Epicardial ultrasound in a case of myocardial bridge and apical hypertrophic cardiomyopathy.

A 59-year-old male with a history of unstable angina was diagnosed with a myocardial bridge of the left anterior descending artery (LAD) and apical variant hypertrophic cardiomyopathy (AHCM). He underwent unroofing of the myocardial bridge and a left ventricular apical myectomy. Intraoperatively, epicardial ultrasound was used to identify the myocardial bridge with systolic compression of the LAD and confirm resolution of this compression postoperatively. Furthermore, epicardial ultrasound was used for guiding the degree of apical resection of the decompressed heart. This novel use of intraoperative epicardial ultrasound can help guide surgeons preoperatively and confirm results immediately after an operation.

Effect of hypothermia on splenic leukocyte modulation and survival duration in severely septic rats.

BACKGROUND: Therapeutic hypothermia (HT) in severe septic shock is associated with prolonged survival. We hypothesized that moderate HT would prolong survival and modulate the inflammatory response in rats with septic shock by exerting its therapeutic effect on splenic leukocytes. MATERIALS AND METHODS: Severe septic shock was created in rats by cecal ligation and incision (CLI). One hour after CLI or laparotomy, rats were randomized to sham, normothermia (NT), or 4 h of HT followed by 2 h of rewarming. HT (31 ± 1°C) was induced using a cooling blanket and monitored via a rectal temperature probe. RESULTS: Survival duration was 2.78 ± 1.0 h in NT rats and 8.33 ± 0.32 h in HT rats (n = 8/group, P < 0.0001). In separate groups, 3 h after CLI, the spleen weight was significantly smaller in NT rats (769 ± 100 mg) than in HT rats (947 ± 157 mg, P = 0.04). Fluorescent immunostaining of formyl peptide receptors on leukocytes in spleen tissue showed considerably higher formyl peptide receptor expression in HT rats than in NT rats. Significantly elevated proinflammatory cytokines and myeloperoxidase enzyme in plasma were found in NT rats compared with HT rats. Anti-inflammatory cytokine, interleukin-10, was significantly higher in HT rats. Both proinflammatory cytokines and plasma myeloperoxidase were significantly reduced in splenectomized NT rats. CONCLUSIONS: Moderate hypothermic therapy significantly prolongs the survival duration of rats with severe septic shock. HT dampens the inflammatory response during septic shock by modulating the spleen to an anti-inflammatory mode and preventing the spleen from releasing activated splenic leukocytes into the blood.

Seasonal Incidence of Emergent Coronary Artery Bypass Grafting Surgery.

BACKGROUND: Emergent coronary artery bypass grafting (CABG) surgery is often required in the case of severe coronary artery disease, which is refractory to traditional management. The objective of our study was to test the hypothesis that there is seasonal variation in the incidence of emergent CABG. METHODS: A sinusoidal logistic regression model was used to analyze operative data at our cardiovascular institute of 270 cases spanning 5939 calendar days. RESULTS: A cyclic peak risk for emergent CABG was observed for late winter (calendar day 66; P = .036). The odds ratios for the 1-, 2- and 3-month window surrounding this peak were 1.8 (95% CI = 0.94-3.5, P = .072), 1.6 (95% CI = 1.06-2.5, P = .024) and 1.4 (95% CI = 0.9-1.8, P = .066), respectively. CONCLUSION: Our results suggest that a seasonal variation may exist in the incidence of patients presenting with severe coronary artery disease requiring emergent CABG. This information is useful in the scheduling of hospital resources and staff. It also provides important etiology clues underlying coronary artery disease that may lead to future interventions or targeted therapies.

Twenty-first century weight loss: banding versus bypass.

