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8 NEGATIVE PRESSURE WOUND THERAPY JOURNAL, VOL. 3, NO. 2, 2016
Negative pressure therapy in the treatment of a
traumatic fistula of glenohumeral joint with
concurrent osteomyelitis and infection of
periarticular tissues.
Bartosz Cybułka, Jacek Rapeła, Andrzej Wach
CASE REPORT
Abstract—A negative pressure dressing system enables effective
dressing of traumatic wounds. Extensive injuries and tissue
defects that accompany bone fractures and articular surface
injuries require special management. In case of compound frac-
tures, the risk of bone, joint and soft tissue infection significantly
increases, so the appropriate healing process of traumatic wound
is limited. Undisturbed healing process of traumatic wound is
conditioned only by the proper wound dressing process by the
removal of necrotic and ischemic tissues and elimination of the
sources of infection. The article shows a case report of a patient
with a traumatic subcapital humerus fracture complicated by a
haematoma and then by a periarticular abscess. After the incision
and drainage of a reservoir of blood and pus, a chronic infected
fistula of glenohumeral joint was formed. During a prolonged
therapeutic process an aggressive surgical management was im-
plemented, by the removal of the infected bone, what eliminated
the actively secreting fistula of glenohumeral joint. Following the
appropriate wound preparation, the negative pressure therapy
was successfully applied. In the described case the application of
negative pressure dressing system enabled a gradual decrease
of total wound depth and surface area and consequently, a
restriction of tissue defects.
Keywords—compound fracture, traumatic bone and joint in-
jury, osteomyelitis, articular haematoma, articular abscess, joint
fistula, NPWT
I. INTRODUCTION
INFLAMMATION of the bones and bone marrow (os-
teomyelitis OM, OT post-traumatic osteomyelitis) is de-
fined as an inflammatory process caused by the pyogenic
organisms in bone tissues and leading to their destruction.1
The Waldvogel classification, distinguishing blood-borne os-
teomyelitis, osteomyelitis spreading through continuity (asso-
ciated or not associated with vascular diseases) and chronic
osteomyelitis, has been used in clinical practice since 1970.
Epidemiologically, in 80% of cases the disease process spreads
through continuity. Only in 20% of the cases the aetiology is
blood-borne.2
Manuscript received 12.02.2016; revised 28.06.2016. This work did not
receive any financial support. Authors declare no conflict of interest.
Author affiliations: Department of Surgery and Gastroenterology, Indepen-
dent Public Healthcare Institution, 62-065 Grodzisk Wielkopolski ul. Mossego
3, Poland, (BC, JR, AW)
*Correspondence to: Bartosz Cybułka (e-mail: b.cybulka@wp.pl).
Nowadays, lesions spreading through continuity are prevail-
ing, mostly due to traumatic injuries as well as orthopaedic
procedures involving implant materials. Such disease presen-
tation mostly occurs in adults and is associated with blood
supply deficits, which are very common in case of prosthetic
joints implantation. A background of vascular disorders re-
stricts normal healing process.3
The Cierny-Mader classifies OM according to anatomical
location of lesions, patient’s condition as well as general and
local risk factors.4The following presentations of osteomyeli-
tis are distinguished on the basis of anatomical range of pathol-
ogy: medullary (type I) - restricted to bone marrow, of blood-
borne aetiology; superficial osteomyelitis (type II); localised
(type III) restricted to cortical bone layer, and diffuse (type
IV) concerning all bone tissue layers. Among the local risk
factors chronic lymphatic oedema, venous stasis, inflammatory
vascular diseases, venous insufficiency, large surface scars,
radiotherapy consequences, neuropathies, tobacco smoking are
the most important. General systemic risk factors include
malnutrition, chronic renal insufficiency, liver dysfunction,
chronic hypoxia, diabetes, advanced age, young age, neoplastic
disease, immunosuppression, and immunodeficiencies.5
Post–traumatic osteomyelitis is a rare medical condition.
Exceptionally the infection of periarticular bone tissues is a
result of a compound fracture. In case of long bone fractures,
chronic inflammatory process occurs in less than 1-3% of
traumatic patients.6
Treatment of chronic osteomyelitis is a prolonged, laborious
and demanding process. Antibacterial treatment has limited
value and systemic antibiotic therapy penetrates poorly to
bone and bone marrow. Topical preparations applied as an-
tiseptics (Octenisept [octenidine]) and lavaseptics (Prontosan
[polyhexanide and betaine]) are not always able to eliminate
the infection process, so new successful methods of therapy
are still being searched for.
