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230 Address for correspondence: Shahzad G. Raja BSc, MBBS, MRCS, FRCS(C-Th), Department of Cardiac Surgery, Harefield Hospital, Hill End Road, Harefield, UB9 6JH, London, United Kingdom. tel. +441895828550, fax +441895828992, e-mail: drrajashahzad@hotmail.com whether they are female (score = 2), diabetic (score = 1), Hb1Ac > 7.5% (score = 3), BMI ≥ 35 (score = 2), ejection fraction ≤ 45% (score = 1), and emergency surgery (score = 2). Identification of patients who are at high or medium risk for SWI then triggers a cascade of events and interventions aimed at eliminating the occurrence of SWI. One of the key areas we have aggressively focused on is the achievement of normoglycaemia in all diabetics, both preas well as postoperatively. There is evidence to suggest that better control of preand postoperative blood glucose levels in patients with diabetes lowers the incidence of sternal wound complications, particularly deep SWI after cardiac surgery [3]. Our commitment to achieving this target is reflected by the fact that we have developed a dedicated diabetic specialist nurse service with input from a consultant endocrinologist. We have recently described our standardized sternotomy wound care bundle in detail [4]. We clip all the side branches during ITA harvest and use the point haemostasis technique to minimize leaving charred tissue on the inside of the chest wall, which could potentially act as a culture medium for microbes. We routinely wash the chest cavity at the end of the procedure with at least a litre of warm saline to remove all debris and use a double wire technique to close the sternum. Our aforementioned sternal wiring technique exerts force both from top to bottom and across the midline, thus achieving a secure closure and fixing any fractures at the same time. We firmly believe that deep wound infection occurrence might be a consequence of technical pitfalls, predominant amongst them being suboptimal sternal wiring technique [5]. Again we standardized this wiring technique in 2007 and it could be a contributory factor to the decline in sternal wound complications in our experience. At about the same time we started using a gentamicin-collagen sponge (Collatamp®, EUSA Pharma [Europe], Oxford, United Kingdom) for all high-risk patients including diabetics with BIMA harvest. Prior to closure of the sternum and after placement of the sternal wires, a single Collatamp® sponge (20 × 5 × 0.5 cm; 1 cm2 containing 2.8 mg LETTERS TO EDITOR

LETTERS TO EDITOR Is it possible to eliminate sternal wound infection after cardiac surgery?