1
|
Sakai H, Kurita H, Kondo E, Tanaka H, Shimane T, Hashidume M, Yamada SI. Dental and oral management in the perioperative period of surgery: A scoping review. JAPANESE DENTAL SCIENCE REVIEW 2024; 60:148-153. [PMID: 38633513 PMCID: PMC11021219 DOI: 10.1016/j.jdsr.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/27/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024] Open
Abstract
Dental and oral management (DOM) is a long-established treatment modality. This scoping review aimed to narratively review previous studies, examine the effects of perioperative DOM, and identify the available evidence. A literature search was conducted using the PubMed electronic database for studies published between January 1, 2000, and March 8, 2022. The search yielded 43 studies, most of which were published in the last 10 years. The results of this study confirmed that improved perioperative oral hygiene is effective in preventing postoperative pneumonia. Our results also suggested that preoperative DOM is effective in preventing postoperative surgical site infections. Perioperative DOM is effective in reducing the incidence of postoperative pneumonia, SSI, and postsurgical complications. Further studies are needed to elucidate the various mechanism of DOM and to examine efficient intervention methods and timing.
Collapse
Affiliation(s)
- Hironori Sakai
- Department of Oral and Maxillofacial Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto-shi, Nagano-ken 390-0872, Japan
| | - Hiroshi Kurita
- Department of Oral and Maxillofacial Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto-shi, Nagano-ken 390-0872, Japan
| | - Eiji Kondo
- Department of Oral and Maxillofacial Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto-shi, Nagano-ken 390-0872, Japan
| | - Hirokazu Tanaka
- Department of Oral and Maxillofacial Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto-shi, Nagano-ken 390-0872, Japan
| | - Tetsu Shimane
- Department of Oral and Maxillofacial Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto-shi, Nagano-ken 390-0872, Japan
| | - Masao Hashidume
- Department of Oral and Maxillofacial Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto-shi, Nagano-ken 390-0872, Japan
| | - Shin-Ichi Yamada
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, 3190 Gofuku, Toyama-shi, Toyama-ken 930-8555, Japan
| |
Collapse
|
2
|
Ferhatoglu MF, Sahin OZ, Kivilcim T, Gurkan A. The positive effects of preoperative chlorhexidine rinse to reduce postoperative pneumonia after kidney transplantation surgery. Surgeon 2024:S1479-666X(24)00066-0. [PMID: 38981842 DOI: 10.1016/j.surge.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 06/28/2024] [Accepted: 07/03/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Postoperative pneumonia is one of the most observed hospital-acquired infections and increases the postoperative mortality rate. Further, it drives the healthcare systems under a severe financial burden. Preventing postoperative pneumonia is an incredibly challenging issue for clinicians. Since immunosuppression therapy, the patients who had kidney transplants are more vulnerable to postoperative infections. There is no data in the scientific literature focusing on the effects of preoperative oral care with chlorhexidine antiseptic solutions on postoperative pneumonia in kidney transplantation surgery cases. In the present research, we studied this topic. METHODS A prospective, randomized clinical trial was conducted at our institution between August 2020 and August 2022. Group A: Received 0.12 % chlorhexidine oral rinse preoperatively; Group B: Not received 0.12 % chlorhexidine oral rinse preoperatively. We analyzed the differences between the two trial groups using a chi-square or t-test. The Mann-Whitney U test was used for the categorical data. RESULTS Nine patients (17.6 %) were diagnosed with postoperative pneumonia in Group A and fourteen (25.9 %) in Group B (p < 0.05). Hospitalization time of Group B was prolonged (p < 0.05). In multivariate analysis, significant risk factors associated with postoperative pneumonia were advanced age, diabetes mellitus, smoking, delayed graft function and not gargling with 0.12 % chlorhexidine (p < 0.05). CONCLUSIONS To reduce postoperative pneumonia risk in patients undergoing kidney transplantation surgery, an oral health protocol including 0.12 % chlorhexidine mouth rinse seems beneficial.
Collapse
Affiliation(s)
| | - Osman Z Sahin
- Istanbul Okan University, Faculty of Medicine, Department of Nephrology, Istanbul, Turkey
| | - Taner Kivilcim
- Istanbul Okan University, Faculty of Medicine, Department of Surgery, Istanbul, Turkey
| | - Alp Gurkan
- Istanbul Okan University, Faculty of Medicine, Department of Surgery, Istanbul, Turkey
| |
Collapse
|
3
|
Darbanian N, Nobahar M, Ghorbani R. Effect of propolis mouthwash on the incidence of ventilator-associated pneumonia in intensive care unit patients: a comparative randomized triple-blind clinical trial. BMC Oral Health 2024; 24:636. [PMID: 38811949 PMCID: PMC11137970 DOI: 10.1186/s12903-024-04412-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/24/2024] [Indexed: 05/31/2024] Open
Abstract
OBJECTIVES Ventilator-associated pneumonia (VAP) increases the length of hospitalization and mortality rate. This study aimed to determine the effect of propolis mouthwash on the incidence of VAP in intensive care unit (ICU) patients. MATERIALS AND METHODS Triple-blind, comparative randomized, controlled clinical trial was conducted over one year, with 110 ICU patients at Imam-Hossein and Bahar hospitals (Shahroud) and Kowsar Hospital (Semnan) in Iran. The intervention group used 15 cc of 0.06% propolis mouthwash solution twice daily at 8 AM and 4 PM for seven days. The control group used 15 cc of 0.2% chlorhexidine mouthwash at the same times and duration. Data were collected using a demographic questionnaire, APACHE II, Beck Oral Assessment Scale, and Modified Clinical Pulmonary Infection Score (MCPIS). RESULTS There was no significant difference in demographic information, disease severity, and oral health between the two groups before and after intervention (P > 0.05). The incidence of VAP in the intervention group compared to the control group was 10.9% vs. 30.9% on the third day (P = 0.0166, 95% CI: 0.53-0.83 and RR = 0.35), 23.6% vs. 43.6% on the fifth day (P = 0.0325 and 95% CI: 0.31-0.95 and RR = 0.54), and 25.5% vs. 47.3% on the seventh day (P = 0.0224, 95% CI: 0.32-0.92, and RR = 0.54). The Mann-Whitney indicated the incidence of VAP was significantly lower in the intervention group on the third, fifth, and seventh days. CONCLUSION Propolis mouthwash can be considered as an alternative to chlorhexidine mouthwash for ICU patients. CLINICAL RELEVANCE Propolis mouthwash serves as a simple, economical intervention to potentially reduce incidence of VAP. TRIAL REGISTRATION (IRCT20110427006318N12, date 02.04.2019).