Recently, the following conditions were added to the clas-
sical contraindications for the application of negative pressure
therapy:
•direct proximity of
–vessels,
FRACO Publishing cb DOI: 10.18487/npwtj.v3i2.21
CYBUŁKA et al. : NPWT IN A CHRONIC TRAUMATIC WOUND 9
Figure 1. RTG - subcapital displaced fracture of right humerus.
Figure 2. Surgical debridement.
–nerves,
–surgical anastomoses (vascular, of gastrointestinal
tract)
–parenchymal organs
•neoplastic process in the wound
•non-intestinal, non-diagnosed fistulas
•presence of necrotic tissue covered with scab in a wound
•haemostatic disturbances
•untreated osteomyelitis.7, 8
A rapid growth in the interest and application of negative
pressure therapy in different domains significantly broadened
the range of action of this modern method in wound treatment.
Negative pressure therapy can be successfully used in previ-
ously non-indicated or even contraindicated clinical cases.
Apart from the classical application of negative pressure,
effective attempts of using the systems enabling simultaneous
wound washing (instillation NPWT - NPWTi ) or hybrid ther-
apies combining endoscopic and negative pressure techniques
(endoVAC, EVT endoscopic vacuum therapy) are described
more and more often.9–12
II. II CASE REPORT
A 60-year-old male patient was admitted to the Department
of Surgery due to the increase of pain in the right glenohumeral
joint. Among the general symptoms, hectic fever was prevail-
ing. Three weeks ago the patient fell down the stairs and
Figure 3. Negative pressure dressing.
Figure 4. Negative pressure value - 120 mmHg.
Figure 5. Osteomyelitis.
Figure 6. Chronic fistula to the humeral bone.
10 NEGATIVE PRESSURE WOUND THERAPY JOURNAL, VOL. 3, NO. 2, 2016
Figure 7. Chronic joint fistula.
Figure 8. Destruction of the elements of the right glenohumeral joint. Open
wound.
Figure 9. Stump of the humeral bone.
Figure 10. The secondary healing of the wound, formation of normal
granulation tissue.
CYBUŁKA et al. : NPWT IN A CHRONIC TRAUMATIC WOUND 11
subcapital, displaced fracture of the right humerus occurred
(Fig. 1). Conservative treatment of the fracture was applied
by immobilisation in temporary shoulder joint orthosis.
On the physical examination: intense redness, increased skin
warmth, pitting oedema of the skin of anterior shoulder area
and the region of right glenohumeral joint were seen. Fluctu-
ation and pathological crepitus in the periarticular tissues was
palpable.
Laboratory examinations revealed leukocytosis and in-
creased C-reactive protein values. LEU: 22.2 K/µL; GRAN:
18.9 K/µL; %GRAN: 85.4%. CRP32: 274.5 mg/L.
In the operating room, under topical anaesthesia, an incision
was made and fluid was drained from the reservoir in the
area of glenohumeral joint. Approximately 150 ml of purulent
content and haemolysed blood was evacuated. A smear was
collected for bacteriological examination which revealed a
Methicilin-susceptible Staphylococcus aureus (MSSA). Grav-
ity drainage was applied and empirical antibiotic therapy
was implemented. At the beginning, drainage management
and washing of the abscess cavity (Octenisept, 0.9% NaCl,
H2O2) were continued. In the periods of increased leakage
of bloody content, the wound was washed with 10% NaCl
solution. The above described management enabled to limit
the inflammatory process and normalise the laboratory indices
of infection. What is important for the patient, also the pain
was reduced.
During the treatment, persistent leakage of serous and
purulent content from the wound was observed. As a result
of prolonged leakage of pathological content, we decided to
perform a surgical revision of abscess cavity and excised a
fistula canal, leading to the level of medullary cavity, spongy
bone layer of head of the humerus, under general anesthesia.
Moreover, the ischaemic, necrotic tissues were removed, as
well as the excessive inflammatory altered granulation tissue,
and single reservoirs of purulent content were evacuated (Fig.
