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The aim of this study was to determine trends in the experience of general surgery residents with endocrine surgery cases.American Association of Endocrine Surgeons national general surgery case logs from 1989 through 2019 were reviewed. The numbers of individuals completing residency and the mean and median number of endocrine surgery cases by type and by level of operating resident surgeon were abstracted from annual data and analyzed. Descriptive statistics and linear regression analyses were performed modeling endocrine surgery cases over time and stratified by procedure type and resident level.The number of individuals completing general surgery residency each year increased from 981 to 1,219 (P.001). The average total number of endocrine surgery cases performed increased from 17 to 33.2 (P.001) but has declined since its peak at 36.9 in 2010 to 2011 (P = .014). Thyroid operations increased from 11.4 to 19.8 (P.001) but peaked at 23.5 in 2010 to 2011 and have since declined (P.001). Parathyroid operations more than doubled from 4.2 to 9.7 (P.001). Adrenal operations increased from 1 to 2.2 (P.001) and pancreatic endocrine operations increased from 0.2 to 1.5 (P.001). Surgeon Chief endocrine surgery cases peaked at 14.4 in 2003 to 2004 but have since declined by 22.2% (P.001). Surgeon Junior endocrine surgery cases increased overall (P.001) but peaked at 22.8 in 2011 to 2012. There was increasing heterogeneity over time in trainee experience (P.001).After having increased for 2 decades, the number of endocrine surgery cases performed by general surgery residents is currently in decline. Possible contributing factors include growth in the number of general surgery residents, variable and narrowed case mix, and encroachment by other learners.

Background The inception of work hour restrictions for resident physicians in 2003 created controversial changes within surgery training programs. On a recent Accreditation Council for Graduate Medical Education survey at our institution, we noted a discrepancy between low recorded violations of the duty hour restrictions and the surgery resident’s perception of poor duty hour compliance. We sought to identify factors that lead to duty hour violations and to encourage accurate reporting among surgery trainees. Methods The A3/Lean methodology, an industry-derived, systematic, problem-solving approach, was used to investigate barriers to accurate reporting of duty hours by residents within the Department of Surgery at our academic institution. In partnership with our office of Graduate Medical Education, we encouraged a 6-month period where residents were asked to record duty hour accurately and to provide honest, descriptive explanations of violations without punitive effects on residents or the program. We performed a 6-month before-and-after analysis of duty hours violations after the A3/Lean implementation. Quantitative analysis was used to elucidate trends in violations by post graduate year and rotation. Qualitative evaluation by key thematic areas revealed resident attitudes and opinions about duty hour violations. Results Residents reported concern for personal and programmatic, punitive measures, desire to retain control of their education, and frustration with the administrative burden after violations as deterrents to honest duty hour reporting. The intervention was successful in changing logging behavior with 10 total violations prior to A3 meeting and 179 violations afterward (P = .003). This change was driven largely from an increase in short break violations (4 vs 134, P = .021). Analysis of violations revealed trends by post-graduate year, rotation, and weekend cross-coverage. Key findings including less than anticipated violations of the 80-hour work week despite high rates of short break violations. The ability to participate in procedures voluntarily and a sense of professional responsibility emerged as the prevailing themes among surgery residents describing violations. Conclusion Systematic evaluation of duty hour reporting within a surgery training program can identify structural and cultural barriers to accurate reporting of duty hours. Accurate reporting can identify program-specific trends in duty hour violations that can be addressed though programmatic intervention.

BACKGROUND Evaluation of fundamental surgical skills is invaluable to the training of medical students and junior residents. This study assessed the effectiveness of crowdsourcing nonmedical personnel to evaluate technical proficiency at simulated vessel ligation. STUDY DESIGN Fifteen videos were captured of participants performing vessel ligation using a low-fidelity model (5 attending surgeons and 5 medical students before and after training). These videos were evaluated by nonmedical personnel recruited through Amazon Mechanical Turk, as well as by 3 experienced surgical faculty. Evaluation criteria were based on Objective Structured Assessment of Technical Skills (scale: 5-25). Results were compared using Wilcoxon signed rank-sum and Cronbach's alpha (α). RESULTS Thirty-two crowd workers evaluated all 15 videos. Crowd workers scored attending surgeon videos significantly higher than pretraining medical student videos (20.5 vs 14.9, p < 0.001), demonstrating construct validity. Across all videos, crowd evaluations were more lenient than expert evaluations (19.1 vs 14.5, p < 0.001). However, average volunteer evaluations correlated more strongly with average expert evaluations (α = 0.95) than the strength of correlation between any 2 individual expert evaluators (α = 0.72-0.88). Combined reimbursement for all workers was $80.00. CONCLUSION After adjustments for score inflation, crowdsourced can evaluate surgical fundamentals with excellent validity. This resource is considerably less costly and potentially more reliable than individual expert evaluations.

Background As of 2012, a downward trend in infection rates for hospital onset of both Clostridium difficile infections and methicillin-resistant Staphylococcus aureus bloodstream infections (2% and 4% decrease respectively) has been noted. Despite the success with these two organisms, several infectious pathogens in the healthcare setting have not decreased. This lack of downward trend highlights the importance of continuing to find and assess rapid detection methods to help confirm that hospital cleaning efforts meet and exceed standards of cleanliness demonstrated to reduce numbers of healthcare- associated infections (HAIs) of these pathogens. Methods This study set out to determine the effectiveness of the swab 3M™ Clean-Trace™ Adenosine Triphosphate (ATP) System over time by comparing the ATP measurements of the culturable organisms to the corresponding quantitative microbiology. The organisms evaluated included: Acinetobacter baumannii, Bacillus anthracis Sterne endospores and vegetative cells, Candida albicans, Clostridium difficile, Escherichia coli, Enterococcus faecalis, methicillin-resistant Staphylococcus aureus and Mycobacterium smegmatis. Results A combined organisms analysis did not demonstrate a significant reduction in measured ATP levels over the course of the organisms' exposures in a controlled environment. The quantitative microbiology did, however, demonstrate a large initial organism die-off within the first 60 min (P Conclusions This study did not demonstrate a significant effect of time in reducing ATP measures over the time periods evaluated. ATP measurements were approximately the same, regardless of the initial organism die-off. Additionally, the live versus dead analysis confirms that ATP bioluminescence is not sensitive enough to distinguish between viable organisms and organic debris remnants on sterilised equipment.

