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Residents that are exposed to rural practice during their training may be more likely to consider working in rural settings after training, whether that be in primary or specialty care. The authors describe 3 programs in northern New England that have had rural rotations and opportunities for residents for decades, and discuss curricular similarities and differences, and workforce outcomes postresidency. In addition, they share a collaborative curriculum and approach to advocacy that brings residents together to share ideas and projects to learn from each other., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The optimal approach and choice of initial aortic valve replacement (AVR) is evolving in the growing era of transcatheter AVR. Further survival and hemodynamic data are needed to compare the emerging role of rapid deployment (rdAVR) versus stented (sAVR) valve options for AVR., Methods: The Northern New England Cardiovascular Database was queried for patients undergoing either isolated AVR or AVR + coronary artery bypass grafting (CABG) with rdAVR or sAVR aortic valves between 2015 and 2021. Exclusion criteria included endocarditis, mechanical valves, dissection, emergency case status, and prior sternotomy. This resulted in a cohort including 1,616 sAVR and 538 rdAVR cases. After propensity weighting, procedural characteristics, hemodynamic variables, and survival outcomes were examined., Results: The breakdown of the overall cohort (2,154) included 1,164 isolated AVR (222 rdAVR, 942 sAVR) and 990 AVR + CABG (316 rdAVR, 674 sAVR). After inverse propensity weighting, cohorts were well matched, notable only for more patients <50 years in the sAVR group (4.0% vs 1.9%, standardized mean difference [SMD] = -0.12). Cross-clamp (89 vs 64 min, SMD = -0.71) and cardiopulmonary bypass (121 vs 91 min, SMD = -0.68) times were considerably longer for sAVR versus rdAVR. Immediate postreplacement aortic gradient decreased with larger valve size but did not differ significantly between comparable sAVR and rdAVR valve sizes or overall (6.5 vs 6.7 mm Hg, SMD = 0.09). Implanted rdAVR tended to be larger with 51% either size L or XL versus 37.4% of sAVR ≥25 mm. Despite a temporal decrease in pacemaker rate within the rdAVR cohort, the overall pacemaker frequency was less in sAVR versus rdAVR (4.4% vs 7.4%, SMD = 0.12), and significantly higher rates were seen in size L (10.3% vs 3.7%, P < 0.002) and XL (15% vs 5.6%, P < 0.004) rdAVR versus sAVR. No significant difference in major adverse cardiac events (4.6% vs 4.6%, SMD = 0.01), 30-day survival (1.5% vs 2.6%, SMD = 0.08), or long-term survival out to 4 years were seen between sAVR and rdAVR., Conclusions: Rapid deployment valves offer a safe alternative to sAVR with significantly decreased cross-clamp and cardiopulmonary bypass times. Despite larger implantation sizes, we did not appreciate a comparative difference in immediate postoperative gradients, and although pacemaker rates are improving, they remain higher in rdAVR compared with sAVR. Longer-term hemodynamic and survival follow-up are needed., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Poor personal financial health has been linked to key components of health including burnout, substance abuse, and worsening personal relationships. Understanding the state of resident financial health is key to improving their overall well-being., Study Design: A secondary analysis of a survey of New England general surgery residents was performed to understand their financial well-being. Questions from the National Financial Capability Study were used to compare to an age-matched and regionally matched cohort., Results: Overall, 44% (250 of 570) of surveyed residents responded. Residents more frequently reported spending less than their income each year compared to the control cohort (54% vs 34%, p < 0.01). However, 17% (39 of 234) of residents reported spending more than their income each year. A total of 65% of residents (152 of 234), found it "not at all difficult" to pay monthly bills vs 17% (76 of 445) of the control cohort (p < 0.01). However, 32% (75 of 234) of residents reported it was "somewhat" or "very" difficult to pay monthly bills. Residents more frequently reported they "certainly" or "probably" could "come up with" $2,000 in a month compared to the control cohort (85% vs 62% p < 0.01), but 16% (37 of 234) of residents reported they could not. In this survey, 21% (50 of 234) of residents reported having a personal life insurance policy, 25% (59 of 234) had disability insurance, 6% (15 of 234) had a will, and 27% (63 of 234) had >$300,000 worth of student loans., Conclusions: Surgical residents have better financial well-being than an age-matched and regionally matched cohort, but there is still a large proportion who suffer from financial difficulties., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Surgical culture has shifted to recognize the importance of resident well-being. This is the first study to longitudinally track regional surgical resident well-being over 5 years., Study Design: An anonymous cross-sectional, multi-institutional survey of New England general surgery residents using novel and published instruments to create three domains: health maintenance, burnout, and work environment., Results: Overall, 75% (15 of 20) of programs participated. The response rate was 44% (250 of 570), and 53% (133 of 250) were women, 94% (234 of 250) were 25 to 34 years old, and 71% (178 of 250) were in a relationship. For health maintenance, 57% (143 of 250) reported having a primary care provider, 26% (64 of 250) had not seen a primary care provider in 2 years, and 59% (147 of 250) endorsed being up to date with age-appropriate health screening, but only 44% (109 of 250) were found to actually be up to date. Only 14% (35 of 250) reported exercising more than 150 minutes/week. The burnout rate was 19% (47 of 250), with 32% (81 of 250) and 25% (63 of 250) reporting high levels of emotional exhaustion and depersonalization, respectively. For program directors and attendings, 90% of residents reported that they cared about resident well-being. Eighty-seven percent of residents believed that it was acceptable to take time off during the workday for a personal appointment, but only 49% reported that they would personally take the time., Conclusions: The personal health maintenance of general surgery residents has changed little over the past five years, despite an overwhelming majority of residents reporting that attendings and program directors care about their well-being. Further study is needed to understand the barriers to improvement of resident wellbeing., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

The New England Neurosurgical Society (NENS) was founded in 1951 under the leadership of its first President (Dr. William Beecher Scoville) and Secretary-Treasurer (Dr. Henry Thomas Ballantine). The purpose of creating the NENS was to unite local neurosurgeons in the New England area; it was one of the first regional neurosurgical societies in America. Although regional neurosurgical societies are important supplements to national organizations, they have often been overshadowed in the available literature. Now in its 70th year, the NENS continues to serve as a platform to represent the needs of New England neurosurgeons, foster connections and networks with colleagues, and provide research and educational opportunities for trainees. Additionally, regional societies enable discussion of issues uniquely relevant to the region, improve referral patterns, and allow for easier attendance with geographic proximity. In this paper, the authors describe the history of the NENS and provide a roadmap for its future. The first section portrays the founders who led the first meetings and establishment of the NENS. The second section describes the early years of the NENS and profiles key leaders. The third section discusses subsequent neurosurgeons who steered the NENS and partnerships with other societies. In the fourth section, the modern era of the NENS and its current activities are highlighted.

