Toronto ethicon lecture jan 2010

1,277
-1

Published on

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,277
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
24
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide
  • Note: Topics to be covered in this deck: Surgical Site Infections (SSIs) Plus SUTURES, including IRGACARE ® MP (triclosan) Integrity Selling Strategy Summary and Key Follow-ups
  • Note: This is a reminder of the common pathogens implicated in surgical site infections, or SSIs Gram-positive organisms are the most common pathogens, specifically staphylococci ( Staphylococcus aureus and coagulase-negative Staphylococcu s [CNS]), and enterococci. Keep in mind that the incidence of methicillin-resistant Staphylococcus aureus (MRSA) is on the rise Gram-negatives, another type of bacteria, include Escherichia coli , and Pseudomonas and Enterobacter species. The incidence of gram-negative resistance is also on the rise
  • Note: The Centers for Disease Control and Prevention, or CDC, classifies surgical wounds into 4 categories: Class I/Clean Class II/Clean-contaminated Class III/Contaminated Class IV/Dirty-infected
  • Note: There are a number of factors that contribute to bacterial colonization that can lead to surgical site infections
  • Note: These SSI risk factors are patient related
  • Note: These are surgical factors that contribute to SSI risk
  • Note: During surgery, these factors can contribute to SSI risk
  • Note: Because SSIs can occur days after surgery, certain postoperative issues are important to consider Discuss targeting the ICU or PA/Residents to determine who changes dressings. A lot of times the resident changes the dressings in the ICU and do not change gloves, which can lead to cross-examination
  • Note: Many factors play a role in the wound closure environment: the operating room, tools used to close the wound, personnel using aseptic technique, and patient factors (eg, other disease states, the extent of the surgical procedure, and level of immune system function)
  • Note: There are some additional factors that affect SSI risk
  • Note: SSIs are a major source of postoperative complications and can result in increased mortality for patients
  • Note: One factor increasing this trend is the prevalence of patients with comorbidities These patient populations include patients who are immunocompromised (HIV, organ transplants), elderly, in renal failure, or have diabetes, as well as other patient populations
  • Note: When microorganisms like bacteria attach themselves to the surface of an implanted medical device like a suture, they form biofilms that make themselves highly resistant to antimicrobial treatment and extremely difficult to remove from the surface of the device
  • Note: SSIs are a deviation from the optimal or “standard” postoperative course When calculating costs related to SSIs, it is important to take into account both direct and indirect costs
  • Note: Direct and indirect costs of SSIs include decreased patient satisfaction and increased litigation
  • Note: Sum up the serious and growing problem
  • Note: IRGACARE ® MP (triclosan) is a biocidal agent used in all Plus SUTURES products IRGACARE MP is a high-purity material that meets United States Pharmacopeia specifications for triclosan and contributes minimally to the background exposure to toxic residues It has demonstrated antibacterial efficacy and a long history of safety. IRGACARE MP is active against the most common pathogens implicated in SSIs, including S aureus , S epidermidis , and others IRGACARE MP is also a great candidate for incorporation into sutures because of its compatibility with suture processing
  • Note: The mode of action of triclosan is widely unknown The triclosan used in Plus SUTURES is the highly purified form, IRGACARE ® MP Recent studies have shown that it acts as a competitive inhibitor of an essential enzyme in fatty acid synthesis: enoyl-acyl carrier protein reductase
