Marys Medicine

Negative Pressure Wound Therapy: Experience in 45 Dogs Kathryn A. Pitt, BS, DVM, MS, and Bryden J. Stanley, BVMS, MVetSc, Diplomate ACVS Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan Corresponding Author Objective: To report experience with negative pressure wound therapy (NPWT) in 45 Bryden Stanley, BVMS, MVetSc, Diplomate consecutive dogs admitted with extensive cutaneous wounds and to determine if NPWT ACVS, Department of Small Animal Clinical is feasible in veterinary hospital practice.
Sciences, College of Veterinary Medicine, Study Design: Prospective descriptive study.
Michigan State University, East Lansing, MI Animals: Dogs (n ¼ 45).
48824. E‐mail: [email protected] Methods: Collected data were organized into 6 categories: patient data, wound data,NPWT data, adjunctive treatments, complications, and final outcome.
Submitted September 2012 Results: Wounds (53 in 45 dogs) were largely traumatic in origin, and distributed fairly Accepted April 2013 evenly to the trunk, proximal and distal aspects of the limbs. Most wounds (34 dogs, 76%) had no granulation tissue and were treated a mean of 4.2 days after wounding,whereas 11 dogs had granulating wounds that were initially treated a mean of 87 daysafter wounding. Median NPWT use was 3 days with a mean hospitalization of 7.8 days.
Most wounds (33; 62%) were closed surgically after NPWT and were healed by14 days. The other 18 wounds healed (mean, 21 days) by second intention after hospitaldischarge. Overall, 96% of the wounds healed; 2 dogs died before definitive closurecould be attempted.
Conclusion: NPWT is applicable to a wide variety of canine wounds, is well tolerated,allows for several days between dressing changes, and can used to optimize the woundbed for surgical closure or second intention healing.
Extensive traumatic cutaneous wounds are challenging, often exudate, and stimulated granulation tissue formation.9–12 requiring repeated daily sedation or anesthesia for wound Subsequent investigations have supported some of these management and dressing changes until the wound is suitable findings (e.g., early granulation tissue formation and increased for reconstruction or continued healing by second intention.
wound perfusion), but other claims remain to be fully Definitive wound closure should not be attempted until the validated.13–16 Nevertheless, NPWT technology has increased wound is free of necrotic tissue, debris and infection, preferably in popularity and is used in all 5,000 primary care hospitals in supporting a healthy bed of granulation tissue.1,2 Clearly, any the US.17 There is an extensive literature reporting use of therapy or dressing that can facilitate conversion of a NPWT in people where it is applied to both acute and chronic contaminated or dirty wound into a clean, vascularized wound wounds, and in surgical applications (e.g., free skin grafts, bed would be beneficial.
compromised flaps, incisional dehiscence, cytotoxic sloughs, Negative pressure wound therapy (NPWT) involves the open abdominal drainage, orthopedic trauma, and burns).5,18–33 application of sub‐atmospheric pressure to a wound and is used NPWT is applied to over 90% of admitted extremity wounds in extensively in human wound care. NPWT is gaining popularity the military.34–41 Shorter hospitalization and lower treatment in veterinary medicine as an adjunctive therapy before wound cost have been reported for NPWT.42–44 closure.3–8 Also termed "vacuum‐assisted closure," "topical Information on NPWT use in veterinary medicine is negative pressure therapy," and "sub‐atmospheric pressure limited. There are 7 case reports of various species (a dog, tiger, dressing," NPWT involves placing a porous primary dressing tortoise, horse, rhinoceros, and 2 cats), 1 retrospective case (typically open‐cell polyurethane ether foam) into the wound series in dogs, and more recently, 2 controlled, experimental bed, sealing the wound with a non‐permeable, adhesive drape, studies in dogs.8,45–53 The variety of veterinary case reports and applying an intermittent or continuous vacuum through indicate that NPWT is of interest in wound management. The 2 tubing connected to a fenestrated pad on the foam. The open controlled, experimental veterinary studies concluded that wound is converted into a closed environment where the entire NPWT was beneficial for management of open wounds and wound surface is subject to a controlled negative pressure; free skin grafts in dogs.52,53 Not documented is the feasibility wound fluid is evacuated through the tubing into a reservoir of learning and using NPWT in a busy veterinary hospital canister (Fig 1).
setting. Information about the practical application of NPWT, Initially studied in pigs, NPWT increased blood flow to wound types where NPWT is used, complications and pitfalls the wound and immediate periwound environment, removed associated with NPWT use in wound care in a clinical setting Veterinary Surgery 43 (2014) 380–387 Copyright 2014 by The American College of Veterinary Surgeons

Negative Pressure Wound Therapy wound outcome (Table 1). Medical records of these 45 dogswere additionally reviewed (K.A.P.) after data accrual.
