Liposomal Nanocarriers Designed for Sub-Endothelial Matrix Targeting under Vascular Flow Conditions.

Vascular interventions result in the disruption of the tunica intima and the exposure of sub-endothelial matrix proteins. Nanoparticles designed to bind to these exposed matrices could provide targeted drug delivery systems aimed at inhibiting dysfunctional vascular remodeling and improving intervention outcomes. Here, we present the progress in the development of targeted liposomal nanocarriers designed for preferential collagen IV binding under simulated static vascular flow conditions. PEGylated liposomes (PLPs), previously established as effective delivery systems in vascular cells types, served as non-targeting controls. Collagen-targeting liposomes (CT-PLPs) were formed by conjugating established collagen-binding peptides to modified lipid heads via click chemistry (CTL), and inserting them at varying mol% either at the time of PLP assembly or via micellar transfer. All groups included fluorescently labeled lipid species for imaging and quantification. Liposomes were exposed to collagen IV matrices statically or via hemodynamic flow, and binding was measured via fluorometric analyses. CT-PLPs formed with 5 mol% CTL at the time of assembly demonstrated the highest binding affinity to collagen IV under static conditions, while maintaining a nanoparticle characterization profile of ~50 nm size and a homogeneity polydispersity index (PDI) of ~0.2 favorable for clinical translation. When liposomes were exposed to collagen matrices within a pressurized flow system, empirically defined CT-PLPs demonstrated significant binding at shear stresses mimetic of physiological through pathological conditions in both the venous and arterial architectures. Furthermore, when human saphenous vein explants were perfused with liposomes within a closed bioreactor system, CT-PLPs demonstrated significant ex vivo binding to diseased vascular tissue. Ongoing studies aim to further develop CT-PLPs for controlled targeting in a rodent model of vascular injury. The CT-PLP nanocarriers established here show promise as the framework for a spatially controlled delivery platform for future application in targeted vascular therapeutics.

Continuing Medical Education and Lifelong Learning.

Continuing medical education is an ongoing process to educate clinicians and provide patients with up-to-date, evidence-based care. Since its inception, the maintenance of certification (MOC) program has changed dramatically. This article reviews the development of MOC and its integration with the 6 core competencies, including the practice-based learning and improvement cycle. The concept of lifelong learning is discussed, with specific focus on different methods for surgeons to engage in learning, including simulation, coaching, and communities of practice. In addition, the future of MOC in continuous professional development is reviewed.

Advances in the Formulation and Assembly of Non-Cationic Lipid Nanoparticles for the Medical Application of Gene Therapeutics.

Lipid nanoparticles have become increasingly popular delivery platforms in the field of gene therapy, but bench-to-bedside success has been limited. Many liposomal gene vectors are comprised of synthetic cationic lipids, which are associated with lipid-induced cytotoxicity and immunogenicity. Natural, non-cationic PEGylated liposomes (PLPs) demonstrate favorable biocompatibility profiles but are not considered viable gene delivery vehicles due to inefficient nucleic acid loading and reduced cellular uptake. PLPs can be modified with cell-penetrating peptides (CPPs) to enhance the intracellular delivery of liposomal cargo but encapsulate leakage upon CPP-PLP assembly is problematic. Here, we aimed to identify parameters that overcome these performance barriers by incorporating nucleic acid condensers during CPP-PLP assembly and screening variable ethanol injection parameters for optimization. CPP-PLPs were formed with R8-amphiphiles via pre-insertion, post-insertion and post-conjugation techniques and liposomes were characterized for size, surface charge, homogeneity, siRNA encapsulation efficiency and retention and cell associative properties. Herein we demonstrate that pre-insertion of stearylated R8 into PLPs is an efficient method to produce non-cationic CPP-PLPs and we provide additional assembly parameter specifications for a modified ethanol injection technique that is optimized for siRNA encapsulation/retention and enhanced cell association. This assembly technique could provide improved clinical translation of liposomal based gene therapy applications.

