Antiseptic efficacy of an innovative perioperative surgical skin preparation: A confirmatory FDA phase 3 analysis.

BACKGROUND: An innovative approach to perioperative antiseptic skin preparation is warranted because of potential adverse skin irritation, rare risk of serious allergic reaction, and perceived diminished clinical efficacy of current perioperative antiseptic agents. The results of a confirmatory US Food and Drug Administration (FDA) phase 3 efficacy analysis of a recently approved innovative perioperative surgical skin antiseptic agent are discussed. METHODS: The microbial skin flora on abdominal and groin sites in healthy volunteers were microbiologically sampled following randomization to either ZuraGard, a 2% chlorhexidine/70% isopropyl alcohol preparation (Chloraprep), or a control vehicle (alcohol-free ZuraGard). Mean log10 reduction of colony-forming units (CFU) was assessed at 30 seconds, 10 minutes, and 6 hours. RESULTS: For combined groin sites (1,721 paired observations) at all time points, the mean log10 CFU reductions were significantly greater in the ZuraGard group than in the Chloraprep group (P < .02). Mean log10 CFU reductions across combined abdominal and groin sites at all time points (3,277 paired observations) were significantly greater in the ZuraGard group than in the Chloraprep group (P < .02). CONCLUSIONS: A confirmatory FDA phase 3 efficacy analysis of skin antisepsis in human volunteers documented that ZuraGard was efficacious in significantly reducing the microbial burden on abdominal and groin test sites, exceeding that of Chloraprep. No significant adverse reactions were observed following the application of ZuraGard. TRIAL REGISTRATION: ClinicalTrials.gov identifiers: NCT02831998 and NCT02831816.

Assessment of a novel antimicrobial surface disinfectant on inert surfaces in the intensive care unit environment using ATP-bioluminesence assay.

BACKGROUND: Cross-contamination from inanimate surfaces can play a significant role in intensive care unit (ICU)-acquired colonization and infection. This study assessed an innovative isopropyl alcohol/organofunctional silane solution (IOS) to reduce microbial contamination on inert surfaces in a medical ICU. METHODS: Baseline adenosine triphosphate bioluminescence testing (ABT)-measurements (N = 200) were obtained on designated inert ICU surfaces followed by IOS treatment. At 1 and 6 weeks, selective surfaces were randomized to either IOS-treated or nontreated controls for comparison using ABT (N = 400) and RODAC colony counts (N = 400). An ABT value of ≤45 relative light units (RLU) was designated as "clean," whereas >45 was assessed as "dirty." RESULTS: Mean RLU baseline values ranged from 870.3 (computer keyboard) to 201.6 (bed table), and 97.5% of surfaces were assessed as "dirty." At 6 weeks, the mean RLU of surfaces treated with IOS ranged from 31.7 (physician workstation) to 51.5 (telephone handpiece), whereas values on comparative control surfaces were 717.3 and 643.7, respectively (P < .001). Some 95.5% of RODAC cultures from IOS-treated sites at 6 weeks were negative, whereas 90.5% of nontreated sites were culture-positive, yielding multiple isolates including multidrug-resistant gram-positive and gram-negative bacteria. CONCLUSIONS: IOS-treated surfaces recorded significantly lower RLU and RODAC colony counts compared with controls (P < .001). A single application of IOS resulted in a persistent antimicrobial activity on inert ICU surfaces over the 6-week study interval.

Unplanned 30-day readmissions after endovascular aneurysm repair: An analysis using the Nationwide Readmissions Database.