  • Note: IRGACARE ® MP (triclosan) withstands manufacturing processes, is cost-effective, and has excellent physical and functional properties Coated polyglactin 910 sutures with triclosan appeared to exhibit no difference from traditional polyglactin 910 sutures with respect to tactile smoothness, dry tie-down, and wet tie-down
  • Note: IRGACARE ® MP (triclosan) has favorable pharmacokinetic properties. It is well absorbed (50% – 100%) by the gastrointestinal tract and well distributed in the body It binds to serum albumin and is present as the sulfate and/or glucuronide conjugate, depending on exposure There is no indication that triclosan accumulates in plasma over time, nor is it stored after single or repeated exposure
  • Note: IRGACARE ® MP (triclosan) has favorable pharmacokinetic properties. It is well absorbed (50% – 100%) by the gastrointestinal tract and well distributed in the body It binds to serum albumin and is present as the sulfate and/or glucuronide conjugate, depending on exposure There is no indication that triclosan accumulates in plasma over time, nor is it stored after single or repeated exposure
  • Note: These results support the suggestion that the use of antimicrobial sutures for cerebrospinal fluid shunt surgery wound closure is safe, effective, and may be associated with a reduced risk of postoperative shunt infection
  • Toronto ethicon lecture jan 2010

    1. 1. Index <ul><li>Understanding SSIs </li></ul><ul><ul><li>Causes </li></ul></ul><ul><ul><li>Risk factors </li></ul></ul><ul><ul><li>Cost and consequences </li></ul></ul><ul><ul><li>IRGACARE ® MP (triclosan) </li></ul></ul><ul><ul><li>Clinical study review </li></ul></ul>Confidential. For Internal Use Only. ® Ciba Corporation Inc *Trademark © ETHICON, INC. 2008 All Rights Reserved
    2. 2. What Are SSIs? <ul><li>SSIs are infections associated with surgical procedures and are a major source of postoperative illness </li></ul><ul><li>These infections are responsible for approximately one quarter of all nosocomial infections and affect 1.4 million people worldwide at any time </li></ul><ul><li>SSIs result in longer hospitalization, increased patient mortality and higher costs for healthcare providers and payers </li></ul>Confidential. For Internal Use Only. Nichols RL. Emerg Infect Dis. 2001;7:220-224. World Health Organization. 2002;1-50. © ETHICON, INC. 2008 All Rights Reserved
    3. 3. SSI-causing Pathogens and Frequencies 0% 5% 10% 15% 20% 25% S taphylococcus aureus CNS Enterococci Escherichia coli Pseudomonas aeruginosa Enterobacter spp Infections (%) Gram positive Gram negative Confidential. For Internal Use Only. CNS=coagulase-negative Staphylococcus . National Nosocomial Infections Surveillance System. www.cdc.gov. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. © ETHICON, INC. 2008 All Rights Reserved
    4. 4. CDC Surgical Wound Categories Confidential. For Internal Use Only. CDC=Centers for Disease Control and Prevention. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. © ETHICON, INC. 2008 All Rights Reserved Class I/Clean Uninfected wound in which no inflammation is encountered and respiratory, alimentary, genital, or uninfected urinary tract is not entered. Class II/Clean-contaminated Operative wound in which respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Class III/Contaminated Open, fresh, accidental wounds. Class IV/ Dirty-infected Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera.
    5. 5. Factors in Bacterial Colonization Leading to SSIs <ul><li>Patient-related </li></ul><ul><li>Procedure/Techniques </li></ul><ul><li>Postoperative </li></ul><ul><li>Implants </li></ul>Confidential. For Internal Use Only. Hebert CK et al. Clin Orthop . 1996;331:140-145. Fletcher N et al. J Bone Joint Surg Am . 2007;89:1605-1618. Mangram AJ et al. Am J Infect Control . 1999;27:97-134. Fry DE. Medscape Surgery . 2003. © ETHICON, INC. 2008 All Rights Reserved
