicrobianos más utilizados en el tratamiento secuencial fueron quinolonas en 31 (64,6%) y rifampicina, siempre asociada a otro antibiótico, en 25 (52,1%). La estancia hospitalaria fue menor en el grupo con tratamiento secuencial (57,57 ± 34,03 vs. 84,35 ± 45,67; p = 0,007). En conjunto, curaron 77 (92,8%) pacientes. La mortalidad hospitalaria fue inferior en el grupo tratado secuencialmente (2,1% vs. 15,2%; p = 0,039). No hubo diferencias en recidivas entre ambos grupos (4,2% vs 9,1%; p = 0,366). Conclusión El tratamiento antimicrobiano secuencial en pacientes con mediastinitis posquirúrgica seleccionados puede tener una eficacia similar al tratamiento exclusivamente intravenoso, permitiendo reducir riesgos y costes asociados.

Introduction: Endosonography with intrathoracic nodal sampling is the single test with the highest diagnostic yield in suspected sarcoidosis. However, the optimal nodal sampling route; either the endobronchial (EBUS) or the transesophageal approach (EUS-B) is under debate. Method(s): A global (4 continents, 9 countries) randomized clinical trial (NCT02540694). Patients with suspected sarcoidosis stage I and II were included and randomized to EBUS or EUS-B and to conventional 22 Gauge aspiration needle or 25G biopsy needle (ProCore). Granuloma detection rate, sensitivity for diagnosing sarcoidosis and procedural operator feasibility (scale 1(not feasible) to 5(very feasible)) were study endpoints. The final diagnosis was based on cytology outcomes, clinical and radiological at 6 months follow-up. Result(s): 322 patients were randomized: 167 patients to EBUS-TBNA and 155 to EUS-B-FNA. Final diagnoses were: sarcoidosis (n=272, 85%), lymphoma (n=7, 2%), (N)SCLC (n=6, 2%), TBC (n=2, 0.5%), other e.g. postinflammation/reactive mediastinal nodal disease (n=35, 10.5%). Granuloma detection rate was 73% overall and 75% for EBUSTBNA and 70.3% for EUS-B-FNA and independent of needle type. Sensitivity of endosonography for diagnosing sarcoidosis was 85% overall, 84% for EBUS and 87% for EUSB. No major complications, specifically no mediastinitis/abcess formation occurred. Mean feasibility score was 4.4 for EUS-B and 4.3 EBUS (p=0.215). Conclusion(s): Endosonography with nodal sampling is safe, feasible and has a high granuloma detecting rate and sensitivity for diagnosing stage I / II sarcoidosis, which is independent of the sampling route (endobronchial vs transesophageal).

Introduction: Endosonography with intrathoracic nodal sampling is the single test with the highest diagnostic yield in suspected sarcoidosis. However, the optimal nodal sampling route; either the endobronchial (EBUS) or the transesophageal approach (EUS-B) is under debate. Method(s): A global (4 continents, 9 countries) randomized clinical trial (NCT02540694). Patients with suspected sarcoidosis stage I and II were included and randomized to EBUS or EUS-B and to conventional 22 Gauge aspiration needle or 25G biopsy needle (ProCore). Granuloma detection rate, sensitivity for diagnosing sarcoidosis and procedural operator feasibility (scale 1(not feasible) to 5(very feasible)) were study endpoints. The final diagnosis was based on cytology outcomes, clinical and radiological at 6 months follow-up. Result(s): 322 patients were randomized: 167 patients to EBUS-TBNA and 155 to EUS-B-FNA. Final diagnoses were: sarcoidosis (n=272, 85%), lymphoma (n=7, 2%), (N)SCLC (n=6, 2%), TBC (n=2, 0.5%), other e.g. postinflammation/reactive mediastinal nodal disease (n=35, 10.5%). Granuloma detection rate was 73% overall and 75% for EBUSTBNA and 70.3% for EUS-B-FNA and independent of needle type. Sensitivity of endosonography for diagnosing sarcoidosis was 85% overall, 84% for EBUS and 87% for EUSB. No major complications, specifically no mediastinitis/abcess formation occurred. Mean feasibility score was 4.4 for EUS-B and 4.3 EBUS (p=0.215). Conclusion(s): Endosonography with nodal sampling is safe, feasible and has a high granuloma detecting rate and sensitivity for diagnosing stage I / II sarcoidosis, which is independent of the sampling route (endobronchial vs transesophageal).

Maxillofacial Surgery, deals with the diagnosis and surgical treatment, coadjuvant of diseases, traumatisms and defects of the jaws and adjacent regions. The procedures performed in this type of treatment in pediatric patients should follow the same principles of surgeries performed in adult patients, with respect to all measures that should be taken into account in biosecurity, diagnosis, need for treatment, instruments and appropriate techniques; of course, without neglecting the size of the oral cavity in the child, patient's age, psychological preparation, consistency of bone tissue, presence of permanent dental germ and pain control. The most common complications in this type of surgical procedure are the infections that occur in the maxillofacial territory and are characterized by frequent pictures, of microbial poly origin, with very variable clinical manifestations and that are associated with multiple pathways for the entry of microorganisms. to the territory. A large percentage of these infections originate in the oralcavity, mainly in bacterial lesions suffered by the teeth. These anomalies are presented in a general way, in the potential spaces and deep planes of the maxillofacial region, whose anatomy is complex. Most of them respond appropriately to surgical and antimicrobial treatment, however, in some cases the local dissemination of the infection can lead to compromise of deep cervical spaces, mediastinitis, cavernous sinus thrombosis or compromise of the airway. Its progression and spread can be due to multiplefactors, including the immunocompetence of the individual, anatomical localization of the infectious process, virulence of the micro-organisms, resistance patterns of the organisms involved, as well as the decisions of the therapeutic management. Hence, the importance of analyzing the complications that may arise in maxillofacial surgeries of pediatric patients and how they will behandled., Cirurgia Maxilofacial, trata do diagnóstico e tratamento cirúrgico, coadjuvante de doenças, traumatismos e defeitos das mandíbulas e regiões adjacentes. Os procedimentos realizados nesse tipo de tratamento em pacientes pediátricos devem seguir os mesmos princípios das cirurgias realizadas em pacientes adultos, com relação a todas as medidas que devem ser consideradas na biossegurança, diagnóstico, necessidade de tratamento, instrumentos e técnicas apropriadas; é claro, sem negligenciar o tamanho da cavidade oral na criança, a idade do paciente, o preparo psicológico, a consistência do tecido ósseo, a presença de germe dentário permanente e o controle da dor. As complicações mais comuns neste tipo de cirurgia são as infecções que ocorrem em maxilo-facial e são caracterizadas por imagens frequentes, poli origem microbiana, com manifestações clínicas muito variáveis que estão associadas com várias vias de entrada de microrganismos para o território. Uma grande porcentagem dessas infecções se origina na cavidade bucal, principalmente emlesões bacterianas sofridas pelos dentes. Essas anomalias são apresentadas de maneira geral, nos espaços potenciais e planos profundos da região maxilofacial, cuja anatomia é complexa. A maioria deles responder adequadamente ao tratamento cirúrgico e antimicrobiano, no entanto, em alguns casos disseminação local da infecção pode levar a espaços cervicais profundos compromisso, mediastinite, trombose do seio cavernoso ou comprometimento das vias aéreas. Sua progressão e disseminação pode ser devido a vários fatores, incluindo imuno -competência do indivíduo, localização anatômica do processo infeccioso, virulência dos microrganismos, padrões de resistência das entidades envolvidas, bem como as decisões de gestão terapêuticas. Daí a importância de analisar as complicações que podem surgir nas cirurgias maxilofaciais de pacientes pediátricos e como elas serão tratadas., La Cirugía Maxilofacial, trata del diagnóstico y del tratamiento quirúrgico, coadyuvante de las enfermedades, traumatismos y defectos de los maxilares y regiones adyacentes. Los procedimientos realizados en este tipo de tratamientos en pacientes pediátricos deben seguir los mismos principios de las cirugías realizadas en pacientes adultos, respecto a todas las medidas que se deben tener en cuenta en bioseguridad, diagnostico, necesidad de tratamiento, instrumental y técnicas adecuadas; claro está, sin dejar de considerar en el niño el tamaño de su cavidad bucal, edad del paciente, preparación psicológica, consistencia del tejido óseo, presencia del germen dental permanente y control del dolor. Las complicaciones más comunes en este tipo de procedimiento quirúrgico son las infecciones que se dan en el territorio maxilofacial y se caracterizan por presentar cuadros frecuentes, de origen poli microbiano, con manifestaciones clínicas muy variables y que están asociadas a múltiples vías de ingreso de los microorganismos al territorio. Un gran porcentaje de estas infecciones se origina en la cavidad oral, principalmente en lesiones bacterianas que sufren los dientes. Estas anomalías se presentan de manera general, en los espacios potenciales y planos profundos de la región maxilofacial, cuya anatomía es compleja. La mayoría de ellas, responden apropiadamente al tratamiento quirúrgico y antimicrobiano, sin embargo, en algunos casos la diseminación local de la infección puede conducir al compromiso de espacios cervicales profundos, mediastinitis, trombosis del seno cavernoso o compromiso de la vía aérea. Su progresión y diseminación puede deberse a múltiples factores, incluyendo la inmuno - competencia del individuo, localización anatómica del proceso infeccioso, virulencia de los micro-organismos, patrones de resistencia de los organismos involucrados, así como también las decisiones del manejo terapéutico. De aquí, la importancia de analizar cuáles son las complicaciones

