Patient-specific Predictors of Surgical Delay in a Large Tertiary-care Hospital Operating Room.

PURPOSE: The purpose of this study was to describe patient-specific factors predictive of surgical delay in elective surgical cases. DESIGN: Retrospective cohort study. METHODS: Data were extracted retrospectively from the electronic health record of 32,818 patients who underwent surgery at a large academic hospital in Los Angeles between May 2012 and April 2017. Following bivariate analysis of patient-specific factors and surgical delay, statistically significant predictors were entered into a logistic regression model to determine the most significant predictors of surgical delay. FINDINGS: Predictors of delay included having monitored anesthesia care (odds ratio [OR], 1.28; 95% confidence intervals [CI], 1.20-1.36), American Society of Anesthesiologist class 3 or above (OR, 1.21; 95% CI, 1.15-1.28), African American race (OR, 1.25; 95% CI, 1.12-1.39), renal failure (OR, 1.20; 95% CI, 1.09-1.32), steroid medication (OR, 1.13; 95% CI, 1.04-1.23) and Medicaid (OR,1.18; 95%CI, 1.09-1.30) or medicare insurance (OR, 1.14; 95% CI, 1.07-1.21). Six surgical specialties also increased the odds of delay. Obesity and cardiovascular anesthesia decreased the odds of delay. CONCLUSIONS: Certain patient-specific factors including type of insurance, health status, and race were associated with surgical delay. Whereas monitored anesthesia care anesthesia was predictive of a delay, cardiovascular anesthesia reduced the odds of delay. Additionally, obese patients were less likely to experience a delay. While the electronic health record provided a large amount of detailed information, barriers existed to accessing meaningful data.

Concomitant Mental Illnesses Diagnoses and Likelihood of Trauma Recidivism.

BACKGROUND: Trauma is the leading cause of death among persons aged 1-44 years. Trauma recidivism occurs when an individual experiences more than one significant injury in a 5-year period. The relationship between a trauma recidivist's perception of recurrent injury has been unclear. OBJECTIVE: To describe the association between select sociodemographic and clinical variables, threat orientation, and the perceived likelihood of recurrent injury of individuals recently experiencing a significant injury. METHODS: A prospective cross-sectional study was conducted with Level II trauma inpatients ( n = 84) in Southern California from October 2021 to January 2022. Participants completed surveys prior to discharge. Clinical variables were extracted from the electronic health record. RESULTS: The trauma recidivism rate was 31%. Mental illness and length of hospital stay were associated with trauma recidivism. In individuals with two or more mental illness diagnoses, the odds of trauma recidivism were approximately 6.5 times higher than in those with no mental illness (odds ratio = 6.48, 95% confidence interval: 1.7-24.6). CONCLUSION: Trauma is a preventable health care concern with timely recognition of risk factors and intervention. This study confirms mental illness as a predominant factor in injury and should be addressed in clinical practice. This study builds upon previous research and emphasizes the necessity of targeting injury prevention and education in the mentally ill. Trauma providers seeking to practice with an upstream mentality have a responsibility in screening patients for mental illness to help prevent further injury and death.

A pilot study of the enhanced recovery after surgery protocol in aortic surgery.

OBJECTIVE: We tested the outcomes with the use of the enhanced recovery after surgery protocol in patients who had undergone open abdominal aortic aneurysm (AAA) repair (enhanced recovery after vascular surgery [ERAVS] protocol). We compared them with those obtained for patients who had undergone endovascular aneurysm repair (EVAR) and for a historical control group of standard open AAA repair in a prospective, single-center pilot study. METHODS: From June to December 2019, all patients who were candidates for open AAA repair at our department were enrolled in the ERAVS protocol (ERAVS group; 17 patients). During the same period, 18 patients had undergone EVAR (EVAR group). The historical control group of standard open AAA repair included 32 patients who had undergone surgery during the 6 months before the study period (standard protocol open repair [OR] group). The three groups were compared on an "on-treatment" basis (prospectively for the ERAVS and EVAR groups and retrospectively for the OR group) in terms of the time to discharge (TTD), interval to the resumption of oral intake, time to ambulation, resumption of bowel function, and postoperative pain. Comparisons were performed using the one-way analysis of variance test, Tukey post hoc test for quantitative data, and χ2 test for qualitative data. RESULTS: The ERAVS protocol was successfully applied for all but one patient (feasibility rate, 94%). The mean TTD was 5.1 days in the ERAVS group, 3.5 days in the EVAR group, and 8.4 days in the OR group [P < .001; F(2,64) = 11.3], with a significant difference between the OR and ERAVS and EVAR groups (P = .1 and P < .001, respectively) but not between the EVAR and ERAVS groups (P = .4). The ERAVS group had intervals to the resumption of oral intake and ambulation similar to those of the EVAR group. In contrast, these were significantly longer for the OR group. The mean time to the resumption of bowel function was similar in the ERAVS and OR groups (2.6 and 2.9 days, respectively; P = .6). In the ERAVS group, the mean value of the maximum referred pain using the numeric rating scale was 3.75 (range, 1-6). The corresponding values for the EVAR and OR groups were 2.6 (range, 0-6) and 4.9 [range, 1-8; F(2,62) = 15.4; P < .001]. The post hoc test showed a significant difference between the OR group and the ERAVS and EVAR group (P = .01 and P < .001, respectively) but not between the ERAVS and EVAR groups (P = .07). CONCLUSIONS: In our early experience, the ERAVS protocol appeared to be effective in reducing the TTD and improving the postoperative outcomes compared with the OR group, without significant differences compared with the EVAR group.

