Timing of a Major Operative Intervention After a Positive COVID-19 Test Affects Postoperative Mortality: Results From a Nationwide, Procedure-matched Analysis.

BACKGROUND: Studies indicate that coronavirus disease 2019 (COVID-19) infection before or soon after operations increases mortality, but they do not comment on the appropriate timing for interventions after diagnosis. OBJECTIVE: We sought to determine what the safest time would be for COVID-19 diagnosed patients to undergo major operative interventions. METHODS: High-risk operations, between January 2020 and May 2021, were identified from the Veterans Affairs COVID-19 Shared Data Resource. Current Procedural Terminology (CPT) codes were used to exact match COVID-19 positive cases (n=938) to negative controls (n=7235). Time effects were calculated as a continuous variable and then grouped into 2-week intervals. The primary outcome was 90-day, all-cause postoperative mortality. RESULTS: Ninety-day mortality in cases and controls was similar when the operation was performed within 9 weeks or longer after a positive test; but significantly higher in cases versus controls when the operation was performed within 7 to 8 weeks (12.3% vs 4.9%), 5 to 6 weeks (10.3% vs 3.3%), 3 to 4 weeks (19.6% vs 6.7%), and 1 to 2 weeks (24.7% vs 7.4%) from diagnosis. Among patients who underwent surgery within 8 weeks from diagnosis, 90-day mortality was 16.6% for cases versus 5.8% for the controls ( P <0.001). In this cohort, we assessed interaction between case status and any symptom ( P =0.93), and case status and either respiratory symptoms or fever ( P =0.29), neither of which were significant statistically. CONCLUSIONS: Patients undergoing major operations within 8 weeks after a positive test have substantially higher postoperative 90-day mortality than CPT-matched controls without a COVID-19 diagnosis, regardless of presenting symptoms.

Treatment of Early Deep Wound Infections after Arterial Reconstructions: A Meta-Analysis and Survey.

BACKGROUND: Peripheral vascular graft infections, a serious concern after open lower extremity interventions, are treated using multiple strategies. Yet, there is no consensus on the optimal treatment. This study summarizes the literature and compares aggregate effect sizes between graft preservation with antibiotic beads and total graft excision. METHODS: Manuscripts published between 1972 and 2019 were systematically queried using Ovid Medline and PubMed. Studies were included if they described early (≤4 months of the index procedure) infection-related outcomes after extracavitary and infrainguinal arterial graft infections that were managed with antibiotic-loaded beads or total excisions. Outcomes assessed included the prevalence of graft preservation failure, reinfection, and major amputation. To examine current preferences on this subject, a voluntary, anonymous survey was administered to practicing members of the Society for Clinical Vascular Surgery. RESULTS: Six graft preservation studies (n = 147 patients) were included in the meta-analysis, based on PRISMA guidelines. The meta-analytic pooled proportion of patients with: (1) graft preservation failure was 0.09 (95% CI: 0.00, 0.46, I2 = 88.8%), (2) reinfection was 0.04 (95% CI: 0.00, 0.18, I2 = 79.7%), and (3) major amputation was 0.00 (95% CI: 0.00, 0.04, I2 = 0%). Five studies addressing total excisions were identified via the systematic review however, their combined sample size (n = 28 patients) impeded use of a meta-analysis. Ninety (19%) licensed surgeons participated in the survey. In a hemodynamically stable, nonseptic patient, 67% (60) of respondents routinely excise the graft, while 31% (28) prefer preservation. CONCLUSIONS: Study design and patient characteristic-related heterogeneity limited our ability to generate robust, clinical evidence-level outcome estimates. A prospective study is necessary to definitively establish the efficacy of antibiotic beads in the treatment and preservation of vascular graft infections.

Outcomes after Endovascular Stent Placement for Long-Segment Superficial Femoral Artery Lesions.

