Identification of Risk Factors for Intra-Abdominal Candidiasis.

Background: Intra-abdominal candidiasis (IAC) is associated with substantial morbidity and mortality in hospitalized patients. Identifying high-risk populations may facilitate early and selective directed therapy in appropriate patients and avoid unwarranted treatment and any associated adverse effects in those who are low risk. Patients and Methods: This retrospective, case-control study included patients >18 years of age admitted from July 1, 2010 to July 1, 2021 who had a microbiologically confirmed intra-abdominal infection (gastrointestinal culture positive for either a Candida spp. [cases] or bacterial isolate [controls] collected intra-operatively or from a drain placed within 24 hours). Patients receiving peritoneal dialysis treatment or with a peritoneal dialysis catheter in place or treated at an outside hospital were excluded. Multivariable regression was utilized to identify independent risk factors for the development of IAC. Results: Five hundred twenty-three patients were screened, and 250 met inclusion criteria (125 per cohort). Multivariable analysis identified exposure to corticosteroids (odds ratio [OR], 5.79; 95% confidence interval [CI], 2.52-13.32; p < 0.0001), upper gastrointestinal tract surgery (OR, 3.51; 95% CI, 1.25-9.87; p = 0.017), and mechanical ventilation (OR, 3.09; 95% CI 1.5-6.37; p = 0.002) were independently associated with IAC. The area under the receiver operating characteristic (AUROC) and goodness of fit were 0.7813 and p = 0.5024, respectively. Conclusions: Exposure to corticosteroids, upper gastrointestinal tract surgery, and mechanical ventilation are independent risk factors for the development of microbiologically confirmed IAC suggesting these factors may help identify high-risk individuals requiring antifungal therapy.

Derivation and Validation of a Clinical Prediction Score to Identify the Isolation of Pseudomonas in Pneumonia.

Given the focus of existing clinical prediction scores on identifying drug-resistant pathogens as a whole, the application to individual pathogens and other institutions may yield weaker performance. This study aimed to develop a locally derived clinical prediction model for Pseudomonas-mediated pneumonia. This retrospective study included patients ≥18 years of age who were admitted to an academic medical center between 1 July 2010 and 31 July 2020 with a CDC National Healthcare Safety Network confirmed pneumonia diagnosis and were receiving antimicrobials during the index encounter, with a positive respiratory culture. Cystic fibrosis patients were excluded. Logistic regression analysis identified risk factors associated with the isolation of Pseudomonas aeruginosa from respiratory cultures within the derivation cohort (n = 186), which were weighted to generate a prediction score that was applied to the derivation and internal validation (n = 95) cohorts. A total of 281 patients met the inclusion criteria. Five predictor variables were identified, namely, tracheostomy status (4 points), chronic obstructive pulmonary disease (5 points), enteral nutrition (9 points), chronic steroid use (11 points), and Pseudomonas aeruginosa isolation from any culture in the prior 6 months (14 points). At a score of >11, the prediction score demonstrated a sensitivity of 52.4% (95% confidence interval [CI], 36.4 to 68.0%) and a specificity of 84.9% (95% CI, 72.4 to 93.35%) in the validation cohort. Score accuracy was 70.5% (95% CI, 60.3 to 79.4%), and the area under the receiver operating characteristic curve (AUROC) was 0.77 (95% CI, 0.68 to 0.87) in the validation cohort. A prediction score for identifying Pseudomonas aeruginosa in pneumonia was derived, which may have the potential to decrease the use of broad-spectrum antibiotics. Validation with larger and external cohorts is necessary. IMPORTANCE In this study, we aimed to develop a locally derived clinical prediction model for Pseudomonas-mediated pneumonia. Utilizing a locally validated prediction score may help direct therapeutic management and be generalizable to other clinical settings and similar populations for the selection of appropriate antimicrobial coverage when data are lacking. Our study highlights a unique patient population, including immunocompromised, structural lung disease, and transplant patients. Five predictor variables were identified, namely, tracheostomy status, chronic obstructive pulmonary disease, enteral nutrition, chronic steroid use, and Pseudomonas aeruginosa isolation from any culture in the prior 6 months. A prediction score for identifying Pseudomonas aeruginosa in pneumonia was derived, which may have the potential to decrease the use of broad-spectrum antibiotics, although validation with larger and external cohorts is necessary.