Representation of women in vascular surgery science and societies.

OBJECTIVE: Medical schools and surgical residencies have seen an increase in the proportion of female matriculants, with 30% of current vascular surgery trainees being women over the past decade. There is widespread focus on increasing diversity in medicine and surgery in an effort to provide optimal quality of patient care and the advancement of science. The presence of gender diversity and opportunities to identify with women in leadership positions positively correlates with women choosing to enter traditionally male-dominated fields. The purpose of this study was to evaluate the representation of women in regional and national vascular surgical societies over the last 20 years. METHODS: A retrospective review of the meeting programs of vascular surgery societies was performed. Data were collected on abstract presenters, moderators, committee members and chairs, and officers (president, president-elect, vice president, secretary, and treasurer). The data were divided into early (1999-2009) and late (2010-2019) time periods. RESULTS: Five regional and five national societies' data were analyzed, including 139 meetings. The mean percentage of female abstract presenters increased significantly from 10.9% in the early period to 20.6% in the late period (P < .001). Female senior authors increased slightly from 8.7% to 11.5%, but this change was not statistically significant (P = .22). Female meeting moderators increased significantly from 7.8% to 17.2% (P < .001), as well as female committee members increased from 10.9% to 20.3% (P = .003). Female committee chairs increased slightly from 10.9% to 16.9%, but this difference was not statistically significant (P = .13). Female society officers increased considerably from 6.4% to 14.8%. (P = .002). Significant variation was noted between societies, with five societies (three regional and two national) having less than 10% women at the officer level in 2019. There was a wide variation noted between societies in the percentage of female abstract presenters (range, 7.6%-34.9%), senior authors (3.9%-17.9%), and meeting moderators (5.4%-40.7%). CONCLUSIONS: Over the past two decades, there has been a significant increase in the representation of women in vascular surgery societies among those presenting scientific work, serving as meeting moderators, and serving as committee members. However, the representation of women among committee chairs, senior authors, and society leadership has not kept up pace with the increase noted at other levels. Efforts to recruit women into the field of vascular surgery as well as to support the professional development of female vascular surgeons are facilitated by the presence of women in leadership roles. Increasing the representation of women in vascular society leadership positions may be a key strategy in promoting gender diversity in the vascular surgery field.

Preliminary results from a multicenter Italian registry on the use of a new branched device for the treatment of thoracoabdominal aortic aneurysms.

OBJECTIVE: The study purpose was to present early outcomes of patients treated for thoracoabdominal aortic aneurysms or complex abdominal aortic diseases using endovascular repair with a new branched endograft. METHODS: This multicenter, retrospective, observational cohort study included all patients treated with a new branched endograft. All elective patients were treated with a staged operative strategy and spinal drainage Primary outcomes of interest were technical success, early (≤30 days) mortality, and late (≥30 days) survival, and freedom from adverse aortic events. RESULTS: A total of 16 consecutive patients were treated for Crawford's extent type I (n = 1), type II (n = 7), type III (n = 1), and type IV (n = 5) endoleaks, with an additional two complex pararenal abdominal aortic lesions (enlarging type Ia endoleak, n = 1; anastomotic pseudoaneurysm, n = 1). There were 13 male (81%) and 3 female (19%) patients with a median age of 72.5 years (interquartile range [IQR], 69-78 years). The median diameter of the aortic aneurysm was 65 mm (IQR, 58-81 mm) and the median EuroSCORE prediction for mortality was 18% (IQR, 12%-36%). Thoracoabdominal aortic aneurysm was secondary to a previous dissection in four patients. A total of 62 of the 64 visceral vessels (96.9%) were stented. Technical success was achieved in 14 (87.5 %) and the cumulative aorta-related mortality rate was 19%. Spinal cord ischemia did not occur. The mean follow-up was 8 ± 4 months (range, 2-15 months). No type I or type III endoleaks were detected. Primary bridging stent patency was 98% (one asymptomatic thrombotic occlusion of a celiac trunk branch). No aortic reintervention was required. CONCLUSIONS: Endovascular repair of complex aortic aneurysms with this new branched endograft can be performed with high technical success and acceptable morbidity. A 19% mortality is quite high; however, it is tolerable in such a high-risk cohort. The survival rate was acceptable, and graft-related outcomes at early follow-up included an absence of threatening endoleaks and a high target visceral vessel patency.