    6. 6. SSI Risk Factors – Patient Related <ul><li>Advanced age </li></ul><ul><li>Malnutrition </li></ul><ul><li>Obesity </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>History of smoking </li></ul><ul><li>Distant infection </li></ul><ul><li>Steroid therapy </li></ul><ul><li>Chronic inflammation </li></ul><ul><li>Open wounds </li></ul><ul><li>Radiation </li></ul><ul><li>Immunosuppressed </li></ul><ul><li>Length of preoperative stay </li></ul>Confidential. For Internal Use Only. Sumnicht RW. Med Bull US Army Eur. 1958;15:51-56. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. Fry DE. Medscape Surgery. 2003. © ETHICON, INC. 2008 All Rights Reserved
    7. 7. SSI Risk Factors – Procedures/Techniques <ul><li>Duration of operation </li></ul><ul><li>Duration of surgical scrub </li></ul><ul><li>Preoperative shaving, skin preparation </li></ul><ul><li>Inadequate OR ventilation </li></ul><ul><li>Inadequate sterilization of instruments </li></ul><ul><li>Surgical technique </li></ul><ul><li>Poor hemostasis </li></ul><ul><li>Failure to obliterate dead space </li></ul><ul><li>Tissue trauma </li></ul><ul><li>Skin antisepsis </li></ul><ul><li>Antimicrobial prophylaxis </li></ul><ul><li>Surgical drains </li></ul>Confidential. For Internal Use Only. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. © ETHICON, INC. 2008 All Rights Reserved
    8. 8. SSI Risk Factors – Procedures/Techniques Cont’d <ul><li>Length of preoperative hospital stay </li></ul><ul><li>Insufficient preoperative preparation </li></ul><ul><li>Personal hygiene, hair removal, skin disinfection </li></ul><ul><li>Insufficient antibiotic therapy </li></ul><ul><li>Intraoperative hypothermia </li></ul><ul><li>Intraoperative hypoxemia </li></ul><ul><li>Intraoperative hypotension </li></ul>Confidential. For Internal Use Only. Nguyen D et al. Infect Cont Hosp Epidemiol. 2001;22:485-492. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. Fry DE. Medscape Surgery. 2003. © ETHICON, INC. 2008 All Rights Reserved
    9. 9. SSI Postoperative Issues <ul><li>Incision care </li></ul><ul><ul><li>Sterile dressing </li></ul></ul><ul><ul><li>Dressing changes (use of sterile technique, aseptic precautions) </li></ul></ul><ul><li>Discharge planning </li></ul><ul><ul><li>Home incision care </li></ul></ul>Confidential. For Internal Use Only. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. © ETHICON, INC. 2008 All Rights Reserved
    10. 10. Objective: Control Microbiologic Risk Personnel Patient Factors Surgical Site Tools Operating Room Confidential. For Internal Use Only. © ETHICON, INC. 2008 All Rights Reserved
    11. 11. Independent Factors Associated With Increased SSI Risk <ul><li>Abdominal operation </li></ul><ul><li>Operation lasting >2 hours </li></ul><ul><li>Surgical site with wound classification of either contaminated or dirty-infected </li></ul><ul><ul><li>All wounds are contaminated; the level of contamination determines the severity or presence of an infection </li></ul></ul><ul><li>Operation performed on patient having ≥3 discharge diagnoses </li></ul>Confidential. For Internal Use Only. Mangram AJ et al. Am J Infect Control . 1999;27:97-134. © ETHICON, INC. 2008 All Rights Reserved
    12. 12. SSI Rates in Various Surgical Procedures <ul><li>Plastic (breast implantations 1964–1991); N=749 women; 2.5% </li></ul><ul><li>Cardiovascular (CABG 1996–1998); N=1,519 procedures; 2.7% </li></ul><ul><li>Orthopedic (1992–1993); N=11,309 hospitalized orthopedic patients; 1.1%– 2.2% </li></ul><ul><li>Gastric (1992–1998); N=1,184 moderate to high-risk procedures; 11% </li></ul>Confidential. For Internal Use Only. CABG=coronary artery bypass graft. Gabriel SE et al. N Engl J Med. 1997;336:677-682. Hollenbeak CS et al. Chest . 2000;118:397-402. Gaynes RP et al. Clin Infect Dis . 2001;33(suppl 2):S69-S77. © ETHICON, INC. 2008 All Rights Reserved