Objectives: The goal of this analysis was to examine the comparative effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention among patients aged less than 60 years., Methods: We performed a multicenter, retrospective analysis of all cardiac revascularization procedures from 2005 to 2015 among 7 medical centers. Inclusion criteria were age less than 60 years and 70% stenosis or greater in 1 or more major coronary artery distribution. Exclusion criteria were left main 50% or greater, ST-elevation myocardial infarction, emergency status, and prior revascularization procedure. After applying inclusion and exclusion criteria, the final study cohort included 1945 patients who underwent cardiac surgery and 2938 patients who underwent percutaneous coronary intervention. The primary end point was all-cause mortality stratified by revascularization strategy. Secondary end points included stroke, repeat revascularization, and 30-day mortality. We used inverse probability weighting to balance differences among the groups., Results: After adjustment, there was no significant difference in 30-day mortality (surgery: 0.8%; percutaneous coronary intervention: 0.7%, P = .86) for patients with multivessel disease. Patients undergoing surgery had a higher risk of stroke (1.3% [n = 25] vs 0.07% [n = 2], P < .001). Overall, surgery was associated with superior 10-year survival compared with percutaneous coronary intervention (hazard ratio, 0.71; 95% confidence interval, 0.57-0.88; P = .002). Repeat procedures occurred in 13.4% (n = 270) of the surgery group and 36.4% (n = 1068) of the percutaneous coronary intervention group, with both groups mostly undergoing percutaneous coronary intervention as their second operation. Accounting for death as a competing risk, at 10 years, surgery resulted in a lower cumulative incidence of repeat revascularization compared with percutaneous coronary intervention (subdistribution hazard ratio, 0.34; 95% confidence interval, 0.28-0.40; P < .001)., Conclusions: Among patients aged less than 60 years with 2-vessel disease that includes the left anterior descending or 3-vessel coronary artery disease, surgery was associated with greater long-term survival and decreased risk of repeat revascularization., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

The FREEDOM trial demonstrated superiority of coronary artery bypass grafting (CABG) for patients with diabetes mellitus (DM) and multivessel coronary artery disease (MV CAD) as compared to percutaneous coronary intervention (PCI) with drug eluting stent (PCI-DES). We sought to study the impact of the FREEDOM trial on clinical practice. We studied trends in the use of CABG vs. PCI and factors associated with revascularization strategy among 6,985 patients with concomitant CAD and MV CAD at 7 centers pre- and post-trial (2008-2012 vs. 2013-2017) as well as hospital outcomes. Multivariable mixed effects logistic regression was performed to identify risk factors associated with choice of revascularization strategy among the patients with 3-vessel CAD (3V CAD). 41% of patients had 3V CAD and 18% were ≥75 years of age. While PCI-DES was the preferred strategy in 2-vessel CAD (2V CAD), 72% of patients with 3V CAD underwent CABG. For patients with 3V CAD, the ratio of CABG to PCI-DES procedures was 2.47 over the decade and did not differ pre- and post-trial (adjusted odds ratio (OR) for CABG (vs. PCI) 1.01, 95% confidence interval (CI) 0.84-1.20). Independent risk factors of CABG among patients with DM and 3V CAD included peripheral arterial disease and absence of prior myocardial infarction and prior PCI. The risk factors for PCI were female sex (OR 0.60, 95% CI 0.50-0.73, p<0.001) and age ≥75 (OR 0.50, 95% CI 0.35-0.72, p<0.001). Center based variability was observed for CABG vs. PCI (center effect, rho=14%, p<0.001). In conclusion, PCI-DES is the preferred strategy for DM patients with MV CAD. Yet, among those with 3V CAD, CABG was chosen in ¾ of patients with no change in clinical practice related to the publication of the FREEDOM trial., Competing Interests: Declaration of Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Wound complications after open infrainguinal revascularization are a frequent cause of patient morbidity, resulting in increased healthcare costs. The purpose of the present study was to assess the effects of closed incision negative pressure therapy (ciNPT) on groin wound complications after infrainguinal bypass and femoral endarterectomy., Methods: A total of 242 patients who had undergone infrainguinal bypass (n = 124) or femoral endarterectomy (n = 118) at five academic medical centers in New England from April 2015 to August 2019 were randomized to ciNPT (PREVENA; 3M KCI, St Paul, Minn; n = 118) or standard gauze (n = 124). The primary outcome measure was a composite endpoint of groin wound complications, including surgical site infections (SSIs), major noninfectious wound complications, or graft infections within 30 days after surgery. The secondary outcome measures included 30-day SSIs, 30-day noninfectious wound complications, readmission for wound complications, significant adverse events, and health-related quality of life using the EuroQoL 5D-3L survey., Results: The ciNPT and control groups had similar demographics (age, 67 vs 67 years, P = .98; male gender, 71% vs 70%, P = .86; white race, 93% vs 93%, P = .97), comorbidities (previous or current smoking, 93% vs 94%, P = .46; diabetes, 41% vs 48%, P = .20; renal insufficiency, 4% vs 7%, P = .31), and operative characteristics, including procedure type, autogenous conduit, and operative time. No differences were found in the primary composite outcome at 30 days between the two groups (ciNPT vs control: 31% vs 28%; P = .55). The incidence of SSI at 30 days was similar between the two groups (ciNPT vs control: 11% vs 12%; P = .58). Infectious (13.9% vs 12.6%; P = .77) and noninfectious (20.9% vs 17.6%; P = .53) wound complications at 30 days were also similar for the ciNPT and control groups. Wound complications requiring readmission also similar between the two groups (ciNPT vs control: 9% vs 7%; P = .54). The significant adverse event rates were not different between the two groups (ciNPT vs control: 13% vs 16%; P = .53). The mean length of the initial hospitalization was the same for the ciNPT and control groups (5.2 vs 5.7 days; P = .63). The overall health-related quality of life was similar at baseline and at 14 and 30 days postoperatively for the two groups. Although not powered for stratification, we found no differences among the subgroups in gender, obesity, diabetes, smoking, claudication, chronic limb threatening ischemia, bypass, or endarterectomy. On multivariable analysis, no differences were found in wound complications at 30 days for the ciNPT vs gauze groups (odds ratio, 1.4; 95% confidence interval, 0.8-2.6; P = .234)., Conclusions: In contrast to other randomized studies, our multicenter trial of infrainguinal revascularization found no differences in the 30-day groin wound complications for patients treated with ciNPT vs standard gauze dressings. However, the SSI rate was lower in the control group than reported in other studies, suggesting other practice patterns and processes of care might have reduced the rate of groin infections. Further study might identify the subsets of high-risk patients that could benefit from ciNPT., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the prevalence of perceived barriers to accessing health care services, self-efficacy, and health-promoting behaviors among Franco-Americans as a higher-risk group for familial hypercholesterolemia (FH), stratified by cardiovascular risk factors., Design: Cross-sectional survey based on components of the Health Belief Model., Setting: Administered in-person at a Franco-American cultural center and online through mailing lists and social media platforms in the Northeastern United States., Sample: Franco-Americans and French Canadians (n = 170)., Measures: Demographic and clinical characteristics (i.e. high cholesterol, prior heart attack or stroke, family history of atherosclerotic cardiovascular disease (ASCVD), diagnosis of FH), perceived barriers to accessing health care services, self-efficacy, and health-promoting behaviors (i.e. taking lipid-lowering medications, seeing a cardiovascular specialist)., Results: In a cohort of Franco-Americans, 42 (25%) had both high cholesterol and family history of ASCVD. Among Franco-Americans with both cardiovascular risk factors, 22% had low self-efficacy and only 16% had discussed FH with their physician. Individuals with both risk factors were significantly more likely to report a concern over a future diagnosis as a barrier to accessing health care services when compared with those with neither risk factor (36% vs. 15%, p = 0.014). Overall, other prominent barriers to care included knowledge of when to seek help (27%) and a distrust in medicine (26%)., Conclusion: Franco-Americans report significant barriers to accessing health care services. Our findings strengthen the case for developing focused public health strategies to raise awareness for FH, particularly among high-risk subpopulations with unmet cardiovascular needs.