A morphovolumetric analysis of aneurysm sac evolution after elective endovascular abdominal aortic repair.

OBJECTIVE: Abdominal aortic aneurysm (AAA) sac shrinkage after endovascular aortic repair (EVAR) has been regarded as positive marker of EVAR success durability. The purpose of this study was to describe the morphovolumetric changes of the AAA sac during follow-up after elective EVAR and to analyze sac shrinkage-related variables. METHODS: This is a single-center, retrospective, observational cohort study from a tertiary referral university hospital. All patients treated with EVAR between January 2013 and December 2018 were identified. Inclusion criteria were elective EVAR for AAA, preoperative computed tomography angiography within 6 months before EVAR and at least one postoperative computed tomography angiography during the follow-up, using a standardized protocol. Aneurysm sac shrinkage was defined as diameter decrease of 1 cm or more, volume shrinkage threshold was identified by a 16% decrease compared with the preoperative value. Primary outcomes were early (≤30 days) and late survival, and freedom from aneurysm-related mortality (ARM), and aortic reintervention. RESULTS: There were 149 of the 325 patients (45.8%) who met the inclusion criteria: 133 (89.3%) were male and 16 (10.7%) female. The mean age was 74 ± 7 years (range, 55-87 years); the median AAA diameter was 56 mm (interquartile range, 50.0-61.2 mm) and the median volume was 138.8 cm3 (range, 99.0-178.3 cm3). Primary technical success was achieved in 145 patients (97.3%). The in-hospital mortality rate was 1.3%. The median follow-up was 42 months (interquartile range, 22.5-58.0 months). Both AAA diameter and volume decreased (P = .001 and P = .035, respectively) compared with preoperative measurements. Diameter shrinkage was adjudicated in 27 patients (18.1%), volume shrinkage was observed in 42 patients (28.2%). A Cox regression analysis demonstrated an association between the AAA diameter shrinkage and the preoperative diameter (P = .002; hazard ratio, 1.03; 95% confidence interval [CI], 1.011-1.052). The presence of a persistent endoleak predicted the absence of volume shrinkage (P = .001; hazard ratio, 7.75; 95% CI, 2.282-26.291). The estimated freedom from ARM was 97.5 ± 1.0% (95% CI, 93-99) at 12 months, and 96 ± 2% (95% CI, 90-98) at both 36 and 60 months. Aortic reintervention during the follow-up period was necessary in 7 patients (4.7%). ARM was only observed in the group characterized by the concomitant absence of diameter and volume shrinkage. CONCLUSIONS: Volumetric analysis showed to have higher sensitivity than the simple two-dimensional measurement of the diameter to study AAA sac changes after EVAR. Although no predictor was found to be associated with AAA volume shrinkage, ARM occurred only in the group of AAAs with the absence of volume shrinkage.

Society for Vascular Surgery best practice recommendations for use of social media.

The use of social media (SoMe) in medicine has demonstrated the ability to advance networking among clinicians and other healthcare staff, disseminate research, increase access to up-to-date information, and inform and engage medical trainees and the public at-large. With increasing SoMe use by vascular surgeons and other vascular specialists, it is important to uphold core tenets of our commitment to our patients by protecting their privacy, encouraging appropriate consent and use of any patient-related imagery, and disclosing relevant conflicts of interest. Additionally, we recognize the potential for negative interactions online regarding differing opinions on optimal treatment options for patients. The Society for Vascular Surgery (SVS) is committed to supporting appropriate and effective use of SoMe content that is honest, well-informed, and accurate. The Young Surgeons Committee of the SVS convened a diverse writing group of SVS members to help guide novice as well as veteran SoMe users on best practices for advancing medical knowledge-sharing in an online environment. These recommendations are presented here with the goal of elevating patient privacy and physician transparency, while also offering support and resources for infrequent SoMe users to increase their engagement with each other in new, virtual formats.

Bridging Stents in Fenestrated and Branched Endovascular Aneurysm Repair: A Systematic REVIEW.