BACKGROUND: The two most commonly performed procedures for bariatric surgery include Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB). While many studies have commented on short-term, postoperative outcomes of these procedures, few have reported long-term data. The purpose of this study was to compare long-term, postoperative outcomes between RYGB and AGB. METHODS: This was a retrospective, cohort comparing all patients undergoing RYGB or AGB at our institution, from 01/1998 to 08/2012. Patients were followed at 1-, 3-, and 5-year intervals. Adjusted, Cox proportional hazard regression and mixed effects repeated measures modeling were performed to generate cure ratios (CR) and 95 % confidence intervals (CI). RESULTS: Two thousand four hundred twenty bariatric surgery patients (380 AGB, 2,040 RYGB) were identified by CPT code. Median (range) follow-up for patients was 3 (1-5) years. Preoperatively, RYGB patients were significantly younger, more obese, had higher hemoglobin A1c, and less often suffered from hypertension (HTN), dyslipidemia, and asthma as compared to AGB patients. Postoperatively, RYGB patients experienced significantly longer operating room times, higher incidences of intensive care unit admissions, longer hospital lengths of stay, and increased incidence of small bowel obstruction compared to AGB patients. After adjusting for statistically significant and clinically relevant factors [e.g., age, gender, body mass index, degenerative joint disease (DJD), diabetes, HTN, dyslipidemia, heart disease, apnea, and asthma], RYGB was independently associated with a significantly greater percentage of total body weight loss (p = 0.0065) and greater CR (95 % CI) regarding gastroesophageal reflux disease [2.1(1.4-3.0)], DJD [3.4(2.0-5.6)], diabetes [3.4(2.2-5.4)], apnea [3.1(1.9-5.3)], HTN [5.5(3.4-8.8)], and dyslipidemia [6.3(3.5-11)] compared to AGB. CONCLUSION: Our results support previous studies that have observed a greater weight loss associated with RYGB as compared to AGB and provide further evidence toward the long-term sustainability of this weight loss. Additionally, RYGB appears to result in a greater reduction of medical comorbidity.

Sex- and diagnosis-dependent differences in mortality and admission cytokine levels among patients admitted for intensive care.

OBJECTIVES: To investigate the role of sex on cytokine expression and mortality in critically ill patients. DESIGN: A cohort of patients admitted to were enrolled and followed over a 5-year period. SETTING: Two university-affiliated hospital surgical and trauma ICUs. PATIENTS: Patients 18 years old and older admitted for at least 48 hours to the surgical or trauma ICU. INTERVENTIONS: Observation only. MEASUREMENTS AND MAIN RESULTS: Major outcomes included admission cytokine levels, prevalence of ICU-acquired infection, and mortality during hospitalization conditioned on trauma status and sex. The final cohort included 2,291 patients (1,407 trauma and 884 nontrauma). The prevalence of ICU-acquired infection was similar for men (46.5%) and women (44.5%). All-cause in-hospital mortality was 12.7% for trauma male patient and 9.1% for trauma female patient (p = 0.065) and 22.9% for nontrauma male patients and 20.6% for nontrauma female patients (p = 0.40). Among trauma patients, logistic regression analysis identified female sex as protective for all-cause mortality (odds ratio, 0.57). Among trauma patients, men had significantly higher admission serum levels of interleukin-2, interleukin-12, interferon-γ, and tumor necrosis factor-α, and among nontrauma patients, men had higher admission levels of interleukin-8 and tumor necrosis factor-α. CONCLUSIONS: The relationship between sex and outcomes in critically ill patients is complex and depends on underlying illness. Women appear to be better adapted to survive traumatic events, while sex may be less important in other forms of critical illness. The mechanisms accounting for this gender dimorphism may, in part, involve differential cytokine responses to injury, with men expressing a more robust proinflammatory profile.

Long-term diabetic response to gastric bypass.

BACKGROUND: As obesity and type II diabetes continue to rise, bariatric surgery offers a solution, but few long-term studies are available. The purpose of this study was to evaluate the long-term outcomes of diabetic patients after gastric bypass. MATERIALS AND METHODS: This was a retrospective cohort study of all diabetic patients undergoing gastric bypass at our institution, from 1998 to 2012. Patients were compared by postoperative diabetic response to treatment (i.e., response = off oral medication/insulin versus refractory = on oral medication/insulin) and followed at 1-, 3-, 5-, and 10-y intervals. Continuous data were analyzed using Student t-test or Wilcoxon rank-sum test. Multivariable, Cox proportional hazard regression model was performed to compute diabetic cure ratios and 95% confidence intervals. RESULTS: A total of 2454 bariatric surgeries were performed at our institution during the time period. A total of 707 diabetic patients were selected by Current Procedural Terminology codes for gastric bypass. Mean follow-up was 2.1 y. Incidence of diabetic response was 56% (1 y), 58% (3 y), 60% (5 y), and 44% (10 y). Postoperatively, responsive patients experienced greater percentage of total body weight loss (1 y [P < 0.0001], 3 y [P = 0.0087], and 5 y [P = 0.013]), and less hemoglobin A1c levels (1 y [P = 0.035] and 3 y [P = 0.040]) at follow-up than refractory patients. Multivariable analysis revealed a significant, independent inverse trend in incidence of diabetic cure as both age and body mass index decreased (Ptrend = 0.0019 and <0.0001, respectively). In addition, degenerative joint disease was independently associated with responsive diabetes (cure ratio = 1.6 [95% confidence interval = 1.1-2.2]). CONCLUSIONS: At follow-up, both groups in our study experienced substantial weight loss; however, a greater loss was observed among the response group. Further research is needed to evaluate methods for optimizing patient care preoperatively and improving patient follow-up.

