Jewish Rehabilitation Hospital

BACKGROUND: The efficacy of prophylaxis against stress ulcers in preventing gastrointestinal bleeding in critically ill patients has led to its widespread use. The side effects and cost of prophylaxis, however, necessitate targeting preventive therapy to those patients most likely to benefit. METHODS: We conducted a prospective multicenter cohort study in which we evaluated potential risk factors for stress ulceration in patients admitted to intensive care units and documented the occurrence of clinically important gastrointestinal bleeding (defined as overt bleeding in association with hemodynamic compromise or the need for blood transfusion). RESULTS: Of 2252 patients, 33 (1.5 percent; 95 percent confidence interval, 1.0 to 2.1 percent) had clinically important bleeding. Two strong independent risk factors for bleeding were identified: respiratory failure (odds ratio, 15.6) and coagulopathy (odds ratio, 4.3). Of 847 patients who had one or both of these risk factors, 31 (3.7 percent; 95 percent confidence interval, 2.5 to 5.2 percent) had clinically important bleeding. Of 1405 patients without these risk factors, 2 (0.1 percent; 95 percent confidence interval, 0.02 to 0.5 percent) had clinically important bleeding. The mortality rate was 48.5 percent in the group with bleeding and 9.1 percent in the group without bleeding (P < 0.001). CONCLUSIONS: Few critically ill patients have clinically important gastrointestinal bleeding, and therefore prophylaxis against stress ulcers can be safely withheld from critically ill patients unless they have coagulopathy or require mechanical ventilation.

There is a lack of consistency among researchers and clinicians in the use of terminology that describes changes in motor ability following neurological injury. Specifically, the terms and definitions of motor compensation and motor recovery have been used in different ways, which is a potential barrier to interdisciplinary communication. This Point of View describes the problem and offers a solution in the form of definitions of compensation and recovery at the neuronal, motor performance, and functional levels within the framework of the International Classification of Functioning model.

OBJECTIVES: This article describes the development of an assessment of functional disability for use with proxy-respondents of community-dwelling persons who have Alzheimer's disease as well as a study testing its reliability. METHOD: Panels composed of health care professionals and caregivers of persons with Alzheimer's disease were used to develop the Disability Assessment for Dementia (DAD). Fifty-nine caregivers participated in the refinement of the content and the testing of reliability. RESULTS: The DAD includes 40 items: 17 related to basic self-care and 23 to instrumental activities of daily living. It demonstrated a high degree of internal consistency (Cronbach's alpha = .96) and excellent interrater (N = 31, ICC = .95) and test-retest (N = 45, ICC = .96) reliability. In addition, it was found not to have gender bias. CONCLUSION: This instrument may help clinicians and caregivers of the population with Alzheimer's disease make decisions regarding the choice of suitable interventions.

BACKGROUND AND PURPOSE: A new gait training strategy for patients with stroke proposes to support a percentage of the patient's body weight while retraining gait on a treadmill. This research project intended to compare the effects of gait training with body weight support (BWS) and with no body weight support (no-BWS) on clinical outcome measures for patients with stroke. METHODS: One hundred subjects with stroke were randomized to receive one of two treatments while walking on a treadmill: 50 subjects were trained to walk with up to 40% of their body weight supported by a BWS system with overhead harness (BWS group), and the other 50 subjects were trained to walk bearing full weight on their lower extremities (no-BWS group). Treatment outcomes were assessed on the basis of functional balance, motor recovery, overground walking speed, and overground walking endurance. RESULTS: After a 6-week training period, the BWS group scored significantly higher than the no-BWS group for functional balance (P = 0.001), motor recovery (P = 0.001), overground walking speed (P = 0.029), and overground w alking endurance (P = 0.018). The follow-up evaluation, 3 months after training, revealed that the BWS group continues to have significantly higher scores for overground walking speed (P = 0.006) and motor recovery (P = 0.039). CONCLUSIONS: Retraining gait in patients with stroke while a percentage of their body weight was supported resulted in better walking abilities than gait training while the patients were bearing their full weight. This novel gait training strategy provides a dynamic and integrative approach for the treatment of gait dysfunction after stroke.