The human papilloma virus (HPV) vaccine is the world's first proven and effective vaccine to prevent cancers in males and females when administered pre-exposure. Like most of the US, barely half of Vermont teens are up-to-date with the vaccination, with comparable deficits in New Hampshire and Maine. The rates for HPV vaccine initiation and completion are as low as 33% in rural New England. Consequently, there is a compelling responsibility to communicate its importance to unvaccinated teenagers before their risk for infection increases. Messaging in rural areas promoting HPV vaccination is compromised by community-based characteristics that include access to appropriate medical care, poor media coverage, parental and peer influence, and skepticism of science and medicine. Current strategies are predominantly passive access to literature and Internet-based information. Evidence indicates that performance-based messaging can clarify the importance of HPV vaccination to teenagers and their parents in rural areas. Increased HPV vaccination will significantly contribute to the prevention of a broadening spectrum of cancers. Reducing rurality-based inequities is a public health priority. Development of a performance-based peer-communication intervention can capture a window of opportunity to provide increasingly effective and sustained HPV protection. An effective approach can be partnering rural schools and regional health teams with a program that is nimble and scalable to respond to public health policies and practices compliant with COVID-19 pandemic-related modifications on physical distancing and interacting in the foreseeable future.

Study Objective: There has been increasing attention to screening for health-related social needs. However, little is known about the screening practices of emergency departments (EDs). Within New England, we seek to identify the prevalence of ED screening for health-related social needs, understand the factors associated with screening, and understand how screening patterns for health-related social needs differ from those for violence, substance use, and mental health needs., Methods: We analyzed data from the 2018 National Emergency Department Inventory-New England survey, which was administered to all 194 New England EDs during 2019. We used descriptive statistics to compare ED characteristics by screening practices, and multivariable logistic regression models to identify factors associated with screening., Results: Among the 166 (86%) responding EDs, 64 (39%) reported screening for at least one health-related social need, 160 (96%) for violence (including intimate partner violence or other violent exposures), 148 (89%) for substance use disorder, and 159 (96%) for mental health needs. EDs reported a wide range of social work resources to address identified needs, with 155 (93%) reporting any social worker availability and 41 (27%) reporting continuous availability., Conclusion: New England EDs are screening for health-related social needs at a markedly lower rate than for violence, substance use, and mental health needs. EDs have relatively limited resources available to address health-related social needs. We encourage research on the development of scalable solutions for identifying and addressing health-related social needs in the ED., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: Understanding the experience of parents with newborns hospitalized with neonatal abstinence syndrome (NAS) across all inpatient settings is important in optimizing their involvement as part of the care team. A descriptive qualitative study design was utilized to understand the parental experience and identify barriers to parent involvement in care of newborns with NAS care., Methods: Semistructured one-on-one interviews were conducted with parents of a convenience sample of fifteen infants admitted for NAS in the newborn nursery and level II/III neonatal intensive care unit within a tertiary care center in Northern New England. Interviews were analyzed using thematic content analysis., Results: Sixty percent of mothers were treated with buprenorphine during pregnancy, and 60% of infants required pharmacological treatment for NAS symptoms. The predominant themes of parental experience included preparation/education for hospitalization, communication with providers, NAS management, family resources, physical hospital environment, and maternal guilt., Conclusion: The parental experience of care for NAS is negatively affected by lack of standardized NAS education in the prenatal and postnatal settings, inconsistent communication with providers, the Finnegan scoring system, lack of provider sensitivity to parental substance use disorder, and maternal guilt. This study also highlights the parental desire to be more involved in the care of newborns with NAS.

Objective: Over the past decade, the Department of Veterans Affairs (VA) has experienced a sizeable shift in its approach to pain. The VA's 2009 Pain Management Directive introduced the Stepped Care Model, which emphasizes an interdisciplinary approach to pain management involving pain referrals and management from primary to specialty care providers. Additionally, the Opioid Safety Initiative and 2017 VA/Department of Defense (DoD) clinical guidelines on opioid prescribing set a new standard for reducing opioid use in the VA. These shifts in pain care have led to new pain management strategies that rely on multidisciplinary teams and nonpharmacologic pain treatments. The goal of this study was to examine how the cultural transformation of pain care has impacted providers, the degree to which VA providers are aware of pain care services at their facilities, and their perceptions of multidisciplinary care and collaboration across VA disciplines., Methods: We conducted semistructured phone interviews with 39 VA clinicians in primary care, mental health, pharmacy, and physical therapy/rehabilitation at eight Veterans Integrated Service Network medical centers in New England., Results: We identified four major themes concerning interdisciplinary pain management approaches: 1) the culture of VA pain care has changed dramatically, with a greater focus on nonpharmacologic approaches to pain, though many "old school" providers continue to prefer medication options; 2) most facilities in this sample have no clear roadmap about which pain treatment pathway to follow, with many providers unaware of what treatment to recommend when; 3) despite multiple options for pain treatment, VA multidisciplinary teams generally work together to ensure that veterans receive coordinated pain care; and 4) veteran preferences for care may not align with existing pain care pathways., Conclusions: The VA has shifted its practices regarding pain management, with a greater emphasis on nonpharmacologic pain options. The proliferation of nonpharmacologic pain management strategies requires stakeholders to know how to choose among alternative treatments., (2019 American Academy of Pain Medicine. This work is written by US Government employees and is in the public domain in the US.)

