Successful AV fistula creation does not lead to higher catheter use: the experience by the Northwest Renal Network 16 Vascular Access Quality Improvement Program. Four years follow-up.

BACKGROUND: In 2002, the Center for Medicare and Medicaid Services (CMS) required all 18 Renal Networks to participate in a Vascular Access Quality Improvement Program (QIP). The Northwest Renal Network (NWRN 16) chose to increase arteriovenous fistula (AVF) use. NWRN 16 hypothesized that strategies which targeted the improvement of AVF rate and the reduction of catheter use were the same. In December 2001, 44.2% of hemodialysis (HD) patients in the NWRN 16 received HD using an AVF which met the Dialysis Outcome Quality Initiative (K/DOQI) 40% AVF guideline for prevalent patients. However, 43% of HD facilities (2869 patients) had less than 40% of AVF and higher HD catheter rates than the average Network catheter rates (25.0 vs. 20.3%). To address the needs of underperforming facilities, NWRN 16 provided education and tools for their vascular access decision makers to promote AVF creation and catheter reduction. METHODS: In 2002, NWRN 16 sponsored four regional workshops targeted at nephrologists, vascular surgeons, HD nurses, and interventional radiologists. RESULTS: Percentage of AVFs in use in invited facilities increased from 31.3% pre-intervention to 56.2% at 4 yrs: 78% increase (99% confidence interval: 77.8% to 81.5%). Percentage of catheters increased from 25% to 25.8%: 3.2% change over 4 yrs (99% confidence interval: 2.5% to 4%). CONCLUSION: The success of Network 16's AVF interventions demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, and innovative strategies to increase dramatically AVF use without substantial increase in catheter use.

Needle aspiration cytologic examination in the management of suspicious lesions of the breast.

The experience of one surgeon with needle aspiration cytologic examination used as an office procedure in the management of suspicious solid lesions of the breast over a period of seven years in presented. Three hundred and thirty-five aspirations were performed with the diagnosis of carcinoma subsequently established in 126 or 37 per cent of the patients. In 79 of these patients (63 per cent) carcinoma was diagnosed preoperatively by positive needle aspiration cytologic examination only. There were no false-positive results. Thus, this group of patients was spared time and added expense of open biopsy before definitive surgical treatment was instituted.

Colostomy wound closure.

The management of the wound at the time of colostomy closure has been controversial, and wound infection is a frequently cited complication of this procedure. We have conducted a prospective randomized study of colostomy wound closure in 105 patients with three study groups: (1) primary closure (n = 38); (2) primary closure with subcutaneous drains (n = 29); and (3) delayed primary closure (n = 38). All patients had mechanical bowel preparation with whole gut lavage as well as oral neomycin sulfate/erythromycin estolate and perioperative parenteral cefazolin sodium (Ancef). Five wound infections (4.8%) occurred. Three infections were in the delayed primary closure group and one infection in each of the other two study groups. No statistical difference in wound infection was demonstrated. On the basis of the findings in this study, we would not recommend delayed primary closure for the management of colostomy closure wounds when careful mechanical and antibiotic preparation has been utilized.