Dietary supplementation with Zyflamend poly-herbal extracts and fish oil inhibits intimal hyperplasia development following vascular intervention.

The polyherbal blend Zyflamend™ has been shown to have anti-inflammatory properties and attenuate inflammatory-modulated pathologies. Fish oils have also been shown to have cardioprotective properties. However, the beneficial effects of their combination have not been investigated. Intimal hyperplasia (IH), a pathological remodeling response of a vessel to injury, is heavily regulated by an immune-mediated reaction. The objective of this study was to determine if dietary supplementation with Zyflamend and/or Wholemega could affect inflammatory-dependent vascular remodeling mechanisms when provided at human equivalent doses. Based on their anti-inflammatory properties and protective benefits demonstrated in previous pre-clinical studies, we hypothesized administration of these supplements would prevent IH in an animal model of vascular injury. The diets of aged male rats were supplemented with human equivalent doses of Zyflamend (Zyf) and/or Wholemega (WMega) or placebo (Plac) for 1wk prior to balloon angioplasty (BA)-induced injury of the left carotid artery. At 28d post-injury morphometric analysis of carotid tissue revealed IH was decreased in Zyf + WMega animals compared to placebo, while Zyf or WMega independently had no significant effect. Serum cytokine screening indicated injury-induced interleukin family isoforms, interferon-γ, and macrophage inflammatory proteins were downregulated by Zyf + WMega. Immunohistochemical staining for monocyte/macrophage phenotypic markers revealed that while overall monocyte/macrophage vessel infiltration was not affected, Zyf + WMega limited the alternative differentiation of M2 macrophages and reduced the presence of myofibroblasts in the injured vessel wall. In summary, dietary supplementation with Zyf + WMega attenuated the acute inflammatory response following vascular injury and inhibited IH development in vivo.

Pleomorphic undifferentiated aortic sarcoma presenting as persistent endoleak after endovascular aneurysm repair.

Sarcomas of the aorta are rare tumors with an unknown incidence and wide variety of clinical presentations. These malignant neoplasms are often manifested in an advanced state and with symptoms of nonmalignant vascular disease owing to a delay in diagnosis. We present the case of a 78-year-old man in whom workup was initially performed for a persistently enlarging abdominal aortic aneurysm after endovascular aortic repair but who was subsequently found to have a pleomorphic undifferentiated sarcoma of the aorta.

The Efficacy of Systemic Doxycycline Administration as an Inhibitor of Intimal Hyperplasia after Balloon Angioplasty Arterial Injury.

BACKGROUND: Intimal hyperplasia (IH) is the most common indicator for secondary intervention in peripheral vascular disease. Matrix metalloproteinases (MMPs) play a role in IH development due to their degradation of the extracellular matrix. Doxycycline (Doxy), a member of the tetracycline family of antibiotics, is a potent MMP inhibitor. We have previously shown that Doxy inhibits MMP activity and vascular smooth muscle cell migration in vitro. We hypothesized that Doxy would decrease MMP activity in vivo and inhibit the development of IH in a rodent model of vascular injury. METHODS AND RESULTS: Doxy (400 mg/pellet) was delivered by a slow-release pellet implanted 3 days prior to or at the time of balloon angioplasty (BA) of the common carotid artery in female rats. At 14 days post-BA, intima-to-media (I:M) ratios were 0.77 ± 0.21 and 1.04 ± 0.32 in the Doxy treated groups, respectively, compared to 1.25 ± 0.26 in the control group (P = not significant; n = 3). Additionally, the tested dose of Doxy in either group had no inhibitory effect on membrane type 1-MMP or MMP-2 tissue levels, as measured by immunohistochemistry, or on systemic levels of MMP, as measured by total MMP serum levels using enzyme-linked immunosorbent assay. At 14 days post-BA, VSMC proliferation in the injured artery was increased to Doxy treatment prior to and at the time of surgery (23.5 ± 3.4 and 27.2 ± 3.9%, respectively), compared to control (11.4 ± 0.4%; n = 3), as measured by proliferating cellular nuclear antigen immunostaining. CONCLUSIONS: In our in vivo model of vascular injury, systemic Doxy administration prior to or at the time of vascular injury does not significantly hinder the progression of IH development. Additional doses and routes of administration could be examined in order to correlate therapeutic serum levels of Doxy with effective MMP inhibition in serum and arterial tissue. However, alternative drug delivery systems are needed in order to optimize therapeutic administration of targeted MMP inhibitors for the prevention of IH development.

