BACKGROUND:Trauma is a major risk factor for the development of a venous thromboembolism (VTE). After observing higher than expected VTE rates within our center's Trauma Quality Improvement Program data, we instituted a change in our VTE prophylaxis protocol, moving to enoxaparin dosing titrated by anti-Xa levels. We hypothesized that this intervention would lower our symptomatic VTE rates. METHODS:Adult trauma patients at a single institution meeting National Trauma Data Standard criteria from April 2015 to September 2019 were examined with regards to VTE chemoprophylaxis regimen and VTE incidence. Two groups of patients were identified based on VTE protocol-those who received enoxaparin 30 mg twice daily without routine anti-Xa levels ("pre") versus those who received enoxaparin 40 mg twice daily with dose titrated by serial anti-Xa levels ("post"). Univariate and multivariate analyses were performed to define statistically significant differences in VTE incidence between the two cohorts. RESULTS:There were 1698 patients within the "pre" group and 1406 patients within the "post" group. The two groups were essentially the same in terms of demographics and risk factors for bleeding or thrombosis. There was a statistically significant reduction in VTE rate ( p = 0.01) and deep vein thrombosis rate ( p = 0.01) but no significant reduction in pulmonary embolism rate ( p = 0.21) after implementation of the anti-Xa titration protocol. Risk-adjusted Trauma Quality Improvement Program data showed an improvement in rate of symptomatic pulmonary embolism from fifth decile to first decile. CONCLUSION:A protocol titrating prophylactic enoxaparin dose based on anti-Xa levels reduced VTE rates. Implementation of this type of protocol requires diligence from the physician and pharmacist team. Further research will investigate the impact of protocol compliance and time to appropriate anti-Xa level on incidence of VTE.

Background Several systems have been developed to predict mortality following intensive care unit (ICU) admission in medical and surgical patients. However, a similar tool specific to cardiac surgical patients with prolonged intensive care unit duration does not exist. The purpose of the present study was to identify independent perioperative predictors of operative mortality among cardiac surgical patients with prolonged ICU duration. Study Design From 2003-2008, 13,105 cardiac surgical patients with ICU durations greater than 48 hours were identified within a statewide database. Perioperative factors, including Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM), were evaluated. Univariate and multivariate analyses identified significant correlates of operative mortality and their relative strength of association as determined by the Wald χ2 statistic. Results Mean patient age was 66.8±11.2 years, median ICU duration was 76.5 [56.0-124.0] hours, and mean STS PROM was 4.4%±6.2%. Among preoperative and operative factors, intra-aortic balloon pump use, patient age, immunosuppressive therapy, hemodialysis requirement, cardiopulmonary bypass time, and heart failure proved to be the strongest correlates of mortality (all p<0.05) on risk-adjusted multivariate analysis. Interestingly, type of cardiac procedure had no significant association with mortality after risk adjustment. Among postoperative complications, cardiac arrest, prolonged mechanical ventilation (>24 hours) and stroke were the strongest predictors of risk-adjusted mortality (all p<0.001). Conclusions Operative mortality may be predicted by select risk factors for cardiac surgical patients with prolonged intensive care unit duration. Patient age, preoperative intra-aortic balloon pump, and postoperative cardiac arrest, prolonged ventilation and stroke have the strongest association with mortality. Identification of these factors in the perioperative setting may enhance resource utilization and improve mortality following cardiac surgery.

Background: Risk factors for catheter-associated urinary tract infections (CAUTIs) in patients undergoing noncardiac surgical procedures have been well documented. However, the variables associated with CAUTIs in the cardiac surgical population have not been clearly defined. Therefore, the purpose of this study was to investigate risk factors associated with CAUTIs in patients undergoing cardiac procedures. Methods: All patients undergoing cardiac surgery at a single institution from 2006 through 2012 (4,883 patients) were reviewed. Patients with U.S. Centers for Disease Control (CDC) criteria for CAUTI were identified from the hospital's Quality Assessment database. Pre-operative, operative, and post-operative patient factors were evaluated. Univariate and multivariable analyses were used to identify significant correlations between perioperative characteristics and CAUTIs. Results: There were 55 (1.1%) documented CAUTIs in the study population. On univariate analysis, older age, female gender, diabetes mellitus, cardiogenic shock, urgent or emergent operation, packed red blood cell (PRBC) units transfused, and intensive care unit length of stay (ICU LOS) were all significantly associated with CAUTI [p < 0.05]. On multivariable logistic regression, older age, female gender, diabetes mellitus, and ICU LOS remained significantly associated with CAUTI. Additionally, there was a significant association between CAUTI and 30-d mortality on univariate analysis. However, when controlling for common predictors of operative mortality on multivariable analysis, CAUTI was no longer associated with mortality. Conclusions: There are several identifiable risk factors for CAUTI in patients undergoing cardiac procedures. CAUTI is not independently associated with increased mortality, but it does serve as a marker of sicker patients more likely to die from other comorbidities or complications. Therefore, awareness of the high-risk nature of these patients should lead to increased diligence and may help to improve peri-operative outcomes. Recognizing patients at high risk for CAUTI may lead to improved measures to decrease CAUTI rates within this population.