BACKGROUND: Concern exists about durability of stent grafts used to bridge aortic grafts to visceral and renal arteries during fenestrated and branched endovascular aneurysm repair (F/B-EVAR). There are no guidelines regarding the ideal technique for joining target vessels (TVs). METHODS: We systematically reviewed data published from 2014 to 2019 using PRISMA guidelines and PICO models. Keywords were searched in MEDLINE, EMBASE, and Cochrane Library. All articles were screened by two authors (a third author in case of discrepancies). Only original articles regarding F/B-EVAR in complex aortic aneurysm, reporting the number and type of TVs mated, the onset of bridging stent complications, and reinterventions on TVs were included. Analysis included quality assessment scoring, types of stent grafts, and complications related to bridging stents. RESULTS: 19 studies were included with 2,796 patients and 9556 TV; 4,797 renal arteries (50.2%), 4,174 visceral arteries (43.6%), and undefined TV (n = 585; 6.1%) were bridged. Balloon-expandable stent-grafts (B-EXP) were used in 40.9% and self-expandable (S-EXP) in 22.7% and undefined stents in 36.3%. The included studies had quality assessment scores ranging between 11/15 and 15/15, with high grade of accordance on reporting general results, but a low grade of accordance on reporting detailed data. Despite study heterogeneity, high-volume analysis confirmed a higher rate of complication in renal arteries than visceral arteries, 6% (95% CI 4-8) vs. 2% (95% CI 1-3), respectively. The rate of reinterventions was similar, 3% (95% CI 2-4) and 2% (95% CI 1-3). S-EXP versus B-EXP stent complication was 4% (95% CI 2-7) vs. 3% (95% CI 2-5), respectively. CONCLUSIONS: This systematic review underlines the low grade of accordance in reporting detailed data of bridging stents in F/B-EVAR. Renal TVs were more prone to complications, with an equivalent reintervention rate to visceral TVs. As to B-EVAR, the choice of B-EXP over S-EXP is still uncertain.

Preventing Surgical Delay and Cancellation with Patient-Centered Interventions.

Delay and cancellation can significantly impact cost and outcomes among surgical patients. While the causes of delay and cancellation are not fully enumerated, possible reasons include delivery-related causes such as facility, equipment, and provider availability as well as patient-related issues such as readiness and health status. Despite limited research explaining patient-related causes, there are many studies that evaluate patient-centered interventions to decrease delay and cancellation. This article highlights patient-centered interventions including preoperative clinics, preoperative screening, and focused education that have been shown to reduce delay and cancellation. This information provides perianesthesia nurses and advanced practice nurses ideas to maximize their roles in improving efficiency by prevention of delay and cancellation. This article should also stimulate additional research to help better understand the causes and the role of the nurse in the implementation of evidence-based practice projects that use patient-centered interventions.

Acute limb ischemia in patients with COVID-19 pneumonia.

Objective: The aim of our study was to determine the incidence, characteristics, and clinical outcomes of patients with the novel coronavirus (COVID-19) infection who had presented with and been treated for acute limb ischemia (ALI) during the 2020 coronavirus pandemic. Methods: We performed a single-center, observational cohort study. The data from all patients who had tested positive for COVID-19 and had presented with ALI requiring urgent operative treatment were collected in a prospectively maintained database. For the present series, successful revascularization of the treated arterial segment was defined as the absence of early (<30 days) re-occlusion or major amputation or death within 24 hours. The primary outcomes were successful revascularization, early (≤30 days) and late (≥30 days) survival, postoperative (≤30 days) complications, and limb salvage. Results: We evaluated the data from 20 patients with ALI who were positive for COVID-19. For the period from January to March, the incidence rate of patients presenting with ALI in 2020 was significantly greater than that for the same months in 2019 (23 of 141 [16.3%] vs 3 of 163 [1.8%]; P < .001)]. Of the 20 included patients, 18 were men (90%) and two were women (10%). Their mean age was 75 ± 9 years (range, 62-95 years). All 20 patients already had a diagnosis of COVID-19 pneumonia. Operative treatment was performed in 17 patients (85%). Revascularization was successful in 12 of the 17 (70.6%). Although successful revascularization was not significantly associated with the postoperative use of intravenous heparin (64.7% vs 83.3%; P = .622), no patient who had received intravenous heparin required reintervention. Of the 20 patients, eight (40%) had died in the hospital. The patients who had died were significantly older (81 ± 10 years vs 71 ± 5 years; P = .008). The use of continuous postoperative systemic heparin infusion was significantly associated with survival (0% vs 57.1%; P = .042). Conclusions: In our preliminary experience, the incidence of ALI has significantly increased during the COVID-19 pandemic in the Italian Lombardy region. Successful revascularization was lower than expected, which we believed was due to a virus-related hypercoagulable state. The use of prolonged systemic heparin might improve surgical treatment efficacy, limb salvage, and overall survival.