BACKGROUND: Endovascular aneurysm repair (EVAR) is the preferred method for addressing abdominal aortic aneurysms (AAAs), with proven reduction in perioperative morbidity and mortality. There are, however limited data examining the readmissions after EVAR that are associated with increased patient morbidity and cost. As EVAR use continues its dominance in the management of AAAs, it becomes imperative to identify and mitigate risk factors associated with unplanned hospital readmissions. METHODS: The Nationwide Readmissions Database (NRD) was queried for all 30-day readmissions after an index EVAR procedure from 2012 to 2014. Preoperative patient demographics, hospital characteristics, readmission diagnosis, and costs were compared between those who were and were not readmitted within 30 days of the index operation. Multivariable logistic regression was used to identify potential risk factors associated with unplanned readmissions within 30 days. RESULTS: We identified 120,646 patients who underwent an EVAR from 2012 to 2014 in the United States. The overall unplanned readmission rate during this period was 11.6% (n = 14,073) within 30 days of the index EVAR procedure. The readmission rate was the highest in 2012, with a rate of 12.3% (P = .02). Multivariate regression analysis showed that EVAR readmissions were significantly higher in patients who were of younger age (18 to 49 years) compared with other age groups (odds ratio [OR], 1.9-2.17; P < .001), female sex (OR, 1.367; P < .001), had Medicare (OR, 1.39) or Medicaid (OR, 1.25) insurance, or a combination of these. Underlying patient comorbidities significantly associated with readmissions included congestive heart failure (OR, 2.4), peripheral vascular disease (OR, 1.1), chronic pulmonary disease (OR, 1.2), cancer with no metastasis (OR, 1.5), metastatic cancer (OR, 2.2), renal failure (OR, 1.8), and diabetes (OR, 1.5). CONCLUSIONS: The trend in 30-day readmission rates after EVAR has decreased slightly since 2012, but overall rates are at 11.6%, which is not insubstantial. Patient factors strongly associated with hospital readmission were younger age and patient comorbidities, including congestive heart failure, concurrent cancer diagnosis, renal failure, and diabetes.

Disseminated Mycotic Aneurysms following Intravesical Bacillus Calmette-Guérin Therapy for Bladder Cancer: Case Discussion and Systematic Treatment Algorithm.

Numerous case reports have highlighted the relationship between bacillus Calmette-Guérin (BCG) therapy and development of systemic mycotic aneurysms but none have established a management algorithm in patients with suspected vascular dissemination of Mycobacterium bovis. Delay in diagnosis of this disease process will lead to delays in initiation of antimycobacterium treatment to prevent dissemination into other arterial beds and potentially complicate effective surgical treatment leading to aneurysmal rupture and other devastating vascular consequences. Given the increasing number of reported cases in the literature and the ongoing, standard of care utilization of BCG for bladder cancer, we believe that a systematic approach to the management of patients with suspected BCG-related mycotic aneurysms should be set in place to prevent misdiagnosis and delays in treatment. In this report, we discuss the presentation, work-up, and report our treatment algorithm of a patient who developed diffuse peripheral mycotic aneurysms following BCG therapy for bladder cancer.

Perioperative hair removal in the 21st century: Utilizing an innovative vacuum-assisted technology to safely expedite hair removal before surgery.

BACKGROUND: Perioperative hair removal using clippers requires lengthy cleanup to remove loose hairs contaminating the operative field. We compared the amount of hair debris and associated microbiologic contamination produced during clipping of surgical sites using standard surgical clippers (SSC) or clippers fitted with a vacuum-assisted hair collection device (SCVAD). METHODS: Trained nurses conducted bilateral hair clipping of the chest and groin of 18 male subjects using SSC or SCVAD. Before and during clipping, measurements of particulate matter and bacterial contamination were evaluated on settling plates placed next to each subject's chest and groin. Skin condition after clipping and total clipping/cleanup times were compared between SSC and SCVAD. RESULTS: The microbial burden recovered from residual hair during cleanup in the SSC group was 3.9 log10 CFU and 4.6 log10 CFU from respective, chest, and groin areas. Use of the SCVAD resulted in a significant (P < .001) reduction in both residual hair and microbial contamination within the operative field compared with SSC. CONCLUSIONS: Use of SCVAD resulted in significant (P < .001) reduction in total time required to clip and clean up residual hair contaminating the operative field compared with standard practice (ie, SSC), eliminating the need to physically remove dispersed hairs, which can harbor a significant microbial burden, from within the operative field.