2). After refreshing the wound edges and wound bed, a
negative pressure dressing was applied (Fig. 3 and 4) in con-
tinuous mode, at the negative pressure value of −120 mmHg
(VivanoTec Hartmann). Total wound surface area and depth
was adequate for using a M dressing (10 cm x 7.5 cm x 3.3
cm). Black polyurethane sponge was shaped to fit the wound,
not allowing to excessively cramming the foam dressing. Prior
to the application of negative pressure dressing, the wound bed
was thoroughly washed with antiseptic solution (Octenisept).
Healthy skin surrounding the wound was carefully dried.
At the beginning, the dressings were changed every 72
hours. As the healing process proceeded and the imperme-
ability of adhesive foil increased, the period between dressing
changes was extended. Dressing changes took place in the
treatment room. The patient received subcutaneously 50 mg
of Dolargan (pethidine) before the dressing change procedure.
Pain tolerance was well achieved. Continuous mode of work
was applied at the negative pressure value of -120 mmHg.
a total of 13 dressing kits were used during the first stage
of negative pressure therapy, before making the decision of
resection of the damaged head of the right humerus.
After the following dressing changes the total wound surface
area has decreased. A gradual approximation of properly
healing wound edges has been observed. Unfortunately a per-
sistent leakage of dense purulent content with tissue fragments
retained (Fig. 5). A chronic fistula penetrating to the level
of humeral bone was diagnosed (Fig.6 and 7). Control X-ray
examinations revealed the features of autolysis of the head of
the humerus and the destruction of the elements of the right
glenohumeral joint. We decided to remove the damaged bone
structures. At the next stage of surgical management, a total
resection of the damaged head of the humerus together with
the present fistula to the medullary cavity, was performed.
The procedure was extended by the partial resection of the
proximal segment of shaft of the humerus. The elements of
articular surface of the right glenoid fossa were refreshed.
Post-operative wound was closed with interrupted sutures, 14
Fr Redon suction drain was applied.
On the second day after the surgery, an active bleeding
from the post-operative wound was observed, which required
an immediate surgical intervention and closure of the arterial
vessel on the posterior surface of humeral stump. At the
following stage of the procedure, the wound was left open
for secondary healing. The level of blood supply in the sur-
rounding muscles and periarticular tissues was also monitored
(Fig. 8 and 9). The negative pressure therapy was applied once
again in the treatment. The schedule of dressing applications
and changes remained the same.The impermeability of film
dressing enabled the dressing change every 72 – 96 hours
at the bedside, in the treatment room. Prior to the dressing
change procedure, the patient was administered an analgesic
agent (Dolargan 50 mg subcutaneously). Pain tolerance was
adequate. Complications in the form of bleeding were not
observed (Fig. 10). After the resection of the fragment of the
humerus, 4 dressing kits were used. In this case of wound
treatment, the decrease of wound surface area, formation of
normal granulation tissue, as well as cleansing of wound
bed and edges with normal morphological condition of the
surrounding tissues were also obtained.
In the above-described case, only complete elimination of
the source of chronic infection in the form of infected head of
the humerus, as well as ischaemic and necrotically altered peri-
articular muscles and soft tissues, created the proper conditions
to optimal approximation of the bed and edges of the traumatic
wound. Thanks to the application of negative pressure therapy,
total wound size has been gradually and significantly reduced.
III. DISCUSSION
Traumatic skin injury caused by surgical intervention and
implantation of synthetic material increase the risk and prob-
ability of infection. In such cases the inflammatory process
spreads through continuity to the bone, bone marrow and
periarticular soft tissues. This type of pathology more often
concerns adult patients. In case of hip joint endoprosthetics,
the risk of infection is 0.3-1.7% and in case of knee joint
reconstruction rises to approximately 0.8-1.9%.13–15
The wound healing process can be disturbed at any stage of
the treatment. Many factors limit the natural processes of clos-
ing the tissue defect. The presence of necrotic and ischaemic
tissue prevent wound coverage with normal granulation tissue
12 NEGATIVE PRESSURE WOUND THERAPY JOURNAL, VOL. 3, NO. 2, 2016
Figure 11. Cascade of adverse events preventing the closure of a traumatic
wound
Table I
TRE ATMEN T OF O STE OM YEL IT IS. S URGICAL PROCEDURES.