Collapse
Affiliation(s)
- Nayereh Darbanian
- Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran
| | - Monir Nobahar
- Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, 3513138111, Iran.
- Department of Nursing, Faculty of Nursing and Midwifery, Semnan University of Medical Sciences, Semnan, Iran.
| | - Raheb Ghorbani
- Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran
- Department of Epidemiology and Biostatistics, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| |
Collapse
|
4
|
Livesey A, Quarton S, Pittaway H, Adiga A, Grudzinska F, Dosanjh D, Parekh D. Practices to prevent non-ventilator hospital-acquired pneumonia: a narrative review. J Hosp Infect 2024:S0195-6701(24)00120-8. [PMID: 38663517 DOI: 10.1016/j.jhin.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/22/2024] [Accepted: 03/24/2024] [Indexed: 07/19/2024]
Abstract
Nosocomial infection has significant consequences in health care, both at the individual level due to increased morbidity and mortality, and at the organizational level due to increased costs. Hospital-acquired pneumonia (HAP) is the most common nosocomial infection, and is associated with high excess mortality, frequent use of broad-spectrum antimicrobials and increased length of stay. This review explores the preventative strategies that have been examined in non-ventilator HAP (NV-HAP). The management of aspiration risk, interventions for oral hygiene, role of mobilization and physiotherapy, modification of environmental factors, and vaccination are discussed. Many of these interventions are low risk, acceptable to patients and have good cost-benefit ratios. However, the evidence base for prevention of NV-HAP is weak. This review identifies the lack of a unified research definition, under-recruitment to studies, and variation in intervention and outcome measures as limitations in the existing literature. Given that the core risk factors for acquisition of NV-HAP are increasing, there is an urgent need for research to address the prevention of NV-HAP. This review calls for a unified definition of NV-HAP, and identification of a core outcome set for studies in NV-HAP, and suggests future directions for research in NV-HAP. Improving care for people with NV-HAP will reduce morbidity, mortality and healthcare costs significantly.
Collapse
Affiliation(s)
- A Livesey
- National Institute for Health Research/Wellcome Trust Clinical Research Facility, University Hospitals Birmingham, Birmingham, UK.
| | - S Quarton
- National Institute for Health Research/Birmingham Biomedical Research Centre, Institute of Translational Medicine, Birmingham, UK
| | - H Pittaway
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - A Adiga
- Warwick Hospital, South Warwickshire University NHS Foundation Trust, Warwick, UK
| | - F Grudzinska
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - D Dosanjh
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - D Parekh
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
5
|
Lund Håheim AL, Olsen I, Thelle DS, Rønningen KS. Comparative analysis of antibodies to four major periodontal bacteria in respiratory diseases: a cohort study. BMJ Open 2024; 14:e082116. [PMID: 38626983 PMCID: PMC11029457 DOI: 10.1136/bmjopen-2023-082116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/26/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES To make a descriptive comparison of antibodies to four major periodontal bacteria and their relation to the respiratory diseases asthma and bronchitis/emphysema, and to cancer incidence. METHODS The serum of a random sample of men with no history of cancer incidence (n=621) was analysed by the ELISA method for antibody levels of four periodontal bacteria; the anaerobes of the so-called red complex Tannerella forsythia (TF), Porphyromonas gingivalis (PG), and Treponema denticola (TD), and the facultative anaerobe Aggregatibacter actinomycetemcomitans (AA). The antibody readings were divided into quartiles and the distribution of cases of the relevant diseases as compared with the non-cases. Comparisons of the quartile distributions were by the Pearson χ2 test. Data and serum from the Oslo II study of Norwegian men from 2000 were used. The ELISA analyses were performed on thawed frozen serum. Cancer data from 17.5 years of follow-up were provided by the Norwegian Cancer Registry. RESULTS In all, 52 men had reported asthma and 23 men had bronchitis/emphysema at the health screening. Results on cancer incidence are given for all respiratory cancers, n=23, and bronchi and lung cancers separately, n=18. Stratified analyses were performed for the four endpoints showing significant association with low levels of TD antibodies for bronchitis; p=0.035. Both TF and TD were significant for low levels of antibodies among daily smokers; p=0.030 for TF and p<0.001 for TD in the analysis of the full study sample. For PG and AA, no such associations were observed. An association with respiratory cancers was not observed. CONCLUSION A low level of TD was associated with bronchitis/emphysema compared with the rest of the cohort. In the total study sample, low levels of antibodies to both TF and TD were associated with daily smoking.
Collapse
Affiliation(s)
| | - Ingar Olsen
- Institute of Oral Biology, University of Oslo, Oslo, Norway
| | - Dag S Thelle
- University of Oslo, Oslo, Norway
- Department of Community Medicine and Public Health, University of Gothenburg, Gothenburg, Sweden
| | | |
Collapse
|
6
|
Wang SR, Zhou K, Zhang W. Application progress of nursing intervention in cardiac surgery. World J Clin Cases 2023; 11:7943-7950. [DOI: 10.12998/wjcc.v11.i33.7943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/27/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023] Open
Abstract
As a stressor, cardiac surgery affects the physiology and psychology of patients, as well as their postoperative recovery. Patients tend to worry about cognitive deficiency, pain, discomfort, the risk of death, sleep, complications, and other factors, resulting in stress and anxiety. Moreover, serious adverse events, such as circulatory and respiratory dysfunction and infection, tend to occur after cardiac surgery and increase the economic burden on patients. Therefore, appropriate nursing interventions should be selected to strengthen patients’ cognitive levels, compliance, and postoperative practices to accelerate their recovery, reduce complications, and shorten hospital stays so as to contribute to patients’ lives and health.