PURPOSE: To identify clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation for individuals with physical disabilities. METHOD: Relevant databases were searched for articles on telerehabilitation published until February 2007. Reference lists were examined and key journals were hand searched. Studies that included telerehabilitation for individuals with physical impairments and used experimental or observational study designs were included in the analysis, regardless of the specific clientele or location of services. Data was extracted using a form to record methodological aspects and results relating to clinical, process, healthcare utilization and cost outcomes. Study quality of randomized clinical trials was assessed using the PEDro rating scale. RESULTS: Some 28 articles were analysed. These dealt with rehabilitation of individuals in the community, neurological rehabilitation, cardiac rehabilitation, follow-up of individuals with spinal cord injuries, rehabilitation for speech-language impairments, and rehabilitation for varied clienteles. Clinical outcomes were generally improved following a telerehabilitation intervention and were at least similar to or better than an alternative intervention. Clinical process outcomes, such as attendance and compliance, were high with telerehabilitation although few comparisons are made to alternative interventions. Consultation time tended to be longer with telerehabilitation. Satisfaction with telerehabilitation was consistently high, although it was higher for patients than therapists. Few studies examined healthcare utilization measures and those that did reported mixed findings with respect to adverse events, use of emergency rooms and doctor visits. Only five of the studies examined costs. There is some preliminary evidence of potential cost savings for the healthcare facility. CONCLUSION: While evidence is mounting concerning the efficacy and effectiveness of telerehabilitation, high-quality evidence regarding impact on resource allocation and costs is still needed to support clinical and policy decision-making.

The primary focus of rehabilitation for individuals with loss of upper limb movement as a result of acquired brain injury is the relearning of specific motor skills and daily tasks. This relearning is essential because the loss of upper limb movement often results in a reduced quality of life. Although rehabilitation strives to take advantage of neuroplastic processes during recovery, results of traditional approaches to upper limb rehabilitation have not entirely met this goal. In contrast, enriched training tasks, simulated with a wide range of low- to high-end virtual reality-based simulations, can be used to provide meaningful, repetitive practice together with salient feedback, thereby maximizing neuroplastic processes via motor learning and motor recovery. Such enriched virtual environments have the potential to optimize motor learning by manipulating practice conditions that explicitly engage motivational, cognitive, motor control, and sensory feedback-based learning mechanisms. The objectives of this article are to review motor control and motor learning principles, to discuss how they can be exploited by virtual reality training environments, and to provide evidence concerning current applications for upper limb motor recovery. The limitations of the current technologies with respect to their effectiveness and transfer of learning to daily life tasks also are discussed.

The sixth update of the Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Reintegration following Stroke. Part one: Rehabilitation and Recovery Following Stroke is a comprehensive set of evidence-based guidelines addressing issues surrounding impairments, activity limitations, and participation restrictions following stroke. Rehabilitation is a critical component of recovery, essential for helping patients to regain lost skills, relearn tasks, and regain independence. Following a stroke, many people typically require rehabilitation for persisting deficits related to hemiparesis, upper-limb dysfunction, pain, impaired balance, swallowing, and vision, neglect, and limitations with mobility, activities of daily living, and communication. This module addresses interventions related to these issues as well as the structure in which they are provided, since rehabilitation can be provided on an inpatient, outpatient, or community basis. These guidelines also recognize that rehabilitation needs of people with stroke may change over time and therefore intermittent reassessment is important. Recommendations are appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. Unlike the previous set of recommendations, in which pediatric stroke was included, this set of recommendations includes primarily adult rehabilitation, recognizing many of these therapies may be applicable in children. Recommendations related to community reintegration, which were previously included within this rehabilitation module, can now be found in the companion module, Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke.

The objective of this study was to characterize participation in leisure activities in children with cerebral palsy (CP) and identify determinants of greater involvement. Ninety-five children of school age (9y 7mo [SD 2y 1mo]) with CP were recruited, and participation was evaluated with the Children's Assessment of Participation and Enjoyment in a subset (67/95; 42 males, 25 females) who could actively participate in completion of the assessment. Most had mild motor dysfunction (Gross Motor Function Classification System: 59% level I, 23% level II, 18% levels III-V) and had a spastic subtype of CP (23 hemiplegia, 17 diplegia, 16 quadriplegia, 11 other). Biomedical, child, family and environmental predictor variables were considered in the analysis. Results demonstrated that these children were actively involved in a wide range of leisure activities and experienced a high level of enjoyment. However, involvement was lower in skill-based and active physical activities as well as community-based activities. Mastery motivation and involvement in rehabilitation services enhanced involvement (intensity and diversity) in particular leisure activities, whereas cognitive and behavioral difficulties, activity limitations, and parental stress were obstacles to participation.