Maxillofacial Surgery, deals with the diagnosis and surgical treatment, coadjuvant of diseases, traumatisms and defects of the jaws and adjacent regions. The procedures performed in this type of treatment in pediatric patients should follow the same principles of surgeries performed in adult patients, with respect to all measures that should be taken into account in biosecurity, diagnosis, need for treatment, instruments and appropriate techniques; of course, without neglecting the size of the oral cavity in the child, patient's age, psychological preparation, consistency of bone tissue, presence of permanent dental germ and pain control. The most common complications in this type of surgical procedure are the infections that occur in the maxillofacial territory and are characterized by frequent pictures, of microbial poly origin, with very variable clinical manifestations and that are associated with multiple pathways for the entry of microorganisms. to the territory. A large percentage of these infections originate in the oralcavity, mainly in bacterial lesions suffered by the teeth. These anomalies are presented in a general way, in the potential spaces and deep planes of the maxillofacial region, whose anatomy is complex. Most of them respond appropriately to surgical and antimicrobial treatment, however, in some cases the local dissemination of the infection can lead to compromise of deep cervical spaces, mediastinitis, cavernous sinus thrombosis or compromise of the airway. Its progression and spread can be due to multiplefactors, including the immunocompetence of the individual, anatomical localization of the infectious process, virulence of the micro-organisms, resistance patterns of the organisms involved, as well as the decisions of the therapeutic management. Hence, the importance of analyzing the complications that may arise in maxillofacial surgeries of pediatric patients and how they will behandled., Cirurgia Maxilofacial, trata do diagnóstico e tratamento cirúrgico, coadjuvante de doenças, traumatismos e defeitos das mandíbulas e regiões adjacentes. Os procedimentos realizados nesse tipo de tratamento em pacientes pediátricos devem seguir os mesmos princípios das cirurgias realizadas em pacientes adultos, com relação a todas as medidas que devem ser consideradas na biossegurança, diagnóstico, necessidade de tratamento, instrumentos e técnicas apropriadas; é claro, sem negligenciar o tamanho da cavidade oral na criança, a idade do paciente, o preparo psicológico, a consistência do tecido ósseo, a presença de germe dentário permanente e o controle da dor. As complicações mais comuns neste tipo de cirurgia são as infecções que ocorrem em maxilo-facial e são caracterizadas por imagens frequentes, poli origem microbiana, com manifestações clínicas muito variáveis que estão associadas com várias vias de entrada de microrganismos para o território. Uma grande porcentagem dessas infecções se origina na cavidade bucal, principalmente emlesões bacterianas sofridas pelos dentes. Essas anomalias são apresentadas de maneira geral, nos espaços potenciais e planos profundos da região maxilofacial, cuja anatomia é complexa. A maioria deles responder adequadamente ao tratamento cirúrgico e antimicrobiano, no entanto, em alguns casos disseminação local da infecção pode levar a espaços cervicais profundos compromisso, mediastinite, trombose do seio cavernoso ou comprometimento das vias aéreas. Sua progressão e disseminação pode ser devido a vários fatores, incluindo imuno -competência do indivíduo, localização anatômica do processo infeccioso, virulência dos microrganismos, padrões de resistência das entidades envolvidas, bem como as decisões de gestão terapêuticas. Daí a importância de analisar as complicações que podem surgir nas cirurgias maxilofaciais de pacientes pediátricos e como elas serão tratadas., La Cirugía Maxilofacial, trata del diagnóstico y del tratamiento quirúrgico, coadyuvante de las enfermedades, traumatismos y defectos de los maxilares y regiones adyacentes. Los procedimientos realizados en este tipo de tratamientos en pacientes pediátricos deben seguir los mismos principios de las cirugías realizadas en pacientes adultos, respecto a todas las medidas que se deben tener en cuenta en bioseguridad, diagnostico, necesidad de tratamiento, instrumental y técnicas adecuadas; claro está, sin dejar de considerar en el niño el tamaño de su cavidad bucal, edad del paciente, preparación psicológica, consistencia del tejido óseo, presencia del germen dental permanente y control del dolor. Las complicaciones más comunes en este tipo de procedimiento quirúrgico son las infecciones que se dan en el territorio maxilofacial y se caracterizan por presentar cuadros frecuentes, de origen poli microbiano, con manifestaciones clínicas muy variables y que están asociadas a múltiples vías de ingreso de los microorganismos al territorio. Un gran porcentaje de estas infecciones se origina en la cavidad oral, principalmente en lesiones bacterianas que sufren los dientes. Estas anomalías se presentan de manera general, en los espacios potenciales y planos profundos de la región maxilofacial, cuya anatomía es compleja. La mayoría de ellas, responden apropiadamente al tratamiento quirúrgico y antimicrobiano, sin embargo, en algunos casos la diseminación local de la infección puede conducir al compromiso de espacios cervicales profundos, mediastinitis, trombosis del seno cavernoso o compromiso de la vía aérea. Su progresión y diseminación puede deberse a múltiples factores, incluyendo la inmuno - competencia del individuo, localización anatómica del proceso infeccioso, virulencia de los micro-organismos, patrones de resistencia de los organismos involucrados, así como también las decisiones del manejo terapéutico. De aquí, la importancia de analizar cuáles son las complicaciones

Maxillofacial Surgery, deals with the diagnosis and surgical treatment, coadjuvant of diseases, traumatisms and defects of the jaws and adjacent regions. The procedures performed in this type of treatment in pediatric patients should follow the same principles of surgeries performed in adult patients, with respect to all measures that should be taken into account in biosecurity, diagnosis, need for treatment, instruments and appropriate techniques; of course, without neglecting the size of the oral cavity in the child, patient's age, psychological preparation, consistency of bone tissue, presence of permanent dental germ and pain control. The most common complications in this type of surgical procedure are the infections that occur in the maxillofacial territory and are characterized by frequent pictures, of microbial poly origin, with very variable clinical manifestations and that are associated with multiple pathways for the entry of microorganisms. to the territory. A large percentage of these infections originate in the oralcavity, mainly in bacterial lesions suffered by the teeth. These anomalies are presented in a general way, in the potential spaces and deep planes of the maxillofacial region, whose anatomy is complex. Most of them respond appropriately to surgical and antimicrobial treatment, however, in some cases the local dissemination of the infection can lead to compromise of deep cervical spaces, mediastinitis, cavernous sinus thrombosis or compromise of the airway. Its progression and spread can be due to multiplefactors, including the immunocompetence of the individual, anatomical localization of the infectious process, virulence of the micro-organisms, resistance patterns of the organisms involved, as well as the decisions of the therapeutic management. Hence, the importance of analyzing the complications that may arise in maxillofacial surgeries of pediatric patients and how they will behandled., Cirurgia Maxilofacial, trata do diagnóstico e tratamento cirúrgico, coadjuvante de doenças, traumatismos e defeitos das mandíbulas e regiões adjacentes. Os procedimentos realizados nesse tipo de tratamento em pacientes pediátricos devem seguir os mesmos princípios das cirurgias realizadas em pacientes adultos, com relação a todas as medidas que devem ser consideradas na biossegurança, diagnóstico, necessidade de tratamento, instrumentos e técnicas apropriadas; é claro, sem negligenciar o tamanho da cavidade oral na criança, a idade do paciente, o preparo psicológico, a consistência do tecido ósseo, a presença de germe dentário permanente e o controle da dor. As complicações mais comuns neste tipo de cirurgia são as infecções que ocorrem em maxilo-facial e são caracterizadas por imagens frequentes, poli origem microbiana, com manifestações clínicas muito variáveis que estão associadas com várias vias de entrada de microrganismos para o território. Uma grande porcentagem dessas infecções se origina na cavidade bucal, principalmente emlesões bacterianas sofridas pelos dentes. Essas anomalias são apresentadas de maneira geral, nos espaços potenciais e planos profundos da região maxilofacial, cuja anatomia é complexa. A maioria deles responder adequadamente ao tratamento cirúrgico e antimicrobiano, no entanto, em alguns casos disseminação local da infecção pode levar a espaços cervicais profundos compromisso, mediastinite, trombose do seio cavernoso ou comprometimento das vias aéreas. Sua progressão e disseminação pode ser devido a vários fatores, incluindo imuno -competência do indivíduo, localização anatômica do processo infeccioso, virulência dos microrganismos, padrões de resistência das entidades envolvidas, bem como as decisões de gestão terapêuticas. Daí a importância de analisar as complicações que podem surgir nas cirurgias maxilofaciais de pacientes pediátricos e como elas serão tratadas., La Cirugía Maxilofacial, trata del diagnóstico y del tratamiento quirúrgico, coadyuvante de las enfermedades, traumatismos y defectos de los maxilares y regiones adyacentes. Los procedimientos realizados en este tipo de tratamientos en pacientes pediátricos deben seguir los mismos principios de las cirugías realizadas en pacientes adultos, respecto a todas las medidas que se deben tener en cuenta en bioseguridad, diagnostico, necesidad de tratamiento, instrumental y técnicas adecuadas; claro está, sin dejar de considerar en el niño el tamaño de su cavidad bucal, edad del paciente, preparación psicológica, consistencia del tejido óseo, presencia del germen dental permanente y control del dolor. Las complicaciones más comunes en este tipo de procedimiento quirúrgico son las infecciones que se dan en el territorio maxilofacial y se caracterizan por presentar cuadros frecuentes, de origen poli microbiano, con manifestaciones clínicas muy variables y que están asociadas a múltiples vías de ingreso de los microorganismos al territorio. Un gran porcentaje de estas infecciones se origina en la cavidad oral, principalmente en lesiones bacterianas que sufren los dientes. Estas anomalías se presentan de manera general, en los espacios potenciales y planos profundos de la región maxilofacial, cuya anatomía es compleja. La mayoría de ellas, responden apropiadamente al tratamiento quirúrgico y antimicrobiano, sin embargo, en algunos casos la diseminación local de la infección puede conducir al compromiso de espacios cervicales profundos, mediastinitis, trombosis del seno cavernoso o compromiso de la vía aérea. Su progresión y diseminación puede deberse a múltiples factores, incluyendo la inmuno - competencia del individuo, localización anatómica del proceso infeccioso, virulencia de los micro-organismos, patrones de resistencia de los organismos involucrados, así como también las decisiones del manejo terapéutico. De aquí, la importancia de analizar cuáles son las complicaciones

La mediastinitis es una infección grave, a veces secundaria a la progresión de un absceso cervical. Describimos el caso de un paciente de 56 años de edad que presentó un cuadro de fiebre, disfonía, dolor torácico y expectoración hemoptoica que fue diagnosticado de epiglotitis y mediastinitis y empiema secundarios.