Optimizing the nutrition support care model: Analysis of survey data.

BACKGROUND: Malnutrition is underrecognized and underdiagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high-risk patients with malnutrition remains low despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models. METHODS: This survey assessed demographics of NSTs, factors contributing to the success of NSTs, elements of nutrition education, and other barriers to professional growth. RESULTS: Of 255 respondents, 235 complete surveys were analyzed. The geographic distribution of respondents correlated with population concentrations of the United States (r = 90.8%, p < .0001). Most responding physicians (46/57; 80.7%) reported being a member of NSTs, compared with 56.5% (88/156) of dietitians. Of those not practicing in NSTs (N = 81/235, 34.4%), 12.3% (10/81) reported an NST was previously present at their institution but had been disbanded. Regarding NSTs, financial concerns were common (115/235; 48.9%), followed by leadership (72/235; 30.6%), and healthcare professional (HCP) interest (55/235; 23.4%). A majority (173/235; 73.6%) of all respondents wanted additional training in nutrition but reported insufficient protected time, ability to travel, or support from administrators or other HCPs. CONCLUSION: Core actions resulting from this survey focused on formalizing physician roles, increasing interdisciplinary nutrition support expertise, utilizing cost-effective screening for malnutrition, and implementing intervention protocols. Additional actions included increasing funding for clinical practice, education, and research, all within an expanded portfolio of pragmatic nutrition support care models.

When All Else Fails: A Rare Case of Postoperative Toxic Shock Syndrome Arising from Surgical Site Infection after Decompressive Neurectomy Successfully Treated with Angiotensin-2.

Toxic shock syndrome is a serious complication of Streptococcus pyogenes or Staphylococcus aureus infections associated with very high morbidity and mortality. Postoperative toxic shock syndrome is an extremely rare phenomenon which manifests as fevers, diffuse rash, septic shock, and death. We present the first reported case of toxic shock syndrome associated with a surgical site infection from a decompressive neurectomy for refractory migraines in a 41-year-old female as well as the first use of angiotensin-2 vasopressor therapy to treat persistent septic shock from toxic shock syndrome refractory to conventional therapies.

Antifungal Therapy in Fungal Necrotizing Soft Tissue Infections.

BACKGROUND: Necrotizing soft tissue infections (NSTIs) are life-threatening surgical emergencies associated with high morbidity and mortality. Fungal NSTIs are considered rare and have been largely understudied. The purpose of this study was to study the impact of fungal NSTIs and antifungal therapy on mortality after NSTIs. METHODS: A retrospective chart review was performed on patients with NSTIs from 2012 to 2018. Patient baseline characteristics, microbiologic data, antimicrobial therapy, and clinical outcomes were collected. Patients were excluded if they had comfort care before excision. The primary outcome measured was in-hospital mortality. RESULTS: A total of 215 patients met study criteria with a fungal species identified in 29 patients (13.5%). The most prevalent fungal organism was Candida tropicalis (n = 11). Fungal NSTIs were more prevalent in patients taking immunosuppressive medications (17.2% versus 3.2%, P = 0.01). A fungal NSTI was significantly associated with in-hospital mortality (odds ratio, 3.13; 95% confidence interval, 1.16-8.40; P = 0.02). Furthermore, fungal NSTI patients had longer lengths of stay (32 d [interquartile range, 16-53] versus 19 d [interquartile range, 11-31], P < 0.01), more likely to require initiation of renal replacement therapy (24.1% versus 8.6%, P = 0.02), and more likely to require mechanical ventilation (64.5% versus 42.0%, P = 0.02). Initiation of antifungals was associated with a significantly lower rate of in-hospital mortality (6.7% versus 57.1%, P = 0.01). CONCLUSIONS: Fungal NSTIs are more common in patients taking immunosuppressive medications and are significantly associated with in-hospital mortality. Antifungal therapy is associated with decreased in-hospital mortality in those with fungal NSTIs. Consideration should be given to adding antifungals in empiric treatment regimens, especially in those taking immunosuppressive medications.

