Revisiting percutaneous cholecystostomy for acute cholecystitis based on a 10-year experience.

OBJECTIVES: To identify patient characteristics leading to percutaneous cholecystostomy (PC) and to compare outcomes between PC and cholecystectomy (CCY) in patients with acute cholecystitis (AC). DESIGN: Retrospective cohort study. SETTING Veterans Affairs Boston Healthcare System. PATIENTS: All consecutive patients with AC per the Tokyo criteria who underwent PC or CCY from January 1, 2001, through December 31, 2010. MAIN OUTCOME MEASURES: Differences in baseline characteristics and outcomes between PC and CCY patients, odds of PC vs CCY use, and odds of death after PC or CCY. RESULTS: Of 480 CCY and 92 PC procedures, 150 CCY and 51 PC procedures were performed for AC. The PC patients were older (70.4 vs 65.0 years, P = .01) and had higher leukocyte counts (16 500 vs 14 700/µL [to convert to × 109/L, multiply by 0.001], P = .046), alkaline phosphatase levels (198.2 vs 140.1 U/L [to convert to microkatals per liter, multiply by 0.0167], P = .02), Charlson comorbidity index scores (3.0 vs 1.0, P < .001), and American Society of Anesthesiologists class (P = .006) compared with CCY patients. The PC patients had longer intensive care unit stays (5.9 vs 2.3 days, P = .008), longer hospital stays (20.7 vs 12.1 days, P < .001), more complications per patient (2.9 vs 1.9, P = .01), and higher readmission rates (31.4% vs 13.3%, P = .006). On multivariate analysis, a Charlson comorbidity index score of 4 or higher was the only independent predictor of treatment with PC vs CCY (odds ratio, 1.226; 95% CI, 1.032-1.457) and was the only independent predictor of death after PC or CCY (odds ratio, 1.318; 95% CI, 1.143-1.521). No differences in survival were found between the PC and CCY groups (P = .14). CONCLUSION: Compared with CCY, PC is associated with higher morbidity rates and should be reserved for patients with prohibitive risks for surgery.

Factors associated with post-operative conversion to methicillin-resistant Staphylococcus aureus positivity or infection in initially MRSA-negative patients.

BACKGROUND: Hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) is associated with morbid, invasive infections and has been implicated in nearly every type of nosocomial infection. Our aim was to identify the risk factors for patient conversion from MRSA negativity pre-operatively to MRSA positivity post-operatively. METHODS: We retrospectively reviewed all patients at the Veterans Affairs-Boston Health Care System who underwent clean or clean-contaminated surgical procedures during the years 2008 and 2009 and had documented pre-operative nasal polymerase chain reaction (PCR) testing for MRSA. We abstracted post-operative MRSA microbiologic testing results, MRSA infections, surgical site infections (SSIs), surgical prophylaxis data, and SSI risk index, as calculated using the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database variables. All patients who had a negative nasal MRSA PCR result in the 31-day pre-operative period and did not have any positive MRSA clinical swab or culture in the 1-year pre-operative period were defined as MRSA-negative. These patients were classified as converters to MRSA positivity if they had at least one documented positive nasal MRSA PCR swab, culture, nosocomial infection, or SSI within 31 days post-operatively. RESULTS: Among 4,238 eligible patients, 3,890 (92%) qualified as MRSA-negative pre-operatively. A total of 1,432 (37%) of these patients were assessed in the VASQIP database, of whom 34 (2%) converted to MRSA positivity post-operatively. On multivariable logistic regression analysis of the VASQIP sample, age (odds ratio [OR] 1.049; 95% confidence interval [CI] 1.016, 1.083), SSI risk index (OR 2.863; 95% CI 1.251-6.554), and vancomycin prophylaxis alone or in combination (OR 3.223; 95% CI 1.174-8.845) were significantly associated with conversion to MRSA positivity. CONCLUSION: In pre-operatively MRSA-negative patients, age, SSI risk index, and vancomycin prophylaxis were significant factors for conversion to MRSA positivity post-operatively. Alternatives to vancomycin prophylaxis in non-colonized patients and optimization of patients' SSI risk factors should be considered before elective surgery.