Background: Residential wood stove use has become more prevalent in high-income countries, but only limited data exist on indoor exposure to PM 2.5 and its components., Methods: From 2014 to 2016, we collected 7-day indoor air samples in 137 homes of pregnant women in Northern New England, using a micro-environmental monitor. We examined associations of wood stove use with PM 2.5 mass and its components [black carbon (BC), organic and elemental carbon and their fractions, and trace elements], adjusted for sampling season, community wood stove use, and indoor activities. We examined impact of stove age, EPA-certification, and wood moisture on indoor pollutants., Results: Median (IQR) household PM 2.5 was 6.65 (5.02) µg/m 3 and BC was 0.23 (0.20) µg/m 3 . Thirty percent of homes used a wood stove during monitoring. In homes with versus without a stove, PM 2.5 was 20.6% higher [although 95% confidence intervals (-10.6, 62.6) included the null] and BC was 61.5% higher (95% CI: 11.6, 133.6). Elemental carbon (total and fractions 3 and 4), potassium, calcium, and chloride were also higher in homes with a stove. Older stoves, non-EPA-certified stoves, and wet or mixed (versus dry) wood were associated with higher pollutant concentrations, especially BC., Conclusions: Homes with wood stoves, particularly those that were older and non-EPA-certified or burning wet wood had higher concentrations of indoor air combustion-related pollutants.

Background: The maternal experience of caring for and bonding with infants affected by neonatal abstinence syndrome (NAS) has not been adequately characterized., Purpose: This study was designed to describe mothers' experiences of, supports for, and barriers to bonding with infants with NAS., Methods: Semistructured interviews were coded using computer-assisted thematic content analysis. A code co-occurrence model was used to visualize the relationships between themes., Results: Thirteen mothers of infants with NAS participated. Trying to Do What Is Best emerged as the overarching theme with which several subthemes co-occurred. Subthemes that captured mothers loving their infants and bonding, feeling supported by the infants' fathers, feeling supported in the community, and receiving information from hospital staff were associated with mothers' trying to do what is best. Barriers to trying to do what is best included feeling unsupported in the community, guilt about taking medications or substances during pregnancy, feeling judged, and infant withdrawal., Implications for Practice: Specific implications for practice may be derived from the mothers' criticisms of NAS assessment tools. Mothers highlighted the value of reassurance and education from providers and the uniquely nonjudgmental support received from peers and male coparents., Implications for Research: There is a lack of information about maternal-infant bonding in dyads affected by NAS and factors that contribute to parental loss of custody. Qualitative, quantitative, and mixed-methods studies in diverse populations might help researchers better understand the long-term outcomes of NAS and develop interventions that decrease family separation.

Background: Readmissions after cardiac surgery are common and associated with increased morbidity, mortality and cost of care. Policymakers have targeted coronary artery bypass grafting to achieve value-oriented health care milestones. We explored the causes of readmission following cardiac surgery among a regional consortium of hospitals., Methods: Using administrative data, we identified patients readmitted to the same institution within 30 days of cardiac surgery. We performed standardized review of readmitted patients' medical records to identify primary and secondary causes of readmission. We evaluated causes of readmission by procedure and tested for univariate associations between characteristics of readmitted patients and nonreadmitted patients in our clinical registry., Results: Of 2218 cardiac surgery patients, 272 were readmitted to the index hospital within 30 days for a readmission rate of 12.3%. Median time to readmission was 9 days (interquartile range 4-16 days) and only 13% of patients were evaluated in-office before readmission. Readmitted patients were more likely to have had valve surgery (31.3% vs 22.7%) than patients not readmitted. Readmitted patients were also more likely to have preoperative creatinine more than or equal to 2 mg/dL (P = .015) or congestive heart failure (CHF) (P = .034), require multiple blood transfusions or sustained inotropic support (P < .001), and experience postoperative atrial fibrillation (P = .022) or renal insufficiency (P < .001). Infection (26%), pleural or pericardial effusion (19%), arrhythmia (16%), and CHF (11%) were the most common primary etiologies leading to readmission., Conclusions: Ensuring early follow-up for high-risk patient groups while improving early detection and management of the principal drivers of readmission represent promising targets for decreasing readmission rates., (© 2019 Wiley Periodicals, Inc.)

Objective: Major adverse event (MAE) rates are used as an outcome measure after surgical procedures. Although MAE rates summarize the occurrences of adverse events, they do not reflect differences in severity of these events. We propose that a measure of complication severity could provide a more accurate assessment about the quality of care. We aimed to analyze and to describe the regional variation in elective endovascular aneurysm repair (EVAR) MAE rates across centers in the Vascular Study Group of New England and to create an index for describing complication severity., Methods: Patients undergoing elective EVAR (n = 4731) at 30 Vascular Study Group of New England centers between 2003 and 2016 were studied. The MAE composite end point was defined as the occurrence of any of the following postoperative events: myocardial infarction, dysrhythmia, congestive heart failure, leg ischemia, renal insufficiency, bowel complication, reoperation, surgical site infection, stroke, respiratory complication, and no home discharge. An adjustment factor (complication severity index) was calculated as a ratio of length of stay for complicated to uncomplicated cases. Multivariate logistic regression was used to calculate predicted MAE rates. The observed and predicted MAE rates as well as complication severity index rates were compared among centers and across quintiles of center volume., Results: Observed MAE rates varied widely, ranging from 0% to 39%. Multivariate predictors of MAE included abdominal aortic aneurysm diameter >6 cm (odds ratio [OR], 2.1; 95% confidence interval [CI], 2.0-2.3), female sex (OR, 2.0; 95% CI, 1.8-2.2), chronic renal insufficiency (OR, 1.9; 95% CI, 1.7-2.1), age >75 years (OR, 1.9; 95% CI, 1.8-2.1), congestive heart failure (OR, 1.7; 95% CI, 1.5-1.9), chronic obstructive pulmonary disease (OR, 1.5; 95% CI, 1.4-1.6), diabetes (OR, 1.4; 95% CI, 1.1-1.7), positive stress test result (OR, 1.2; 95% CI, 1.1-1.4), preoperative beta blocker (OR, 1.2; 95% CI, 1.1-1.3), and no preoperative statin (OR, 1.2; 95% CI, 1.1-1.3). Predicted MAE rates had little variation (range, 21%-29%). In comparing observed MAE rates and complication severity, there was an inverse relation between the two, suggesting that although certain centers had a greater number of MAEs, the complications were less severe., Conclusions: MAE rates after elective EVAR vary widely. However, centers with higher MAE rates tended to have less severe complications, suggesting that observed MAE rates may not be a good measure of outcomes assessment after elective EVARs., (Published by Elsevier Inc.)

