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Background: There is wide variation in stress test utilization before major vascular surgery and adherence to practice guidelines is unclear. We defined rates of stress test compliance at our institution and led a quality improvement initiative to improve compliance with American Heart Association (ACC/AHA) guidelines. Methods: We implemented a stress testing order set in the electronic medical record at one tertiary hospital. We reviewed all patients who underwent elective, major vascular surgery in the 6 months before (Jan 1, 2022 – Jul 1, 2022) and 6 months after (Aug 1, 2022 – Jan 31, 2023) implementation. We studied stress test guideline compliance, changes in medical or surgical management, and major adverse cardiac events (MACE). Results: Before order set implementation, 37/122 patients (30%) underwent stress testing within the past year (29 specifically ordered preoperatively) with 66% (19/29) guideline compliance. After order set implementation, 50/173 patients (29%) underwent stress testing within the past year (41 specifically ordered preoperatively) with 80% (33/41) guideline compliance. In the pre- and postimplementation cohorts, stress testing led to a cardiovascular medication change or preoperative coronary revascularization in 24% (7/29) and 27% (11/41) of patients, and a staged surgery or less invasive anesthetic strategy in 14% (4/29) and 4.9% (2/41) of patients, respectively. All unindicated stress tests were surgeon-ordered and none led to a change in management. There was no change in MACE after order set implementation. Conclusions: Electronic medical record-based guidance of perioperative stress testing led to a slight decrease in overall stress testing and an increase in guideline-compliant testing. Our study highlights a need for improved preoperative cardiovascular risk assessment prior to major vascular surgery, which may eliminate unnecessary testing and more effectively guide perioperative decision-making. [ABSTRACT FROM AUTHOR]

The Centers for Disease Control and Prevention has made the prevention of in-hospital Clostridium difficile infection a priority. However, whether there is a differential impact of Clostridium difficile on surgical patients remains undefined. Therefore, we quantified the procedure-specific association between postoperative Clostridium difficile and surgical outcomes to define opportunities for targeted quality improvement. We studied patients undergoing major cardiac, vascular, general, or oncologic procedures using the Vizient database from 2015 to 2019. Our primary exposure was postoperative Clostridium difficile infection. Our primary outcomes were postoperative length of stay, hospitalization cost, readmission, and in-hospital mortality. We used linear and logistic regression for risk adjustment. The incidence of Clostridium difficile infection was 1.6% (n = 6,506/397,750). Patients with Clostridium difficile were older, more comorbid, and more frequently underwent urgent surgery. The median postoperative length of stay was 7 days (interquartile range: 5–11 days), and it was 66% longer among those with Clostridium difficile (P <.001). Similarly, the median hospitalization cost was $31,000 (interquartile range: $20,000–$49,000), and it was 51% greater among patients with Clostridium difficile (P <.001). Postoperative Clostridium difficile was associated with more readmissions after coronary artery bypass grafting, small bowel resection, colectomy, gastrectomy, pancreatectomy, and infrainguinal bypass (adjusted odds ratio range: 1.4–1.7), but not after open aneurysm repair, suprainguinal bypass, or esophagectomy. Clostridium difficile was associated with increased mortality after coronary artery bypass grafting, small bowel resection, colectomy, and infrainguinal bypass (adjusted odds ratio range: 1.3–2.7), but not after open aneurysm repair, suprainguinal bypass, esophagectomy, gastrectomy, or pancreatectomy. Postoperative Clostridium difficile infection was differentially associated with increased length of stay, cost, readmissions, and mortality across specific procedures. This was most apparent after infrainguinal bypass, small bowel resection, colectomy, and coronary artery bypass grafting. Accordingly, a targeted Clostridium difficile reduction effort for these procedures may offer a more effective approach toward reducing infection rates. [ABSTRACT FROM AUTHOR]

Objectives: The growing prevalence of diabetes and concomitant peripheral arterial disease (DM/PAD) has led to an increase in patients at risk for adverse limb events in current practice. Despite a widespread perception that minor amputation may result in both limb salvage and preserved functionality, the natural history of minor amputations remains unknown. Thus, we sought to quantify the rates of subsequent major amputation and survival among DM/PAD patients with any prior minor amputation., Methods: We performed a retrospective cohort study using US Medicare claims from 2007 to 2019. We included patients with DM/PAD based on International Classification of Diseases, 9th and 10th editions, diagnosis codes. We excluded patients lacking continuous fee-for-service coverage or with incomplete demographic data. The primary exposure was prior minor (below-ankle) amputation. The primary outcome was major (above-ankle) amputation. Statistical analyses were performed using the Kaplan-Meier method and Cox proportional hazards modeling., Results: We identified 12,257,174 patients (age 73 ± 11 years; 48% male; 76% White) with DM/PAD. Of these patients, 2.2% (n = 274,225) underwent prior minor amputation. Patients with prior minor amputation were more likely to be male (63% vs 47%; P < .0001), Black non-Hispanic (17% vs 13%; P < .0001), and rural (25% vs 21%; P < .0001) than those without prior minor amputation. The 5-year Kaplan-Meier cumulative incidence of major amputation was 27% (n = 58,613) of patients with prior minor amputation, compared with 1.4% (n = 129,872) of patients without prior minor amputation. After risk-adjustment, patients with prior minor amputations were 6.1-fold more likely to require a subsequent major amputation (hazard ratio, 6.11; 95% confidence interval, 6.04-6.18) compared with those without prior minor amputations., Conclusions: This contemporary claims-based analysis demonstrates that approximately 25% of Medicare beneficiaries with DM/PAD and prior minor amputation will necessitate a major amputation within 5 years. Prior minor amputation carries a risk of major amputation comparable with de novo tissue loss and is a stronger predictor than any demographic or socioeconomic exposure. These results help to inform both clinical decision-making and anticipated real-world outcomes among those at greatest risk for limb loss., Competing Interests: Disclosures None., (Copyright © 2025 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Treatment of throat cancers have improved due to minimally-invasive trans-oral approaches. Surgeons rely on preoperative imaging to guide their resection; however, large tissue deformations occur during trans-oral procedures due to placement of necessary retractors and laryngoscopes which hinders the surgeon's ability to accurately assess tumor extent and location of critical structures. We propose an image-guided framework utilizing intraoperative imaging and deformation modeling to improve surgeon accuracy and confidence. A CT-compatible laryngoscopy system previously developed was evaluated in this framework. Intraoperative images were acquired during laryngoscopy; force-sensing capabilities were enabled in the laryngoscope; and tracking of the scope and anatomic features was trialed. Tissue deformation and displacement were quantified and determined to be extensive, with values <; 4.6 cm in the tongue, <; 1.8 cm in bony structures, and <; 108.9 cm 3 in airway volume change. Surgical navigation using intraoperative imaging and tracking was evaluated. Preliminary assessment of deformation modeling showed potential to supplement intraoperative imaging. Future work will involve streamlined integration of the components of this framework.