Preoperative nasal methicillin-resistant Staphylococcus aureus status, surgical prophylaxis, and risk-adjusted postoperative outcomes in veterans.

OBJECTIVES: To determine whether preoperative nasal methicillin-resistant Staphylococcus aureus (MRSA) carriage is a significant predictor of postoperative infections, after accounting for surgical infection risk and surgical prophylaxis. DESIGN: Retrospective cohort study. PATIENTS: Veterans Affairs (VA) Boston patients who had nasal MRSA polymerase chain reaction screening performed in the 31 days before clean or clean contaminated surgery in 2008-2009. METHODS: Postoperative MRSA clinical cultures and infections, total surgical site infections (SSIs), and surgical prophylaxis data were abstracted from administrative databases. MRSA infections were confirmed via chart review. Multivariate analysis of risk factors for each outcome was conducted using Poisson regression. SSI risk index was calculated for a subset of 1,551 patients assessed by the VA National Surgical Quality Improvement Program. RESULTS: Among 4,238 eligible patients, 279 (6.6%) were positive for preoperative nasal MRSA. Postoperative MRSA clinical cultures and infections, including MRSA SSIs, were each significantly increased in patients with preoperative nasal MRSA. After adjustment for surgery type, vancomycin prophylaxis, chlorhexidine/alcohol surgical skin preparation, and SSI risk index, preoperative nasal MRSA remained significantly associated with postoperative MRSA cultures (relative risk [RR], 8.81; 95% confidence interval [CI], 3.01-25.82) and infections (RR, 8.46; 95% CI, 1.70-42.04). Vancomycin prophylaxis was associated with an increased risk of total SSI in those negative for nasal MRSA (RR, 4.34; 95% CI, 2.19-8.57) but not in patients positive for nasal MRSA. CONCLUSIONS: In our population, preoperative nasal MRSA colonization was independently associated with MRSA clinical cultures and infections in the postoperative period. Vancomycin prophylaxis increased the risk of total SSI in nasal MRSA-negative patients.

Healthy Living Cambridge Kids: a community-based participatory effort to promote healthy weight and fitness.

The objective of this study was to assess the impact of a community-based healthy weight intervention on child weight and fitness. Cambridge Public Schools (CPS) have monitored BMI and fitness annually since 2000. Annual increases of overweight and obesity from 2000 (37.0%) to 2004 (39.1%), triggered a multidisciplinary team of researchers, educators, health care, and public health professionals to mobilize environmental and policy interventions. Guided by the social-ecological model and community-based participatory research (CBPR) principles, the team developed and implemented Healthy Living Cambridge Kids (HLCK), a multicomponent intervention targeting community, school, family, and individuals. The intervention included city policies and community awareness campaigns; physical education (PE) enhancements, food service reforms, farm-to-school-to-home programs; and family outreach and "BMI and fitness reports". Baseline (2004) to follow-up (2007) evaluation design assessed change in children's weight and fitness status. A cohort of 1,858 K-5th grade children participated: 37.3% black, 14.0% Hispanic, 37.1% white, 10.2% Asian, 1.7% other race; 43.3% were lower income. BMI z-score (0.67-0.63 P < 0.001) and proportion obese (20.2-18.0% P < 0.05) decreased, and mean number of fitness tests (0-5) passed increased (3.7-3.9 P < 0.001). Whereas black and Hispanic children were more likely to be obese at baseline (27.0 and 28.5%, respectively) compared with white (12.6%) and Asian (14.3%) children, obesity among all race/ethnicity groups declined. Concurrent with a 3-year community intervention, modest improvements in obesity and fitness were observed among CPS children from baseline to follow-up. The CBPR approach facilitated sustaining policies and program elements postintervention in this diverse community.