BACKGROUND: Restenosis is a major limitation of coronary angioplasty. Directional coronary atherectomy was developed with the expectation that it would provide better results than angioplasty, including a lower rate of restenosis. We undertook a randomized, multicenter trial to compare the rates of restenosis for atherectomy and angioplasty when used to treat lesions of the proximal left anterior descending coronary artery. METHODS: Of 274 patients referred for first-time, non-surgical revascularization of lesions of the proximal left anterior descending coronary artery, 138 were randomly assigned to undergo atherectomy and 136 to undergo angioplasty; 257 of 265 eligible patients (97 percent) underwent follow-up angiography at a median of 5.9 months. Computer-assisted quantitative measurements of luminal dimensions were determined from the angiograms obtained before and immediately after the procedure and at follow-up. The primary end point of restenosis was defined as stenosis of more than 50 percent of the vessel's diameter at follow-up. RESULTS: Quantitative analysis showed that the procedural success rate was higher in patients who underwent atherectomy than in those who had angioplasty (94 percent vs. 88 percent, P = 0.061); there was no significant difference in the frequency of major in-hospital complications (5 percent vs. 6 percent). At follow-up, the rate of restenosis was 46 percent after atherectomy and 43 percent after angioplasty (P = 0.71). Despite a larger initial gain in the minimal luminal diameter with atherectomy (mean [+/- SD], 1.45 +/- 0.47 vs. 1.16 +/- 0.44 mm; P < 0.001), there was a larger late loss (0.79 +/- 0.61 vs. 0.47 +/- 0.64 mm; P < 0.001), resulting in a similar minimal luminal diameter in the two groups at follow-up (1.55 +/- 0.60 vs. 1.61 +/- 0.68, P = 0.44). The clinical outcomes at six months were not significantly different between the two groups. CONCLUSIONS: The role of atherectomy in percutaneous coronary revascularization remains to be fully defined. However, as compared with angioplasty, atherectomy did not result in better late angiographic or clinical outcomes in patients with lesions of the proximal left anterior descending coronary artery.

A virtual reality (VR)-based locomotor training system has been developed for gait rehabilitation post-stroke. The system consists of a self-paced treadmill mounted onto a 6-degrees-of-freedom motion platform. Virtual environments (VEs) that are synchronized with the speed of the treadmill and the motions of the platform are rear-projected onto a screen in front of the walking subject. A feasibility study was conducted to test the capability of two stroke patients and one healthy control to be trained with the system. Three VE scenarios (corridor walking, street crossing, and park stroll) were woven into a gait-training program that provided three levels of complexity (walking speed, slopes, collision avoidances), progression criteria (number of successful trials) and knowledge of results. Results show that, with practice, patients can effectively increase their gait speed as demanded by the task and adapt their gait with respect to the change in physical terrain. However, successful completion of tasks requiring adaptation to increasing demands related to speed and physical terrains does not necessarily predict the patient's ability to anticipate and avoid collision with obstacles during walking. This feasibility study demonstrates that persons with stroke are able to adapt to this novel VR system and be immersed in the VEs for gait training.

Recent evidence suggests that poststroke depression is associated with the location of the brain infarct, proximity to the frontal pole being associated with greater depression following left hemisphere injury, and an opposite relationship being seen with injury to the right hemisphere. This study was designed to replicate and extend previous investigation of this issue. Depression was assessed following recent stroke in patients with localized right (n = 16) or left (n = 19) hemisphere lesions. No overall differences between these groups were found on several measures of depression. Although there appeared to be a negative linear relationship between severity of depression and distance of the lesion from the frontal pole in left hemisphere patients, this association failed to attain statistical significance. A curvilinear relationship was evident in right hemisphere patients, with anterior and posterior lesions associated with high depression scores. These data support the notion that lesion location is associated with the severity of poststroke depression, although the nature of this association may be more complex than has previously been suggested.