The care of patients with Ebola virus disease (EVD) requires the application of critical care medicine principles under conditions of stringent infection control precautions. The care of patients with EVD requires a number of elements in terms of physical layout, personal protective apparel, and other equipment. Provision of care is demanding in terms of depth of staff and training. The key to safely providing such care is a system that brings many valuable skills to the table, and allows communication between these individuals. We present our approach to leadership structure and function--a variation of incident command--in providing care to 3 patients with EVD.

Objective Many benchtop surgical simulators assess laparoscopic proficiency, yet few address core open surgical skills. The purpose of this study is to describe a cost-effective benchtop vessel ligation simulator and provide construct validation. Design A prospective comparison of blinded proficiency assessments among participants performing a benchtop vessel ligation simulation task. Evaluations were performed using Objective Structured Assessments of Technical Skills. Setting This study took place at the University of Virginia, School of Medicine: a large academic medical institution. Participants The participants included fourth-year medical students participating in a focused surgical elective course ( n = 16), postgraduate year 2 to 3 surgery residents ( n = 6), and surgical faculty ( n = 5). Results The total fixed costs of the vessel ligation simulator was $30. Flexible costs of operation were less than $0.20 per attempt. The median task-specific checklist scores among the medical students, residents, and faculty were 4.83, 7.33, and 7.67, respectively. Median global rating scores across the 3 groups were 2.29, 4.43, and 4.76, respectively. Significant proficiency differences were noted between the students and the residents/faculty for both the metrics (p Conclusions A cost-effective benchtop simulator can effectively measure proficiency with basic open surgical techniques such as vessel ligation. Among the junior surgical trainees, this tool can identify learning gaps and improve operative skills in a preclinical setting.

Background Decontamination of hospital isolation rooms can be conducted using vaporised hydrogen peroxide (VHP). A more rapid biological indicator, such as adenosine triphosphate (ATP) bioluminescence, could allow rooms to be reoccupied sooner and reduce down time. Aim This study examined the ATP bioluminescence assay as a way to evaluate biological indicators to confirm decontamination following the use of VHP. Methods Response to VHP exposure was evaluated using microbial inactivation by standard culture methods and by the ATP bioluminescence assay. Range finding determined the approximate exposure time necessary to achieve partial and complete inactivation of the organisms. Two-hundred-and-fifty parts per million of VHP was delivered to the chamber during the exposure cycle. Fifty cm 2 stainless steel coupons were inoculated with 50 mL of organism suspensions containing >10 9 colony forming units (CFU) of the following: Acinetobacter baumannii, Klebsiella pneumoniae , and methicillin-resistant Staphylococcus aureus . The standard manufactured biological indicator stainless steel discs containing concentrations of 10 4 , 10 5 and 10 6 CFU/surface of Geobacillus stearothermophilus spores were also evaluated. Findings Multiple log-reductions were shown utilising standard culture methods for each organism, but the ATP bioluminescence assay did not show a corresponding log-reduction. Conclusion The ATP bioluminescence assay was not considered an effective alternate to standard culture-based methodologies for the confirmation of VHP decontamination.

The 30-day readmission rate is a quality metric under the Affordable Care Act. Readmission rates after thyroidectomy and parathyroidectomy and associated factors remain ill-defined. We evaluated patient and perioperative factors for association with readmission after thyroidectomy and parathyroidectomy.The American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2011) data for thyroid (n = 3,711) and parathyroid (n = 3,358) resections were analyzed. Patient- and operation-related factors were assessed by univariate and multivariate analyses.Among 7,069 patients, 30-day readmission rate was 4.0%: 4.1% after thyroidectomy and 3.8% after parathyroidectomy. Significant associations for 30-day readmission included declining functional status (odds ratio [OR], 6.4-10.1), preoperative hemodialysis (OR, 2.6; 95% CI, 1.5-4.7), malnutrition (OR, 3.4; 95% CI, 1.2-10.1), increasing American Society of Anesthesiologists class (OR 1.3-4.7), unplanned reoperation (OR, 61.6), and length of stay (LOS)24 hours (OR, 0.61; 95% CI, 0.45-0.85; all P.05). Readmission was associated with greater total and postoperative LOS and major postoperative complications, including renal insufficiency (all P.01).Thirty-day readmission after cervical endocrine resection occurs in 4% of patients. Discharge within 24 hours of operation does not affect the likelihood of readmission. Risk factors for readmission are multifactorial and driven by preoperative conditions. Decreasing the index hospital stay and preventing major postoperative complications may decrease readmissions and improve quality metrics.

Background Although an emphasis has been placed on protecting patients by improving health care worker compliance with infection control techniques, challenges associated with patient isolation do exist. To address these issues, a more consistent mechanism to evaluate specific clinical behaviors safely is needed. Methods The research method described in this study used a high fidelity simulation using a live standardized patient recorded by small cameras. Immediately after the simulation experience, nurses were asked to view and comment on their performance. A demographic survey and a video recorded physical evaluation provided participant description. A questionnaire component 1 month after the simulation experience offered insight into the timing of behavior change in clinical practice. Results Errors in behaviors related to donning and doffing equipment for isolation care were noted among the nurses in the study despite knowing they were being video recorded. This simulation-based approach to clinical behavior analysis provided rich data on patient care delivery. Conclusion Standard educational techniques have not led to ideal compliance, and this study demonstrated the potential for using video feedback to enhance learning and ultimately reduce behaviors, which routinely increase the likelihood of disease transmission. This educational research method could be applied to many complicated clinical skills.