Preventable Complications Driving Rising Costs in Management of Patients with Critical Limb Ischemia.

BACKGROUND: This study aimed to identify factors that drive increasing health-care costs associated with the management of critical limb ischemia in elective inpatients. METHODS: Patients with a primary diagnosis code of critical limb ischemia (CLI) were identified from the 2001-2011 Nationwide Inpatient Sample. Demographics, CLI management, comorbidities, complications (bleeding, surgical site infection [SSI]), length of stay, and median in-hospital costs were reviewed. Statistical analysis was completed using Students' t-test and Mann-Kendall trend analysis. Costs are reported in 2011 US dollars corrected using the consumer price index. RESULTS: From 2001 to 2011, there were a total of 451,823 patients who underwent open elective revascularization as inpatients for CLI. Costs to treat CLI increased by 63% ($12,560 in 2001 to $20,517 in 2011, P < 0.001 in trend analysis). Endovascular interventions were 20% more expensive compared with open surgery ($19,566 vs. $16,337, P < 0.001). Age, gender, and insurance status did not affect the cost of care. From 2001 to 2011, the number of patient comorbidities (7.56-12.40) and percentage of endovascular cases (13.4% to 27.4%) increased, accounting for a 6% annual increase in total cost despite decreased median length of stay (6 to 5 days). Patients who developed SSI had total costs 83% greater than patients without SSIs ($30,949 vs. $16,939; P < 0.001). Patients who developed bleeding complications had total costs 41% greater than nonbleeding patients ($23,779 vs. $16,821, P < 0.001). Overall, there was a 32% reduction in SSI rates but unchanged rates of bleeding complications during this period. CONCLUSIONS: The cost of CLI treatment is increasing and driven by rising endovascular use, SSI, and bleeding in the in-patient population. Further efforts to reduce complications in this patient population may contribute to a reduction in health care-associated costs of treating CLI.

Is Staphylococcal Screening and Suppression an Effective Interventional Strategy for Reduction of Surgical Site Infection?

BACKGROUND: Staphylococcus aureus has been recognized as a major microbial pathogen for over 100 y, having the capacity to produce a variety of suppurative and toxigenic disease processes. Many of these infections are life-threatening, with particularly enhanced virulence in hospitalized patients with selective risk factors. Strains of methicillin-resistant Staphylococcus aureus (MRSA) have rapidly spread throughout the healthcare environment such that approximately 20% of S. aureus isolates recovered from surgical site infections are methicillin-resistant, (although this is now reducing following national screening and suppression programs and high impact interventions). METHODS: Widespread nasal screening to identify MRSA colonization in surgical patients prior to admission are controversial, but selective, evidence-based studies have documented a reduction of surgical site infection (SSI) after screening and suppression. RESULTS: Culture methods used to identify MRSA colonization involve selective, differential, or chromogenic media. These methods are the least expensive, but turnaround time is 24-48 h. Although real-time polymerase chain reaction (RT-PCR) technology provides rapid turnaround (1-2 h) with exceptional testing accuracy, the costs can range from three to 10 times more than conventional culture methodology. Topical mupirocin, with or without pre-operative chlorhexidine showers or skin wipes, is the current "gold-standard" for nasal decolonization, but inappropriate use of mupirocin is associated with increasing staphylococcal resistance. CONCLUSIONS: Selection of an effective active universal or targeted surveillance strategy should be based upon the relative risk of MSSA or MRSA surgical site infection in patients undergoing orthopedic or cardiothoracic device related surgical procedures.

Preadmission Application of 2% Chlorhexidine Gluconate (CHG): Enhancing Patient Compliance While Maximizing Skin Surface Concentrations.