BACKGROUND: Endovascular intervention is commonly pursued as first-line management of symptomatic, long-segment superficial femoral artery (SFA) disease. The relative effectiveness and comparative long-term outcomes among bare metal stents (BMS), covered stents (CS), and drug-eluting stents (DES) for long-segment SFA lesions remain uncertain. METHODS: A retrospective cohort study identified patients with symptomatic SFA lesions measuring at least 15 cm in length who successfully received an endovascular stent (BMS, CS, or DES). The outcomes were patency, patient presentation upon stent occlusion, amputation-free survival (AFS), and all-cause mortality. Proportional hazards regressions and a multinomial logistic regression model were used to control for significant confounders. RESULTS: A total of 226 procedures were analyzed (BMS: 95 [42%]; CS: 74 [33%]; DES: 57 [25%]). There were no significant differences among the 3 stent types with respect to age, prevalence of either diabetes or end-stage renal disease, or smoking history. The median length of the SFA lesion varied across the cohorts (BMS: 28 cm [interquartile range, IQR 20-30]; CS: 26 cm [IQR 20-30]; DES: 20 cm [IQR 16-25]; P = 0.002). The unadjusted primary patency of BMS at 12, 24, and 48 month following index stent placement was 57%, 47%, and 44%, respectively. This is compared to 62%, 49%, and 42% for CS, and 81%, 66%, and 53% for DES, respectively (log-rank P = 0.044). In adjusted models, however, there were no significant differences in primary patency among the stent types. Compared to CS however, DES was associated with improved primary-assisted patency (hazard ratio [HR] for patency loss: 0.35, P = 0.008) and secondary patency (HR: 0.32, P = 0.011). Across the entire follow-up period, stent occlusions occurred in 38 (40%) BMS cases, 42 (57%) CS, and 11 (19%) DES (P < 0.001). Of these, acute limb ischemia (ALI) occurred in 2 (5%) BMS cases, 14 (33%) CS, and 1 (9%) DES (P = 0.010). After adjustment, the relative risk of presenting with ALI as opposed to claudication was 27 times greater among patients re-presenting with occluded CS compared to BMS (P = 0.020). There were no significant differences in AFS or all-cause mortality across the 3 cohorts. CONCLUSIONS: For long-segment SFA lesions, DES is associated with improved primary-assisted and secondary patency over long-term follow-up. In the event of stent occlusion, CS is associated with an increased risk of ALI.

Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers.

OBJECTIVE: Effective diabetic foot ulcer (DFU) care has been stymied by a lack of input from patients and caregivers, reducing treatment adherence and overall quality of care. Our objectives were to capture the patient and caregiver perspectives on experiencing a DFU and to improve prioritization of patient-centered outcomes. METHODS: A DFU-related stakeholder group was formed at an urban tertiary care center. Seven group meetings were held across 4 months, each lasting ∼1 hour. The meeting facilitator used semistructured questions to guide each discussion. The topics assessed the challenges of the current DFU care system and identified the outcomes most important to stakeholders. The meetings were audio recorded and transcribed. Directed and conventional content analyses were used to identify key themes. RESULTS: Six patients with diabetes (five with an active DFU), 3 family caregivers, and 1 Wound Clinic staff member participated in the stakeholder group meetings. The mean patient age was 61 years, four (67%) were women, five (83%) were either African American or Hispanic, and the mean hemoglobin A1c was 8.3%. Of the five patients with a DFU, three had previously required lower extremity endovascular treatment and four had undergone at least one minor foot amputation. Overall, stakeholders described how poor communication between medical personnel and patients made the DFU experience difficult. They felt overwhelmed by the complexity of DFU care and were persistently frustrated by inconsistent medical recommendations. Limited resources further exacerbated their frustrations and barriers to care. To improve DFU management, the stakeholders suggested a centralized healthcare delivery pathway with timely access to a coordinated, multidisciplinary DFU team. The clinical outcomes most valued by stakeholders were (1) avoiding amputation and (2) maintaining or improving health-related quality of life, which included independent mobility, pain control, and mental health. From these themes, we developed a conceptual model to inform DFU care pathways. CONCLUSIONS: Current DFU management lacks adequate care coordination. Multidisciplinary approaches tailored to the self-identified needs of patients and caregivers could improve adherence. Future DFU-related comparative effectiveness studies will benefit from direct stakeholder engagement and are required to evaluate the efficacy of incorporating patient-centered goals into the design of a multidisciplinary DFU care delivery system.