Background: High prevalence and high mortality rates associated with healthcare-associated Infections (HAI) indicate there is a need to prevent HAIs from spreading. Cleaning and disinfection of hospital surfaces are fundamental to preventing HAIs, as is the confirmation of the success of these processes. Adenosine triphosphate bioluminescence has been identified as a quicker way to confirm cleaning, but questions remain regarding its specificity regarding microorganisms important to HAIs. Methods: This study evaluated ATP bioluminescence' se fficacy in determining microbial contamination on 17 surfaces from the healthcare environment, and to determine if the ATP measurements of Acinetobacter baumannii, Candida albicans, Enterococcus faecalis, Escherichia coli, Mycobacterium smegmatis, and methicillin-resistant Staphylococcus aureus corresponded to quantitative microbiology. Results: A strong positive correlation was discovered for each of the six organisms associated with HAIs, as well as an additional 'all organisms' analysis that combined all the six organisms. Conclusion: This study demonstrated a correlation between ATP bioluminescence measurements and quantitative microbiology; however, it was not as strong at low bacterial concentrations. Additional keywords: Acinetobacter baumannii, Adenosine triphosphate (ATP), ATP measurement, Candida albicans, Enterococcus faecalis, Escherichia coli, healthcare-associated infections, Mycobacterium smegmatis, and methicillin-resistant Staphylococcus aureus.

Video review and scoring was used to evaluate the behaviors of nurses wearing N95 filtering face piece respirators while providing isolation care in a simulated patient care environment. This study yielded a detailed description of behaviors related to N95 respirator use in a health care setting. Developing a more robust and systematic behavior analysis tool for use in demonstration, simulation, and clinical care would allow for improved respiratory protection of health care workers.

Background The environment is increasingly appreciated as a factor in healthcare associated infections. Several methods for measuring environmental contamination are available. Our goal was to compare quantitative microbiology to adenosine triphosphate (ATP) detection on a sample of hospital surfaces both pre- and post-cleaning, and to assess fluorescent marker results in the same rooms. Methods In a sample of 10 rooms, ATP readings by relative light units (RLU) and quantitative determination of colony forming units (CFU) were measured pre- and post-cleaning on 10 high-touch hospital environmental surfaces. Removal of fluorescent markers (FM) was evaluated post-cleaning in the same rooms. Methods were compared using correlational analyses. Results The ATP readings were usually higher than CFU readings compared with their respective norms for cleanliness. The direction of change in cleanliness assessment (usually down after cleaning) was consistent between the RLU and CFU methods. In addition, CFU and RLU values correlated pre-cleaning, but not postcleaning. Areceiver operating characteristic (ROC) curve suggested a ‘clean' cutoff of 8 RLU/cm 2 for the ATP assay, higher than 2.5 RLU/cm 2 cutoff most often used. Neither method correlated well with FM results. Conclusions The methods for measuring environmental cleanliness have shown inconsistent correlation, but measure different parameters. Additional studies are needed to assess the correlation and predictive value of the three methods for room cleanliness assessment.

Background The environment has increasingly been shown to be involved in transmission of healthcare-associated infections, but data on environmental cleanliness assessment are relatively sparse. Method Environmental samples were collected from 18 high touch surfaces in 10 different acute care hospital rooms before cleaning to provide data on the rank order of cleanliness by site using both adenosine triphosphate (ATP) detection and quantitative microbiology. In addition, pre-and post-cleaning pooled samples of surfaces from 10 rooms were analysed by culture and sensitivity analysis to detect organisms of concern in the hospital. Results Four surfaces were ranked in the top six for contamination by both ATP and culture detection (bedrail control panel, nurse call light, patient phone, and bedrail). Additionally, the top three areas for cleanliness were identical between the two methods (main light switch, mattress, and bathroom interior door handle). Overall, quantitative microbiology andATPanalysisshowed directional agreement in assessment of environmental cleanliness with higher ATP readings found on surfaces designated as ‘dirty' by quantitative microbiology. Several organisms of concern for hospital infection control were seldomdetected in the pre-cleaning environmental samples, and not at all in the post-cleaning samples. Conclusions In this study environmental bioburden decreased after cleaning, and few hazardous nosocomial organisms were noted. Although quantitative microbiology and ATP detection measure somewhat different aspects of environmental contamination, they both generally agree in distinguishing clean from dirty surfaces.

To appreciate the current advances in the field of health care epidemiology, it is important to understand the history of hospital infection control. Available historical sources were reviewed for 4 different historical time periods: medieval, early modern, progressive, and post-World War II. Hospital settings for the time periods are described, with particular emphasis on the conditions related to hospital infections.

Background Given the potential for the transfer of infectious diseases among patients in isolation, health care workers (HCWs), and other patients in the hospital environment, the proper use of personal protective equipment (PPE) is paramount. The literature is limited regarding studies of HCWs’ use of PPE in patient care tasks. Methods A pilot study was conducted to examine the feasibility of using a simulated health care environment to assess HCWs’ technique when implementing standard airborne and contact isolation precautions. The participants (n = 10) were assigned patient care tasks based on their specific professional roles. The encounters were digitally recorded during donning and doffing of PPE, as well as during interactions with the simulated patient. Powdered fluorescent marker was used as a measure of contamination. Results The pilot data show various inconsistencies in the HCWs’ PPE technique. Each of the 10 participants committed at least one breach of standard airborne and contact isolation precautions. Conclusion An expanded research study of HCW behaviors is needed to properly examine these contamination and exposure pathways. Training programs should be developed that emphasize the common errors in HCWs’ PPE technique.