Race and survival among diabetic patients after coronary artery bypass grafting.

BACKGROUND: Diabetes is a known predictor of decreased long-term survival after coronary artery bypass grafting (CABG). Differences in survival by race have not been examined. METHODS: A retrospective cohort study was conducted for CABG patients between 1992 and 2011. Long-term survival was compared in patients with and without diabetes and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. RESULTS: Out of the 13,053 patients undergoing CABG, 35% (black n = 1,655; white n = 2,884) had diabetes at the time of surgery. The median follow-up for study participants was 8.2 years. Long-term survival after CABG was similar between black and white diabetic patients (no diabetes, HR = 1.0; white diabetic patients, adjusted HR = 1.5, 95%CI = 1.4-1.6; black diabetic patients, adjusted HR = 1.5, 95%CI = 1.4-1.7). CONCLUSION: A survival disadvantage after CABG was not observed among black versus white diabetic patients in our study.

The effect of preoperative ß-blocker use and race on long-term survival after coronary artery bypass grafting.

OBJECTIVE: To date, racial differences in the long-term survival of coronary artery bypass grafting (CABG) patients who receive preoperative ß-blockers have not been specifically examined. The purpose of this study was to examine the effect of preoperative ß-blockers on long-term survival among black CABG patients and to compare the magnitude of this effect with white patients. DESIGN: A retrospective cohort study. SETTING: A tertiary referral heart hospital. PARTICIPANTS: 13,354 patients undergoing CABG between 1992 and 2011. MEASUREMENTS AND MAIN RESULTS: Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. A total of 1,448 (62%) black and 6,094 (55%) white patients had a history of preoperative ß-blocker use. Among black patients, those receiving ß-blockers survived longer than those not receiving ß-blockers (adjusted HR = 0.77, 95% CI = 0.67-0.88). The survival advantage was comparable to that observed among white patients (adjusted HR = 0.88, 95% CI = 0.82-0.93). CONCLUSION: Black CABG patients benefited from preoperative ß-blockers and the magnitude of the effect was comparable to that among white patients.

Operative status and survival after coronary artery bypass grafting.

BACKGROUND: The effect of race on long-term survival of patients undergoing elective and nonelective coronary artery bypass grafting (CABG) is currently unknown. The purpose of this study was to compare long-term survival between black and white CABG patients by operative status. METHODS: Long-term survival of black versus white patients undergoing elective and nonelective CABG procedures between 1992 and 2011 was compared. Survival probabilities were computed using the Kaplan-Meier product-limit method and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. RESULTS: A total of 13,774 patients were included in this study. The median follow-up time for study participants was 8.2 years. Black patients undergoing elective CABG died sooner than whites (adjusted HR = 1.4, 95% CI = 1.2-1.5). Survival was similar between blacks and whites in the nonelective population (adjusted HR = 1.0, 95% CI = 0.96-1.1). CONCLUSIONS: Black race was a statistically significant predictor of long-term survival after elective but not nonelective CABG.

Cleaved TMEM106B forms amyloid aggregates in central and peripheral nervous systems.

