Katharine L. McGinigle

The Use of Active Surveillance Cultures in Adult Intensive Care Units to Reduce Methicillin-Resistant Staphylococcus aureus-Related Morbidity, Mortality, and Costs: A Systematic Review

Active surveillance cultures (ASCs) are universal or targeted microbiological screening cultures for patients admitted to a hospital. ASCs have been proposed to control the increasing numbers of infections due to multidrug-resistant organisms, but their efficacy and cost-effectiveness are unproven. We conducted a systematic review of the literature pertaining to the use of ASCs and control of methicillin-resistant Staphylococcus aureus (MRSA). We searched relevant journals and the PubMed Medline, Web of Science, CINAHL, and Cochrane Library databases. No randomized, controlled trials were identified. Sixteen observational studies and 4 economic analyses were reviewed. Only 2 of the observational studies had a control group. None of the studies were of good quality. Thus, we identified important gaps in the literature, including a need for a clear definition of ASCs, a clear implementation protocol, and rigorous economic evaluations. Existing evidence may favor the use of ASCs, but the evidence is of poor quality, and definitive recommendations cannot be made.

Living in a medically underserved county is an independent risk factor for major limb amputation

OBJECTIVE Despite an increase in the incidence of hospital admissions for comorbid conditions, such as diabetes, the incidence of major limb amputation in North Carolina has decreased. The decline in amputation rate has not been uniformly realized across the state. The objective of this study was to determine the association between major vascular limb amputation and living in an underserved county in North Carolina. METHODS We analyzed discharges aged 18 to 100 years old with a peripheral arterial disease (PAD)-related admission from the North Carolina Inpatient Discharge Database from 2006 to 2009. Medically underserved counties are defined by the United States Health Resources and Services Administration as having too few primary care providers, high infant mortality, high poverty, or high elderly population. The association between major amputation prevalence and medically underserved counties was calculated using a binomial regression model adjusted for sex, age, diabetes, end-stage renal disease, PAD, and critical limb ischemia. Each confounder was assessed using backward elimination modeling. RESULTS Among the 222,920 discharges with a PAD-related hospital admission from 2006 to 2009, 8601 (3.9%) were from medically underserved counties. There were 7328 major amputations. The adjusted prevalence odds ratio of the association between underserved counties and major vascular limb amputation is 1.29 (95% confidence interval, 1.16-1.44). None of the confounders significantly affected the association between underserved counties and number of amputations. CONCLUSIONS Living in an underserved county in North Carolina is associated with a 29% increase in the odds of undergoing major limb amputation. Gender, age, and comorbidities, including diabetes, end-stage renal disease, and PAD, do not significantly affect the relationship.

The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS® and ERAS® USA Societies

BackgroundEnhanced recovery after surgery (ERAS) programs are multimodal care pathways designed to minimize the physiological and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature.MethodsTo improve the quality of ERAS reporting, ERAS® USA and the ERAS® Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus.ResultsThe Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines.ConclusionsThe RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS-related studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals.

Limited adoption of abdominal aortic aneurysm screening guidelines associated with no improvement in aneurysm rupture rate

Background: Screening for abdominal aortic aneurysms can prevent life‐threatening rupture. The Screening Abdominal Aortic Aneurysms Very Efficiently Act was implemented in 2007. This provides for a one‐time abdominal aortic aneurysm screening. We hypothesize that the Screening Abdominal Aortic Aneurysms Very Efficiently Act has increased the screening rate and identified more abdominal aortic aneurysms, leading to fewer ruptured abdominal aortic aneurysms. Methods: Centers for Medicare and Medicaid Services data were used to estimate the number of Medicare enrollees eligible for screening and the number screened. The Nationwide Inpatient Sample database was queried for discharges involving abdominal aortic aneurysm rupture and/or repair from the years 2000 to 2015 to assess national trends in abdominal aortic aneurysm admissions. The main outcomes were abdominal aortic aneurysm screening rates and standardized yearly incidence of abdominal aortic aneurysm rupture and abdominal aortic aneurysm repairs (stratified by open and endovascular). Results: The number of patients screened increased from 9,884 (2007) to 95,243 (2015). The screening rate increased from 0.2% (2007) to 1.4% (2015) (P < .001) of eligible patients. The number of abdominal aortic aneurysm ruptures increased slightly after the initiation of the Screening Abdominal Aortic Aneurysms Very Efficiently Act from 8.3 per 100,000 to 9.4 per 100,000 (incidence rate ratio 1.12, 95% confidence interval 1.06–1.19). The average yearly change in abdominal aortic aneurysm ruptures was not significant (95% confidence interval –0.01 to 0.00, P=.30). The number of open abdominal aortic aneurysm repairs declined, while endovascular repairs increased during the study period. Conclusion: The Screening Abdominal Aortic Aneurysms Very Efficiently Act has increased the number of patients being screened; however, screening rates remain low. The number of patients presenting with rupture has not decreased. Screening strategies need to be reassessed or made more widely available for this legislation to have an impact.

Vascular Surgery Training: Multiple Pathways to Success

Much like in other surgical specialties, vascular surgery has more than one pathway to success. Alternate training pathways allow for individuals to choose which might be best for them and allow them to optimally accomplish their career goals. This chapter highlights the various vascular surgery programs and the pros and cons of each.