Breast cancer metastasis suppressor 1 (BRMS1) is a metastasis suppressor gene in several solid tumors. The role of BRMS1 in non-small cell lung cancer (NSCLC) is not well established. To assess in vitro and in vivo metastatic behavior H1299 NSCLC cells stably expressing BRMS1 or a vector control were created. BRMS1 expression significantly decreases both migration and invasion of NSCLC cells in vitro. Importantly, in flank xenografts, BRMS1 suppresses the formation of pulmonary and hepatic metastases but does not significantly affect primary tumor growth. To evaluate whether BRMS1 is related to the progression of NSCLC, we examined BRMS1 expression in human NSCLC. Both BRMS1 mRNA and protein levels are diminished in NSCLC compared to adjacent non-cancerous lung. BRMS1 expression is also lower in squamous cell carcinoma compared to adenocarcinoma. Moreover, preservation of tumor BRMS1 expression is associated with improved patient survival. Thus, BRMS1 functions as a metastasis suppressor and may be a prognostic indicator for human NSCLC.

ObjectiveThe best current noninvasive surrogate for tumor biology is fluorodeoxyglucose positron emission tomography (FDG–PET). Both FDG–PET maximal standardized uptake values and selected tumor markers have been shown to correlate with stage, nodal disease, and survival in non–small cell lung cancer (NSCLC). However, there are limited data correlating FDG–PET with tumor markers. The purpose of this study was to determine the correlation of tumor marker expression with FDG–PET maximal standardized uptake values in NSCLC.MethodsFDG–PET maximal standardized uptake values were calculated in patients with NSCLC (n = 149). No patient had induction chemoradiotherapy. Intraoperative NSCLC tissue was obtained and tissue microarrays were created. Immunohistochemical analysis was performed for 5 known NSCLC tumor markers (glucose transporter 1, p53, cyclin D1, epidermal growth factor receptor, and vascular endothelial growth factor). Each tumor marker was assessed independently by two pathologists using common grading criteria. Subgroup analysis based on histologic characteristics and regional nodal status was performed.ResultsFDG–PET correlated with T classification (P < .0001), N stage (P = .002), and greatest tumor dimension (P < .0001). In addition, increasing maximal standardized uptake values correlated with increased expression of glucose transporter 1 (P < .0001) and p53 (P = .04) in adenocarcinoma. Epidermal growth factor receptor expression correlated with maximal standardized uptake values without predilection for histologic subtype (P = .004).ConclusionFDG–PET maximal standardized uptake values correlate with an increased expression of glucose transporter 1 and p53 in lung adenocarcinoma, but not squamous cell cancer. Future studies attempting to correlate FDG–PET with tumor biology will need to consider the effect of different tumor histologic types.

Long-term care facilities (LTCFs) may be defined as institutions that provide health care to people who are unable to manage independently in the community.1 This care may be chronic care management or short-term rehabilitative services. The term nursing home is defined as a facility licensed with an organized professional staff and inpatient beds that provides continuous nursing and other services to patients who are not in the acute phase of an illness. There is considerable overlap between the 2 terms. More than 1.5 million residents reside in United States (US) nursing homes. In recent years, the acuity of illness of nursing home residents has increased. LTCF residents have a risk of developing health care-associated infection (HAI) that approaches that seen in acute care hospital patients. A great deal of information has been published concerning infections in the LTCF, and infection control programs are nearly universal in that setting. This position paper reviews the literature on infections and infection control programs in the LTCF. Recommendations are developed for long-term care (LTC) infection control programs based on interpretation of currently available evidence. The recommendations cover the structure and function of the infection control program, including surveillance, isolation precautions, outbreak control, resident care, and employee health. Infection control resources are also presented. Hospital infection control programs are well established in the US. Virtually every hospital has an infection control professional (ICP), and many larger hospitals have a consulting hospital epidemiologist. The Study on the Efficacy of Nosocomial Infection Control (SENIC) documented the effectiveness of a hospital infection control program that applies standard surveillance and control measures.2 The major elements leading to a HAI are the infectious agent, a susceptible host, and a means of transmission. These elements are present in LTCFs as well as in hospitals. It is not surprising, therefore, that almost as many HAIs occur annually in LTCFs as in hospitals in the US.3 The last 2 decades have seen increased recognition of the problem of infections in LTCFs, with subsequent widespread development of LTCF infection control programs and definition of the role of the ICP in LTCFs. An increasingly robust literature is devoted to LTC infection control issues such as the descriptive epidemiology of LTCF infections, the microbiology of LTCF infections, outbreaks, control measures, and isolation. Nevertheless, there is as yet no SENIC-equivalent study documenting the efficacy of infection control in LTCFs, and few controlled studies have analyzed the efficacy or cost-effectiveness of the specific control measures in that setting. Although hospitals and LTCFs both have closed populations of patients requiring nursing care, they are quite different. They differ with regard to payment systems, patient acuity, availability of laboratory and x-ray, and nurse-to-patient ratios. More fundamentally, the focus is different. The acute care facility focus is on providing intensive care to a patient who is generally expected to recover or improve, and high technology is integral to the process. In LTCFs, the patient population may be very heterogeneous. Most LTCFs carry out plans of care that have already been established in acute care or evaluate chronic conditions. The LTCF is functionally the home for the resident, who is usually elderly and in declining health and will often stay for years, hence comfort, dignity, and rights are paramount. It is a low-technology setting. Residents are often transferred between the acute care and the LTC setting, adding an additional dynamic to transmission and acquisition of HAIs. Application of hospital infection control guidelines to the LTCF is often unrealistic in view of the differences noted above and the different infection control resources. Standards and guidelines specific to the LTCF setting are now commonly found. The problem of developing guidelines applicable to all LTCFs is compounded by the varying levels of nursing intensity (eg, skilled nursing facility vs assisted living), LTCF size, and access to physician input and diagnostic testing. This position paper provides basic infection control recommendations that could be widely applied to LTCFs with the expectation of minimizing HAIs in LTC. The efficacy of these measures in the LTCF, in most cases, is not proven by prospective controlled studies but is based on infection control logic, adaptation of hospital experience, LTCF surveys, Centers for Disease Control and Prevention (CDC) and other guidelines containing specific recommendations for LTCFs, and field experience. Every effort will be made to address the unique concerns of LTCFs. Because facilities differ, the infection risk factors specific to the resident population, the nature of the facility, and the resources available should dictate the scope and focus of the infection control program. In a number of instances, specific hospital-oriented guidelines have been published and are referenced (eg, guidelines for prevention of intravascular (IV) device-associated infection). These guidelines are relevant, at least in part, to the LTC setting but may be adapted depending on facility size, resources, resident acuity, local regulations, local infection control issues, etc. Reworking those sources to a form applicable to all LTCFs is beyond the scope of this guideline. Any discussion of infection control issues must be made in the context of the LTCF as a community. The LTCF is a home for residents, a home in which they usually reside for months or years; comfort and infection control principles must both be addressed.