Filaments made of residues 120-254 of transmembrane protein 106B (TMEM106B) form in an age-dependent manner and can be extracted from the brains of neurologically normal individuals and those of subjects with a variety of neurodegenerative diseases. TMEM106B filament formation requires cleavage at residue 120 of the 274 amino acid protein; at present, it is not known if residues 255-274 form the fuzzy coat of TMEM106B filaments. Here we show that a second cleavage appears likely, based on staining with an antibody raised against residues 263-274 of TMEM106B. We also show that besides the brain TMEM106B inclusions form in dorsal root ganglia and spinal cord, where they were mostly found in non-neuronal cells. We confirm that in the brain, inclusions were most abundant in astrocytes. No inclusions were detected in heart, liver, spleen or hilar lymph nodes. Based on their staining with luminescent conjugated oligothiophenes, we confirm that TMEM106B inclusions are amyloids. By in situ immunoelectron microscopy, TMEM106B assemblies were often found in structures resembling endosomes and lysosomes.

Impact of race and postoperative atrial fibrillation on long-term survival after coronary artery bypass grafting.

BACKGROUND AND AIM: Postoperative atrial fibrillation (POAF) is a known predictor of in-hospital morbidity and short-term survival after coronary artery bypass grafting (CABG). The impact of race and long-term survival has not been examined in this population. We aimed to examine the influence of these factors on long-term survival in patients undergoing CABG. METHODS: Patients undergoing first-time, isolated CABG between 1992 and 2011 were included in this study. Long-term survival was compared in patients with and without POAF and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. RESULTS: A total of 2,907 (22%) patients developed POAF (black n=370; white n=2,537) following CABG (N=13,165). Median follow-up for study participants was 8.2 years. Long-term survival after CABG differed by POAF status and race (no POAF: HR=1.0; white POAF: adjusted HR=1.1, 95% CI=1.06-1.2; black POAF: adjusted HR=1.4, 95% CI=1.2-1.6; pTrend=0.0002). lack POAF patients also died sooner after surgery than their white counterparts (adjusted HR=1.2, 95% CI=1.02-1.4). CONCLUSION: Black race was a statistically significant predictor of decreased survival among POAF patients after CABG. This finding provides useful outcome information for surgeons and their patients.

The relation of race and type of health insurance to long-term risk of mortality among lung cancer patients in rural Eastern North Carolina.

BACKGROUND: Black patients with lung cancer have a higher mortality rate than do their white counterparts. Differences in insurance coverage, demographic characteristics, and treatment profiles may explain this disparity. The purpose of this study was to compare the longterm risk of mortality of black lung cancer patients with that of white lung cancer patients, by insurance type. METHODS: Patients who were diagnosed with lung cancer in Eastern North Carolina and treated at the Leo Jenkins Cancer Center between 2001 and 2010 were included in this study. A Cox regression model was used to compare the risk of mortality of black patients with that of white patients. RESULTS: A total of 2,351 lung cancer patients (717 black and 1,634 white) were treated at the Leo Jenkins Cancer Center during the study period. Independent of age and sex, black patients with lung cancer were observed to die sooner than their white counterparts (hazard ratio = 1.2; 95% confidence interval, 1.04-1.3; P = .0070). However, this difference was not statistically significant after controlling for and stratifying by insurance type. LIMITATIONS: Residual confounding and the misclassification of some variables could have biased estimated study effects. CONCLUSION: The racial disparity in lung cancer mortality observed in Eastern North Carolina is no longer apparent after health insurance type is accounted for.

Increase in Tau Pathology in P290S Mapt Knock-In Mice Crossed with App NL-G-F Mice.

Alzheimer's Disease (AD) is characterized by the pathologic assembly of amyloid ß (Aß) peptide, which deposits into extracellular plaques, and tau, which accumulates in intraneuronal inclusions. To investigate the link between Aß and tau pathologies, experimental models featuring both pathologies are needed. We developed a mouse model featuring both tau and Aß pathologies by knocking the P290S mutation into murine Mapt and crossing these Mapt P290S knock-in (KI) mice with the App NL-G-F KI line. Mapt P290S KI mice developed a small number of tau inclusions, which increased with age. The amount of tau pathology was significantly larger in App NL-G-F xMapt P290S KI mice from 18 months of age onward. Tau pathology was higher in limbic areas, including hippocampus, amygdala, and piriform/entorhinal cortex. We also observed AT100-positive and Gallyas-Braak-silver-positive dystrophic neurites containing assembled filamentous tau, as visualized by in situ electron microscopy. Using a cell-based tau seeding assay, we showed that Sarkosyl-insoluble brain extracts from both 18-month-old Mapt P290S KI and App NL-G-F xMapt P290S KI mice were seed competent, with brain extracts from double-KI mice seeding significantly more than those from the Mapt P290S KI mice. Finally, we showed that App NL-G-F xMapt P290S KI mice had neurodegeneration in the piriform cortex from 18 months of age. We suggest that App NL-G-F xMapt P290S KI mice provide a good model for studying the interactions of aggregation-prone tau, Aß, neuritic plaques, neurodegeneration, and aging.