Wide incision
Drainage of purulent content
Removal of necrotic and ischaemic tissues
Dressing, elimination of necrotic anatomical spaces
Appropriate bone stabilization
Maintaining physiological conditions in the joint
Negative pressure therapy (NPWT, NPWTi)
Filling the tissue defects
and scar. Local blood supply disturbances, and improper nerve
stimulation in case of pareses, are factors that disturb the
healing process. If necrotic tissues are not removed early
enough, a chronic infection develops. Local infection process
alters proper tissue architecture, leading to the destruction
of surrounding tissues. The presence of necrotic foci, infec-
tions or foreign bodies significantly limits and alters tissue
regeneration. The current state of knowledge unambiguously
indicates the effectiveness and advantages of negative pressure
therapy in the treatment of osteomyelitis. In December 2015,
Table II
INFECTIONS ARE THE DOMINANT AETIOLOGICAL FACTORS OF
OSTEOMYELITIS.16–18
Staphylococcus aureus
Staphylococcus epidermidis – coagulase-negative Staphylococcus (CoNS),
Streptococcus viridans
Haemophilus influenzae
Escherichia coli
Klebsiella pneumoniae
Neisseria gonorrhoeae
Neisseria meningitidis
Mycobacterium tuberculosis
Pseudomonas aeruginosa
Fungal infections
Table III
DIAGNOSTIC PROCEDURES
Laboratory examinations:
Complete blood count
C-reactive protein
ESR
Imaging examinations:
Bones and joints X-ray
CT
MRI
Sayed described an effective application of negative pressure
therapy in the treatment of primary osteomyelitis of sternum
with mediastinal abscess in a newborn infant. It is the first
description of the application of negative pressure in a neonatal
patient.19
In the subject literature, the descriptions of the efficient
attempts of the application of negative pressure therapy in
such difficult disease entity as the infection of bones and
bone marrow, appear more and more often. The application
of negative pressure therapy in the treatment of extensive
sternum injuries resulting from cardiac surgical interventions
is indisputable and fully accepted. In such cases the terms
DSWI (Deep Sternal Wound Infection) and SSWI (Secondary
Sternal Wound Infection) are sometimes used. A complication
in the form of a deep, infected sternal wound significantly
prolongs the hospitalisation period, requires the administration
of a broad-spectrum antibiotic therapy, puts the patient at risk
of suffering and increases the costs of surgical care. The basis
of the effective therapy is the removal of necrotic tissues and
stimulation of the granulation process by negative pressure.
The final closure of the defect is performed using grafts of
pedicled muscle flaps, grafts of greater omentum or plastic
surgery of chest walls with mobilised pectoral muscles.20, 21
If osteomyelitis develops in the location other than sternum,
the situation becomes more complicated. However, the effec-
tive attempts of using negative pressure therapy in such cases
are described more often.
Investigators from China report that negative pressure ther-
apy is effective in the treatment of complicated traumatic
calcaneal fracture with concomitant necrosis in the wound and
delayed bone union.22
Another example from China indicates that negative pres-
sure was useful in the treatment of traumatic osteomyelitis
of tibia in 23 patients between 2007 – 2013. The infection
process was reduced by preliminary, careful debridement of
necrotic tissues and appropriate use of negative pressure
therapy. Finally, the defect was closed with autologous bone
grafts.23
Negative pressure therapy is very effective in the treatment
of post-traumatic osteomyelitis. It contributes to eradication
of chronic infection and facilitates the management of soft
tissue defects, directly surrounding the bones. The mechanism
of action concerns the activation of the desired granulation
process, exudate elimination, cleaning wound environment of
bacterial colonisation and reduction of bacterial biofilm. The
reduced wound depth and surface area limits the necessity to
apply demanding reconstruction surgery procedures.24
CYBUŁKA et al. : NPWT IN A CHRONIC TRAUMATIC WOUND 13
IV. CONCLUSION
The application of negative pressure therapy in the treatment
of extensive traumatic wounds is a widely accepted therapeutic
method. The attempts of using negative pressure for the
treatment of osteomyelitis complicated by injury are taken
more often and the final effects are promising.