BACKGROUND AND PURPOSE: The instantaneous adaptations to speed and load changes during overground locomotion have major implications for mobility after stroke. We examined the extent to which stroke subjects could increase their overground walking speed with respect to speed and unloading changes. METHODS: Twelve subjects with a unilateral stroke were evaluated while walking overground full weight bearing (FWB) or with body weight support (BWS) at preferred or fast speed. On the basis of their preferred walking speed, subjects were classified as high (> or =45 cm/s) or low functioning (<45 cm/s). Gait speed, temporal distance factors (TDFs), as well as movements and muscle activation of the lower limbs were measured and compared across the conditions. RESULTS: FWB-Fast condition induced marked (165%) increment in gait speed in all subjects. BWS at preferred speed induced faster speeds in low- but not the high-functioning subjects, whereas combined BWS and fast walking yielded further speed increments in the high-functioning subjects. Fast walking was associated with bilateral increases in joint excursion and muscle activation, as well as improved symmetry in some TDFs. BWS favored a hip flexion strategy in early swing while decreasing limb circumduction. CONCLUSIONS: This study shows that stroke subjects can increase substantially their walking speed without deleterious effects. Fast walking induces marked speed-related improvements in body and limb kinematics and muscle activation patterns. BWS during overground walking also increases gait speed, but to a lesser extent and only in low-functioning subjects. The combination of BWS with fast speed produces the greatest increments in walking speed in all subjects.

BACKGROUND: The purpose of this investigation was to compare capillarity and fiber type proportions of the vastus lateralis muscle between patients with chronic obstructive pulmonary disease (COPD) and healthy subjects. METHODS: Fifteen male subjects were included in the study (8 COPD: 61.0 +/- 1.8 years [mean +/- SEM]; forced expiratory volume in 1 second 42.0 +/- 2.1% predicted; 7 N: age 54.0 +/- 1.1). Subjects were submitted to a symptom-limited maximal exercise test on ergocycle. After a transcutaneous biopsy of the vastus lateralis muscle, sections were cut 8 to 10 microns thick and stained with the Andersen method for capillarity and Stevens method for fiber typing. RESULTS: Patients with COPD had a decrease in peak oxygen consumption compared with healthy subjects (1.2 +/- 0.1 versus 3.0 +/- 0.2 L/min). Number of capillaries per square millimeter was lower in patients with COPD versus healthy subjects (92.6 +/- 16.1 and 213.3 +/- 33.5, P < 0.001); percentages of fiber types were 43.5 +/- 5.5% type I, 56.5 +/- 5.5% type II in COPD, and 56.7 +/- 3.4% type I, 43.2 +/- 3.4% type II in healthy subjects (P < 0.05). In addition, capillaries/fiber ratio was 0.83 +/- 0.05 in COPD, and 1.56 +/- 0.10 in healthy subjects (P < 0.001). CONCLUSION: As expected, patients with COPD showed a decrease in exercise capacity. The muscle analysis results indicate that patients with COPD have a greater proportion of type II fibers and a much lower capillaries/fiber ratio than normal subjects. We conclude that COPD adversely affects fiber type and capillarization of the lower limbs. This could be partly caused by deconditioning in these patients.

INTRODUCTION: Despite interest in virtual environments (VEs) for poststroke arm motor rehabilitation, advantages over physical environment (PE) training have not been established. OBJECTIVE: The authors compared kinematic and clinical outcomes of dose-matched upper-limb training between a 3D VE and a PE in chronic stroke. METHODS: Participants (n = 32) were randomized to a 3D VE or PE for training. They pointed to 6 workspace targets (72 trials, 12 trials/target, randomized) for 12 sessions over 4 weeks with similar feedback on precision, movement speed, and trunk displacement. Primary (kinematics, clinical arm motor impairment) and secondary (activity level, arm use) outcomes were compared by time (PRE, POST, and follow-up, RET), training environment, and impairment severity (mild, moderate-to-severe) using mixed-model analyses of variance (ANOVAs). RESULTS: Endpoint speed, overall performance on a reach-to-grasp task, and activity levels increased in both groups. Only participants in the VE group improved shoulder horizontal adduction at POST (9.5°) and flexion at both POST (6.3°) and RET (13°). Impairment level affected outcomes. After VE training, the mild group increased elbow extension (RET, 25.5°). The moderate-to-severe group in VE increased arm use at POST (0.5 points) and reaching ability at RET (2.2 points). The moderate-to-severe group training in PE increased reaching ability earlier (POST, 1.7 points) and both elbow extension (10.7°) and arm use (0.4 points) at RET, but these changes were accompanied by increased compensatory trunk displacement (RET, 30.2 mm). CONCLUSION: VE training led to more changes in the mild group and a motor recovery pattern in the moderate-to-severe group indicative of less compensation, possibly because of a better use of feedback.

