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Studies have shown above- or below-the-knee amputation has a profound impact on physical, mental, and emotional health; the impact of having a toe(s) amputated is unknown., Purpose: This descriptive research study measured health-related quality of life (HRQoL) using the Vascular Quality-of-Life Questionnaire-6 (VascuQol-6) among persons with peripheral arterial disease (PAD) who had undergone toe amputations., Methods: A list of 127 patients discharged from the hospital in 2016 with a diagnosis of PAD and toe amputation was provided to the investigator. The independent variables of age (subsequently divided into groups of persons <65 and ≥65 years of age), gender, race, diabetes mellitus, and time of PAD diagnosis (within the year or 2 to 7 years before 2016) were abstracted from the patient charts. A letter was mailed to potential participants that explained the study and the VascuQol-6 tool, along with a prepaid envelope to return the completed tool. The VascuQol-6 tool is a valid and reliable instrument for assessing HRQoL that covered the different aspects of quality of life (QoL) affected by PAD. The tool contains six 4-point Likert scale questions about activity, symptoms, pain, emotional status, and social life, resulting in a total score between 6 and 24. Higher values indicate better perceived quality of life. Variables were analyzed using frequencies, percentages, means, and standard deviations, and a standard t test was used to compare interval scale items. Statistical significance was noted when P <.05., Results: Thirty-eight (38) completed surveys were returned (30% completion rate). The mean total score was 15.5 ± 3.93 (range 7-24), and the mean overall score of the 6 items was 2.66 ± 0.90 (range 1-4). In addition to a low overall QoL score, the data showed QoL was negatively affected in every area assessed, but some participants were strongly affected whereas others were not affected at all. No significant differences in QoL scores were noted concerning age groups, gender, race, the presence of diabetes mellitus, or time since PAD diagnosis., Conclusion: In this study, patients with PAD and toe amputations had low QoL scores related to their disease. Additional research is needed to better understand HRQoL related to PAD to facilitate education of patients considering toe amputation.

Purpose: The purpose of this study was to identify factors that increase the risk of vascular graft infections (VGI) in patients following abdominal or lower extremity revascularization surgery., Design: Retrospective, descriptive study., Methods: We reviewed the electronic health records of 223 patients who had undergone abdominal or lower extremity revascularization procedures from July 2012 to November 2014, looking for factors associated with VGI. We reviewed 28 preoperative, intraoperative, and post-operative factors. Descriptive statistics (mean, range, and standard deviation) were used to describe the sample; χ was used to determine correlations between the risk factors and subsequent VGIs. The level of significance was determined at P = .05, with a confidence level of 95%., Results: We identified 33 cases of VGIs for the 223 charts reviewed, yielding an incidence rate of 15%. Seventeen of the 33 patients with VGI (51.5%) were male. The average age of patients who experienced VGI was 60.9 years (standard deviation, 12.2 years, range, 29-81 years). Preoperative factors that were shown to show statistical significance for the development of VGI were sequential procedures (P = .003), diabetes mellitus (P = .002), hemoglobin A1c more than 7.0 (P = .0002), blood glucose more than 180 mg/dL (P = .0006), and lack of mobility (0.0097). Intraoperative factors associated with VGI were hemostatic agents applied to the surgical field intraoperatively (P = .003) and perioperative hypoxemia (P = .027). Postoperative factors associated with VGI were discharge from the hospital to skilled nursing facility or acute rehabilitation facility (P = .005) and unscheduled clinic visits (P = .008)., Conclusion: We measured a 15% incidence of VGI and identified multiple pre-, intra-, and postoperative associated factors. Vigilance is required to prevent VGI and knowledge of specific risk factors is important.