Collapse
Affiliation(s)
- Si-Ru Wang
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Ke Zhou
- Department of Cardiac Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Wei Zhang
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| |
Collapse
|
7
|
Suenaga H, Schifter M, Chen N, Ali F, Byth K, Peck C. Impact of oral/dental disease burden on postoperative infective complications: a prospective cohort study. Clin Oral Investig 2023; 27:6461-6470. [PMID: 37730892 PMCID: PMC10630249 DOI: 10.1007/s00784-023-05251-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/09/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES This prospective cohort study aimed to assess the association between dental disease burden and postoperative infective complications (POICs) in patients undergoing major surgical procedures under general anaesthesia. METHODS Pre-surgical dental assessment was undertaken on patients planned for major surgery. Demographic and surgical variables including putative risk factors for POICs and POIC status were documented. The univariable association between POIC status and each factor was examined. Those variables associated at P value ≤ 0.2 were candidates for inclusion in multiple logistic regression models. Backward stepwise variable selection was used to identify the independent predictors for POIC in the best fitting logistic regression model. The area under the receiver operating curve (AUC) was used to quantify the model's global classification performance. RESULTS Among the 285 patients, 49 patients (17.2%) had POICs. The independent predictors for POIC were expected length of hospital stay (4-6 days; odds ratio [OR] = 4.80, 95% confidence internal [CI]: 1.30-17.70, P = 0.018, 7-9 days; OR = 5.42, 95% CI: 1.51-19.41, P = 0.009, ≥ 10 days; OR = 28.80, 95% CI: 4.12-201.18, P < 0.001), four or more decayed teeth (OR = 6.03, 95% CI: 2.28-15.94, P < 0.001) and visible tongue plaque (OR = 3.21, 95% CI: 1.54-6.70, P = 0.002). The AUC was 0.78 (95% CI: 0.71-0.85) indicating good discrimination. A simple screening tool for POIC was developed. CONCLUSIONS/CLINICAL RELEVANCE In addition to systemic/surgical factors, this study identified clinically detected decayed teeth and visible tongue plaque as independent predictors for POICs. Preoperative dental assessment/care might be beneficial to assess risk for POICs and improve postoperative outcomes.
Collapse
Affiliation(s)
- Hanako Suenaga
- Sydney Dental School, Faculty of Medicine and Health, The University of Sydney, Level 2-3 Westmead Centre for Oral Health, Westmead, NSW, 2145, Australia.
- Division of Advanced Prosthetic Dentistry, Tohoku University Graduate School of Dentistry, 4-1 Seiryo-Machi, Aoba-Ku, Sendai, 980-8575, Japan.
| | - Mark Schifter
- Sydney Dental School, Faculty of Medicine and Health, The University of Sydney, Level 2-3 Westmead Centre for Oral Health, Westmead, NSW, 2145, Australia
- Department of Oral Medicine, Oral Pathology and Special Needs Dentistry, Westmead Centre for Oral Health, Level 3, Westmead, NSW, 2145, Australia
| | - Nancy Chen
- Department of Oral Medicine, Oral Pathology and Special Needs Dentistry, Westmead Centre for Oral Health, Level 3, Westmead, NSW, 2145, Australia
| | - Farheen Ali
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Cnr Darcy & Hawkesbury Roads, Westmead, NSW, 2145, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Chris Peck
- Sydney Dental School, Faculty of Medicine and Health, The University of Sydney, Level 2-3 Westmead Centre for Oral Health, Westmead, NSW, 2145, Australia
| |
Collapse
|
8
|
Quinton K, Guy-Frank CJ, Syed S, Klugh JM, Dhanani NH, Adibi SS, Kao LS. Poor Oral Health in Trauma Intensive Care Unit Patients: Application of a Novel Oral Health Score. Surg Infect (Larchmt) 2023; 24:657-662. [PMID: 37695683 DOI: 10.1089/sur.2023.171] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Abstract
Background: Although oral hygiene in patients in the intensive care unit (ICU) has been shown to reduce hospital-associated infections, baseline and progressive oral health are often not reported because of lack of a standardized tool. The Oral Health Risk Assessment Value Index (OHRAVI) is a comprehensive oral assessment validated by dental providers. This study hypothesizes that non-dental providers can use OHRAVI in trauma ICU patients with minimal training and acceptable inter-rater reliability (IRR). Patients and Methods: Dentulous adult patients in the ICU at a level 1 trauma center were scored, excluding those with severe orofacial trauma. The eight categories of the OHRAVI were scored 0 to 3 (best to worst) with summed total and index (average) score. Index scores 1 or less need routine oral care; greater than 1-2 require moderate care; and greater than 2-3 require extensive oromaxillofacial care. Inter-rater reliability was assessed by two to three raters with Krippendorff's α (≥0.80 for good and ≥0.667 for acceptable). Results: Eighty-four ratings were completed across 34 patients, with 16 patients (47%) scored by all three raters. Ten patients (29%) had an index score <1. The average index score for patients was 1.28 (median, 1.34; range, 0.63-2). Krippendorff's α for index score was 0.86. For individual categories, α ranged from 0.44 to 1, with six of the eight categories achieving an α ≥ 0.667. Conclusions: With minimal training, non-dental providers were able to use OHRAVI with a good IRR for index score and an acceptable/good IRR for most individual categories. This novel, simple, comprehensive oral health score could help standardize oral assessment and facilitate future studies of peri-operative oral hygiene interventions.
Collapse
Affiliation(s)
- Kayli Quinton
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Chelsea J Guy-Frank
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Sophia Syed
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - James M Klugh
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Naila H Dhanani
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Shawn S Adibi
- UTHealth Houston, School of Dentistry, Houston, Texas, USA
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| |
Collapse
|
9
|
Cruz JC, Martins CK, Piassi JEV, Garcia Júnior IR, Santiago Junior JF, Faverani LP. Does chlorhexidine reduce the incidence of ventilator-associated pneumonia in ICU patients? A systematic review and meta-analysis. Med Intensiva 2023; 47:437-444. [PMID: 36464582 DOI: 10.1016/j.medine.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE This study aimed to investigate chlorhexidine's efficacy in preventing ventilator-associated pneumonia (VAP). DESIGN A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. SETTINGS The data were obtained from Pubmed, Cochrane Library, and EMBASE. PATIENTS OR PARTICIPANTS Only mechanically ventilated patients for at least 48h were included. INTERVENTIONS Randomized clinical trials applying any dosage form of chlorhexidine were eligible. MAIN VARIABLES OF INTEREST The relative risk (RR) of the VAP incidence and all-cause mortality was assessed using the random-effects model. The mean difference in days of mechanical ventilation duration and intensive care unit (ICU) length of stay were also appraised. RESULTS Ten studies involving 1233 patients were included in the meta-analysis. The oral application of CHX reduced the incidence of VAP (RR, 0.73 [95% CI, 0.55, 0.97]) and did not show an increase in all-cause mortality (RR, 1.13 [95% CI, 0.96, 1.32]). CONCLUSIONS CHX proved effective to prevent VAP. However, a conclusion on mortality rates could not be drawn because the quality of the evidence was very low for this outcome.