Increased risk of atrial fibrillation among patients undergoing coronary artery bypass graft surgery while receiving nitrates and antiplatelet agents.

Background Postoperative atrial fibrillation (POAF) is a frequent complication of coronary artery bypass graft (CABG) surgery. This arrhythmia occurs more frequently among patients who receive perioperative inotropic therapy (PINOT). Administration of nitrates with antiplatelet agents reduces the conversion rate of cyclic guanosine monophosphate to guanosine monophosphate. This process is associated with increased concentrations of free radicals, catecholamines, and blood plasma volume. We hypothesized that patients undergoing CABG surgery who receive PINOT may be more susceptible to POAF when nitrates are administered with antiplatelet agents. Methods Clinical records were examined from a prospectively maintained cohort of 4,124 patients undergoing primary isolated CABG surgery to identify POAF-associated factors. Results POAF risk was increased among patients receiving PINOT, and the greatest effect was observed when nitrates were administered with antiplatelet therapy. Adjustment for comorbidities did not substantively change the study results. Conclusions Administration of nitrates with certain antiplatelet agents was associated with an increased POAF risk among patients undergoing CABG surgery. Additional studies are needed to determine whether preventive strategies such as administration of antioxidants will reduce this risk.

Perioperative Inotrope Therapy and Atrial Fibrillation Following Coronary Artery Bypass Graft Surgery: Evidence of a Racial Disparity.

BACKGROUND AND OBJECTIVE: Following coronary artery bypass graft (CABG) surgery, mortality rates are significantly higher among black patients who experience postoperative atrial fibrillation (POAF). Perioperative inotropic therapy (PINOT) was associated with POAF in previous reports, but the extent to which race influences this association is unknown. In the present study, the relationship between PINOT, race, and POAF was examined in patients undergoing CABG surgery. METHODS AND SETTING: Clinical records were examined from a prospectively maintained cohort of 11,855 patients (median age 64 yrs; 70% male; 16% black) undergoing primary isolated CABG at a large cardiovascular institute in the southeastern region of the United States. Relative risk (RR) and 95% confidence intervals (CIs) were computed using log-binomial regression. MAIN RESULTS: The association between PINOT and POAF was significantly increased among black patients (adjusted RR 1.7, CI 1.4-2.0) compared with white patients (adjusted RR 1.3, CI 1.2-1.4) (pinteraction  = 0.013). CONCLUSIONS: These findings suggest that PINOT may be disproportionately associated with POAF among black patients undergoing CABG surgery. Additional studies are needed to examine further the potential underlying mechanisms of this association.

Top Guns: The "Maverick" and "Goose" of Empiric Therapy.

