Center for Disease Control and Prevention (CDC) criteria of DSWI (modified from Mangan et al[5])
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\n'}],latestNews:[{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"},{slug:"intechopen-s-chapter-awarded-the-guenther-von-pannewitz-preis-2020-20200715",title:"IntechOpen's Chapter Awarded the Günther-von-Pannewitz-Preis 2020"}]},book:{item:{type:"book",id:"5802",leadTitle:null,fullTitle:"Ion Implantation - Research and Application",title:"Ion Implantation",subtitle:"Research and Application",reviewType:"peer-reviewed",abstract:"Ion implantation is one of the promising areas of sciences and technologies. It has been observed as a continuously evolving technology. In this book, there is a detailed overview of the recent ion implantation research and innovation along with the existing ion implantation technological issues especially in microelectronics. The book also reviews the basic knowledge of the radiation-induced defects production during the ion implantation in case of a semiconductor structure for fabrication and development of the required perfect microelectronic devices. The improvement of the biocompatibility of biomaterials by ion implantation, which is a hot research topic, has been summarized in the book as well. Moreover, advanced materials characterization techniques are also covered in this book to evaluate the ion implantation impact on the materials.",isbn:"978-953-51-3238-7",printIsbn:"978-953-51-3237-0",pdfIsbn:"978-953-51-4793-0",doi:"10.5772/65528",price:119,priceEur:129,priceUsd:155,slug:"ion-implantation-research-and-application",numberOfPages:152,isOpenForSubmission:!1,isInWos:1,hash:"b7a1bd893c9f0b454cf061b5906d99de",bookSignature:"Ishaq Ahmad",publishedDate:"June 14th 2017",coverURL:"https://cdn.intechopen.com/books/images_new/5802.jpg",numberOfDownloads:6199,numberOfWosCitations:1,numberOfCrossrefCitations:1,numberOfDimensionsCitations:3,hasAltmetrics:0,numberOfTotalCitations:5,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 3rd 2016",dateEndSecondStepPublish:"October 24th 2016",dateEndThirdStepPublish:"January 20th 2017",dateEndFourthStepPublish:"April 20th 2017",dateEndFifthStepPublish:"June 19th 2017",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,editors:[{id:"25524",title:"Prof.",name:"Ishaq",middleName:null,surname:"Ahmad",slug:"ishaq-ahmad",fullName:"Ishaq Ahmad",profilePictureURL:"https://mts.intechopen.com/storage/users/25524/images/system/25524.jpg",biography:"Ishaq Ahmad joined the National Centre for Physics in 1999 and currently holds the positions of Director, Experimental Physics Department, National Centre for Physics, Islamabad, and Co-Director of NPU-NCP Joint International Research Centre on Advanced Nanomaterials and Defects Engineering, Northwestern Polytechnical University, Xian, China. He has co-authored more than 130 publications in SCI journals and supervised several master’s, PhD, and postdoctoral students. He has published a number of books and book chapters. His research interests are focused on ion implantation, radiation-induced modification of materials/nanomaterials, synthesis of nanomaterials/thin films, and ion beam analysis of materials. He is a senior fellow of UNESCO UNISA AFRICA Chair in Nanosciences/Nanotechnology, South Africa. He was a TWAS-UNESCO-iThemba LABS research associate from 2014 to 2016. He obtained his PhD at the Graduate University of the Chinese Academy of Sciences, China.",institutionString:"National Center for Physics",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"4",institution:{name:"Quaid-i-Azam University",institutionURL:null,country:{name:"Pakistan"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"953",title:"Thermal Engineering",slug:"metals-and-nonmetals-thermal-engineering"}],chapters:[{id:"55259",title:"Introductory Chapter: Introduction to Ion Implantation",doi:"10.5772/intechopen.68785",slug:"introductory-chapter-introduction-to-ion-implantation",totalDownloads:1289,totalCrossrefCites:0,totalDimensionsCites:1,signatures:"Ishaq Ahmad and Waheed Akram",downloadPdfUrl:"/chapter/pdf-download/55259",previewPdfUrl:"/chapter/pdf-preview/55259",authors:[{id:"204045",title:"Dr.",name:"Ishaq",surname:"Ahmad",slug:"ishaq-ahmad",fullName:"Ishaq Ahmad"}],corrections:null},{id:"54711",title:"Metal Ions Implantation‐Induced Effects in GaN Thin Films",doi:"10.5772/68042",slug:"metal-ions-implantation-induced-effects-in-gan-thin-films",totalDownloads:854,totalCrossrefCites:0,totalDimensionsCites:0,signatures:"Ghulam Husnain and Morgan Madhuku",downloadPdfUrl:"/chapter/pdf-download/54711",previewPdfUrl:"/chapter/pdf-preview/54711",authors:[{id:"198564",title:"Dr.",name:"Ghulam",surname:"Husnain",slug:"ghulam-husnain",fullName:"Ghulam Husnain"},{id:"198568",title:"Dr.",name:"Morgan",surname:"Madhuku",slug:"morgan-madhuku",fullName:"Morgan Madhuku"}],corrections:null},{id:"54446",title:"MeV Electron Irradiation of Ion-Implanted Si-SiO2 Structures",doi:"10.5772/67761",slug:"mev-electron-irradiation-of-ion-implanted-si-sio2-structures",totalDownloads:823,totalCrossrefCites:0,totalDimensionsCites:0,signatures:"Sonia B. Kaschieva and Sergey N. Dmitriev",downloadPdfUrl:"/chapter/pdf-download/54446",previewPdfUrl:"/chapter/pdf-preview/54446",authors:[{id:"199109",title:"D.Sc.",name:"Sonia",surname:"Kaschieva",slug:"sonia-kaschieva",fullName:"Sonia Kaschieva"},{id:"199111",title:"Prof.",name:"Sergey N.",surname:"Dmitriev",slug:"sergey-n.-dmitriev",fullName:"Sergey N. Dmitriev"}],corrections:null},{id:"54532",title:"Ion-Beam-Induced Defects in CMOS Technology: Methods of Study",doi:"10.5772/67760",slug:"ion-beam-induced-defects-in-cmos-technology-methods-of-study",totalDownloads:1069,totalCrossrefCites:0,totalDimensionsCites:1,signatures:"Yanina G. Fedorenko",downloadPdfUrl:"/chapter/pdf-download/54532",previewPdfUrl:"/chapter/pdf-preview/54532",authors:[{id:"199149",title:"Dr.",name:"Yanina",surname:"Fedorenko",slug:"yanina-fedorenko",fullName:"Yanina Fedorenko"}],corrections:null},{id:"54561",title:"Development of Optical Waveguides Through Multiple-Energy Ion Implantations",doi:"10.5772/67829",slug:"development-of-optical-waveguides-through-multiple-energy-ion-implantations",totalDownloads:1165,totalCrossrefCites:1,totalDimensionsCites:1,signatures:"Heriberto Márquez Becerra, Gloria V. Vázquez, Eder G. Lizárraga-\nMedina, Raúl Rangel-Rojo, David Salazar and Alicia Oliver",downloadPdfUrl:"/chapter/pdf-download/54561",previewPdfUrl:"/chapter/pdf-preview/54561",authors:[{id:"7229",title:"Dr.",name:"Raul",surname:"Rangel-Rojo",slug:"raul-rangel-rojo",fullName:"Raul Rangel-Rojo"},{id:"126639",title:"Dr.",name:"Alicia",surname:"Oliver",slug:"alicia-oliver",fullName:"Alicia Oliver"},{id:"199002",title:"Dr.",name:"Heriberto",surname:"Marquez",slug:"heriberto-marquez",fullName:"Heriberto Marquez"},{id:"199078",title:"Dr.",name:"Gloria Veronica",surname:"Vazquez",slug:"gloria-veronica-vazquez",fullName:"Gloria Veronica Vazquez"},{id:"205046",title:"Dr.",name:"Eder",surname:"Lizarraga",slug:"eder-lizarraga",fullName:"Eder Lizarraga"},{id:"205047",title:"Dr.",name:"David",surname:"Salazar",slug:"david-salazar",fullName:"David Salazar"}],corrections:null},{id:"54806",title:"Surface Modification of Silicone Rubber by Ion Implantation to Improve Biocompatibility",doi:"10.5772/intechopen.68298",slug:"surface-modification-of-silicone-rubber-by-ion-implantation-to-improve-biocompatibility",totalDownloads:999,totalCrossrefCites:0,totalDimensionsCites:0,signatures:"Xin Zhou, Yiming Zhang, Xiaohua Shi and Dongli Fan",downloadPdfUrl:"/chapter/pdf-download/54806",previewPdfUrl:"/chapter/pdf-preview/54806",authors:[{id:"198994",title:"Dr.",name:"Dongli",surname:"Fan",slug:"dongli-fan",fullName:"Dongli Fan"},{id:"199084",title:"MSc.",name:"Xin",surname:"Zhou",slug:"xin-zhou",fullName:"Xin Zhou"},{id:"199085",title:"Dr.",name:"Yiming",surname:"Zhang",slug:"yiming-zhang",fullName:"Yiming Zhang"},{id:"199126",title:"Dr.",name:"Xiaohua",surname:"Shi",slug:"xiaohua-shi",fullName:"Xiaohua Shi"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},relatedBooks:[{type:"book",id:"6140",title:"Accelerator Physics",subtitle:"Radiation Safety and Applications",isOpenForSubmission:!1,hash:"f68c778ce6d0271e05997c75618cd6b6",slug:"accelerator-physics-radiation-safety-and-applications",bookSignature:"Ishaq Ahmad and Maaza Malek",coverURL:"https://cdn.intechopen.com/books/images_new/6140.jpg",editedByType:"Edited by",editors:[{id:"25524",title:"Prof.",name:"Ishaq",surname:"Ahmad",slug:"ishaq-ahmad",fullName:"Ishaq Ahmad"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8188",title:"Ion Beam Techniques and Applications",subtitle:null,isOpenForSubmission:!1,hash:"4f212072e7141ba20788b6fe79d28370",slug:"ion-beam-techniques-and-applications",bookSignature:"Ishaq Ahmad and Tingkai Zhao",coverURL:"https://cdn.intechopen.com/books/images_new/8188.jpg",editedByType:"Edited by",editors:[{id:"25524",title:"Prof.",name:"Ishaq",surname:"Ahmad",slug:"ishaq-ahmad",fullName:"Ishaq Ahmad"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6845",title:"Graphene and Its Derivatives",subtitle:"Synthesis and Applications",isOpenForSubmission:!1,hash:"63a9783e678fc42ce981efb35be02096",slug:"graphene-and-its-derivatives-synthesis-and-applications",bookSignature:"Ishaq Ahmad and Fabian I. Ezema",coverURL:"https://cdn.intechopen.com/books/images_new/6845.jpg",editedByType:"Edited by",editors:[{id:"25524",title:"Prof.",name:"Ishaq",surname:"Ahmad",slug:"ishaq-ahmad",fullName:"Ishaq Ahmad"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3480",title:"Recent Developments in the Study of Recrystallization",subtitle:null,isOpenForSubmission:!1,hash:"a56b6e28967152fcfcce3021465d0709",slug:"recent-developments-in-the-study-of-recrystallization",bookSignature:"Peter Wilson",coverURL:"https://cdn.intechopen.com/books/images_new/3480.jpg",editedByType:"Edited by",editors:[{id:"92584",title:"Prof.",name:"Peter",surname:"Wilson",slug:"peter-wilson",fullName:"Peter Wilson"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2448",title:"Heat Treatment",subtitle:"Conventional and Novel Applications",isOpenForSubmission:!1,hash:"fe6f42d3837b5d92c89a243b4829515f",slug:"heat-treatment-conventional-and-novel-applications",bookSignature:"Frank Czerwinski",coverURL:"https://cdn.intechopen.com/books/images_new/2448.jpg",editedByType:"Edited by",editors:[{id:"16295",title:"Dr.",name:"Frank",surname:"Czerwinski",slug:"frank-czerwinski",fullName:"Frank Czerwinski"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2183",title:"Shape Memory Alloys",subtitle:"Processing, Characterization and Applications",isOpenForSubmission:!1,hash:"99c926b3930c93145173801b18b8a5aa",slug:"shape-memory-alloys-processing-characterization-and-applications",bookSignature:"Francisco Manuel Braz Fernandes",coverURL:"https://cdn.intechopen.com/books/images_new/2183.jpg",editedByType:"Edited by",editors:[{id:"147555",title:"Dr.",name:"Francisco Manuel",surname:"Braz Fernandes",slug:"francisco-manuel-braz-fernandes",fullName:"Francisco Manuel Braz Fernandes"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],ofsBooks:[]},correction:{item:{id:"72181",slug:"corrigendum-to-potassium-channels-as-a-potential-target-spot-for-drugs",title:"Corrigendum to: Potassium Channels as a Potential Target Spot for Drugs",doi:null,correctionPDFUrl:"https://cdn.intechopen.com/pdfs/72181.pdf",downloadPdfUrl:"/chapter/pdf-download/72181",previewPdfUrl:"/chapter/pdf-preview/72181",totalDownloads:null,totalCrossrefCites:null,bibtexUrl:"/chapter/bibtex/72181",risUrl:"/chapter/ris/72181",chapter:{id:"71907",slug:"potassium-channels-as-a-potential-target-spot-for-drugs",signatures:"Vladimir Djokic and Radmila Novakovic",dateSubmitted:"October 13th 2019",dateReviewed:"March 18th 2020",datePrePublished:"April 28th 2020",datePublished:"December 16th 2020",book:{id:"10143",title:"Molecular Pharmacology",subtitle:null,fullTitle:"Molecular Pharmacology",slug:"molecular-pharmacology",publishedDate:"December 16th 2020",bookSignature:"Angel Catala and Usama Ahmad",coverURL:"https://cdn.intechopen.com/books/images_new/10143.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"196544",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"313382",title:"Ph.D.",name:"Radmila",middleName:null,surname:"Novakovic",fullName:"Radmila Novakovic",slug:"radmila-novakovic",email:"radmila.novakovic@med.bg.ac.rs",position:null,institution:null}]}},chapter:{id:"71907",slug:"potassium-channels-as-a-potential-target-spot-for-drugs",signatures:"Vladimir Djokic and Radmila Novakovic",dateSubmitted:"October 13th 2019",dateReviewed:"March 18th 2020",datePrePublished:"April 28th 2020",datePublished:"December 16th 2020",book:{id:"10143",title:"Molecular Pharmacology",subtitle:null,fullTitle:"Molecular Pharmacology",slug:"molecular-pharmacology",publishedDate:"December 16th 2020",bookSignature:"Angel Catala and Usama Ahmad",coverURL:"https://cdn.intechopen.com/books/images_new/10143.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"196544",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"313382",title:"Ph.D.",name:"Radmila",middleName:null,surname:"Novakovic",fullName:"Radmila Novakovic",slug:"radmila-novakovic",email:"radmila.novakovic@med.bg.ac.rs",position:null,institution:null}]},book:{id:"10143",title:"Molecular Pharmacology",subtitle:null,fullTitle:"Molecular Pharmacology",slug:"molecular-pharmacology",publishedDate:"December 16th 2020",bookSignature:"Angel Catala and Usama Ahmad",coverURL:"https://cdn.intechopen.com/books/images_new/10143.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"196544",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},ofsBook:{item:{type:"book",id:"6870",leadTitle:null,title:"Novel Metal Electrodeposition and the Recent Application",subtitle:null,reviewType:"peer-reviewed",abstract:"Gold and noble metals have been attractive to humans from ancient times because of their beautiful features. In modern society, noble metals, especially gold, play important roles as components in electronic devices because of their high electrical conductivity, chemical stability, and density. In the field of MEMS devices, the demand for continuous miniaturization and sensitivity enhancement is always high. Especially for MEMS accelerometers, sensitivity is affected by Brownian noise, and components with sufficient mass are needed to suppress this noise. Therefore, it is difficult to reduce the dimensions of components to allow further miniaturization of the device. This book presents recent progress in noble metal electrodeposition and applications of gold-based materials in the realization of highly sensitive CMOS-MEMS accelerometers.",isbn:"978-1-78985-296-7",printIsbn:"978-1-78985-295-0",pdfIsbn:"978-1-83962-063-8",doi:"10.5772/intechopen.73382",price:119,priceEur:129,priceUsd:155,slug:"novel-metal-electrodeposition-and-the-recent-application",numberOfPages:168,isOpenForSubmission:!1,hash:"be9124dc8c5a6c7c7d367cac1ac9062a",bookSignature:"Masato Sone and Kazuya Masu",publishedDate:"March 6th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/6870.jpg",keywords:null,numberOfDownloads:4507,numberOfWosCitations:0,numberOfCrossrefCitations:1,numberOfDimensionsCitations:2,numberOfTotalCitations:3,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 19th 2018",dateEndSecondStepPublish:"May 10th 2018",dateEndThirdStepPublish:"July 9th 2018",dateEndFourthStepPublish:"September 27th 2018",dateEndFifthStepPublish:"November 26th 2018",remainingDaysToSecondStep:"3 years",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:"Edited by",kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"157966",title:"Prof.",name:"Masato",middleName:null,surname:"Sone",slug:"masato-sone",fullName:"Masato Sone",profilePictureURL:"https://mts.intechopen.com/storage/users/157966/images/system/157966.png",biography:"Prof. Masato Sone completed his doctor degree in engineering at the age of 28 at Tokyo Institute of Technology. He worked as a researcher in the Nippon Oil Company from 1996 to 2000. He was an assistant professor and then a research associate professor at Tokyo University of Agriculture and Technology from 2000 to 2005. He attained his current position of associate professor and full professor at Tokyo Institute of Technology in 2005. He has published more than 170 papers in scientific journals. His interests are microelectronics, metallurgy, surface finishing, chemical engineering, and liquid crystal and polymer science. His recent topic of interest is material design and the evaluation of electroplated gold alloys for high-sensitivity CMOS-MEMS accelerometers.",institutionString:"Tokyo Institute of Technology",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Tokyo Institute of Technology",institutionURL:null,country:{name:"Japan"}}}],coeditorOne:{id:"255244",title:"Dr.",name:"Kazuya",middleName:null,surname:"Masu",slug:"kazuya-masu",fullName:"Kazuya Masu",profilePictureURL:"https://mts.intechopen.com/storage/users/255244/images/system/255244.jpg",biography:"Prof. Kazuya Masu received B.E., M.E. and Ph.D. degrees in Electronics Engineering from Tokyo Tech. He was an assistant professor and an associate professor with Tohoku University from 1982. In 2000, he moved to Tokyo Tech. He is currently a professor and Director-General of Institute of Innovative Research, Tokyo Tech. He was a visiting Professor in Georgia Institute of Technology in 2002 and 2005. He has published more than 225 papers in scientific journals. He received IEICE Electronics Society Award in 2004, IEICE Achievement Award in 2013, and IEEJ Outstanding Achievement Award in 2014. He served as Vice President of JSAP in 2014-2015. He is JSAP Fellow, IEEJ Fellow, and IEICE Fellow.",institutionString:"Tokyo Institute of Technology",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"158",title:"Metals and Nonmetals",slug:"metals-and-nonmetals"}],chapters:[{id:"63477",title:"Evaluation Methods of Mechanical Properties of Micro-Sized Specimens",slug:"evaluation-methods-of-mechanical-properties-of-micro-sized-specimens",totalDownloads:586,totalCrossrefCites:0,authors:[null]},{id:"64415",title:"Morphology Controlled