Long-term outcomes of lower extremity graft preservation using antibiotic beads in patients with early deep wound infections after major arterial reconstructions.

OBJECTIVE: Bypass graft preservation with wound sterilization using serial antibiotic bead exchange has been described in patients presenting with deep wound infections after extremity bypass. The long-term benefits of this approach remain poorly understood. We examined whether graft preservation and wound sterilization with antibiotic beads affect amputation rates and patient survival. METHODS: Patients who underwent operations for aortoiliac or infrainguinal aneurysmal or occlusive arterial disease were retrospectively analyzed. The Infection group included those with patent vascular grafts who developed Szilagyi class II or III deep wound infections within 90 days of index reconstruction and had no evidence of anastomotic or arterial bleeding. All patients in the infection group were managed with graft preservation using serial antibiotic bead exchange every 3 to 5 days until wound cultures became negative. This group was compared with a contemporary group of controls who underwent similar interventions but did not develop wound infections postoperatively. The primary outcome was amputation-free survival, defined as survival without major amputation. Secondary outcomes included major amputations and the occurrence of anastomotic pseudoaneurysms necessitating repair. Inverse propensity score weighting was used for risk adjustment between the groups. RESULTS: Over an 8-year period, we treated 701 patients (infection, 68; controls, 633). Compared with controls, patients in the infection group had a higher body mass index (mean, 28.5 vs 26.3, P = .002) and more prosthetic conduits placed during the index reconstruction. Amputation-free survival for the infection vs the control group was 78 vs 76% at 2 years, 61 vs 66% at 4 years, and 51 vs 57% at 6 years postoperatively (log-rank test, P = .516). Freedom from major amputation for the infection vs the control group was 82 vs 86% at 2 years, 80 vs 82% at 4 years, and 80 vs 76% at 6 years postoperatively (log-rank test, P = .568). In the risk-adjusted model, the presence of treated infection did not affect amputation-free survival (hazard ratio, 0.82; P = .440) or major amputation (hazard ratio, 1.02; P = .949). Anastomotic pseudoaneurysms occurred only in the Infection group (4.4%; P = .001), and were treated with interposition grafts without complications. CONCLUSIONS: Bypass graft preservation with wound sterilization using serial antibiotic bead exchange is associated with excellent limb salvage and survival rates, similar to those of noninfected wounds. With the use of this preservation strategy, close follow-up for timely detection of anastomotic pseudoaneurysms is recommended.

Delayed gratification and adherence to exercise among patients with claudication.

Few studies have explicitly identified factors that explain an individual's willingness to engage in community-based exercise for claudication. Identifying the unique characteristics of those inclined toward physical activity would inform interventions that encourage walking. We examined the utility of behavioral economics-related concepts in understanding walking among Veterans with claudication. Patients who received care at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, were surveyed on symptom severity, behavioral economics, stress, and depression. The primary outcome was a binary variable measuring current walking for exercise and defined as walking for at least 30 minutes every day. Multivariable logistic regression models were used to identify variables, both clinically and statistically significant, at a p-value < 0.05. Between April 2017 and March 2018, we received 148 (30%) responses. A total of 35% (n = 51) of respondents indicated that they walked recreationally for exercise compared to 65% (n = 94) who did not. Characteristics that were significantly associated with walking included regularly saving money (adjusted odds ratio (aOR) = 10.7, p = 0.001), seeking complex problem-solving (aOR = 0.12, p = 0.002), and severe symptoms (aOR = 0.24, p = 0.017). Individuals describing a preference for the future rather than immediate benefit also reported currently walking for exercise. Defining the characteristics of those who exercise may help inform strategies designed to increase walking among those who do not adhere to recommendations.

Health Care Resource Distribution of Texas Counties With High Rates of Leg Amputations.