The Fundamentals of Endoscopic Surgery (FES) skills test: factors associated with first-attempt scores and pass rate.

BACKGROUND: The Fundamentals of Endoscopic Surgery (FES) program became required for American Board of Surgery certification as part of the Flexible Endoscopy Curriculum (FEC) for residents graduating in 2018. This study expands prior psychometric investigation of the FES skills test. METHODS: We analyzed de-identified first-attempt skills test scores and self-reported demographic characteristics of 2023 general surgery residents who were required to pass FES. RESULTS: The overall pass rate was 83%. "Loop Reduction" was the most difficult sub-task. Subtasks related to one another only modestly (Spearman's ρ ranging from 0.11 to 0.42; coefficient α = .55). Both upper and lower endoscopic procedural experience had modest positive association with scores (ρ = 0.14 and 0.15) and passing. Examinees who tested on the GI Mentor Express simulator had lower total scores and a lower pass rate than those tested on the GI Mentor II (pass rates = 73% vs. 85%). Removing an Express-specific scoring rule that had been applied eliminated these differences. Gender, glove size, and height were closely related. Women scored lower than men (408- vs. 489-point averages) and had a lower first-attempt pass rate (71% vs. 92%). Glove size correlated positively with score (ρ = 0.31) and pass rate. Finally, height correlated positively with score (r = 0.27) and pass rate. Statistically controlling for glove size and height did not eliminate gender differences, with men still having 3.2 times greater odds of passing. CONCLUSIONS: FES skills test scores show both consistencies with the assessment's validity argument and several remarkable findings. Subtasks reflect distinct skills, so passing standards should perhaps be set for each subtask. The Express simulator-specific scoring penalty should be removed. Differences seen by gender are concerning. We argue those differences do not reflect measurement bias, but rather highlight equity concerns in surgical technology, training, and practice.

Clinical Diagnosis of Infection in Surgical Intensive Care Unit: You're Not as Good as You Think!

Background: Because of the everincreasing costs and the complexity of institutional medical reimbursement policies, the necessity for extensive laboratory work-up of potentially infected patients has come into question. We hypothesized that intensivists are able to differentiate between infected and non-infected patients clinically, without the need to pan-culture, and are able to identify the location of the infection clinically in order to administer timely and appropriate treatment. Methods: Data collected prospectively on critically ill patients suspected of having an infection in the surgical intensive care unit (SICU) was obtained over a six-month period in a single tertiary academic medical center. Objective evidence of infection derived from laboratory or imaging data was compared with the subjective answers of the three most senior physicians' clinical diagnoses. Results: Thirty-nine critically ill surgical patients received 52 work-ups for suspected infections on the basis of signs and symptoms (e.g., fever, altered mental status). Thirty patients were found to be infected. Clinical diagnosis differentiated infected and non-infected patients with only 61.5% accuracy (sensitivity 60.3%; specificity 64.4%; p = 0.0049). Concordance between physicians was poor (κ = 0.33). Providers were able to predict the infectious source correctly only 60% of the time. Utilization of culture/objective data and SICU antibiotic protocols led to overall 78% appropriate initiation of antibiotics compared with 48% when treatment was based on clinical evaluation alone. Conclusion: Clinical diagnosis of infection is difficult, inaccurate, and unreliable in the absence of culture and sensitivity data. Infection suspected on the basis of signs and symptoms should be confirmed via objective and thorough work-up.

Transfer Is Associated with a Higher Mortality Rate in Necrotizing Soft Tissue Infections.