Cerebellar injury is an important complication of preterm birth with far-reaching neuropsychiatric sequelae. We have previously shown a significant association between isolated injury to the premature cerebellum and subsequent impairment of regional volumetric growth in the contralateral cerebrum. In the current study, we examine the relationship between these remote regional impairments of cerebral volumetric growth and domain-specific functional deficits in these children. In 40 ex-preterm infants with isolated cerebellar injury, we performed neurodevelopmental evaluations and quantitative magnetic resonance imaging (MRI) studies at a mean age of 34 months. We measured cortical gray matter volumes in 8 parcellated regions of each cerebral hemisphere, as well as right and left cerebellar volumes. We show highly significant associations between early signs of autism and dorsolateral prefrontal cortex volume (P < 0.001); gross motor scores and sensorimotor cortical volumes (P < 0.001); and cognitive and expressive language scores and premotor and mid-temporal cortical volumes (P < 0.001). By multivariate analyses, each unit increase in the corresponding regional cerebral volume was associated with lower odds of abnormal outcome score, adjusted for age at MRI and contralateral cerebellar volume. This is the first report linking secondary impairment of remote cerebral cortical growth and functional disabilities in survivors of prematurity-related cerebellar brain injury.

BACKGROUND: Recovery of the upper limb (UL) after a stroke occurs well into the chronic stage. Stroke survivors can benefit from adaptive plasticity to improve UL movement through motor relearning. The provision of feedback has been shown to decrease the use of compensatory UL movement patterns. However, the effectiveness of feedback in improving UL motor recovery after a stroke has not yet been systematically reviewed. OBJECTIVE: The objective of this review was to systematically examine the role of extrinsic feedback on implicit motor learning after stroke, focusing on UL movement and functional recovery. RESULTS: The authors retrieved 9 studies that examined the role of feedback on UL motor recovery. Of these, 6 were randomized controlled trials (RCTs), 1 was a single-subject design, 1 was a pre-post design, and 1 was a cohort study. The studies were rated on the basis of Sackett's levels of evidence and PEDro (Physiotherapy Evidence Database) scores for RCTs. Levels of evidence were limited (level 2b) for UL motor learning of the less-affected extremity and strong (level 1a) for the more-affected extremity. DISCUSSION AND CONCLUSIONS: The results suggest that people with stroke may be capable of using extrinsic feedback for implicit motor learning and improving UL motor recovery. Emergent questions regarding the advantages of using different media for feedback delivery and the optimal type and schedule of feedback to enhance motor learning in patient populations still need to be addressed.

While most upper limb training interventions in neurological rehabilitation are based on established principles of motor learning and neural plasticity, recovery potential may be improved if the focus includes remediating an individual's specific motor impairment within the framework of a motor control theory. This paper reviews current theories of motor control and motor learning and describes how they can be incorporated into training programs to enhance sensorimotor recovery in patients with neurological lesions. An emphasis is placed on dynamical systems theory and the use of new technologies such as virtual, augmented and mixed reality applications for rehabilitation to facilitate learning.Implications for RehabilitationKinematic abundance allows the healthy nervous system to produce different combinations of joint rotations to perform a desired task.The structure of practice to improve the movement repertoire in rehabilitation should take into account the kinematic abundance of the system.Learning can be enhanced by varied practice with feedback about key movement elements.Virtual reality environments provide opportunities to manipulate the structure and schedule of practice and feedback.

Rehabilitation interventions involving virtual reality (VR) technology have been developed for the promotion of functional independence post stroke. A scoping review was performed to examine the efficacy of VR-based interventions on balance and mobility disorders post stroke. Twenty-four articles in the English language examining VR game-based interventions and outcomes directed at balance and mobility disorders were included. Various VR systems (customized and commercially available) were used as rehabilitation tools. Outcome measures included laboratory and clinical measures of balance and gait. Outcome measures of dynamic balance showed significant improvements following VR-based interventions as compared to other interventions. Further, it was observed that VR-based intervention may have favorable effects in improving walking speed and the ability to deal with environmental challenges, which may also facilitate independent community ambulation. VR-based therapy thus has the potential to be a useful tool for balance and gait training for stroke rehabilitation. Utilization of motor learning principles related to task-related training may have been an important factor leading to positive results. Other principles such as repetition, feedback etc. were used in studies but were not explored explicitly and may need to be investigated to further improve the strength of results. Lastly, robust study designs with appropriate attention towards the intensity and dose-response aspects of VR training, clear study objectives and suitable outcomes would further aid in determining evidence-based efficacy for VR game-based interventions in the future.