The application of negative pressure enables, at the location
of its action: faster formation of well blood-supplied granula-
tion tissue, growth factor synthesis, cell proliferation, exudate
elimination, oedema reduction and reduction in the number of
bacterial colonies. Thanks to the activation of these processes,
the reduction of wound depth and total wound surface area
is possible. Based on the case described above it is worth
noticing and remembering that prior optimal preparation of a
traumatic wound is a necessary condition of effective negative
pressure therapy. Primarily, a complete removal of ischaemic
and necrotic tissues (debridement) is absolutely necessary. It
enables the elimination of mechanical and bacterial contam-
inants, which prevent complete wound closure. On the basis
of the above-described case it is evident that only after the
removal of infected, morphologically altered bone tissue, in
the form of the head and part of shaft of humeral bone as well
as the elimination of chronic infected fistula of glenohumeral
joint, the effective application of dressings in negative pressure
system was possible.
V. ACKNOWLEDGMENTS
I wish to extend special thanks to Tomasz Banasiewicz MD,
PhD from Department of General and Endocrine Surgery and
Gastroenterological Oncology, Pozna´
n University of Medical
Sciences for his support and confidence.
[2] V. J. Mandracchia, S. M. Sanders, A. J. Jaeger, and W. Nickles,
“Management of osteomyelitis,” Clinics in Podiatric Medicine and
Surgery, vol. 21, no. 3, pp. 335–351, jul 2004. [Online]. Available:
http://dx.doi.org/10.1016/j.cpm.2004.03.008
[3] D. P. Lew and F. A. Waldvogel, “Osteomyelitis,” The Lancet,
vol. 364, no. 9431, pp. 369–379, jul 2004. [Online]. Available:
http://dx.doi.org/10.1016/S0140-6736(04)16727-5
[4] “A good MATCH,” The Lancet, vol. 364, no. 9445, p. 1575, oct 2004.
[Online]. Available: http://dx.doi.org/10.1016/S0140-6736(04)17298-X
[5] S. Esposito, S. Leone, M. Bassetti, S. Borrè, F. Leoncini, E. Meani,
M. Venditti, and F. Mazzotta, “Italian guidelines for the diagnosis and
infectious disease management of osteomyelitis and prosthetic joint
infections in adults,” Infection, vol. 37, no. 6, pp. 478–496, nov 2009.
[Online]. Available: http://dx.doi.org/10.1007/s15010-009-8269-2
[6] C. Coles and M. Gross, “Closed tibial shaft fractures: management and
treatment complications. a review of the prospective literature,” Can J
Surg, vol. 43, no. 4, pp. 256–62, 2000.
[7] R. Rock, Wound Care Advisor, 2014. [Online].
Available: http://woundcareadvisor.com/wp-content/uploads/2014/03/
GUIDELINES_M-A14.pdf
[8] K. Ballard and H. Baxter, “Vacuum-assisted closure,” Nurs Times,
vol. 97, pp. 51–52, 2001.
[9] P. Kim, C. Attinger, J. Steinberg, and K. Evans, “Negative pressure
wound therapy with instillation: past, present, and future,” Surg Technol
Int, vol. 26, pp. 51–6, 2015.
[10] S. Gupta, A. Gabriel, J. Lantis, and L. Téot, “Clinical recommendations
and practical guide for negative pressure wound therapy with
instillation,” International Wound Journal, vol. 13, no. 2, pp. 159–174,
may 2015. [Online]. Available: http://dx.doi.org/10.1111/iwj.12452
REFERENCES
[1] P. J. Carek, L. M. Dickerson, and S. J. L, “Diagnosis and management
of osteomyelitis.” Am Fam Physician, vol. 63, pp. 2413–20, 2001.
[11] F. Kuehn, L. Schiffmann, F. Janisch, F. Schwandner, G. Alsfasser,
M. Gock, and E. Klar, “Surgical endoscopic vacuum therapy for
defects of the upper gastrointestinal tract,” Journal of Gastrointestinal
Surgery, vol. 20, no. 2, pp. 237–243, dec 2015. [Online]. Available:
http://dx.doi.org/10.1007/s11605-015-3044-4
[12] N. R. Smallwood, J. W. Fleshman, S. G. Leeds, and J. S. Burdick,
“The use of endoluminal vacuum (e-vac) therapy in the management
of upper gastrointestinal leaks and perforations,” Surgical Endoscopy,
vol. 30, no. 6, pp. 2473–2480, sep 2015. [Online]. Available:
http://dx.doi.org/10.1007/s00464-015-4501-6
[13] E. Jämsen, “Risk factors for infection after knee arthroplasty. a
register-based analysis of 43, 149 cases,” The Journal of Bone and
Joint Surgery (American), vol. 91, no. 1, p. 38, jan 2009. [Online].