Background: Necrotizing soft tissue infections (NSTI) are a surgical emergency with significant morbidity and mortality rates. It has been thought that NSTIs are best treated in large tertiary centers. However, the effect of transfer has been under-studied. We examined whether transfer status is associated with a higher mortality rate in NSTIs. Methods: We conducted a retrospective review of patients with an International Classification of Disease (ICD) code associated with NSTI seen from 2012-2015 at two tertiary care institutions. Patients transferred to a tertiary center (T-NSTI) were compared with those who were treated initially at a tertiary center (P-NSTI). The primary endpoint was in-hospital death. Results: A total of 138 patients with NSTI met our study criteria, 39 transfer patients (28.0%) and 99 (72.0%) who were treated primarily at our institutions. The mortality rate was significantly higher for T-NSTI patients than P-NSTI patients (35.9% versus 14.1%; p < 0.01) with an adjusted odds ratio of 5.33 (95% confidence interval 1.02-28.30; p = 0.04). The need for hemodialysis was an independent predictor of in-hospital death. Treatment at a Level 1 trauma center and current smoking status were independent protectors???? of in-hospital death. For the transfer patients, the timing of transfer and debridement status were not different in survivors and non-survivors. However, there was a trend toward a lower in-hospital mortality rate if patients were transferred early without prior debridement than in all other transfers (21.4% versus 40.0%; p = 0.21). The in-hospital mortality rate was significantly lower at the Level 1 trauma center than at the non-trauma tertiary center (15.5% versus 34.3%; p = 0.02). Conclusion: Transfer status is an independent predictor of in-hospital death in patients with NSTI. Larger, multi-institutional studies are needed to elucidate further what factors contribute to the higher mortality rate in these patients.

FES exam outcomes in year two of a proficiency-based endoscopic skills curriculum.

BACKGROUND: FES certification is required to sit for the ABS Qualifying Exam. Previous work demonstrated a 40% FES pass rate for residents with standard clinical endoscopy training. After implementing a proficiency-based simulation curriculum, our FES pass rate increased to 87%. The purpose of this study was to monitor the success of our curriculum in its second year. We also hypothesized that residents who took the FES exam within 30 days of their clinical endoscopy rotation would have superior pass rates to residents who waited longer. METHODS: PGY4 residents (N = 12) underwent flexible endoscopy training including a 1 month clinical rotation plus proficiency-based simulation training using bench-top models (Trus, Operation Targeting Task) and a virtual reality task on the GI Mentor. Residents that passed FES on their first attempt were compared to residents that did not pass based on number of endoscopies logged, hours spent practicing on simulators, and time elapsed between completing their endoscopy rotation and taking the FES exam. FES total scores and section scores were compared to historical controls. RESULTS: Nine residents (75%) passed FES on their first attempt. Overall, 80% of residents who tested within 30 days of their endoscopy rotation (n = 5) passed FES while 71% of residents who waited longer (n = 7) passed FES (p = non-significant). Residents that passed FES were not significantly different from residents who did not pass based on number of endoscopies logged or hours spent practicing on simulators. Compared to historical controls, scores on loop reduction improved significantly with the new curriculum. CONCLUSIONS: FES pass rates decreased during the second year of our curriculum. Based on other literature, our trainees would benefit from higher volumes of endoscopy and/or a more robust proficiency-based simulation curriculum. Scheduling the FES exam in the month following the endoscopy rotation did not significantly improve pass rates.

Are you better off than you were 4 years ago? Measuring the impact of the ABS flexible endoscopy curriculum.