Objective: The aim of this analysis was to define independent predictive variables for the development of mediastinitis after cardiovascular surgery and develop a validated score to stratify the risk for mediastinitis.Methods: Data were retrieved from the CONAREC XVI study comprising adults undergoing cardiovascular surgery between September 2007 and October 2008 in 49 centers of 16 provinces in Argentina. Mediastinitis was defined as the presence of clinical signs attributable to the condition or positive cultures. Epidemiological and clinical variables, type of surgery, intraoperativeand postoperative variables and complementary tests were evaluated. A logistic regression model was used toidentify the independent variables associated with perioperative mediastinitis. A two-tailed alpha error < 0.05 was consideredstatistically significant. A score was constructed and was externally validated in patients from other surgical centers.Results: A total of 2553 patients were analyzed: coronary artery bypass graft surgery, 1465 patients (57.4%); aortic valve replacement,359 (14.1%); mitral valve surgery, 169 (6.6%); combined procedure (revascularization-valve surgery), 312 (12.2%); other procedures, 248 (9.7%). The overall incidence of medistinitis was 1.88%. The variables associated with the development of mediastinitis were: smoking habits (OR, 2.3; 95% CI,1.1-5,1; p=0.02), severe left ventricular dysfunction (OR, 2.8; 95% CI,1.3-6.2; p=0.001), reoperation (OR, 4,6; 95% CI,1.8-11.3; p=0.01) and postoperative renal failure (OR, 4.3; 95% CI, 1.9-9,6;p=0.0001). A risk score was constructed assigning 1 point for severe left ventricular dysfunction, 1 point for the history of smoking habits, 2 points for the development of renal failure and 2 points for need for reoperation. The area under the ROC curve for mortality was 0.72 (95% CI, 0.64-0,81; Hosmer Lemeshow test p=0.9). The external validation was performed on1657 patients, mean age 62.8±13.3 years. The incidence of medi, Objetivos: El objetivo de este análisis fue definir variables predictoras independientes para la aparición de mediastinitis poscirugíacardíaca, y desarrollar un puntaje validado para estratificar el riesgo de manifestación de mediastinitis.Materiales y métodos: Se analizaron datos el estudio CONAREC XVI de adultos sometidos a cirugía cardíaca entre 2007 y 2008, en 49 centros de 16 provincias argentinas. Se definió mediastinitis como la presencia de signos clínicos o cultivos positivos. Se evaluaron variables epidemiológicas, clínicas, tipo de cirugía, variables intraoperatorias y posoperatorias, estudios complementarios .Se realizó un análisis de regresión logística múltiple para identificar variables independientemente asociadas a la manifestación de mediastinitis posoperatoria. Se consideró como significativa un error alfa menor del 5% a dos colas. Se construyó un score y se realizó una validación externa con pacientes de otros centros quirúrgicos.Resultados: Se analizaron 2553 pacientes: 1465 (57,4%) sometidos a cirugía coronaria, 359 (14,1%) a reemplazo valvular aórtico,169 (6,6%) a cirugía valvular mitral, 312 (12,2%) a cirugía combinada y 248 (9,7%) a otras. La incidencia de mediastinitis fue1,88% en la población global. Las variables asociadas al desarrollo de mediastinitis fueron: antecedente de tabaquismo, OR:2,3 (IC 95% 1,1-5,1) p = 0,02, disfunción ventricular grave, OR: 2,8 (IC 95% 1,3-6,2) p = 0,001, reoperación, OR: 4,6 (IC 95%1,8-11,3) p = 0,001, e insuficiencia renal posoperatoria, OR: 4,3 (IC 95% 1,9-9,6) p = 0,0001. Se construyó un score de riesgo adjudicando los siguientes puntajes según la presencia o ausencia de cada una de los cuatros variables del modelo resultante:1 punto en caso de disfunción ventricular grave, 1 punto para el antecedente de tabaquismo, 2 puntos para el desarrollo deinsuficiencia renal y 2 puntos para la necesidad de reoperación. El área ROC para mortalidad fue 0,72 (IC 95% 0,64-0,81)(Hosmer Lemeshow p = 0,9). El grupo de va

The objective of the study. To conduct an analysis of clinical diagnosis, symptoms and purulent mediastinal syndromes in patients with acute purulent mediastinitis (APM). Materials and methods of research. During 2000-2018 there were 65 patients with APM in the thoracic department of the Ivano-Frankivsk Regional Clinical Hospital. Research results. Clinical picture of APM consists of symptoms of the main disease and local manifestations of purulent process in the mediastinum: chest pain - in 62 (95.4%) patients, iPNiltrative changes and hyperemia of the thoracic wall were observed in 13 (20%), mediastinal emphysema at 29 ( 44.6%); general symptoms of endogenous intoxication: increased body temperature in 100% of patients, pallor of the skin in 34 (52.3%), cyanotic changes - in 24 (36.9%), shortness of breath - 37 (56.9%), tachycardia in 100% patients; clinical symptoms of damage to other organs of the mediastinum and chest: upper respiratory tract syndrome in 11 (16.9%), dysphagia in 9 (13.8%), hiccup in 2 (3.1%), hoarseness of voice in 6 (9.2%), cough - 23% (35.4%), exudative pleurisies ­- 6% (78.4%)  and purulent pericarditis - in 18 (27.6%) patients. Conclusions. Knowledge of the symptoms and syndromes of acute purulent mediastinitis is the basis for timely diagnosis of this disease. A clear clinical interpretation of the symptoms of acute purulent mediastinitis allows suspect this disease already at the initial stages of providing medical care. Early diagnosis of acute purulent mediastinitis is one of the decisive factors in the successful treatment of patients.

Актуальность. Проблема адекватного лечения глубокого нагноения шеи и средостения является одной из самых сложных в хирургии. Это обусловлено такими ­осложнениями, как медиастинит, сепсис, аррозивные кровотечения и др. Цель: изучить особенности клиники, диагностики и лечения больных с флегмонами шеи и медиастинитами вследствие окологлоточных нагноений. Материалы и методы. Представлены результаты лечения 31 больного с флегмонами шеи в результате воспаления окологлоточных пространств. Средний возраст исследованных — 48,24 ± 15,60 года, мужчин было 18 (58 %), женщин — 13 (42 %). Все имели признаки тяжелой эндогенной интоксикации. Срок от начала заболевания до момента операции составил в среднем 4 суток (от одних до семи). Результаты. Частыми причинами флегмон шеи были парафарингеальные нагноения — 16 (51,6 %), далее идут паратонзиллярные абсцессы — 11 (35,5 %), ретрофарингеальные нагноения — 3 (9,7 %), а также рак гортани — 1 (3,2 %). Чувствительность боковой рентгенографии шеи, которая выполнялась всем пациентам до операции, составила 100 %. В то же время чувствительность обзорной рентгенографии органов грудной клетки на предмет медиастинита — всего 60 %. Хирургические доступы предусматривали широкие цервикотомии (чаще билатеральные) и сквозное полидренирование предпозвоночного пространства. При развитии медиастинита (15 случаев, или 48,4 %), когда в гнойный процесс вовлекалось верхнее заднее средостение (11 наблюдений, или 73,3 %), дренирование выполнялось слепо. Однажды для лечения тотального заднего медиастинита понадобилась правосторонняя торакотомия. Умерли четверо (13 %) пациентов. Во всех летальных случаях развились нисходящий медиастинит и сепсис. Летальность в группе пациентов с медиастинитом составила 26,7 %. Выводы. Флегмоны шеи в результате нагноения окологлоточных пространств характеризуются агрессивным течением с выраженной эндогенной интоксикацией и распространением на средостение в 48,4 % случаев с летальностью 13 %. Боковая рентгенография шеи показана, Актуальність. Проблема адекватного лікування глибокого нагноєння клітковини шиї і середо­стіння є однією з найбільш складних в хірургії. Це обумовлене розвитком таких ускладнень, як медіастиніт, сепсис, арозивні кровотечі та ін. Мета: вивчити особливості клініки, діагностики та лікування пацієнтів з флегмонами шиї та медіастинітами внаслідок навкологлоткових нагноєнь. Матеріали та методи. Подано результати лікування 31 хворого з флегмонами шиї внаслідок гнійного запалення навкологлоткових просторів. Середній вік досліджених — 48,24 ± 15,60 року, чоловіків було 18 (58 %), жінок — 13 (42 %). Усі госпіталізовані мали ознаки тяжкої ендогенної інтоксикації. Строк від початку захворювання до моменту хірургічного втручання становив у середньому 4 доби (від однієї до семи). Результати. Найчастішими причинами флегмон шиї були парафарингеальні нагноєння — 16 (51,6 %), за ними йдуть паратонзилярні абсцеси — 11 (35,5 %), ретрофарингеальні нагноєння — 3 (9,7 %), а також рак гортані — 1 (3,2 %). Чутливість бокової рентгенографії шиї, яка виконувалась всім пацієнтам до операції, дорівнювала 100 %. Натомість чутливість оглядової рентгенографії органів грудної клітки щодо медіастиніту — всього 60 %. Хірургічні доступи передбачали широкі цервікотомії (частіше білатеральні) та наскрізне полідренування передхребтового простору. При розвитку медіастинітів (15 випадків, або 48,4 %), коли до гнійного процесу залучалося верхнє заднє середостіння (11 спостережень, або 73,3 %), дренування виконувалось сліпо. Один раз для лікування тотального заднього медіастиніту знадобилася правобічна торакотомія. Померли четверо (13 %) пацієнтів. У всіх летальних випадках розвинувся низхідний медіастиніт і сепсис. Летальність у групі пацієнтів із медіастинітами становила 26,7 %. Висновки. Флегмони шиї внаслідок нагноєння навкологлоткових просторів характеризуються агресивним перебігом із вираженою ендогенною інтоксикацією та поширенням на середостіння у 48,4 % випадків із летальністю 13 %. Бокова рентгеног, Background. The problem of adequate treatment for deep neck and mediastinal suppuration is one of the most difficult in surgery. It leads to such complications as mediastinitis, sepsis, arrosive bleeding, etc. The purpose was to investigate clinical, diagnostic and treatment features in patients with neck phlegmons and mediastinitis caused by pharyngeal suppurations. Materials and methods. The results of treatment of 31 patients with parapharyngeal phlegmons were presented. The average age of them was 48.24 ± 15.60 years, men were 18 (58 %), women — 13 (42 %). All persons suffered from severe endogenous intoxication. The time from the onset of the disease to surgery was about 4 days (from one to seven). Results. Most frequently, parapharyngeal suppuration was detected — in 16 (51.6 %) patients, then paratonsillar abscesses — in 11 (35.5 %), retropharyngeal suppurations — in 3 (9.7 %), and laryngeal cancer — in 1 (3.2 %). Lateral neck radiographs were performed in all patients preoperatively. Sensitivity of this investigation was 100 %. At the same time, chest X-ray to detect mediastinitis showed low rates of sensitivity — 60 %. Surgical approaches included extensive cervicotomy (often bilateral) and penetrative polydrainage of prevertebral space. Mediastinitis was found in 15 cases (48.4 %). It was enough to use blind drainage for upper posterior mediastinitis (11 cases, or 73.3 %). Right-sided thoracotomy was performed in one case of total posterior mediastinitis. Four patients died (13 %). Descending mediastinitis and sepsis were found in all lethal cases. Mortality rate in the group of patients with mediastinitis was 26.7 %. Conclusions. Neck phlegmons as a result of parapharyngeal suppuration are characterized by an aggressive course with significant endogenous intoxication and spread to the mediastinum in 48.4 % of cases with a lethality of 13 %. The lateral neck X-ray must be performed to all patients with suspicion of a deep neck phlegmon. In most cases (80 %

