Evaluation of antimicrobial purchasing by companion animal veterinary facilities in Canada, the United Kingdom, and the United States of America (2019-2021).

BACKGROUND: Measuring antimicrobial use is a core component of antimicrobial stewardship. Purchasing data may be easier to obtain than prescription data in some situations, but differences in clinic size, caseload and collection timeframes must be considered. OBJECTIVE: Our objective was to evaluate purchases of systemic antibacterial agents by small animal veterinary facilities in 5 networks across 3 countries, using a mg/veterinarian full time equivalent (FTE)/week as the metric. METHODS: Data were obtained from purchasing records of 2194 veterinary facilities from networks from the United States (US, n = 3: US-A, 1036 facilities; US-B, 101 facilities; US-C, 886 facilities), Canada (n = 1: 117 facilities) and the United Kingdom (UK, n = 1: 54 facilities) during 2019-2021. RESULTS: In total, 20 020 269 767 mg (20.02 t) of antimicrobials were purchased. Overall differences between the UK and North America were driven by significantly higher purchases of amoxicillin-clavulanic acid in the UK (P < .001), with substantially less purchasing of third generation cephalosporins in the UK (P < .0001). A significant association was found between FTE and purchasing, with decreased purchasing (mg/FTE/week) as facility FTE increased. Significant differences also were found among US regions. Facilities in the top 10% of total purchasing accounted for 23%-30% of purchases, compared to only 1.6%-3.8% for the bottom 10%. CONCLUSIONS AND CLINICAL IMPORTANCE: These data provide useful information about general purchasing trends, inter- and intraregional differences and differences among facility types and identify high purchasing outliers for further investigation.

Strategies for Pertrochanteric Fracture Reduction and Intramedullary Nail Placement: Technical Tips and Tricks.

The incidence of pertrochanteric hip fractures continues to rise as the aging population expands. Despite advancements in techniques and implants, failure rates remain up to 16% in the literature. The recognition of challenging fracture patterns and the use of meticulous preoperative planning can help to avoid common pitfalls. Understanding fluoroscopic views for reduction assessment and implant placement is instrumental in preventing fixation failure. In addition, adjunctive techniques including the use of a bone hook, cerclage wire, and colinear clamps can facilitate reduction efforts. It is imperative for the surgeon to recognize common pitfalls and to consider a wide array of techniques to manage these challenging and common fractures.

Renal disease is a risk factor for complications and mortality after open reduction internal fixation of proximal humerus fractures.

Background: Renal osteodystrophy predisposes renal disease patients to fracture. Proximal humerus fractures (PHFs) frequently undergo open reduction internal fixation (ORIF); however, the effect of renal disease on outcomes is unknown. Methods: A retrospective review of the Nationwide Readmissions Database used International Classification of Diseases, 9th Revision, codes to identify patients who underwent ORIF for closed PHF from 2010 to 2014 with no renal disease, predialysis chronic renal disease (CRD), and end-stage renal disease (ESRD). Results: A total of 85,433 patients were identified, including 5498 (6.4%) CRD and 636 (0.7%) ESRD. CRD and ESRD patients had increased age, comorbidities, and rates of Medicare insurance. After adjusting for differences, CRD and ESRD patients were at increased risk of any complication (odds ratio [OR] 2.48, 1.66), blood transfusion (OR 1.85, 3.31), respiratory complications (OR 1.14, 1.59), acute renal failure (OR 4.80, 1.67), systemic infection (OR 2.00, 3.14), surgical site infection (OR 1.52, 3.87), longer length of stay (7.1 and 12.9 days vs. 5.9 days), and higher cost ($21,669 and $35,413 vs. $20,394) during index hospitalization, as well as surgical site infection (OR 1.43, 3.03) and readmission (OR 1.61, 3.69) within 90 days of discharge, respectively, compared with no renal disease patients. During index hospitalization, CRD patients also had increased risk for periprosthetic fracture (OR 4.97) and cardiac complications (OR 1.47), whereas ESRD patients had increased risk of mortality (OR 5.79), wound complication (2.67), and deep vein thrombosis (OR 16.70). Conclusion: These findings suggest renal patients are at increased risk for complications after PHF ORIF, highlighting the importance of close perioperative monitoring and appropriate patient selection in this population, including strong consideration of nonoperative management.

Public health, autonomous automobiles, and the rush to market.