Collapse
Affiliation(s)
- J C Cruz
- University of São Paulo (USP), Ribeirão Preto, Brazil.
| | - C K Martins
- Department of Medicine, University of Ribeirão Preto (UNAERP), Ribeirão Preto, Brazil
| | - J E V Piassi
- Division of Oral and Maxillofacial Surgery, Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo, Brazil
| | - I R Garcia Júnior
- Division of Oral and Maxillofacial Surgery, Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo, Brazil
| | - J F Santiago Junior
- Department of Health Sciences. Dentistry Course, Unisagrado: Centro Universitário Sagrado Coração, Bauru, SP, Brazil
| | - L P Faverani
- Division of Oral and Maxillofacial Surgery, Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo, Brazil
| |
Collapse
|
10
|
Herczegh A, Csák B, Dinya E, Moldován A, Ghidán Á, Palcsó B, Lohinai ZM. Short- and long term antibacterial effects of a single rinse with different mouthwashes: A randomized clinical trial. Heliyon 2023; 9:e15350. [PMID: 37095907 PMCID: PMC10121446 DOI: 10.1016/j.heliyon.2023.e15350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/14/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023] Open
Abstract
Objectives Reducing the microbial level in the aerosol created during dental procedures is essential to avoiding infections. The aim of this study was to examine the change in Streptococcus mutans (S. mutans) and the total bacterial load in human saliva in vivo after a single rinse with different mouthwashes. Material and methods One mL of unstimulated saliva was collected from volunteers with poor oral hygiene at baseline and 5 min after a 1-min rinsing with diluted Solumium Oral® (hyper-pure 0.0015% chlorine dioxide; ClO2), Listerine Total Care®, Corsodyl® (0.2% chlorhexidine-digluconate; CHX), or BioGate Si*CLEAN for bacterial investigation. In a second study, volunteers rinsed with 0.003% ClO2 or CHX for 1 min, and saliva was collected at baseline, after 5 min, and after 90 min. After plating, the total plate and S. mutans colony numbers were determined. Results In the first study, ClO2 and CHX similarly reduced both total germ and S. mutans numbers, while Listerine Total Care® decreased only the S. mutans counts. BioGate Si*Clean had no effect on either the total germ or S. mutans numbers. In the second study, an increasing tendency toward bacterial regrowth was observed with CHX after 90 min compared to the 5-min value, while no change was measured after ClO2 rinsing. Conclusion Hyper-pure ClO2 rinsing may be a new promising preventive and therapeutic adjuvant in dental practice, as it is similar in effectiveness to the gold standard CHX-containing mouthwashes, especially in patients concerned with taste or tooth discoloration during oral health therapy.
Collapse
|
11
|
Henricks EM, Pfeifer KJ. Pulmonary assessment and optimization for older surgical patients. Int Anesthesiol Clin 2023; 61:8-15. [PMID: 36794803 DOI: 10.1097/aia.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Evan M Henricks
- Division of Geriatric and Palliative Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kurt J Pfeifer
- Department of Medicine, Section of Perioperative & Consultative Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
12
|
Réhabilitation améliorée après chirurgie cardiaque adulte sous CEC ou à cœur battant 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
13
|
Wang D, Lu Y, Sun M, Huang X, Du X, Jiao Z, Sun F, Xie F. Pneumonia After Cardiovascular Surgery: Incidence, Risk Factors and Interventions. Front Cardiovasc Med 2022; 9:911878. [PMID: 35845037 PMCID: PMC9280273 DOI: 10.3389/fcvm.2022.911878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/13/2022] [Indexed: 01/28/2023] Open
Abstract
Postoperative pneumonia (POP) is prevalent in patients undergoing cardiovascular surgery, associated with poor clinical outcomes, prolonged hospital stay and increased medical costs. This article aims to clarify the incidence, risk factors, and interventions for POP after cardiovascular surgery. A comprehensive literature search was performed to identify previous reports involving POP after cardiovascular surgery. Current situation, predictors and preventive measures on the development of POP were collected and summarized. Many studies showed that POP was prevalent in various cardiovascular surgical types, and predictors varied in different studies, including advanced age, smoking, chronic lung disease, chronic kidney disease, cardiac surgery history, cardiac function, anemia, body mass index, diabetes mellitus, surgical types, cardiopulmonary bypass time, blood transfusion, duration of mechanical ventilation, repeated endotracheal intubation, and some other risk factors. At the same time, several targeted interventions have been widely reported to be effective to reduce the risk of POP and improve prognosis, including preoperative respiratory physiotherapy, oral care and subglottic secretion drainage. Through the review of the current status, risk factors and intervention measures, this article may play an important role in clinical prevention and treatment of POP after cardiovascular surgery.
Collapse
Affiliation(s)
- Dashuai Wang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yang Lu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Manda Sun
- China Medical University-The Queen's University of Belfast Joint College, China Medical University, Shenyang, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhouyang Jiao
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fuqiang Sun
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fei Xie
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
14
|
Mertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, Chatel D, Cholley B, Curtil A, Grimaud JP, Houel R, Kattou F, Fellahi JL, Guidon C, Guinot PG, Lebreton G, Marguerite S, Ouattara A, Provenchère Fruithiot S, Rozec B, Verhoye JP, Vincentelli A, Charbonneau H. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med 2022; 41:101059. [PMID: 35504126 DOI: 10.1016/j.accpm.2022.101059] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. METHODS Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. CONCLUSIONS Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- Paul-Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Julien Amour
- Institut de Perfusion, de Réanimation, d'Anesthésie de Chirurgie Cardiaque Paris Sud, IPRA, Hôpital Privé Jacques Cartier, Massy, France
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France; MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Lionel Camilleri
- Department of Cardiovascular Surgery, CHU Clermont-Ferrand, T.G.I, I.P., CNRS, SIGMA, UCA, UMR 6602, Clermont-Ferrand, France
| | - Thierry Caus
- Department of Cardiac Surgery, UPJV, Amiens University Hospital, Amiens Picardy University Hospital, Amiens, France
| | - Didier Chatel
- Department of Cardiac Surgery (D.C.), Institut du Coeur Saint-Gatien, Nouvelle Clinique Tours Plus, Tours, France
| | - Bernard Cholley
- Anaesthesiology and Intensive Care Medicine, Hôpital Européen Georges-Pompidou, AP-HP, Université de Paris, INSERM, IThEM, Paris, France
| | - Alain Curtil
- Department of Cardiac Surgery, Clinique de la Sauvegarde, Lyon, France
| | | | - Rémi Houel
- Department of Cardiac Surgery, Saint Joseph Hospital, Marseille, France
| | - Fehmi Kattou
- Department of Anaesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France; Faculté de Médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Intensive Care, Dijon University Hospital, Dijon, France; University of Bourgogne and Franche-Comté, LNC UMR1231, Dijon, France; INSERM, LNC UMR1231, Dijon, France; FCS Bourgogne-Franche Comté, LipSTIC LabEx, Dijon, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, Unité mixte de recherche CardioMetabolisme et Nutrition, ICAN, AP-HP, Hôpital Pitié-Salpétrière, Paris, France