Цель исследования: повысить качество диагностики перфораций пищевода (ПП) и острого гнойного медиастинита (ОГМ) с применением инструментальных методов диагностики. Материалы и методы. В 2000–2018 гг. на лечении в отделении торакальной хирургии Ивано-Франковской областной больницы находились 92 больных с ПП, из них ОГМ диагностирован у 33 (35,8 %). Результаты. Для решения поставленных задач были проанализированы результаты диагностики с применением рентгенографии органов грудной клетки, спиральной компьютерной томографии, рентгенконтрастного обследования пищевода, эзофагогастродуоденоскопии, фибробронхоскопии, ультразвуковой диагностики клетчатки шеи, верхнего средостения, плевральных синусов, сердца и перикарда. Выводы. Использование комплекса инструментальных исследований является решающим фактором в верной диагностике острого гнойного медиастинита. Наиболее информативным методом для диагностики острого гнойного медиастинита является спиральная компьютерная томография, диагностическая ценность которой составляет 100 %. Применение дополнительных методов исследования, а именно ренгенконтрастного обследования пищевода, ультразвукового исследования, фибробронхоскопии, позволяет подтвердить диагноз острого гнойного медиастинита и определить характер осложнений, является определяющим в выборе дальнейшей хирургической тактики лечения., Мета дослідження: підвищити якість діагностики перфорацій стравоходу (ПС) та гострого гнійного медіастиніту (ГГМ) із застосуванням інструментальних методів діагностики. Матеріали та методи. У 2000–2018 рр. на лікуванні у відділенні торакальної хірургії Івано-Франківської обласної лікарні перебували 92 хворі із ПС, із них ГГМ діагностований у 33 (35,8 %). Результати. Для вирішення поставлених завдань були проаналізовані результати діагностики із застосуванням рентгенографії органів грудної клітки, спіральної комп’ютерної томографії, рентгенконтрастного обстеження стравоходу, езофагогастродуоденоскопії, фібробронхоскопії, ультразвукової діагностики клітковини шиї, верхнього середостіння, плевральних синусів, серця та перикарду. Висновки. Використання комплексу інструментальних досліджень є вирішальним фактором у вірній діагностиці гострого гнійного медіастиніту. Найбільш інформативним методом для діагностики гострого гнійного медіастиніту є спіральна комп’ютерна томографія, діагностична цінність якої становить 100 %. Застосування додаткових методів дослідження, а саме ренгенконтрастного обстеження стравоходу, ультразвукового дослідження, фібробронхоскопії, дозволяє підтвердити діагноз гострого гнійного медіастиніту та визначити характер ускладнень, що є визначальним у виборі подальшої хірургічної тактики лікування., The purpose of the study: to improve the quality of diagnosis of esophageal perforations and acute purulent mediastinitis using instrumental diagnostic methods. Materials and methods. In 2000–2018, 92 patients with esophageal perforations were treated at the department of thoracic surgery of Ivano-Frankivsk Regional Hospital, 33 (35.8 %) of them were diagnosed with acute purulent mediastinitis. Results. To solve the taska, the results of the diagnosis were analyzed using chest X-ray, spiral computed tomography, esophagogram, esophagogastroduodenoscopy, fiber-optic bronchoscopy, ultrasound of the neck, upper mediastinum, pleural sinuses, heart and pericardium. Conclusions. The use of a set of instrumental researches is a decisive factor in the correct diagnosis of acute purulent mediastinitis. The most informative method for the diagnosis of acute purulent mediastinitis is spiral computed tomography with a diagnostic value of 100 %. The use of additional research methods, namely esophagogram, ultrasound, fiber-optic bronchoscopy, can confirm the diagnosis of acute purulent mediastinitis and determine the nature of complications, which is decisive in cho­osing further surgical treatment.

Background and Aims: Endobronchial Ultrasound Transbronchial Needle Aspiration (EBUS TBNA) is established as a minimally invasive way to sample intrathoracic abnormalities. The EBUS scope may be passed into the oesophagus to perform Endodoscopic UltraSound with Bronchoscope-guided Fine Needle Aspiration (EUS-B-FNA). In the setting of suspected lung cancer, the combination of the two techniques is now recommended by consensus guidelines. EBUS TBNA is usually performed by pulmonologists, however, the learning curve for EUS-B-FNA, which may be performed during the same procedure, has not been described. Method(s): Multicentre, observational Australian study using prospec-tively collected data from three experienced pulmonologists. Cumulative sum (cusum) analysis was used to generate visual learning curves. Result(s): 152 target lesions were sampled in 137 patients, with an overall sensitivity for malignancy of 94.8%. The sensitivity for malignant lesions outside the 2009 International Association for the Study of Lung Cancer lymph node map (largely intraparenchymal lesions) was 92.9%. All three operators were competent by conventional cusum criteria. There was one pneumothorax and no episodes of mediastinitis or oesophageal perforation. Conclusion(s): Our data suggest experienced pulmonologists can safely and accurately perform EUS-B-FNA, with high diagnostic sensitivity for both lymph node and non-nodal lesions.

INTRODUCCIÓN: La mediastinitis es una infección profunda del sitio operatorio con compromiso del espacio retroesternal, su incidencia varía de 0,2% a 5,0% según lo reportado por American College of Cardiology/American Heart Association (ACC/AHA). OBJETIVO: Establecer el efecto del cambio de esquema de profilaxis antibiótica sobre la incidencia de mediastinitis posquirúrgica en pacientes sometidos a cirugía cardiovascular con implante de prótesis en los años 2012-2013 en la FCI–IC. METODOLOGÍA: Estudio observacional analítico de cohorte histórica en pacientes sometidos a cirugía cardíaca con implante de prótesis. Se compararon las cohortes de pacientes que recibieron Cefalosporinas Vs Vancomicina-Gentamicina. RESULTADOS: Se realizó el análisis sobre una población de 464 pacientes, 163 recibieron profilaxis con Cefalosporinas (Cef) y 301 con Vancomicina – Gentamicina (Van-Gen). Los 3 procedimientos más frecuentemente realizados fueron reemplazo de válvula aortica (40.1%) Válvula mitral (22.2%) y Cirugía de Bentall (11.6%). La incidencia acumulada anual de mediastinitis fue de 4.76 y de 1.57 en el 2012 y 2013 respectivamente, siendo mayor en el grupo de Cef. El riesgo de ocurrencia de mediastinitis con Van-Gen es menor comparado con el uso de cefalosporinas (RR 0.25 IC 0.08-0.79) ajustado por edad y género. El principal germen aislado fué Staphylococcus Aureus MS (29.4%). CONCLUSIONES: Si existen diferencias en esta población con respeto a la incidencia de mediastinitis en pacientes sometidos a cirugía cardíaca con implante de prótesis, siendo menor en el grupo que recibe profilaxis antibiótica con Van-Gen comparado con Cef., INTRODUCTION: Mediastinitis is a deep infection of the surgical site with involvement of the retrosternal space, its incidence varies from 0.2% to 5.0% as reported by the American College of Cardiology / American Heart Association (ACC / AHA). OBJECTIVE: Establish the effect of the change of antibiotic prophylaxis scheme on the incidence of postoperative mediastinitis in patients undergoing cardiovascular surgery with prothesis implantation in the years 2012-2013 in the FCI-IC. METHODS: An observational, historical cohort study of patients undergoing cardiac surgery with prothesis implant. Cohorts of patients receiving Cephalosporins Vs Vancomycin-Gentamicin were compared. RESULTS: A population of 464 patients was analyzed, 163 received cephalosporin prophylaxis (Cef) and 301 Vancomycin - Gentamicin (Van - Gen) prophylaxis. The three most frequently performed procedures were aortic valve replacement (40.1%), mitral valve (22.2%) and Bentall's surgery (11.6%). The cumulative annual incidence of mediastinitis was 4.76 and 1.57 in 2012 and 2013 respectively, being higher in the group of Cef. The risk of occurrence of mediastinitis with Van-Gen was lower compared to the use of cephalosporins (RR 0.25 IC 0.08-0.79) adjusted for age and gender. The main isolated germ was Staphylococcus Aureus MS (29.4%). CONCLUSIONS: The incidence of mediastinitis in patients undergoing cardiac surgery with prothesis implantation, was lower in the group receiving antibiotic prophylaxis with Van-Gen compared to Cef.

Objective: to study the results of treatment in patients with descending necrotizing mediastinitis, depending on the etiology and spread of suppuration. Materials and methods. 137 patients with deep neck phlegmons have been included. Descending necrotizing media­stinitis was diagnosed in 67 (48.9 %) of them. Results. In most cases, suppuration in the mediastinum arose from odontogenic neck phlegmons (34 patients, or 50.8 %). In 17 (25.4 %) cases of perforation of cervical esophagus and hypopharynx, pus extended downward into the posterior mediastinum. Paratonsillar and retropharyngeal abscesses were complicated by descending necrotizing mediastinitis in 13 (19.4 %) patients, and in 10 cases pus spread into the posterior mediastinum. In 56 (82 %) of the 67 observations, mediastinitis limited to the upper parts, and it was the same lesion of anterior-upper (27 persons, or 40.3 %) and posterior-upper (28, or 41.7 %) mediastinum. Spread to the inferior mediastinum was found in 7 (10.5 %) patients. Synchronous suppuration in the anterior-upper and posterior-upper parts of mediastinum was observed in 5 (7.5 %) cases. Surgical debridement of deep neck phlegmons has been always finished with the revision of the mediastinum through cervicomediastinotomy. During the surgery, a target search for directions of pus spread was performed according to their origin. Conclusions. Among the descending necrotizing mediastinitis, odontogenic neck phlegmons are the most common — a half of the cases (34 patients, or 50.8 %). Perforations of cervical esophagus are observed in 25.4 % of cases of descending necrotizing mediastinitis, and paratonsillar abscesses — in 19.4 %. Incision and drainage of deep neck phlegmons would always include a target revision of suppurations in the mediastinum, depending on their origin., Цель исследования: изучить результаты лечения пациентов с острыми нисходящими медиастинитами в зависимости от этиологии и распространения нагноения. Материалы и методы. Исследованием было охвачено 137 больных с глубокими флегмонами шеи, среди которых острый нисходящий медиастинит был установлен у 67 (48,9 %). Результаты. Частой причиной нагноений в средостении были одонтогенные флегмоны шеи (34 пациента, или 50,8 %). При перфорациях шейного отдела пищевода и гортаноглотки гнойные затеки образовывались в задних отделах средостения (17 случаев, или 25,4 %). Для нагноений в медиастинуме на фоне паратонзиллярных и ретрофарингеальных абсцессов (13 наблюдений, или 19,4 %) было характерно распространение чаще в задние (10 из 13), чем в передние (3 из 13) медиастинальные отделы. Если говорить о путях распространения в средостении, то в 56 (82 %) из 67 наблюдений медиастинит ограничился верхними его этажами и почти одинаково поразил как передневерхний (27, или 40,3 %), так и задневерхний (28, или 41,7 %) отделы. Опускание в нижнее средостение было обнаружено у 7 (10,5 %) больных. Одновременное нагноение в передне- и задневерхнем этажах медиастинума наблюдалось у 5 (7,5 %) пациентов. Вскрытие флегмон шеи всегда завершалось ревизией средостения через цервикомедиастинотомии. В ходе вмешательств проводился целенаправленный поиск заплывов по вероятным направлениям распространения нагноения в зависимости от их происхождения. Выводы. Острые нисходящие медиастиниты одонтогенного происхождения встречаются чаще всего в половине наблюдений (50,8 %), вдвое реже развиваются нагноения в средостении на фоне перфораций шейного отдела пищевода (25,4 %) и тонзилогенных абсцессов (19,4 %). Вскрытие и дренирование глубокой флегмоны шеи должно всегда включать целенаправленную ревизию гнойных затеков в медиастинум в зависимости от причинного ее фактора., Мета дослідження. Вивчити результати лікування пацієнтів з гострими низхідними медіастинітами залежно від етіології і поширення нагноєнь. Матеріали та методи. Дослідженням було охоплено 137 хворих з глибокими флегмонами шиї, серед яких гострий низхідний медіастиніт був встановлений у 67 (48,9 %). Результати. Найчастішою причиною нагноєнь в середостінні були одонтогенні флегмони шиї (34 пацієнти, або 50,8 %). При перфораціях шийного відділу стравоходу і гортаноглотки гнійні запливи утворювалися у задніх відділах середостіння (17 випадків, або 25,4 %). Для нагноєнь в медіастинумі на фоні паратонзилярних і ретрофарингеальних абсцесів (13 спостережень, або 19,4 %) було характерне поширення частіше в задні (10 з 13), ніж у передні (3 з 13) медіастинальні відділи. Щодо шляхів поширення в середостінні, то у 56 (82 %) із 67 спостережень медіастиніт обмежився верхніми його поверхами і майже однаково вразив як передньоверхній (27, або 40,3 %), так і задньоверхній (28, або 41,7 %) відділ. Опускання в нижнє середостіння було виявлено у 7 (10,5 %) хворих. Одночасне нагноєння в передньо- і задньоверхньому поверхах медіастинума виявлялося у 5 (7,5 %) пацієнтів. Розкриття флегмон шиї завжди завершувалося ревізією середостіння через цервікомедіастинотомії. Під час втручань проводився цілеспрямований пошук запливів по ймовірних напрямках поширення нагноєнь залежно від їх походження. Висновки. Гострі низхідні медіастиніти одонтогенного походження зустрічаються найчастіше — в половині спостережень (50,8 %), вдвічі рідше розвиваються нагноєння в середостінні на фоні перфорацій шийного відділу стравоходу (25,4 %) і тонзилогенних абсцесів (19,4 %). Розкриття і дренування глибокої флегмони шиї повинні завжди включати цілеспрямовану ревізію гнійних запливів у медіастинум залежно від причинного її фактора.