Objective Effects of daclizumab and antithymocyte globulin induction on acute rejection, bronchiolitis obliterans syndrome, and survival after lung transplantation are unknown. We hypothesized that daclizumab results in less acute rejection and bronchiolitis obliterans and better survival than antithymocyte globulin. Methods Consecutive adult lung transplants (n = 163) at the University of Virginia from January 1998 to May 2006 were reviewed. Antithymocyte globulin induction was routinely performed before January 2002 (65 patients), after which all patients received daclizumab (98 patients). Estimates of cumulative event rate of acute rejection, bronchiolitis obliterans, and death were calculated by Kaplan–Meier method and between-group differences compared by log-rank test. Cox proportional hazards models were fitted to assess treatment effects adjusted for covariates. Results Groups were similar in demographics and preoperative and intraoperative risk factors. Maintenance immunosuppression changed during the study, and mycophenolate mofetil was more commonly given to patients receiving daclizumab. By Kaplan–Meier method, daclizumab was associated with significantly less acute rejection ( P = .002), less bronchiolitis obliterans ( P = .02), and improved overall survival ( P = .04). Induction agent was highly associated with acute rejection ( P = .002), bronchiolitis obliterans ( P = .02), and mortality ( P = .05); antimetabolite agent was associated only with acute rejection ( P = .01). Adjusting for covariates, induction agent remained significantly predictive for acute rejection ( P = .02) and bronchiolitis obliterans ( P = .05), approaching significance for survival ( P = .07). Conclusion Lung transplant recipients receiving daclizumab for induction had significantly less acute rejection and bronchiolitis obliterans than those receiving antithymocyte globulin, with possibly improved survival. Improvements in acute rejection may have been confounded by the use of mycophenolate mofetil.

Although the benefits of mitral valve repair for degenerative disease are well established, many consider surgery for functional ischemic mitral regurgitation (MR) less amenable to operative treatment. We hypothesized that mitral valve repair for ischemic MR results in outcomes similar to those for mitral valve repair for degenerative MR.Retrospective review of nonemergent mitral valve repairs for an 8-year period revealed 105 patients with functional ischemic MR, of whom 39 were treated for severe tethering (ischemic group), and 245 patients with degenerative MR (degenerative group).Patients in the ischemic group had more comorbidities (p0.01) and worse preoperative left ventricular dysfunction (ejection fractionor = 0.29) compared with patients in the degenerative group; (ischemic, 37.1% [39 of 105] versus degenerative, 2.0% [5 of 245]; p0.01). Immediate postrepair transesophageal echocardiogram revealed a 0 to 1+ MR in all patients in both groups (not significant). The hospital mortality rate was 1.9% (2 of 105) in the ischemic group and 1.2% (3 of 245) in the degenerative group (p = 1.00). The 5-year survival rate was 83.9% in the ischemic group and 94.3% in the degenerative group (p0.01). Five-year freedom from reoperation for recurrent MR was 100% and 97.5% in the ischemic and degenerative groups, respectively (p = 0.14). Postoperative renal failure and stroke rates were similar between both groups (not significant). The incidence of moderate or greater MR after more than 1 year of follow-up was similar between groups (not significant).Despite the multiple comorbidities that afflict patients with ischemic MR, mitral valve repair for ischemic and degenerative disease produces comparable and satisfactory outcomes. An aggressive approach to repair of functional ischemic MR, including treatment of tethering, leads to durable results.

In this paper, we describe a computational methodology to couple physical processes defined over independent subdomains, that are partitions of a global domain in three-dimensions. The methodology presented helps to compute the numerical solution on the global domain by appropriately piecing the local solutions from each subdomain. We discuss the mixed method formulation for the technique applied to a model problem and derive an error estimate for the finite element solution. We demonstrate through numerical experiments that the method is robust and reliable in higher dimensions.