    13. 13. Additional Factors Affecting SSI Rates <ul><li>Growing problems </li></ul><ul><ul><li>-Emergence of resistant organisms </li></ul></ul><ul><ul><li>-More debilitated, elderly, immunocompromised patients; comorbid disease </li></ul></ul><ul><ul><li>-Organ transplants </li></ul></ul><ul><ul><li>-Prosthetic implants </li></ul></ul><ul><li>The risk of SSI can be generally defined as the amount of bacterial contamination at the site of the infection combined with the virulence, or degree of pathogenicity, of the bacteria in relation to the immune system resistance of the patient </li></ul>Dose of Bacterial Contamination  Virulence Resistance of the Host Patient Risk of SSI = Confidential. For Internal Use Only. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. © ETHICON, INC. 2008 All Rights Reserved
    14. 14. The Risks of Biofilm <ul><li>Biofilm is created when microorganisms like bacteria attach themselves to living or nonliving surfaces in internal or external environments </li></ul><ul><li>For instance, postoperative bacteria may contaminate the tissue in a surgical wound as well as the suture material itself </li></ul><ul><li>Furthermore, the bacteria develop extracellular polymers that promote greater adhesion and resistance to antimicrobial treatment </li></ul>Confidential. For Internal Use Only. Donlan RM. Emerg Infect Dis . 2001;7:277-281. Edmiston CE et al. J Am Coll Surg. 2006;203:481-489. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. © ETHICON, INC. 2008 All Rights Reserved
    15. 15. Consequences & Costs Associated With SSIs <ul><li>Increased length of hospital stay (7–10 days), cost, and mortality (doubled) </li></ul><ul><ul><li>60% more likely to spend time in the intensive care unit </li></ul></ul><ul><ul><li>5 times more likely to be readmitted to the hospital </li></ul></ul><ul><li>Cost ranges from $400 for superficial incisional SSI to >$30,000 for sternal wound or other serious infection </li></ul><ul><ul><li>Indirect costs (patient, family) are rarely considered </li></ul></ul><ul><ul><ul><li>Loss of productivity, functional capacity </li></ul></ul></ul><ul><li>Nearly 90,000 people die annually from healthcare-acquired infections (HAIs). SSIs are the most common HAI among surgical patients </li></ul><ul><li>More people die from HAIs than AIDS, motor vehicle accidents, and breast cancer combined </li></ul>Confidential. For Internal Use Only. Bratzler DW et al. Am J Surg. 2005;189:395-404. Bratzler DW et al. Clin Infect Dis. 2006;43:322-330. Urban JA. Surg Infect (Larchmt). 2006;7(suppl 1):S19-S22. Kovach TL. Infect Cont Today . June 1, 2005. © ETHICON, INC. 2008 All Rights Reserved
    16. 16. Additional Costs Associated With SSIs <ul><li>Indirect costs </li></ul><ul><ul><li>Lost productivity (patient, family) </li></ul></ul><ul><ul><li>Temporary or permanent impairment of physical/mental function </li></ul></ul><ul><ul><li>Decreased patient satisfaction </li></ul></ul><ul><ul><li>Decreased referrals </li></ul></ul><ul><ul><li>Increased litigation </li></ul></ul><ul><li>Direct costs </li></ul><ul><ul><li>Prolonged hospitalization, readmission </li></ul></ul><ul><ul><li>Outpatient and emergency care visits </li></ul></ul><ul><ul><li>Additional surgical procedures </li></ul></ul><ul><ul><ul><li>Incision and drainage </li></ul></ul></ul><ul><ul><ul><li>Staged reimplantation </li></ul></ul></ul><ul><ul><li>Prolonged antibiotic therapy </li></ul></ul><ul><ul><li>Increased use of ancillary services </li></ul></ul><ul><ul><ul><li>Home health visits </li></ul></ul></ul><ul><ul><ul><li>Radiology, laboratory </li></ul></ul></ul><ul><ul><li>Drug costs </li></ul></ul><ul><ul><li>Durable medical equipment </li></ul></ul>Confidential. For Internal Use Only. Urban JA. Surg Infect (Larchmt). 2006;7(suppl 1):S19-S22. © ETHICON, INC. 2008 All Rights Reserved