BACKGROUND: Vancomycin and piperacillin-tazobactam are commonly used first guns in the empiric management of critically ill patients. Current studies suggest an increased prevalence of acute kidney injury with concomitant use, however, these studies are few and limited by small sample size. The purpose of this study was to compare the prevalence of nephrotoxicity after treatment with vancomycin alone and concomitant vancomycin and piperacillin-tazobactam treatment at our institution. HYPOTHESIS: Concomitant vancomycin and piperacillin-tazobactam-treated patients will experience greater prevalence of nephrotoxicity compared with vancomycin-only treated patients. METHODS: This was a retrospective cohort of patients treated with vancomycin for gram-positive or mixed infections in our facility from 2005 to 2009 who were not receiving hemodialysis at the time of admission. Included patients were stratified by treatment with vancomycin, vancomycin/piperacillin-tazobactam, or vancomycin/an alternative gram-negative rod (GNR) antibiotic. p values for categorical variables were computed using χ(2) while continuous variables were computed using Kruskal-Wallis. Variables deemed statistically significant (< 0.05) were included in the multivariable, log-binomial regression model. Relative risk (RR) and 95% confidence intervals (CI), and p values were computed using a generalized estimating equation (GEE) approach with robust standard errors (i.e., Huber White "sandwich variance" estimates) to accommodate a correlated data structure corresponding to multiple episodes of infection per individual. RESULTS: A total of 530 patients with 1,007 episodes of infection, were treated with vancomycin (150 patients/302 episodes of infection), vancomycin/piperacillin-tazobactam (213 patients/372 episodes of infection), or vancomycin/GNR alternative (167 patients/333 episodes of infection). Patient demographics, comorbidities, sites of infection, and organisms of infection were compared among groups. After adjusting for statistically significant variables, neither vancomycin/piperacillin-tazobactam (RR = 1.1, 95% CI = 0.99-1.2; p = 0.073) nor vancomycin/GNR alternative (RR = 1.1, 95% CI = 0.98-1.2; p = 0.097) were found to be associated with an increased risk for nephrotoxicity compared with vancomycin alone. CONCLUSION: A difference in nephrotoxicity was not observed between vancomycin and vancomycin/piperacillin-tazobactam-treated patients at our institution. Concomitant use as empiric therapy is appropriate, although larger sample sizes are needed to analyze closely this relation among at-risk subsets of this population.

Operative Start Time Does Not Affect Post-Operative Infection Risk.

BACKGROUND: Surgical care is delivered 24 h a day at most institutions. Alarmingly, some authors have found that certain operative start times are associated with greater morbidity and mortality rates. This effect has been noted in both the public and private sector. Although some of these differences may be related to process, they may also be caused by the human circadian rhythm and corresponding changes in host defenses. We hypothesized that the time of day of an operation would impact the frequency of certain post-operative outcomes significantly. METHODS: Cases at a single tertiary-care center reported to the American College of Surgeons National Surgical Quality Improvement Program over a 10-year period were identified. Operative start times were divided into six-hour blocks, with 6 am to noon serving as the reference. Standard univariable techniques were applied. Multivariable logistic regression with mixed effects modeling then was used to determine the relation between operative start times and infectious outcomes, controlling for surgeon clustering. Statistical significance was set at p < 0.01. RESULTS: A total of 21,985 cases were identified, of which 2,764 (12.6%) were emergency procedures. Overall, 9.7% (n = 2,142) of patients experienced some post-operative infectious complication. Seventy percent of these infections (n = 1,506) were surgical site infections. On univariable analysis considering all cases, nighttime and evening operations had higher rates of post-operative infections than those in performed during the day (9.1% from 6 am to noon; 9.7% from noon to 6 pm; 14.8% from 6 pm to midnight; and 14.4% from midnight to 6 am; p < 0.001). On multivariable analysis, operative start time was not associated with the risk of post-operative infection, even when emergency cases were considered independently. CONCLUSION: Our data suggest that operative start times have no correlation with post-operative infectious complications. Further work is required to identify the source of the time-dependent outcome variability observed in previous studies.

Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates.

BACKGROUND: No consensus exists regarding the definition of ventilator-associated pneumonia (VAP). Even within a single institution, inconsistent diagnostic criteria result in conflicting rates of VAP. As a Level 1 trauma center participating in the Trauma Quality Improvement Project (TQIP) and the National Healthcare Safety Network (NHSN), our institution showed inconsistencies in VAP rates depending on which criteria was applied. The purpose of this study was to compare VAP definitions, defined by culture-based criteria, National Trauma Data Bank (NTDB) and NHSN, using incidence in trauma patients. METHODS: A retrospective chart review of consecutive trauma patients who were diagnosed with VAP and met pre-determined inclusion and exclusion criteria admitted to our rural, 861-bed, Level 1 trauma and tertiary care center between January 2008 and December 2011 was performed. These patients were identified from the National Trauma Registry of the American College of Surgeons (NTRACS) database and an in-house infection control database. Ventilator-associated pneumonia diagnosis criteria defined by the U.S. Center for Disease Control and Prevention (used by the NHSN), the NTDB, and our institutional, culture-based criteria gold standard were compared among patients. RESULTS: Two hundred seventy-nine patients were diagnosed with VAP (25.4% met NHSN criteria, 88.2% met NTDB, and 76.3% met culture-based criteria). Only 58 (20.1%) patients met all three criteria. When NHSN criteria were compared with culture-based criteria, NHSN showed a high specificity (92.5%) and low sensitivity (28.2%). The positive predictive value (PPV) was 84.5%, but the negative predictive value (NPV) was 47.1%. The agreement between the NHSN and the culture-based criteria was poor (κ = 0.18). Conversely, the NTDB showed a lower specificity (57.8%), but greater sensitivity (86.4%) compared with culture-based criteria. The PPV and NPV were both 74% and the two criteria showed fair agreement (κ = 0.41). CONCLUSIONS: The lack of standard diagnostic criteria for VAP resulted in variable reporting to different agencies. Emphasis on establishing a consensus VAP definition should be undertaken.