| | - Sandrine Marguerite
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, UMR 1034, Biology of Cardiovascular Diseases, F-33600 Pessac, France
| | - Sophie Provenchère Fruithiot
- Department of Anaesthesia, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France; Centre d'Investigation Clinique 1425, INSERM, Université de Paris, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laennec, CHU Nantes, Nantes, France; Université de Nantes, CHU Nantes, CNRS, INSERM, Institut duDu Thorax, Nantes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - André Vincentelli
- Department of Cardiac Surgery, University of Lille, CHU Lille, Lille, France
| | | |
Collapse
|
15
|
An innovative oral management procedure to reduce postoperative complications. JTCVS OPEN 2022; 10:442-453. [PMID: 36004276 PMCID: PMC9390213 DOI: 10.1016/j.xjon.2022.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 01/13/2022] [Indexed: 12/01/2022]
Abstract
Background Numerous studies have shown that improving oral hygiene contributes to a reduction in the risk of postoperative complications in patients with head and neck cancer, cardiac disease, and esophageal cancer. However, the beneficial standard for oral management procedures during the perioperative period has not yet been established. Therefore, our aim was to determine whether or not their innovative oral management intervention contributed to a reduction in postoperative complications in lung cancer. Methods We performed a retrospective analysis of medical records of patients who underwent lung cancer surgery with lobectomy and pneumonectomy at Kyorin University Hospital. Patients were divided into 2 groups: a perioperative oral management intervention group that underwent lung cancer surgery from April 2016 to March 2018 (n = 164), and a control group without oral management that underwent surgery from April 2014 to March 2016 (n = 199). In particular, our oral management procedure emphasized oral mucosa stimulation to induce saliva discharge as in gum chewing, rather than simply using teeth brushing to reduce oral microbiome. Therefore, our oral management procedure is different from traditional oral care. Results This study demonstrated that our oral management practice was associated with a decline in the occurrence of postoperative pneumonia (odds ratio, 0.184; 95% CI, 0.042-0.571; P = .009), postoperative hospital stay duration (β coefficient, −4.272; 95% CI, −6.390 to −2.155; P < .001) and Clavian-Dindo classification grade II or above (odds ratio, 0.503; 95% CI, 0.298-0.835; P = .009). Conclusions We propose an innovative new strategy using their unique oral management procedure to reduce postoperative complications resulting from pulmonary resection.
Collapse
|
16
|
Wang D, Li Y, Sheng W, Wang H, Le S, Huang X, Du X. Development and validation of a nomogram model for pneumonia after redo cardiac surgery. J Cardiovasc Med (Hagerstown) 2022; 23:325-334. [PMID: 37594436 DOI: 10.2459/jcm.0000000000001302] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
AIMS Postoperative pneumonia (POP) after redo cardiac surgery is prevalent, associated with poor outcome. The aim of this study was to identify independent risk factors for POP after redo cardiac surgery and to develop and validate a prediction model. METHODS Adults undergoing redo cardiac surgery from 2016 to 2019 were identified in a single-institution database. Using a 2: 1 ratio, the patients were randomly divided into training and validation sets. Univariate and multivariate analyses were applied to identify independent predictors for POP in the training set. A nomogram model was constructed for clinical utility and was validated in the validation set. RESULTS POP developed in 72 of the 376 patients (19.1%). Four independent risk factors were identified, including age, chronic obstructive pulmonary disease, serum creatinine level and intraoperative blood transfusion volume. A nomogram based on the four predictors was constructed, with good discrimination in both the training (c-index: 0.86) and validation sets (c-index: 0.78). The model was well calibrated, with a Hosmer-Lemeshow χ 2 -value of 7.31 ( P = 0.50) in the training set and 7.41 ( P = 0.49) in the validation set. The calibration was also good by visual inspection. The decision and clinical impact curves of the nomogram indicated good clinical utility. Three risk intervals were identified based on the nomogram for better risk stratification. CONCLUSION We developed and validated a nomogram model for POP after redo cardiac surgery. The model may have good clinical utility in risk evaluation and individualized treatment to reduce adverse events. Graphical abstract Incidence, risk factor, and outcomes of postoperative pneumonia after redo cardiac surgery: http://links.lww.com/JCM/A445 .
Collapse
Affiliation(s)
| | - Yixue Li
- Department of Emergency General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiyong Sheng
- Department of Emergency General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | - Sheng Le
- Department of Cardiovascular Surgery
| | | | | |
Collapse
|
17
|
Lin MR, Chang PJ, Hsu PC, Lin CS, Chiu CH, Chen CJ. Comparison of Efficacy of 2% Chlorhexidine Gluconate-Alcohol and 10% Povidone-Iodine-Alcohol against Catheter-Related Bloodstream Infections and Bacterial Colonization at Central Venous Catheter Insertion Sites: A Prospective, Single-Center, Open-Label, Crossover Study. J Clin Med 2022; 11:jcm11082242. [PMID: 35456335 PMCID: PMC9031555 DOI: 10.3390/jcm11082242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 12/04/2022] Open
Abstract
An effective antiseptic agent is an essential component of a central venous catheter (CVC) care bundle, to protect against catheter-related bloodstream infections (CRBSIs). We conducted a trial to compare the incidences of CRBSI and the growth of insertion site flora in patients with CVC using 2% chlorhexidine gluconate−alcohol (CHG) or 10% povidone-iodine−alcohol (PVI) in the CVC care bundle. Patients who were admitted to two medical intensive care units (ICUs) and had CVC placement for >48 h were enrolled. Using a two-way crossover design with two six-month interventions, the ICUs were assigned to use either CHG or PVI in their care bundles. A total of 446 catheters in 390 subjects were enrolled in the study. The detection rate of flora was greater in the PVI group on both day 7 (26.6% versus 6.3%, p < 0.001) and day 14 (43.2% versus 15.8%, p < 0.001). The incidence rate of CRBSI was higher in the PVI group compared to the CHG group (2.15 vs. 0 events per 1000-catheter-days, p = 0.001), although the significance was lost in the multivariate analysis. In conclusion, 2% CHG was superior to 10% PVI in the CVC care bundle in terms of the inhibition of skin flora growth at CVC insertion sites and was potentially associated with lower incidence rates of CRBSI.
Collapse
Affiliation(s)
- Ming-Ru Lin
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-R.L.); (C.-H.C.)
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (P.-J.C.); (P.-C.H.)
| | - Po-Jui Chang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (P.-J.C.); (P.-C.H.)
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taipei 105, Taiwan
| | - Ping-Chih Hsu
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (P.-J.C.); (P.-C.H.)