Acute Limb Ischemia.

This article details the classification of limb ischemia, outlines the numerous causes of limb ischemia, highlights the diagnosis with treatment options and describes common postoperative conditions after limb ischemia intervention. The acute limb ischemia causes in the article are divided into sections including the presentation, diagnosis, and therapy for each cause. The broad limb ischemia causes include embolism, thrombosis, venous obstruction, trauma, and upper-extremity unique pathologic condition. Postoperative management is extremely important after revascularization of an acutely ischemic extremity. Reperfusion injury, myoglobinuria, and compartment syndrome are summarized in the postoperative section.

Diabetic Foot Ulcers: The Importance of Patient Comorbidity Recognition and Total Contact Casting in Successful Wound Care.

Diabetic foot ulcers (DFUs) are a major burden on the health-care system. The purpose of this study is to investigate factors affecting the healing rate of DFU in a university wound care center. Records of DFU patients treated between July 2013 and February 2015 were reviewed. Demographics, comorbidities, wound characteristics, and treatment modalities including offloading, hyperbaric oxygen treatment, total contact casting, and bioengineered skin were investigated. All patients underwent weekly debridement regardless of treatment modality. A total of 114 patients ages 18 to 98 comprised the study population. Total contact casting was the only treatment associated with increased healing (P = 0.02). Smoking (P = 0.004) and deep vein thrombosis history (P = 0.001) significantly decreased the likelihood of wound healing. Patients with past vascular event trended toward longer healing times (P = 0.07). Total contact casting in combination with weekly wound debridement showed benefit in DFU wound healing, whereas patients with a history of deep vein thrombosis and smoking were less likely to heal.

Three-dimensional fusion computed tomography decreases radiation exposure, procedure time, and contrast use during fenestrated endovascular aortic repair.

OBJECTIVE: Endovascular surgery has revolutionized the treatment of aortic aneurysms; however, these improvements have come at the cost of increased radiation and contrast exposure, particularly for more complex procedures. Three-dimensional (3D) fusion computed tomography (CT) imaging is a new technology that may facilitate these repairs. The purpose of this analysis was to determine the effect of using intraoperative 3D fusion CT on the performance of fenestrated endovascular aortic repair (FEVAR). METHODS: Our institutional database was reviewed to identify patients undergoing branched or FEVAR. Patients treated using 3D fusion CT were compared with patients treated in the immediate 12-month period before implementation of this technology when procedures were performed in a standard hybrid operating room without CT fusion capabilities. Primary end points included patient radiation exposure (cumulated air kerma: mGy), fluoroscopy time (minutes), contrast usage (mL), and procedure time (minutes). Patients were grouped by the number of aortic graft fenestrations revascularized with a stent graft, and operative outcomes were compared. RESULTS: A total of 72 patients (41 before vs 31 after 3D fusion CT implementation) underwent FEVAR from September 2012 through March 2014. For two-vessel fenestrated endografts, there was a significant decrease in radiation exposure (3400 ± 1900 vs 1380 ± 520 mGy; P = .001), fluoroscopy time (63 ± 29 vs 41 ± 11 minutes; P = .02), and contrast usage (69 ± 16 vs 26 ± 8 mL; P = .0002) with intraoperative 3D fusion CT. Similarly, for combined three-vessel and four-vessel FEVAR, significantly decreased radiation exposure (5400 ± 2225 vs 2700 ± 1400 mGy; P < .0001), fluoroscopy time (89 ± 36 vs 64 ± 21 minutes; P = .02), contrast usage (90 ± 25 vs 39 ± 17 mL; P < .0001), and procedure time (330 ± 100 vs 230 ± 50 minutes; P = .002) was noted. Estimated blood loss was significantly less (P < .0001), and length of stay had a trend (P = .07) toward being lower for all patients in the 3D fusion CT group. CONCLUSIONS: These results demonstrate that use of intraoperative 3D fusion CT imaging during FEVAR can significantly decrease radiation exposure, procedure time, and contrast usage, which may also decrease the overall physiologic impact of the repair.