INTRODUCTION: In 2014, the ABS introduced the Flexible Endoscopy Curriculum (FEC). The FEC did not alter the minimum defined category case volumes for endoscopy; however, it did introduce specific cognitive and technical milestones for endoscopy training. It also mandated that residents pass the Fundamentals of Endoscopic Skills (FES) exam to qualify for board certification. Although significant research has been published regarding residents' success on the FES exam, very little is known regarding how the FEC has changed the way general surgery programs train their residents in surgical endoscopy. The aim of this study was to quantify changes in flexible endoscopy education at a large academic program in the 4 years since the FEC was published. METHODS: We classified the impact of FEC into four categories: (a) case volume or distribution, (b) clinical rotations, (c) required didactics or simulation exercises, and (d) FES pass rates. For category (a), we reviewed current and historical case logs for all categorical residents from 2013 to 2018. Mann-Whitney U tests were used to compare endoscopy volumes for each PGY level in 2013-2014 to the respective PGY level in 2017-2018 with p < 0.05 considered significant. For categories (b)-(d), we gathered historical records from the residency coordinator and endoscopy rotation director. RESULTS: Complete data were available for 57 residents in the 2013-2014 academic year and 56 residents in the 2017-2018 academic year. Median total endoscopies performed by PGY2, PGY3, and PGY5 residents all significantly increased during the FEC rollout. Our program's focus on endoscopy also expanded with absolute increases in endoscopy rotations, didactics, and simulation exercises. These changes translated into significantly increased pass rates on the FES exam from 40 to 100%. CONCLUSIONS: Implementation of the FEC at a large academic program led to measurable improvements in clinical experience, program structure, educational programing, and performance on high-stakes assessments.

Proficiency-based preparation significantly improves FES certification performance.

BACKGROUND: The Fundamentals of Endoscopic Surgery (FES) certification has recently been mandated by the American Board of Surgery but best methods for preparing for the exam are lacking. Our previous work demonstrated a 40% pass rate for PGY5 residents in our program. The purpose of this study was to determine the effectiveness of a proficiency-based skills and cognitive curriculum for FES certification. METHODS: Residents who agreed to participate (n = 15) underwent an orientation session, followed by skills pre-testing using three previously described models (Trus, Operation targeting task, and Kyoto) as well as the actual FES skills exam (vouchers provided by the FES committee). Participants then trained to proficiency on all three models for the skills curriculum and completed the FES online didactic material for the cognitive curriculum. Finally, participants post-tested on the models and took the actual FES certification exam. Values are mean ± SD; p < 0.05 was considered significant. RESULTS: Of 15 residents who participated, 8 (53%) passed the FES skills exam at baseline. Participants required 2.7 ± 1.3 h to achieve proficiency on the models and approximately 3 h to complete the cognitive curriculum. At post-test, 14 (93%, vs. pre-test 53%, p = 0.041) passed the FES skills exam. 14 (93%) passed the FES cognitive exam and 13/15 (87%) passed both the skills and cognitive exam and achieved FES certification. CONCLUSIONS: Our traditional clinical endoscopy curricula were not sufficient for senior residents to pass the FES exam. Implementation of a proficiency-based flexible endoscopy curriculum using bench-top models and the FES online materials was feasible and effective for the majority of learners. Importantly, with a modest amount of additional training, 87% of our trainees were able to pass the FES examination, which represents a significant improvement for our program. We expect that additional refinements of this curriculum may yield even better results for preparing future residents for the FES examination.

Do Polymicrobial Intra-Abdominal Infections Have Worse Outcomes than Monomicrobial Intra-Abdominal Infections?

BACKGROUND: Numerous studies have demonstrated microorganism interaction through signaling molecules, some of which are recognized by other bacterial species. This interspecies synergy can prove detrimental to the human host in polymicrobial infections. We hypothesized that polymicrobial intra-abdominal infections (IAI) have worse outcomes than monomicrobial infections. METHODS: Data from the Study to Optimize Peritoneal Infection Therapy (STOP-IT), a prospective, multicenter, randomized controlled trial, were reviewed for all occurrences of IAI having culture results available. Patients in STOP-IT had been randomized to receive four days of antibiotics vs. antibiotics until two days after clinical symptom resolution. Patients with polymicrobial and monomicrobial infections were compared by univariable analysis using the Wilcoxon rank sum, χ(2), and Fisher exact tests. RESULTS: Culture results were available for 336 of 518 patients (65%). The durations of antibiotic therapy in polymicrobial (n = 225) and monomicrobial IAI (n = 111) were equal (p = 0.78). Univariable analysis demonstrated similar demographics in the two populations. The 37 patients (11%) with inflammatory bowel disease were more likely to have polymicrobial IAI (p = 0.05). Polymicrobial infections were not associated with a higher risk of surgical site infection, recurrent IAI, or death. CONCLUSION: Contrary to our hypothesis, polymicrobial IAI do not have worse outcomes than monomicrobial infections. These results suggest polymicrobial IAI can be treated the same as monomicrobial IAI.