Background and Aims: Endobronchial Ultrasound Transbronchial Needle Aspiration (EBUS TBNA) is established as a minimally invasive way to sample intrathoracic abnormalities. The EBUS scope may be passed into the oesophagus to perform Endodoscopic UltraSound with Bronchoscope-guided Fine Needle Aspiration (EUS-B-FNA). In the setting of suspected lung cancer, the combination of the two techniques is now recommended by consensus guidelines. EBUS TBNA is usually performed by pulmonologists, however, the learning curve for EUS-B-FNA, which may be performed during the same procedure, has not been described. Method(s): Multicentre, observational Australian study using prospec-tively collected data from three experienced pulmonologists. Cumulative sum (cusum) analysis was used to generate visual learning curves. Result(s): 152 target lesions were sampled in 137 patients, with an overall sensitivity for malignancy of 94.8%. The sensitivity for malignant lesions outside the 2009 International Association for the Study of Lung Cancer lymph node map (largely intraparenchymal lesions) was 92.9%. All three operators were competent by conventional cusum criteria. There was one pneumothorax and no episodes of mediastinitis or oesophageal perforation. Conclusion(s): Our data suggest experienced pulmonologists can safely and accurately perform EUS-B-FNA, with high diagnostic sensitivity for both lymph node and non-nodal lesions.

ABSTRAKT Bakgrund: Mediastinit är en allvarlig komplikation efter öppen hjärtkirurgi. Syftet med post- thorax västen är att förebygga och förhindra mediastinit genom att stötta upp instabilitet och minska friktion i sternum efter operation. Uttalade osäkerheter och brister i erfarenheter av att jobba med västen väckte författarnas intresse för att intervjua intensivvårdssjuksköterskor och sjuksköterskor om deras erfarenheter med att arbeta med post-thorax västen. Syfte: Syftet med studien var att belysa sjuksköterskors erfarenheter av att vårda patienter som bar Post-thorax väst. Design: En kvalitativ intervjustudie Metod: Semistrukturerade intervjuer av 14 stycken grundutbildade och intensivvårdsutbildade sjuksköterskor som arbetade vid två enheter på ett sjukhus i Norra Sverige och hade mer än 6 månaders erfarenhet av att arbeta med västen. Intervjuerna analyserades genom en kvalitativ innehållsanalys. Resultat: Sjuksköterskors erfarenheter av att vårda patienter som burit Post-thorax väst resulterade i 4 kategorier och 13 subkategorier. Följande kategorier finns representerade: Ambivanlens, Säkerhet, Svårigheter, Motivation. Konklusion: Resultatet i studien visade att deltagarna hade varierande erfarenheter av att arbeta med patienter som bär väst. Deltagare utryckte svårigheter och fördelar med västen samt sin egen osäkerhet kring den. Deltagare ville ha utbildning och en utvärdering av västen och de beskrev motivationsarbetet och varför det är viktigt. Deltagarnas erfarenheter av patienternas upplevelser var något som genomsyrade alla kategorier. Resultatet kan tala för att implementeringen av västen på berörda enheter inte genomförts på ett optimalt sätt., Background: Mediastinitis is an infection in the mediastinum which can be a serious complication after open heart surgery. The purpose of the Post-thorax vest is to prevent mediastinitis by providing the required support to and minimize any friction within the sternum after heart surgery. There are outspoken uncertainties and gaps in the experience of working with the vest which aroused the interest of the authors to interview nurses and intensive care nurses about their experiences of working with the Post-thorax vest. Aim: The aim of this study was to investigate nurses’ experiences of working with patients who wear a Post-thorax vest. Design: A qualitative interview study Method: Semi-structured qualitative interview study of 14 nurses and intensive care nurses who worked at two units in the north of Sweden who had at least 6 months of experience working with the vest. The interviews were analyzed using content analysis. Results: Nurses’ experiences of working with patients who wore Post-thorax vests resulted in 4 categories and 13 sub-categories. The following categories are represented: Ambivalence, Security, Difficulties, Motivation. Conclusion: The result of the study showed that the participants had various experiences of working with patients wearing the vest. Participants expressed difficulties and benefits of the vest, and their own uncertainty about it. Participants wanted education and an evaluation of the vest and they described why motivational work was important. The participants described patients' experiences of the vest in almost every category. The result may indicate that the implementation of the vest at the units in question where not completed in an optimal way.

ABSTRAKT Bakgrund: Mediastinit är en allvarlig komplikation efter öppen hjärtkirurgi. Syftet med post- thorax västen är att förebygga och förhindra mediastinit genom att stötta upp instabilitet och minska friktion i sternum efter operation. Uttalade osäkerheter och brister i erfarenheter av att jobba med västen väckte författarnas intresse för att intervjua intensivvårdssjuksköterskor och sjuksköterskor om deras erfarenheter med att arbeta med post-thorax västen. Syfte: Syftet med studien var att belysa sjuksköterskors erfarenheter av att vårda patienter som bar Post-thorax väst. Design: En kvalitativ intervjustudie Metod: Semistrukturerade intervjuer av 14 stycken grundutbildade och intensivvårdsutbildade sjuksköterskor som arbetade vid två enheter på ett sjukhus i Norra Sverige och hade mer än 6 månaders erfarenhet av att arbeta med västen. Intervjuerna analyserades genom en kvalitativ innehållsanalys. Resultat: Sjuksköterskors erfarenheter av att vårda patienter som burit Post-thorax väst resulterade i 4 kategorier och 13 subkategorier. Följande kategorier finns representerade: Ambivanlens, Säkerhet, Svårigheter, Motivation. Konklusion: Resultatet i studien visade att deltagarna hade varierande erfarenheter av att arbeta med patienter som bär väst. Deltagare utryckte svårigheter och fördelar med västen samt sin egen osäkerhet kring den. Deltagare ville ha utbildning och en utvärdering av västen och de beskrev motivationsarbetet och varför det är viktigt. Deltagarnas erfarenheter av patienternas upplevelser var något som genomsyrade alla kategorier. Resultatet kan tala för att implementeringen av västen på berörda enheter inte genomförts på ett optimalt sätt., Background: Mediastinitis is an infection in the mediastinum which can be a serious complication after open heart surgery. The purpose of the Post-thorax vest is to prevent mediastinitis by providing the required support to and minimize any friction within the sternum after heart surgery. There are outspoken uncertainties and gaps in the experience of working with the vest which aroused the interest of the authors to interview nurses and intensive care nurses about their experiences of working with the Post-thorax vest. Aim: The aim of this study was to investigate nurses’ experiences of working with patients who wear a Post-thorax vest. Design: A qualitative interview study Method: Semi-structured qualitative interview study of 14 nurses and intensive care nurses who worked at two units in the north of Sweden who had at least 6 months of experience working with the vest. The interviews were analyzed using content analysis. Results: Nurses’ experiences of working with patients who wore Post-thorax vests resulted in 4 categories and 13 sub-categories. The following categories are represented: Ambivalence, Security, Difficulties, Motivation. Conclusion: The result of the study showed that the participants had various experiences of working with patients wearing the vest. Participants expressed difficulties and benefits of the vest, and their own uncertainty about it. Participants wanted education and an evaluation of the vest and they described why motivational work was important. The participants described patients' experiences of the vest in almost every category. The result may indicate that the implementation of the vest at the units in question where not completed in an optimal way.

An 80-year-old woman from Iran presented to our institution for evaluation of insidious onset of dyspnea and progressive hypoxemia. She had a history of hypertension, COPD attributed to secondhand smoke, and an unprovoked pulmonary embolus that was treated with lifelong anticoagulation. In addition, she had a history of latent TB status posttreatment with isoniazid 10 years prior. One year ago, home oxygen therapy was started at 4 L/min via nasal cannula, and because of her decline, her son had brought her to the United States 3 months earlier for medical help. After a contrast-enhanced thoracic CT scan followed by a nondiagnostic thoracentesis, another hospital informed her that she likely had inoperable lung cancer. She presented to our institution for a second opinion.

An 80-year-old woman from Iran presented to our institution for evaluation of insidious onset of dyspnea and progressive hypoxemia. She had a history of hypertension, COPD attributed to secondhand smoke, and an unprovoked pulmonary embolus that was treated with lifelong anticoagulation. In addition, she had a history of latent TB status posttreatment with isoniazid 10 years prior. One year ago, home oxygen therapy was started at 4 L/min via nasal cannula, and because of her decline, her son had brought her to the United States 3 months earlier for medical help. After a contrast-enhanced thoracic CT scan followed by a nondiagnostic thoracentesis, another hospital informed her that she likely had inoperable lung cancer. She presented to our institution for a second opinion.