Objective Bone marrow–derived mesenchymal stem cells (MSCs) have shown therapeutic potential in acute lung injury. Recently, placenta-derived human mesenchymal stem cells (PMSCs) have shown similarities with bone marrow–derived MSCs in terms of regenerative capabilities and immunogenicity. This study investigates the hypothesis that treatment with PMSCs reduces the development of bronchiolitis obliterans in a murine heterotopic tracheal transplant model. Methods A murine heterotopic tracheal transplant model was used to study the continuum from acute to chronic rejection. In the treatment groups, PMSCs or PMSC-conditioned medium (PMSCCM) were injected either locally or intratracheally into the allograft. Phosphate-buffered saline (PBS) or blank medium was injected in the control groups. Tracheal luminal obliteration was assessed on sections stained with hematoxylin and eosin. Infiltration of inflammatory and immune cells and epithelial progenitor cells was assessed using immunohistochemistry and densitometric analysis. Results Compared with injection of PBS, local injection of PMSCs significantly reduced luminal obliteration at 28 days after transplantation (P = .015). Intratracheal injection of PMSCs showed similar results to local injection of PMSCs compared with injection of PBS and blank medium (P = .022). Tracheas treated with PMSC/PMSCCM showed protection against the loss of epithelium on day 14, with an increase in P63+CK14+ epithelial progenitor cells and Foxp3+ regulatory T cells. In addition, injection of PMSCs and PMSCCM significantly reduced the number of neutrophils and CD3+ T cells on day 14. Conclusions This study demonstrates that treatment with PMSCs is protective against the development of bronchiolitis obliterans in an heterotopic tracheal transplant model. These results indicate that PMSCs could provide a novel therapeutic option to reduce chronic rejection after lung transplant.

Objective For descending thoracic aortic aneurysms (TAAs), it is generally considered that endovascular stents (TEVARs) reduce operative morbidity and mortality compared to open surgical repair. However, long-term differences in patient survival have not been demonstrated, and an increased need for aortic reintervention has been observed. Many assume that TEVAR becomes less cost effective through time due to higher rates of reintervention and surveillance imaging. This study investigated mid-term outcomes and hospital costs of TEVAR compared with open TAA repair. Methods This was a retrospective, single institution review of elective thoracic aortic aneurysm repairs between 2005 and 2012. Patient demographics, operative outcomes, reintervention rates, and hospital costs were assessed. The literature was also reviewed to determine commonly observed complication and reintervention rates for TEVAR and open repair. Monte Carlo simulation was utilized to model and forecast hospital costs for TEVAR and open TAA repair up to 3 years post-intervention. Results Our cohort consisted of 131 TEVARs and 27 open repairs. TEVAR patients were significantly older (67.2 vs. 58.7, p=0.02) and trended towards a more severe comorbidity profile. Operative mortality for TEVAR and open repair was 5.3% and 3.7%, respectively (p=1.0). There was a trend towards more complications in the TEVAR group, although not statistically significant (all p>0.05). In-hospital costs were significantly greater in the TEVAR group ($52,008 vs. $37,172, p=0.001). However, cost modeling utilizing reported complication and reintervention rates from the literature overlaid with our cost data produced a higher cost for the open group in-hospital ($55,109 vs. $48,006) and at 3 years ($58,426 vs. $52,825). Interestingly, TEVAR hospital costs, not reintervention rates, were the most significant driver of cost in the TEVAR group. Conclusions Our institutional data showed a trend toward lower mortality and complication rates with open TAA repair, with significantly lower costs within this cohort compared to TEVAR. These findings were likely at least in part due to the milder comorbidity profile within these patients. In contrast, cost modeling using Monte Carlo simulation demonstrated lower costs with TEVAR compared to open repair at all time points up to 3 years post-intervention. Our institutional data shows that with appropriate patient selection, open repair can be performed safely with low complication rates comparable to TEVAR. The cost model argues that despite the costs associated with more frequent surveillance imaging and reinterventions, TEVAR remains the more cost effective option even years after TAA repair.