OBJECTIVE: Surgical site infections (SSIs) are responsible for significant morbidity and mortality. Preadmission skin antisepsis, while controversial, has gained acceptance as a strategy for reducing the risk of SSI. In this study, we analyze the benefit of an electronic alert system for enhancing compliance to preadmission application of 2% chlorhexidine gluconate (CHG). DESIGN, SETTING, AND PARTICIPANTS: Following informed consent, 100 healthy volunteers in an academic, tertiary care medical center were randomized to 5 chlorhexidine gluconate (CHG) skin application groups: 1, 2, 3, 4, or 5 consecutive applications. Participants were further randomized into 2 subgroups: with or without electronic alert. Skin surface concentrations of CHG (µg/mL) were analyzed using a colorimetric assay at 5 separate anatomic sites. INTERVENTION: Preadmission application of chlorhexidine gluconate, 2% RESULTS: Mean composite skin surface CHG concentrations in volunteer participants receiving EA following 1, 2, 3, 4, and 5 applications were 1,040.5, 1,334.4, 1,278.2, 1,643.9, and 1,803.1 µg/mL, respectively, while composite skin surface concentrations in the no-EA group were 913.8, 1,240.0, 1,249.8, 1,194.4, and 1,364.2 µg/mL, respectively (ANOVA, P<.001). Composite ratios (CHG concentration/minimum inhibitory concentration required to inhibit the growth of 90% of organisms [MIC90]) for 1, 2, 3, 4, or 5 applications using the 2% CHG cloth were 208.1, 266.8, 255.6, 328.8, and 360.6, respectively, representing CHG skin concentrations effective against staphylococcal surgical pathogens. The use of an electronic alert system resulted in significant increase in skin concentrations of CHG in the 4- and 5-application groups (P<.04 and P<.007, respectively). CONCLUSION: The findings of this study suggest an evidence-based standardized process that includes use of an Internet-based electronic alert system to improve patient compliance while maximizing skin surface concentrations effective against MRSA and other staphylococcal surgical pathogens.

Evidence for a Standardized Preadmission Showering Regimen to Achieve Maximal Antiseptic Skin Surface Concentrations of Chlorhexidine Gluconate, 4%, in Surgical Patients.

IMPORTANCE: To reduce the amount of skin surface bacteria for patients undergoing elective surgery, selective health care facilities have instituted a preadmission antiseptic skin cleansing protocol using chlorhexidine gluconate. A Cochrane Collaborative review suggests that existing data do not justify preoperative skin cleansing as a strategy to reduce surgical site infection. OBJECTIVES: To develop and evaluate the efficacy of a standardized preadmission showering protocol that optimizes skin surface concentrations of chlorhexidine gluconate and to compare the findings with the design and methods of published studies on preoperative skin preparation. DESIGN, SETTING, AND PARTICIPANTS: A randomized prospective analysis in 120 healthy volunteers was conducted at an academic tertiary care medical center from June 1, 2014, to September, 30, 2014. Data analysis was performed from October 13, 2014, to October 27, 2014. A standardized process of dose, duration, and timing was used to maximize antiseptic skin surface concentrations of chlorhexidine gluconate applied during preoperative showering. The volunteers were randomized to 2 chlorhexidine gluconate, 4%, showering groups (2 vs 3 showers), containing 60 participants each, and 3 subgroups (no pause, 1-minute pause, or 2-minute pause before rinsing), containing 20 participants each. Volunteers used 118 mL of chlorhexidine gluconate, 4%, for each shower. Skin surface concentrations of chlorhexidine gluconate were analyzed using colorimetric assay at 5 separate anatomic sites. Individual groups were analyzed using paired t test and analysis of variance. INTERVENTION: Preadmission showers using chlorhexidine gluconate, 4%. MAIN OUTCOMES AND MEASURES: The primary outcome was to develop a standardized approach for administering the preadmission shower with chlorhexidine gluconate, 4%, resulting in maximal, persistent skin antisepsis by delineating a precise dose (volume) of chlorhexidine gluconate, 4%; duration (number of showers); and timing (pause) before rinsing. RESULTS: The mean (SD) composite chlorhexidine gluconate concentrations were significantly higher (P < .001) in the 1- and 2-minute pause groups compared with the no-pause group in participants taking 2 (978.8 [234.6], 1042.2 [219.9], and 265.6 [113.3] µg/mL, respectively) or 3 (1067.2 [205.6], 1017.9 [227.8], and 387.1 [217.5] µg/mL, respectively) showers. There was no significant difference in concentrations between 2 and 3 showers or between the 1- and 2-minute pauses. CONCLUSIONS AND RELEVANCE: A standardized preadmission shower regimen that includes 118 mL of aqueous chlorhexidine gluconate, 4%, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface (16.5 µg/cm2) concentrations of chlorhexidine gluconate that are sufficient to inhibit or kill gram-positive or gram-negative surgical wound pathogens. This showering regimen corrects deficiencies present in current nonstandardized preadmission shower protocols for patients undergoing elective surgery.