BACKGROUND: Lower extremity amputation rates associated with peripheral arterial disease in Texas are high and vary disproportionately among different populations. We sought to assess the impact of socioeconomic status and health care resource distribution on the geographic prevalence of lower extremity amputation in Texas counties. MATERIALS AND METHODS: We collated 2005-2009 data on all 254 Texas counties. The primary outcome was the number of nontraumatic lower extremity amputations. Population-adjusted regressions identified factors that could explain increasing amputation rates. RESULTS: We identified 33 counties with population-weighted amputation rates in the highest 25%. These counties had higher rates of diabetes, larger populations of people categorized as black, fewer health care resources, and lower health care utilization. In the presence of more emergency room visits, dual Medicare/Medicaid eligibility decreased total amputations. In counties with more than 70% rural communities, additional primary care providers also significantly decreased amputations per 100,000 residents (mean difference = -0.12, 95% confidence interval: -0.23, -0.0008). CONCLUSIONS: Policy-driven strategic health care resource allocation at the local level may benefit patients in high-need, low-resource areas and promote a reduction in amputations.

Long-Term Wound Palliation to Manage Exposed Hardware in the Setting of Peripheral Arterial Disease.

Exposed orthopedic hardware in the lower extremity complicated by peripheral arterial disease typically demands multiple operative procedures by several disciplines to maintain skeletal integrity and achieve complete wound healing. For ambulatory patients that are either not candidates for lower extremity revascularization or prefer not to pursue surgical attempts at limb preservation, wound palliation is a potential management strategy. We discuss a patient with a history of severe peripheral arterial disease and a left pilon fracture previously treated with open reduction and internal fixation. He presented with a 2-month history of open wounds and exposed hardware over his left tibia. Though he initially underwent surgical revascularization to improve circulation to his lower extremity, the arterial bypass occluded within 6 months of the operation. At that point, the patient decided to forego any additional surgical intervention, including hardware removal, in favor of local wound care and expectant management. Remarkably, the wound remained stable in size over the next 14 years, he remained ambulatory, and never developed a deep wound infection. Though palliative wound care alone is understandably not the recommended first-line therapy for managing nonhealing wounds, it may be a safe and potentially durable alternative to major lower extremity amputation when revascularization and soft-tissue coverage cannot be achieved.

Using an anonymous, resident-run reporting mechanism to track self-reported duty hours.

BACKGROUND: Implementation of resident duty hour policies has resulted in a need to document work hours accurately. We compared the number of self-reported duty hour violations identified through an anonymous, resident-administered survey to that obtained from a standardized, ACGME-sanctioned electronic tracking system. METHODS: 10 cross-sectional surveys were administered to general surgery residents over five years. A resident representative collected and de-identified the data. RESULTS: A median of 54 residents (52% male) participated per cohort. 429 responses were received (79% response rate). 111 violations were reported through the survey, while the standardized electronic system identified 76, a trend significantly associated with PGY-level (p < 0.001) and driven by first-year residents (n = 81 versus 37, p = 0.001). CONCLUSIONS: An anonymous, resident-run mechanism identifies significantly more self-reported violations than a standardized electronic tracking system alone. This argues for individual program evaluation of duty hour tracking mechanisms to correct systematic issues that could otherwise lead to repeated violations.

Successful Smoking Cessation Associated with Walking Behavior in Patients with Claudication.