Elective endovascular aortic repair conversion for type Ia endoleak is not associated with increased morbidity or mortality compared with primary juxtarenal aneurysm repair.

OBJECTIVE: Type Ia endoleak after endovascular aortic repair (EVAR) can be a challenging complication to manage, and due to concerns regarding morbidity and mortality of open surgical conversion (OSC), reports of complex endoluminal salvage techniques are increasing. Despite development of these endovascular remedial strategies, many patients ultimately require OSC. The purpose of this analysis was to outcomes of elective OSC for type Ia endoleak and compare them with elective primary open juxtarenal aneurysm repair (OJAR) to determine if these concerns are warranted. METHODS: From 2000 to 2012, 54 patients underwent EVAR OSC at median time of 27 months (interquartile range, 9-55 months). Indications included endograft thrombosis in 2 (4%), intraoperative EVAR failure in 3 (6%), rupture in 5 (9%), graft infection in 6 (11%), and type Ia endoleak in 25 (all: 38 [70%]). Because many OSCs are performed for emergency indications without endovascular options, we chose elective type Ia endoleak patients as our study group. These 25 patients were compared with an elective OJAR cohort matched by anatomy and comorbidities. Primary end points were 30-day and 1-year mortality. Secondary end points included early complications, cross-clamp time, procedure time, blood loss, and length of stay. RESULTS: Demographic and comorbidity data in the OSC and OJAR groups did not differ, with the exception that OJAR patients presented with smaller aneurysm diameter and a higher rate of chronic obstructive pulmonary disease (P = .03). OSC patients more frequently underwent a nontube graft repair (OSC, n = 20 [80%] vs OJAR, n = 6 [24%]; P = .0002), required longer procedure times (P = .03), and received more plasma transfusions (P = .03). The 30-day mortality was 4% in both groups (observed difference in rates, 0%; 95% confidence interval for difference in mortality rates, -14.0% to 14.0%; P = 1). A similar rate of major complications occurred (OSC, n = 9 [36%] vs OJAR, n = 8 [32%]; P = 1). One-year survival was 83% in OSC and 91% in OJAR (observed difference, 7%; 95% confidence interval, -15% to 29%; P = .65). CONCLUSIONS: Despite many advances in EVAR technology, the need for OSC persists and will likely become more common as older-generation devices fail or providers attempt EVAR in more anatomically complex patients. Elective OSC for type Ia endoleak can be technically challenging but is not associated with increased morbidity or mortality compared with OJAR in appropriately selected patients. These results should be considered before pursuing complex endovascular remediation of EVAR failures.

A contemporary rural trauma center experience in blunt traumatic aortic injury.