Assessment of an innovative antimicrobial surface disinfectant in the operating room environment using adenosine triphosphate bioluminescence assay.

Terminal cleaning in the operating room is a critical step in preventing the transmission of health care-associated pathogens. The persistent disinfectant activity of a novel isopropyl alcohol/organofunctional silane solution (ISO) was evaluated in 4 operating rooms after terminal cleaning. Adenosine triphosphate bioluminescence documented a significant difference (P < .048) in surface bioburden on IOS-treated surfaces versus controls. RODAC plate cultures revealed a significant (P < .001) reduction in microbial contamination on IOS-treated surfaces compared with controls. Further studies are warranted to validate the persistent disinfectant activity of ISO within selective health care settings.

The effect of Surgical Care Improvement Project measures on national trends on surgical site infections in open vascular procedures.

OBJECTIVE: The Surgical Care Improvement Project (SCIP) is a national initiative to reduce surgical complications, including postoperative surgical site infection (SSI), through protocol-driven antibiotic usage. This study aimed to determine the effect SCIP guidelines have had on in-hospital SSIs after open vascular procedures. METHODS: The Nationwide Inpatient Sample (NIS) was retrospectively analyzed using International Classification of Diseases, Ninth Revision, diagnosis codes to capture SSIs in hospital patients who underwent elective carotid endarterectomy, elective open repair of an abdominal aortic aneurysm (AAA), and peripheral bypass. The pre-SCIP era was defined as 2000 to 2005 and post-SCIP was defined as 2007 to 2010. The year 2006 was excluded because this was the transition year in which the SCIP guidelines were implemented. Analysis of variance and χ(2) testing were used for statistical analysis. RESULTS: The rate of SSI in the pre-SCIP era was 2.2% compared with 2.3% for carotid endarterectomy (P = .06). For peripheral bypass, both in the pre- and post-SCIP era, infection rates were 0.1% (P = .22). For open, elective AAA, the rate of infection in the post-SCIP era increased significantly to 1.4% from 1.0% in the pre-SCIP era (P < .001). Demographics and in-hospital mortality did not differ significantly between the groups. CONCLUSIONS: Implementation of SCIP guidelines has made no significant effect on the incidence of in-hospital SSIs in open vascular operations; rather, an increase in SSI rates in open AAA repairs was observed. Patient-centered, bundled approaches to care, rather than current SCIP practices, may further decrease SSI rates in vascular patients undergoing open procedures.

Antimicrobial activity of ceftaroline and other anti-infective agents against microbial pathogens recovered from the surgical intensive care patient population: a prevalence analysis.