Increased Vascular Pathology in Older Veterans With a Purple Heart Commendation or Chronic Post-Traumatic Stress Disorder.

The goal of this retrospective cohort study was to determine whether stressors related to military service, determined by a diagnosis of chronic post-traumatic stress disorder (cPTSD) or receiving a Purple Heart (PH), are associated with an increased risk of vascular risk factors and disease, which are of great concern for veterans, who constitute a significant portion of the aging US population. The Veterans Integrated Service Network (VISN) 16 administrative database was searched for individuals 65 years or older between October 1, 1997 to September 30, 1999 who either received a PH but did not have cPTSD (PH+/cPTSD-; n = 1499), had cPTSD without a PH (PH-/cPTSD+; n = 3593), had neither (PH-/cPTSD-; n = 5010), or had both (PH+/cPTSD+; n = 153). In comparison to the control group (PH-/cPTSD-), the PH+/cPTSD- group had increased odds ratios for incidence and prevalence of diabetes mellitus, hypertension, and hyperlipidemia. The PH-/cPTSD+ group had increased odds ratios for prevalence of diabetes mellitus and for the incidence and prevalence of hyperlipidemia. The PH-/cPTSD+ and PH+/cPTSD- groups were associated with ischemic heart disease and cerebrovascular disease, but not independently of the other risk factors. The PH+/cPTSD+ group was associated only with an increase in the incidence and prevalence of hyperlipidemia, though this group's much smaller sample size may limit the reliability of this finding. We conclude that certain physical and psychological stressors related to military service are associated with a greater incidence of several vascular risk factors in veterans aged 65 years or older, which in turn are associated with greater rates of ischemic heart disease and cerebrovascular disease.

Comparison of Hybrid Vascular Grafts and Standard Grafts in Terms of Kidney Injury for the Treatment of Thoraco-Abdominal Aortic Aneurysm.

BACKGROUND: We present a comparison of renal function outcomes during HTAR with the use of a new hybrid vascular graft (GHVG) or standard graft. METHODS: It is a multicenter, retrospective, observational study. Between January 2015 and March 2019, 36 patients were treated with HTAR. We compared HTAR performed with the use of the GHVG and with the use of standard bypass graft. Primary outcome measures were hospital mortality, acute kidney injury (AKI) at 30 days and GHVG patency. RESULTS: Mean GHVG ischemia time was significantly lower for both renal arteries (right: GHVG, 4 ± 2 vs. standard graft, 15 ± 7 min; 95% CI 2.23-6.69, P < 0.001; left: GHVG, 3 ± 2 vs. standard graft, 13 ± 7 min; 95% CI 2.44-5.03, P < 0.001). Hospital mortality was 17% (6/36); while mortality did not differ between the two groups, postoperative acute kidney injury rate was 30.5% (11/36 patients) and was more common in the standard graft group (7% vs. 29%; OR 3.2, P = 0.074). Estimated primary patency was 92% ± 2 (95% CI 79.5-97%) at 36 months and was not different between the two groups (GHVG 94% ± 6 vs. standard graft 91% ± 6; log-rank χ2 = 0.260, P = 0.610). CONCLUSIONS: In our experience of HTAR, ischemia time was significantly shorter and postoperative AKI occurrence was lower with GHVG if compared to standard graft bypass, with satisfactory midterm patency rate comparable to that of standard graft bypass.

A Retrospective Comparison Between Hybrid Treatment and Prosthetic Above-the-Knee Femoro-Popliteal Bypass in the Management of the Obstructive Disease of the Superficial Femoral Artery.

OBJECTIVE: We assessed early and late outcomes following hybrid intervention (common femoral artery endarterectomy and superficial femoral artery (SFA) stenting) versus above-the-knee (AK) femoro-popliteal bypass performed for peripheral artery occlusive disease (PAOD) in a double-center retrospective comparative cohort study. MATERIALS AND METHODS: From January 2006 to December 2017, 82 hybrid revascularizations with femoral endarterectomy and SFA stenting (HY Group) and 98 AK femoro-popliteal bypasses with femoral endarterectomy (BP Group) were performed at two academic vascular centers. The two groups were compared in terms of preoperative and intraoperative details and of perioperative (<30 days) outcomes with χ2 test. Long-term results were compared using Kaplan-Meier curves and log-rank test. RESULTS: No differences were found in demographics variables, risk factors, comorbidities and clinical presentation between the two groups. Also perioperative outcomes were similar between the two groups. Median duration of follow-up was 38 months. At five years, the estimated survival rate was 60% in HY Group and 77.5% in BP Group (p = 0.002) Five-year primary patency rates were 46% in HY Group and 64% in BP Group (p = 0.005). Overall, 13 patients in HY Group required conversion to open surgery and 6 patients in BP Group underwent below-knee (n = 4) or distal (n = 2) bypass. The 5-year rate of limb maintenance was 85% in HY Group and 94% in BP Group (p = 0.1) and was not significantly different regardless of presentation, claudication or critical limb ischemia. CONCLUSIONS: In patients with PAOD due to complex long lesions of the infrainguinal arteries, open-surgical treatment with AK bypass provided better long-term survival and patency rates compared to a hybrid approach.