Initial Wound Management Protocol After any required cardiovascular or respiratory stabilization ofthe dog, wounds had a standardized management protocolbefore NPWT use. Under general anesthesia, the open woundarea was covered with a sterile water‐based lubricant jelly(MediChoice1 Lubricating Jelly, Owens & Minor, Mechanics-ville, VA). The periwound skin was liberally clipped for aminimum 10 cm around the wound, and cleansed withchlorhexidine scrub (Nolvasan Surgical Scrub1, Fort DodgeAnimal Health, Fort Dodge, IA) and isopropyl alcohol (SunMark1, McKesson, San Francisco, CA). The open wound wasthen cleansed thoroughly with gauze swabs soaked in 0.05%chlorhexidine solution (Nolvasan Solution1, Fort DodgeAnimal Health). The wound was then draped and gentlyexplored using aseptic technique. The full extent of the woundwas identified, hemorrhage controlled, and communicationsestablished between any pocketed areas. After surgicaldebridement, copious wound lavage (3 L bag minimum) Data Collected From Each of the Cases Enrolled in This Study (A) Extensive open wound on medial aspect of left thigh and Were Organized Into Six Major Categories crus of a dog. (B) After application of NPWT using open cell foam (KCI, San Antonio, TX) as the contact layer. The wound has been sealed with adhesive drapes and a vacuum applied through the pump unit. Negative Medical record, name, owner pressure is achieved via tubing leading to a disc applied to a fenestration created in the drape. This converts the open wound into a controlled, closed environment.
AgeWeight, body condition scoreDate of admission; date of dischargeComorbidities would be helpful to those considering investing in NPWT.
Age of wound (days) Thus, our purpose was to collate patient and wound data on 45 Granulation tissue present or absent dogs treated with NPWT, detail the difficulties and compli- cations associated with the NPWT use, and report wound Wound description Location ID1 ¼ trunk, 2 ¼ head/neck, 3 ¼ proximal limb, 4 ¼ distal limb Location descriptionSize ID at widest point: 1 < 5cm, MATERIALS AND METHODS 2 ¼ 5–10 cm, 3 > 10cm Primary dressing type—foam or gauze; Inclusion Criteria Days from admission to NPWT application Inclusion criteria were the first 45 dogs with open wounds that Days from wounding to NPWT application had NPWT (July 2006–June 2011). All dogs with open wounds Total days on NPWT were considered for NPWT, but the final decision on study Number of dressing changes enrollment was made after consultation between the senior Intermittent or continuous setting author (B.J.S.) and owner. Dogs were excluded if their wounds Days between dressing changes did not penetrate the full thickness of the skin, were closed Sedation protocol for dressing changesDefinitive closure type immediately, if it was thought the NPWT system could not be Definitive closure day secured (e.g., face), or if owner declined to participate.
Days from end of NPWT to reconstruction Wounds were photographed on admission and at each Adjunctive treatments dressing change using a high‐resolution digital camera (DSC‐ Complications associated with NPWT T200, Sony USA, New York, NY). Data collected were categorized: patient data, wound data, NPWT data, adjunctive The Ohio State University: Body Condition Scoring Chart. (http://vet.
treatments, complications associated with NPWT, and final Veterinary Surgery 43 (2014) 380–387 Copyright 2014 by The American College of Veterinary Surgeons

Negative Pressure Wound Therapy with a sterile, buffered solution (lactated Ringers) wasperformed with pulsatile irrigation system (Interpulse1,Stryker, Kalamazoo, MI).