- Division of Thoracic Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chun-Sui Lin
- Infection Control Committee, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
| | - Cheng-Hsun Chiu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-R.L.); (C.-H.C.)
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (P.-J.C.); (P.-C.H.)
- Molecular Infectious Diseases Research Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chih-Jung Chen
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-R.L.); (C.-H.C.)
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (P.-J.C.); (P.-C.H.)
- Molecular Infectious Diseases Research Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Correspondence: or ; Tel.: +886-3-3288957
| |
Collapse
|
18
|
Wang D, Abuduaini X, Huang X, Wang H, Chen X, Le S, Chen M, Du X. Development and validation of a risk prediction model for postoperative pneumonia in adult patients undergoing Stanford type A acute aortic dissection surgery: a case control study. J Cardiothorac Surg 2022; 17:22. [PMID: 35197097 PMCID: PMC8864916 DOI: 10.1186/s13019-022-01769-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 02/10/2022] [Indexed: 01/28/2023] Open
Abstract
Background Pneumonia is a common complication after Stanford type A acute aortic dissection surgery (AADS) and contributes significantly to morbidity, mortality, and length of stay. The purpose of this study was to identify independent risk factors associated with pneumonia after AADS and to develop and validate a risk prediction model. Methods Adults undergoing AADS between 2016 and 2019 were identified in a single-institution database. Patients were randomly divided into training and validation sets at a ratio of 2:1. Preoperative and intraoperative variables were included for analysis. A multivariate logistic regression model was constructed using significant variables from univariate analysis in the training set. A nomogram was constructed for clinical utility and the model was validated in an independent dataset. Results Postoperative pneumonia developed in 170 of 492 patients (34.6%). In the training set, multivariate analysis identified seven independent predictors for pneumonia after AADS including age, smoking history, chronic obstructive pulmonary disease, renal insufficiency, leucocytosis, low platelet count, and intraoperative transfusion of red blood cells. The model demonstrated good calibration (Hosmer–Lemeshow χ2 = 3.31, P = 0.91) and discrimination (C-index = 0.77) in the training set. The model was also well calibrated (Hosmer–Lemeshow χ2 = 5.73, P = 0.68) and showed reliable discriminatory ability (C-index = 0.78) in the validation set. By visual inspection, the calibrations were good in both the training and validation sets. Conclusion We developed and validated a risk prediction model for pneumonia after AADS. The model may have clinical utility in individualized risk evaluation and perioperative management.
Collapse
Affiliation(s)
- Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Jiefang Road, No. 1277, Wuhan, 430022, China
| | - Xiaerzhati Abuduaini
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Jiefang Road, No. 1277, Wuhan, 430022, China.
| | - Hongfei Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Jiefang Road, No. 1277, Wuhan, 430022, China
| | - Xing Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Jiefang Road, No. 1277, Wuhan, 430022, China
| | - Sheng Le
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Jiefang Road, No. 1277, Wuhan, 430022, China
| | - Manhua Chen
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Jiefang Road, No. 1277, Wuhan, 430022, China.
| |
Collapse
|
19
|
Wang D, Chen X, Wu J, Le S, Xie F, Li X, Wang H, Huang X, Zhang A, Du X. Development and Validation of Nomogram Models for Postoperative Pneumonia in Adult Patients Undergoing Elective Cardiac Surgery. Front Cardiovasc Med 2021; 8:750828. [PMID: 34708096 PMCID: PMC8542719 DOI: 10.3389/fcvm.2021.750828] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/15/2021] [Indexed: 01/28/2023] Open
Abstract
Background: Postoperative pneumonia (POP) is a frequent complication following cardiac surgery, related to increased morbidity, mortality and healthcare costs. The objectives of this study were to investigate the risk factors associated with POP in adults undergoing elective cardiac surgery and to develop and validate nomogram models. Methods: We conducted a multicenter retrospective study in four cardiac centers in China. Adults operated with elective open-heart surgery from 2016 to 2020 were included. Patients were randomly allocated to training and validation sets by 7:3 ratio. Demographics, comorbidities, laboratory data, surgical factors, and postoperative outcomes were collected and analyzed. Risk factors for POP were identified by univariate and multivariate analysis. Nomograms were constructed based on the multivariate logistic regression models and were evaluated with calibration, discrimination and decision curve analysis. Results: A total of 13,380 patients meeting the criteria were included and POP developed in 882 patients (6.6%). The mortality was 2.0%, but it increased significantly in patients with POP (25.1 vs. 0.4%, P < 0.001). Using preoperative and intraoperative variables, we constructed a full nomogram model based on ten independent risk factors and a preoperative nomogram model based on eight preoperative factors. Both nomograms demonstrated good calibration, discrimination, and were well validated. The decision curves indicated significant clinical usefulness. Finally, four risk intervals were defined for better clinical application. Conclusions: We developed and validated two nomogram models for POP following elective cardiac surgery using preoperative and intraoperative factors, which may be helpful for individualized risk evaluation and prevention decisions.
Collapse
Affiliation(s)
- Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xing Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wu
- Key Laboratory for Molecular Diagnosis of Hubei Province, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Le
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Xie
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ximei Li
- Department of Nursing, Huaihe Hospital of Henan University, Kaifeng, China
| | - Hongfei Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Anchen Zhang
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
20
|
Wei J, He L, Weng F, Huang F, Teng P. Effectiveness of chlorhexidine in preventing infections among patients undergoing cardiac surgeries: a meta-analysis and systematic review. Antimicrob Resist Infect Control 2021; 10:140. [PMID: 34620240 PMCID: PMC8499511 DOI: 10.1186/s13756-021-01009-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 08/30/2021] [Indexed: 01/15/2023] Open
Abstract
Background Although several meta-analyses reported the impact of chlorhexidine (CHX) use in patients undergoing various types of surgery, no meta-analysis summarized the overall effectiveness of CHX specifically for cardiac surgery. This meta-analysis aimed to examine the impact of CHX on infections after cardiac surgery compared with other cleansers or antiseptics. Methods PubMed, Embase, and the Cochrane Library were searched from inception up to October 2020 for potentially eligible studies: (1) population: patients who underwent cardiac surgery; (2) intervention or exposure: any type of CHX use in the treatment or exposed group; (3) outcome: number of patients with infections; (4) comparison: placebo or other antiseptic agents; (5) English. The primary outcome was surgical site infection (SSI). Results Fourteen studies were included, with 8235 and 6901 patients in the CHX and control groups. CHX was not protective against SSI (OR = 0.77, 95% CI: 0.57–1.04, P = 0.090). CHX was protective for superficial wound infection (OR = 0.42, 95% CI: 0.26–0.70, P = 0.001), but not with deep wound infection (P = 0.509). CHX was not protective against urinary tract of infection (P = 0.415) but was protective for bloodstream infection (OR = 0.36, 95% CI: 0.16–0.80, P = 0.012), nosocomial infections (OR = 0.55, 95% CI: 0.44–0.69, P < 0.001), and pneumonia (OR = 0.26, 95% CI: 0.11–0.61, P = 0.002). Conclusions In patients undergoing cardiac surgery, CHX does not protect against SSI, deep wound infection, and urinary tract infections but might protect against superficial SSI, bloodstream infection, nosocomial infections, and pneumonia. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-01009-3.