Available: http://dx.doi.org/10.2106/JBJS.G.01686
[14] G. Peersman, R. Laskin, J. Davis, M. G. E. Peterson, and T. Richart,
“Prolonged operative time correlates with increased infection rate after
total knee arthroplasty,” HSS Journal, vol. 2, no. 1, pp. 70–72, jan
2006. [Online]. Available: http://dx.doi.org/10.1007/s11420-005-0130-2
[15] L. Pulido, E. Ghanem, A. Joshi, J. J. Purtill, and J. Parvizi,
“Periprosthetic joint infection: The incidence, timing, and predisposing
factors,” Clinical Orthopaedics and Related Research, vol. 466, no. 7,
pp. 1710–1715, apr 2008. [Online]. Available: http://dx.doi.org/10.
1007/s11999-008- 0209-4
[16] L. S. Jorge, A. G. Chueire, and A. R. B. Rossit, “Osteomyelitis:
a current challenge,” Brazilian Journal of Infectious Diseases,
vol. 14, no. 3, pp. 310–315, jun 2010. [Online]. Available:
http://dx.doi.org/10.1590/S1413-86702010000300020
[17] V. Weston, “Guideline for the management of the hot swollen joint
in adults with a particular focus on septic arthritis,” Journal of
Antimicrobial Chemotherapy, vol. 58, no. 3, pp. 492–493, jul 2006.
[Online]. Available: http://dx.doi.org/10.1093/jac/dkl295
[18] G. Coakley, “BSR & BHPR, BOA, RCGP and BSAC guidelines
for management of the hot swollen joint in adults,” Rheumatology,
vol. 45, no. 8, pp. 1039–1041, feb 2006. [Online]. Available:
http://dx.doi.org/10.1093/rheumatology/kel163a
[19] S. Sayed, S. Prabhu, M. Thomas, C. A. McBride, and N. Alphonso,
“Primary sternal osteomyelitis with extensive mediastinal abscess in a
neonate,” The Annals of Thoracic Surgery, vol. 100, no. 4, pp. e85–e87,
oct 2015. [Online]. Available: http://dx.doi.org/10.1016/j.athoracsur.
2015.05.133
[20] A. Akil, P. Schnorr, and K. Wiebe, “Behandlungsstrategien bei
postoperativen sternuminfektionen,” Zentralblatt für Chirurgie -
Zeitschrift für Allgemeine, Viszeral-, Thorax- und Gefäßchirurgie,
vol. 141, no. 01, pp. 93–101, oct 2015. [Online]. Available:
http://dx.doi.org/10.1055/s-0035-1558097
[21] M. Chan, E. Yusuf, S. Giulieri, N. Perrottet, L. V. Segesser, O. Borens,
and A. Trampuz, “A retrospective study of deep sternal wound
infections: clinical and microbiological characteristics, treatment, and
risk factors for complications,” Diagnostic Microbiology and Infectious
Disease, vol. 84, no. 3, pp. 261–265, mar 2016. [Online]. Available:
http://dx.doi.org/10.1016/j.diagmicrobio.2015.11.011
[22] C. X. V. s. d. f. t. t. o. i. p. w. d. a. c. f. Liu G, Pan SP, Zhongguo Gu
Shang, vol. 25, no. 9, pp. 782–4, 2012.
[23] Q. Du, H. Cong, Y. Shi, H. Jiang, and H. Sui, “Treatment of tibial
traumatic osteomyelitis with vacuum sealing drainage combined with
open bone graft.” Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi, vol. 28,
no. 5, pp. 562–5, 2014.
[24] Y. Tan, X. Wang, H. Li, Q. Zheng, J. Li, G. Feng, and Z. Pan,
“The clinical efficacy of the vacuum-assisted closure therapy in
the management of adult osteomyelitis,” Arch Orthop Trauma Surg,
vol. 131, no. 2, pp. 255–259, dec 2010. [Online]. Available:
http://dx.doi.org/10.1007/s00402-010-1197-x
