Matthew D. Whealon

Methicillin-Resistant Staphylococcus aureus (MRSA) Carriage in 10 Nursing Homes in Orange County, California

County, California • Author(s): Courtney Reynolds, MS; Victor Quan, BA; Diane Kim, BS; Ellena Peterson, PhD; Julie Dunn, MPH; Matthew Whealon, BS; Leah Terpstra, BA; Hildy Meyers, MD, MPH; Michele Cheung, MD, MPH; Bruce Lee, MD, MBA; Susan S. Huang, MD, MPH Source: Infection Control and Hospital Epidemiology, Vol. 32, No. 1 (January 2011), pp. 91-93 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/657637 . Accessed: 20/05/2014 22:28

Nursing home characteristics associated with methicillin-resistant Staphylococcus aureus (MRSA) Burden and Transmission.

BackgroundMRSA prevalence in nursing homes often exceeds that in hospitals, but reasons for this are not well understood. We sought to measure MRSA burden in a large number of nursing homes and identify facility characteristics associated with high MRSA burden.MethodsWe performed nasal swabs of residents from 26 nursing homes to measure MRSA importation and point prevalence, and estimate transmission. Using nursing home administrative data, we identified facility characteristics associated with MRSA point prevalence and estimated transmission risk in multivariate models.ResultsWe obtained 1,649 admission and 2,111 point prevalence swabs. Mean MRSA point prevalence was 24%, significantly higher than mean MRSA admission prevalence, 16%, (paired t-test, p<0.001), with a mean estimated MRSA transmission risk of 16%.In multivariate models, higher MRSA point prevalence was associated with higher admission prevalence (p=0.005) and higher proportions of residents with indwelling devices (p=0.01). Higher estimated MRSA transmission risk was associated with higher proportions of residents with diabetes (p=0.01) and lower levels of social engagement (p=0.03).ConclusionsMRSA importation was a strong predictor of MRSA prevalence, but MRSA burden and transmission were also associated with nursing homes caring for more residents with chronic illnesses or indwelling devices. Frequent social interaction among residents appeared to be protective of MRSA transmission, suggesting that residents healthy enough to engage in group activities do not incur substantial risks of MRSA from social contact. Identifying characteristics of nursing homes at risk for high MRSA burden and transmission may allow facilities to tailor infection control policies and interventions to mitigate MRSA spread.

Predicting High Prevalence of Community Methicillin-Resistant Staphylococcus aureus Strains in Nursing Homes

We assessed characteristics associated with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) carriage among residents of 22 nursing homes. Of MRSA-positive swabs, 25% (208/824) were positive for CA-MRSA. Median facility CA-MRSA percentage was 22% (range, 0%-44%). In multivariate models, carriage was associated with age less than 65 years (odds ratio, 1.2; P<.001) and Hispanic ethnicity (odds ratio, 1.2; P=.006). Interventions are needed to target CA-MRSA.

Risk Factors for Traumatic Injury Findings on Thoracic Computed Tomography Among Patients With Blunt Trauma Having a Normal Chest Radiograph

HYPOTHESIS We sought to identify risk factors that might predict acute traumatic injury findings on thoracic computed tomography (TCT) among patients having a normal initial chest radiograph (CR). DESIGN In this retrospective analysis, Abbreviated Injury Score cutoffs were chosen to correspond with obvious physical examination findings. Multivariate logistic regression analysis was performed to identify risk factors predicting acute traumatic injury findings. SETTING Urban level I trauma center. PATIENTS All patients with blunt trauma having both CR and TCT between July 1, 2005, and June 30, 2007. Patients with abnormalities on their CR were excluded. MAIN OUTCOME MEASURE Finding of any acute traumatic abnormality on TCT, despite a normal CR. RESULTS A total of 2435 patients with blunt trauma were identified; 1744 (71.6%) had a normal initial CR, and 394 (22.6%) of these had acute traumatic findings on TCT. Multivariate logistic regression demonstrated that an abdominal Abbreviated Injury Score of 3 or higher (P = .001; odds ratio, 2.6), a pelvic or extremity Abbreviated Injury Score of 2 or higher (P < .001; odds ratio, 2.0), age older than 30 years (P = .004; odds ratio, 1.4), and male sex (P = .04; odds ratio, 1.3) were significantly associated with traumatic findings on TCT. No aortic injuries were diagnosed in patients with a normal CR. Limiting TCT to patients with 1 or more risk factors predicting acute traumatic injury findings would have resulted in reduced radiation exposure and in a cost savings of almost

Laser Doppler Imaging for Early Detection of Hemorrhage

250,000 over the 2-year period. Limiting TCT to this degree would not have missed any clinically significant vertebral fractures or vascular injuries. CONCLUSION Among patients with a normal screening CR, reserving TCT for older male patients with abdominal or extremity blunt trauma seems safe and cost-effective.