BACKGROUND AND PURPOSE: Upper limb motor impairment poststroke is commonly evaluated using clinical outcome measures such as the Fugl-Meyer Assessment. However, most clinical measures provide little information about motor patterns and compensations (eg, trunk displacement) used for task performance. Such information is obtained using movement quality kinematic variables (joint ranges, trunk displacement). Evaluation of movement quality may also help distinguish between levels of motor impairment severity in individuals poststroke. Our objective was to estimate concurrent and discriminant validity of movement quality kinematic variables for pointing and reach-to-grasp tasks. METHODS: A retrospective study of kinematic data (sagittal trunk displacement, shoulder flexion, shoulder horizontal adduction, elbow extension) and Fugl-Meyer Assessment scores from 86 subjects (subacute to chronic stroke) performing pointing and reaching tasks was done. Multiple and logistic regression analyses were used to estimate concurrent and discriminant validity respectively. Cutoff points for distinguishing between levels of upper limb motor impairment severity (mild, moderate to severe) were estimated using sensitivity/specificity decision plots. The criterion measure used was the Fugl-Meyer Assessment (upper limb section). RESULTS: The majority of variance in Fugl-Meyer Assessment scores was explained by a combination of trunk displacement and shoulder flexion (51%) for the pointing task and by trunk displacement alone (52%) for the reach-to-grasp task. Trunk displacement was the only variable that distinguished between levels of motor impairment severity. Cutoff points were 4.8 cm for pointing and 10.2 cm for reach-to-grasp movements. CONCLUSIONS: Movement quality kinematic variables are valid measures of arm motor impairment levels poststroke. Their use in regular clinical practice and research is justified.

OBJECTIVE: This study was undertaken to examine the outcome of patients with deep sternal wound infection (DSWI) now treated with vacuum-assisted closure (VAC) therapy as a bridge to sternal osteosynthesis with horizontal titanium plate fixation. METHODS: From 1992 to 2007, a consecutive cohort of 23,499 patients underwent open-heart surgery (OHS) in our institution. The period under study was divided in two according to the use of therapeutic modalities: conventional (1992-2001, N=118 DSWI): debridement/drainage with primary closure and irrigation (N=37), debridement/drainage, open packing followed by pectoralis myocutaneous flaps (PMFs) (N=81); contemporary (2002-2007, N=149 DSWI): conventional treatment (N=24) and VAC therapy (N=125/83.8%). VAC was followed by sternal osteosynthesis with horizontal titanium plates in 92 patients (61.7%). RESULTS: DSWI was diagnosed in 267 out of 23 499 (1.1%) patients of our entire series according to Center for Disease Control - Atlanta (CDC) criteria, 118 out of 13 180 (0.9%) in the first and 149 out of 10 319 (1.4%) in the second period (p=0.001). Hospital mortality (N=267/23,499) has been 10.25% for the entire cohort under study without any difference between groups (1992-2001: 11.4%; 2002-2007: 9.1%, p=0.67). More recently, VAC therapy (N=125) was associated with a lower mortality (4.8% vs 14.1%, p=0.01). Stepwise multivariable logistic regression analysis for both periods revealed that prolonged intubation in the intensive care unit (ICU), use of bilateral internal thoracic artery grafting (BIMA), diabetes, re-operation for bleeding and body mass index (BMI) >30 kgm(-2) are the most powerful predictors of DSWI. In the more recently treated patients using VAC therapy, combined procedures (valve and graft) also emerged as a significant predictor. For the entire study, Staphylococcus epidermidis (49.6%) has been the most frequently identified pathogen, followed by Staphylococcus aureus (38.8%). Methicillin-resistant S.aureus (MRSA) was observed in 4.9% of the cohort. Neither of these bacteria was associated with increased mortality. Survival analysis with Cox regression model and propensity score adjustment 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 submitted to OHS without DSWI (p=0.01). Early adjusted survival for patients with DSWI treated with VAC therapy 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 without VAC (p=0.02). CONCLUSIONS: DSWI remains a major and challenging complication of OHS. VAC therapy with sternal preservation followed by delayed sternal osteosynthesis and PMF has been recently proposed as a new therapeutic strategy. Most patients treated with VAC therapy in our second group showed decreased perioperative mortality and increased short-term survival.