During the reporting period, both foam‐ and gauze‐basedNPWT commercial systems were used because of inconsistentavailability of a single system. The foam‐based systeminvolved the application of a proprietary polyurethane etherfoam, wound sealing kit and suction pad connected to the pumpunits (V.A.C.1 Granufoam1, T.R.A.C. Pad1, V.A.C.1Freedom units and canisters, Kinetic Concepts, Inc., SanAntonio, TX). The 2 gauze‐based systems (EZCare, Smith &Nephew, Largo, FL and VenturiTM, Talley Medical, Hamp-shire, UK) used saline‐moistened, wide‐weave gauze intowhich a fenestrated tube was embedded. The proprietarywound sealing kits (containing primary dressing, tubing,hydrogels, adhesive drapes) were used for all dressing changes,and the dressings were applied according to manufacturerinstructions.54–57 In accord with a change in manufacturers'recommendations at the beginning of the study, most dogs(42/45) were managed using the continuous setting. Whenapplying the adhesive drapes, care was taken to eliminatepotential loss of seal by filling all depressions. On wounded (A) Successful placement of the NPWT dressing is confirmed areas close to joints, digits and other irregular areas, the use of as it takes on a shrunken, hard and wrinkled appearance when the ostomy pastes (Stomahesive1, ConvaTec USA, Skillman, NJ; vacuum is applied. A foam dressing (KCI, San Antonio, TX) placed on an open elbow hygroma in a dog. (B) Successful placement of the NPWT Coloplast USA, Minneapolis, MN), to fill crevices or dressing is confirmed as it takes on a shrunken, hard and wrinkled depressions facilitated the smooth application of the adhesive appearance when the vacuum is applied. A gauze dressing (EZCare, drape. The evacuation tubing was then connected to the Smith & Nephew, Largo, FL) placed on a dehisced stifle incision in a dog.
canister and the pump activated to the appropriate pressure: 80 mmHg for gauze based systems, 125 mmHg for thefoam‐based system. In all cases, successful dressing placementwas confirmed by shrinkage, hardening and wrinkling of the age on admission, 5.6 years (range, 1–12.4 years). Mean foam or gauze once the machine was turned on (Fig 2). If a leak weight was 31.1 kg (range, 3.1–62.3 kg) and mean body was suspected, the investigators would listen closely to the condition score (BCS) was 5.2/9 (range, 1.5–8). Mean dressing for a low, whistling sound to determine its location, hospitalization was 7.75 days (range, 1–21 days). Comorbid- and reinforce the seal if necessary. Once an appropriate seal ities were widely varied and depended on the individual dog's was obtained, the NPWT dressing was covered with a soft, health before injury, as well as the cause of the injury. The most padded bandage, where possible (e.g., limb), to help maintain common comorbidities thought to have an effect on wound the integrity of the primary dressing. Tubing was arranged and healing were: orthopedic injuries (14 dogs), anemia (12), bandaged in such a way that it would not impede movement of concurrent infection (8), endocrinopathies (4), respiratory the dog. Each bandage change was performed in similar disease (3), wound lymphedema (2), coagulopathy (2), renal disease (2), shock (2), neoplasia (2), neurologic (2),cardiovascular (1), and hepatic (1) disease. Less relevantcomorbidities included conjunctivitis (3 dogs), lumbosacraldisease (3), and arthritis (2).
Most dogs remained within the hospital, but 3 were managed with NPWT at home, and came in for dressing bandage In 45 dogs, 53 wounds received NPWT. Mean wound age was 7 days (range, 0–365 days). Thirty‐four dogs (76%) had nogranulation tissue in their wounds (mean wound age, 4.2 days; range, 0–21 days) whereas 11 dogs (24%) had granulationtissue in their wounds and were considered chronic (mean Although 22 different dog breeds were treated, the most wound age, 87 days; range, 7–365 days). Three chronic common dog type was mixed breed (n ¼ 11). There were 26 wounds were >140 days old and had been classed before males (16 neutered) and 19 females (15 neutered), with a mean referral as chronic, non‐healing wounds.
Veterinary Surgery 43 (2014) 380–387 Copyright 2014 by The American College of Veterinary Surgeons

Negative Pressure Wound Therapy widely (range, 0–368 days; mean, 26 days) because of thechronicity of some wounds. Median time (right skewed data) ofNPWT use was 3 days (range, 1–22 days) with 42 dogs (93%)treated <8 days (Figs 3 and 4). Dressing changes wereconsistently performed every 2 or 3 days (mean, 2.4 days;range, 1–3.5 days). Forty‐one (82%) dogs required heavysedation or anesthesia for dressing changes. A consistentsedation protocol was not recorded in 9 dogs (i.e., it differedeach dressing change). The most commonly used drugs wereacepromazine (51%), hydromorphone (49%), and propofolwith isoflurane (40%). Additional drugs used were fentanylboluses (9%), butorphanol (16%), ketamine and diazepam(20%), and medetomidine (4%) at dosages based on anesthesiaservice recommendations.
Definitive closure method in 19 (36%) wounds was delayed primary closure (mean, 2.7 days of NWPWT; range, Graph depicting the number of dogs receiving NPWT in each stratified time period, and primary dressing (foam or gauze) that was used.