BACKGROUND: Behavioral economics theories suggest that a preference for delayed benefits promotes positive behavioral change, a concept relevant to both smoking cessation and community-based exercise regimens for claudication. Given the high rate of smoking among older veterans, we were interested in examining the association between smoking cessation, exercise regimen adherence, and preferences for delayed versus immediate benefits. METHODS: Between April 2017 and March 2018, patients with claudication at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, received questionnaires collecting information on social, behavioral, and psychological characteristics. A dual validation system, via the electronic medical record and survey data, measured the primary outcome-smoking cessation versus current smoking. Self-reported physical activity was measured through the validated Ainsworth's compendium of Physical Activities and binary survey questions. The Walking Impairment and Barratt's Impulsivity Questionnaires measured subjective symptom severity and behavioral economics factors, respectively. Multivariable, logistic regression models identified significant associations. RESULTS: The survey was mailed to 500 patients who met the eligibility criteria. We received responses from 148 individuals (30%), and 67 of 141 (48%) indicated that they had successfully quit smoking. In unadjusted comparisons, the median cognitive complexity score in the smoking cessation group was higher than that in the current smoking group. A greater proportion of patients who reported walking for exercise (n = 46) also reported successful smoking cessation (28/46, 61%). Among those who were not walking for exercise (n = 88), more individuals reported current smoking (49/88, 56%). In the multivariable model, individuals who had successfully stopped smoking were older (odds ratio [OR]: 7.59, P < 0.001), more likely to walk for exercise (OR: 3.94, P = 0.009), more interested in the future than in the present (OR: 1.73, P = 0.030), and more likely to regularly save money (OR: 3.49, P = 0.046). CONCLUSIONS: We found that participants who reported successful smoking cessation were more likely to report walking for exercise. Our findings suggest that adherence to walking may be less challenging for patients who have already successfully implemented and continue to implement another beneficial health behavior (smoking cessation). Patients with claudication who are current smokers may be less likely to adopt exercise recommendations.

Missing Data in Surgical Data Sets: A Review of Pertinent Issues and Solutions.

Incomplete data is a common problem in research studies. Methods to address missing observations in a data set have been extensively researched and described. Disseminating these methods to the greater research community is an ongoing effort. In this article, we describe some of the basic principles of missing data and identify practical, commonly used methods of adjustment relevant to surgical data sets. Through an example data set, we compare models generated through complete case analysis, single imputation (SI), and multiple imputation (MI). We also provide information on the steps to conduct MI using Stata IC. In our comparisons, we found that differences in odds ratios were greatest between the results from complete case analysis compared to the SI and MI models indicating that in this case the reduction in statistical power has a non-negligible effect on the parameter estimates. Odds ratio estimates from the SI and MI methods were largely similar. In some instances, when compared to the MI method, the SI method tended to overestimate effect sizes. While in this example the differences in odds ratios do not vary greatly between the SI and MI methods, there are clear indications supporting the use of MI over SI. By describing the issues surrounding missing data and the available options for adjustment, we hope to encourage the use of robust imputation methods for missing observations.

A Multi-Component Strategy to Decrease Wound Complications after Open Infra-Inguinal Re-Vascularization.

BACKGROUND: Wound complications remain a significant source of morbidity for patients undergoing open infra-inguinal re-vascularization. The purpose of this study was to determine the impact of several infection-control strategies on post-operative wound complications after open infra-inguinal re-vascularization. METHODS: A retrospective cohort study was conducted among all patients who underwent an open infra-inguinal re-vascularization procedure before and after 2014. Since 2014, we have implemented strategies to reduce post-operative wound complications, including: (1) Decreasing the use of incisional skin staples, (2) increasing the use of negative pressure wound therapy (NPWT) dressings, and (3) implementing an outpatient elective decontamination protocol for methicillin-resistant Staphylococcus aureus. "Pre-era" is defined as the period between January 2012 and December 2013, before the implementation of infection control strategies; "Post-era" is between January 2015 and August 2016, after implementation. The primary outcome of interest is 30-day wound complications (infection or dehiscence). Multi-variable logistic regression analysis was used to identify significant predictors of wound-related complications between the two cohorts. Propensity score adjustment controlled for baseline patient characteristics, peri-operative variables, and surgeon experience. RESULTS: A total of 338 open infra-inguinal procedures were performed: 175 in the pre-era and 163 in the post-era. Chlorhexidine skin preparation was used in the majority (321 [95%]) of cases. Comparing the periods, the post-era is characterized by a significant decrease in the use of groin staples (118 [67%] vs. 51 [31%], p < 0.001), and an increased application of NPWT dressings (6 [4%] vs. 66 [43%], p < 0.001). Thirty-five (37%) outpatient elective cases received the pre-operative decontamination protocol in the post-era. Compared with the pre-era, there was a decrease in the 30-day rate of wound complications (68 [39%] to 42 [26%], p = 0.011), and infection-related re-admissions (31 [17.7%] to 21 [12.9%], p = 0.220). When adjusting for patient characteristics, operative variables, and surgeon experience, post-era had significantly lower wound complications (odds ratio [OR] 0.33, p = 0.002) and re-operations (OR 0.16, p = 0.007). Among outpatient elective cases, the decontamination protocol was also independently associated with these two outcomes (wound complications: OR 0.05, p = 0.006; re-operations: 0.06, p = 0.002). The use of groin staples was an independent predictor of deep groin infections (OR 248, p < 0.001) and re-operations (OR 8.16, p = 0.032). CONCLUSIONS: Wound complications after open infra-inguinal re-vascularization have decreased significantly after the implementation of several infection-control strategies. Findings suggest that skin staples should be avoided in groin wounds, and anti-staphylococcal decontamination protocols decrease wound complications and prevent re-operations.