Vancomycin-Associated Nephrotoxicity: The Obesity Factor.

BACKGROUND: Current recommendations suggest that vancomycin dosing utilize actual rather than ideal body weight in obese patients. Thus, obese patients may be at greater risk for nephrotoxicity. The purpose of this study was to compare the incidence of nephrotoxicity in vancomycin-treated obese and lean patients at our institution, where unadjusted, actual body weight-based dosing (capped at 2 g per dose twice daily) is used. We expected obese patients to experience a greater incidence of nephrotoxicity than lean patients. METHODS: This study examined a retrospective cohort of patients treated with vancomycin for gram-positive or mixed infections in our facility from 2005-2009 who were not receiving hemodialysis at the time of admission. Patients were stratified by body mass index (BMI; obese ≥30 kg/m(2) vs. lean <30 kg/m(2)). Relative risk (RR), 95% confidence intervals (CIs), and p values were computed using a generalized estimating equation to accommodate a correlated data structure corresponding to multiple episodes of infection per individual. Multivariable analysis was performed. RESULTS: A total of 530 patients (207 obese; 323 lean) with 1,007 episodes of infection were treated with vancomycin. Patient demographics, co-morbidities, sites of infection, and infecting organisms were similar in the two groups. Female gender (p=0.042), diabetes mellitus (DM) (p=0.018), and hypertension (HTN) (p=0.0009) were more often associated with obesity, whereas allografts (p=0.022) and peripheral vascular disease (p=0.036) were more often present in lean patients. The Acute Physiology and Chronic Health Evaluation II score >21 was the only variable associated with nephrotoxicity (p=0.039). After adjusting for statistically significant variables, obesity was found not to be associated with a greater risk of nephrotoxicity (RR=0.98; 95% CI=0.93-1.04; p=0.59). CONCLUSION: No difference in nephrotoxicity was observed between lean and obese patients treated with vancomycin at our institution.

Can Nasal Methicillin-Resistant Staphylococcus aureus Screening Be Used to Avoid Empiric Vancomycin Use in Intra-Abdominal Infection?

BACKGROUND: Vancomycin is used widely as empiric therapy for gram-positive organisms in patients with an intra-abdominal infection (IAI), even in those with no history of methicillin-resistant Staphylococcus aureus (MRSA) infection or colonization. Potential adverse effects of vancomycin include nephrotoxicity, increased cost, and bacterial resistance. We hypothesized that MRSA nasal screening could be used to predict patients with a MRSA IAI and used to avoid unnecessary empiric vancomycin use. METHODS: A surgical infections database collected prospectively from a single institution was reviewed for all IAIs between January 1, 2000-December 31, 2011. Patients with and without MRSA obtained from abdominal cultures as either a monomicrobial or polymicrobial isolate were compared by univariate analysis. A multivariable logistic regression was performed to identify independent predictors of MRSA IAI. RESULTS: Of 2,591 patients with an IAI, 240 patients had a nasal MRSA screen within 30 d prior to infection and abdominal culture data, with an incidence of 23% for MRSA IAI. Patients with MRSA IAI (n=45) had more healthcare associated infections, lower white blood cell counts and greater rates of positive nasal MRSA screenings compared with those with non-MRSA IAI. By multivariable analysis (C statistic=0.908), the strongest independent predictor of an MRSA IAI was a positive MRSA screen (odds ratio [OR] 40.9, confidence interval [CI] 14.2-118.1). The positive predictive value for a MRSA screen was 53% whereas the negative predictive value of a MRSA screen was 97%. CONCLUSION: A negative MRSA nasal screen indicates with near certainty the absence of MRSA as part of an IAI. In the setting of a recent screen, empiric vancomycin can be withheld. Further, rapid MRSA nasal screening could be used to forego or to discontinue vancomycin therapy rapidly in the setting of IAI. This change in empiric antibiotic management of IAI may lead to decreased morbidity, reduction in cost, and a decrease in bacterial resistance.