Advanced recipient age is reported to negatively affect survival after lung transplantation (LTX). We hypothesized that LTX in patients agedor = 60 years could be performed with acceptable outcomes.We identified 182 consecutive LTX recipients from 1995 to 2005. Outcomes were analyzed and survival compared with results in recipients aged60, as well as with United Network for Organ Sharing (UNOS) registry outcomes for the same age and study period. Actuarial survivals were calculated by the Kaplan-Meier method.During the study period, 29% (52/182) of LTX recipients wereor = 60 years old (range, 60 to 69 years). Median follow-up was 2.9 years (range, 0 to 10 years). All patients but one received a single lung. Indications included chronic obstructive pulmonary disease in 63% (33/52), idiopathic pulmonary fibrosis in 27% (14/52), and other in 10% (5/52). In-hospital mortality was 12% (6/52) for those agedor = 60 compared with 7% (9/130) for those aged60 (p = NS). Complications included reoperation in 10% (5/52), requirement for extracorporeal membrane oxygenation in 6% (3/52), renal failure in 12% (6/52), and stroke in 4% (2/52). Actuarial survivals at 30 days, and 1, 3, and 5 years were 90% (82, 98), 86% (76, 96), 71% (56, 85), and 55% (37, 73), respectively. No significant difference in survival was observed between age cohorts for our institutional data by Kaplan-Meier analysis (p = 0.34) or by Cox proportional hazard model (p = 0.15). A significant survival advantage was noted for our institution compared with UNOS for this cohort (p = 0.018).In carefully selected recipientsor = 60 years of age, LTX offers acceptable outcomes and survival.

We have previously demonstrated that the transcription factor NF-kappaB is activated by histone deacetylase inhibitors in a PI3K/Akt-dependent manner. The molecular mechanisms governing this process have not been well described. By virtue of their inhibitory action, it is unclear whether the addition of histone deacetylase inhibitors simply preserves the acetylation status of RelA/p65 or whether they actively stimulate signaling cascades that result in increased acetylation and transcription of NF-kappaB. Here we provide evidence that suberoylanilide hydroxamic acid stimulates NF-kappaB transcription through a signaling cascade that involves activation of both the serine/threonine kinase Akt and the p300 acetyltransferase. Using newly developed phosphospecific antibodies to p300 (pSer(1834)), and site-directed mutant proteins, we find that suberoylanilide hydroxamic acid stimulates Akt activity, which is required to phosphorylate p300 at Ser(1834). Akt-mediated phosphorylation of p300 dramatically increases its acetyltransferase activity as measured by an increased acetylation of RelA/p65 at Lys(310), a modification that is required for full NF-kappaB transcription. Importantly, coordinate activation of Akt/p300 pathway by suberoylanilide hydroxamic acid occurs at the chromatin level, resulting in recruitment of activated Akt (pSer(473)), p300 (pSer(1834)), acetylated RelA/p65 (Lys(310)), and RNA polymerase II to the NF-kappaB-dependent cIAP-2 and Bfl-1/A1 promoters. These studies provide evidence that histone deacetylase inhibitors, such as suberoylanilide hydroxamic acid, not only inhibit deacetylase activity but also stimulate active NF-kappaB transcription and cell survival through signaling pathways involving Akt and increased p300 acetyltransferase activity.

Patricia A. Lenaghan, ENA Chapter, Nebraska #21663, Nursing Consultant, Nebraska Medical Center, Omaha, Neb. Philip W. Smith, MD, Medical Director, The Nebraska Biocontainment Patient Care Unit, Nebraska Medical Center, Omaha, Neb. Deepali Gangahar, BBA, Medical Student, University of Nebraska Medical Center, Omaha, Neb. For correspondence, write: Patricia A. Lenaghan, RN, MS, CEN, FAAN, Nebraska Medical Center, 988458 Nebraska Medical Center, Omaha NE 68198-8458; E-mail: plenaghan@nebraskamed.com. J Emerg Nurs 2006;32:394-7. Available online 28 August 2006. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.06.001

One aspect of the definition of institutional value for any program is based on the return on investment (ROI) for that program. Program requests for future resource allocations depend, in part, on that information. The purpose of this project was to determine the ROI for initial outpatient visits only for our General Thoracic Surgery (GTS) program.The number of GTS outpatient visits, studies, and requested consultations ordered by GTS surgeons only was determined after review of the hospital database and office records for the calendar year 2003. Only charges associated with the initial outpatient visits (no inpatient or physician charges) were included. Charges were based on hospital finance department data. The ROI for GTS outpatient services was calculated using total hospital costs and hospital collections.There were 689 initial outpatient GTS visits. The majority were for lung cancer (48%), benign lung diseases (21%), and esophageal diseases (14%). Total outpatient charges were 1.25M dollars and by disease process were lung cancer (644,000 dollars), benign lung disease (90,000 dollars), esophageal disease (159,000 dollars), and other (357,000 dollars). The most significant hospital charges were the following: radiology (850,000 dollars), laboratory studies (82,000 dollars), gastrointestinal medicine studies (59,000 dollars), and cardiology (42,000 dollars). Total operational costs for the GTS clinic were 415,000 dollars and hospital collections were 513,000 dollars, yielding an ROI of 98,000 dollars or an operating margin of 19%.An operating margin of 19% for GTS outpatient services is better than most Fortune 500 companies. Acquisition of this type of information by GTS surgeons may be helpful for future program development and institutional resource allocation.

This paper addresses the question of density of binomials in C[a,b]. This seemingly innocuous question turns out to be equivalent in certain instances to the moment problem.

In engineering applications, there is a constant need for solving problems using finite elements, over large and complicated domains. Such analysis is often accomplished by decomposing the global domain into several sub-domains and performing the analysis individually on each local sub-domain. The global analysis can then be realized by piecing together the information that is available from each sub-domain. Non-conforming finite elements are particularly useful in this regard. In this paper, we discuss such a technique for a model problem. We derive necessary and sufficient conditions in order for the mixed method formulation of such a non-conforming method to have a unique solution. Error estimates for the finite element solution are obtained. Finally, we present computational experiments to demonstrate that this non-conforming technique is a good candidate for finite element implementation.