RACIAL AND GEOGRAPHIC VARIATION IN LEG AMPUTATIONS AMONG TEXANS.

BACKGROUND: The existence of racial and ethnic disparities in leg amputations rates is well documented. Despite this, approaches to addressing these alarming disparities have been hampered by the inability to identify at-risk individuals in a region and design targeted interventions. We undertook this study to identify small geographic areas in which efforts focused on high-risk individuals with peripheral artery disease (PAD) could address disparities in leg amputation rates. METHODS: We used de-identified Texas state admission data to identify PAD-related admissions associated with an initial revascularization (leg angioplasty or leg bypass) or an primary leg (above-ankle) amputation between from 2004 through 2009. RESULTS: 21,273 major initial procedures were performed in Texas from 2004 through 2009 for PAD-related diagnoses, including 16,898 revascularizations and 4,375 leg amputations. A multivariate logistic regression demonstrated that an initial leg amputations done without revascularization was significantly associated with, among other variables: people categorized as black (odds ratio [OR] 1.79) or Hispanic (OR 1.42); those with Medicaid coverage (OR 1.89); and those treated at low volume hospitals (OR 1.78; p<0.001 for all). Four geographic regions were identified with significantly higher risk-adjusted leg amputation rates. Of the 349 Texas hospitals performing major procedures, 72 (21%) reported no revascularization procedures during the six year period studied. CONCLUSIONS: Prevention efforts directed at specific geographic areas may be more likely to reach at-risk people with PAD and thereby reduce leg amputations disparities in Texas. Such efforts might also find strategies to direct patients toward higher volume centers with higher revascularization rates.

Association of the Addition of Oral Antibiotics to Mechanical Bowel Preparation for Left Colon and Rectal Cancer Resections With Reduction of Surgical Site Infections.

IMPORTANCE: Surgical site infections (SSIs) after colorectal surgery remain a significant complication, particularly for patients with cancer, because they can delay the administration of adjuvant therapy. A combination of oral antibiotics and mechanical bowel preparation (MBP) is a potential, yet controversial, SSI prevention strategy. OBJECTIVE: To determine the association of the addition of oral antibiotics to MBP with preventing SSIs in left colon and rectal cancer resections and its association with the timely administration of adjuvant therapy. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was performed of 89 patients undergoing left colon and rectal cancer resections from October 1, 2013, to December 31, 2016, at a single institution. A bowel regimen of oral antibiotics and MBP (neomycin sulfate, metronidazole hydrochloride, and magnesium citrate) was implemented August 1, 2015. Patients receiving MBP and oral antibiotics and those undergoing MBP without oral antibiotics were compared using univariate analysis. Multivariable logistic regression controlling for factors that may affect SSIs was used to evaluate the association between use of oral antibiotics and MBP and the occurrence of SSIs. MAIN OUTCOMES AND MEASURES: Surgical site infections within 30 days of the index procedure and time to adjuvant therapy. RESULTS: Of the 89 patients (5 women and 84 men; mean [SD] age, 65.3 [9.2] years) in the study, 49 underwent surgery with MBP but without oral antibiotics and 40 underwent surgery with MBP and oral antibiotics. The patients who received oral antibiotics and MBP were younger than those who received only MBP (mean [SD] age, 62.6 [9.1] vs 67.5 [8.8] years; P = .01), but these 2 cohorts of patients were otherwise similar in baseline demographic, clinical, and cancer characteristics. Surgical approach (minimally invasive vs open) and case type were similarly distributed; however, the median operative time of patients who received oral antibiotics and MBP was longer than that of patients who received MBP only (391 minutes [interquartile range, 302-550 minutes] vs 348 minutes [interquartile range, 248-425 minutes]; P = .03). The overall SSI rate was lower for patients who received oral antibiotics and MBP than for patients who received MBP only (3 [8%] vs 13 [27%]; P = .03), with no deep or organ space SSIs or anastomotic leaks in patients who received oral antibiotics and MBP compared with 9 organ space SSIs (18%; P = .004) and 5 anastomotic leaks (10%; P = .06) in patients who received MBP only. Despite this finding, there was no difference in median days to adjuvant therapy between the 2 cohorts (60 days [interquartile range, 46-73 days] for patients who received MBP only vs 72 days [interquartile range, 59-85 days] for patients who received oral antibiotics and MBP; P = .13). Oral antibiotics and MBP (odds ratio, 0.11; 95% CI, 0.02-0.86; P = .04) and minimally invasive surgery (odds ratio, 0.22; 95% CI, 0.05-0.89; P = .03) were independently associated with reduced odds of SSIs. CONCLUSIONS AND RELEVANCE: The combination of oral antibiotics and MBP is associated with a significant decrease in the rate of SSIs and should be considered for patients undergoing elective left colon and rectal cancer resections.