Collapse
Affiliation(s)
- Jianhua Wei
- Surgical Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, China.
| | - Lingying He
- Surgical Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Fengxia Weng
- Surgical Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Fangfang Huang
- Surgical Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Peng Teng
- Surgical Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, China
| |
Collapse
|
21
|
Wang DS, Huang XF, Wang HF, Le S, Du XL. Clinical risk score for postoperative pneumonia following heart valve surgery. Chin Med J (Engl) 2021; 134:2447-2456. [PMID: 34669637 PMCID: PMC8654438 DOI: 10.1097/cm9.0000000000001715] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background: Postoperative pneumonia (POP) is one of the most common infections following heart valve surgery (HVS) and is associated with a significant increase in morbidity, mortality, and health care costs. This study aimed to identify the major risk factors associated with the occurrence of POP following HVS and to derive and validate a clinical risk score. Methods: Adults undergoing open HVS between January 2016 and December 2019 at a single institution were enrolled in this study. Patients were randomly assigned to the derivation and validation sets at 1:1 ratio. A prediction model was developed with multivariable logistic regression analysis in the derivation set. Points were assigned to independent risk factors based on their regression coefficients. Results: POP occurred in 316 of the 3853 patients (8.2%). Multivariable analysis identified ten significant predictors for POP in the derivation set, including older age, smoking history, chronic obstructive pulmonary disease, diabetes mellitus, renal insufficiency, poor cardiac function, heart surgery history, longer cardiopulmonary bypass, blood transfusion, and concomitant coronary and/or aortic surgery. A 22-point risk score based on the multivariable model was then generated, demonstrating good discrimination (C-statistic: 0.81), and calibration (Hosmer-Lemeshow χ2 = 8.234, P = 0.312). The prediction rule also showed adequate discriminative power (C-statistic: 0.83) and calibration (Hosmer-Lemeshow χ2 = 5.606, P = 0.691) in the validation set. Three risk intervals were defined as low-, medium-, and high-risk groups. Conclusion: We derived and validated a 22-point risk score for POP following HVS, which may be useful in preventive interventions and risk management. Trial Registration: Chictr.org, ChiCTR1900028127; http://www.chictr.org.cn/showproj.aspx?proj=46932
Collapse
Affiliation(s)
- Da-Shuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | | | | | | | | |
Collapse
|
22
|
Liang S, Zhang X, Hu Y, Yang J, Li K. Association between perioperative chlorhexidine oral care and postoperative pneumonia in non-cardiac surgical patients: A systematic review and meta-analysis. Surgery 2021; 170:1418-1431. [PMID: 34092377 DOI: 10.1016/j.surg.2021.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/23/2021] [Accepted: 05/04/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pneumonia is the third most common complication after surgery, and its occurrence is associated with a poor prognosis in patients. Perioperative chlorhexidine oral care has been reported to reduce the incidence of postoperative pneumonia in patients undergoing cardiac surgery. However, whether perioperative chlorhexidine oral care can reduce the incidence of postoperative pneumonia in noncardiac surgical patients is still unknown. The aim of this systematic review and meta-analysis was to determine the association between perioperative chlorhexidine oral care and postoperative pneumonia in noncardiac surgical patients. METHODS A comprehensive systematic search of PubMed, Ovid Embase, Web of Science, the Cochrane Library, Wanfang Database, and the China National Knowledge Infrastructure was conducted to include studies from the inception of each database through March 2021. The reference lists of all included studies were also searched by hand. Eligible studies were published and unpublished randomized controlled trials and observational studies evaluating the effect of perioperative chlorhexidine oral care on the reported incidence of postoperative pneumonia. Relative risks or odds ratio with their 95% confidence intervals were calculated and risk of bias was assessed for eligible studies. RESULTS Seven randomized controlled trials with a total of 1,773 patients and 3 observational studies with a total of 12,528 noncardiac surgical patients were included. A total of 621 and 5,904 patients received perioperative chlorhexidine oral care in randomized controlled trials and observational studies, respectively. Six (85%) randomized controlled trials had a high risk of bias, and 2 (67%) observational studies had a high quality. Perioperative chlorhexidine oral care significantly reduced the incidence of postoperative pneumonia in randomized controlled trials (relative risk, 0.60; 95% confidence interval, 0.44-0.80; P < .001) and observational studies (odds ratio, 0.26; 95% confidence interval, 0.08-0.90; P = .03). CONCLUSION Perioperative chlorhexidine oral care led by a nurse significantly decreases the incidence of postoperative pneumonia in noncardiac surgical patients and may be more convenient and economical compared with dental professional-led perioperative oral care.
Collapse
Affiliation(s)
- Shiqi Liang
- West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China. https://twitter.com/SeventeenLeung
| | - Xingxia Zhang
- West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Yanjie Hu
- West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Yang
- Department of Gastrointestinal Surgery, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Ka Li
- West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
23
|
Wang D, Huang X, Wang H, Le S, Yang H, Wang F, Du X. Risk factors for postoperative pneumonia after cardiac surgery: a prediction model. J Thorac Dis 2021; 13:2351-2362. [PMID: 34012584 PMCID: PMC8107540 DOI: 10.21037/jtd-20-3586] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Postoperative pneumonia is the main infectious complication following cardiac surgery and is associated with significant increases in morbidity, mortality and health care costs. The aim of this study was to identify potential risk factors related to the occurrence of postoperative pneumonia in adult patients undergoing cardiac surgery and to develop a predictive system. Methods Adult patients who underwent open heart surgery in our institution between 2016 and 2019 were enrolled in this study. Preoperative and intraoperative variables were collected and analyzed. A multivariate prediction model for evaluating the risk of postoperative pneumonia was established using logistic regression analysis via forward stepwise selection, and points were assigned to significant risk factors based on their regression coefficient values. Results Postoperative pneumonia occurred in 530 of the 5,323 patients (9.96%). Prolonged stays in the postoperative intensive care unit (ICU) and hospital, as well as higher mortality (25.66% versus 0.65%), were observed in patients with postoperative pneumonia. Multivariate analysis identified 13 independent risk factors including patient demographics, comorbidities, cardiac function, cardiopulmonary bypass (CPB) duration, and blood transfusion. The prediction model showed good discrimination (C-statistic: 0.80) and was well calibrated (Hosmer-Lemeshow χ2=7.907, P value =0.443). A 32-point risk score was generated, and then three risk intervals were defined. Conclusions We derived and validated a prediction model for postoperative pneumonia after cardiac surgery incorporating 13 easily discernible risk factors. The scoring system may be helpful for individualized risk estimations and clinical decision-making.