–5 days) defined as closure before appearance of an established granulation tissue bed but presence of some earlygranulation tissue. Fourteen wounds (26%) had secondary Wound cause varied; 28 (62%) dogs had wounds of closure (closure over well‐established granulation tissue) after traumatic origin (vehicular trauma, bite wounds, gunshot, or 2–22 days of NPWT (mean, 6.9 days). Definitive closure unknown trauma) and 17 had wounds caused by incisional procedures included direct apposition, skin flap, or free dehiscence (7%), hygroma/pressure wounds (5%), abscesses cutaneous graft. For wounds that had surgical closure, the (13%), envenomation (4%), and chronic non‐healing wounds NPWT device was removed either immediately before, or of unknown origin (9%).
the day before reconstructive surgery. When free skin grafts All 53 wounds had full thickness skin loss and were were used, NPWT was re‐applied at a continuous pressure of anatomic degloving or shear injuries (31%), punctures (20%), 80 mmHg, with a layer of petrolatum‐impregnated knitted lacerations (16%), abscesses (13%), chronic non‐healing open cellulose acetate (Adaptic1, Johnson & Johnson, Arlington, wounds (9%), dehiscence (7%), and physiologic degloving TX) over the graft. Eighteen wounds (34%) were managed (4%). Wounds were distributed fairly evenly to the trunk (28%), until they healed by second intention; NPWT was discontinued proximal (32%), and distal (34%) aspects of the limbs. Only 3 once a smooth, vascular granulation tissue bed was evident wounds (6%) were located on the head/neck. Six (11%) wounds (mean, 5.4 days; range, 1–15 days), after which, semi‐ were <5 cm diameter, 22 (42%) were >5 cm but <10 cm in occlusive, non‐adherent wound dressings (Adaptic1, Johnson largest diameter, and 25 (47%) were >10 cm in largest diameter.
& Johnson, Arlington, TX or TelfaTM, Covidien, Mansfield,MA) were applied. In 2 dogs, no definitive wound closure occurred because the dogs died before reconstruction.
Twenty‐four (53%) dogs were treated with foam‐based NPWT Adjunctive Treatment (125 mmHg), and 21 (47%) had gauze‐based NPWT(80 mmHg). Mean time from admission to NPWT use was Adjunctive treatments varied depending mainly on comorbid- 2 days (range, 0–14). Time from wounding to NPWT varied ities and concurrent illnesses and the severity of injuries. All (A) Necrotic wound on the right brachium and antebrachium caused by an untreated impalement in a 2‐year male neutered Labrador retriever.
(B) During debridement, before placement of NPWT. (C) Wound appearance after 3 days of NPWT, immediately before reconstruction. Note the early appearance of granulation tissue in the wound.
Veterinary Surgery 43 (2014) 380–387 Copyright 2014 by The American College of Veterinary Surgeons Negative Pressure Wound Therapy dogs were administered intravenous crystalloids and systemic neurologic disease. Both these dogs had substantial and antibiotics at some time during hospitalization. Common multiple comorbidities, including systemic infection, shock, antibiotics administered were clavamox, cephalexin, and coagulopathy, thoracic and neurologic trauma. Another dog enrofloxacin. Adjunctive treatments included orthopedic had an extensive necrotizing wound of the right thoracic limb, repairs (7 dogs), blood component therapy (2), abdominal axilla, and sternum caused by envenomation. Although the drains (1), hyaluronic acid (2), teeth extractions (2), topical wound responded well to NPWT, the initial reconstructive oxygen emulsion (1), and nasogastric tube placement (1).
effort (a thoracodorsal axial pattern flap) failed and this dogsubsequently had successful forequarter amputation.
Complications Associated With NPWT Complications were minor, especially as clinicians and staffgained experience applying the dressings and became familiarwith the machines (e.g., intensity setting, tampering lock). The We found that NPWT is feasible for a wide variety of wound major issue reported with NPWT was the loss of vacuum causes and types, and a useful mechanical adjunct to wound because of inadequate periwound adhesion. This was most management in a well‐staffed veterinary hospital setting.