Despite authority's centrality to the medical profession, providers routinely forgo their medical authority during clinical encounters. Research focuses on patients challenging medical authority but indicates these confrontations are uncommon and providers seldom relinquish their authority in response. Using rare data of 75 audio recordings of adolescent vaccine discussions during clinical encounters and interviews with and observations of medical staff, I examine how staff leverage or abandon their medical authority to convince parents to vaccinate. I find medical professionals use less authority when at risk of stigmatizing patients: Medical professionals are less authoritative when recommending human papillomavirus (HPV) vaccination versus other adolescent vaccines, particularly when addressing the need to vaccinate before sexual onset due to concerns of labeling the child as sexually active. Medical staff defer to parents in ways that potentially discourage HPV vaccine uptake: They encourage HPV vaccination less than other vaccines and infrequently challenge parents' sex-related reasons for vaccine refusal.

Background: Moose-motor vehicle collisions (MMVC) are especially dangerous to vehicle occupants because of the height and mass of the animal, which often collapses the roof and has a direct impact into the passenger compartment., Study Design: Public data on MMVC were obtained from the states of New England (NE), and trauma registry data from centers in NH and ME., Results: For all of NE, the annual incidence of reported MMVC has declined from a peak of >1,200 in 1998, but has still averaged >500 over the last 5 years, predominantly in ME, NH, and VT. Public education may have contributed to the decline, but the moose population has also apparently decreased due to environmental changes. In NE, MMVCs are most frequent in the summer months and evening hours. Maine data on crashes involving wild ungulates from 2003 to 2017 document 50,281 collisions with deer and 7,061 collisions with moose; 26 of the latter (0.37%) resulted in a human fatality. Logistic regression models demonstrate that vehicle occupant mortality, after controlling for multiple factors related to vehicle speed, is greatly increased when striking a moose rather than a deer (odds ratio [OR] 13.4, 95% CI 6.3, 28.7). In these data, there were no fatalities among occupants of Swedish cars, which are specifically engineered to tolerate MMVC. Three NH/ME trauma centers registered 124 cases of MMVC: median Injury Severity Score was 9; 5 patients died (4%); and 76 patients (61%) had injuries of the head, face, and/or cervical spine., Conclusions: Moose-motor vehicle collisions remain a frequent and serious hazard to motor vehicle occupants in northern NE. Trauma services should recognize characteristic injury patterns. Continuing public education, cautious driving, and moose herd management are warranted., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Patch angioplasty has been shown to decrease rates of restenosis after carotid endarterectomy (CEA). In 2003, the Vascular Study Group of New England (VSGNE) implemented its first quality initiative aimed at increasing the rates of patch closure after CEA. This study reports the effects of that initiative on the rate of patch closure in the VSGNE and also postoperative and 1-year CEA outcomes., Methods: Patients undergoing CEA (N = 14,636) within the VSGNE between 2003 and 2014 were studied. Rates of in-hospital postoperative events (death, ipsilateral stroke or transient ischemic attack [TIA], and return to the operating room for bleeding) and events during 1 year of follow-up (stroke or TIA and restenosis >70% or occlusion) were compared by repair type-patch closure, primary closure, or eversion. One-year follow-up events were also compared over time and by annualized surgeon volume., Results: During the 12 years studied, patch use increased from 71% to 91% (P < .001). There was no difference in postoperative death or ipsilateral stroke or TIA between the repair types. However, there was a statistically lower rate of return to the operating room for bleeding (P < .001), 1-year stroke or TIA (P < .003), and 1-year restenosis or occlusion (P < .001) with patch closure. Overall, the rates of 1-year stroke or TIA and restenosis decreased over time in the VSGNE. The initiative affected patch closure rates and outcomes of high-volume surgeons (>47 CEAs/y) the most. High-volume surgeons increased patch use from 50% to 90% and decreased their restenosis rates from 9.0% to 1.2% and 1-year stroke or TIA from 4.9% to 1.9% (P < .001)., Conclusions: The VSGNE carotid patch quality initiative successfully increased the rates of CEA patch closure. During the same time, there has been a decrease in postoperative bleeding requiring reoperation and 1-year ipsilateral neurologic events and restenosis or occlusion., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Acute Kidney Recovery (AKR) is a potential benefit of transcatheter aortic valve implantation (TAVI). We determined the incidence and predictors of AKR in a multicenter prospective registry of TAVI. After excluding patients on dialysis or who died within 48 hours postprocedure, we reviewed 1,502 consecutive patients underwent TAVI in Northern New England from 2012 to 2017. Patients were categorized into 3 groups based on the change in postprocedure estimated glomerular filtration rate (eGFR): Acute Kidney Injury (AKI, decrease in eGFR >25%), AKR (increase in eGFR >25%) or no change in kidney function on discharge creatinine following TAVI. We then focused in patients with baseline chronic kidney disease (CKD defined as eGFR ≤60 ml/min; n = 755) and developed multivariate predictor models to determine the clinical and procedural variables associated with AKR. For the TAVI cohort (n = 1,502), the overall incidence of AKR was 17.8%. AKR was threefold higher in patients with eGFR ≤60 ml/min as compared to those with eGFR >60 ml/min (26.6% vs 8.9%, p < 0.001). In the CKD population, hospital complications were similar among patients with no change in renal function and AKR; patients with AKI had a higher rate of hospital mortality, pacemaker implantation, length of hospitalization, and transfusions. Using multivariable logistic regression, moderate to severe lung disease, eGFR < 50 ml/min and previous aortic valve surgery were found to be independent predictors of AKR. Patients with diabetes mellitus, baseline anemia, and Society of thoracic surgeons score >6.1 were less likely to develop AKR. In conclusion, AKR occurred in 1 of 4 of all TAVI patients with baseline CKD and was a more frequent phenomena than AKI. Patients with decreased lung function, previous aortic valve surgery and worse baseline renal function were more likely to demonstrate AKR, whereas patients with diabetes mellitus, baseline anemia, and higher Society of thoracic risk scores were less likely to see improvements in renal function after TAVI., (Copyright © 2018. Published by Elsevier Inc.)

Objective: We aimed to assess the parent experience of therapeutic hypothermia (TH), specifically focusing on unmet expectations., Study Design: Open-ended questions were used in a focus group setting. We employed an inductive approach to develop thematic content from the transcribed recordings., Results: 30 parents of infants treated with TH participated. Within the principal theme of managing expectations, four sub-themes emerged. These included parental concerns about morphine use; specifically the association of morphine with end-of-life care and addiction. Parents perceived their role as key in the decision to implement TH and were emotionally burdened by this during and after TH. Parents recall intense fear for the infant's immediate survival and were not sufficiently reassured regarding survival. Parents also experience ongoing uncertainties about the long-term prognosis after TH., Conclusion: The identification of these four areas in which parents have unmet expectations is important in order to improve the delivery of care.