Reducing Opioid Prescriptions in Outpatient Pediatric Urological Surgery.

PURPOSE: We assessed the impact of a 2-phase Plan-Do-Study-Act cycle to decrease opioid prescriptions following pediatric urological surgery. MATERIALS AND METHODS: Parents of children undergoing outpatient urological procedures were given questionnaires to assess opioid dosing and pain scores using the Parents' Postoperative Pain Measure scale. Age, procedure and opioid prescription data were recorded, as well as volume of medication administered. During the first phase of data collection children received an opioid prescription for 10 doses. In the second phase opioid prescriptions were reduced by 50%. Nonparametric tests and Fisher exact test were used for analysis. RESULTS: Of 250 eligible children 98 (39%) with a median age of 3.0 years (IQR 7.0) participated. In the 81 patients prescribed opioids a median of 2 doses (IQR 3.6) were used in the preintervention and postintervention groups (p = 0.68). Using nonparametric statistical testing, no significant differences were found between pain scores in the 5-dose group (31 patients) and the 10-dose group (24 patients; p = 0.05 for day 1, p = 0.07 for day 2, p = 0.06 for day 3). There was no association between age and percent opioid used (p = 0.83). There were no significant differences in median pain scores or median doses among procedure types. CONCLUSIONS: In outpatient pediatric surgical practice opioid prescriptions can be decreased without increasing pain scores. Physician prescribing practices may contribute more to opioid consumption than actual pain patterns.

Prevalence and risk factors for heparin-bonded expanded polytetrafluoroethylene vascular graft infection after infrainguinal femoropopliteal bypasses.

BACKGROUND: To analyze the prevalence and predictors of prosthetic vascular graft infection (PVGI) in a multicenter registry. METHODS: This registry-based, multicenter study retrospectively evaluated PVGI that developed after infrainguinal revascularization performed with a heparin-bonded expanded polytetrafluoroethylene graft that was used in 1400 interventions between 2002 and 2016. A prosthetic graft with infection was defined as direct involvement of the graft with positive bacterial cultures of graft or perigraft material, intraoperative gross purulence or failure of graft incorporation, or exposed graft in an infected wound. RESULTS: Critical limb ischemia (CLI) was the main indication for bypass (n = 915 [65%]). The median duration of follow-up was 29 months (range, 1-168 months; interquartile range, 12-60 months). A total of 33 heparin-bonded expanded polytetrafluoroethylene grafts (2.3%) became infected; the median time to occurrence was 5 months (range, 1-54 months; interquartile range; 2.00-13.25 months). Freedom from PVGI at 1 year was 98% (standard error, 0.4; 95% confidence interval [CI], 97.2-98.9), and 97% (standard error, 0.6; 95% CI, 95.6-98.0) at 5 years. The multivariate model identified CLI (P = .042; hazard ratio, 0.39; 95% CI, 0.164-0.969) to be independently associated with PVGI. In-hospital mortality of PVGI treatment was 12% (n = 4/33). Freedom from major amputation was significantly different between patients with PVGI and those who did not experience this complication (at 1 year, 67.0% vs 88.5%; Log-rank χ2 = 22.5; P = .001). CONCLUSIONS: In our "real-world" multicenter experience the prevalence of PVGI after infrainguinal femoropopliteal bypasses was relatively low at 2.3%, but still associated with significant mortality and limb loss. CLI was the only significant predictor of PVGI. This conclusion is reasonable; however, more comprehensive data are required to confirm these findings, because the presence of ischemic ulcers or gangrene was not predictive of PVGI.

Outcomes From the Multicenter Italian Registry on Primary Endovascular Treatment of Aortoiliac Occlusive Disease.