The USA has the worst motor vehicle safety problem among high-income countries and is pressing forward with the development of autonomous automobiles to address it. Government guidance and regulation, still inadequate, will be critical to the safety of the public. The analysis of this public health problem in the USA reveals the key factors that will determine the benefits and risks of autonomous vehicles around the world.

Modified Mohs micrographic surgery for periocular melanoma and melanoma in situ: long-term experience at Scripps Clinic.

BACKGROUND: Excision of invasive melanoma and melanoma in situ (MIS) using variations of the Mohs micrographic surgery (MMS) technique is becoming increasingly common in difficult areas, such as the periocular area, where standard surgical margins may not be feasible, and clinical margins are poorly defined. However, little long-term data evaluating the treatment of periocular melanoma are available in the literature. OBJECTIVE: To present our long-term experience in the treatment of periocular melanoma using a staged, modified Mohs excision technique with rush permanent, paraffin-embedded tissue sections. MATERIALS AND METHODS: A total of 35 patients with periocular melanoma and MIS were treated using modified MMS during a 15-year period. Twenty-nine patients were available with adequate follow-up of greater than 5 years duration. The mean follow-up duration was 94 months. RESULTS: There were a total of five recurrences (17.2%) detected an average of 85 months after excision. Four of the five recurrent tumors had been previously excised. The recurrence rate for primary tumors was 5% (1/20). The recurrence rate for previously excised tumors was 44.4% (4/9). CONCLUSION: Margin-control surgery is favored in the treatment of periocular melanoma to maximize the cure rate and minimize postoperative morbidity by sparing normal tissue. Ample follow-up intervals are required to adequately assess recurrence rates. The best opportunity for cure is associated with the first tumor excision.

PET changes management and improves prognostic stratification in patients with recurrent colorectal cancer: results of a multicenter prospective study.

UNLABELLED: The aims of our study were to examine the impact of PET in changing management in patients with proven or suspected colorectal cancer recurrence and to assess the impact of management change on disease-free survival. METHODS: Symptomatic patients with a residual structural lesion suggestive of recurrent tumor (group A) or patients with pulmonary or hepatic metastases considered to be potentially resectable (group B) underwent PET scans. Pre-PET management plans were documented by referring clinicians unaware of the PET results, and follow-up to 12 mo was performed to determine actual management and clinical outcomes. RESULTS: A total of 191 patients (118 men and 73 women; mean age, 66 y) were studied. PET detected additional sites of disease in 48.4% of patients in group A and in 43.9% of patients in group B. A change in planned management was documented in 65.6% of group A and in 49.0% of group B patients. These management plans were implemented in 96% of patients. Follow-up data in group A showed progressive disease in 60.5% of patients with additional lesions detected by PET, compared with conventional imaging, and in 36.2% of patients with no additional lesions detected by PET (P=0.04). In group B, progressive disease was identified in 65.9% of patients with additional lesions detected by PET and in 39.2% of patients with no additional lesions detected by PET (P=0.01). PET also provided valuable prognostic information on patients stratified into curative- or palliative-intent groups. CONCLUSION: These data demonstrate the significant impact of PET on management and outcomes in patients with suspected recurrent colorectal cancer.

Treatment of dermatofibroma sarcoma protuberans using modified Mohs micrographic surgery: no recurrences and smaller defects.

OBJECTIVES: The purpose of this study was to evaluate the use of modified Mohs micrographic surgery (MMS) for dermatofibroma sarcoma protuberans (DFSP) in a single institution by a single surgeon. METHODS: The authors conducted a retrospective analysis of 25 patients with DFSP who were treated with modified MMS over the past 19 years at Scripps Clinic. RESULTS: Of the 25 patients treated with modified MMS for DFSP, there were no identifiable recurrences. The mean follow-up time was 101 months. The defect sizes of DFSP lesions treated by modified MMS are smaller than if the lesions had been treated with the standard wide local excision (WLE) margins of 3 cm. LIMITATIONS: This is a retrospective analysis using the data of one surgeon. Five of the 25 patients were not examined in our office. Not all patients had 5-year follow-up. There were no cases of the fibrosarcomatous variant. CONCLUSION: Our data support the growing literature that modified MMS achieves excellent local control for DFSP with a possible benefit of smaller defects when compared with treatment with WLE. The authors have indicated no significant interest with commercial supporters.