Bakgrund: I sjuksköterskans ansvarsområde ingår det att använda omvårdnadsåtgärder för att förebygga komplikationer efter operation. På thoraxkirurgiska vårdavdelningar skiljer sig rutinerna vid postoperativ vård och på vissa avdelningar används Posthorax-västen för att förhindra instabilitet i sternum efter sternotomi. Syfte: Syftet var att undersöka vilka postoperativa omvårdnadsåtgärder sjuksköterskor använder sig av på sternotomerade patienter för att förebygga mediastinit samt hur sjuksköterskor upplever att omvårdnadsåtgärderna påverkar patienterna. Metod: Data samlades in via en enkätundersökning på tre thoraxkirurgiska vårdavdelningar på tre olika sjukhus i Sverige. Resultat: Enkätundersökningen lyfte fram vilka omvårdnadsåtgärder som vanligtvis används på olika avdelningar, vilka omvårdnadsåtgärder som sjuksköterskor ansåg var viktigast samt faktorer som sjuksköterskor uppger främjar och hämmar omvårdnadsåtgärder. Slutsats: Sjuksköterskor uppgav att den viktigaste postoperativa omvårdnadsåtgärden efter sternotomi var Mobiliseringsrestriktioner. De största hindren var postoperativ förvirring, smärta och illamående samt organisatoriska faktorer som hög arbetsbelastning, stress och bristande rutiner. Klinisk betydelse: Denna studie har visat på behovet av vidare forskning genom att ha lyft fram vilka postoperativa omvårdnadsåtgärder som sjuksköterskor uppger att de använder i klinisk praxis på thoraxkirurgiska vårdavdelningar., Background: Nurses have a responsibility to use nursing interventions to prevent complications after surgery. There is a difference in which procedures are used in thoracic surgical wards for postoperative prevention and some hospitals use the Posthorax vest to prevent sternal instability. Aims: The aim of this study was to investigate nursing interventions used to prevent mediastinitis on patients who have undergone sternotomy and how nursing interventions affect patients according to nurses. Methods: A survey was used to procure data from three different thoracic surgical wards in hospitals in Sweden. Results: The survey has shown the most commonly used nursing interventions in different thoracic surgical wards and what nursing interventions nurses’ state are most important. The survey also found promoting and inhibiting factors for nursing interventions according to nurses. Conclusion: According to nurses the most important nursing intervention was restricting the use of upper body extremities. The most inhibiting factors for nursing interventions were postoperative confusion, pain, nausea and organizational factors as high workload, stress and inadequate procedures. Clinical implications: This study has shown the need for further research by determining the postoperative nursing interventions used in clinical practice in thoracic surgical wards.

Chest pain is for the physician, an immediate challenge. This symptom is usually a benign etiology, but sometimes may portend an imminent catastrophe. Medical texts tend always to emphasize the high-risk nature with regard to this and its association with life-threatening etiologies, which can be a disabling or fatal nature and require an effective approach for diagnosis (1-2 ). The clinical history becomes a vital element for making a correct diagnosis through adequate description of (characteristics, intensity, location, duration, and triggers pain mitigating factors, associated symptoms, and in some cases the factors risk of some diseases) that rely on specific physical findings. Importantly, the prevalence of the etiologies of chest pain varies depending on the studied population (3). Studies in patients treated in emergency departments as presented interesting data: 60% of diagnoses of chest pain are not “organic” origin (not due to heart disease, gastrointestinal or pulmonary disease), chest pain cause skeletal muscle constitutes 36% of all diagnoses, followed by reflux esophagitis 13% and finally stable angina pectoris is responsible for 11% of episodes of chest pain, unstable angina or acute myocardial infarction presented at 1.5%. Among the causes of chest pain are also those arising in the mediastinum although they are rare; these are associated with signs and symptoms according to the involvement of different compromised or surrounding structures (4). The mediastinitis is an inflammation or infection of connective tissue surrounding mediastinal structures., El dolor torácico representa para el médico, un reto inmediato. Este síntoma suele ser de etiología benigna, pero algunas veces puede augurar una catástrofe inminente. Los textos de medicina siempre suelen hacer hincapié en la naturaleza de alto riesgo en lo referente a este y su asociación con etiologías que amenazan la vida, las cuales pueden tener un carácter incapacitante o mortal y requieren un enfoque eficaz para el diagnóstico (1-2). La historia clínica se convierte en un elemento de vital importancia para la realización de un diagnóstico correcto a través de la adecuada descripción de (características, intensidad, localización, duración, factores atenuantes y desencadenantes del dolor, síntomas asociados, y en algunos casos los factores de riesgo de algunas enfermedades) que se apoyan en hallazgos físicos específicos. Es importante destacar que la prevalencia de las etiologías del dolor torácico varía en función de la población estudiada (3). En estudios realizados en pacientes atendidos en los servicios de urgencias se presentan datos interesantes como: el 60% de diagnósticos de dolor torácico no son de origen “orgánico” (no se debían a patologías cardíacas, gastrointestinales, o enfermedad pulmonar), el dolor torácico de causa músculo esquelética constituye el 36% de todos los diagnósticos, seguido de la esofagitis por reflujo 13% y finalmente la angina de pecho estable es responsable del 11% de los episodios de dolor de pecho, la angina inestable o infarto agudo de miocardio se presentaron en el 1,5 %. Dentro de las causas de dolor torácico también se encuentran las originadas en el mediastino a pesar que son poco frecuentes; estas se asocian con signos y síntomas según la implicación de diferentes estructuras comprometidas o circundantes (4). La mediastinitis se define como la inflamación o la infección del tejido conectivo que rodea a las estructuras mediastínicas.

Bakgrund: I sjuksköterskans ansvarsområde ingår det att använda omvårdnadsåtgärder för att förebygga komplikationer efter operation. På thoraxkirurgiska vårdavdelningar skiljer sig rutinerna vid postoperativ vård och på vissa avdelningar används Posthorax-västen för att förhindra instabilitet i sternum efter sternotomi. Syfte: Syftet var att undersöka vilka postoperativa omvårdnadsåtgärder sjuksköterskor använder sig av på sternotomerade patienter för att förebygga mediastinit samt hur sjuksköterskor upplever att omvårdnadsåtgärderna påverkar patienterna. Metod: Data samlades in via en enkätundersökning på tre thoraxkirurgiska vårdavdelningar på tre olika sjukhus i Sverige. Resultat: Enkätundersökningen lyfte fram vilka omvårdnadsåtgärder som vanligtvis används på olika avdelningar, vilka omvårdnadsåtgärder som sjuksköterskor ansåg var viktigast samt faktorer som sjuksköterskor uppger främjar och hämmar omvårdnadsåtgärder. Slutsats: Sjuksköterskor uppgav att den viktigaste postoperativa omvårdnadsåtgärden efter sternotomi var Mobiliseringsrestriktioner. De största hindren var postoperativ förvirring, smärta och illamående samt organisatoriska faktorer som hög arbetsbelastning, stress och bristande rutiner. Klinisk betydelse: Denna studie har visat på behovet av vidare forskning genom att ha lyft fram vilka postoperativa omvårdnadsåtgärder som sjuksköterskor uppger att de använder i klinisk praxis på thoraxkirurgiska vårdavdelningar., Background: Nurses have a responsibility to use nursing interventions to prevent complications after surgery. There is a difference in which procedures are used in thoracic surgical wards for postoperative prevention and some hospitals use the Posthorax vest to prevent sternal instability. Aims: The aim of this study was to investigate nursing interventions used to prevent mediastinitis on patients who have undergone sternotomy and how nursing interventions affect patients according to nurses. Methods: A survey was used to procure data from three different thoracic surgical wards in hospitals in Sweden. Results: The survey has shown the most commonly used nursing interventions in different thoracic surgical wards and what nursing interventions nurses’ state are most important. The survey also found promoting and inhibiting factors for nursing interventions according to nurses. Conclusion: According to nurses the most important nursing intervention was restricting the use of upper body extremities. The most inhibiting factors for nursing interventions were postoperative confusion, pain, nausea and organizational factors as high workload, stress and inadequate procedures. Clinical implications: This study has shown the need for further research by determining the postoperative nursing interventions used in clinical practice in thoracic surgical wards.

BackgroundMost surgical specialties working with bone have transitioned from wire fixation to more stable plate and screw fixation. Rigid plate fixation results in more rapid bony healing with decreased rates of nonunion, malunion, and infection. Despite sternotomies being the most frequently performed osteotomy, cerclage wire fixation remains the standard technique of closure. This study reviews our 5-year experience with rigid fixation at the University of California Davis Medical Center.Materials and methodsA retrospective review of patients who underwent rigid sternal fixation between January 2006 and December 2012 at UC Davis Medical Center was performed. Demographic factors, indications for surgery, and risk factors for postoperative complications including mediastinitis and nonunion were reviewed. The type of fixation system was recorded. Outcomes assessed included dehiscence, deep and superficial infections, sternal instability, and need for reoperation.ResultsFifty-seven rigid sternal fixations were performed (M/F, 37:20; average age, 54 years; range, 16-79 years). Indications for operation included prophylaxis against mediastinitis (61.4%), sternal nonunion (24.6%), sternal fractures (7.0%), and pectus deformities (7.0%). Of the rigid fixation systems used, 87.3% used SternaLock, 12.7% used Talon, 1.8% Lactosorb, and 1.8% Flexigrip. Thirty-five patients were plated for prophylaxis against mediastinitis. In the prophylactic group, the average number of risk factors per patient was 3.92, indicating very high-risk patients. Fourteen patients were plated for sternal nonunion. The average number of risk factors in the nonunion group was 1.57. Other less common indications for rigid sternal stabilization included sternal fracture (4 patients) and pectus deformity (4 patients). Eight patients had a pectoralis flaps performed at the time of their sternal fixation, 7 for soft tissue coverage of plates and 1 for coverage of a contaminated wound bed. All patients wen

Deep sternal wound infections (DSWI) are infections of the sternum, mediastinum, or the muscle, fascia and soft tissue that overlie the sternum, typically occurring within a month of cardiac surgery. They are infrequent though severe complications of cardiac surgery. Diagnosis is made by the clinical presentation of fever, chest pain, or sternal instability in the setting of wound drainage, positive wound cultures, or chest radiographic findings. We describe the case of an elderly man presenting 6 months after cardiac surgery with DSWI. Due to the atypical nature of such a late presentation, definitive therapy was delayed. Given a severely ill patient with multiple risk factors for poor wound healing, the clinician must maintain a high index of suspicion for DSWI despite a delayed presentation. [West J Emerg Med. 2014;15(2):134–136.]

