The issue of the aging physician and when to cease practice has been controversial for many years. There are reports of prominent physicians who practiced after becoming dangerous in old age, but the ...profession has not demonstrated the ability to prevent this. A mandatory retirement age could be discriminatory and take many competent physicians out of practice and risk a physician shortage. An increasing body of evidence regarding the relationship between physicians' age and performance has led organizations, such as the American College of Surgeons, to revisit this challenge.
Since 1975, the number of practicing physicians older than 65 years in the United States has increased by more than 374%, and in 2015, 23% of practicing physicians were 65 years or older. Research shows that between ages 40 and 75 years, the mean cognitive ability declines by more than 20%, but there is significant variability from one person to another, indicating that while some older physicians are profoundly impaired, others retain their ability and skills. There are age-based requirements for periodic testing and/or retirement for many professions including pilots, judges, air traffic controllers, Federal Bureau of Investigation employees, and firefighters. While there are not similar requirements for physicians, a few hospitals have introduced mandatory age-based evaluations.
As physicians age, a required cognitive evaluation combined with a confidential, anonymous feedback evaluation by peers and coworkers regarding wellness and competence would be beneficial both to physicians and their patients. While it is unlikely that this will become a national standard soon, individual health care organizations could develop policies similar to those present at a few US institutions. In addition, large professional organizations should identify a range of acceptable policies to address the aging physician while leaving institutions flexibility to customize the approach. Absent robust professional initiatives in this area, regulators and legislators may impose more draconian measures.
Antibiotic prophylaxis is frequently continued for 1 day or more after surgery to prevent surgical site infection. Continuing antibiotic prophylaxis after an operation might have no advantage ...compared with its immediate discontinuation, and it unnecessarily exposes patients to risks associated with antibiotic use. In 2016, WHO recommended discontinuation of antibiotic prophylaxis after surgery. We aimed to update the evidence that formed the basis for that recommendation.
For this systematic review and meta-analysis, we searched MEDLINE, Embase, CINAHL, CENTRAL, and WHO regional medical databases for randomised controlled trials (RCTs) on postoperative antibiotic prophylaxis that were published from Jan 1, 1990, to July 24, 2018. RCTs comparing the effect of postoperative continuation versus discontinuation of antibiotic prophylaxis on the incidence of surgical site infection in patients undergoing any surgical procedure with an indication for antibiotic prophylaxis were eligible. The primary outcome was the effect of postoperative surgical antibiotic prophylaxis continuation versus its immediate discontinuation on the occurrence of surgical site infection, with a prespecified subgroup analysis for studies that did and did not adhere to current best practice standards for surgical antibiotic prophylaxis. We calculated summary relative risks (RRs) with corresponding 95% CIs using a random effects model (DerSimonian and Laird). We evaluated heterogeneity with the χ2 test, I2, and τ2, and visually assesed publication bias with a contour-enhanced funnel plot. This study is registered with PROSPERO, CRD42017060829.
We identified 83 relevant RCTs, of which 52 RCTs with 19 273 participants were included in the primary meta-analysis. The pooled RR of surgical site infection with postoperative continuation of antibiotic prophylaxis versus its immediate discontinuation was 0·89 (95% CI 0·79–1·00), with low heterogeneity in effect size between studies (τ2=0·001, χ2 p=0·46, I2=0·7%). Our prespecified subgroup analysis showed a significant association between the effect estimate and adherence to best practice standards of surgical antibiotic prophylaxis: the RR of surgical site infection was reduced with continued antibiotic prophylaxis after surgery compared with its immediate discontinuation in trials that did not meet best practice standards (0·79 95% CI 0·67–0·94) but not in trials that did (1·04 0·85–1·27; p=0·048). Whether studies adhered to best practice standards explained all variance in the pooled estimate from the primary meta-analysis.
Overall, we identified no conclusive evidence for a benefit of postoperative continuation of antibiotic prophylaxis over its discontinuation. When best practice standards were followed, postoperative continuation of antibiotic prophylaxis did not yield any additional benefit in reducing the incidence of surgical site infection. These findings support WHO recommendations against this practice.
None.
Abstract
Objective.
The incidence of acute pancreatitis varies from 5 to 80 per 100,000 throughout the world. The most common cause of death in these patients is infection of pancreatic necrosis by ...enteric bacteria, spurring the discussion of whether or not prophylactic antibiotic administration could be a beneficial approach. In order to provide evidence of the effect of antibiotic prophylaxis in severe acute pancreatitis (SAP) we performed an updated systematic review and meta-analysis on this topic.