INTRODUCTION: Traumatic aortic injury (TAI) is a rare yet highly lethal injury associated with blunt force deceleration injury. The adoption of thoracic endovascular aortic repair (TEVAR) has become a safer option than traditional open repair. The purpose of this study is to review a rural trauma center experience with TAI. METHODS: A retrospective analysis was performed, reviewing all patients who presented with TAI between 2000 and 2009. Clinical, anatomical, and procedural variables of all cases were systematically reviewed. Clinical endpoints included mortality, and aortic-related mortality, and hospital length of stay. The study population was stratified by those that underwent surgical repair (SR) and those managed medically (MM). RESULTS: Fifty-six patients presented with blunt TAI; 35 patients (62.5%) were surgically repaired (22 open, 13 TEVAR), while 21 (37.5%) were MM. The only difference in comorbidities was a higher rate of coronary artery disease in MM. Mean hospital arrival time (SR, 188.6 ± 30.3 minutes, MM, 253 ± 65.3 minutes), aortic injury grade (SR, 2.7 ± 0.1; MM, 2.3 ± 0.2), and injury severity score were not significantly different between the groups. Head Abbreviated Injury Score (AIS) was worse in the MM group, while chest AIS was worse in the SR group (P < .05). There were nine (42.9%) deaths in the MM group, while there were only two (5.7%) in the SR group (P < .001). There was no significant difference in aortic-related mortality. Mean follow-up time was not statistically different. CONCLUSION: These data provide a group of stable patients to examine the management of TAI in the endovascular era. The low aortic-related mortality in the MM group demonstrates that there is time for a thorough evaluation in patients sustaining TAI who arrive without hemodynamic instability.

Preoperative statin therapy is associated with improved outcomes and resource utilization in patients undergoing aortic aneurysm repair.

INTRODUCTION: This study hypothesized that preoperative statin therapy would have a protective effect on patients undergoing elective abdominal aortic aneurysm (AAA) repair and that the risk-reduction effect of these agents would result in a reduction in subsequent total hospital costs. METHODS: All patients who underwent an elective endovascular AAA repair (EVAR) or open AAA repair (OAR) between 2004 and 2007 were retrospectively reviewed. Clinical end points included postoperative days, length of hospital stay, postoperative complications (myocardial infarction, stroke, renal failure, hemorrhage, pneumonia, urinary tract infection, wound infection), and 30-day mortality. The financial end point was total hospital cost associated with the procedure. RESULTS: We identified 401 patients, consisting of 173 EVAR patients (43%) and 228 OAR (57%). Despite a higher Society for Vascular Surgery risk score, the EVAR statin cohort had significantly reduced postoperative days (1.9 +/- 0.2 vs 2.3 +/- 0.3, P < .05) and hospital length of stay (2.3 +/- 0.3 vs 2.8 +/- 0.4, P < .05) compared with the nonstatin EVAR cohort. Postoperative complications (4.4% vs 14.7%, P < .05) and the mortality rate (0.0% vs 5.9%, P < .05) were significantly decreased in the OAR statin cohort compared with the nonstatin OAR cohort and trended to be decreased in the EVAR statin group. Statin therapy translated into a lower total cost per patient of $3,205 for EVAR and $3,792 for OAR (P < .05). CONCLUSION: With respect to both clinical outcome measures and subsequent resource utilization, statin therapy is associated with a beneficial effect in patients undergoing elective AAA repair. These data suggest that preoperative statin therapy should be an integral part of the risk optimization for patients undergoing AAA repair.

The association of periprocedural hypertension and adverse outcomes in patients undergoing catheter-directed thrombolysis.