BACKGROUND: Ceftaroline is a new parenteral cephalosporin agent with excellent activity against methicillin-sensitive (MSSA) and resistant strains of Staphylococcus aureus (MRSA). Critically ill surgical patients are susceptible to infection, often by multi-drug-resistant pathogens. The activity of ceftaroline against such pathogens has not been described. METHODS: Three hundred thirty-five consecutive microbial isolates were collected from surgical wounds or abscesses, respiratory, urine, and blood cultures from patients in the surgical intensive care unit (SICU) of a major tertiary medical center. Using Clinical and Laboratory Standards Institute (CLSI) standard methodology and published breakpoints, all aerobic, facultative anaerobic isolates were tested against ceftaroline and selected comparative antimicrobial agents. RESULTS: All staphylococcal isolates were susceptible to ceftaroline at a breakpoint of ≤1.0 mcg/mL. In addition, ceftaroline exhibited excellent activity against all streptococcal clinical isolates and non-ESBL-producing strains of Enterobacteriaceae (93.5%) recovered from SICU patients. Ceftaroline was inactive against ESBL-producing Enterobacteriaceae, Pseudomonas aeruginosa, vancomycin-resistant enterococci, and selective gram-negative anaerobic bacteria. CONCLUSIONS: At present, ceftaroline is the only cephalosporin agent that is active against community and healthcare-associated MRSA. Further studies are needed to validate the benefit of this novel broad-spectrum anti-infective agent for the treatment of susceptible serious infections in the SICU patient population.

Surgical site infections after lower extremity revascularization procedures involving groin incisions.

BACKGROUND: We sought to evaluate the incidence, epidemiology, and factors associated with surgical site infections (SSIs) after lower extremity revascularization procedures involving groin incisions and determine outcomes based on SSI status. METHODS: This is a single-institution, retrospective cohort study of 106 patients who underwent lower extremity revascularization procedures involving femoral artery exposure through a groin incision at a tertiary referral hospital. The primary outcome was occurrence of SSI at the groin wound. The duration of hospital stay, reoperation within 30 days, discharge disposition, and 30-day mortality were also evaluated. Independent variables included patient demographics and operative variables (i.e., procedure type, transfusion requirements, preoperative antibiotics, intraoperative vasopressors, and operative duration). Statistical analysis included chi-squared tests, t-tests, and multivariable regression analysis. RESULTS: Of the 106 patients who underwent a lower extremity revascularization procedure with a groin incision for femoral artery exposure, 62% were male, and the mean age was 62 years. Comorbidities included hypertension (93%), dyslipidemia (65%), statin use (63%), active smoker (50%), diabetes (24%), and chronic obstructive pulmonary disease (23%). All patients received preoperative antibiotics, 50% required intraoperative pressors, 21% received a blood transfusion, and the mean operative time was 296 min. The overall duration of stay was 10.7 days, the 30-day reoperation rate was 18%, and the 30-day mortality rate was 12%. Overall, 22% developed a seroma or hematoma, and 31% developed a SSI. Patients who developed an SSI compared with those who did not were more likely to have a postoperative seroma or hematoma (55% vs 5%) and to receive a blood transfusion (33% vs 15%), but less likely to be treated with a statin (47% vs 69%) or carry a diagnosis of dyslipidemia (50% vs 72%), respectively, all P < 0.05. Patients with an SSI had a longer duration of stay (14.5 vs 8.7 days) and a higher reoperative rate (49% vs 4%), but had a lower 30-day mortality (0% vs 18%) than those who did not develop an SSI (all P < 0.05). On multivariable regression analysis adjusting for differences in patient and operative variables, the occurrence of a wound seroma or hematoma remained an independent predictor for SSI (odd ratio: 27.6; 95% confidence interval: 5.4-139.6). CONCLUSIONS: The incidence of postoperative surgical site complications after lower extremity revascularization procedures involving a groin incision was 31% and was significantly associated with blood transfusion, postoperative seroma or hematoma, dyslipidemia, and statin usage. After adjusting for differences in patient and operative variables, postoperative seroma or hematoma was an independent predictor of SSI. Patients with a SSI have a longer duration of hospitalization and higher reoperative rate. Additional prospective cohort studies are warranted to delineate ways to decrease the rate of SSI.

Carotid endarterectomy national trends over a decade: does sex matter?