Synthesis of the Nanostructured Gold by Electrodeposition Techniques",slug:"morphology-controlled-synthesis-of-the-nanostructured-gold-by-electrodeposition-techniques",totalDownloads:559,totalCrossrefCites:1,authors:[null]},{id:"64406",title:"Cu Wiring Fabrication by Supercritical Fluid Deposition for MEMS Devices",slug:"cu-wiring-fabrication-by-supercritical-fluid-deposition-for-mems-devices",totalDownloads:525,totalCrossrefCites:0,authors:[null]},{id:"63479",title:"Pulse-Current Electrodeposition of Gold",slug:"pulse-current-electrodeposition-of-gold",totalDownloads:532,totalCrossrefCites:0,authors:[null]},{id:"64201",title:"Electrodeposition of Gold Alloys and the Mechanical Properties",slug:"electrodeposition-of-gold-alloys-and-the-mechanical-properties",totalDownloads:555,totalCrossrefCites:0,authors:[null]},{id:"64607",title:"Hard Pure-Gold and Gold-CNT Composite Plating Using Electrodeposition Technique with Environmentally Friendly Sulfite Bath",slug:"hard-pure-gold-and-gold-cnt-composite-plating-using-electrodeposition-technique-with-environmentally",totalDownloads:589,totalCrossrefCites:0,authors:[null]},{id:"64769",title:"Electrodeposition of High-Functional Metal Oxide on Noble Metal for MEMS Devices",slug:"electrodeposition-of-high-functional-metal-oxide-on-noble-metal-for-mems-devices",totalDownloads:482,totalCrossrefCites:0,authors:[null]},{id:"64336",title:"Multi-Physics Simulation Platform and Multi-Layer Metal Technology for CMOS-MEMS Accelerometer with Gold Proof Mass",slug:"multi-physics-simulation-platform-and-multi-layer-metal-technology-for-cmos-mems-accelerometer-with-",totalDownloads:680,totalCrossrefCites:0,authors:[null]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"252211",firstName:"Sara",lastName:"Debeuc",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/252211/images/7239_n.png",email:"sara.d@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"6426",title:"Titanium Dioxide",subtitle:"Material for a Sustainable Environment",isOpenForSubmission:!1,hash:"5626c0fe0b53330717e73094946cfd86",slug:"titanium-dioxide-material-for-a-sustainable-environment",bookSignature:"Dongfang Yang",coverURL:"https://cdn.intechopen.com/books/images_new/6426.jpg",editedByType:"Edited by",editors:[{id:"177814",title:"Dr.",name:"Dongfang",surname:"Yang",slug:"dongfang-yang",fullName:"Dongfang Yang"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6282",title:"Noble and Precious Metals",subtitle:"Properties, Nanoscale Effects and Applications",isOpenForSubmission:!1,hash:"e4c28d6be4fd7b5f5b787d4dabbf721b",slug:"noble-and-precious-metals-properties-nanoscale-effects-and-applications",bookSignature:"Mohindar Singh Seehra and Alan D. Bristow",coverURL:"https://cdn.intechopen.com/books/images_new/6282.jpg",editedByType:"Edited by",editors:[{id:"48086",title:"Prof.",name:"Mohindar",surname:"Seehra",slug:"mohindar-seehra",fullName:"Mohindar Seehra"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7213",title:"Shape-Memory Materials",subtitle:null,isOpenForSubmission:!1,hash:"4e3e756cd4f8a8617dffdc36f8dce7c7",slug:"shape-memory-materials",bookSignature:"Alicia Esther Ares",coverURL:"https://cdn.intechopen.com/books/images_new/7213.jpg",editedByType:"Edited by",editors:[{id:"91095",title:"Dr.",name:"Alicia Esther",surname:"Ares",slug:"alicia-esther-ares",fullName:"Alicia Esther Ares"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6529",title:"Bismuth",subtitle:"Advanced Applications and Defects Characterization",isOpenForSubmission:!1,hash:"55ed997d678e9c18382af23ab873ba85",slug:"bismuth-advanced-applications-and-defects-characterization",bookSignature:"Ying Zhou, Fan Dong and Shengming Jin",coverURL:"https://cdn.intechopen.com/books/images_new/6529.jpg",editedByType:"Edited by",editors:[{id:"176372",title:"Prof.",name:"Ying",surname:"Zhou",slug:"ying-zhou",fullName:"Ying Zhou"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5825",title:"Superalloys for Industry Applications",subtitle:null,isOpenForSubmission:!1,hash:"4cbaaafeb4958d641b74988e33229020",slug:"superalloys-for-industry-applications",bookSignature:"Sinem Cevik",coverURL:"https://cdn.intechopen.com/books/images_new/5825.jpg",editedByType:"Edited by",editors:[{id:"117212",title:"MSc.",name:"Sinem",surname:"Cevik",slug:"sinem-cevik",fullName:"Sinem Cevik"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8787",title:"Bismuth",subtitle:"Fundamentals and Optoelectronic Applications",isOpenForSubmission:!1,hash:"7751170d0b538f61d14a27a56e6567a5",slug:"bismuth-fundamentals-and-optoelectronic-applications",bookSignature:"Yanhua Luo, Jianxiang Wen and Jianzhong Zhang",coverURL:"https://cdn.intechopen.com/books/images_new/8787.jpg",editedByType:"Edited by",editors:[{id:"226148",title:"Dr.",name:"Yanhua",surname:"Luo",slug:"yanhua-luo",fullName:"Yanhua Luo"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9949",title:"Lead Chemistry",subtitle:null,isOpenForSubmission:!1,hash:"b2f999b9583c748f957f612227976570",slug:"lead-chemistry",bookSignature:"Pipat Chooto",coverURL:"https://cdn.intechopen.com/books/images_new/9949.jpg",editedByType:"Edited by",editors:[{id:"197984",title:"Ph.D.",name:"Pipat",surname:"Chooto",slug:"pipat-chooto",fullName:"Pipat Chooto"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7787",title:"Rare Earth Elements and Their Minerals",subtitle:null,isOpenForSubmission:!1,hash:"7ba4060b0830f7a68f00557da8ed8a39",slug:"rare-earth-elements-and-their-minerals",bookSignature:"Michael Aide and Takahito Nakajima",coverURL:"https://cdn.intechopen.com/books/images_new/7787.jpg",editedByType:"Edited by",editors:[{id:"185895",title:"Dr.",name:"Michael",surname:"Aide",slug:"michael-aide",fullName:"Michael Aide"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7775",title:"Metallic Glasses",subtitle:null,isOpenForSubmission:!1,hash:"665fb007e1e410d119fc09d709c41cc3",slug:"metallic-glasses",bookSignature:"Dragica Minić and Milica Vasić",coverURL:"https://cdn.intechopen.com/books/images_new/7775.jpg",editedByType:"Edited by",editors:[{id:"30470",title:"Prof.",name:"Dragica",surname:"Minić",slug:"dragica-minic",fullName:"Dragica Minić"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"43520",title:"Current Challenges in the Treatment of Deep Sternal Wound Infection Following Cardiac Surgery",doi:"10.5772/55310",slug:"current-challenges-in-the-treatment-of-deep-sternal-wound-infection-following-cardiac-surgery",body:'Median sternotomy due to its technical simplicity and excellent exposure of the heart, great vessels and pulmonary hila is the most common incision performed in cardiothoracic surgery worldwide [1]. Originally described by Julian more than 100 years ago and re-induced by Milton in 1957, median sternotomy replaced gradually thoracotomy or bilateral transverse sternothoracotomy (clamshell incision) for routine access to the heart [2,3]. Even though median sternotomy is still considered to be the gold standard, efforts remain ongoing to use less invasive methods such as partial sternotomy or small thoracotomy to influence the risk of wound healing complications, patient’s satisfaction and better quality of life [4].
Infection involving the sternal bones and/or retrosternal space is a serious complication of median sternotomy. Although, DSWI can be described from many perspectives, the definition according to the Center for Disease Control and Prevention (CDC), is used for distinguishing DSWI from others types of sternal wound infections (SWIs), and is respected by most authors (Table 1) [5]. Looking through the incidence of DSWI ranging between 0.3 to 3.2%, no considerable changes have been observed in the incidence of DSWI over the last 30 years [6-22]. It could be perceived that the numerous advances in cardiac surgery, post-operative care and employment of preventive measurements may have played a role in reducing the incidence of DSWI in the last 10 years. Today surgically treated patients’ cohorts are different than patients operated on 20 years ago in terms of advanced age, co-morbidities, and surgical complexity. In other words, the relatively steady status of DSWI incidence over the last three decades might be considered a satisfactory result [23]. Recently Matros et al showed from a large single institution experience with 21,000 sternotomies a reduction in the incidence of DSWI from 1.57 to 0.88% in the last 15 years. They concluded that the rate of DSWI was significantly diminished particularly in the diabetic population, from 3.2% to 1.0%, related to tight glycemic control [19].
\n\t\t\t\tDiagnosis of DSWI requires at least one of the following criteria:\n\t\t\t | \n\t\t
(1) anorganism is isolated from culture of mediastinal tissue or fluid | \n\t\t
(2) evidence of mediastinitis is seen during operation or byhistopathological examination | \n\t\t
(3) one of the following, fever("/>38º C), chest pain, or sternal instability, is present\n\t | \n
and there is either purulent drainage from the mediastinum | \n
or an organism isolated from blood culture or culture of drainage of the mediastinal area | \n
Center for Disease Control and Prevention (CDC) criteria of DSWI (modified from Mangan et al[5])
The identification of risk factors for the development of DSWI is crucial in the effort to reduce the risk of infection [6-22]. Although more than two dozen factors were obtained for uni-, and multivariable analyses, only obesity and diabetes mellitus were constantly proven in published studies [6-18,21,22]. Obesity is a strong risk factor for development of DSWI. Even though BMI does not correlate closely with body fat, there is a step-wise relationship between BMI and the risk of major surgical infection in cardiac surgery [7,15,24]. It is caused not only through technical obesity-related problems, but also through less effective penetration of antibiotics into the fat tissue [24]. Undoubtedly, diabetics are at a higher risk of developing DSWI, making the role of perioperative glycemic control crucial. Unsatisfactory preoperative glycemic control is considered to be an important risk factor for development of DSWI [25,26]. Internal mammary artery (IMA) harvesting, particularly in the pedicled fashion, has been found to have a higher incidence of DSWI in a CABG cohort compared with valvular procedures [7,8]. Furthermore, this risk becomes stronger when both IMA are used for revascularization or in the diabetic population, but this effect might be attenuated when both IMA are taken down in a skeletonized fashion, even in diabetics [10,27,28]. Chronic obstructive pulmonary disease (COPD) or smoking increases the risk of infectious complications, prolonged post-operative ventilation, and jeopardizes sternal stability from excessive coughing [6,12,15]. Data addressing the impact of early tracheostomy on DSWI incidence is conflicting [29-31]. Historically, a strong relationship between early tracheostomy and DSWI has not been confirmed; but tracheostomy is known to reduce the need for mechanical ventilation and thereby may limit risk of pulmonary infection and ICU stay [32]. Furthermore, re-exploration for bleeding has been analyzed as an independent risk factor for DSWI in several studies [11,12]. The components of this risk factor include the risk of iatrogenic bacteriological wound contamination within the inherent re-exposure, the deleterious effect of anemia and/or concomitant hemodynamic instability, and the amount of given allogenic blood transfusion units [10,33]. Other factors traditionally associated with an increased risk of DSWI are inconsistently seen in analyses of retrospective studies including advanced age, emergency surgery, hemodynamic instability, low ejection fraction, duration of surgery and CPB time, and renal failure [6-22]. Incidence and risk factors based on multivariable analysis from larger retrospective studies are summarized in Table 2.
\n\t\t\tAuthors\n\t\t | \n\t\t\n\t\t\tPatients´ enrollement\n\t\t | \n\t\t\n\t\t\tNo. of patients\n\t\t | \n\t\t\n\t\t\tDSWI incidence\n\t\t | \n\t\t\n\t\t\tIndependent risk factors\n\t\t | \n\t
Loop FD et al [6] | \n\t\t1985-1987 | \n\t\t6504 | \n\t\t1.1% | \n\t\tObesity, BIMA+diabetes, time of operation, | \n\t
Milano CA et al [7] | \n\t\t1987-1995 | \n\t\t6459 | \n\t\t1.3% | \n\t\tObesity, CHF, re-do surgery, CPB time | \n\t
Braxton et al [8] | \n\t\t1992-1996 | \n\t\t15406 | \n\t\t1.25% | \n\t\tObesity, low EF, COPD | \n\t
Eklund et al [9] | \n\t\t1990-1999 | \n\t\t10713 | \n\t\t1.1% | \n\t\tObesity, BMI | \n\t
The Parisian Mediastinitis Study Group [10] | \n\t\t1996 | \n\t\t1830 | \n\t\tNA | \n\t\tObesity, BIMA, hemodynamic instability, re-do surgery | \n\t
Hollenbeak et al [11] | \n\t\t1996-1998 | \n\t\t1519 | \n\t\t2.7% | \n\t\tObesity, renal inssuficieny, re-exploration | \n\t
Filsouri et al [12] | \n\t\t1998-2005 | \n\t\t5798 | \n\t\t1.80% | \n\t\tObesity, MI, diabetes, COPD, CPB time, re-exploration, prolonged ventilation | \n\t
Tang et al [13] | \n\t\t1990-2003 | \n\t\t30102 | \n\t\t0.77% | \n\t\tAge, diabetes, stroke, CHF, BIMA+diabetes/CHF | \n\t
Toumpoulis et al [14] | \n\t\t1992-2002 | \n\t\t3760 | \n\t\t1.1% | \n\t\tDiabetes,dialysis, hemodynamic instability, BIMA | \n\t
Risnes et al [15] | \n\t\t1989-2000 | \n\t\t18532 | \n\t\t0.6% | \n\t\tAge, male gender, obesity, COPD, diabetes | \n\t
Crabtree et al [16] | \n\t\t1996-2003 | \n\t\t4004 | \n\t\t2.2% | \n\t\tObesity, diabetes,"/>2 transfusion units | \n
Fowler et al [17] | \n\t2002-2003 | \n\t331429 | \n\tNA | \n\tObesity, diabetes, MI, urgent surgery | \n
Sjoegren et al [18] | \n\t1999-2004 | \n\t4781 | \n\t0.95% | \n\tDiabetes, obesity, low EF, renal failure | \n
Matros et al [19] | \n\t1991-2006 | \n\t21000 | \n\t1.35% | \n\tProlonged CPB time | \n
De Feo et al [20] | \n\t1979-2009 | \n\t22366 | \n\t0.89% | \n\tNA | \n
Upton et al [21] | \n\t1998-2003 | \n\t5176 | \n\t1.2% | \n\tDiabetes, urgent surgery, low EF | \n
Sachithanandan et al [22] | \n\t2001-2005 | \n\t4586 | \n\t1.65% | \n\tDiabetes, smoking, age, prolonged ventilation | \n
Analyses of incidence and risk factors of DSWI
NA - not adrressed
BIMA - bilateral IMA harvesting
EF - ejection fraction
COPD - chronic obstructive pulmonary disease
CHF - congestive heart failure
MI - myocardial infaction
Staphylococci, either S. aureus (SA) or coagulase-negative Staphylococcus (CONS) represent the most causative organism of DSWI, accounting for 60 to 80% of cases [34]. The proportion of individual strains of Staphylococcus and their methicillin-sensitivity varies between countries and institutions, reflecting their long-term hygienic and antibiotic policies [35]. Although surgical site infections are typically perceived to be an exogenous problem related to exposure to healthcare workers, the most causative pathogens are endogenous from patient’s own skin or mucosal flora [36,37]. Nasal carriage of SA has been identified as a potential risk factor for DSWI [38], and genetically identical SA from nasal flora have been cultivated from sternotomy wounds [39]. Unlike SA which caused a more aggressive presentation, CONS infection accompanied with bacteremia as observed in 50-60% of cases [34, 40] had a rather indolent course, clinically manifested later, and was more prone to recurrence [41, 42]. DSWI is diagnosed in 40-70% of patients post-discharge, thus post-discharge surveillance of up to 90 days is recommended [43]. Gram negative strains contribute less commonly in the pathogenesis of DSWI and mostly translocate from other host site infections, such as pneumonia, urinary or abdominal infections [34]. Finally, no significant difference in mortality was observed between DSWI infections caused by CoNS, when compared to SA, or Gram-negative pathogens [34]. Mekontso-Dessap et al suggested that DSWI caused by methicillin-resistant SA (MRSA) may have worse actuarial survival than sensitive strains (MSSA) in terms of 1 month, 1-year, and 3- year survival (60.0%±12.6%, 52.5%±-3.4%, and 26.3%±19.7% versus 84.6%±7.1%, 79.0%±8.6%, and 79.0%±-8.65, p=0.04), and a regression analysis revealed MRSA as an independent risk factor for overall mortality [44].
Unsurprisingly, DSWI negatively affected outcomes in cardiac surgery. Even with the adoption of modern treatment strategies, the reported in-hospital mortality for DSWI varies from 1.1 to 19% [6-9,11,16,45]. Although the mortality rate is similar to data reported from the 1980s, it appears that implementation of negative pressure wound therapy (NPWT) may improve long-term survival of patients [18,20,46]. Regardless of treatment strategy, in-hospital stay of DSWI patients is at least two weeks longer compared to patients with an uncomplicated post-operative course [6,10,11]. DSWI-related morbidity was repeatedly reported in relation to prolonged mechanical ventilation, renal impairment, atrial and ventricular arrhythmias, cerebrovascular accidents, need for hemodynamic support, and healing-related complications [20,47]. The cause of death in the early post-operative period is mostly multiple organ failure initiated by sepsis or specific DSWI-related complications such as serious bleeding [6-8,16,18,20]. Predictors of a poor outcome in DSWI patients that have been reported include length of intensive care unit (ICU) stay, late indication for surgical revision, bacteremia, hemodynamic instability, and prolonged mechanical ventilation [47,48]. Loop et al presented the worse survival data of DSWI in patients operated on during the 1980s in comparison with a standard CABG population within a 3-year follow-up after surgery [6]. Survival analyses published in the last decade consistently confirm long-term complications of patients with mid-, and long term survival rates who were successfully treated for DSWI (Table 3) [8,11,12,14,15,18,22,46]. Specific reasons for worsening of long-term survival are not yet clear. Risnes et al reported significantly higher cardiac-related deaths in the post-DSWI group (34.6 vs. 21.4%, p<0.006) and poorer survival for males ten years after surgery [15]. In contrast with this data, Sjoegren et al and Bailot et al showed unimpaired long-term survival of DSWI patients in comparison with patients who had uncomplicated surgery once NPWT was used [18,46].