Outcomes of open and endovascular lower extremity revascularization in active smokers with advanced peripheral arterial disease

BACKGROUND Laser Doppler Imaging (LDI) is a noninvasive means to measure blood flow through the superficial skin capillary plexus using flux units. Our objective was to determine the ability of LDI of the skin to detect and quantify rapid, severe hemorrhage. METHODS Five Yucatan mini-pigs (25-35 kg) underwent controlled hemorrhage of 25 mL/kg blood for 20 minutes. Median flux of a 10 cm × 10 cm area of the lower abdomen was measured at 2-minute intervals from initiation of hemorrhage to resuscitation with concurrent measurement of heart rate (HR), systolic blood pressure (SBP), and mean arterial pressure (MAP). RESULTS Average time to a change of 5 U in flux following start of hemorrhage was 2.4 minutes. This was significantly faster than time to change in HR (19.2 minutes, p < 0.05) and showed a trend toward more rapid identification of hemorrhage relative to changes in SBP (3.2 minutes, p = 0.157) and MAP (3.6 minutes, p = 0.083). Flux changes occurred at smaller % total blood volume lost than HR (3.94% vs. 28.8%, p < 0.05) and trended toward smaller volume identification than SBP (4.88%, p = 0.180) and MAP (5.36%, p = 0.102). Average correlation (ρ) of blood volume lost to flux was -0.974; HR, 0.346; SBP, -0.978; and MAP, -0.975. A change of 5 flux units was significantly more sensitive for hemorrhage than a change of 5 beats per minute in HR or 5 mm Hg in SBP or MAP (0.596 vs. 0.169, 0.438, and 0.287 respectively, all p < 0.05). CONCLUSION LDI is a sensitive, specific, and early means to detect and quantify severe hemorrhage.

Future of Minimally Invasive Colorectal Surgery.

Objective: Concern over perioperative and long‐term durability of lower extremity revascularizations among active smokers is a frequent deterrent for vascular surgeons to perform elective lower extremity revascularization. In this study, we examined perioperative outcomes of lower extremity endovascular (LEE) revascularization and open lower extremity bypass (LEB) in active smokers with intermittent claudication (IC) and critical limb ischemia (CLI). Methods: Active smokers undergoing LEE or LEB from 2011 to 2014 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular data set. Patient demographics, comorbidities, anatomic features, and perioperative outcomes were compared between LEE and LEB procedures. Subgroup analysis was performed for patients undergoing revascularization for IC and CLI independently. Results: From 2011 to 2014, 4706 lower extremity revascularizations were performed in active smokers (37% of all revascularizations). In this group, 1497 were LEE (55.6% for CLI, 13.4% for below‐knee pathology) and 3209 were LEB (68.9% CLI, 34.7% below‐knee). Patients undergoing LEE had higher rates of female gender, hypertension, end‐stage renal disease, and diabetes (all P ≤ .02). LEE patients also had a higher frequency of prior percutaneous interventions (22.7% vs 17.2%; P < .01) and preoperative antiplatelet therapy (82.3% vs 78.7%; P = .02). On risk‐adjusted multivariate analysis, LEE patients had higher need for reintervention on the treated arterial segment than LEB (5.1% vs 5.2%; odds ratio [OR], 1.52; 95% confidence interval [CI], 1.08‐2.13; P = .02) but had lower wound complications (3.1% vs 13.2%; OR, 0.32; 95% CI, 0.23‐0.45; P < .01) and no statistically significant difference in 30‐day mortality (0.6% vs 0.9%), myocardial infarction or stroke (1.1% vs 2.6%), or major amputation (3.2% vs 2.1%) in the overall cohort of active smokers. In the IC subgroup, myocardial infarction or stroke was significantly higher in the LEB group (1.9% vs 0.6%; OR, 1.83; 95% CI, 1.17‐1.97; P = .03), although no difference was found in the CLI subgroup (2.8% vs 1.4%; OR, 0.75; 95% CI, 0.37‐1.52; P = .42,). Also in IC group, there was a trend for lower major amputation rates ≤30 days in the LEE group, whereas in the CLI group, LEE had a trend toward higher risk of early amputation compared with LEB. Conclusions: In active smokers, LEB for IC and CLI requires fewer reinterventions but is associated with a higher rate of postoperative wound complications compared with LEE revascularization. However, the risk for limb amputation is higher in actively smoking patients when treated by LEE compared with LEB for CLI. Importantly, cardiovascular complications are significantly higher in actively smoking patients with IC undergoing LEB compared with LEE. This additional cardiovascular risk should be carefully weighed when proposing LEB for actively smoking patients with nonlimb‐threatening IC.