    17. 17. Summary <ul><li>The major pathogens that lead to SSIs are: </li></ul><ul><ul><li>Staphylococcus aureus </li></ul></ul><ul><ul><li>Staphylococcus epidermidis </li></ul></ul><ul><ul><li>Methicillin-resistant Staphylococcus aureus (MRSA) </li></ul></ul><ul><ul><li>Methicillin-resistant Staphylococcus epidermidis (MRSE) </li></ul></ul><ul><li>Staphylococcus aureus is a major pathogen that leads to surgical site infection </li></ul><ul><li>There are 4 classes of surgical wound categories </li></ul><ul><li>Comprehensive infection-control protocols include dozens of preoperative, intraoperative, and postoperative components </li></ul><ul><li>SSIs are costly to hospitals and patients: $400 – $30,000 </li></ul><ul><li>Medicare is restricting the payment of hospital-acquired conditions </li></ul><ul><li>SSIs are costly in terms of longer hospitalization and increased mortality for patients, and higher costs for hospitals </li></ul>Confidential. For Internal Use Only. Nichols RL. Emerg Infect Dis. 2001;7:220-224. © ETHICON, INC. 2008 All Rights Reserved
    18. 18. IRGACARE ® MP (triclosan) Properties <ul><li>IRGACARE MP </li></ul><ul><ul><li>2,4,4′-tri-chloro-2′-hydroxydiphenyl ether </li></ul></ul><ul><ul><li>High-purity material that meets USP specifications for triclosan, with minimal residue content </li></ul></ul><ul><li>IRGACARE MP is safe </li></ul><ul><ul><li>Biocompatible, nontoxic </li></ul></ul><ul><ul><li>Consumer products </li></ul></ul><ul><li>IRGACARE MP is effective </li></ul><ul><ul><li>Active against methicillin-sensitive and methicillin-resistant S aureus and S epidermidis (most common for device infections) </li></ul></ul><ul><ul><li>Active against Escherichia coli and Klebsiella pneumoniae </li></ul></ul><ul><li>IRGACARE MP is compatible with suture processing </li></ul><ul><ul><li>Maintains excellent suture properties </li></ul></ul>Confidential. For Internal Use Only. USP=United States Pharmacopeia. Zurita R et al. Macromol Biosci. 2006;6:58-69. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457. Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53. ® Ciba Corporation Inc © ETHICON, INC. 2008 All Rights Reserved
    19. 19. IRGACARE ® MP (triclosan): Mode of Action <ul><li>Chlorinated phenolic biocide—a “phenol” with multitargeted biocidal mechanisms </li></ul><ul><ul><li>Actions widely unknown </li></ul></ul><ul><ul><li>Nonspecific effects on cell membrane activities and cell membrane integrity </li></ul></ul><ul><ul><li>Blocks active site of the enoyl-acyl carrier protein reductase—an essential enzyme in fatty acid synthesis—building cellular components and reproduction </li></ul></ul>Confidential. For Internal Use Only. Zurita R et al. Macromol Biosci. 2006;6:58-69. ® Ciba Corporation Inc © ETHICON, INC. 2008 All Rights Reserved
    20. 20. Why IRGACARE ® MP (triclosan)? <ul><li>Able to withstand the manufacturing process </li></ul><ul><li>Cost-effective </li></ul><ul><li>Effective, safe, and compatible </li></ul><ul><li>Performance/function properties </li></ul><ul><ul><li>Handling </li></ul></ul><ul><ul><li>Absorption profile, breaking-strength retention </li></ul></ul>Confidential. For Internal Use Only. Storch M et al. Surg Infect (Larchmt). 2002;3(suppl 1):S65-S77. ® Ciba Corporation Inc © ETHICON, INC. 2008 All Rights Reserved
    21. 21. IRGACARE ® MP (triclosan): Pharmacokinetics <ul><li>Well absorbed after oral administration </li></ul><ul><li>Well distributed in the body </li></ul><ul><li>Rapidly metabolized in liver to the glucuronide/sulfate conjugate </li></ul><ul><ul><li>T½=10 to 13 hours </li></ul></ul><ul><li>Excreted through kidneys </li></ul>Confidential. For Internal Use Only. Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53. ® Ciba Corporation Inc © ETHICON, INC. 2008 All Rights Reserved