Background: Cigarette smoking is strongly associated with atherosclerotic disease. It is incumbent on vascular surgeons to provide smoking cessation counseling (SCC) to their patients. The objective of this study was to determine the association of SCC and improvement in quality of care., Methods: As a quality project using retrospective data, the study received institutional review board exemption status. A retrospective review of prospectively maintained database from April 2014 through March 2015 of outpatient encounters in a vascular surgery clinic was performed of current smokers. Through the quality support team, providers were encouraged to counsel smokers to quit, document the discussion, and bill specific Evaluate and Management codes (99406 and 99407). The number of outpatients by smoking status, documentation and billing of SCC, demographics of current smokers, and monetary collections were collected. Data were compared using a correlation coefficient calculated and tested for statistical significant using two-tailed t-test., Results: A sample of 1,077 visits by 612 currently smoking patients accounted for 24% of all outpatient vascular surgery visits. The average age was 61 years, and 64% were male. Comorbidities included 77% with hypertension, 32% with diabetes mellitus, and 14% with chronic kidney disease. Medically, 72% were on aspirin, 71% on statin, and 48% on beta blocker. A total of 208 (34%) never underwent a vascular intervention, and 183 (30%) had an intervention during the study period (44% for peripheral artery disease, 10% for carotid stenosis, 14% amputations, and 10% abdominal aortic aneurysm). Documentation improved from 65% of encounters during the first month to 89% in the peak month and 79% of total encounters. All-cause mortality rate was 2%, and this cohort demonstrated 75% SCC for 28 encounters. Fifty-five patients (9%) quit smoking for more than 30 days at the end of the study period, and this cohort had 69% of their 97 encounters with documented SCC. Increased SCC was correlated with decreased 30-day readmissions during the concurrent month (r = -0.711, P = 0.009) and the following month (r = -0.719, P = 0.008). There was a weak correlation with decreased amputations the following month (r = -0.5, P = 0.08). From a financial perspective, $1,373 was collected for 33 patients with a potential for collection of $7,460 predicted for minimum Medicare payment of 1 visit per patient., Conclusions: Advising vascular patients in the arduous process of smoking cessation benefits both the patient and the health system. Proper documentation and billing decreases costs of early readmissions and increases departmental revenue., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Health care bullying is a pervasive, underestimated, and underreported problem that results in poor outcomes for staff, patients, and health care organizations. The most common form of health care bullying occurs between nurses. Nurse managers hold an important role in the prevention and elimination of frontline nurse-to-nurse bullying. An anonymous Web-based survey was conducted to uncover what behaviors nurse managers perceive as bullying and how they respond to bullying acts. Respondents who had witnessed or been victimized by bullying were more apt to identify bullying and those who had been victimized or supervised nurses for more than 20 years were more prone to act upon bullying behaviors. There was only a moderate correlation between the identification of and response to bullying behaviors. Finally, overt bullying elicited a stronger response for intervention than covert bullying. Although nurse managers are well positioned to prevent and eliminate nurse-to-nurse bullying, they may not recognize it and often lack the skills and support necessary to address it. Decreases in nurse-to-nurse bullying reduce health care costs, improve nurse and patient satisfaction, and enhance patient outcomes. Therefore, nurse managers at all levels need education and support to ensure proper identification of bullying and, furthermore, to prevent and eliminate the behaviors.

Background: Mediastinitis costs hospitals thousands of dollars a year and increases the incidence of patient morbidity and mortality. No studies have been done to evaluate adenosine triphosphate (ATP) counts on disposable and nondisposable electrocardiography (ECG) lead wires in pediatric patients., Objective: To compare the cleanliness of disposable and nondisposable ECG lead wires in postoperative pediatric cardiac surgery patients by measuring the quantity of ATP (in relative luminescence units [RLUs]). ATP levels correlate with microbial cell counts and are used by institutions to assess hospital equipment and cleanliness., Methods: A prospective, randomized trial was initiated with approval from the institutional review board. Verbal consent was obtained from the parents/guardians for each patient. Trained nurses performed ATP swabs on the right and left upper ECG cables on postoperative days 1, 2, and 3., Results: This study enrolled 51 patients. The disposable ECG lead wire ATP count on postoperative day 1 (median, 157 RLUs) was significantly lower (P < .001) than the count for nondisposable ATP lead wires (median, 610 RLUs). On postoperative day 2, the ATP count for the disposable ECG lead wires (median, 200 RLUs) was also lower (P = .06) than the count for the nondisposable ECG lead wires (median, 453 RLUs)., Conclusion: Results of this study support the use of disposable ECG lead wires in postoperative pediatric cardiac surgery patients for at least the first 48 hours as a direct strategy to reduce the ATP counts on ECG lead wires., (©2014 American Association of Critical-Care Nurses.)