BACKGROUND: Peripheral thrombolysis is an indispensible tool in the treatment of occlusive peripheral vascular disease (PVD). However, the use of intravascular thrombolytic agents carries a significant risk of morbidity and mortality. The aim of this study is to review a contemporary series of patients treated with catheter-directed thrombolytics in the treatment of occlusive PVD. METHODS: A retrospective analysis was performed reviewing all patients who underwent catheter-directed thrombolytic therapy for PVD with recombinant tissue plasminogen activator (rt-PA) between 2005 and 2008. Data included clinical and demographic variables potentially associated with endpoints of technical success, hemorrhagic complications, and death. Data were analyzed with univariate and multivariate measures. Significance was assigned with p <0.05. RESULTS: Over the 36-month study, 125 thrombolytic procedures were performed. Indication for treatment was occlusive thrombus in native artery (49 cases, 37.6%), vein (13 cases, 10.4%), or arterial bypass graft (63 cases, 49.6%). Twenty three cases (14.3%) used ultrasound-assisted catheter technology. Mean patient age was 57.9 +/- 1.1 years. Technical success was achieved in 82% of cases. Mean rt-PA dose was 47.3 +/- 1.4 mg (13.5 +/- 4.5 mg with ultrasound assisted catheter technology). Hemorrhagic complications occurred in 22.4% of patients with a 5.6% stroke rate. Intracranial hemorrhage (ICH) correlated with poor hypertensive control (systolic blood pressure >160 mmHg; OR, 13.67; CI, 1.59-117.68; p = 0.006) and advanced age (>80 years; OR, 9.04; CI, 1.40-58.57, p = 0.049). Hemorrhagic complications (including minor access site hematomas) correlated with poor hypertensive control (systolic blood pressure >180 mmHg; OR, 3.48; CI, 1.22-9.94; p = 0.021) and in patients with congestive heart failure (OR, 3.26; CI, 1.09-9.76; p = 0.036). Overall mortality occurred in 7 patients (5.6%), 4 as a result of hemorrhagic complications. Correlates of mortality were patients with diabetes mellitus (OR, 8.85; CI, 1.62-48.26; p = 0.003), end stage renal disease (OR, 15.33; CI, 2.07-113.39; p < .001) and congestive heart failure (OR, 6.06; CI, 1.22-30.13; p = .014). Serum fibrinogen levels, pre-procedural hypertension, and rt-PA dosage did not correlate with hemorrhagic complication or death. CONCLUSION: Peripheral thrombolysis with catheter-based technologies has a high incidence of technical success. However, the procedure continues to carry a significant complication rate. This study emphasizes the importance of periprocedural hypertensive control and identifies subgroups of patients at risk of untoward complications. On the basis of these data, the authors advocate stricter blood pressure parameters in patients undergoing peripheral thrombolysis.

Correlation of cerebral oximetry with internal carotid artery stump pressures in carotid endarterectomy.

OBJECTIVE: This study compares internal carotid artery (ICA) mean stump pressures (SPs) with cerebral oximetry monitoring during carotid endarterectomy (CEA). METHODS: A total of 104 consecutive patients undergoing CEA under general anesthesia (GA) during a 10-month period were prospectively evaluated. Baseline and postcarotid clamp regional cerebral oxygen saturation (rSO(2)) and mean ICA SPs were measured. Demographic, surgical, and medical variables were recorded for each case. RESULTS: There were no postoperative strokes. Thirteen patients were excluded because of incomplete data. Of the 40 patients who had <10% drop in rSO(2), 6 had SP <40 mm Hg. Regional cerebral oxygen saturation with a 15% saturation drop threshold was 76.3% sensitive and 81.1% specific in detecting patients with SP <40 mm Hg. With a threshold of 20% drop, sensitivity and specificity were 57.9% and 86.8%, respectively. CONCLUSIONS: Relative drop in rSO( 2) is neither sensitive nor specific in detecting patients with mean SP <40 mm Hg. These data do not support the use of cerebral oximetry as the sole monitoring modality during carotid endarterectomy under GA.

A comparison of two methods of hemostasis in thyroidectomy.

Safe thyroid surgery requires meticulous hemostasis. The objective of the current study is to compare the effectiveness and safety of ultrasonic dissection (UD) and electronic vessel sealing (EVS) in patients undergoing thyroidectomy. A retrospective analysis of a prospectively maintained database was performed. Between January 1, 2007 and January 25, 2008, hemostasis was achieved using EVS (LigaSure Precise, Valleylab, Boulder, CO). Since January 25, 2008, hemostasis has been achieved using UD (Harmonic Focus, Ethicon Endo-Surgery, Cincinnati, OH). Operative time, estimated blood loss, gland weight, and postoperative complications were compared. Differences were analyzed using unpaired t test and Chi square with significance assigned P < 0.05. Seventy-four patients underwent total thyroidectomy (EVS n = 59, UD n = 15). Operative time (EVS 115.0 +/- 38.3 min, UD 88.0 +/- 14.0 min, P = 0.012) was significantly decreased in the UD group compared with the EVS group. There were no significant differences in mean age (EVS 50.4 +/- 13.9 years, UD 49.1 +/- 15.6 years), gender distribution (EVS 78% female, UD 87% female), estimated blood loss (EVS 49.4 +/- 44.7 mL, UD 47.0 +/- 70.4 mL), and gland weight (EVS 67.4 +/- 66.4 gm, UD 41.3 +/- 26.6 gm). Analysis of complications, including hematoma, hypocalcemia, and recurrent laryngeal nerve palsy showed no significant difference. Based on the current analysis, ultrasonic dissection is a safe method of hemostasis for thyroid surgery. Its use decreases operative time when compared with electronic vessel sealing.