Background: The Rapid Ruptured Abdominal Aortic Aneurysm Score (RrAAAS) was developed from Vascular Study Group of New England (VSGNE) data (649 ruptured abdominal aortic aneurysm (rAAA) patients, repaired both open and endovascularly), using preoperative age, creatinine, and blood pressure. This study validates that model using the larger National Vascular Quality Initiative (VQI) data set and compares its performance to previous models., Methods: The VQI registry was queried for patients undergoing rAAA repair from 2006 to 2016. The performance of our original model, RrAAAS, was tested on this data set excluding VSGNE patients (VQI minus VSGNE), and its performance was then compared to the performance of the Glasgow Aneurysm Score (GAS) and Edinburgh Ruptured Aneurysm Score (ERAS)., Results: VQI contained 2,704 eligible patients, of which 715 had been contributed by VSGNE. The discrimination of RrAAAS was similar to GAS or ERAS (area under a receiver operator characteristic curve = 0.66). Neither GAS nor ERAS provides a direct prediction of mortality; observed mortality in the VQI minus VSGNE cohort tended to be somewhat lower than predictions of the original RrAAAS. A recalibrated equation predicting the percent mortality was Mortality (%) = 16 + 12*(age > 76) + 8*(creatinine > 1.5) + 20*(systolic blood pressure < 70)., Conclusions: The previously described RrAAAS has similar discrimination as the GAS and ERAS, is easier to obtain in an emergency setting, and has been recalibrated to reflect the experience of a large national sample. The RrAAAS could be useful for clinicians caring for these patients and could be used for risk adjustment when comparing regional differences in mortality associated with rAAA repair., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The Vascular Study Group of New England (VSGNE) requires documentation of follow-up for >80% of patients at least 9 months postprocedure. However, many participating groups fall short of this goal. We sought to identify factors independently associated with loss to long-term follow-up (LTF)., Methods: The VSGNE was queried from 2008 to 2012, for all carotid endarterectomy (CEA), endovascular aneurysm repair (EVAR), open abdominal aortic aneurysm repair (OPEN), infrainguinal bypass (INFRA), and suprainguinal bypass (SUPRA) procedures in patients who survived greater than 9 months postprocedure. Our primary endpoint was loss to LTF, with LTF defined as documentation of a phone call or office visit ≥9 months postprocedure. Multivariable logistic regression was used to identify independent predictors of loss to LTF. Covariates included patient and procedural characteristics, and treatment center/physician. Relative contributions of covariates to the model were assessed by evaluation of the relative model Wald chi-squared values., Results: We identified 14,452 procedures (6567 CEA, 2391 EVAR, 3356 INFRA, 979 OPEN, and 1159 SUPRA). Of those, 4669 (32%) were lost to LTF. Rates of loss to LTF varied by center, and ranged from 9.8% to 100%. Independent predictors of loss to LTF were history of coronary artery disease or percutaneous coronary artery intervention (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.1-1.7), procedure type (OPEN, OR 1.4, 95% CI: 1.2-1.7; CEA, OR 1.2, 95% CI: 1.1-1.4; referent, EVAR), and discharge to rehab (OR 1.2, 95% CI: 1.1-1.4; referent, home). Center variation was the strongest determinant of loss to LTF with a model χ 2 over 40 times as large as the second strongest determinant., Conclusions: LTF is central to outcome reporting and is vital to the success of any registry effort. In the VSGNE experience, center variation is the strongest predictor of loss to LTF, outweighing patient and procedural factors. Other predictors of loss to LTF included history of coronary revascularization, procedure type, no prior history of congestive heart failure, and discharge location. High performing centers likely have specific process measures that decrease loss to LTF. As the Society for Vascular Surgery Vascular Quality Initiative continues to roll out nationally, high performing centers in VSGNE should be studied to document and propagate best practices for minimizing loss to LTF., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Previous risk prediction models of mortality after ruptured abdominal aortic aneurysm (rAAA) repair have been limited by imprecision, complexity, or inclusion of variables not available in the preoperative setting. Most importantly, these prediction models have been derived and validated before the adoption of endovascular aneurysm repair (EVAR) as a treatment for rAAA. We sought to derive and validate a new risk-prediction tool using only easily obtainable preoperative variables in patients with rAAA who are being considered for repair in the endovascular era., Methods: We used the Vascular Study Group of New England (VSGNE) database to identify all patients who underwent repair of RAAA (2006-2015). Variables were entered into a multivariable logistic regression model to identify independent predictors of 30-day mortality. Linear regression was then used to develop an equation to predict risk of 30-day mortality., Results: During the study period, 649 patients underwent repair of rAAA; of these, 247 (38.1%) underwent EVAR and 402 (61.9%) underwent an open repair. The overall mortality associated with rAAA was 30.7% (open, 33.4% and EVAR, 26.2%). On multivariate modeling, the primary determinants of 30-day mortality were advanced age (>76 vs. ≤76 years, odds ratio [OR] = 2.91 and CI: 2.0-4.24), elevated creatinine (>1.5 mg/dL vs. ≤1.5 mg/dL, OR = 1.57 and CI: 1.05-2.34), and lowest systolic blood pressure (SBP) (BP <70 mm Hg vs. ≥70 mm Hg, OR = 2.65 and CI: 1.79-3.92). The logistic regression model had an area under a c-statistic of 0.69. The corresponding linear model used to provide a point estimate of 30-day mortality (%) was % mortality = 14 + 22 * (age >76) + 9 * (creatinine >1.5) + 20 * (bp <70) Using this model, patients can be stratified into different groups, each with a specific estimated risk of 30-day mortality ranging from a low of 14% to a high of 65%., Conclusions: In the endovascular era where both open and endovascular treatment are offered for the treatment of rAAA three variables, easily obtained in an emergency setting, accurately predict 30-day mortality for patients operated on for rAAA. This simple risk prediction tool could be used as a point of care decision aid to help the clinician in counseling patients and their families on treatment of those presenting with rAAA., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Prior descriptions of the psychometric properties of validated knowledge assessment tools designed to determine Emergency medicine (EM) residents understanding of physiologic and clinical concepts related to mechanical ventilation are lacking. In this setting, we have performed this study to describe the psychometric and performance properties of a novel knowledge assessment tool that measures EM residents' knowledge of topics in mechanical ventilation., Methods: Results from a multicenter, prospective, survey study involving 219 EM residents from 8 academic hospitals in northeastern United States were analyzed to quantify reliability, item difficulty, and item discrimination of each of the 9 questions included in the knowledge assessment tool for 3 weeks, beginning in January 2013., Results: The response rate for residents completing the knowledge assessment tool was 68.6% (214 out of 312 EM residents). Reliability was assessed by both Cronbach's alpha coefficient (0.6293) and the Spearman-Brown coefficient (0.6437). Item difficulty ranged from 0.39 to 0.96, with a mean item difficulty of 0.75 for all 9 questions. Uncorrected item discrimination values ranged from 0.111 to 0.556. Corrected item-total correlations were determined by removing the question being assessed from analysis, resulting in a range of item discrimination from 0.139 to 0.498., Conclusion: Reliability, item difficulty and item discrimination were within satisfactory ranges in this study, demonstrating acceptable psychometric properties of this knowledge assessment tool. This assessment indicates that this knowledge assessment tool is sufficiently rigorous for use in future research studies or for assessment of EM residents for evaluative purposes.