Comparison of percutaneous versus open femoral cutdown access for endovascular repair of ruptured abdominal aortic aneurysms

Minimally invasive surgery is slowly taking over as the preferred operative approach for colorectal diseases. However, many of the procedures remain technically difficult. This article will give an overview of the state of minimally invasive surgery and the many advances that have been made over the last two decades. Specifically, we discuss the introduction of the robotic platform and some of its benefits and limitations. We also describe some newer techniques related to robotics.

Lymph Node Positivity in Appendiceal Adenocarcinoma: Should Size Matter?

Objective Ruptured endovascular aortic aneurysm repair (REVAR) is being increasingly used to treat ruptured abdominal aortic aneurysms (rAAAs). However, the comparison between totally percutaneous (pREVAR) vs femoral cutdown (cREVAR) access for REVAR has not been studied. We used a national surgical database to evaluate the 30‐day outcomes in patients undergoing pREVAR vs cREVAR. Methods Patients who underwent EVAR for rAAA between 2011 and 2014, inclusively, were studied in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular database. Univariate and multivariate analyses were used to compare preoperative demographics, operation‐specific variables, and postoperative outcomes between those who had pREVAR and cREVAR. Results We identified 502 patients who underwent REVAR, of which 129 had pREVAR (25.7%) and 373 cREVAR (74.3%). Between 2011 and 2014, the use of totally percutaneous access for repair increased from 14% to 32%. Of all patients undergoing REVAR, 24% had bilateral percutaneous access, 2% had attempted percutaneous access converted to cutdown, 64% had bilateral femoral cutdowns, and 10% had single femoral cutdown. Univariate analysis showed there were no significant differences in age, gender, body mass index, AAA size, or other high‐risk physiologic comorbidities between the two groups. There was also no difference in rates of preoperative hemodynamic instability (48.1% vs 45.0%; P = .55) or need for perioperative transfusion (67.4% vs 67.8%; P = .94). There was a higher incidence of use of regional anesthesia for pREVAR compared with cREVAR (20.9% vs 7.8%; P < .01). The incidence of postoperative wound complications was similar between both groups (4.8% vs 5.4%; P = .79), whereas hospital length of stay was shorter in the pREVAR group (mean difference, 1.3 days). Overall 30‐day mortality was higher in the pREVAR group (28.7% vs 20.1%; P = .04), and operative time was longer (mean difference, 6.3 minutes). However, when pREVARs done in 2011 to 2012 were compared with those done in 2013 to 2014, 30‐day mortality decreased from 38.2% to 25.3% and operative time decreased by 25 minutes (188 to 163 minutes). Multivariate analysis showed there were no significant differences in mortality, wound complications, hospital length of stay, or operative time between pREVAR and cREVAR. Conclusions The ACS NSQIP targeted vascular database shows that there has been increased adoption of pREVAR in recent years, with improved mortality and operative time over the 4‐year study period. At this point, pREVAR has not yet been shown to be superior to cREVAR for rAAA, but these outcome improvements are encouraging and likely attributable to increased operator experience.

Volume and outcomes relationship in laparoscopic diaphragmatic hernia repair

BACKGROUND The management algorithm for appendiceal adenocarcinoma is not well defined. This study sought to determine whether tumor size or depth of invasion better correlates with the presence of lymph node metastases in appendiceal adenocarcinoma, and to compare these rates with colon adenocarcinoma. STUDY DESIGN A retrospective review of the National Cancer Database was performed to identify patients with appendiceal or colonic adenocarcinoma from 2004 to 2013 who underwent surgical resection. Cases were categorized by tumor size and by T stage. Rates of lymph node metastases were examined as a function of size and T stage. RESULTS A total of 3,402 appendiceal and 314,864 colonic cases were identified. For appendiceal adenocarcinoma, larger tumor size was associated with higher T stage: Pearson correlation of 0.41 (95% CI 0.408 to 0.414; p < 0.001). Lymph node metastases were present in 19.1%, 27.8%, 39.6%, 39.4%, 42.4% and 39.1% for tumor sizes <1 cm, >1 to 2 cm, >2 to 3 cm, >3 to 4 cm, >4 to 5 cm, and >5 cm, respectively. Lymph node metastases were present in 0%, 11.2%, 12.3%, 35.5%, and 40.0% for in situ, T1, T2, T3, and T4 tumors, respectively. There was no difference in the rates of lymph node metastases between appendiceal and colonic adenocarcinoma for tumor sizes <3 cm, or for in situ and T1 tumors. Rates of lymph node metastases are higher in colonic adenocarcinoma for tumor sizes >3 cm and for T2, T3, and T4 tumors (p < 0.01). CONCLUSIONS In appendiceal adenocarcinoma, the rate of lymph node metastases is substantial, even for small tumors. Tumor size should play no role in the decision of whether to perform a hemicolectomy. Appendectomy alone does not produce an adequate lymph node sample. Right hemicolectomy should be performed for all appendiceal adenocarcinomas.