Background Fibrocytes are integral in the development of fibroproliferative disease. The CXCL12/CXCR4 chemokine axis has been shown to play a central role in fibrocyte migration and the development of bronchiolitis obliterans post lung transplantation. Inhibition of the mTOR (mammalian target of rapamycin) pathway with rapamycin has been shown to decrease expression of both CXCR4 and its receptor agonist, CXCL12. Thus, we hypothesize that rapamycin treatment would decrease fibrocyte trafficking into tracheal allografts and prevent bronchiolitis obliterans. Methods A total alloantigenic mismatch, murine heterotopic tracheal transplant model of bronchiolitis obliterans was used. Animals were either treated with rapamycin or dimethyl sulfoxide (DMSO) for 14 days post tracheal transplant. Fibrocyte levels were assessed via flow cytometry, and allograft neutrophil, CD3+ T-cell, macrophage, and smooth muscle actin levels were assessed via immunohistochemistry. Tracheal luminal obliteration was assessed on hematoxylin and eosin stains. Results Compared to DMSO controls, rapamycin-treated mice showed a significant decrease in fibrocyte levels in tracheal allografts. Fibrocytes levels in recipient’s blood showed a similar pattern, although not statistically significant. Furthermore, animals treated with rapamycin showed a significant decrease in tracheal allograft luminal obliteration compared to controls. Based on immunohistochemistry analyses, populations of α-SMA positive cells, neutrophils, CD3+ T-cells, and macrophages were all decreased in rapamycin-treated allograft versus DMSO controls. Conclusions Rapamycin effectively reduces recruitment of fibrocytes into tracheal allografts and mitigates development of tracheal luminal fibrosis. Further studies are needed to determine the cellular and molecular mechanisms that mediate the protective effect of rapamycin against bronchiolitis obliterans.

Background: The inception of work hour restrictions for resident physicians in 2003 created controversial change within surgery training programs. On a recent ACGME survey at our institution, we noted a discrepancy between low recorded duty hour violations and 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 surgical trainees.Methods: A3/Lean methodology, an industry derived systematic problem-solving approach, was used to investigate barriers to accurate duty hour reporting by residents within the department of surgery at an academic institution. In partnership with our Graduate Medical Education office, we encourage a 6-month period where residents were asked to accurately record duty hours and provide 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 following 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 fear of personal and programmatic punitive measures, desire to retain control of their surgical education, and frustration with the administrative burden following 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 =

BACKGROUND Meaningful education of residents in systems-based practice is notoriously challenging, despite its recognition as 1 of the 6 Accreditation Council for Graduate Medical Education core competencies. To address this challenge, surgery residents and other members of the health care team were organized into interdisciplinary workgroups that were tasked with developing solutions to “systems issues” confronted on a daily basis. The project’s goals included providing more meaningful, hands-on educational experience for residents in system-based practice, while also generating practical solutions to workflow issues through interprofessional collaboration. PROJECT DESIGN Project participants included all surgery residents at the University of Virginia in Charlottesville, VA, as well as surgical health care professionals across all disciplines. Participants were organized into workgroups. Over the course of 3 sessions, each of 1-hour, each workgroup identified commonly encountered systems issues, chose 1 issue to address, and determined an implementable solution for this issue. In total, 140 participants were divided among 13 workgroups. PROJECT EXECUTION Workgroup topics ranged from improving paging etiquette to standardizing interdisciplinary communication. In total, 9 of the 13 proposals have been piloted or fully implemented as standard practice at our institution, either within a single unit or over the entire health system. DISCUSSION This project demonstrates an innovative approach toward resident education in system-based practice, providing residents with a hands-on experience in problem solving from a systems perspective. These inter-disciplinary workgroups generated effective solutions to issues that were meaningful to frontline health care providers. Interdisciplinary collaboration within the workgroups served as a valuable team-building exercise to improve relations between the disciplines. This project can serve as a model for other institutions desiring meaningful education in the Accreditation Council for Graduate Medical Education competency of systems-based practice.