notable in the gauze‐based systems, where the evacuation Although this study was not comparative, the short time to tubing had to be secured to the skin. It was also recorded for the reconstruction appears to be consistent with previous reports of digits, where crevices and movement caused drape detachment NPWT showing a rapid formation of a smooth granulation and leakage. Meticulous attention to clipping and cleansing the tissue bed.8,52,53 periwound skin, using a spray adhesive, and creating a dam Although the dogs were fairly evenly distributed between across the uneven surfaces (such as interdigital areas) with early reconstruction, late reconstruction, and second intention stoma paste mitigated this problem. Chewing or kinking of the healing, NPWT was generally used for less than a week, similar tubing caused device failure in 3 dogs and was resolved by to the 15 dogs reported by Ben‐Amotz.8 This suggests it is most appropriate attention to E‐collar placement and cage confine- useful in stimulating the development of a healthy wound bed ment. In 1 young dog with a large abscessed elbow hygroma, suitable for a reconstructive effort, rather than a long‐term granulation tissue was noted to adhere slightly to the foam management option. In these and other authors' opinions, dressing. Although not included in the analysis, we concur- wounds undergoing NPWT were closed in a shorter time (first rently treated 3 cats and 2 horses and found that cats were or second dressing change) than is typical for traumatic intolerant of intermittent therapy—flinching and occasional wounds.8,49,52 In our dogs, NPWT also appeared to accelerate vocalization was noted upon pump activation. One dog or "kick‐start" the chronic wound beds into the reparative developed mild skin irritation with prolonged NPWT (after phase, optimizing the wound environment for epithelialization 7–10 days). This complication was reduced by allowing the and contraction.
original adhesive drape to remain on the periwound skin, and One interesting finding was the lack of dogs where NPWT simply cutting off the dressing immediately over the wound was used for head and neck wounds, considering that we often bed, and any other non‐adherent portion. With increasing see wounds (e.g., bite wounds) in these areas. In this study, we experience using NPWT, far fewer management and technical selected against head and neck wounds because of our lack of issues occurred.
expertise in obtaining a seal and maintaining integrity of thedressings in this anatomical region. In people, application ofNPWT in the nuchal area not only improves healing, but allows increased patient mobility (neck movement is socially andfunctionally very important).21,58 As we gain further experi- One dog was lost to follow up after definitive closure, so ence with NPWT, innovative approaches should be considered outcome was assessed for 44 dogs (52 wounds); 50 wounds for wounds around the head and neck. Such approaches may (96%; 23 dogs foam‐based, 20 of 21 dogs gauze‐based include more extensive clipping of the face, head, and neck, use dressings) healed and no statistical difference in outcome was of temporary tarsorrhaphies, additional protective padding detected between dressing types (x2 2‐tailed, P ¼.98). All 32 with loop sutures over the NPWT dressings, and meticulous surgically closed wounds were considered healed by the 10– attention being paid to "building up" the initial application of 14‐day postoperative recheck. All 18 wounds healing by the dressing (e.g., with stoma paste).
second intention were considered healed (fully epithelialized) A limitation of our study is the lack of data on wounds that between 14 and 32 days (mean, 21 days) after discharge. Nine presented to the VTH and did not receive NPWT. However, it of 32 wounds (28%) had minor complications after closure, appears that this modality was used more frequently in larger including seroma (2) superficial flap tip or partial superficial wounds. Almost 90% of the wounds in this study were >5 cm graft necrosis (3), partial incisional dehiscence after delayed diameter, and 50% were >10 cm diameter. Wounds in primary closure (1), and wound lymphedema (3); all published reports have typically been large; however, in the complications resolved and the wounds healed. Two dogs series of 15 dogs with extremity wounds, dimensions were not (4%) died before wound healing was achieved. One had stated.8,45–49,51 Mean hospitalization time in our study was cardiac arrest before final closure could be attempted, and 1 1 week; this appears to be a shorter time than typical for was euthanatized because of progression of concurrent wounds of this size, and is slightly less than the 10 days in the Veterinary Surgery 43 (2014) 380–387 Copyright 2014 by The American College of Veterinary Surgeons Negative Pressure Wound Therapy reported case series.8 Smaller wounds (<5 cm) were often not using the therapy, and the animals only come in for dressing selected for NPWT because these wounds do not pose the same changes or if a complication arises.