BACKGROUND: The objective was to evaluate the difference in timing (if any) of in-hospital carotid endarterectomy (CEA) or outcomes of CEA based on sex among men and women hospitalized for carotid artery disease. METHODS: This was a retrospective cross-sectional study using the Nationwide Inpatient Sample Database. All patients from 2000-2009 who underwent CEA during their hospitalization were examined. International Classification of Diseases, 9th revision codes were used to identify patients who underwent CEA during hospitalization, stratify asymptomatic and symptomatic patients, determine time in days from admission to CEA, and examine in-hospital complications, including perioperative stroke, cardiac events, and death. Statistical analysis was performed with chi-squared and t-tests. Linear and logistic regression models were used to evaluate relationships between sex and outcomes. The main outcome measures were time from admission to surgery, in-hospital mortality, complications, mean duration of stay, and discharge disposition. RESULTS: Two hundred twenty-one thousand two hundred fifty three patients underwent CEA during hospitalization. More than 9% (9.2%) had symptomatic carotid artery disease. Among symptomatic patients, bivariate analysis found that women had a longer mean time from admission to surgery (2.8 vs. 2.6 days; P < 0.001) and a longer duration of hospital stay (6.4 vs. 5.9 days; P < 0.001) than their male counterparts. However, there was no difference between men and women with regard to rates of perioperative stroke, cardiac complications, myocardial infarction, or death. Among asymptomatic patients, women had a longer mean time from admission to surgery (0.53 vs. 0.48 days; P < 0.001) and a trend toward increased perioperative stroke (0.6% vs. 0.5%; P = 0.06), but a lower rate of cardiac complications (1.5% vs. 1.7%; P = 0.01) and in-hospital mortality (0.26% vs. 0.31%; P = 0.05). However, on multivariable analysis adjusting for differences in age, elective status, insurance, race, hospital location, hospital region, and hospital teaching status, there was no sex disparity in time from admission to surgery, regardless of symptomatic status. In addition, asymptomatic women were less likely than men to have a cardiac complication (odds ratio [OR]: 0.90; 95% confidence interval [CI]: 0.83-0.97) or in-hospital mortality (OR: 0.83; 95% CI: 0.70-0.98). Symptomatic women were also less likely than men to have a cardiac complication (OR: 0.78; 95% CI: 0.63-0.97). CONCLUSIONS: In this decade-long national population-based study of hospitalized patients undergoing CEA, women had lower perioperative cardiac morbidity and mortality rates than men. After adjusting for patient, clinical, and hospital factors, there is no discernible difference in timing of CEA based on sex.

Endovascular management of a traumatic renal-caval arteriovenous fistula in a pediatric patient.

Traumatic renal arteriovenous fistula involving the inferior vena cava (IVC) are exceptionally rare, but if left untreated can have devastating clinical consequences, including development of renovascular hypertension, cardiomegaly, and congestive heart failure. We report a rare, pediatric case of a renal-caval arteriovenous fistula that developed after a gunshot wound to the abdomen and its subsequent treatment with endovascular means. We review our case and the world literature on the evaluation and management of trauma-related renal-caval arteriovenous fistulae.

Management of carotid stenosis in women.

The management of carotid stenosis in women remains a topic of controversy. In this review article, we aimed to define carotid disease burden in women, review outcomes of carotid endarterectomy and carotid artery stenting in women, discuss differences in practice patterns based on sex, and provide guidelines for management of women with carotid stenosis. Symptomatic women with high-grade stenosis derive benefit from carotid endarterectomy, although they have different risk profiles than men and are often not taking appropriate medical therapy. Women with asymptomatic carotid artery stenosis have less stroke risk reduction with CEA than their male counterparts; therefore, they should be screened for other treatable risk factors for stroke, with the institution of lifestyle changes and the appropriate medical therapy. After medical optimization, the decision to proceed with CEA in asymptomatic women must be made by carefully assessing that the benefits of stroke risk reduction outweigh perioperative risks.

Ruptured mycotic infrapopliteal aneurysm.

Mycotic aneurysms involving infrapopliteal arteries are rare. Ruptured infrapopliteal aneurysms are particularly uncommon and represent a surgical or endovascular emergency. We describe a case of 51-year-old male who presented with a 12-cm ruptured aneurysm of the tibioperoneal trunk 5 years after an episode of bacterial endocarditis. Our surgical approach included using extremity exsanguination and tourniquet to control hemorrhage during aneurysm ligation, followed by successful arterial reconstruction. Review of the English literature suggests that this is the largest ruptured infrapopliteal aneurysm reported.