Background: Thoracic endovascular aortic repair (TEVAR) offers a less invasive treatment option in type B aortic dissection (TBAD) patients and its value has been demonstrated in acute and chronic dissection patients. Total false lumen thrombosis (FLT) is associated with better long-term outcome in these patients, however, this is not obtained in all patients. The purpose of this study was to investigate predictors of FLT., Methods: We retrospectively investigated patients who underwent TEVAR for a type B dissection in a large referral center between 2005 and 2012. All patients with a CT angiogram (CTA) obtained preoperatively, postoperatively and after one year of follow-up were selected for analysis. Volume measurements and several morphologic characteristics were analyzed for all scans using Aquarius iNtuition software (TeraRecon, San Mateo, Calif, USA). Multivariate logistic regression analyses were used to study the influence of these characteristics on FLT., Results: Of 132 patients that received TEVAR for an aortic dissection, 43 patients (mean age, 60.3±14.2; 30 male) met our inclusion criteria, of whom 16 (37%) developed full FLT after 1 yr of follow-up. Multivariate logistic regression showed that side branch involvement [odds ratio (OR), 0.03; 95% confidence interval (CI), 0.00-0.92; P=0.045] and a total patent false lumen (FL) at presentation (OR, 0.01; 95% CI, 0.00-0.58; P=0.027) were associated with decreased complete FLT. Volumetric data showed significantly more reduction of the thoracic false lumen in FLT patients compared with non-FLT (-52.3% vs. -32.4%; P=0.043) and also a tendency of less volume increase in the abdominal segment (-5.0±37.5 vs. 21.8±44.3; P=0.052)., Conclusions: Patients admitted with type B dissection and branch vessel involvement or a patent entry tear after TEVAR are less likely to develop FLT and aortic remodeling during follow-up. These findings suggest that these patients may require a more extensive procedure and more intensive follow-up to prevent long-term complications.

Marfan Syndrome (MFS) is an autosomal dominant, connective tissue disorder that is due to a deficiency in the structural protein, fibrillin. MFS patients are more likely to experience aortic aneurysms and dissections, dislocated lens, and/or severe musculoskeletal deformities than non-MFS patients. Attainment of a longer lifespan in MFS patients is directly dependent on vigilant blood pressure (BP) control, frequent cardiology surveillance, annual eye exams and frequent dental hygiene visits. This study evaluated the effect of a Marfan Syndrome Teaching algorithm (MFSTA) on 20 MFS patients, with regard to BP management, cardiovascular medication adherence; adherence to activity restrictions; and attendance at scheduled eye, cardiology and dental exams. This study demonstrated adherence improvement in the attendance at scheduled cardiology, ophthalmology, and dental exams from 50%, 55% and 70% prior to the study, respectively, to 95%, 90% and 100% post study. Furthermore, subject adherence with self-administration of ordered cardiovascular medications increased from 50% (pre-study) to 93.3% (93.3%), and subject adherence with activity restrictions escalated from 70% (pre-study) to 95% (post study). All subjects demonstrated proficiency in regular testing and recording of their blood pressure. There was no significant change in the mean systolic BP (SBP) for 13 of the subjects who had both pre- and post-intervention BP recording, although the post intervention SBP was slightly higher (p = 0.30). However all subjects in the intervention period demonstrated a mean SBP of 124.7 mm Hg, with standard deviation (SD) of 12.9 mm Hg. Limited pre-intervention BP readings of 7 subjects prevented a pre- and post-SBP comparison. The MFSTA model should be considered for other patient populations involving chronic cardiovascular healthcare conditions., (Copyright © 2013 Society for Vascular Nursing, Inc. Published by Mosby, Inc. All rights reserved.)

Atelectasis is a major factor in postoperative morbidity for patients undergoing cardiopulmonary surgery. We evaluated the effectiveness of stacked inspiratory spirometry (STIS) in 17 patients status postcoronary artery bypass graft in a nonrandomized fashion. We measured pulmonary shunt as an endpoint, and compared the magnitudes before and after the STIS maneuver. Our results showed an 8.66 percent reduction in pulmonary shunt (p < 0.05). The reduction in shunt was modest; however, repetitive maneuvers might result in greater improvement.