Candidate genes that may be responsible for the unusual resistances exhibited by Bacillus pumilus SAFR-032 spores.

The spores of several Bacillus species, including Bacillus pumilus SAFR-032 and B. safensis FO-36b, which were isolated from the spacecraft assembly facility at NASA's Jet Propulsion Laboratory, are unusually resistant to UV radiation and hydrogen peroxide. In order to identify candidate genes that might be associated with these resistances, the whole genome of B. pumilus SAFR-032, and the draft genome of B. safensis FO-36b were compared in detail with the very closely related type strain B. pumilus ATCC7061(T). 170 genes are considered characteristic of SAFR-032, because they are absent from both FO-36b and ATCC7061(T). Forty of these SAFR-032 characteristic genes are entirely unique open reading frames. In addition, four genes are unique to the genomes of the resistant SAFR-032 and FO-36b. Fifty three genes involved in spore coat formation, regulation and germination, DNA repair, and peroxide resistance, are missing from all three genomes. The vast majority of these are cleanly deleted from their usual genomic context without any obvious replacement. Several DNA repair and peroxide resistance genes earlier reported to be unique to SAFR-032 are in fact shared with ATCC7061(T) and no longer considered to be promising candidates for association with the elevated resistances. Instead, several SAFR-032 characteristic genes were identified, which along with one or more of the unique SAFR-032 genes may be responsible for the elevated resistances. These new candidates include five genes associated with DNA repair, namely, BPUM_0608 a helicase, BPUM_0652 an ATP binding protein, BPUM_0653 an endonuclease, BPUM_0656 a DNA cytosine-5- methyltransferase, and BPUM_3674 a DNA helicase. Three of these candidate genes are in immediate proximity of two conserved hypothetical proteins, BPUM_0654 and BPUM_0655 that are also absent from both FO-36b and ATCC7061(T). This cluster of five genes is considered to be an especially promising target for future experimental work.

Correlation between ankle-brachial index and microalbuminuria in type 2 diabetes mellitus.