Background: We undertook a microbiologic survey of long-term care facilities to categorize bacteria found in cultures of residents. Culture and sensitivity data were collected on 566 samples from indwelling bladder catheters, percutaneous gastrostomy tubes, nares, stool, wounds, pressure ulcers, and tracheostomies in 25 Nebraska and Iowa facilities. Information was also collected on resident factors (eg, presence of indwelling urinary catheter, prior antibiotic administration) and institutional variables (eg, number of beds, nosocomial infection rates). Results: There were 478 gram-negative isolates, the leading organisms being Pseudomonas aeruginosa, Proteus mirabilis, Escherichia coli, and Klebsiella pneumoniae. There were 221 gram-positive isolates, the most frequently seen of which were enterococci and Staphylococcus aureus. Of the 442 residents sampled in the study, 168 (38%) were taking, or had within the previous month been taking, a systemic antibiotic. Quinolones were the most frequently prescribed antibiotic class. The institutional prevalence of urinary catheterization averaged 6.7%. Conclusions: Significant antibiotic pressure exists in long-term care facilities, a fact that is reflected in antibiotic resistance patterns. A variety of gram-positive and gram-negative bacteria were found in nursing home culture specimens. (AJIC Am J Infect Control 2000;28:8-13)

Clinical practices surrounding the current Ebola epidemic have been center stage in discourse concerning research and practice of care. As the medical community becomes more sophisticated in understanding the many facets of treating and containing this virus, the Nebraska Biocontainment Unit Q6 has identified Ebola medical waste disposal as a key area of concern for U.S. hospitals. The requirements for processing Ebola medical waste stand to impact most U.S. hospitals currently preparing readiness plans to receive and treat patients with suspected or confirmed Ebola virus disease (EVD). The U.S. Centers for Disease Control and Prevention (CDC) has issued recommendations to guide health care facilities in preparing to isolate potential or confirmed EVD patients, and hospitals have established plans to isolate and care for these patients.1,2 The CDC’s guidance includes facility and provider EVD preparedness checklists to aid the U.S. health system in preparing to prevent the spread of the virus within the United States.3 Hospitals are undertaking multiple measures to minimize the risk of EVD, including establishing EVD staffing, appropriate levels of personal protective equipment (PPE), infection prevention and control measures, environmental cleaning, laboratory procedures, public health reporting, and clinical protocols to minimize the exposure risks of health care workers (HCWs). Health care facilities and providers routinely use PPE precautions and are able to refine and implement existing protocols to effectively protect HCWs treating a suspected or confirmed patient, but waste associated with caring for an EVD patient cannot be processed as standard medical waste. Two high-level isolation facilities located at the University of Nebraska Medical Center and Emory University have treated EVD patients in the U.S. These units are ideally equipped for treating patients in high-level isolation because each unit is staffed with HCWs rigorously trained in donning and doffing PPE, and the facilities have been specifically engineered for high-level isolation with in-unit waste processing capability.4 The Nebraska Biocontainment Unit’s strategy for waste management uses a pass-through autoclave to process all medical waste exiting the high-level isolation unit. Through discussions with health care entities planning for EVD patients, first-hand knowledge gained by treating EVD patients transported to the United States, and review of current guidance, we provide insight into key logistical and regulatory considerations for management of EVD medical waste in facilities without in-unit waste sterilization capabilities.

Background: In spring 1993, four students in a high school were diagnosed with tuberculosis resistant to isoniazid, streptomycin, and ethionamide. Methods: To investigate potential transmission of drug-resistant tuberculosis, a retrospective cohort study with case investigation and screening by tuberculin skin tests and symptom checks was conducted in a high school of approximately 1400 students. Current and graduated high-school students were included in the investigation. DNA fingerprinting of available isolates was performed. Results: Eighteen students with active tuberculosis were identified, Through epidemiologic and laboratory investigation, 13 cases were linked; 8 entered 12th grade in fall 1993; 9 of 13 had positive cultures for Mycobacterium tuberculosis with isoniazid, streptomycin, and ethionamide resistance, and all 8 available isolates had identical DNA fingerprints. No staff member had tuberculosis. One student remained infectious for 29 months, from January 1991 to June 1993, and was the source case for the outbreak. Another student was infectious for 5 months before diagnosis in May 1993 and was a treatment failure in February 1994 with development of rifampin and ethambutol resistance in addition to isoniazid, streptomycin, and ethionamide. In the fall 1993 screening, 292 of 1263 (23%) students tested had a positive tuberculin skin test. Risk of infection was highest among 12th graders and classroom contacts of the two students with prolonged infectiousness. An additional 94 of 928 (10%) students tested in spring 1994 had a positive tuberculin skin test; 22 were classroom contacts of the student with treatment failure and 21 of these had documented tuberculin skin test conversions. Conclusion: Extensive transmission of drug-resistant tuberculosis was documented in this high school, along with missed opportunities for prevention and control of this outbreak. Prompt identification of tuberculosis cases and timely interventions should help reduce this public health problem. (J Pediatr 1997;131:863-8)

We consider the problem of approximating data in space that arises from a geometric curve (that is, a curve with no explicit parameterization given). We treat theoretical and numerical aspects of a parametric orthogonal distance regression problem which arises naturally in the context of geometric data fitting.

A number of immunologic functions have been shown to decline in an age-related fashion, particularly cell-mediated immunity and antibody response to an immunogen. Underlying degenerative diseases and medications further contribute to the immunologic abnormalities noted in the elderly. The elderly in hospitals and nursing homes are a particularly vulnerable subset, with a high incidence of institutionally acquired infection. Aspects of disease prevention in the elderly are discussed.