What do surgical nurses know about surgical residents?

OBJECTIVE: A fundamental premise of establishing collaborative relationships between residents and nurses is a basic understanding of the attributes of each group. The intent of this study was to determine what surgical nurses know about surgical residents. DESIGN: A piloted survey tool was administered to a cross-section of nurses working in 3 surgical intensive care units, a surgical intermediate unit, and 2 general surgical floors. Surgical residents completed the same survey tool. The percentage of residents giving the most frequent response was compared with the percentage of nurses giving the same response. SETTING: A university, teaching hospital. PARTICIPANTS: One hundred twenty-four of 129 surgical nurses and 24 of 25 surgical residents who completed the survey tool. RESULTS: The response rate for nurses on the 2 survey days was 94%, or 54% of all surgical nurses employed by the hospital, and 96% for residents. The nurses surveyed were equally distributed between the units. Ninety-nine percent of nurses did not have a surgical resident as a significant other, 55% of nurses had greater than 5 years experience, and 95% were licensed registered nurses. Seventy-eight percent of nurses correctly indicated that a medical doctorate is the highest degree required to start residency (p = 0.01), but only 57% accurately identified the length of surgical residency (p = 0.02). Nurses perceived residents devoted less time to patient care (p < 0.01) and more time to studying (p < 0.01). Forty percent of nurses do not think interns are legally physicians (p < 0.01) or hold a medical license (p < 0.01). Forty percent of nurses are aware of the 80-hour work week restriction (p < 0.01). Eighteen percent of nurses have the perception that residents are not allowed to perform bedside procedures without an attending physician present (p = 0.03), while 56% have the perception that residents are not allowed to perform any part of an operation without an attending physician (p < 0.01). There is a misperception among 32% of nurses that residents pay tuition for residency (p < 0.01), while only 52% accurately identified the range of a resident's salary (p = 0.01) and 11% the amount of resident debt (p < 0.01). CONCLUSIONS: Despite the importance of the collaborative relationship in surgical patient care, surgical nurses have a limited understanding of surgical residents. Educating nurses about the education, roles, and responsibilities of surgical residents might improve collaborative relationships and ultimately patient care.

A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients.

BACKGROUND: We initiated a multidisciplinary clinical pathway targeting patients greater than 45 years of age with more than 4 rib fractures. The purpose of the current study was to evaluate the effect of this pathway on infectious morbidity and mortality. METHODS: This was a prospective cohort study. Data evaluated included patient demographics, injury characteristics, pain management details, lengths of stay, morbidity, and mortality. Univariate and multivariate analyses were performed using a significance level of P < .05. RESULTS: When adjusting for age, injury severity score, and number of rib fractures, the clinical pathway was associated with decreased intensive care unit length of stay by 2.4 days (95% confidence interval [CI] -4.3, -0.52 days, P = .01) hospital length of stay by 3.7 days (95% CI -7.1, -0.42 days, P = .02), pneumonias (odds ratio [OR] 0.12, 95% CI 0.04 to 0.34, P < .001), and mortality (OR 0.37, 95% CI 0.13 to 1.03, P = .06). CONCLUSIONS: Implementation of a rib fracture multidisciplinary clinical pathway decreased mechanical ventilator-dependent days, lengths of stay, infectious morbidity, and mortality.