INTRODUCTION: Microalbuminuria is a reliable marker of diabetic nephropathy. Establishment of peripheral vascular complications leads to early diagnosis, prevention, and treatment of renal and cardiovascular complications. This study investigated the value of ankle-brachial index (ABI) for prediction of microalbuminuria in type 2 diabetic patients. MATERIALS AND METHODS: Measurement of ABI with color Doppler ultrasonography was carried out for 206 patients with type 2 diabetes mellitus. An ABI Index less than 0.9 was defined as a predictive marker for atherosclerosis. Microalbuminuria and risk factors of atherosclerosis were compared between the patients categorized based on the ABI values. RESULTS: The mean ABI was 1.1 ± 0.2 (range, 0.052 to 1.6), and 41 (20%) had an abnormal ABI (< 0.9). The correlations were significant between abnormal ABI and duration of disease (P = .04), cardiovascular event and cardiac care unit admission (P = .001), hypertension (P = .01), and dyslipidemia (P = .01). There was a significant correlation between ABI and microalbuminuria (odds ratio, 0.05; 95% confidence interval, 0.038 to 0.630; P < .001). A cutoff point of an ABI less than or equal to 1.04 had a sensitivity of 71.6% and a specificity of 64.2% for prediction of microalbuminuria. CONCLUSIONS: The ABI is a noninvasive and reliable assay for detection of peripheral and cardiovascular complications, and also early stage of nephropathy in diabetic patients. In patients with an abnormal ABI, long-term follow-up for earlier detection and prevention of complications is helpful.

Prophylactic distal revascularization and interval ligation procedure during femoral vein transposition fistula creation in patients at high risk for ischemic complications.

Femoral vein transposition arteriovenous fistula (FVt AVF) is a viable autologous option when upper extremity dialysis access sites have become compromised. High volume flow through the AVF can lead to ischemic complications, including steal syndrome (SS), and may threaten access and limb viability. Risk factors for SS include: age >60 years, female sex, diabetes, atherosclerosis, hypertension, and previous limb procedures. Two dialysis patients, who were at high risk for SS in their lower extremities as assessed during the preoperative evaluation for an elective FVt AVF, had a distal revascularization and interval ligation (DRIL) procedure concurrently performed. At 42 and 24 months from their respective surgeries, both patients are reliably using their lower extremity autologous access sites and have not developed any signs or symptoms of ischemia. DRIL may represent an effective surgical strategy that can prophylactically be used to minimize the incidence of ischemic complications during FVt AVF in carefully selected, high-risk patients.

Left common iliac artery to inferior vena cava abdominal wall arteriovenous graft for hemodialysis access.

We describe a novel arteriovenous graft configuration in the abdominal wall for hemodialysis in a 51-year-old woman with sickle cell disease. Upper extremity access sites were exhausted, and intrathoracic central veins occluded. Because of diminished quality of the left groin due to scar tissue from previous infected access, inadequate vasculature, and the presence of functional femoral catheter in the right groin with common iliac vein stenosis, we decided to create an arteriovenous graft from the left common iliac artery to the inferior vena cava. Adequate thrill and uneventful postoperative recovery was observed. At 4 months, the patient has been successfully using her graft.

Emerging roles for the transforming growth factor-{beta} superfamily in regulating adiposity and energy expenditure.

Members of the TGF-ß superfamily regulate many aspects of development, including adipogenesis. Studies in cells and animal models have characterized the effects of superfamily signaling on adipocyte development, adiposity, and energy expenditure. Although bone morphogenetic protein (BMP) 4 is generally considered a protein that promotes the differentiation of white adipocytes, BMP7 has emerged as a selective regulator of brown adipogenesis. Conversely, TGF-ß and activin A inhibit adipocyte development, a process augmented in TGF-ß-treated cells by Smads 6 and 7, negative regulators of canonical TGF-ß signaling. Other superfamily members have mixed effects on adipogenesis depending on cell culture conditions, the timing of expression, and the cell type, and many of these effects occur by altering the expression or activities of proteins that control the adipogenic cascade, including members of the CCAAT/enhancer binding protein family and peroxisome proliferator-activated receptor-γ. BMP7, growth differentiation factor (GDF) 8, and GDF3 are versatile in their mechanisms of action, and altering their normal expression characteristics has significant effects on adiposity in vivo. In addition to their roles in adipogenesis, activins and BMP7 regulate energy expenditure by affecting the expression of genes that contribute to mitochondrial biogenesis and function. GDF8 signals through its own receptors during adipogenesis while antagonizing BMP7, an example of a ligand from one major branch of the superfamily regulating the other. With such intricate relationships that ultimately affect adiposity, TGF-ß superfamily signaling holds considerable promise as a target for treating human obesity and its comorbidities.