Evaluation of an antimicrobial surgical glove to inactivate live human immunodeficiency virus following simulated glove puncture.

BACKGROUND: Percutaneous injuries associated with cutting instruments, needles, and other sharps (eg, metallic meshes, bone fragments, etc) occur commonly during surgical procedures, exposing members of surgical teams to the risk for contamination by blood-borne pathogens. This study evaluated the efficacy of an innovative integrated antimicrobial glove to reduce transmission of the human immunodeficiency virus (HIV) following a simulated surgical-glove puncture injury. METHODS: A pneumatically activated puncturing apparatus was used in a surgical-glove perforation model to evaluate the passage of live HIV-1 virus transferred via a contaminated blood-laden needle, using a reference (standard double-layer glove) and an antimicrobial benzalkonium chloride (BKC) surgical glove. The study used 2 experimental designs. In method A, 10 replicates were used in 2 cycles to compare the mean viral load following passage through standard and antimicrobial gloves. In method B, 10 replicates were pooled into 3 aliquots and were used to assess viral passage though standard and antimicrobial test gloves. In both methods, viral viability was assessed by observing the cytopathic effects in human lymphocytic C8166 T-cell tissue culture. Concurrent viral and cell culture viability controls were run in parallel with the experiment's studies. RESULTS: All controls involving tissue culture and viral viability were performed according to study design. Mean HIV viral loads (log(10)TCID(50)) were significantly reduced (P < .01) following passage through the BKC surgical glove compared to passage through the nonantimicrobial glove. The reduction (log reduction and percent viral reduction) of the HIV virus ranged from 1.96 to 2.4 and from 98.9% to 99.6%, respectively, following simulated surgical-glove perforation. CONCLUSION: Sharps injuries in the operating room pose a significant occupational risk for surgical practitioners. The findings of this study suggest that an innovative antimicrobial glove was effective at significantly (P < .01) reducing the risk for blood-borne virus transfer in a model of simulated glove perforation.

Microbiology of explanted suture segments from infected and noninfected surgical patients.

Sutures under selective host/environmental factors can potentiate postoperative surgical site infection (SSI). The present investigation characterized microbial recovery and biofilm formation from explanted absorbable (AB) and nonabsorbable (NAB) sutures from infected and noninfected sites. AB and NAB sutures were harvested from noninfected (70.9%) and infected (29.1%) sites in 158 patients. At explantation, devices were sonicated and processed for qualitative/quantitative bacteriology; selective sutures were processed for scanning electron microscopy (SEM). Bacteria were recovered from 85 (53.8%) explanted sites; 39 sites were noninfected, and 46 were infected. Suture recovery ranged from 11.1 to 574.6 days postinsertion. A significant difference in mean microbial recovery between noninfected (1.2 isolates) and infected (2.7 isolates) devices (P < 0.05) was noted. Staphylococcus epidermidis, Staphylococcus aureus, coagulase-negative staphylococci (CNS), Peptostreptococcus spp., Bacteroides fragilis, Escherichia coli, Enterococcus spp., Pseudomonas aeruginosa, and Serratia spp. were recovered from infected devices, while commensal skin flora was recovered from noninfected devices. No significant difference in quantitative microbial recovery between infected monofilament and multifilament sutures was noted. Biofilm was present in 100% and 66.6% of infected and noninfected devices, respectively (P < 0.042). We conclude that both monofilament and braided sutures provide a hospitable surface for microbial adherence: (i) a significant difference in microbial recovery from infected and noninfected sutures was noted, (ii) infected sutures harbored a mixed flora, including multidrug-resistant health care-associated pathogens, and (iii) a significant difference in the presence or absence of a biofilm in infected versus noninfected explanted devices was noted. Further studies to document the benefit of focused risk reduction strategies to minimize suture contamination and biofilm formation postimplantation are warranted.