Background: Few affordable training opportunities are specifically designed for the long-term care facility infection control practitioner. There is also little evidence of the success of training in improving infection control practices. The Nebraska Infection Control Network developed a 2-day basic skills training program for Midwestern long-term care facility infection control practitioners that was later disseminated to eastern and western training sites. In this study we examined the effectiveness of the training program in terms of trainee knowledge and practice. Methods: From 1986 to 1990, a total of 17 courses conducted at the three sites were attended by a total of 266 infection control practitioners. Trainees completed a 40-item multiple choice test before and after training to evaluate their knowledge gain. Implementation of eight key infection control practices and time devoted to infection control duties were measured before training and at 3 and 12 months after training. Implementation of infection control practices was also evaluated in a second study, with infection control practitioners randomly assigned to trained and wait-control conditions. Results: Significant increases after training were found at each site for both knowledge and implementation measures. These increases were maintained at 12 months follow-up. Time devoted to infection control duties increased significantly at the midwest and western sites but not at the eastern site. In the second study, significant differences were found between the trained and the wait-control group in use of infection control practices, providing evidence for a causal relationship between training and increased use of practices. Conclusions: The training program was effective in producing improvenments in knowledge and implementation of recommended infection control practices in long-term care facilities. These improvements were consistent across three diverse geographic areas. There were some specific geographic differences.

The 1980s saw the birth and growth of the distinct field of infection control in the extended care facility (ECF). Major advances in the field during the last decade have been surveys documenting the magnitude of the problem of ECF nosocomial infections, descriptive studies of ECF nosocomial infections, descriptive studies of ECF epidemics, development of ECF infection control programs, and recognition of the unique problems of the ECF infection control program. As the field matures, areas that should receive additional attention during the upcoming decade include: analysis of the risk factors and consequences of ECF nosocomial infections; analysis of resident and institutional variables that predict nosocomial infection; and studies on the efficacy of both infection control programs and specific infection control measures. ECF infection control programs have benefited a great deal from hospital infection control, but ECF infection control problems are quite different and demand unique solutions.

The Guidelines Committee of APIC is in the process of developing a series entitled “APIC Guidelines for Infection Control Practice.” The first APIC Guideline, “Guideline for Use of Topical Antimicrobial Agents,” by Elaine Larson, RN, PhD, FAAN, was published in the December 1988 issue of the AMERICAN JOURNAL OF INFECTION CONTROL. The second Guideline, “APIC Guideline for Selection and Use of Disinfectants,” by William A. Rutala, PhD, MPH, was published in the April 1990 issue of the JOURNAL. The Guidelines Committee is now pleased to announce completion of the draft of the third APIC guideline for infection control practice: “Guideline for Infection Prevention and Control in the Long Term Care Facility” by Philip W. Smith, MD, FACP, and Patricia G. Rusnak, RN. It is a working draft that is subject to general comment after having been reviewed by the Guidelines Committee, the APIC Board of Directors, and a number of national organizations. At this time we would like to invite all interested parties to comment on the proposed Guideline before its final approval and adoption by APIC. To be considered, comments must be received in writing no later than Monday, Jun. 7,1991. Please send your comments to: Marjorie A. Underwood, RN, BSN, CIC Chairman, APIC Guidelines Committee Manager, Infection Control Services Children’s Hospital of San Francisco 3700 California St. San Francisco, CA 94118

Several Omaha businesses were surveyed on pandemic influenza preparedness and general disaster preparedness. Most businesses had started pandemic influenza planning, but few had exercised the plan or used it to educate employees. Responses provided insight into the status of business planning. The survey uncovered a need for providing assistance to businesses in pandemic preparedness as well as training in infection control in the workplace, which should be a niche for infection control professionals.

Aging is associated with an increased frequency and severity of many infectious diseases, including nosocomial infections in the hospital and nursing home. An age-related decline in host defense functions is the primary explanation for this phenomenon. The epidemiology, morbidity, mortality, and preventive aspects of nosocomial infections in the elderly are reviewed in this article.

In May 1986, a group of individuals with experience in the field of infection control in long-term care met to discuss several aspects of infection prevention and control in nursing homes. This article provides background information, along with points of general consensus among the group. The consensus items are also intended to stimulate further discussion and research in the field of infection prevention and control in long-term care facilities.

A case of Haemophilus parainfluenzae bacterial endocarditis is described. This is the first reported case of endocarditis caused by ampicillin resistant H parainfluenzae. Resistance was not mediated by a beta lactamase. Ampicillin therapy had not controlled the infection, but a four-week course of chloramphenicol was curative. Several general therapeutic points are discussed.

Matrix A with characteristic polynomial Q(z) is defined positive or negative Hurwitz according to whether Q(z) or Q(-z) is a Hurwitz polynomial. Leading principle sections of the Tikhonova growth matrix have associated characteristic polynomials Pn(-z) which satisfy the recursion P n+1 (z)=zP n (z)+ 1 n(n+1) P n-1 (z),P 0 (z)=1,P 1 (z)=1+z That the Tikhonova growth matrix is negative Hurwitz is established through applying the Wall-Stieltjes theory of continued fraction expansions to show the Pn(-z) are Hurwitz polynomials. The Kayeya-Enestrom theorem and a procedure for refinement of the Gerschgorin estimate are used to obtain analytical bounds on spectral radii for the Tikhonova model, which provides estimates of maximal growth rates. The theory allows generalization to more complicated growth models.

where iIfIIm = sup{]f(x)l : 0 < x < 1:. For example, p,& = 2P+‘T, , where T,(x) = cos(n cos-l x) are the Chebyshev polynomials. It is easy to verify that not all the coefficients of p,*,, are bounded as IZ tends to infinity. In fact, the “middle” coefficients of pa,, have the order of magnitude n-lj2 (27/16)“j4. In this paper, we show that if m does not tend to infinity with n, then all the coefficients of pz,, are bounded. This is included in the following

In 1934, Walsh noted that the Taylor polynomial of degree n can be obtained by taking the limit as ϵ → 0 + of the net of n th degree polynomials which best approximate f in the closed discs ¦ z ¦ ⩽ ϵ . Later, this result was generalized to rational approximation. In a recent paper, Shisha and the first two authors generalized this idea to the idea of best local approximation . In this paper, using a different technique, we study this problem in the L 2 setting. Consequently, better results follow under weaker hypotheses.