Negative pressure wound therapy is a concept introduced initially to assist in the treatment of chronic open wounds. Recently, there has been growing interest in using the technique on closed incisions after surgery to prevent potentially severe surgical site infections and other wound complications in high-risk patients. Negative pressure wound therapy uses a negative pressure unit and specific dressings that help to hold the incision edges together, redistribute lateral tension, reduce edema, stimulate perfusion, and protect the surgical site from external infectious sources. Randomized, controlled studies of negative pressure wound therapy for closed incisions in orthopedic settings (which also is a clean surgical procedure in absence of an open fracture) have shown the technology can reduce the risk of wound infection, wound dehiscence, and seroma, and there is accumulating evidence that it also improves wound outcomes after cardiothoracic surgery. Identifying at-risk individuals for whom prophylactic use of negative pressure wound therapy would be most cost-effective remains a challenge; however, several risk-stratification systems have been proposed and should be evaluated more fully. The recent availability of a single-use, closed incision management system offers surgeons a convenient and practical means of delivering negative pressure wound therapy to their high-risk patients, with excellent wound outcomes reported to date. Although larger, randomized, controlled studies will help to clarify the precise role and benefits of such a system in cardiothoracic surgery, limited initial evidence from clinical studies and from the authors’ own experiences appears promising. In light of the growing interest in this technology among cardiothoracic surgeons, a consensus meeting, which was attended by a group of international experts, was held to review existing evidence for negative pressure wound therapy in the prevention of wound complications after surgery and to p

Deep sternal wound infections (DSWI) are infections of the sternum, mediastinum, or the muscle, fascia and soft tissue that overlie the sternum, typically occurring within a month of cardiac surgery. They are infrequent though severe complications of cardiac surgery. Diagnosis is made by the clinical presentation of fever, chest pain, or sternal instability in the setting of wound drainage, positive wound cultures, or chest radiographic findings. We describe the case of an elderly man presenting 6 months after cardiac surgery with DSWI. Due to the atypical nature of such a late presentation, definitive therapy was delayed. Given a severely ill patient with multiple risk factors for poor wound healing, the clinician must maintain a high index of suspicion for DSWI despite a delayed presentation. [West J Emerg Med. 2014;15(2):134–136.]

BackgroundMost surgical specialties working with bone have transitioned from wire fixation to more stable plate and screw fixation. Rigid plate fixation results in more rapid bony healing with decreased rates of nonunion, malunion, and infection. Despite sternotomies being the most frequently performed osteotomy, cerclage wire fixation remains the standard technique of closure. This study reviews our 5-year experience with rigid fixation at the University of California Davis Medical Center.Materials and methodsA retrospective review of patients who underwent rigid sternal fixation between January 2006 and December 2012 at UC Davis Medical Center was performed. Demographic factors, indications for surgery, and risk factors for postoperative complications including mediastinitis and nonunion were reviewed. The type of fixation system was recorded. Outcomes assessed included dehiscence, deep and superficial infections, sternal instability, and need for reoperation.ResultsFifty-seven rigid sternal fixations were performed (M/F, 37:20; average age, 54 years; range, 16-79 years). Indications for operation included prophylaxis against mediastinitis (61.4%), sternal nonunion (24.6%), sternal fractures (7.0%), and pectus deformities (7.0%). Of the rigid fixation systems used, 87.3% used SternaLock, 12.7% used Talon, 1.8% Lactosorb, and 1.8% Flexigrip. Thirty-five patients were plated for prophylaxis against mediastinitis. In the prophylactic group, the average number of risk factors per patient was 3.92, indicating very high-risk patients. Fourteen patients were plated for sternal nonunion. The average number of risk factors in the nonunion group was 1.57. Other less common indications for rigid sternal stabilization included sternal fracture (4 patients) and pectus deformity (4 patients). Eight patients had a pectoralis flaps performed at the time of their sternal fixation, 7 for soft tissue coverage of plates and 1 for coverage of a contaminated wound bed. All patients wen

Background Although the utility of flaps for the treatment of sternal wound infections following median sternotomy has been reported for 30 years, there have been few reports on the risk factors for complications after reconstruction. The objective of this investigation was to identify factors related to complications after the reconstruction of sternal wound infections. Methods A retrospective analysis of 74 patients with reconstructive surgery after sternal wound infection over a 5-year period was performed. Clinical data including age, sex, body mass index (BMI), comorbidities, bacterial culture, previous cardiac surgery, wound depth, mortality rate, type of reconstructive procedure, and complication rate were collected. Results The patients' BMI ranged from 15.2 to 33.6 kg/m2 (mean, 23.1±3.74 kg/m2). Wound closure complications after reconstructive surgery were observed in 36.5% of the cases. The mortality rate was 2.7%. Diabetes mellitus significantly affected the rate of wound closure complications (P=0.041). A significant difference in the number of complications was seen between Staphylococcus aureus (S. aureus) and coagulase-negative Staphylococci (P=0.011). There was a correlation between harvesting of the internal thoracic artery and postoperative complications (P=0.048). The complication rates of the pectoralis major flap, rectus abdominis flap, omentum flap, a combination of pectoralis major flap and rectus abdominis flap, and direct closure were 23.3%, 33.3%, 100%, 37.5%, and 35.7%, respectively. Conclusions Diabetes mellitus, S. aureus, harvesting of the internal thoracic artery, and omentum flap were significant factors for complications after reconstruction. The omentum flap volume may be related to the complications associated with the omentum flap transfer in the present study.

to report a clinical case with diagnosis of a descending necrotizing mediastinitis of dental origin given its low incidence and high mortality, which was managed with an aggressive cervical drainage through thoracoscopy. Clinical Case: a case of a patient which develops mediastinitis of dental origin whom it is diagnosed in an early manner, and treated with open cervicofacial drainage and a bilateral thoracoscopy Discussion: descending necrotizing mediastinitis is a disease with a low incidence percentage but with a high mortality rate. Its medical treatment should be successful only if an early diagnosis is made and a correct drainage is performed. The gold standard in its management resides in cervicofacial drainage plus mediastinal drainage though thoracotomy. Conclusion: to improve the survival rate of patients suffering descending necrotizing mediastinitis, an early suspicion is required to perform an early diagnosis. In selected cases, mediastinal drainage can be made through thoracoscopy technique to improve the initial response in the immediate postsurgical time. (MÉD.UIS. 2012;25(1):71-4), Objetivo: reportar un caso clínico de mediastinitis necrotizante descendente de origen odontogénico dada su baja incidencia y alta mortalidad asociada, el cual fue manejado con un drenaje cervical y mediastinal mediante toracoscopia. Caso clínico: se describe el caso de un paciente que desarrolla mediastinitis de origen odontogénico diagnosticado de manera oportuna y tratado multidisciplinariamente de manera temprana mediante drenaje cervicofacial abierto y toracoscopia bilateral. Discusión: la mediastinitis necrotizante descendente es una enfermedad con una baja incidencia pero con una alta mortalidad, cuyo manejo médico no es exitoso si no se realiza un diagnóstico temprano y un drenaje adecuado. El estándar de oro en cuanto al manejo es el drenaje cervicofacial más drenaje mediastínico por toracotomía. Conclusiones: con la finalidad de mejorar la sobrevida de los pacientes con mediastinitis necrotizante descendente es necesario un alto índice de sospecha para un diagnóstico temprano. En casos seleccionados el drenaje mediastinal puede realizarse por toracoscopia, siendo el marcador pronóstico favorable la respuesta inicial del paciente en el posquirúrgico inmediato. (MÉD.UIS. 2012;25(1):71-4).

to report a clinical case with diagnosis of a descending necrotizing mediastinitis of dental origin given its low incidence and high mortality, which was managed with an aggressive cervical drainage through thoracoscopy. Clinical Case: a case of a patient which develops mediastinitis of dental origin whom it is diagnosed in an early manner, and treated with open cervicofacial drainage and a bilateral thoracoscopy Discussion: descending necrotizing mediastinitis is a disease with a low incidence percentage but with a high mortality rate. Its medical treatment should be successful only if an early diagnosis is made and a correct drainage is performed. The gold standard in its management resides in cervicofacial drainage plus mediastinal drainage though thoracotomy. Conclusion: to improve the survival rate of patients suffering descending necrotizing mediastinitis, an early suspicion is required to perform an early diagnosis. In selected cases, mediastinal drainage can be made through thoracoscopy technique to improve the initial response in the immediate postsurgical time. (MÉD.UIS. 2012;25(1):71-4), Objetivo: reportar un caso clínico de mediastinitis necrotizante descendente de origen odontogénico dada su baja incidencia y alta mortalidad asociada, el cual fue manejado con un drenaje cervical y mediastinal mediante toracoscopia. Caso clínico: se describe el caso de un paciente que desarrolla mediastinitis de origen odontogénico diagnosticado de manera oportuna y tratado multidisciplinariamente de manera temprana mediante drenaje cervicofacial abierto y toracoscopia bilateral. Discusión: la mediastinitis necrotizante descendente es una enfermedad con una baja incidencia pero con una alta mortalidad, cuyo manejo médico no es exitoso si no se realiza un diagnóstico temprano y un drenaje adecuado. El estándar de oro en cuanto al manejo es el drenaje cervicofacial más drenaje mediastínico por toracotomía. Conclusiones: con la finalidad de mejorar la sobrevida de los pacientes con mediastinitis necrotizante descendente es necesario un alto índice de sospecha para un diagnóstico temprano. En casos seleccionados el drenaje mediastinal puede realizarse por toracoscopia, siendo el marcador pronóstico favorable la respuesta inicial del paciente en el posquirúrgico inmediato. (MÉD.UIS. 2012;25(1):71-4).

Negative pressure wound therapy (NPWT) has been widely adopted for the treatment of deep sternal wound infections due to its excellent clinical outcome. However, the mechanisms of action and effects on hemodynamics have not been thoroughly elucidated. The aims of the work presented in this thesis were, therefore, to examine the effects of NPWT on sternotomy wounds and on the intrathoracic organs. An uninfected porcine sternotomy wound model was used in all studies. The studies showed that negative pressure is transmitted only to tissues that are in direct contact with the foam dressing and not to deeper parts of the wound or thoracic cavity. As NPWT was applied, a transient increase was seen in the plasma levels of norepinephrine and epinephrine, followed by an increase in the adrenergic co-transmitter neuropeptide Y, which may reflect the effect of NPWT on the intrathoracic organs. Increased levels of the sensory nerve transmitter substance P may result from shearing forces arising from the mechanical effects of the negative pressure. Magnetic resonance imaging showed that cardiac output increased while the cardiac pumping efficiency decreased following sternotomy, and then returned to presternotomy values when the negative pressure resealed the thorax. NPWT contracts the wound and causes macrodeformation of the wound edge tissue. This may contribute to the clinical benefits of NPWT over open-chest treatment, including the stabilizing effect and reduced need for mechanical ventilation. The results of the present work underline the importance of correct placement of the wound filler with regard to pressure transmission. The findings also reduce concerns that NPWT could impair cardiac output, and emphasize the beneficial effects of temporary closure provided by NPWT on restoring the intrathoracic anatomy.