Purpose: To report the results of endovascular treatment of iliac and complex aortoiliac occlusive disease (AIOD) in a multicenter Italian registry. Materials and Methods: A retrospective, multicenter, observational cohort study analyzed 713 patients (mean age 68±10 years; 539 men) with isolated iliac and complex aortoiliac lesions treated with primary stenting between January 2015 and December 2017. Indications for treatment were claudication in 406 (57%) patients and critical limb ischemia in 307 (43%). According to the TransAtlantic Inter-Society Consensus II (TASC) classification, the lesions were categorized as type A (104, 15%), type B (171, 24%), type C (170, 24%), and type D (268, 37%). Early (<30 days) endpoints included mortality, thrombosis, and major complications. Late major outcomes were primary and secondary patency and freedom from reintervention as estimated by Kaplan-Meier analysis; estimates are given with the 95% confidence intervals (CIs). Associations between baseline variables and primary patency were sought with multivariate analysis; the results are presented as the hazard ratio (HR) and 95% CI. Results: Technical success was achieved in 708 (99%) lesions; in-hospital mortality was 0.6% (n=4). The median follow-up was 11 months (range 0-42). The estimated primary patency rate was 96% (95% CI 94% to 97%) at 1 year and 94% (95% CI 91% to 96%) at 2 years. The estimated secondary patency was 99% (95% CI 97% to 99%) at 1 year and 98% (95% CI 95% to 99%) at 2 years. The estimated freedom from reintervention was 98% (95% CI 96% to 99%) at 1 year and 97% (95% CI 94% to 98.5%) at 2 years. Cox regression analysis demonstrated that the application of a covered stent was associated with an increased need for reintervention (HR 1.4, 95% CI 1.10 to 1.74, p=0.005). Chronic obstructive pulmonary disease was associated with decreased primary patency (HR 3.7, 95% CI 1.25 to 10.8, p=0.018). Conclusion: Endovascular intervention with primary stent placement for aortoiliac occlusive disease achieved satisfactory 2-year patency regardless of the complexity of the lesion. Almost all TASC lesions should be considered for primary endovascular intervention if suitable.

Does Gender Matter in Septic Patient Outcomes?

PURPOSE: The purpose of this study was to examine potential gender disparities in relation to factors associated with sepsis management among a cohort of patients admitted through an emergency department with a discharge diagnosis of severe sepsis or septic shock. Sepsis is one of the leading causes of death globally, with significant associated costs. Predictors of survival for those with sepsis-related diagnoses are complex. DESIGN AND METHODS: The study had a retrospective, descriptive cross-sectional design. The sample (N = 482) included patients 18 years of age or older who presented to the emergency department of a nonprofit, Magnet-recognized, acute care hospital located in southern California. Subjects included those who subsequently met the criteria for a discharge diagnosis of severe sepsis or septic shock as defined by the Surviving Sepsis Campaign. Patient characteristics, clinical variables, care management processes, and outcomes were extracted from the electronic health record. A multivariate model was analyzed. FINDINGS: The sample included 234 women (48.5%) and 248 men (51.5%). Logistic regression with eight independent variables (discharge diagnosis, age, comorbidities, length of hospital stay, source of infection, first serum lactate level measured, recommended fluids administered, and gender) reliably predicted odds for patient survival, Ï°2 (12) = 118.38, p < .001, and correctly classified 77.3% of cases. All eight independent variables significantly contributed to the model. Men had a higher likelihood of hospital survival than women (odds ratio 1.68; 95% confidence interval 1.01-2.79; p = .045). CONCLUSIONS: The Surviving Sepsis Campaign has provided a clear pathway for care of patients with sepsis-related diagnoses. Therapeutic strategies should be developed to address differences in outcome by gender. The adoption of more aggressive applications of evidence-based interventions for these patients may result in better patient outcomes. CLINICAL RELEVANCE: Providers should understand the importance of adhering to sepsis protocols, minimizing treatment disparities, and recognizing gender differences.

Alignment of American Association of Colleges of Nursing Graduate-Level Nursing Informatics Competencies With American Medical Informatics Association Health Informatics Core Competencies.

This study yielded a map of the alignment of American Association of Colleges of Nursing Graduate-Level Nursing Informatics Competencies with American Medical Informatics Association Health Informatics Core Competencies in an effort to understand graduate-level accreditation and certification opportunities in nursing informatics. Nursing Informatics Program Directors from the American Medical Informatics Association and a health informatics expert independently mapped the American Association of Colleges of Nursing competencies to the American Medical Informatics Association Health Informatics knowledge, skills, and attitudes. The Nursing Informatics Program Directors' map connected an average of 4.0 American Medical Informatics Association Core Competencies per American Association of Colleges of Nursing competency, whereas the health informatics expert's map connected an average of 5.0 American Medical Informatics Association Core Competencies per American Association of Colleges of Nursing competency. Agreement across the two maps ranged from 14% to 60% per American Association of Colleges of Nursing competency, revealing alignment between the two groups' competencies according to knowledge, skills, and attitudes. These findings suggest that graduates of master's degree programs in nursing, especially those specializing in nursing informatics, will likely be prepared to sit for the proposed Advanced Health Informatics Certification in addition to the American Nurses Credentialing Center bachelor's-level Informatics Nursing Certification. This preliminary map sets the stage for further in-depth mapping of nursing informatics curricula with American Medical Informatics Association Core Competencies and will enable interprofessional conversations around nursing informatics specialty program accreditation, nursing workforce preparation, and nursing informatics advanced certification. Nursing informaticists should examine their need for credentials as key contributors who will address critical health informatics needs.