Collapse
Affiliation(s)
- Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongfei Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Le
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Han Yang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
24
|
Abstract
Cardiothoracic surgery posits an arrangement of large, significant hemodynamic, and physiologic alterations upon the human body, which predisposes a patient to develop pathology. The care of these patients in the postoperative realm requires an astute physician with deep understanding of the cardiopulmonary system, who is able to address subtle developing problems promptly, before the patient suffers further sequelae. In this review, we describe the presentation and management of an assortment of important complications which occur in the pulmonary system. In addition, we aim to shed better light upon how the physiology of a patient responds to the condition of cardiothoracic surgery.
Collapse
|
25
|
Moosavi MS, Aminishakib P, Ansari M. Antiviral mouthwashes: possible benefit for COVID-19 with evidence-based approach. J Oral Microbiol 2020; 12:1794363. [PMID: 32944152 PMCID: PMC7482897 DOI: 10.1080/20002297.2020.1794363] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/29/2020] [Accepted: 07/06/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The outbreak, and pandemic of COVID-19 causing widespread concerns in all health systems of countries. Virus-carrying aerosols can penetrate the healthy human body and lungs, resulting in rapid transmission. For the first time, in this evidence-based article, the effects of different types of mouthwashes to reduce the viral load were investigated. Also, another aim of this essay is a reduction in viral load in patients with COVID-19 and prevention developing ventilator-associated pneumonia in critically ill patients. METHODS Related databases were comprehensively searched for relevant studies. The present study was performed according to the preferred cases for standard systematic reviews (PRISMA). RESULTS Five original studies in which the subject matter was directly evaluated were included. Different types of mouthwashes and viruses were investigated in this study. CONCLUSIONS The antiviral mouthwashes play a certainly important role in reducing the viral load of the salivary virus. In the present study, this importance could be proved in two different aspects, that is, the use of mouthwash before dental procedures to reduce the risk of transmission of the virus to the dental team and the use of this mouthwash in COVID-19 patients to help improve systemic problems associated with oral microbial flora.
Collapse
Affiliation(s)
- Mahdieh-Sadat Moosavi
- Dental Research Center, Dentistry Research Institute, Department of Oral Medicine, Faculty of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Pouyan Aminishakib
- Oral and Maxillofacial Pathology Department, Pathology Department, School of Dentistry, Cancer Institute Hospital, IKHC, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Ansari
- School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
26
|
Koksal GM, Beyoglu CA, Esquinas AM. How Can We Prevent Postoperative Pneumonia. Am Surg 2020. [DOI: 10.1177/000313482008600126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Guniz M. Koksal
- Department of Anesthesiology and Reanimation Cerrahpasa Medical Faculty Istanbul Cerrahpasa University Istanbul, Turkey
| | - Cigdem A. Beyoglu
- Department of Anesthesiology and Reanimation Cerrahpasa Medical Faculty Istanbul Cerrahpasa University Istanbul, Turkey
| | - Antonio M. Esquinas
- Intensive Care and Non Invasive Ventilatory Unit Hospital Morales Meseguer Murcia, Spain
| |
Collapse
|
27
|
Kapoor M. Reducing the viral load while securing the airway. J Anaesthesiol Clin Pharmacol 2020; 36:S147-S148. [PMID: 33100668 PMCID: PMC7573992 DOI: 10.4103/joacp.joacp_229_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 11/04/2022] Open
|
28
|
Kottmann HE, Derman SHM, Noack MJ, Barbe AG. The underestimated problem of oral Candida colonization-An observational pilot study in one nursing home. Clin Exp Dent Res 2019; 5:683-691. [PMID: 31890306 PMCID: PMC6934342 DOI: 10.1002/cre2.238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/02/2019] [Accepted: 08/07/2019] [Indexed: 01/22/2023] Open
Abstract
Objectives Older people are at increased risk of intraoral yeast colonization. In this observational case series, we assessed Candida colonization among nine nursing home residents to investigate possible correlations with their individual characteristics, general health parameters, and oral care. We also described the effect of professional dental cleaning (PDC) including prosthesis cleaning on colonization cases. Materials and methods General clinical and oral health was assessed in nine residents, and samples were taken from six oral mucosa sites or prosthetic surfaces. PDC was performed to achieve macroscopically clean results, and residents were re-examined 2 weeks later. Results We found that six residents were intraorally colonized with Candida albicans; four also had Candida glabrata. Prostheses were particularly infected. Dementia, multimorbidity, and presence of prostheses reduced oral hygiene ability; requiring assistance for oral hygiene care was a risk indicator for Candida colonization. PDC reduced C. albicans (at the expense of increased C. glabrata) but was not optimal for maintaining Candida reduction. Conclusion In this pilot study, Candida colonization is prevalent among nursing home residents, especially those with cognitive impairment, multimorbidity, or reduced oral hygiene capacity. Potential negative effects on general health necessitate diagnostic and therapeutic guidelines. PDC alone did not maintain the reduction in Candida colonization; additional methods for daily oral care are necessary.
Collapse
Affiliation(s)
- Hannah Elisa Kottmann
- Centre of Dental Medicine, Department of Operative Dentistry and PeriodontologyUniversity of CologneKölnGermany
| | - Sonja Henny Maria Derman
- Centre of Dental Medicine, Department of Operative Dentistry and PeriodontologyUniversity of CologneKölnGermany
| | - Michael Johannes Noack
- Centre of Dental Medicine, Department of Operative Dentistry and PeriodontologyUniversity of CologneKölnGermany
| | - Anna Greta Barbe
- Centre of Dental Medicine, Department of Operative Dentistry and PeriodontologyUniversity of CologneKölnGermany
| |
Collapse
|
29
|
Commentary: The power (under control) of meta-analysis in the synthesis of clinical knowledge. J Thorac Cardiovasc Surg 2019; 158:1101-1102. [PMID: 30797584 DOI: 10.1016/j.jtcvs.2019.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 11/19/2022]
|