\n\t\t\tAuthors\n\t\t | \n\t\t\n\t\t\tPatients´ enrollement\n\t\t | \n\t\t\n\t\t\tSurvival analysis\n\t\t | \n\t
Loop FD et al [6] | \n\t\t1985-1987 | \n\t\t3-year survival of 62.5% compared to 69.0% survival for patients with positive cultures. Overall, the 3-year survival was 75%, which is significantly below previously reported 5-year and even 10-year survival for isolated coronary bypass patients | \n\t
Braxton et al [8] | \n\t\t1992-1996 | \n\t\tThe adjusted survival rates at 30 days, 1 year, and 4 years were 93%, 78%, and 65% among patients with mediastinitis and 97%, 95%, and 89% without mediastinitis, respectively (p<0.001) | \n\t
Hollenbeak et al [11] | \n\t\t1996-1998 | \n\t\tDSWI patient had a 1-year survival of 78% vs. 99% for non-infected CABG patients, p=0.0001 | \n\t
Filsouri et al [12] | \n\t\t1998-2005 | \n\t\tSurvival rates at 1,3, and 5 years were 72.4%, 64.3% and 55.8% for patients with DSWI compared with 93.8%, 88% and 82% for the control (p<0.001) | \n\t
Toumpoulis et al [14] | \n\t\t1992-2002 | \n\t\tFreedom from all cause mortality in patients in whom DSWI developed at 1 year, 5 years, and 10 years after the operation was 66.2%, 50.8%, and 40.6% respectively, compared with 87.2%, 72.8%, and 54.3% in patients without DSWI (p=0.0007) | \n\t
Risnes et al [15] | \n\t\t1989-2000 | \n\t\tThe 10-year, long-term survival for patients with mediastinitis was 49.5%, compared with 71.0% in non-mediastinitis patients (p<0.01) | \n\t
Sjoegren et al [18] | \n\t\t1999-2004 | \n\t\tThe actuarial survival at 1 year, 3 years, and 5 years was 92.9% , 89.2%, and 89.2% for patients with mediastinitis and 96.5%, 92.1%, and 86.9 for those without mediastinitis(p=0. 578) | \n\t
Sachithanandan et al [22] | \n\t\t2001-2005 | \n\t\tUnadjusted freedom from all-cause mortality in patients with DSWI at 1 year, 2 years, and 3 years after surgery was 78.6 ± 4.8% (95% CI 69–88.2%), 75.6 ± 5.0% (95% CI 65.6–85.6%) and 69.4 ± 5.8% (95% CI 57.8–81%) respectively compared with 92.8 ± −0.4% (95% CI 92.4–93.2%), 90.7 ± 0.5% (95% CI 90.2–91.2%) and 87.7 ± 0.6% (95% CI 87.1–88.3%) for patients without DSWI (p < 0.001) | \n\t
Bailot et [46] | \n\t\t1992-2007 | \n\t\tSurvival in patients with DSWI showed freedom from all-cause mortality at 1, 5 and 10 years to be, respectively, 91.8%, 80.4% and 61.3% compared with 94.0%, 85.5% and 70.2%, respectively, for patients (p = 0.01). Adjusted survival for patients with DSWI treated with NPWT was 92.8%, 89.8% and 88.0%, respectively, at 1, 2 and 3 years, compared with 83.0%, 76.4% and 61.3%, respectively, for patients with DSWI treated conventionaly(p = 0.02) | \n\t
Analyses of compared mid-term and long-term survival of patients with DSWI with non-DSWI patients
Patients who develop DSWI are 2.5 to 3 times more expensive to manage compared with patients who have an uncomplicated post-operative course [6,11]. The first calculation of cost originated from the Loop et al paper, published in the late 1980´s, and found a 2.8 times increase in cost [6]. Patients who died of DSWI consequences consumed 60,500 USD more, making the total cost of these patients approximately 80,000 USD compared with 11,000 USD an uncomplicated CABG patient cost, as showed by Hollenbeak et al [11]. Recent data from Germany showed a doubling in cost (36,261 vs. 13,356 EUR, p<0.001) for DSWI patients [49], while Ennker et al calculated a 9,000 EUR increase in cost on average for any DSWI case [50]. The majority of the increased cost is spent on repeat surgical and ICU service, and extension of in-hospital stay [11,51,52]. In looking for cost-effectiveness of treatment strategies, NPWT does not seem to be a more expensive treatment in comparison with the conventional therapy for DSWI, as calculated in the Swedish healthcare system by Mokhari et al [52]. Atkins et al reported lower NPWT costs than Medicare charges for conventional therapy (152,000 vs. 300,000 USD) of DSWI [53].
As mentioned previously, diabetes mellitus is a strong independent risk factor for development of DSWI, and concomitant obesity doubles the risk of further infection [24]. Unfortunately, both risk factors are difficult to modify. Zerr et al showed that a continuous insulin infusion started immediately after surgery to maintain a serum glucose level of 150-200mg/dl (8-11 mmol/l) led to a significant decrease in the incidence of DSWI in diabetics (2.4% to 1.5%, p < 0.02) compared with subcutaneously administered insulin [54]. A tight glycemic control protocol appears beneficial from the Portland group experience, nevertheless, decreasing serum glucose below 100mg/dl (6 mmol/l) did not bring any additional impact on DSWI rate, and was associated with a higher risk of stroke or death [55].
It has been demonstrated many times that antibiotic prophylaxis effectively prevents sternal wound infection [56]. As Staphylococcal stains are a major causative pathogen, beta-lactam antiobiotics are recommended for prophylaxis, particularly first or second generation cephalosporins [57]. The use of glycopeptides, which are highly effective against MRSA, has not been linked with a reduction in sternal wound infection rates compared to standard prophylaxis, with one study suggesting higher SSI´s rate (3.7 vs. 1.3%, p<0.05) when vancomycin prophylaxis was chosen [58]. Local application of a gentamicin soaked-collagen sponge between the sternal lamella was suggested to reduce all SWI´s, particularly DSWI. Friberg et al reported a significant reduction in SWI´s (3.7 vs. 9%, p<0.001), and also DSWI (1.5 vs. 3.3%, p<0.003) [59,60], however, further randomized controlled trials and meta-analyses did not confirm a benefit of using a gentamicin sponge for DSWI prevention as well as a recently published meta-analysis [61,62]. Although SA caused DSWI might be reduced by locally applied gentamicin, primarily gentamicin-resistant strains such a CONS may overgrow [62].
Another prophylactic issue is patient decontamination before surgery. As Staphylococci colonization is seen in a majority of DSWI, skin and nasopharyngeal decontamination became popular [38,39]. The use of chlorhexidine for skin care before surgery showed a significant reduction in the microbial count including SA [63]. In comparison to general surgery where reduction of SSI´s due to skin decontamination was confirmed [64], data for cardiac surgery is lacking, nevertheless, protocols involving chlorhexidine or a different skin cleanser are already widely accepted. Locally applied ointment containing mupirocin is 80 to 90% effective in eradicating all types of SA from the nasopharyngeal mucosa [65]. Cimochowski et al reported about the efficacy of this practice on reducing DSWI rates from 2.7% to 0.9% [66]. A randomized controlled trial published by Konvalinka et al did not confirm a reduced DSWI rate from the use of nasal mupirocin ointment (0.8 vs. 0.8%) [67].
The surgical technique in performing median sternotomy and its closure certainly influences the risk of DSWI. Careful handling of skin and pre-sternal soft tissue, mid-lined sternal incision and avoidance of bone wax are essential, in addition to keeping scrub protocol, checking for glove injury, changing gloves after sternotomy and after sternal wiring, and leaving the closed wound primarily covered for at least 48 hours [68].
It has been proposed that the method of IMA harvesting affects the incidence of DSWI, particularly when both IMA (BIMA´s) are demanded for revascularization [7,8,10,27,28]. A recent meta-analysis published by Saso et al showed a reduced risk of SWI´s once IMA or BIMA´s were harvested in a skeletonized fashion compared with a pedicled graft. The risk was reduced both in the non-diabetic (2.96% vs. 11.7%) and diabetic populations (2.4% vs. 14.2%) [69]. Besides harvesting methods of BIMA´s in diabetics, as was mentioned above, tight long-term glycemic control influenced the risk of DSWI. A hemoglobin A1c (HbA1c) ≥7% had a higher incidence of DSWI compared with patients who had a HbA1c <7% (5.0% vs. 1.4%, P = 0.014). A 31% increased risk of DSWI (OR = 1.31, 95% CI 1.16-1.49, P < 0.001) was seen by Halkos et al [26]. Even through diabetic patients may have a comparable risk of developing DSWI when IMA in skeletonized fashion is taken down, the BIMA´s harvesting need is to be considered carefully because additional risk factors such an obesity and COPD are commonly presented in this cohort [24,70].
The crucial point in preventing DSWI is achievement of stable sternal approximation. Standard sternal wire cerclage, if performed well, is fast, easy and effective [71]. Facing poor sternal quality, sternal fracture, or increased traction forces in obese or COPD patients, some modifications of this technique were proposed. Parasternal wire reinforcement, described originally by Robicsek and modified by Sharma, proved to reduce the risk of sternal wound complications [72,73]. Friberg et al reported that the use of more than 6 or 7 simple wires may also reduce DSWI rates (0.4% vs. 4.2%, p=0.001) [74]. Recently, a large multicenter prospective study conducted by Schimmer et al comparing the Robicsek technique with standard cerclage failed to reduce the risk of SWI and sternal dehiscence [75]. Primary plating, mirroring the experience in maxillofacial surgery, was proposed for patients at high risk of sternal non-union [76]. Plates could be anchored only into the sternal bone (SternaLock system™,Biomet Microfixation Inc, Jacksonville, US) or into the ribs (Titanium Sternal Fixation system™, Syntes, Switzeland). Raman et al reported better chest bone healing after primary plating than rewiring at 6-month follow up (70 vs. 24%, p=0.003) and lower pain scores, with no difference in SWI rates [77]. Others systems are used for sternal approximation including, thermoreactive nitinol clips (Flexigrip™, Praesidia SRL, Bologna, Italy), titanium locked staples (Sternal Talon™, KLS Martin Group, US), and Poly-Ether-Ether-Ketone tapes (Sternal ZipFix system™, Syntes, Switzeland), all designed for parasteral fixation. Negri et al reported a significant reduction of mechanical dehiscence (2.8% vs. 0.2%, p=0.002), but the same risk of DSWI (1.2% vs. 2.4%) when thermoactive clips were compared with standard wire cerclage [78]. Snyder et al reported 5 years of experience with the SternaLock system™ for primary plating in high risk patients. Superiority of plate over wires was seen in the incidence of early presentation (<30 days) of SWI (0% vs. 12%, p<0.06) and shorter in-hospital stay (7 vs. 8 days, p=0.02) [79]. A pilot study published by Bennett-Guerrero et al showed insignificantly higher spirometry volume in the SternalTalon™ arm (67% ± 32%) versus the wire arm (58% ± 24%). Use of the Talon was associated with decreased use of opiates (21.3 ± 11.8 vs. 25.4 ± 21.6 mg, P = 0.44), duration of mechanical ventilation (0.5 vs. 1.0 days, P = 0.24) and hospital length of stay (4.5 ± 3.2 vs. 5.3 ± 4.0 days, P = 0.40) [80].
A promising method to reduce SSI seems to be the application of NPWT on surgically closed sternal wounds. A commercially available system (Prevena® Incision Management System, KCI, St. Antonio, USA) is used, with skin preservation through a semipermeable membrane that has contact with foam, and one proposal pump system with reservoir is added [81]. Limited clinical experience has shown a decreased risk of wound hematoma, seroma and SSI [82]. Other positive effects from wound application of NPWT might include promotion of microvascular flow and decreased tissue edema and myofibroblast activation [83]. Colli and Atkins et al reported no wound healing complications in patients at high risk for sternal wound infections after cardiac surgery, but both studies were retrospective and done on smaller cohort of patients, 10 and 57, respectively [84,85].
Even though treatment of DSWI has considerably evolved, a generally accepted treatment strategy remains controversial. Robicsek postulated three valid principles addressing this issue: first, that the infectious process should be brought under control within the shortest possible time, secondly, that adequate debridement and drainage of the infected area should occur, and third that sternal stability should be assured [86]. Until the 1960s, patients suffering from DSWI were treated conservatively with antibiotic therapy, limited drainage, or exposure of the sternotomy wound until closure with granulation tissue occurred [87]. Mortality rates then reached over 50% and survivors’ quality of life was limited due to significant morbidity [87]. In 1964, Shumacker and Mandelbaum reported their experience with single-stage technique of wound debridement, primary sternal re-wiring and continuous antibiotic irrigation [88]. Their original method was consequently modified in terms of the type of antibiotic or antiseptic solution used including its amount, or the setting of indwelling drains for irrigation and suction [89-90]. Closed chest drainage became widely used with reported mortality from DSWI ranging from 4.8% to 28%, with an associated risk of primary therapy failure ranging from 12.5% to 48% [89,90-92]. Lee et al proposed in 1976 the use of an omental flap for covering infected sternotomy wounds [93]. Vital greater omentum was turned into the chest cavity following sternal debridement. It was suggested that well-vascularized omentum fulfills dead spaces, ensures high antibiotic levels, and yielded angiogenic and absorptive capacity [13,93]. Jurkiewicz et al first reported the use of muscle flaps, preferably the pectoralis flap, and radical sternal debridement in the treatment of DSWI in 1980 [94]. Consequently, 20-years of experience in the Emory group with 409 patients showed 8.1% in-hospital mortality and 5.1% primary therapy failure. 87.1% of procedures were done in single-stage fashion; the pectoralis major was used in 76.6%, rectus abdominis in 19.4%, and omentum in 2.2% [95]. This approach has received many modifications regarding the timing of wound closure, choice of flap, and type of advancement, with reported mortality ranging from 0% to 19% [96,97]. Comparing the omental to the pectoralis flap, Milano et al reported that the omental flap had lower mortality (4.8% vs. 10.5%, p<0.05), early wound related complications (9.5% vs. 27.7%,p<0.001), and in-hospital stay (10.7 vs. 18.8%, p<0.05) [98]. El Oakley and Wright suggested classification of DSWI based on the time of presentation, presence of risk factors such as obesity, diabetes or immunosuppressive therapy, and number of failed therapeutic attempts in 1996 (Table 3) [99]. The identification of five subtypes of DSWI seemed to be a relevant tool for choice of therapeutic method and patient prognosis. Adjusted to the El Oakley and Wright classification, closed chest irrigation has comparable mortality data for type I and II DSWI compared with radical sternal resection and concomitant flap, but with lower flap-related associated morbidity [100-102]. Ringelman et al noted that at 48 month follow-up, 51% of patients had pain or discomfort, 44% had numbness, 42% complained of sternal instability, and 33% claimed to have shoulder weakness, when pectoral flap was used for reconstruction [103]. Closed chest irrigation carries a higher rate of therapy failure when used for type III, and particularly type IV and V El Oakley and Wright classification [104-107]. Thus, these patients might have benefit from more radical sternal debridement and employment of well-vascularized tissue to replenish residual defects. Flap-related morbidity may be addressed with less invasive techniques such as a laparoscopic greater omentum harvesting [108]. Atkins et al recently reported on the influence of sternal repair choice (pectoral, omental flap, or secondary closure) on long-term survival [109].
There is limited data evaluating hyperbaric oxygen (HBO) therapy in the treatment of SWI, despite theoretical advantages, availability of HTO close to the cardiac surgical unit impedes its routine use [110]. Siondalski et al reported successful healing of 55 DSWI patients with no mortality, nevertheless therapy required 20-40 HBO sessions after surgical revision. HTO was taken as an adjunct therapy to perform radical debridement and muscle flap [111].
\n\t\t\tClass\n\t\t | \n\t\t\n\t\t\tDescription of DSWI\n\t\t | \n\t
Type I | \n\t\tMediastinitis presenting within 2 weeks after operation in the absence of risk factors | \n\t
Type II | \n\t\tMediastinitis presenting at 2 to 6 weeks after operation in the absence of risk factors | \n\t
Type IIIA | \n\t\tMediastinitis type I in the presence of one or more risk factors | \n\t
Type IIIB | \n\t\tMediastinitis type II in the presence of one or more risk factors | \n\t
Type IVA | \n\t\tMediastinitis type I, II, or III after one failed therapeutic trial | \n\t
Type IVB | \n\t\tMediastinitis type I, II, or III after more than one failed therapeutic trial | \n\t
Type V | \n\t\tMediastinitis presenting for the first time more than 6 weeks after operation | \n\t
El Oakley and Wright classification of DSWI (modified from El Oakley et[99])
Accepted risk factors: diabetes, obesity, immunosupressive therapy intake
In 1997, Obdeijin et al described the first application of NPWT for treatment of DSWI in 3 consecutive patients [112]. They found that physical therapy contracted the wound, provided sufficient chest stability, and allowed patients to be extubated. Catarino et al reported the first retrospective comparison between NPWT and closed chest irrigation in 2000. In comparing 9 versus 10 patients, they found superiority of NPWT in length of in-hospital stay (15 vs. 40.5 days, p=0.02) and therapy failure (0 vs. 5, p=0.03) [113]. Furthermore, Gustafsson et al and Fleck et al, from the two most active European centers (Lund and Vienna), reported similar in-hospital and 30-day or 90-day mortality of DSWI patients, with 60% of all cases having class III according to El Oakley and Wright [114,115]. Consequently, the Lund group reported survival data from 1,3, and 5 year follow-up which showed comparable survival (92.9%, 89%, 89%) with patients without DSWI after CABG (96%,92%, 86%) and showed potential survival benefit of NPWT therapy unlike data known from conventional therapy [18]. Recently published data from a larger group of patients showed 1.1-5.4% mortality at 30 days and 8-15% 1 year mortality with a 2 to 6% risk of primary therapy failure [116-119]. The mean length of application of NPWT was 8 to 14 days with a mean number of 4 to 6 dressing changes [116-119]. The amount of dressing used by centers has only minor variability in first-line application protocol, with the only differences reported being the materials used for interface dressing and the timing of wound closure [116-119]. It was suggested that low C-reactive protein level (<50 mg/l) might be a good indicator for timing of wound closure [120]. Since the introduction of NPWT, its comparison with conventional therapy, closed chest irrigation or sternal resection and flap have been studied. So far, we have data only from retrospective comparative studies, with the compared arms being heterogeneous in number of patients, time periods and type of DSWI based on El Oakley classification. It was suggested that NPWT positively influenced the risk of primary therapy failure and survival of patients at short and long-term follow-up [18,46,121-138]. Outcomes of NPWT are DSWI causative pathogen independent, even comparing therapeutic response to MRSA and MSSA caused DSWI [139]. From multivariable analyses, obesity, renal failure and sepsis were calculated as independent risk factors of NPWT failure [128,129]. Results of comparative studies and published meta-analyses are shown in Table 5.