Background: A postoperative length of stay (LOS) >1 day after elective surgery incurs financial losses for hospitals, given fixed diagnosis-related group-based reimbursement. We sought to identify factors leading to a prolonged LOS (>1 postoperative day) after carotid endarterectomy (CEA)., Methods: Patients undergoing CEA in 23 centers of the Vascular Study Group of New England between 2003 and 2011 (n = 8860) were analyzed. Only elective, primary CEAs were analyzed, leaving a study cohort of 7108 procedures. Hierarchical multivariable logistic regression analysis was performed to identify predictors of a postoperative LOS >1 day. A Knaus-Wagner chi-pie analysis was performed to determine the relative contributions of each significant covariate to a postoperative LOS >1 day., Results: A postoperative LOS >1 day occurred in 17.5% of the sample (n = 1244). The average LOS was 1.4 days (range, 1-91 days; median, 1). There was significant variation in rates of postoperative LOS >1 day across centers (range, 5%-100%; P < .001). Factors independently associated with a postoperative LOS >1 day and their percentage contribution to the prediction model included the need for postoperative intravenous medications for hypertension or hypotension (26%), any major adverse event (MAE) postoperatively (21%), low-volume (<15 CEAs per year) surgeons (28%), increasing age (7%), female gender (4%), positive result on a preoperative stress test (3%), preoperative major stroke ≤30 days (2%), medication-dependent diabetes (1%), severe chronic obstructive pulmonary disease (1%), history of congestive heart failure (1%), and CEA performed on Friday (2%)., Conclusions: Certain patient characteristics predispose to a postoperative LOS >1 day after elective CEA. However, patient characteristics play only a modest (17%) role in determining LOS. The need for postoperative blood pressure control and MAEs are the biggest drivers of postoperative LOS >1 day, but system factors, such as low operative volume, contribute substantially to postoperative LOS >1 day, independent of MAEs. These findings can be used to guide quality improvement efforts designed to reduce LOS after elective CEA., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Many patients undergoing vascular surgical procedures are not on appropriate medical therapy. This study sought to examine the variation and impact of antiplatelet (AP) and statin therapy on early and late mortality in patients undergoing vascular surgery in our region., Methods: We studied all patients (n = 14,489) undergoing elective carotid endarterectomy (n = 6978), carotid stenting (n = 524), and suprainguinal (n = 763) and infrainguinal bypass (n = 3053), as well as patients with known coronary risk factors undergoing open (n = 1044) and endovascular (n = 2127) abdominal aortic aneurysm repair from 2005 to 2012 in the Vascular Study Group of New England. Optimal medical management was defined as treatment with both AP and statin agents, preoperatively and at discharge. We analyzed temporal, procedural, and center variation of medication use. Multivariable analyses were used to determine the adjusted impact of AP and statin therapy on 30-day mortality and 5-year survival., Results: Optimal medical management improved over the study interval (55% in 2005 to 68% in 2012; P trend < .01) with carotid interventions having the highest rates of optimal medications use (carotid artery stenting, 78%; carotid endarterectomy, 74%) and abdominal aortic aneurysm repair in patients with known cardiac risk factors having the lowest (open, 57%; endovascular aneurysm repair, 56%). Optimal medication use varied by center as well (range, 40%-86%). Preoperative AP and statin use was associated with reduced 30-day mortality (odds ratio, 0.76; 95% confidence interval [CI], 0.5-1.05; P = .09). AP and statin prescription at discharge was additive in survival benefit with improved 5-year survival (hazard ratio, 0.5; 95% CI, 0.4-0.7; P < .01) that was consistent across procedure types. Patients prescribed AP and statin at discharge had 5-year survival of 79% (95% CI, 77%-81%) compared with only 61% (95% CI, 52%-68%; P < .001) for patients on neither medication., Conclusions: AP and statin therapy preoperatively and at discharge was associated with reduced 30-day mortality and an absolute 18% improved 5-year survival after vascular surgery. However, one-third of patients are suboptimally managed in real world practice. This demonstrates an opportunity for quality improvement that can substantially improve survival after vascular surgery., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Outcomes for patients undergoing intervention for restenosis after prior ipsilateral carotid endarterectomy (CEA) in the era of carotid angioplasty and stenting (CAS) are unclear. We compared perioperative results and durability of CAS vs CEA in patients with symptomatic or asymptomatic restenosis after prior CEA and investigated the risk of reintervention compared with primary procedures., Methods: Patients undergoing CAS and CEA for restenosis between January 2003 and March 2012 were identified within the Vascular Study Group of New England (VSGNE) database. End points included any stroke, death or myocardial infarction (MI) within 30 days, cranial nerve injury at discharge, and restenosis ≥ 70% at 1-year follow-up. Multivariable logistic regression was done to identify whether prior ipsilateral CEA was an independent predictor for adverse outcome., Results: Out of 9305 CEA procedures, 212 patients (2.3%) underwent redo CEA (36% symptomatic). Of 663 CAS procedures, 220 patients (33%) underwent CAS after prior ipsilateral CEA (31% symptomatic). Demographics of patients undergoing redo CEA were comparable to patients undergoing CAS after prior CEA. Stroke/death/MI rates were statistically similar between redo CEA vs CAS after prior CEA in both asymptomatic (4.4% vs 3.3%; P = .8) and symptomatic patients (6.6% vs 5.8%; P = 1.0). No significant difference in restenosis ≥ 70% was identified between redo CEA and CAS after prior CEA (5.2% vs 3.0%; P = .5). Redo CEA vs primary CEA had increased stroke/death/MI rate in both symptomatic (6.6% vs 2.3%; P = .05) and asymptomatic patients 4.4% vs 1.7%; P = .03). Prior ipsilateral CEA was an independent predictor for stroke/death/MI among all patients undergoing CEA (odds ratio, 2.1; 95% confidence interval, 1.3-3.5). No difference in cranial nerve injury was identified between redo CEA and primary CEA (5.2% vs 4.7%; P = .8)., Conclusions: In the VSGNE, CEA and CAS showed statistically equivalent outcomes in asymptomatic and symptomatic patients treated for restenosis after prior ipsilateral CEA. However, regardless of symptom status, the risk of reintervention was increased compared with patients undergoing primary CEA., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Aims: A quality improvement initiative of nursing/chaplain collaboration on the early identification and referral of oncology patients at risk of spiritual distress., Background: Research shows that spiritual distress may compromise patient health outcomes. These patients are often under-identified, and chaplaincy staffing is not sufficient to assess every patient. The current nursing admission form with a question of 'Any spiritual practices that may affect your care?' is ineffective in screening for spiritual distress., Method(s): Ten nurses on the oncology unit were recruited and trained in a two-question screening tool to be utilized upon admission., Results: Six nurses made referrals; a total of 14 patients. Four (28%) were at risk of spiritual distress and were assessed by the chaplains., Conclusions: Nurses are interested in the spiritual well-being of their patients and observe spiritual distress. They appreciate terminology/procedures by which they can assess more productively the spiritual needs of their patients and make appropriate chaplain referrals., Implications for Nursing Management: The use of a brief spiritual screening protocol can improve nursing referrals to chaplains. The better utilization of chaplains that this enables can improve patient trust and satisfaction with their overall care and potentially reduce the harmful effects of spiritual distress., (© 2012 Blackwell Publishing Ltd.)