Pre-operative Color Doppler Ultrasonography Predicts Endovenous Heat Induced Thrombosis after Endovenous Radiofrequency Ablation.

OBJECTIVES: The aim was to identify pre-operative color Doppler ultrasound (CDUS) variables predictive of post-operative endovenous heat induced thrombosis (EHIT) after radiofrequency ablation (RFA) of the saphenous veins. DESIGN: This was a single centre, observational study with retrospective analysis of consecutive patients treated from December 2010 to February 2017. MATERIALS AND METHODS: Pre-operatively, the diameter of the sapheno-femoral junction (dSFJ), distance between superficial epigastric vein and SFJ (dSEV-SFJ) [corrected], maximum great saphenous vein (GSV) diameter (mdGSV), diameter of the saphenous-popliteal junction (dSPJ), and mean small saphenous vein (SSV) diameter (adSSV) were measured. All patients received low molecular weight heparin (LWMH) at a prophylactic dose for a week. Post-operatively, CDUS was performed after 72 h, 1 week, and 3 months. RESULTS: Venous interventions on 512 patients were performed: 449 (87.7%) underwent RFA of the GSV (Group 1), and 63 (12.3%) of the SSV (Group 2). At Day 3 post-operatively, CDUS documented 100% complete closure of the treated saphenous vein segment. Overall, 40 (7.8%) cases of post-operative EHIT were identified: 29 in Group 1, and 11 in Group 2 (6.4% vs. 17.5%, p = .005). Deep venous thrombosis or pulmonary embolism did not occur in either group. At the 1 month follow up, all cases of EHIT regressed. In Group 1, on multivariate analysis, dSEV-SFJ [corrected] (OR, 1.13, p = .036; 95% CI 1.01-1.27) was the only statistically significant predictor for EHIT. A dSEV-SFJ [corrected] distance of 4.5 mm yielded an 84% of sensitivity for EHIT prediction with a 72.4% positive predictive value. In Group 2, univariate analysis did not identify independent risk factors for EHIT occurrence. CONCLUSIONS: EHIT was higher than previously reported. The dSEV-SFJ [corrected] was the most significant predictor for EHIT in the GSV group. A greater distance between the tip of the radiofrequency catheter and the SFJ may decrease the risk of developing this complication.

Statin prescription rates and their facility-level variation in patients with peripheral artery disease and ischemic cerebrovascular disease: Insights from the Department of Veterans Affairs.

The 2013 American College of Cardiology/American Heart Association cholesterol guideline recommends moderate to high-intensity statin therapy in patients with peripheral artery disease (PAD) and ischemic cerebrovascular disease (ICVD). We examined frequency and facility-level variation in any statin prescription and in guideline-concordant statin prescriptions in patients with PAD and ICVD receiving primary care in 130 facilities across the Veterans Affairs (VA) health care system between October 2013 and September 2014. Guideline-concordant statin intensity was defined as the prescription of high-intensity statins in patients with PAD or ICVD ≤75 years and at least moderate-intensity statins in those >75 years. We calculated median rate ratios (MRR) after adjusting for patient demographic factors to assess the magnitude of facility-level variation in statin prescribing patterns independent of patient characteristics. Among 194,151 PAD patients, 153,438 patients (79.0%) were prescribed any statin and 79,435 (40.9%) were prescribed a guideline-concordant intensity of statin. PAD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin therapy less frequently (69.1% and 28.9%, respectively). Among 339,771 ICVD patients, 265,491 (78.1%) were prescribed any statin and 136,430 (40.2%) were prescribed a guideline-concordant intensity of statin. ICVD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin less frequently (70.9% and 30.5%, respectively). MRRs for both PAD and ICVD patients demonstrated a 20% and 28% variation among two facilities in treating two identical patients with statin therapy and guideline-concordant intensity of statin therapy, respectively. The prescription of statins, especially guideline-recommended intensity of statin therapy, is suboptimal in PAD and ICVD patients, with significant facility-level variation not explained by patient-level factors.