\n\t\t\tAuthors\n\t\t | \n\t\t\n\t\t\tFollow-up\n\t\t | \n\t\t\n\t\t\tPatients´cohort\n\t\t | \n\t\t\n\t\t\tEndpoints\n\t\t | \n\t\t\n\t\t\tResults\n\t\t | \n\t
Catarino et al [113] | \n\t\tRetrospective | \n\t\t11 pts NPWT vs. 9 pts closed irrigation | \n\t\tIn-hospital stay, primary therapy failure | \n\t\tNPWT linked with shorter in-hospital stay (15 vs. 40.5 days, p=0.02) and lower therapy failure (0 vs. 5%, p=0.03) than closed irrigation | \n\t
Berg et al [121] | \n\t\tRetrospective | \n\t\t31 pts NPWT vs. 29 pts closed irrigation | \n\t\tPrimary therapy failure, in-hospital stay and mortality | \n\t\tNPWT group had a lower risk of therapy failure (52 vs. 16%, p<0.05) and in-hospital stay (22 vs. 26 days, p<0.05), with comparable in-hospital mortality (6,9 vs. 6,6%, NS) to closed irrigation | \n\t
Doss et al [122] | \n\t\tRetrospective | \n\t\t22 pts NPWT vs. 22 closed irrigation | \n\t\tPrimary therapy failure, in-hospital stay and mortality | \n\t\tNPWT group had shorter overall length of therapy (17.2±5.8 vs. 22.9±10.8 days, p=0.01) and in-hospital stay (27.9±6.6 vs. 33.0±11.0 dnů, p=0.03), with comparable mortality (5 vs. 5%, NS) to closed irrigation | \n\t
Song et al [123] | \n\t\tRetrospective | \n\t\t17 pts NPWT vs. 18 pts open packing | \n\t\tPrimary therapy failure, number of dressing changes, in-hospital stay and mortality | \n\t\tNPWT associated with shorter length of therapy ( 6.2 vs. 8.5 days, p<0,05), lower number of dresssing changes (3±2.5 vs. 17±8.6 , p<0.01), and comparable in-hospital mortality (11 vs. 6%, NS) | \n\t
Luckraz et al [124] | \n\t\tRetrospective | \n\t\t27 pts NPWT vs. 13 pts closed irrigation | \n\t\tPrimary therapy failure, in-hospital mortality, and cost of therapy | \n\t\tNPWT linked with lower therapeutic failure rate (15 vs. 30.7%, p<0.05), in-hospital mortality (7.5% vs. 18.5%, p<0.05) and overall cost of therapy (16 400 vs. 20 000 USD) compared with closed irrigation | \n\t
Fuchs et al [125] | \n\t\tRetrospective | \n\t\t35 pts NPWT vs. 33 pts open packing | \n\t\tLenght to achieve sterile woud, length of therapy, in-hospital stay, and 1-year survival | \n\t\tNPWT led to faster bacterial decontamination of wounds (16 vs. 26 days, p<0.01), shorter length of therapy (21 vs. 28 days, p<0.01) and in-hospital stay (25 vs. 34 days, p<0.01) and better 1-year survival (97.1 vs. 74.7%, p<0,05) compared with open packing | \n\t
Sjoegren at el [126] | \n\t\tRetrospective | \n\t\t61 pts NPWT vs. 40 closed irrigation/open packing | \n\t\tTherapy failure, 1- and 5-year mortality | \n\t\tNPWT had lower risk of therapy failure (0 vs.15%,p<0.01), 90 day mortality (0 vs. 15%, p<0,01), and 1- and 5-year survival (93 vs. 82%, 83 vs. 59%, p<0.05) against conventional therapy | \n\t
Immer et al [127] | \n\t\tRetrospective | \n\t\t38 pts NPWT vs. 17 sternectomy and flap | \n\t\tIn-hospital stay and in-hospital mortality, quality of life | \n\t\tNPWT led to shorter in-hospital stay (51.5±20.8 vs. 70.7±28.8 dnů, p<0.05), non-significantly lower in-hospital mortality (5.3 vs 11.8, NS) and better quality of life based on questionnaire SF-36 compared with sternectomy and flap | \n\t
Segers [128] | \n\t\tRetrospective | \n\t\t29 pts NPWT vs. 34 pts closed irrigation | \n\t\tTherapy failure, in-hospital, and 1-year mortality | \n\t\tNPWT decreased primary therapy failure (27.6 vs. 58.9%, p<0.05), with comparable 30 day (3,5 vs. 2,9%, NS)and 1-year mortality (31.0 vs. 23.5%, NS) to closed irrigation | \n\t
Bailot et al [46] | \n\t\tRetrospektive conventional and prospective for NPWT | \n\t\t125 pts NPWT vs. 24 pts. open packing | \n\t\tIn-hospital mortality and 1-,5-, and 10 years survival | \n\t\tLower mortality in NPWT group (4.8 vs. 14.1%, p=0.01), but insignificantly better 1,5, and 10 year survival(92.8 vs. 83.0%, 89.8 vs. 76.4%, 88.0 vs. 61.3%, NS) | \n\t
Petzina et al [129] | \n\t\tRetrospective | \n\t\t69 pts NPWT vs. 49 closed irrigation | \n\t\tPrimary therapy failure, in-hospital stay and mortality | \n\t\tNPWT associated with lower therapeutic failure (2.9% vs.18.3% p<0.05) and in-hospital mortality (5.8% vs. 24.5% p<0.05), but comparable in-hospital stay (38 vs. 41 days, NS) with closed irrigation | \n\t
Simek et al [130] | \n\t\tRetrospective for conventional and propective pro NPWT | \n\t\t38 pts withNPWT vs. 28 pts closed irrigation | \n\t\tPrimary therapy failure, in-hospital stay, in-hospital, and 1 year mortality | \n\t\tNPWT had lower failure of primary therapy (5.8 vs. 39.2%, p<0.05), ICU stay (209.6±33.3 vs. 516.1±449.5 hours, p<0.01),and in-hospital (5.8 vs. 21.4%, p<0.05) and 1-year mortality (14.7 vs 39.2%, p<0.05), but comparable in-hospital stay (40.2±16.3 vs. 48.8±29.2, NS) with closed irrigation. | \n\t
De Feo et al [131] | \n\t\tRetrospective | \n\t\t74 pts NPWT vs. 83 pts closed irrigation | \n\t\tPrimary therapy failure, in-hospital stay and mortality | \n\t\tNPWT group with lower risk of therapy failure (1.4 vs. 16.9%, p<0.001), shorter in-hospital stay (23.3±9 vs. 3.0.5±3, p<0,05), and lower in-hospital mortality (1.4 vs. 3,6 %, p<0,.05) compared with closed irrigation | \n\t
Assman et al [132] | \n\t\tRetrospective | \n\t\t82 pts NPWT vs. 38 closed irrigation | \n\t\tIn-hospital stay and mortality | \n\t\tNPWT patients had shorter in-hospital stay (45.6 ± 18.5 vs. 55.2 ± 23.6 dnů, p<0.05), and lower in-hospital mortality (14.6 vs. 32.4 %, p<0.05) | \n\t
Vos et al [133] | \n\t\tRetrospective | \n\t\t89 pts NPWT vs. 24 open packing | \n\t\tIn-ICU and hospital stay and mortality | \n\t\tNPWT led to shorter ICU stay (6.8±14.4 vs. 18.5±21.0 dnů, p<0.01), in-hospital stay (74.4±61.2 vs. 69.1±62.7 days, p<0.01), and lower in-hospital mortality (12.4 vs. 41.7%, p<0.01) | \n\t
Deniz et al [134] | \n\t\tRetrospective | \n\t\t47 pts NPWT vs. 43 pts closed irrigation | \n\t\tPrimary therapy failure, in-hospital stay and 1-, 3 years mortality | \n\t\tNPWT had insignificantly lower rate of primary therapy failure (2.1% vs. 4.7%, NS) and shorter in-hospital stay (18±9 vs. 24±10 days, NS), 90 days mortality significantly lower (8.5 vs. 23.2%, p<0.05) and better 1-, and 3-year survival (91.5% vs.76.7%, p<0,05, 87.2 vs. 69.8%, P<0.05) | \n\t
Fleck et al [135] | \n\t\tRetrospective | \n\t\t326 pts NPWT vs. 198 closed irrigation/open packing | \n\t\tPrimary therapy failure, in-hospital mortality | \n\t\tNPWT was associated with lower primary therapy failure (8.5% vs. 34% p<0.001), and in-hospital mortality (3.6% vs. 10%, p<0.05) | \n\t
Sjoegren at el [18] | \n\t\tMeta-analysis | \n\t\t12 papers focused on comparison of NPWT with conventional therapy | \n\t\tPrimary therapy failure, in-hospital stay and mortality | \n\t\tNPWT associated with lower primary therapy failure, shorter in-hospital stay, and lower in-hospital and 1-year mortality | \n\t
Raja et al [136] | \n\t\tMeta-analysis | \n\t\t13 papers focused on comparison of NPWT with conventional therapy | \n\t\tPrimary therapy failure, in-hospital stay and mortality | \n\t\tNPWT seemed to be effective at high-risk DSWI patients, but weak evidence for routine first-line application in DSWI | \n\t
Schimmer et al [137] | \n\t\tMeta-analysis | \n\t\t15 papers focused on comparison of NPWT with conventional therapy | \n\t\tPrimary therapy failure, in-hospital stay and mortality, evaluation of German hearts centers protocols | \n\t\tNPWT is associated with lower therapeutic failure, and in-hospital mortality. Routinely applied as first-line treatment in 35% of German heart centers | \n\t
Damiani G et al [138] | \n\t\tMeta-analysis | \n\t\t6 papers focused on comparison of NPWT with conventional therapy and chest reconstruction options | \n\t\tPrimary therapy failure, in-hospital stay and mortality | \n\t\tNPWT prone to have shorter in-hospital stay and lower mortality | \n\t
Analyses and Meta-analyse of comparison NPWT with conventional therapy
Addressing specific complications of DSWI, it is seen that NPWT does not increase the risk of late infection recurrence. Reported rates of chronic fistulas after conventional therapy and NPWT were comparable between 8-12% [18,130,134,140,41], and long-term survival of these patients is negatively affected [140,142]. CONS was identified as a pathogen with a higher risk of recurrence; its low virulence, ability to create biofilm on metallic materials and inherent low sensitivity against prophylactically administrated antibiotics limit its eradication [41,143].
With the rise in use of NPWT came an increased number of reported serious bleeding complications [144,145]. The risk of heart injury, particularly the right ventricle, bypass grafts or great vessels is well known from conventionally treated patients. Infectious erosion, displacement of heart structures towards sternal margins, or tractions of fibrosis adhesion were identified as potential mechanism of injury [146]. The incidence of these complications by conventional therapy was found to be between 2-14.8% [147-149], with data from a larger group of NPWT treated patients showing 2 to 5%, thus NPWT does not seem to increase the incidence of serious complications [116,118,127,130,146,150]. Mortality from these complications varies between 25 to 70%, with emergency surgery as well as proper covering of mediastinal structures with interface dressing being crucial for management [146-148,150]. Several layers of paraffin gauze or silicone mesh are usually put below sternal margins on the heart and grafts. Development towards more suitable material, particularly rigid barrier for mediastinal protection is in progress, including mediastinal protection and preserved drainage ability of therapy [151].
Wire re-cerclage was a commonly used method for addressing sternal approximation in patients with sternal dehiscence after DSWI [72,86,102]. The quality of residual sternal bone or its loss makes re-cerclage troublesome or even risky for achieving sternal stability. The occurrence of extensive adhesions below the sternum in DSWI patients increases the risk of damage to the right ventricle and bypass grafts when peri-, trans- and parasternal wiring techniques are used [72,99,100]. Today, stable osteosynthesis of the sternum, particularly using transverse plates, has become a method of treatment of post-DSWI sternal dehiscence [76]. Voss at el reported an institutional experience with Titanium Sternal Fixation system™ plates for sternal non-union in 15 patients, in which four patients had more than two previous attempts to stabilize the chest with some modification of wire re-cerclage, and four patients were treated for DSWI with NPWT prior to plating. All patients were successfully stabilized and healed, with one patient from the DSWI group experiencing a late infection recurrence and one dying from a complication not related to plating [152]. Larger experience with the same plate system has been reported by Baillot et al in a group of 92 patients after DSWI [46]. They achieved chest stabilization in all cases, with 9 patients (9.8%) undergoing further procedure for late infection recurrence including removal of the plate with no impact on sternal stability [153]. Chest stability after a healed DSWI improves respiratory function, augments wound healing processes, shortens in-hospital stay, and improves patient quality [46,72,80]. Plating seems to be an effective method of chest wall stabilization, but may fail in cases of massive loss of chest bone tissue. In these cases, the bone residue does not allow sufficient anchoring for the plates or there is a large bone tissue gap. Shear forces may loosen screws and threaten stability. Persistent pain and respiratory discomfort were also reported in this case [154]. A conventional surgical approach to manage the large residual bone defect leaves the sternotomy wound unstable and employs the greater omentum or a muscle flap to fulfill any dead spaces [93,95,99,103]. This approach resulted in sternal instability and flap-related morbidity even when wounds were well-healed [154]. Some case reports have included the use of an autologous bone iliac crest graft or allogenous fibula graft to supply residual bone defects after DSWI [155,156]. Marulli reported the first use of an allogenous sternocostal bone graft for sternal reconstruction after chondrosarcoma removal [157]. Consequently, Dell\'amore et al described four patients who were managed with the same technique with no wound healing complications and preserved chest wall stability [158]. The same authors proposed this technique for major post-DSWI defects, and [159] Kalab et al described the possibility of using an allogenous calva bone graft to address this issue. Allogenous bony grafts being fixed with transverse plates in mentioned cases [158-160]. Bone allograft usage for transplantation is under law restriction of local governments and European Association of Tissue Banks [161,162].
There are a broad range of possibilities for managing sternal soft tissue defects caused by DSWI. In the case of minor defects, a direct suture with tissue undermining can be effective. In wide dehiscence, some type of flap transfer is needed and excessive bone and soft tissue loss are dependent on close co-operation between the cardiac and reconstructive surgeons. There are two crucial conditions influencing the reconstructive strategy. The first condition is the size of the defect, while the second is the vascular network, which would optimally remain uncompromised after primary surgery or previously failed reconstructions. Although various flaps and their modifications have been proposed, none have been found to be a reconstructive option for all defects [97,163,164], therefore Greig et al suggested a simple classification system to address the choice of flap based on the size and location of the post-sternotomy defect (Table 6) [165]. It is not possible, however, to follow this classification system because various factors and conditions influencing the result must be taken into the account.
\n\t\t\tWound type\n\t\t | \n\t\t\n\t\t\tSite of sternal wound\n\t\t | \n\t\t\n\t\t\tRecommended flap for reconstruction\n\t\t | \n\t
Type A | \n\t\tUpper half sternum | \n\t\tPectoralis major | \n\t
Type B | \n\t\tLower half sternum | \n\t\tCombined pectoralis major and rectus abdominis bipedicled flap | \n\t
Type C | \n\t\tWhole sternum | \n\t\tCombined pectoralis major and rectus abdominis bipedicled flap | \n\t
Classification of sternal wounds according to anatomical site (modified from Greig et al [165])
In 1976, Lee et al were the first to report on the use of a pedicled greater omentum to fulfill the large defect after total sternectomy [93]. In 1980, Jurkiewicz et al introduced the bilateral pectoralis turnover flap for the same indication. Although various muscle flaps, along with their modifications have been reported, there is still debate about using muscular versus cutaneous or fasciocutaneous flaps to cover difficult defects. It has been presumed that muscular flaps carry richer vascular networks, thus bringing a better blood supply to the defect, along with a higher antibiotic concentration. Recent studies, however, did not support this hypothesis and suggested that muscle flaps have no particular advantage over fasciocutaneous flaps in terms of improving vascularity and eradicating infection [166,167]. Nevertheless, there is still a reasonable argument for muscular flaps as additional muscle brings enough tissue for planed reconstruction.
The pectoralis major provides many qualities that make it a suitable flap choice for covering sternal defects including close proximity to the sternotomy, triple blood supply (the thoracoacromial artery, perforating branches of the internal thoracic artery and the lateral thoracic artery), and versatility of the flap as either the thoracoacromial or internal thoracic artery vascular axis may be used separately to nourish the flap [168]. Netcher et al did not show an adverse influence of the pectoral muscle transposition on pulmonary function [169], moreover, pain and loss of strength appeared to be related more to sternal instability rather than to the muscle transposition. Additionally, Cohen et al reported an improvement of spirometric parameters (forced vital capacity and standardized forced expiratory volume in 1 second) before and after pectoral flap transfer, thus supporting the crucial role of the flap in chest stabilization [170].
The pectoral muscle advancement flap is based on the thoracoacromial pedicle and is considered to be the best muscular reconstructive option in this area due to its technical simplicity, versatility, and low risk of flap loss (<3%). There is, however, some risk of skin island necrosis or partial necrosis (≈30%) [171, 172]. Dissection and elevation of the flap begins along the median line of the costal grid until reaching the relatively avascular plane under the muscle. Undermining then proceeds by blunt dissection laterally as necessary to achieve approximation of the bilateral flaps at the median line without tension. The thoracoacromial vascular pedicle is visible at the dorsal plane of the muscle. The humeral and clavicular insertion of the muscle can be released if needed. If the distal portion of the sternum is exposed, dissection continues distally under the anterior sheet of the rectus abdominis which then becomes part of the flap [164]. Though the flap is elevated mostly in a myocutaneous fashion [73,163,164,173,174], Brutus et al reported on the use of a pectoral muscle flap released from skin for covering the entire sternal defect [175]. Completely dissected and freed from all of its origins, the pectoral muscle was advanced medially on the skeletonized vascular pedicle to cover the full length of the sternal defect. Separating the skin from the muscle can jeopardize the cutaneous blood supply and increase risk of skin necrosis. This technique included the release of humeral insertion from a short skin counter incision [175].