The machines we used were designed for human hospital One major advantage of using NPWT is avoidance of use with many functions unnecessary for animals (e.g., daily anesthesia/sedation as required for traditional wet‐to‐dry tampering lock). Veterinary‐specific VAC1 units are now dressings. As evident from the types of drugs used, NPWT available that are smaller, lighter, more robust and display dressing changes require heavy sedation (or anesthesia), but the fewer pump alerts than when we conducted this study. These 3 days between NPWT dressing changes allows patients to smaller devices can be carried in a halter or harness, which recover adequately to eat, drink, eliminate, ambulate, and would reduce any kinking complications.
interact with visiting owners. In comparison, the wet‐to‐dry One of the most controversial claims of NPWT is the dressing needs to be re‐dressed every 12–24 hours, requiring ability to decrease the bacterial burden of a wound.14 Although some form of sedation or anesthesia each time, thus increasing nearly all wounds were cultured, NPWT placement was not patient morbidity and cost. Nutritional intake (providing influenced by this test. Culture results were generally not calories) and ambulation (promoting lymphatic drainage) are reported until NPWT had been in place for several days (or both critical for optimizing wound healing. An additional sometimes even removed). Because of lack of a control group advantage that was noted with NPWT was that strike‐through is in this study we are unable to provide any data to support or completely eliminated, as all exudate and wound fluids are refute any claims of increased bacterial clearance with NPWT.
collected into the canister.
Cost comparison studies in human wound care have Most dogs tolerated the NPWT well. Because of the shown decreased overall cost of care when NPWT is intolerance to intermittent therapy in cats, presumably because used.43,44,60–63 We did not attempt to compare costs of using of pain when the vacuum is activated, we now use continuous NPWT with standard‐of‐care. The costs of initial machine mode in cats. The negative outcomes in 2 dogs were considered purchase and dressing materials need to be offset against the to be unrelated to the use of NPWT.
cost of decreased dressing changes, shortened time to Although there are around a dozen different proprietary reconstruction, and shorter hospitalization times.
NPWT systems in the human wound care market, the main Overall, our clinical experience with NPWT over the difference is in the contact layer, consisting of either foam or course of this study and since (over 250 cases) has been very gauze. The most commonly reported is a polyurethane ether positive, concurring with the outcome of the other case series.8 foam‐based system, marketed by Kinetic Concepts Incor- In our hospital, NPWT has replaced the wet‐to‐dry dressing as porated (KCI, San Antonio, TX), which holds the major standard‐of‐care for acute traumatic wounds, skin grafts, and market share for this modality. Both primary dressings dehiscence. The encouraging findings of our study should be reportedly have similar mechanisms of action,59,60 and we validated with randomized, controlled, clinical trials compar- did not find any difference in wound outcome between the 2 ing NPWT with wet‐to‐dry and other dressings, specifically for time to reconstruction, and hospitalization time and cost, Maintenance of therapy was quite simple once initial before widespread recommendations are made.
technical hurdles were overcome. The steepest learning curvewas in securing of a good periwound seal in areas where theskin was uneven, for example, between the digits, over the hock, the perineum. Techniques that were developed duringour study included using various stoma pastes, and adding a We thank Chris Phipps, LVT, for maintaining log of cases, and to all liquid skin adhesive to ensure adequate periwound adhesion.
NCU technicians involved in the care of patients on NPWT.
The gauze‐based systems were more difficult to securecompared with the foam‐based system, because of the way the evacuation tubing had to be applied to the skin.
Interestingly, placing the system over areas of mobility (e.g., After acceptance of this manuscript, Dr. B.J. Stanley has acted axilla, inguinal area, over joints) did not appear to cause a loss as a consultant to Kinetic Concepts, Inc; otherwise, the authors of dressing integrity, possibly because of the disruptive shear report no financial or other conflicts related to this study.
forces were neutralized by "splinting" of the area. Whenpossible, NPWT dressings were covered with a soft, paddedbandage for protection. As dogs started to heal and becamemore mobile, they would sometimes start to circle before they lay down. This behavior should be noted, and any twisting ofthe tubing can be corrected at that time.
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Fakultät Technik und InformatikStudiendepartment Informatik Hamburg, den 28.Februar 2008 1. Einleitung und Motivation 2.2. Pervasive Gaming Computing . . . . . . . . . . . . . 3. Projekt 3.2. Aufgabenverteilung . . . . . . . . . . . . . . . . 3.4.1. PS Community Manager . . . . . . . . . . . . 3.4.2. PS Orientierungseinheit 3.5.1. Fachliche Anforderungen . . . . . . . . . . . .

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Pharmaceutical Patents, Global Health and the TRIPS Agreement Dr. med. Alexandra Grosse Matriculation Nr.: A9801310 ao. Univ.-Prof. Dr. Irmgard Marboe Institute of International Law University of Vienna 030084 SE International Law Seminar Inhalt 1. Abbreviations . 3  2. Introduction . 4  3. The Agreement on Trade-Related Aspects of Intellectual Property Rights . 6