Can we define surgical site infection accurately in colorectal surgery?

BACKGROUND: Increasingly, surgical site infection (SSI) is being tied to quality of care. The incidence of SSI after colorectal surgery differs widely. We hypothesize that it is difficult to define SSI reliably and reproducibly when adhering to the U.S. Centers for Disease Control and Prevention (CDC) definitions. METHODS: Elective intra-abdominal colorectal procedures via a clean-contaminated incision performed at a single institution between January 1 and May 1, 2011 were queried. Three attending surgeons examined all patients' records retrospectively for documentation of SSI. These data were compared with the institutional National Surgeon Quality Improvement Program (NSQIP) data with regard to deep and superficial incisional SSI. RESULTS: Seventy-one cases met the inclusion criteria. There were six SSIs identified by NSQIP, representing 8.4% of cases. Review of the three attending surgeons demonstrated a significantly higher incidence of SSI, at 27%, 38%, and 23% (p=0.002). The percent of overall agreement between all reviewers was 82.16 with a kappa of 0.64, indicating only modest inter-rater agreement. Lack of attending surgeon documentation and subjective differences in chart interpretation accounted for most discrepancies between the surgeon and NSQIP SSI capture rates. CONCLUSIONS: This study highlights the difficulty in defining SSI in colon and rectal surgery, which oftentimes is subjective and difficult to discern from the medical record. According to these preliminary data from our institution, there is poor reliability between clinical reviewers in defining SSI on the basis of the CDC criteria, which has serious implications. The interpretation of clinical trials may be jeopardized if we cannot define SSI accurately. Furthermore, according to current CDC definitions and infection tracking strategies, these data suggest that the institutional incidence of SSI may not be a reliable measure by which to compare institutions. Better methods for defining SSI should be implemented if these data are made publicly available and tied to performance measures.

Influence of hemodialysis on clinical outcomes after lung transplantation.

BACKGROUND: Chronic renal failure after lung transplantation is associated with significant morbidity. However, the significance of acute kidney injury (AKI) after lung transplantation remains unclear and poorly studied. We hypothesized that hemodialysis (HD)-dependent AKI after lung transplantation is associated with significant mortality. MATERIALS AND METHODS: We performed a retrospective review of all patients undergoing lung transplantation from July 1991 to July 2009 at our institution. Recipients with AKI (creatinine > 3 mg/dL) were identified. We compared recipients without AKI versus recipients with and without HD-dependent AKI. Kaplan-Meier survival curves were compared by log rank test. RESULTS: Of 352 lung transplant recipients reviewed at our institution, 17 developed non-HD-dependent AKI (5%) and 16 developed HD-dependent AKI (4.6%). Cardiopulmonary bypass was significantly higher in patients with HD-dependent AKI. None of the recipients who required HD had recovery of renal function. The 30-day mortality was significantly greater in recipients requiring HD (63% versus 0%; P < 0.0001). One-year mortality after transplantation was significantly increased in recipients with HD-dependent AKI compared with those with non-HD-dependent AKI (87.5% versus 17.6%; P < 0.001). CONCLUSIONS: Hemodialysis is associated with mortality after lung transplantation. Fortunately, AKI that does not progress to HD commonly resolves and has a better overall survival. Avoidance, if possible, of cardiopulmonary bypass may attenuate the incidence of AKI. Aggressive measures to identify and treat early postoperative renal dysfunction and prevent progression to HD may improve outcomes after lung transplantation.

Geographic distance between donor and recipient does not influence outcomes after lung transplantation.