The name of Tapia's Syndrome is given to ipsilateral paralysis of a vocal chord and the corresponding side of the tongue from extracranial affectation of the pneumogastric (X) and hypoglossal (XII) nerves. In the few published cases, traumatic and compressive mechanisms are the most frequent triggers. We present a patient who, following right thoracotomy, showed unilateral hypoglossal-vagal paralysis. It is possible that etiopathogeneis might be found in the effect of the traction on and stretching of these nerves from the mediastinum., La parálisis ipsolateral de la cuerda vocal y de la hemilengua correspondiente, por afectación extracraneal de los nervios neumogástrico (X) e hipogloso (XII), recibe el nombre de síndrome de Tapia. En los pocos casos publicados, el mecanismo traumático y el compresivo son los desencadenantes más frecuentes. Presentamos a un paciente que, tras toracotomía derecha, manifestó una parálisis hipogloso-vagal del mismo lado. La explicación etiopatogénica podría encontrarse en el efecto de la tracción y estiramiento de estos nervios desde el mediastino.

The name of Tapia's Syndrome is given to ipsilateral paralysis of a vocal chord and the corresponding side of the tongue from extracranial affectation of the pneumogastric (X) and hypoglossal (XII) nerves. In the few published cases, traumatic and compressive mechanisms are the most frequent triggers. We present a patient who, following right thoracotomy, showed unilateral hypoglossal-vagal paralysis. It is possible that etiopathogeneis might be found in the effect of the traction on and stretching of these nerves from the mediastinum., La parálisis ipsolateral de la cuerda vocal y de la hemilengua correspondiente, por afectación extracraneal de los nervios neumogástrico (X) e hipogloso (XII), recibe el nombre de síndrome de Tapia. En los pocos casos publicados, el mecanismo traumático y el compresivo son los desencadenantes más frecuentes. Presentamos a un paciente que, tras toracotomía derecha, manifestó una parálisis hipogloso-vagal del mismo lado. La explicación etiopatogénica podría encontrarse en el efecto de la tracción y estiramiento de estos nervios desde el mediastino.

Anaerobic mediastinitis after cardiac surgery is a rare and poorly understood condition. We observed a patient with diabetes and myelodysplastic syndrome who developed Bacteroides fragilis mediastinitis in conjunction with a prostatic abscess, several days after coronary artery bypass surgery; this hitherto unpublished observation suggests that suppurative infection of the genito-urinary tract may constitute a portal of entry for postoperative anaerobic mediastinitis in predisposed patients. Keywords: Coronary artery bypass grafts; Mediastinal infection; Complication; Infection; Comorbidity.

To determine the early and long-term morbidity of patients treated with a total laryngopharyngectomy and reconstruction using a jejunum interposition or gastric pull-up procedure. It is a retrospective study; and it is conducted in tertiairy referral center. Sixty-three patients were included in whom 70 reconstructions were performed (51 jejunum interpositions and 19 gastric pull-up procedures) between 1990 and 2007. The studied parameters were success rate of the reconstruction, early and long-term complication rate, and functional outcome including quality of life. Subjective quality of life analysis was determined by two questionnaires: the EORTC Quality of Life Questionnaire (QLQ)-C30 Dutch version 3.0, and the EORTC-Head and Neck (H & N 35). The success rates were 84 and 74%, respectively. The procedures were associated with a high complication rate (63% after jejunum interposition and 89% after gastric pull-up), and a lengthy rehabilitation. Surviving patients were found to have a good long-term quality of life. Complete oral intake was achieved in 97%, and speech rehabilitation in 95%. These procedures are associated with significant morbidity, high complication rates, lengthy rehabilitation, but a good long-term quality of life.

Early tracheostomy may increase the risk of mediastinitis after median sternotomy. Patients who had postoperative tracheostomy after cardiac surgery in the period 2000-2005 were retrospectively analyzed (total: 5095 patients) to evaluate the incidence of mediastinitis and sternal wound infections. Fifty-seven cases (1.1% of all operated patients) had postoperative tracheostomy at an average 5.6 +/- 0.7 days postoperatively. None of these patients had mediastinitis. Eleven cases of aseptic sternal instability and ten cases of mild-to-moderate infection limited to subcutaneous planes were observed. There was no correlation between the time to performance of tracheostomy and the isolation of bacteria from the thoracic wounds (p = 0.61). The bacterial strains isolated from subcutaneous infection were qualitatively and quantitatively different from those isolated from bronchial secretions. We conclude that in this study there is no demonstrable link between early tracheostomy after sternotomy and mediastinitis. Early tracheostomy should not be denied due to concerns of increasing the risk of mediastinitis.

OBJECTIVES: To evaluate a simple treatment algorithm in sternal wound infection (SWI) allowing for primary closure and to describe the different surgical techniques and their associated morbidity and mortality. METHODS: A retrospective analysis of all patients operated on between 1996 and 2004 in a single tertiary care institution. All epidemiological and surgical data were prospectively collected in our database. Univariate and multivariate analysis were used to determine preoperative and perioperative risks factors for 90-day and long-term mortality. RESULTS: Out of 5905 procedures, 146 sternal wound infections were documented (2.4%). The respective incidence of SWI for CABG, isolated valve, or combined procedures were 2.8%, 1.1%, and 3.2%. Pathogens involved were S. epidermidis (44.5%), S. aureus (31.5%), and gram-negative rods (19.2%). Re-operation was required in 131/146 patients. Mean time to the first re-operation was 17.3+/-12 days. Modalities of treatment consisted of drainage alone (44 patients), rewiring (25 patients), debridement, rewiring and mediastinal lavage (52 patients), and partial/complete sternal resection (10 patients). Additional procedures were required in 49 patients (37.7%). The 90-day mortality for uninfected patients and patients with superficial SWI were 4.4% and 2.8% (p=0.78) whereas for patients with deep SWI, 90-day mortality was 14.5% (DSWI vs others, p<0.0001). CONCLUSIONS: Deep sternal wound infection (DSWI) remains a dreadful complication in contemporary cardiac surgery while risk factors are currently well defined. Using a simple approach of primary closure together with liberal use of vascularized flaps has allowed us to achieve satisfactory short-term outcome in this subset of patients.

Several studies have suggested that mediastinitis is a strong predictor for poor long-term survival after coronary artery bypass surgery (CABG). In those studies, several conventional wound-healing techniques were used. Previously, we have shown no difference in long-term survival between CABG patients with topical negative pressure (TNP)-treated mediastinitis and CABG patients without mediastinitis. The present study was designed to elucidate if TNP, applied over the myocardium, resulted in an increase of the total amount of coronary blood flow. Six pigs underwent median sternotomy. The coronary blood flow was measured, before and after the application of TNP (-50 mmHg), using coronary electromagnetic flow meter probes. Analyses were performed before left anterior descending artery (LAD) occlusion (normal myocardium) and after 20 minutes of LAD occlusion (ischaemic myocardium). Normal myocardium: 171.3 +/- 14.5 ml/minute before to 206.3 +/- 17.6 ml/minute after TNP application, P <0.05. Ischaemic myocardium: 133.7 +/- 18.4 ml/minute before to 183.2 +/- 18.9 ml/minute after TNP application, P <0.05. TNP of -50 mmHg applied over the LAD region induced a significant increase in the total coronary blood flow in both normal and ischaemic myocardium.

Several studies have suggested that mediastinitis is a strong predictor for poor long-term survival after coronary artery bypass surgery (CABG). In those studies, several conventional wound-healing techniques were used. Previously, we have shown no difference in long-term survival between CABG patients with topical negative pressure (TNP)-treated mediastinitis and CABG patients without mediastinitis. The present study was designed to elucidate if TNP, applied over the myocardium, resulted in an increase of the total amount of coronary blood flow. Six pigs underwent median sternotomy. The coronary blood flow was measured, before and after the application of TNP (-50 mmHg), using coronary electromagnetic flow meter probes. Analyses were performed before left anterior descending artery (LAD) occlusion (normal myocardium) and after 20 minutes of LAD occlusion (ischaemic myocardium). Normal myocardium: 171.3 +/- 14.5 ml/minute before to 206.3 +/- 17.6 ml/minute after TNP application, P <0.05. Ischaemic myocardium: 133.7 +/- 18.4 ml/minute before to 183.2 +/- 18.9 ml/minute after TNP application, P <0.05. TNP of -50 mmHg applied over the LAD region induced a significant increase in the total coronary blood flow in both normal and ischaemic myocardium.

Few studies have focussed on patients' experiences of and suffering due to mediastinitis following Coronary Artery by-pass Graft (CABG). Mediastinitis creates a complex and invasive experience for the patient with prolonged hospitalisation, and would be expected to be a significant stressor. The aim of the present study was to capture patients' experiences of the medical and nursing care they received for mediastinitis following CABG. Content analysis revealed three themes with regard to how the patients coped with the stress and threats of mediastinitis and its treatment and how they thought it would influence their future life. A first theme centred on physical and psychological discomfort and impact on autonomy. The staff's medical knowledge and the quality of nursing care as well as the patients' understanding of the situation influenced their experience. A second theme was how patients dealt with perceived danger and stress. Coping strategies such as problem solving, information seeking, dissociation, distraction, minimisation and expression of emotion were used to handle the situations. The third theme comprised the patients' belief that the mediastinitis would not affect the outcome of the CABG procedure, even though their confidence in this was influenced by uncertainty about the rehabilitation process.

Few studies have focussed on patients’ experiences of and suffering due to mediastinitis following Coronary Artery by-passGraft (CABG). Mediastinitis creates a complex and invasive experience for the patient with prolonged hospitalisation, and would be expected to be a significant stressor. The aim of the present study was to capture patients’ experiences of themedical and nursing care they received for mediastinitis following CABG. Content analysis revealed three themes withregard to how the patients coped with the stress and threats of mediastinitis and its treatment and how they thought it wouldinfluence their future life. A first theme centred on physical and psychological discomfort and impact on autonomy. Thestaff ’s medical knowledge and the quality of nursing care as well as the patients’ understanding of the situation influencedtheir experience. A second theme was how patients dealt with perceived danger and stress. Coping strategies such asproblem solving, information seeking, dissociation, distraction, minimisation and expression of emotion were used to handlethe situations. The third theme comprised the patients’ belief that the mediastinitis would not affect the outcome of theCABG procedure, even though their confidence in this was influenced by uncertainty about the rehabilitation process.