If the defect is wide, it may be difficult to achieve tension-free suturing in the midline. A modification of the advancement flap with a skin relaxing incision has been reported [176]. Majure et al proposed shifting the skin island over the pectoralis muscle in the V-Y manner to cover the entire sternotomy defect, but this method requires secondary skin grafting from an island donor site [177]. This technique was adopted and modified by Molitor et al [178]. The skin island is dissected, while the underlying muscle fascia and pectoralis major are elevated and completely released from their insertions to the humerus, sternocostal junctions and abdominal muscles. The thoracoacromial vessels are visualized and the clavicular insertion of the muscle is released to achieve comfortable advancement of the flap to the defect. The secondary defect in the lateral thoracic wall is then sutured in the V-Y manner and no skin graft is needed [178].
Finally, the pectoralis major musculocuteneous flap can be mobilized in a rotational manner when the skin-muscle flap is elevated based on the thoracoacromial pedicle and is rotated to the defect [179].
This flap is based on perforators of the internal mammary artery. Once the skin is elevated off of the anterior pectoralis fascia, the distal rib, proximal clavicular origin and humeral insertion of the muscle are divided. Then, the thoracoacromial pedicle is dissected and ligated, and the pectoralis major is elevated from lateral to medial until the perforating vessels from the internal thoracic artery are identified, and the muscle is then turned into the defect. To gain additional width of the narrowing humeral portion of the flap, fascial release incisions along the direction of the muscle fibers can be done. By this maneuver an average increase in flap width of 5.8 cm can be obtained [181]. Usually bilateral turnover muscle flaps are used [94,95]. The disadvantages of this flap include limitations in the distal parts of the sternum, need for wide skin undermining, dependence on an intact internal mammary artery, and an unfavorable aesthetic consequence including a missing anterior axillary line and parasternal subcutaneous tissue bulkiness [95].
This flap was first used in cardiac surgery by Jurkiewicz in the case of a pectoral turnover flap failing to cover the entire defect [94,95]. To cover the sternal defect, the rectus abdominis flap is used exclusively as a pedicled flap based on the superior epigastric artery [182]. Because this artery is the terminal branch of the internal thoracic artery, the flap cannot be used if the ipsilateral internal thoracic artery was used for bypass grafting. The functional consequences of using the rectus abdominis to reconstruct sternal defects were assessed by Netscher et al [169]. They found no significant differences in abdominal wall function between the groups of patients in whom the rectus muscle was used for reconstruction and the group without sternal wound complications. There is a higher associated risk of hernia (11%) or fascial weakness (42%) as was reported [103,183]. The rectus abdominis flap may be used as a muscular flap [94,184) or as a myocutaneous island flap [171,185].
The rectus abdominis muscular flap may be dissected without the use of a skin island. The skin incision continues distally to the desired point according to the necessary flap length. The skin is undermined over the rectus fascia to expose the muscle. Then, the rectus anterior sheet is divided and the muscle is dissected and mobilized. The distal pedicle inferior epigastric vessels are ligated and divided. The muscle is then turned to the defect. The exposed muscle and pedicle is covered either by skin suture or grafting [95].
The myocutaneous flap can have a skin island oriented vertically along the used muscle (VRAM-vertical rectus abdominis muscle flap), or horizontally, as well as perpendicular to the muscle distal to the umbilicus (TRAM-transverse rectus abdominis muscle flap). The transverse orientation permits harvest of a larger skin paddle. Dissection of the VRAM starts with marking the skin island over the used muscle. The skin component should be placed medially near the umbilicus to include important periumbilical perforators. The skin island is cut and the skin overlying the muscle is undermined above the muscle fascia. Then, the rectus sheet is divided bilaterally at the edges of the muscle and the muscle is dissected and mobilized. The distal pedicle inferior epigastric vessels are ligated and divided. The flap is then turned to the defect. The TRAM is marked transversely under the umbilicus and skin island which can involve the entire area between the umbilicus and symphysis bilaterally. The flap is dissected in the similar way as the VRAM flap, but the mobilization of the skin island continues away from the muscle pedicle crossing the midline to the contralateral side [171,185]. Care must be taken to avoid pedicle compression passed through the subcutaneous tunnel to the sternal defect.
For full length sternal defects, a combined pectoralis major and rectus abdominis flap (Pec-Rec flap) was proposed [186]. The flap is predominantly created on the left side, but can occasionally be bilateral. The skin overlying the pectoral muscle is elevated up to the mid-axillary line laterally and from the clavicle to the inferior costal line in a vertical direction. The pectoral muscle is elevated while preserving the thoracoacromial vessels. The muscle is detached from its humeral insertion and medially from one third of the clavicle. Dissection of the flap continues distally while elevating the thoracoepigastric fascial attachments from the chest wall between the pectoralis major and the rectus abdominis. Distal to the fascia, the anterior sheet of the rectus abdominis is incised medially and laterally and the muscle is mobilized from the posterior fascia. The muscular connections of the rectus abdominis to the distal ribs are detached as the last step of flap harvesting. The superior epigastric artery can be preserved or it can be divided close to the muscle if necessary for better medial transposition of the flap [186].
The latissimus dorsi flap is based on a thoracodorsal artery that has not been jeopardized by previous cardiac surgery. Moreover, a large flap can be harvested (the main surface area of muscle is 105 cm2 for women and 192 cm2 for men) [187]. The main disadvantages of this flap include the need for a lateral decubital position during flap harvesting that can endanger patients with large sternal bone defect and sternal instability and shoulder functional limitation followed latissimus dorsi muscle harvesting. Patients who are dependent on their shoulder girdle strength, such as paralytic patients in a wheelchair or walker dependent patients, may endorse strength difficulties after muscle harvesting as well as tennis and golf players or those whose profession involves overhead tasks [187]. Up to 50% of patients may complain of localized numbness at the harvesting area [172].
Usually the muscle from the non-dominant side is used. The arc of rotation and position of the skin island is assessed and marked. The skin component is predominantly oriented perpendicular to the muscle fibers near the vertebral column, but a longitudinal course from the medial axillary line to the medial caudal dorsum is also possible. The flap is dissected using the whole muscle up to the pedicle. Thoracodorsal vessels are skeletonized and humeral muscle insertion is divided, allowing an additional 4-10 cm of flap advancement. Then the flap is transposed to the defect through a subcutaneous tunnel superficial to the pectoralis major [188,189].
Obese female patients with large breasts are at higher risk of sternal dehiscence due to the infero-lateral tension of the breasts, especially on the distal third of the sternotomy [72].This instability results from the greater protrusion of the lower thorax and abdomen during respiration, greater dimensions of the lower versus the upper thorax, the concentration of forces from the attachment of the ribs, and the reduced thickness of the lower sternum [72]. Therefore a special bandage, supporting bra, or other garment is used to release the tension resulting from large breasts. The technique of covering the sternal dehiscence with a bilateral pectoral muscle advancement flap with simultaneous breast reduction has been reported [190-192]. Large breasts carry an enormous amount of relatively well vascularized tissue that can potentially be used to cover the sternal defect [193,194]. The vascular supply of the breast is basically the same as the pectoral muscle. There is, however, a unique vascular network inside the breast gland, known as Würinger´s septum. Uygur et al reported a method of covering a large distal sternum defect with bilateral fasciocutaneous V-Y flaps from the breasts [193]. These flaps were anatomically based on the Würinger´s septum [193,195]. Another method has been suggested by Hamdi et al [196]. They performed a septum-based therapeutic mammoplasty on two patients. The principle of this technique is to reduce breast mass with harvesting of a large fasciocutaneous flap from the inferomedial part of the breast
Another possibility for utilizing the breasts to cover the sternal defect is a Cyclops´ flap. In this technique the whole breast is transposed to the central or even contralateral chest defect, so that the areola is centralized. The breast flap in this case is based on the lateral and central vascular pedicles of the breast [197,198].
The greater omentum is a well-vascularized tissue with plentiful lymphatic drainage and angiogenic activity [93,98,199]. Its size can be up to 36x46 cm and is reliable to cover large defects. It is difficult, however, to predict the flap size preoperatively because the greater omentum volume has no direct correlation with the patient’s habitus [200]. The omentum can be transposed to the defect in various ways such as, pedicled on both gastroepiploic arteries for defects in the distal part of sternotomy wound or mobilized on either of the gastroepiploic vessels to cover full-length sternotomy defects [201-203]. Passing the omental flap subcutaneously from the upper portion of the laparotomy bears up to a 21% risk of late herniation [202], thus, a better solution seems to create the transdiaphragmatical tunnel just right of the falciform ligament [204]. The risk of abdominal cavity infection is rare [205], but the traction on the gastroepiploic artery can cause motility disturbances of the stomach and duodenum [206], and one case of fatal cecum volvulus have been reported [207]. Laparoscopic harvesting seems to be promising in reduction of access complications and pain [108,208,209].
Microsurgical free flaps can be used to cover sternal defects in particular situations. This technique, due to its duration and technical complexity, should serve as a last treatment option. The use of the tensor fascia lata myocutaneous flap, rectus abdominis myocutaneous flap and deep inferior epigastric artery fasciocutaneous flap for this indication have been reported [210]. As a donor vessel, the thoracoacromial, internal thoracic or cervical vessels can be used. The cephalic vein attached to the thoracoacromial or cervical arteries, can be used for lengthening the donor vessel (arterio-venous loop) [210,211].
There are special requirements for care after flap surgery. In general, it is important to protect the blood circulation within the flap, maintaining both general and local hemodynamics. Vascular spasm must be prevented by using vasodilator drugs if possible. The elevated and transposed flap usually loses most of its physiological blood and lymphatic network and is dependent only on a small part of it, so varying degrees of edema are usually present. Large swelling of the tissue compresses the capillaries and decreases the blood flow in the flap, increasing the tension on the suture. Corticosteroids are used to prevent swelling for several days in most flap surgeries unless serious contraindications are present. The flap must be kept from topical pressure, particularly in places of passing vascular pedicle and in peripheral parts of the flap because of limited vascular competence. Undoubtedly, changes in body position influence the blood supply of the flap. Furthermore, stretching of the arms causes increased tension on the medial sternal suture. In the case of the pectoral and latissimus dorsi flap, the use of muscles of the shoulder girdle should be avoided. When using the rectus abdominis flap, the abdominal wall must be relaxed and supported with bandages for several weeks to prevent hernia formation. Finally, nutritional support with enteral feeding is essential for successful healing.
We retrospectively analyzed our experience with treatment strategies of DSWI since February 2002, when our department was established. A total of 100 patients fulfilling CDC criteria [5] for DSWI were enrolled until September 2011 with an overall incidence of DSWI of 1.36%. The results of 28 patients (March 2002-June 2004) primarily treated with closed chest irrigation using diluted iodine solution were compared with 76 patients (September 2004 to September 2009) treated with NPWT (VAC ATS™, KCI, St. Antonio, USA). A standardized protocol for first-line application of NPWT is depicted in Figure 1. Six patients from the interim period (June to September 2004) when closed irrigation and NPWT were combined were excluded from the analysis. Both groups had comparable demographic and perioperative characteristics, however, the NPWT arm had an insignificant trend towards advanced age, higher logistic EUROSCORE, more complex primary cardiac surgery. No difference in the rate of causative agent was found, with SA and CONS identified in almost 70% of cases. Escherichia coli (5.8%) and Pseudomonas species (7.2%) as leading Gram negative strains were cultivated. The time to presentation of DSWI was insignificant between groups (17.5±15.0 vs. 13.8±16.3, p=0.55) as well as readmission for late clinical presentation of DSWI (38.6% vs. 50%, p=0.12). Although the overall length of DSWI therapy was comparable (14.3±11.9 vs. 14.9±7.9 days, p=0.82), NPWT required more dressing changes (5.4±2.3 vs. 1.8±1.2, p<0.001), but was associated with substantially lower failure of primary therapy (5.1 vs. 39.2%, p<0.01) with closed chest irrigation. In-ICU stay was significantly shorter in the NPWT group (209.6±331.3 vs. 516.1±449.5 hours, p<0.001), nevertheless, shortened in-hospital stay (40.2±16.3 vs. 48.8±29.2 days, p=0.16) was insignificant in this group. Addressing mortality, 30-day and 1-year mortality was considerably lower in the NPWT arm (3.9 vs. 21.4%, p<0.05, 15.8 vs. 39.2%, p<0.05, respectively). A Kaplan-Meier 1 year-survival analysis is shown in Figure 2. The risk of major bleeding complications was comparable between groups, with 2 patients (3.6%) from the closed chest irrigation group having erosion of venous bypass graft and right ventricle (RV), and 3 patients (3.9%) from the NPWT group, including 1 debridement-related and 2 spontaneous injuries of the RV. Employment of local and advancement flaps for covering of residual defects was higher in the NPWT groups (65.7 vs. 17.8%, p<0.01). Our experience showed that NPWT is effective in the treatment of DSWI, compared with closed chest irrigation, leading to lower failure of primary therapy, ICU stay, and better short- and mid-survival of patients. We did not prove NPWT influenced length of in-hospital stay or risk of major bleeding, however, residual defects required more complex approach to assure sternal stability and covering defects [119,130].
The first-line application protocol of NPWT for treatment of DSWI
1-year Kaplan-Meier survival analysis comparing NPWT with conventional therapy (CONV)
Non-complicated sternal dehiscence following DSWI that is not associated with considerable bone loss can be stabilized with transverse titanium plates (Titanium Sternal Fixation system™, Synthes, Switzerland) at our department. Plates are applied on the anterior surface of the ribcage to achieve sufficient stability of the chest wall while minimizing the risk of an iatrogenic injury to the heart. From January 2008 to September 2012 we performed 31 sternal wall reconstructions using the Titanium Sternal Fixation system™. In four cases, osteosynthesis was applied to treat a sterile mechanical dehiscence of the median sternotomy, while 27 other chest osteosyntheses were performed after DSWI when wound bed decontamination was achieved with NPWT. In the postoperative period, 2 patients (7.4%) needed to be operatively revised due to bleeding from pectoral flap advancement; in 3 cases (11.1%) the plates needed to be removed for soft tissue healing complications post-reconstruction. Nevertheless, removal could be postponed until satisfactory healing of the sternal bones was achieved. One patient (3.7%) had to be drained for iatrogenic pneumothorax. We also retrospectively analyzed 21 patients with post-DSWI sternal dehiscence from January 2005 to January 2010, comparing 11 patients with re-cerclage wiring and 10 patients with titanium plate osteosynthesis. DSWI was managed with the same protocol of NPWT prior to reconstruction mentioned above [119]. Plating was accompanied by a lower risk of therapy failure (1% vs. 1.85%), shorter in-hospital stay (22 vs. 59%), and reduction in costs ((€8,243 vs. €33,365) (unpublished data).
In cases of minor sternal bone loss, we use an autologous bone graft harvested from the patient ´s own iliac crest. The graft is preferably prepared as bi-cortical. There is a limit to the extent of bone tissue that can be solved through this method. Fixation of the bone graft and chest stabilization is done in the manner described above. From 2009 to 2012 we used this method in 2 patients. In both cases the wounds healed successfully and the sternal wall regained full stability. Both sternal defects represented partial loss of bone tissue from 6 to 8 cm in length.
Based on this experience, we decided to apply a novel approach for the treatment of massive bone loss after DSWI, by supplying the bone defect with an allogenous bone graft. It allows treating large sternal defects in the same way as a total or near-total sternectomy and fixed properly with titanium plate system ensures chest cage stability. An allogenous bone transplant doesn´t contain any vital bone marrow cells, which eliminates difficulties in immuno-genetic acceptance of the graft by a patient; it represents a biological tissue transfer, which even under conditions of maximum precautions represents a minor risk for transmission of viral or bacterial infections. An allogenous graft must meet legislative criteria from the Czech Republic and the European Association of Tissue Banks [161,162]. Prior to graft harvesting, each donor is cross-checked for registration within the National Registry for organ donation refusal. All deceased donors treated for infectious disease, sepsis, malignant tumors, or systemic and autoimmune diseases at the time of death are withdrawn from the donor list. Donor blood serum samples are tested for antibodies and HIV types 1 and 2, hepatitis B surface antigen (HbsAg), hepatitis C antibodies (anti-HCV), and HTLV I and II antibodies. Harvest of a sternal bone graft is performed under strictly sterile conditions by a team from the National Tissue Center in Brno. The graft is harvested under sterile conditions and stored in the freezer at −80°C. Prior to its clinical use, the graft is thawed at 4-6°C for 12 hours, soaked with a 1% gentamicin solution, prepared for its final shape, and stored in the freezer again at −80°C. If bacterial sampling is negative, the graft is thawed for 12 hours before transplantation, and submerged in a bath with 1% neomycin solution immediately before surgery.
Inherent surgical technique is modified by a more aggressive debridement of residual chest bone or ribs (1-2 cm safety line). Afterwards, the bone graft is adjusted to the size of the bone defect and fixed with plates anchored by self-cutting or self-drilling cortical screws. An uneven surface and tiny bone deficiency can be filled in with a spongy bone which is prepared from another graft provided by the tissue bank (femoral or tibial graft source). Residual soft tissue defect is covered with monolateral or bilateral pectoral muscle flap transfer. Within the postoperative period, it is strongly recommended to avoid excessive coughing or any rough mechanical strain on the sternal wall. Intravenous antibiotics are administered for at least three weeks after the reconstruction. Between January 2010 and September 2012, we performed six reconstructions of the sternal wall using an allogenous bone graft. We used a cadaveric sternum in four cases (Figure 3), and due to a lack of allografts, we had to use a calva bone in one patient (Figure 4) and a split femoral diaphysis in one patient. Successful healing after the reconstruction was achieved in five cases (83%), while one patient required additional treatment for partial skin necrosis. One obese female experienced flap failure and died from multiple organ failure. Follow-up of the other patients at 3, 6 and 12 months after reconstruction proved stability of the chest wall. A radio-isotope scan using technetium as a tracer of autologous leukocytes (Technetium-HMPAO) carried out at 3, 6 and 12 months after the reconstruction showed a high level of healing activity within the area of the allogenous bone implant, and further chest wall stability with allograft union was confirmed through 3D-CT evaluation done 5 to 7 months after the reconstruction (unpublished data).
Cadaveric sternal allograft and its use for large residual bone defect
Cadaveric calva bone allograft in large bone defect repair and CT reconstruction showing the bone re-union
In a group of 76 consecutive patients primarily treated with NPWT for DSWI from September 2004 to September 2011, 19 residual defects (25%) were closed by direct suture, and 57 patients (75%) underwent flap transfer to achieve reliable tension-free suture. All but 2 patients (2.7 %) underwent sternal stabilization with re-cerclage (61.8%) or transverse plates with or without bone graft (35.5%). Local fasciocutaneous advancement was used in 12 patients (21.1%), bilateral pectoralis advancement flap in 35 patients (61.2%), monolateral pectoralis flap with V-Y skin island in 7 patients (12.3%), bipedicled pectoral and rectus abdominis flap in 1 patient (1.7%), and vertical rectus abdominis flap in 2 patients (3.5%). We faced 2 flap failures (3.5%) and one whole monolateral pectoralis flap with V-Y skin island was lost due to vascular pedicle thrombosis, with 50% of the mass of the VRAM flap needing to be removed for flap necrosis. Minor healing complications requiring further local wound care were noted in 15 cases (26.3%). While the bilateral pectoralis advancement flap is a technique used by cardiac surgeons, other flaps used for covering larger residual soft tissue defects are utilized by plastic surgeon. The pectoral major flap with V-Y skin island is the first choice (Figure 5). When the defect is wide and deep, or in a female patient with large breasts, the VRAM pedicled flap is considered. If these two options fail or are not accessible, the latissimus dorsi pedicled flap is the next choice, and as a last resort, the microsurgical transfer is taken into account.