BACKGROUND: The shortage in organ donation is a major limiting factor for patients with end-stage lung disease. Expanding the donor pool would be beneficial. We investigated the importance of geographic distance between the donor and recipient and hypothesized that it would not be a critical determinant of outcomes after lung transplantation. METHODS: We retrospectively reviewed the United Network for Organ Sharing lung transplant database from 2000 to 2005 to allow sufficient time for bronchiolitis obliterans syndrome (BOS) development. Allograft recipients were stratified by geographic distance from their donors (local, regional, and national) and had yearly follow-up. The primary end points were the development of BOS and 1-year and 3-year mortality. Posttransplant outcomes were compared using a multivariable Cox proportional hazard model. Kaplan-Meier curves were compared by log-rank test. RESULTS: Of 6,055 allograft recipients, donors were local in 59%, regional in 19.3%, and national in 21.7%. BOS-free survival did not differ by geographic distance. Geographic distance did not independently predict BOS (hazard ratio, 1.03; 95% confidence interval, 0.96 to 1.10). Similarly, Kaplan-Meier survival curves were not significantly worse for recipients with national donors. Geographic distance did not independently predict 3-year mortality (hazard ratio, 0.95; 95% confidence interval, 0.89 to 1.01). CONCLUSIONS: With appropriate donor selection, moderately long geographic distance (average ischemic time < 6 hours) between the donor and recipient is not associated with the development of BOS or increased death after lung transplantation. By placing less emphasis on distance, more donors could potentially be used to expand the donor pool.

Cardiothoracic surgery.

Cardiothoracic surgeons provide care to neonates, children, adults, and the elderly with a range of disorders of the heart, lungs, esophagus, and major blood vessels of the chest. The field of cardiothoracic surgery continues to thrive among the transformations in thoracic and cardiovascular medicine. This article is intended to provide a guide to medical students and physicians on the training, certification, research, and funding opportunities as well as societies and journals specific to cardiothoracic surgery.

Bronchiolitis obliterans syndrome occurs earlier in the post-lung allocation score era.

OBJECTIVES: In 2005, the time-based waiting list for lung transplantation was replaced by an illness/benefit lung allocation score (LAS). Although short-term outcomes after transplantation have been reported to be similar before and after the new system, little is known about long-term results. The objective of this study was to evaluate the impact of LAS on the development of bronchiolitis obliterans syndrome as well as on overall 3-year and bronchiolitis obliterans syndrome-related survival. METHODS: Data obtained from the United Network for Organ Sharing were used to review 8091 patients who underwent lung transplantation from 2002 to 2008. Patients were stratified according to time of transplantation into those treated before initiation of the LAS (pre-LAS group, January 2002-April 2005, n = 3729) and those treated after implementation of the score (post-LAS group, May 2005-May 2008, n = 4362). Overall, 3-year survivals for patient groups were compared using a univariate analysis, Cox proportional hazards model to generate a relative risk, and Kaplan-Meier curve analyses. RESULTS: During the 3-year follow-up period, bronchiolitis obliterans syndrome developed in 22% of lung transplant recipients (n = 1801). Although the incidence of postoperative bronchiolitis obliterans syndrome development was similar between groups, post-LAS patients incurred fewer bronchiolitis obliterans syndrome-free days (609 ± 7.5 vs 682 ± 9; P <.0001; log-rank test P = .0108) than did pre-LAS patients. Overall 3-year survival was lower in post-LAS patients and approached statistical significance (P = .05). Similarly, bronchiolitis obliterans syndrome-related survival was worse for patients in the post-LAS group (log-rank test P = .01). CONCLUSIONS: In the current LAS era, lung transplant recipients have significantly fewer bronchiolitis obliterans syndrome-free days after 3-year follow-up. Compared with the pre-LAS population, overall and bronchiolitis obliterans syndrome-related survival appears worse in the post-LAS era. Limitation of known risk factors for development of bronchiolitis obliterans syndrome-may prove even more important in this patient population.