    22. 22. IRGACARE ® MP (triclosan) and Microbial Resistance <ul><li>IRGACARE MP is very effective against S aureus , S epidermidis , and E coli , which are the 3 most important bacteria related to SSIs </li></ul><ul><li>There is no connection between the use of IRGACARE MP and significant antibiotic resistance </li></ul><ul><li>The use of IRGACARE MP may lead to the overall reduction of the antibiotic burden </li></ul><ul><ul><li>Decreases the risk of SSIs and the resulting application of stronger antibiotics against SSIs </li></ul></ul><ul><ul><li>The use of IRGACARE MP is not associated with increased bacterial virulence that raises the antibiotic burden </li></ul></ul>Confidential. For Internal Use Only. Ming X et al. Surg Infect (Larchmt). 2007;8:209-213. Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53. Ford HR et al. Surg Infect (Larchmt). 2005;6:313-321. ® Ciba Corporation Inc © ETHICON, INC. 2008 All Rights Reserved
    23. 23. Triclosan-Coated Sutures for the Reduction of Sternal Wound Infections: Economic Considerations <ul><li>Fleck T, Moidl R, Blacky A, et al. Ann Thorac Surg . 2007;84:232-236. </li></ul>Confidential. For Internal Use Only. © ETHICON, INC. 2008 All Rights Reserved
    24. 24. Results <ul><li>Total patients enrolled 479 </li></ul><ul><ul><li>103 closed with Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture </li></ul></ul><ul><ul><li>376 closed with non-coated sutures </li></ul></ul><ul><li>Reported a cost of infection of $11,200 </li></ul><ul><ul><li>“ 24 patients had superficial infections (n=10) or deep (n=14) sternal wound infections” </li></ul></ul><ul><li>“ In the triclosan group, no wound infection or dehiscence was observed during hospital stay and follow-up visits” </li></ul><ul><li>This information concerns a use that has not been cleared by the FDA (Infection Reduction Claim) </li></ul>Fleck T et al. Ann Thorac Surg . 2007;84:232-236. *Trademark © ETHICON, INC. 2008 All Rights Reserved
    25. 25. Antimicrobial Suture Wound Closure for Cerebrospinal Fluid Shunt Surgery: a Prospective, Double-blinded, Randomized Controlled Trial Rozzelle CJ, Leonardo J, Li V. J Neurosurg Pediatrics. 2008;2:111-117. Confidential. For Internal Use Only. © ETHICON, INC. 2008 All Rights Reserved
    26. 26. Results and Conclusions <ul><li>Total patients enrolled = 61 </li></ul><ul><li>Total procedures performed = 84 </li></ul><ul><ul><li>Over 21 months </li></ul></ul><ul><li>Shunt infection rate </li></ul><ul><ul><li>2 (4.3%) infections in 46 procedures for study group </li></ul></ul><ul><ul><li>8 (21%) infections in 38 procedures for control group ( P =0.038) </li></ul></ul><ul><li>This information concerns a use that has not been cleared by the FDA (Infection Reduction Claim) </li></ul>Confidential. For Internal Use Only. Rozzelle CJ et al. J Neurosurg Pediatrics . 2008;2:111-117. © ETHICON, INC. 2008 All Rights Reserved
    27. 27. <ul><li>Antibiotic coating of abdominal closure sutures and wound infection </li></ul><ul><li>Dr Justinger (Germany) from department of General, Visceral, Vascular and Pediatric Surgery </li></ul>
    28. 28. Results and Conclusions <ul><li>Objective : Dr Justinger compared the use of Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture with PDS*II (polydioxanone) Suture (loop suture) for the closure of midline laparotomy to evaluate the reduction in wound infections. </li></ul><ul><li>Patients : 2088 operations between October 2004 and September 2006 </li></ul><ul><li>Procedures : Abdominal wall closure (midline incision) </li></ul><ul><li>Findings : with PDS Suture (loop suture) for abdominal wall closure, 10.8% of patients with wound infections were detected. The number of patients with infections using Coated VICRYL Plus Suture decreased to 4.9% despite no changes in protocols of patient care . </li></ul>
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×