Technique of unilateral pectoral muscle flap advancement with V-Y skin island
DSWI remains a potentially fatal complication of cardiac surgery. Even though risk factors for development of DSWI have been identified, few are modifiable. Tight perioperative glycemic control, proper surgical technique, skeletonization of IMA grafts particularly in diabetics, and primary stable sternal approximation for high risk patients including diabetics, obese, immunosuppressed or those with COPD seem to reduce the risk of DSWI. Thanks to the unique combination of closed and open chest treatment, NPWT positively influences the survival of DSWI patients even at long-term follow-up in comparison with conventional therapy. Transverse titanium plates alone or with auto- or allograft bone allows chest cage stability irrespective to the bone mass loss. Better quality of life and lower extent of soft tissue defect might be promising for these patients who faced sternal instability and considerable flap-related morbidity some/few years ago. Plastic surgeons should be included in team planning post-DSWI sternotomy wound closure, not only called when previous closure attempt failed or residual defect seems to be extent.
Nursing care is facing (is going through) an unprecedented crisis in terms of lack of skilled (health) care workforces. Like all high-income countries (HIC), Germany is going through the said crisis, which is continuously accentuating year after year. The workforce’s needs for long-term care in German nursing houses have been estimated in [1] for the period from 2009 to 2030, expecting an increase:
from 94.000 to 331.000 professional nursing and
from 157.000 to 298.000 care staff.
Elke Peters et al. have estimated in [2] the number of people living in Germany requesting nursing care to 3 million and to 5 million by 2050. The authors present a recent assessment of the nursing care services at nursing homes and at patient’s home and point out the needs for patients to live at home despite the benefit of all care services.
In November 2016, in Mondorf-les-Bains (Germany), a workshop [3] on nursing care had taken place. The topic of the workshop was: Nursing Care at the (German) border Regions? (Ger. Pflege an der Grenze?). The workshop’s main objectives were to strengthen the social aspect of nursing care and to more consider the nursing care to be taken place at the place of residence of the patient because of the demographic change and economic as well as employment market policy change. The said workshop pointed out that the share of family nursing care (also called care at home) is very small in comparison with ambulant nursing care. This means, family members do not care for their member requesting for nursing care. One of the main reasons leading to this situation is that the person requesting nursing care at home is living alone. Furthermore, direct family members are requested to participate in care costs. In order to participate, they must work to gain the necessary financial means to face the costs. This situation drives sometimes the family members to employ care staff without or with beginner’s care skills to care their parents at home or they send their parents aboard to East-European countries since the nursing care costs are cheaper there though caring at home for a person is not as easy as one can think. Prof. Dr. Eckart Hammer points out in [4] that many dementia patients are subjected to violence by family members who are caring for them at home. By analyzing this book section, one can understand why the German government put effort to solve the care workforce issues faced in order to admit enough nursing care requesting people to the care or nursing homes. Thus, family members who are not able to care for their patients can send them to a nursing/care home. They obviously also want to help the family to decently and lovingly care for their patients and protect the patient against as well as prevent violence. Violence can result from stress faced by the caring person. And the causes of stress are multiple. Violence also occurs in nursing care houses.
People with advanced dementia have complex needs [5]. Schmidt et al. have investigated the needs in a recent study. The study shows the evidence that people with advanced dementia are requesting monitoring round the clock even for a simple activity like “food intake.” At nursing care house, monitoring is guaranteed. But what happens if those people are living at their regular residence? This research question is justified by the results carried out by [6], which point out the causes of nursing care workforce shortage and provide recommendations to overcome the issues faced. In [7], the author recommends a series of solutions to fix the workforce shortage. One of these solutions is to use telemedicine to overcome the shortage of issues faced. He writes
Other solutions proposed to reduce the effects of shortages include the use of telemedicine to reach far-away neurologists (though this is unlikely to reduce workloads), the development of artificial intelligence to help in making diagnoses, and expanding neurological care to include non-neurologist physicians and advanced practitioners (specially trained nurses and physicians’ assistants)…
The recommended solutions are intended for neurology, though some of them can suite other medical fields.
Using telemedicine to overcome workforce shortage implies to keep a patient at his residence or at the care unit with only primary care services. A further research question rising here is what is the quality of life (QoL) of patients treated at home? Is it worth treating dementia patients at home instead of a nursing care home? Rebecca Palm et al. investigated in [8] the environment as a factor impacting the health-related QoL regarding nursing care for dementia patients. The study reveals that the structural and organizational characteristics of care units may impact the QoL though the study does clearly prove through empirical evidence that the care unit’s structure and organization influence the QoL. However, to our best knowledge, no study has investigated the impact of homecare on the health-related QoL based on the QoL measurement metrics pointed out in [8] such as temperature, noise, lightning, familiarity, adequate space, and opportunities to participate in domestic activities; it could be subsequently deduced that if the patient’s residence place also provides the same environmental criteria as temperature, familiarity, sufficient food, and water, etc., the patient treated at home will undergo the same health-related QoL. In [9], the authors investigated the impact small-scaled nursing care homes have on health outcome-related QoL. They found out that moving from large-scaled to a small-scaled nursing house can improve the aspect of the QoL by reducing the anxiety. This study allows us to conclude that a patient treated at home in his family circle and habituated residence place has less anxiety and better QoL.
It is obvious that patients requesting nursing care can receive nursing care at their residence places with a better health-related QoL. The factors impacting the QoL are well known though caring for dementia, Parkinson’s disease, and elderly patients suffering from possible cognitive impairments is a challenging task. The research question raised here is how to assess the factors impacting the QoL for better health outcome?
The literature review on technologies in nursing care or commonly in healthcare reveals that nursing care at home for dementia and elderly patients can take benefit of the technology (cf. section methodology/literature review).
Homecare is increasingly getting attention among the population for multiple reasons such as the nursing care crisis. This research mainly aims at proposing smart home automation enabled personalized homecare solution for a better quality of life (QoL) for the patient and for assisting the patient’s family members to cost-effectively and efficiently care for their patients at home without any impairment of QoL. Furthermore, this study pursues the objectives to assess the impacts of being assisted by home automation system on the QoL of all involving family members.
This study contributes to the multidimensionality of the concept of the smart home where many dimensions of home automation have been considered. The study focuses on many aspects of home automation such as energy saving [10, 11], temperature management, and regulation, security, and safety by managing the entrance, control doors, and windows.
Additionally, the study creates an environment for well-being for people limited in the movement.
The remainder of the chapter presents in Section 2 some backgrounds and definitions. The research methodology, consisting of a literature review, research data, and system design, is presented in Section 3. Research findings and discussion are presented in Section 4. Section 5 handles a daily personal assistance system, which is designed and implemented to assist patients receiving nursing care at home and who is most of the time alone, and Section 6 concludes the study.
According to NIH-UK (National Institute of Health United Kingdom), a nursing home provides hospital-like care services to people (outpatients, elderly, palliative, etc.) that cannot stay in the hospital for any aftercare or for elderly care.
A nursing home is a place for people who don\'t need to be in a hospital but can\'t be cared for at home. Most nursing homes have nursing aides and skilled nurses on hand 24 hours a day. (NIH-UK)
It is worth noting the main risk factors of being admitted to nursing and/or care homes (both are similar but are different regarding the qualification of the care-staff—see care homes vs nursing homes).
Age: elderly people have more chance of being admitted to a nursing/care home.
Low income: people with low income are vulnerable and have not enough possibilities to hire private care workforce to care for them at home.
Precisely for these reasons, they have a higher chance of being admitted to a nursing home.
Poor family support: especially in cases where the older adult lacks a spouse or children.
Low social activity: isolated people because of cognitive or age-related impairment.
Functional or mental difficulties.
Regarding the risk factors of being admitted to nursing or care homes, it is obvious that a group of people can be excluded from being admitted since they would not meet the conditions.
According to [12], nursing homes have been recommended to employ higher skilled nurse staffing in their homes, with 24-hour registered nursing care.
As the Balcombe Care Homes defines on its website:1
A nursing home will provide all the day-to-day care that you would expect from any care home, but the care is supervised by registered nurses who are on duty all day and all night.
while
Care homes are staffed 24 hours a day and a proportion of the staff will be qualified care assistants with NVQs (National Vocational Qualifications) at Level 2 or 3.
Segen’s Medical Dictionary defines nursing care as
A nonspecific term in medicine; among medically qualified doctors in the UK, nursing care generally refers to procedures or medications which are solely or primarily aimed at providing comfort to a patient or alleviating that person’s pain, symptoms or distress, and includes the offer of oral nutrition and hydration
Based on the Segen’s Medical Dictionary definition of nursing care, nursing care can be assimilated to palliative as well as elderly care. Most elderly people are requesting nursing care due to health conditions such as cognitive impairments that include dementia, Parkinson, blindness, etc. [13, 14]. Though their chance of being admitted to a nursing home is low, modern technology, as well as methodology such as remote care, can assist to provide them with the needed nursing care at their residence place. The question raised is how will this work?
The demographic structure of the developed countries (DC) or high-income countries (HIC) contains a large number of older (from 85+ years) and elderly (from 60+ years) people than young people (up to 59 years) and a very small number of teenagers (up to 15 years) in their population. The population of older adults is fastly growing in HIC [15], whereas the population in developing or low- and middle-income countries (LMIC) is remaining younger, although the number of young people is decreasing (see the example of Uganda—Figure 1). The median age in LMIC is around 15 years (see Figure 1), while the median age in the European Union (EU) is predicted to pass from 36.5 years in 1995 to 47.6 years in 2060 with an increasing tendency [16]. Thus, EU countries are facing an increasingly elderly population with all related needs like nursing and care homes, accommodated elderly healthcare services, etc.
Projection on demographic change LMIC versus HIC (from 1950 to 2050) [source [19]].
The term “Elderly people” is defined as adults aged 60+ years, while people aged 65+ years are considered as an elder. Orimo, Hajime et al. had reviewed the definition of the term “elderly” in [17] and found out a correlation between elderly and the request or need of medium to severe nursing care.
According to the conventional definition presented by the authors in contrary to the definition above, the elderly is from 65+ years.
Conventionally, “elderly” has been defined as a chronological age of 65 years old or older, while those from 65 through 74 years old are referred to as “early elderly” and those over 75 years old as “late elderly.” [17].
Though the World Health Organization (WHO) considers people aged 60+ years as elderly.
At the moment, there is no United Nations standard numerical criterion, but the UN agreed cutoff is 60+ years to refer to the older population [18].
And arguments follow such as why no one can exactly determine the age at which one has to be considered as elderly.
In addition, chronological or “official” definitions of aging can differ widely from traditional or community definitions of when a person is older. We will follow the lead of the developed worlds, for better or worse, and use the pensionable age limit often used by governments to set a standard for the definition [18].
According to the United Nations projection, about 79% of the world elder population aged 60 years or over will live in LMIC by 2050 [19]. Therefore, 20% of them will live in HIC.
Analyzing the population distribution (Figure 6 in [19]) reveals that in countries like Germany, population will count more aging people while an LMIC’s population like Uganda’s population will remain young.
As a conclusion, it is worth noting that the needs of nursing and care homes are higher in HIC than in LMIC. Therefore, the chapter will more focus on the nursing situation in HIC.
Age-related impairment mostly known as cognitive impairment is a group of diseases, which occurs with advancing age. Cognitive impairment can also occur in young people. Mostly age-related cognitive impairments are dementia, Alzheimer’s, Parkinson’s, loss of vision, hearing loss, depression, incontinence, etc.
Obviously, cognitive impairment progresses with advancing age. In [17], the authors found out that elderly need from 75+ years severe nursing care. Though nursing care shows the potential to improve the individual’s quality of life (QoL), most cognitive impairments cannot be cured. The patient, therefore, needs more attention, for example, reminding him to take food and drink enough water, and bringing him to get socialized again.
In order to better understand why these patients need more nursing care than others, it is worth understanding the symptoms of some cognitive diseases as follows.
Dementia is a progressive health condition mostly in elderly people. Dementia is a consequence of health conditions like Alzheimer and is characterized by cognitive impairment (loss of cognitive capabilities or abilities).
The Journal of the American Medical Association defines Dementia as
Dementia is diagnosed only when both memory and another cognitive function are each affected severely enough to interfere with a person’s ability to carry out routine daily activities.
The free dictionary gives a similar definition as
Loss of cognitive abilities, including memory, concentration, communication, planning, and abstract thinking, resulting from brain injury or from a disease such as Alzheimer’s disease or Parkinson’s disease. It is sometimes accompanied by emotional disturbance and personality changes.
Regarding the characteristics of dementia, it is highly requested to assist round the clock people suffering from such health condition in order to protect them against any accident that can result from forgetfulness. On one hand, they need assistance, and on the other hand, they can be refused to being admitted to nursing or care home. Furthermore, keeping these people at home remains challenging. Family members caring for these people are mostly by day time at their own job. In this case, the only solution is to employ care/nursing personnel to care for them during the absence of all family members. It is reportedly known that most “care/nursing personnel” hired for homecare are poorly skilled and mostly come from a different cultural background as the patient. The question is can all these factors impact the patient’s QoL? Especially, can the cultural differences contribute to QoL loss? Answering this question is out of the scope of the present study.
Parkinson’s disease is one of the best-known and most common diseases of the nervous system. It is a cognitive disease and mostly related to advancing age. James Parkinson, the British physician, described the typical symptoms of the disease for the first time in 1817 and gave his name to the disease. Like a most cognitive disease, is a slowly progressive neurological disease that affects certain areas of the brain. The main symptom of Parkinson’s disease is the movement disorder.
People suffering from Parkinson’s disease are, therefore, dependent on other people since they are limited in their movement. Furthermore, they can lose the sense of smelling and mostly suffer from Dementia, depression, and anxiety.
The main role of home automation is to control and manage devices at the local network(s) in the house. It can enable remote interactions with the network in order to access some information or to set command. For example, one can remotely ask his fridge or the fridge can send him a grocery list. Many technologies are included in home automation. Technologies like wireless sensor networks, videos, and connected devices support smart home automation paradigm. In [20], Toschi et al. reviewed the technologies that enabled a machine-to-machine (M2M)-based house automation. According to the authors, home automation is tending beyond connecting autonomous toward smart process and devices.
In this section, two technologies are briefly presented. In prior, the term automation is defined.
In [21], Vasseur and Dunkels defined home automation as follows:
Home automation is an area of multiple and diverse applications that include lighting control, security and access control, comfort and convenience, energy management, remote home management, and aging independently and assisted living.
In the context of nursing care, home automation (HA) is a network system and application that includes at the first place bio-signal monitoring, well-being control, and other medical means like medication intake, physical exercises, etc. Further, HA includes temperature management, patient-safety, and security by preventing dangerous actions like leaving furnace or gas on, going out without adequate wearing.
Figure 2 (Source Figure 23.1 in [21]) presents a sample of home control devices.
In [22], Pham et al. defined smart home automation as an environment context-related data for precise health monitoring. They write:
A smart home environment provides ample contextual data related to a resident’s health, which allows more accurate health monitoring than only using physiological signals.
They further presented cloud-based home automation that collects bio-signals and location information in order to accurately monitor nursing home residents.
Sample of home control devices (source: [21]/Figure 23.1).
The Internet of things is a paradigm for autonomous data gathering and processing. In [23], Luigi Atzori et al. had defined the Internet of things as follows:
“The Internet of Things (IoT) is a novel paradigm that is rapidly gaining ground in the scenario of modern wireless telecommunications. The basic idea of this concept is the pervasive presence around us of a variety of things or objects, such as Radio-Frequency IDentification (RFID) tags, sensors, actuators, mobile phones, etc., which, through unique addressing schemes, are able to interact with each other and cooperate with their neighbors to reach common goals.”
Internet of health things (IoHT) is designed for medical data gathering and processing. IoHT connects unconnected health means with network connectivity ability. Digital and physical medical objects can thus network with each other in collaborating for data collection, processing, and storage. IoHT is a special case of the Internet of things (IoT) that combines health technologies and IoT and takes full advantage of IoT technology like the ability to initiate actions based on collected and analyzed data [24].
IoT finds its application already in the medical world as Istepanian et al. discussed in [25]. Williams et al. have defined the healthcare Internet of things (also called IoHT—Internet of health things) as
“…the new embedded sensing capabilities of devices together with the availability of always being connected, to improve patient care whilst reducing costs [26].”
The common architecture of IoT consists of sensors and actuators called things. Things are located at the data perception level. Behind the things are placed the IoT-gateways and data acquisition systems, followed by the edge IT and the data center (commonly on a remote server) and cloud. There are three (03) layers: (i) perception layer, (ii) gateway layer, and (iii) IoT platform layer.
IoT has the potential to enable home automation in collecting and processing data as well as to autonomously request actuators to execute some tasks for example temperature control by regulating the heater according to the set (for patient comfortable) room temperature.
IoT presents various domain-specific architectures that use various technologies and areas such as RFID, service-oriented architecture, wireless sensor network, supply chain management, industry, healthcare, smart city, logistics, connected living, big data, cloud computing, social computing, and security. Figure 3 shows an IoT-enabled healthcare data perception system.
Healthcare domain specific IoT architecture (source: [27]).
Wireless sensor networks (WSNs) find their use in smart home automation application since a while. They are used for medical application and devices to measure the patient’s vital parameter. Bio-signals like body temperature, blood pressure, pulse oximetry, ECG, and breathing activity can autonomously and event-based automatically and seamless be measured.
Clinics, hospitals, and care/nursing homes can remotely use end-point devices like video and audio devices to assist family members to care for their sick member at home. Thus, home automation systems can be connected to medical emergency stations at clinics and hospitals close to the patient’s residence place and regularly forward the patient’s critical data gathered by WSMs and BANs. How this works is presented by Moghadam et al. in [28] where they have designed and implemented a communication system single and multi-antenna in a BAN. They wrote:
“an energy efficient data transmission technique for communication between a single-antenna medical sensor/microrobot inside the body to a multi-antenna receiver on the body surface through non-homogeneous propagation environment.”