Background: Respiratory pathogens from CF patients can contaminate inpatient settings, which may be associated with increased risk of patient-to-patient transmission. Few data are available that assess the rate of bacterial contamination of outpatient settings. We determined the frequency of contamination of CF clinics and the effectiveness of alcohol-based disinfectants in reducing hand carriage of bacterial pathogens., Methods: We conducted a point prevalence survey and before-after trial in outpatient clinics at 7 CF centers. The study examined CF patients with positive respiratory cultures for Pseudomonas, Staphylococcus, Stenotrophomonas or Burkholderia species. Hand carriage and environmental contamination with respiratory pathogens were assessed during clinic visits (Part I) and the effectiveness of hand hygiene performed by CF patients (Part II) was determined using molecular typing of recovered isolates., Results: In Part I (n=97), the contamination rate was 13.6%. Pseudomonas and S. aureus, including methicillin-resistant strains, were cultured from patients' hands (7%), the exam room air (8%), and less commonly, environmental surfaces (1%). In Part II (n=100), the hand carriage rate of pathogens was 13.5% and 4 participants without initial detection of pathogens had hand contamination when recultured at the end of the clinic visit., Conclusions: Respiratory pathogens from CF patients can contaminate their hands and the clinic environment, but the actual risk of patient-to-patient transmission in the outpatient setting remains difficult to quantify. These findings support several recommendations CF infection control recommendations including hand hygiene for staff and patients, contact precautions for certain pathogens, and disinfecting equipment and surfaces touched by patients and staff.

Harvey W. Cushing, MD, is the most renowned surgeon in American history. Every aspect of his career including his many accomplishments--articles, essays, and vast correspondence--has been documented and analyzed and is the subject of at least 4 biographies and numerous articles and reminisces. Despite this scrutiny, and given his active involvement in national and international surgical and scientific organizations, his relationship with the New England Surgical Society was tenuous at best and has not been examined.

Mediastinitis is a dreaded complication of CABG surgery. Short-term outcomes have been described, but there have been only a few long-term studies. We examined the survival of patients undergoing isolated CABG surgery between 1992 and 2001. Mediastinitis was identified during the index admission. Proportional hazards regression was used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI 95%). Among 36,078 consecutive patients, there were 5749 deaths during 148,319 person years of follow-up. There were 418 cases of mediastinitis (1.16%). The incidence of death was 11.15 per 100 person/years with mediastinitis and 3.81 deaths/100 person years without. (P < 0.001). We also examined the mortality rates of patients who survived at least 6 months after their CABG surgery. Patients with mediastinitis had an incidence rate of 5.70 deaths per 100 person/years while those without had a rate of 2.66 deaths per 100 person/years (P < 0.001). After adjustment for baseline differences in patient and disease characteristics, the hazard ratio was 2.12 (CI95% = 1.86,2.58; P < 0.001). The adjusted hazard ratios for patients who survived 6 months postsurgery was 1.70 (CI95% = 1.36,2.13; P < 0.001). Mediastinitis is associated with a marked increase in both acute and long-term mortality rates.

Objectives: We sought to evaluate the changing outcomes of percutaneous coronary interventions (PCIs) in recent years., Background: The field of interventional cardiology has seen considerable growth in recent years, both in the number of patients undergoing procedures and in the development of new technology. In view of recent changes, we evaluated the experience of a large, regional registry of PCIs and outcomes over time., Methods: Data were collected from 1990 to 1997 on 34,752 consecutive PCIs performed at all hospitals in Maine (two), New Hampshire (two) and Vermont (one) supporting these procedures, and one hospital in Massachusetts. Univariate and multivariate regression analyses were used to control for case mix. Clinical success was defined as at least one lesion dilated to <50% residual stenosis and no adverse outcomes. In-hospital adverse outcomes included coronary artery bypass graft surgery (CABG), myocardial infarction and mortality., Results: Over time, the population undergoing PCIs tended to be older with increasing comorbidity. After adjustment for case mix, clinical success continued to improve from a low of 88.2% in earlier years to a peak of 91.9% in recent years (p trend <0.001). The rate of emergency CABG after PCI fell in recent years from a peak of 2.3% to 1.3% (p trend <0.001). Mortality rates decreased slightly from 1.2% to 1.1% (p trend 0.007)., Conclusions: There has been a significant improvement in clinical outcomes for patients undergoing PCIs in northern New England, including a significant decline in the need for emergency CABG.

Objectives: To explore the relation between older age and clinical presentation, procedural success, and in-hospital outcomes among a large unselected population undergoing percutaneous transluminal coronary angioplasty (PTCA)., Background: Although more elderly patients are receiving PTCA, studies of post-PTCA outcomes among the elderly have been limited by small numbers and exclusive selection criteria., Methods: Data were collected as a part of a prospective registry of all percutaneous coronary interventions performed in Maine, New Hampshire, and from 1 institution in Massachusetts between October 1989 and December 1993. Comparisons across 4 age groups, (<60, 60 to 69, 70 to 79, and 80 years and above) were performed using chi-square tests, the Mantel-Haenzsel test for trend, and logistic regression., Results: Twelve thousand one hundred seventy-two hospitalizations for PTCA were performed with 507 of them (4%) in persons at least 80 years old. Octogenarians were more likely to be women, have multivessel disease, high-grade stenoses, and complex lesions but were less likely to have hypercholesterolemia, a history of smoking, or have undergone a previous PTCA. In the elderly, PTCAs were more often performed urgently and for unstable syndromes compared with younger age groups. Advancing age is strongly associated with in-hospital death, and among the oldest old with an increased risk of postprocedural myocardial infarction. Despite differing presentation and procedural priority, angiographic success and subsequent bypass surgery did not vary by age., Conclusions: With the increasing age of the population at large as well as that segment at risk for cardiac revascularization, information about age-associated risks of the procedure, especially the substantially higher risk of death in octogenarians, will be critical for both physicians and patients considering PTCA.