Long-Term Survival after Cardiac Surgery in Patients with Chronic Obstructive Pulmonary Disease.

BACKGROUND: Although many patients with chronic obstructive pulmonary disease (COPD) require a prolonged length of stay (PLOS) following coronary artery bypass grafting (CABG), the impact of PLOS on long-term survival has not been examined in this population. OBJECTIVES: To determine the association between PLOS and long-term survival among COPD and non-COPD patients after CABG and to examine consequent policy and practice-based implications. METHODS: A retrospective cohort study of CABG patients was conducted between 2002 and 2011. Long-term survival was compared in patients with and without COPD and stratified by PLOS. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. RESULTS: A total of 203 patients (4.2%) had PLOS after nonemergent CABG (N = 4801). PLOS was an important independent predictor of decreased long-term survival (no COPD, no PLOS: HR = 1.0; COPD, no PLOS: adjusted HR [95% CI], 1.8 [1.5-2.1]; no COPD, PLOS: 3.3 [2.5-4.4]; COPD, PLOS: 6.0 [4.4-8.2]; PTrend < .001). CONCLUSIONS: COPD and PLOS are 2 of many factors that affect long-term mortality in postoperative CABG patients. Aggressive treatment strategies aimed at early weaning off of mechanical ventilation and prevention of reintubation among COPD patients must be considered carefully as a means to reduce length of stay after CABG. Our results also have important implications for the long-term management of these patients and strategies for containing costs over the life course of the patient.

Obesity Is Not Associated with Antimicrobial Treatment Failure for Intra-Abdominal Infection.

BACKGROUND: Obesity and commonly associated comorbidities are known risk factors for the development of infections. However, the intensity and duration of antimicrobial treatment are rarely conditioned on body mass index (BMI). In particular, the influence of obesity on failure of antimicrobial treatment for intra-abdominal infection (IAI) remains unknown. We hypothesized that obesity is associated with recurrent infectious complications in patients treated for IAI. METHODS: Five hundred eighteen patients randomized to treatment in the Surgical Infection Society Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated. Patients were stratified by obese (BMI ≥30) versus non-obese (BMI≥30) status. Descriptive comparisons were performed using Chi-square test, Fisher exact test, or Wilcoxon rank-sum tests as appropriate. Multivariable logistic regression using a priori selected variables was performed to assess the independent association between obesity and treatment failure in patients with IAI. RESULTS: Overall, 198 (38.3%) of patients were obese (BMI ≥30) versus 319 (61.7%) who were non-obese. Mean antibiotic d and total hospital d were similar between both groups. Unadjusted outcomes of surgical site infection (9.1% vs. 6.9%, p = 0.36), recurrent intra-abdominal infection (16.2% vs. 13.8, p = 0.46), death (1.0% vs. 0.9%, p = 1.0), and a composite of all complications (25.3% vs. 19.8%, p = 0.14) were also similar between both groups. After controlling for appropriate demographics, comorbidities, severity of illness, treatment group, and duration of antimicrobial therapy, obesity was not independently associated with treatment failure (c-statistic: 0.64). CONCLUSIONS: Obesity is not associated with antimicrobial treatment failure among patients with IAI. These results suggest that obesity may not independently influence the need for longer duration of antimicrobial therapy in treatment of IAI versus non-obese patients.