Transmitting over multiple spatial and temporal scales is challenging in advanced health informatics [29] though advancement achieved in the Internet of things (IoT) protocols like LoRaWAN with platforms like the things network (TTN) [
Wireless body area network (WBAN) is part of wireless sensor networks (WSNs) that can enable monitoring and collecting the patient bio-signal. This has been shown in a previous study [30] where a wireless sensor network system has been used at a cardiologic intensive care unit (CICU) for collecting and monitoring, round the clock, cardiologic activities in-patients. WSNs were connected to the patients and thus bio-signals have been collected in real time. This study has shown the feasibility of using WSNs and WBNs in home automation.
The main objectives behind the research questions are on one hand to investigate the tendency toward homecare regarding the nursing care homes and care workforce shortage and on the other hand to additionally investigate challenges and issues people are facing in homecare. Homecare is when family members care for their sick member at home. The needs in terms of appropriate solutions to overcome challenges and issues faced by caring for patients in homecare are assessed.
Q1: What is the tendency for homecare regarding the current nursing care crisis facing HIC?
Three nursing care options are noticed in Germany: (i) nursing care residences with 24 h registered care services and (ii) homecare with the assistance of ambulant nursing staff for a couple of hours per day. Many families hire care personnel from abroad (e.g., Yugoslavia, Budapest, and Ukraine), mostly with beginner’s skills or no skills at all to care for their sick parents. Family members also care for the patient following medical instructions, (iii) regarding nursing care homes practiced fees, many families send their sick parents abroad in East European countries.
Q2: What challenges and issues are facing homecare?
Caring for a patient in homecare can be challenging for family members since many patients request round the clock nursing care. This is a full-time job. This study aims at investigating the challenges and issues that can be faced in such a situation.
Q3: Is it worth caring for dementia patients in homecare instead of at nursing care home?
Dementia patients are forgetful. They can forget to take food and drink water. They could forget to turn off a furnace or turn on a heater. Regarding these issues, it is worth assessing how to handle dementia patients.
Q4: What is the quality of life (QoL) of patients treated in homecare?
Many studies investigated the patient’s QoL in nursing homes. Measuring or assessing the QoL level of patients in homecare is not achieved. This study aims at assessing it.
Q5: How to assess the factors impacting the health-related QoL for homecare?
There are well-established metrics for assessing the level of QoL in the nursing context though patient in homecare is exposed to additional environmental means. Therefore, it matters to investigate the impact of the QoL of other members on the QoL of the patient. Furthermore, can noise negatively impact the QoL in homecare? A grand-mutter (an elderly) will not be disturbed by a crying grand-child. It is, therefore, important to analyze which criteria are contributing to measuring the QoL in the case of homecare.
Q6: Can the technology assist to overcome homecare-related challenges and issues?
Round the clock care cannot be achieved by one person. It is a challenge. Previous studies have shown evidence for using the technology in healthcare to deliver care at remote, to monitor 24 h a day intensive care patients, etc. Many works have been achieved regarding mental health sensing and assessment, etc. In the present context, this study aims at investigating how home automation supported solution can assist in homecare and overcome challenges and issues faced.
H1: The tendency to care for patients in homecare is on increase since the nursing crisis.
The study would like to verify if the nursing crisis has impacted the family member behavior.
H2: Smart automation home technology assists in homecare and impacts the QoL of both family members and the patient.
H3: Smart home automation enables to combine occupation (job) and caring adequately (efficiently and effectively) for a patient at home.
Measuring the quality of services of nursing/care homes is out of the scope of this study, whereas only assessment of the patient’s QoL in homecare before and after using the proposed solution constitutes the scope of the present work.
This section presents the conducted literature review on the smart home automation for healthcare purposes. Additionally, data have been collected using semi-structured interview methodology with the objectives to answer the research question and verify the hypotheses.
In order to conduct a quantitative and qualitative literature review, papers have been sampled using snowball technology. Each found paper provides with numerous other papers through its references. Appropriate papers were thus found and used for the purpose of this study.
Papers were sought on three major bases: (i) home automation for medical applications, energy, security in the smart home, and trends in the smart home at cities. Beyond the technical part, papers dealing with the nursing care home, homecare, quality of life in nursing residences, and user satisfaction toward the nursing care are the main expressions used to find papers in the better academic literature database.
Table 1 summarizes the important papers reviewed.
Pos. | Title | Abstract | Year of publication | Reference |
---|---|---|---|---|
1 | Design of an IoT smart home system | This paper basically deals with the design of an IoT smart home system (IoTSHS) which can provide the remote control to smart home through mobile, infrared (IR) remote control as well as with PC/laptop. | 2018 | [31] |
2 | A systematic review of the smart home literature: A user perspective | To facilitate the implementation and adoption of smart home technology, it is important to examine the user’s perspective and the current state of smart homes. Given the fast pace with which the literature has been developing in this area, there is a strong need to revisit the literature. The aim of this paper is to systematically review the smart home literature and survey the current state of play from the users’ perspective. | 2019 | [11] |
3 | Implementation of Smart home automation system on FPGA board using IoT | There has been a rapid introduction of network-enabled digital technologies in home automation. These technologies provide a lot of opportunities to improvise the connectivity of devices within the home. Internet helps to bring in with an immediate solution for many problems and also able to connect from any of the remote places which contribute to overall cost reduction and energy consumption. Intelligence based on microprocessors is used by home automation to incorporate electronic structures in the household. | 2018 | [32] |
4 | Smart home technologies in everyday life: do they address key energy challenges in households? | This paper interrogates their contribution to the ambitious carbon emission reduction efforts required under the 1.5 _C mitigation pathway set by the Paris Agreement and their suitability for energy poverty alleviation goals. In contrast to aspirational claims for a ‘smart utopia’ of greener, less energy-intensive, and more comfortable homes currently present in market and policy discourses, we argue that SHTs may reinforce unsustainable energy consumption patterns in the residential sector, which are not easily accessible by vulnerable consumers, and do little to help the ‘energy poor’ secure adequate and affordable access to energy at home. | 2018 | [32] |
5 | Environmental impacts and benefits of smart home automation: life cycle assessment of home energy management system | This paper discusses the life-cycle environmental impact of home energy management system (HEMS), in terms of its potential benefits and detrimental impacts. It is the expectation that adapting smart home automation (SHA) would lead to reduced electricity usage in the household and overall environmental advantages. | — | [33] |
6 | A review of smart homes—present state and future challenges | In the era of information technology, the elderly and disabled can be monitored with numerous intelligent devices. Sensors can be implanted into their home for continuous mobility assistance and nonobtrusive disease prevention. Modern sensor-embedded houses, or smart houses, cannot only assist people with reduced physical functions but help resolve the social isolation they face. They are capable of providing assistance without limiting or disturbing the resident’s daily routine, giving him or her greater comfort, pleasure, and well-being. This article presents an international selection of leading smart home projects, as well as the associated technologies of wearable/implantable monitoring systems and assistive robotics. The latter are often designed as components of the larger smart home environment. The paper will conclude by discussing the future challenges of the domain. | 2008 | [10] |
7 | Home automation networks: A survey | Home automation networks provide a promising opportunity in designing smart home systems and applications. In this context, machine-to-machine (M2M) networks are emerging as an efficient means to provide automated communication among distributed ubiquitous devices in a standardized manner, but none have been adopted universally. In an effort to present the technologies used in the M2M and home integration environment, this paper presents the home area network elements and definitions and reviews the standards, architectures, and initiatives created to enable M2M communication and integration in several different environments, especially at the smart home domain. This paper points out the differences between them and identifies trends for the future. | 2017 | [20] |
Selected literature among the sampling.
A semi-structured interview was conducted. Patients living at home as well as at nursing care home, care and nursing staffs, and people on the street were interviewed. The data collection was carried anonymously in accordance with the operative data privacy regulation in the country.
The data collection method has included questionnaires with a mixture of closed-ended (yes or no questions) and open-ended questions. Nursing home residents and patients in homecare were interviewed. Data were thus collected about nursing place tendencies and health-related as well as patient’s quality of life with regard to the residence place: nursing home or homecare. No data on the quality of services in any nursing were collected.
Quality of experience (QoE/QoX) or the satisfaction level is commonly based on a subjective appreciation of the quality of services. Patient’s quality of life can be subjective somehow. For example, two distinct persons can differently appreciate noise or the presence of other people. Some elderly can feel uncomfortable when the nurse is a foreigner and ignore some elementary cultural rules. Therefore, nursing home residents were especially interviewed about their feeling, about what makes them feel uncomfortable in order to detect the impacts on their quality of life.
An important point was to determine their subjectivity level toward what makes them feel uncomfortable. Furthermore, test participants were asked about any discomfort the system has caused to them as well as if they feel observed or patronized.
This approach is the more appropriate method to sample the research cohort since sensible data were (anonymously) collected, and for this reason, precisely, it is difficult to find people willing to provide with their medical data. Participants have been selected on the basis of trust in the person who recruits them.
Table 2 summarizes the nursing home resident’s cohort. A total of 33 patients were selected and classified per age range and gender. Table 3 shows the structure of the patients in homecare. A total of 30 patients were selected. The two cohorts were interviewed for investigating the health-related QoL in nursing homes or in homecare as well as their preference in terms of staying at residence or living at home with their family.
Age range | Total cohort size N = 33 | |||
---|---|---|---|---|
N = 17 | N = 16 | |||
Female | Male | |||
Number | Health conditions | Number | Health conditions | |
< 50 | 2 | 1 Victim of road accident (outpatient) | 4 | 1 Heart attack |
1 Physically disabled | 1 Depression | |||
2 Schizophrenia | ||||
50–64 | 4 | 2 Dementia (early stage) | 5 | 2 Depression |
1 Blindness + anxiety | 2 Physically disabled | |||
1 Not diagnosed with a mental disorder | 1 Anxiety | |||
65–80 | 5 | 3 Alzheimer | 4 | 2 Alzheimer |
2 Anxiety | 2 Depression | |||
>80 | 6 | 3 Parkinson’s disease Advanced dementia | 3 | 2 Alzheimer |
3 Alzheimer | 1 Advanced dementia |
Nursing home residents (cohort structure and diseases they are suffering from).
Age range | Total cohort size N = 30 | |||
---|---|---|---|---|
N = 14 | N = 16 | |||
Female | Male | |||
Number | Health conditions | Number | Health conditions | |
< 50 | 4 | 3 Heart attack | 7 | 2 Heart attack |
1 Physically disabled | 3 Depression | |||
2 Blindness | ||||
50–64 | 5 | 2 Mental disorder (early stage) | 5 | 2 Depression |
2 Anxiety | 2 Physically Disabled | |||
1 Physically disabled | 1 Anxiety | |||
65–80 | 3 | 2 Alzheimer | 3 | Depression |
1 Anxiety | ||||
> 80 | 2 | 1 Parkinson’s disease | 1 | 1 Alzheimer |
1 Alzheimer |
Homecare patients (cohort structure and diseases they are suffering from).
Table 4 presents the cohort for investigating challenges and issues faced by homecare.
Assessment method | Total cohort size N = 515 | ||
---|---|---|---|
N = 50 | N = 68 | N = 397 | |
Care staff* | Nursing staff`* | Other individuals** | |
Paper-based questionnaires | 45 | 60 | 385 |
1:1 semi-structural interview | 5 | 8 | 12 |
Nursing staff and people interviewed on the street.
Only people that are caring or have cared for a family member were selected to participate.
Only staff involved in homecare.
Table 5 presents an overview of the structure of the testing cohort. According to [17], elderly people aged 75+ years request severe nursing care. Based on this finding, the testing cohort is split into two groups: (i) < 65 year old participants and (ii) 65+ year old participants. All test participants are living at home. Participants living or having poor family support as well as participants with good family support have been selected. The objective was to verify to what extent the proposed solution can assist the patient even if he has no support. Furthermore, the limitations of the proposed system need to be tested in terms of to what extent the third person is needed so that they can fully assist the patient.
Age range | Gender | Participants | Family support | Dementia | Other cognitive diseases | NCD/CD | |||
---|---|---|---|---|---|---|---|---|---|
Good | Poor | Yes | No | Yes | No | ||||
<65 | Female | 6 | 5 | 1 | 1 | 5 | 4 | 1 | Diabetes |
Male | 9 | 4 | 5 | 0 | 9 | 7 | 2 | Heart diseases diabetes | |
>65 | Female | 11 | 8 | 3 | 3 | 8 | 8 | 3 | |
Male | 7 | 2 | 5 | 1 | 6 | 6 | 1 |
The testing cohort.
NCD, non-communicable diseases; CD, communicable diseases/infectious diseases. No data collected on CDs.
This section summarizes the different questionnaires (Tables 6–8) used for the different surveys. At nursing homes and at participant’s home (case of homecare), the questionnaires were used in 1:1 structured interview followed by a semi-structured interview. Distractor or control questions are inserted into the questionnaire in order to detect discrepancies in the responses and thus filter the biased responses (Tables 6–8).
Pos. | Questions | Observations |
---|---|---|
1 | What do you most of all miss here? | Check how many patients prefer staying at home instead of living at the residence |
2 | Do your relatives visit you? | |
3 | How often do your parents visit you? | |
4 | Do you have any close friends here? | Socialization measurement |
5 | Are you missing your former friends? | Socialization, if he misses his former friends, this means he does not find a one here |
6 | Do you miss your parents, children, and grandchildren? | If yes, it means he does not receive enough or regular visits |
7 | Do you like living here? | |
8 | Do you have enough space for you? | |
9 | Are you missing your home? | |
10 | Do you receive enough and regularly food and water? | |
11 | What did you eat today? | Check if he is forgetful in order to consider or not the responses above |
12 | How do you feel today? | Assess the quality-of-life related to the patient’s health state and care services he is provided with |
13 | Are the nurses nice to you? | |
14 | Which nurse is your best friend? |
Questionnaire for patients.
Pos. | Questions | Observations |
---|---|---|
1 | Do you face any challenge during the admission process? | Assess how hard is it to get admitted to a nursing home |
2 | Would you prefer caring for your parent in homecare? If yes, why? If no, why? | Assess the tendency for homecare And find out why they have a tendency for one or other |
3 | Are you more confident to let care for your parent in a nursing home? If yes, what gives you that confidence? If no, why? Do you have no trust in nursing? | |
4 | Do you have a job? If yes, full-time or part-time? | Determine how one can manage both activities |
5 | If you respond to questions 2 and 4 by yes, then continue here; otherwise, go to the next question. How could you care for your parent in homecare and go to your job or on holidays? | |
6 | Have you ever experienced caring for a parent at home? If yes, how challenging was this? | Find out the real challenges people who experienced homecare are facing |
7 | Do you have any idea about which challenges and issues can be faced in homecare? If yes, which ones? | Challenges and issues in homecare. Home automation system should help to overcome these issues |
8 | Can modern information technology assist in homecare? If yes, how? | Determine the most needed functionality |
Questionnaire for no-care staff to check their tendency for homecare or nursing care homes.
Pos. | Questions | Observations |
---|---|---|
1 | Which challenges and issues are you facing daily? | |
2 | Do you have any technical assistance? | |
3 | How do you monitor the residents around the clock? | |
4 | Do you often assess the health-related quality of life of each patient? | |
5 | How many admissions do you register every year? | Assess the admission tendency |
6 | What is the admission tendency? | |
7 | How can you explain the tendency? |
Questionnaire for care-staff to investigate the trend toward the admission application.
Data analysis was made using IBM SPSS Statistics. Data were cleaned up; biased responses were not included in the analysis. Data dealing with a tendency for care at home as well as at nursing were accordingly classified. An AVG of the scores each category reaches was built. Before building the AVG, the different scores per category (stay at home or living at a nursing residence) obtained were compared with each other. The tendencies were plotted for visual analysis.
Participants (Table 5) were selected using a snowball approach.
The action research methodology was applied for the testing. The system was adjusted according to the results in a phase and re-tested in the next phase. The test lasted one (01) week in the first phase. Data were collected and analyzed. The second phase took one (01) week again and findings from phase 1 were worked into phase 2.
At the end of each phase, a quantitative and qualitative analysis was performed. Patient’s quality of life (QoL) and satisfaction level were measured in the light of the defined metrics (Table 9).
Quality of life measurement metrics | Description |
---|---|
Food and water intake | This metric verifies how many times the participant failed to take food and water. |
Medication intake | Does the participant follow the medical instructions and take the medicine as prescribed? |
Physical activities | Does the participant go out for physical activities or perform some at home? |
Socialization | How many social contacts the patient has? Does he connect to other people or is he isolated? |
Room temperature management | Does the system correctly learn from the participant preferences and set the temperature accordingly? |
Noise and lighting control | Noise and light can make the individual feel uncomfortable |
Familiarity | How familiar is the place to the individual |
Accident rate | Does the system assist and prevent the participant from accident such as injury with a knife, fall down, etc.? |
Emergency management | Does the system correctly detect emergency cases and thus manage the emergency? |
Bio-signal gathering and data quality |
Quality of life measurement metrics.
An important point was to involve participants living alone or having poor family support as well as those who have good family support. The objective to do so was to test if the system is well designed to assist people living alone too and how they are comfortable toward using the system (usability).
In order to measure and asses the impacts of the proposed solution on the quality of life, a set of quality of life metrics were defined. The results of the experiment were analyzed in light of these metrics.
Authorization and written informed participant consents were received from all major participants and their parents. An ad-hoc ethics committee at the involved clinics examined the request to conduct such an interview involving home’s residents and approved it. Resident’s parents also approved the study.
This section presents the study findings and discusses the results in light of data analytics.
The literature review has pointed out that only a few previous types of research consider the multidimensionality of the concept of the smart home. Mostly the studies are focused on one aspect of smart home such as energy management [11].
A total of 656 abstracts and 239 full papers (journal and conference papers) were reviewed. Only 41 papers were retained having met the requirement of the present study. Unfortunately, only two papers have discussed many dimensions of smart homes. The rest mostly handle the topic of energy management at home. Smart home for elderly people is well considered in many papers, but the papers have failed to consider the multidimensionality of the concept of “aging at home”.
Regarding the results, a novel solution considering the multidimensionality is therefore highly needed.
The interview with nursing home residents has revealed that elderly people prefer staying at home in their familiar and usual social environment (familiarity) and take care of their health by themselves as long as they are able to though only participants with good family support and those who have children, grandchildren, and good social contacts have the wish to stay at home as long as possible. However, alone living people, poor people, and people having no family support feel comfortable at the nursing residence.
Table 10 summarizes the results of the interview. Up to 91% of people living alone prefer residing in nursing homes, while more than 91% of people with good family support prefer staying at home with their family members.
Category | Social status | Number | Preferences | |
---|---|---|---|---|
Living at nursing care home | Staying at home | |||
Nursing home residents (33 participants) | Poor family support Poor (financial) Have lived alone | 21 | 17 (85%) | 4 (15%) |
Rich Good family support Good social contact | 12 | 01 (8.3%) | 11 (91.7%) | |
Homecare participants (30 participants) | Living alone | 23 | 21 (91.30%) | 2 (8.70%) |
Living with family | 7 | 0 | 7 (100%) |
Participant’s preferences toward living in nursing homes or staying at home.
Beyond the research questions, three (03) hypotheses were set. One hypothesis concerns the tendency for homecare as well as for nursing care home.
H1: The tendency to care for patients in homecare is on increase since the nursing crisis.
The study verifies on the light of interview results the hypothesis H1. The survey was carried out to investigate the impact of the nursing crisis on the family member behavior toward the nursing care option for their patients.
The surveys point out the following results:
There exist two categories of care: (i) stationary and (ii) ambulant nursing care [34].
People traditionally choose nursing residences for many reasons: (i) many people are living alone or have poor family support, (ii) the patient is at the end of life and needs severe intensive and palliative care, (iii) the care level (Ger. Pflegestufe).
A total of 118 healthcare staffs were interviewed. A total of 397 individuals on the street were also interviewed. A total of 56.78% of the interviewed care personnel admitted that the number of applicants for being admitted to a nursing home is being slowly decreasing, while 58.69% of people interviewed on the street prefer to care for relatives in homecare.
Tables 11 and 12 show the tendencies of nursing care. The results obtained have confirmed the hypothesis H1.
Assessment method | N = 118 | ||
---|---|---|---|
Application for being admitted in nursing care residence | |||
Decreasing | Increasing | Stable | |
Care personnel | 67 (56.78%) | 23 (19.50) | 28 (23.72) |
Tendency viewed by healthcare staff.
Assessment method | N = 397 | |||
---|---|---|---|---|
Care experience | Care for sick family members in homecare | |||
Prefer | Do not prefer | Prefer going abroad | ||
People on the street | 200 experienced with nursing homes | 233 (58.69%) | 97 (24.43%) | 67 (16.87%) |
197 not experienced with nursing homes |
Preference of caring for a patient at home.
The quantitative results regarding challenges and the number of people that reported these challenges and issues by caring for a family member are summarized in Table 13 (Diagram 1). The quantitative data analysis reveals that very few people in home care are faced with data collection issues. This means data are rarely collected in home care. Thus, patients laying at home do not produce patient-centric data. The few data there produce is patient-centered. It is though known that patient-centered data are subjective, incomplete, and sometimes biased [27, 35].
Pos. | N = 397 | |||
---|---|---|---|---|
Challenges and issues | Number (%) | Comments | ||
1 | Nocturnal rest | 397 (100%) | The family members have no rest. They can sleep well since assisted by the machine | |
2 | Emergency issues | 375 (99.5%) | Patient-centric data are collected. | |
3 | Limited round the clock nursing | 397 (100%) | x | |
4 | Inaccurate collected data | 40 (10.07%) | x | |
5 | Combining job and care for a family member | The system shows potential to assist people in caring for their in parents aging in place | ||
Only part-time | 317 (80.01%) | |||
Stress | 397 (100%) | |||
Financial issue | 298 (74.81%) | |||
6 | Loss of quality of life | 397 (100%) | ||
7 | Limited social activities | 290 (73.04%) | ||
8 | Depression | 15 (3.8%) |
Challenges and issues faced in homecare.
Number of participants facing challenges and issues in homecare.
H2: Smart automation home technology assists in homecare and impact the QoL of both family members and the patient.
The testing has confirmed the hypothesis (H2) regarding the user satisfaction‘s level and the quality of life (QoL) at both patient side and family side. Table 14 (Diagram 2), Table 15 (Diagram 3), and Table 16 show detailed results.
Comparison of patient’s quality of life before and after applying the proposed solution.
QoL level.
Metric [Link to Table 14 (column YES in after test)] | Cohort sampled after the test. It contains people having good metrics. | ||
---|---|---|---|
Total participants | Participants with good QoL and the family support level they received during the test | ||
Poor | Good | ||
Food and water intake [L1] | N = 22 | 7 | 15 |
Medication intake [L2] | N = 23 | 5 | 18 |
Physical activities [L3] | N = 11 | 2 | 9 |
Socialization [L4] | N = 13 | 3 | 10 |
Results | About 7 have good QoL among 30 Patients after the test About 18 have good QoL among 30 Patients after the test |
Impact of family support level on the patient’s QoL.
Impact of family support on the QoL.
N = 45 (patient’s relatives) | ||
---|---|---|
Metrics | Before the test (Survey + 5 days observation) | After the test (Data provided by the system + observation) |
Quality of life | Average | Very good |
Socialization | Few | Good |
Nocturnal rest | Bad | Very good |
Emergency management (quick medical assistance) | Bad | Good |
Quality of communication with doctors | Bad | Improved |
Bio-signal gathering and data quality | Worst | Improved (good) |
Job situation | Worst (no job, part-time job) | Good (mostly full time) |
Financial issues | Bad | Improved |
Depression | Highly depressive | Less depressive |
Comparison of family member’s quality of life before and after applying the proposed solution.
H3: Smart home automation enables to combine job outside and adequately (efficiently and effectively) care for the patient in homecare.
The hypothesis is verified. Working family members can partially, full-time, work at home (home office), or go to the job and also care for a member.
Overall, broad satisfaction is noticed among the participants and their relations.
The solution shows positive impacts on the quality of life (Good++, 36.6% started physical activities and 43.33% re-socialize). Due to the solution, 36.6% reconnect to physical activities, which means an increment of 23.3%. Nevertheless, about 62% remains without physical activities.
The solution has the pottential to assist people in combining full-time or parttime job with caring for a family member in home care. Since many people aging in place still have the ability and capability to walk and can go out and back home alone, the system assists them and monitor their health condition in order to timely alerte parents and medical doctors in the case of emergency. The results had also shown evidence of improving the quality of life. An upcoming paper will report work conducted on this topic.
This section presents the concept of a multidimensional smart home automation Internet of health things for assisting dementia patients and elderly to “aging well at home”. Additionally, the solution should assist the patient’s family members to care for them and go to their occupation as usual.
The section presents the system requirements, features, concept, and architectural view.
The need analysis including the analysis of collected data leads to define the following system requirements and features, which the smart home solution for elderly and dementia patients will provide. As shown above, the health-related quality of life (QoL) is measurable by means of:
The nutrition level (intake of food and water): elderly and/or dementia patient is the most forgetful and could forget to take food and regularly drink water. This can cause severe health issues.
Medication adherence: medication adherence level influences patient health outcomes. Dementia patient who adheres to the prescribed medication could have comfortable days.
Physical activities and socialization level: both influence the patient’s QoL.
Family support: Makes the patient feel more confident, secure, and safe. This is a factor impacting the patient’s QoL.
Space and comfort: More space is a comfort that prevents anxiety in an individual since small space limits activities and movements.
Regarding the QoL measurement metrics, the following system requirements have been defined:
Qualitatively and quantitatively assess a patient’s QoL level
Provide daily living assistance
Support patient empowerment and autonomy
Positively impact patient’s health outcomes
Collect patient-centric data and information for accommodated and personalized health care services
Further, assist family members to efficiently and effectively care for their sick member at home
The main system-relevant requirement is to provide patients with a cheaper, simple, and better usability by considering their cognitive impairment like eye, hearing, and feeling impairment, restricted movement, etc. Additionally, the proposed solution should work online and offline.
According to the system concept, the following features are provided to meet the requirements above.
A designed water and food dispenser monitors the patient and can provide him with the food he needs. The system ensures that the patient drinks enough water so as to prevent him from feeling thirsty.
Day menu presented.
The patient chooses a menu or the system selects 3 favorites based on historical data collected.
Food is ordered at the close restaurant and registered for the program.
Food is delivered.
Food is stored in the special fridge (WaFoD).
At an appropriate time, the food is warmed.
The patient is served.
In case a family member is at home and wants to care for the patient, WaFoD sends an alert to the member.
In the case of ordering food, then food order process will run otherwise the food dispenser will run.
Similar to food intake, a drug dispenser is equipped with a high-resolution camera which logs the drug intake. A future extension will automatically perform anomaly detection on recorded films.
The medication intake is then logged. The logs are sent to the family member and the doctor.
Special TV programs are displayed at certain times of the day to help the patient to train himself. The patient wears a body-area-networking (BAN) equipped with bio-sensors and accelerometer, which continually controls the position of the patient in order to detect if the patient is falling down or lying on the bed.
For dementia patients, no outdoor program is set.
Temperature control is a well-achieved domain application in smart home automation. Existing devices and systems are added to the network.
This feature prevents any noise and controls the lighting.
Doors and windows are controlled and closed when too noisy.
A smartphone-based application plays the role of a reminder and assistant. It follows the patient everywhere. Based on the patient calendar, this application can autonomously and automatically plan the whole day for the patient.
It can look for an appointment with the treating doctor for the next medical visit. The application is parametrizable.
This section presents the concept of the proposed systems and gives an overview of its architecture.
The system features (i) a data perception unit, (ii) water, food, and medication management unit, and (iii) outside and inside activities.
IoT-enabled patient-monitoring systems present many advantages for the patient and for treating care personnel. Patient-centric data are collected. Personalized care can be based on these data. Actually, healthcare professionals base their treatment on patient-centered data, which can be biased since they are subjective. Further diagnoses are therefore needed or performed to verify the patient-centered data. Patient-centered data are data provided by the patient through narratives, while patient-centric data are data collected using modern information technologies like (wireless) body area network (W-BAN) or (wireless) sensor networks (WSNs).
Aging persons are often forgetful and thus provide mostly biased information when they are requested to report on their health conditions. Though in a smart home automation enabled healthcare solution for “aging well,” collecting patient-centric data in an autonomous way is mandatory. In a previous study [35], various advantages of collecting patient-centric data were discussed. The healthcare personal gets a complete picture of the patient’s health condition and can thus pose the right diagnosis.
Based on the requirement above, the proposed concept provides a patient-centric data collector in terms of sensors connected with the patient that fully collects any bio-signal as well as positions data and sends the data to a record system at the remote. A duplicated copy of the data is saved on the local server and serves as training data for a machine learning (ML) routing. Additionally, a set of networking capable video recorders are used to collect the patient’s body expressions, behaviors, mimic, and any physical activities. These data are also used by the ML algorithm to predict patient’s behaviors, expectations, and physiological needs (like thirst, hunger, going to the toilet, etc.).
Sensors (in a body area network) connect the patient to an IoT-gateway that transfers the collected data, using the MQTT protocol, to the local server. We talk of edge-computing that happens at the edge. Collected data are processed and stored on the local server. Using the CoApp protocol, data are sent to the cloud. Treating care/nursing homes or medical doctor as well as patient’s family members can access the data and can send data to the local server, which would use received data to regulate some connected devices.
For “food and water intake”, a smart device is designed. This device combines microwaves and the fridge. The device called water and food dispenser (WaFoD) with networking ability is connected to the patient’s smartphone and the local server, which in turn is connected to a remote server at the cloud that connects the home to the outside and can dispatch information and data in the whole network. WaFoD can learn from the individual’s behaviors and preferences.
WaFoD is connected to the IoT gateway and can collect data, transfer data, and receive data from a remote unit (system or individual). Registered behaviors build the training data for a machine learning processor (ML) located on the local server, the master in the entire network. The ML processor predicts patient menus, proposes menus to the patient, and can order at the registered restaurant the selected menu. All proposed services to the patient are based on his behaviors and preferences.
WaFoD is designed to remind the patient to regularly drink water. It dispenses water or soft drinks. It can warm food and serve the food to the patient. The system logs each nutrition behavior and sends at the end of the day an activity journal, or in the case of emergency (that means the patient does not drink for a while or refuse to take food), it alerts the nursing home close to the patient’s residence.
The patient is provided with a touchscreen that displays TV programs and can display the pictures of menus proposed by WaFoD.
The entire system is designed following the Internet of things (IoT) paradigm: (i) data collection unit(s) and (ii) IoT-gateway place between the local server. The local server is a light copy of the remote server at the cloud, which can perform complex and memory consuming computing activities; (iii) the IoT platform at the cloud.
A copy of data like room temperature, updated patient’s preferences, etc. that are needed for any computing action are stored at the local server.
The patient is provided with a set of accelerometers (sensors to determine his position- fall down, laying , staying, seating, etc.). with the objective to detect, predict if the patient is falling down or will. Furthermore, other sensors like “Feuer alrm” have been used to monitor fire harzard.
A drug dispenser is provided. The dispenser is connected to the IoT-gateway via Bluetooth. It features an alarm and can remind the patient to take his medicine. The medication intake is logged and a protocol is stored on the network. Family members can be informed if the patient does not take the medicine on time, thus, action can be taken to help the patient to take the medicine. Care/nursing homes are also connected to the dispenser via the le cloud and can get alerted when the patient refuses to take the medicine.
The local server is connected to a touchscreen TV. It can display physical activity programs, which can let the patient to also do so, for example, activities like a walk in the room, some light movements, etc.
Elderly people need real socialization. They need therefore to go out and meet other people. The solution proposed feature a smartphone-based application that manages and looks for senior-meeting close to residence place. This application integrates Google Maps that drives the patient to the meeting and takes him back home.
Similar is done with medical visit.
The architectural view presents 4 layers (Figure 4).
Bio-signals, behavior, preferences, room temperature, physical activities, food, water, and medication intake data are collected at this stage through sensors.
The data collected data are forwarded to the aggregation stage.
At this stage, collected data are aggregated, filtered, cleaned up, processed, and pre-stored.
Processed data from the prior stage are used here, but also forwarded the cloud.
Stages A, B, and C happen in the local area (patient residence). In order to enable communication with the remote side, data are forwarded to the cloud. A communication line is, therefore, open between C and D.
Family members, restaurants, nursing homes, and all people authorized to deal with the stored data can access the data through the cloud.
Architectural view of the proposed system.
This topic will be discussed in the upcoming paper.
This study has investigated the state-of-the-art of “ageing well at home.” Many previous studies had archived interesting works on making the “home” comfortable and smarter for elderly and dementia patients. Though most of the previous works have failed in providing a complete solution of smart home automation (multidimensionality of the concept of the smart home) for people requesting homecare, this study covers this limitation and shows that smart home automation can impact the patient’s and his family member’s QoL in a positive way. People staying alone at home as well as those living in nursing care homes would take benefits from such a solution.
The future works aim at launching a human hologram in the program to assist the patient. The patient would though see a family member and can receive from him any instructions or discuss with him. As Table 15 shows, the presence of a family member has a great impact on the patient’s health-related quality of life and thus on his health outcomes.
Setting and remotely regulating the room temperature is well achieved though patient temperature feeling also depends on the treatment he is under. Certain drug or after-physical activities make the patient feel warm or hot. There exists no system that can automatically and autonomously recognize that the patient’s room temperature is not more appropriate. Therefore, we plan to design a wearable that can verify if the patient is feeling cold or hot and thus regulate the heater.
The Open Access model is applied to all of our publications and is designed to eliminate subscriptions and pay-per-view fees. This approach ensures free, immediate access to full text versions of your research.
",metaTitle:"Open Access Publishing Fees",metaDescription:"Open Access Publishing Fees",metaKeywords:null,canonicalURL:"/page/OA-publishing-fees",contentRaw:'[{"type":"htmlEditorComponent","content":"As a gold Open Access publisher, an Open Access Publishing Fee is payable on acceptance following peer review of the manuscript. In return, we provide high quality publishing services and exclusive benefits for all contributors. IntechOpen is the trusted publishing partner of over 118,000 international scientists and researchers.
\\n\\nThe Open Access Publishing Fee (OAPF) is payable only after your full chapter, monograph or Compacts monograph is accepted for publication.
\\n\\nOAPF Publishing Options
\\n\\n*These prices do not include Value-Added Tax (VAT). Residents of European Union countries need to add VAT based on the specific rate in their country of residence. Institutions and companies registered as VAT taxable entities in their own EU member state will not pay VAT as long as provision of the VAT registration number is made during the application process. This is made possible by the EU reverse charge method.
\\n\\nServices included are:
\\n\\nSee our full list of services here.
\\n\\nWhat isn't covered by the Open Access Publishing Fee?
\\n\\nIf your manuscript:
\\n\\nYour Author Service Manager will inform you of any items not covered by the OAPF and provide exact information regarding those additional costs before proceeding.
\\n\\nOpen Access Funding
\\n\\nTo explore funding opportunities and learn more about how you can finance your IntechOpen publication, go to our Open Access Funding page. IntechOpen offers expert assistance to all of its Authors. We can support you in approaching funding bodies and institutions in relation to publishing fees by providing information about compliance with the Open Access policies of your funder or institution. We can also assist with communicating the benefits of Open Access in order to support and strengthen your funding request and provide personal guidance through your application process. You can contact us at oapf@intechopen.com for further details or assistance.
\\n\\nFor Authors who are still unable to obtain funding from their institutions or research funding bodies for individual projects, IntechOpen does offer the possibility of applying for a Waiver to offset some or all processing feed. Details regarding our Waiver Policy can be found here.
\\n\\nAdded Value of Publishing with IntechOpen
\\n\\nChoosing to publish with IntechOpen ensures the following benefits:
\\n\\nBenefits of Publishing with IntechOpen
\\n\\nAs a gold Open Access publisher, an Open Access Publishing Fee is payable on acceptance following peer review of the manuscript. In return, we provide high quality publishing services and exclusive benefits for all contributors. IntechOpen is the trusted publishing partner of over 118,000 international scientists and researchers.
\n\nThe Open Access Publishing Fee (OAPF) is payable only after your full chapter, monograph or Compacts monograph is accepted for publication.
\n\nOAPF Publishing Options
\n\n*These prices do not include Value-Added Tax (VAT). Residents of European Union countries need to add VAT based on the specific rate in their country of residence. Institutions and companies registered as VAT taxable entities in their own EU member state will not pay VAT as long as provision of the VAT registration number is made during the application process. This is made possible by the EU reverse charge method.
\n\nServices included are:
\n\nSee our full list of services here.
\n\nWhat isn't covered by the Open Access Publishing Fee?
\n\nIf your manuscript:
\n\nYour Author Service Manager will inform you of any items not covered by the OAPF and provide exact information regarding those additional costs before proceeding.
\n\nOpen Access Funding
\n\nTo explore funding opportunities and learn more about how you can finance your IntechOpen publication, go to our Open Access Funding page. IntechOpen offers expert assistance to all of its Authors. We can support you in approaching funding bodies and institutions in relation to publishing fees by providing information about compliance with the Open Access policies of your funder or institution. We can also assist with communicating the benefits of Open Access in order to support and strengthen your funding request and provide personal guidance through your application process. You can contact us at oapf@intechopen.com for further details or assistance.
\n\nFor Authors who are still unable to obtain funding from their institutions or research funding bodies for individual projects, IntechOpen does offer the possibility of applying for a Waiver to offset some or all processing feed. Details regarding our Waiver Policy can be found here.
\n\nAdded Value of Publishing with IntechOpen
\n\nChoosing to publish with IntechOpen ensures the following benefits:
\n\nBenefits of Publishing with IntechOpen
\n\n