Methods.
The review of randomized controlled trials was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. We conducted a search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. For assessment of the treatment effects we calculated the risk ratios (RRs) for dichotomous data of included studies.
Results.
Fourteen trials were included with a total of 841 patients. The use of antibiotic prophylaxis was not associated with a statistically significant reduction in mortality (RR 0.74 95% CI 0.50-1.07), in the incidence of infected pancreatic necrosis (RR 0.78 95% CI 0.60-1.02), in the incidence of non-pancreatic infections (RR 0.70 95% CI 0.46-1.06), and in surgical interventions (RR 0.93 95% CI 0.72-1.20).
Conclusion.
In summary, to date there is no evidence that supports the routine use of antibiotic prophylaxis in patients with SAP.
Bariatric procedures are increasingly performed but their impact on survival is unknown.
We evaluated short- and longterm mortality rates of patients undergoing gastric bypass on a population level ...compared with a nonoperated cohort of patients with morbid obesity in a retrospective study, using the Washington State Comprehensive Hospital Abstract Reporting System database and the Vital Statistics database. The study included all patients (age 18 to 65 years) from 1987 to 2001 who underwent gastric bypass with ICD-9 diagnostic codes for obesity. The comparator group included patients of similar age with a diagnosis of obesity or morbid obesity who did not have a bariatric procedure. Survival analysis was used to determine the association of surgeon experience on 30-day mortality and of the procedure on survival while controlling for age, gender, and comorbidity index.
Of the 66,109 obese patients we evaluated, 3,328 had a bariatric procedure. Incidence of the procedure increased from 0.7 to 10.6 per 100,000 from 1987 to 2001, with a 2.5-fold increase in incidence rate of the procedure in the years after 1996 (incidence rate ratio, 2.5; 95% CI, 2.4 to 2.7). Thirty-day mortality was 1.9% and was associated with surgical inexperience. Within the surgeon’s first 19 procedures the odds of death within 30 days were 4.7 times higher (95% CI, 1.2 to 18.2) than at later points in a surgeon’s case order. At 15 years followup, 16.3% of nonoperated patients had died as compared with 11.8% of patients who had the bariatric procedure. When survival was compared beginning 1 year after the procedure, the adjusted hazard for death was 33% lower than that of nonoperated patients (hazard ratio 0.67; 95% CI, 0.54 to 0.85).
Thirty-day mortality after gastric bypass is higher than previously reported and closely linked to surgeon inexperience. A modest overall survival benefit was associated with the procedure but a marked survival advantage was noted for patients who survive to the first postoperative year.
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) ...prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
Whether contact precautions (CP) are required to control the endemic transmission of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in acute care ...hospitals is controversial in light of improvements in hand hygiene, MRSA decolonization, environmental cleaning and disinfection, fomite elimination, and chlorhexidine bathing.
To provide a framework for decision making around use of CP for endemic MRSA and VRE based on a summary of evidence related to use of CP, including impact on patients and patient care processes, and current practices in use of CP for MRSA and VRE in US hospitals.
A literature review, a survey of Society for Healthcare Epidemiology of America Research Network members on use of CP, and a detailed examination of the experience of a convenience sample of hospitals not using CP for MRSA or VRE.
Hospital epidemiologists and infection prevention experts.
No high quality data support or reject use of CP for endemic MRSA or VRE. Our survey found more than 90% of responding hospitals currently use CP for MRSA and VRE, but approximately 60% are interested in using CP in a different manner. More than 30 US hospitals do not use CP for control of endemic MRSA or VRE.
Higher quality research on the benefits and harms of CP in the control of endemic MRSA and VRE is needed. Until more definitive data are available, the use of CP for endemic MRSA or VRE in acute care hospitals should be guided by local needs and resources.
There has been recent controversy regarding recommendations and regulations concerning operating room attire. We performed a nonsystematic literature search regarding operating room attire and ...surgical site infection (SSI) risk. Much of the literature relies on air sampling and culture of operating room equipment but does not present evidence regarding effect on SSI risk. There is no evidence regarding SSI risk related to operating room attire except for sterile gowns and the use of gloves. Naked surgeons shed fewer bacteria into the operating room environment than ones wearing scrub suits.
Hospital-acquired infections (HAIs) are a persistent concern and include surgical site infections, intravascular line-associated infections, pneumonia, catheter-associated urinary tract infections, ...and C. difficile infection.
Review of the pertinent English-language literature.
Hospital-acquired infections result in significant increases in morbidity, mortality rates, and cost and are a focus of efforts at reduction.
I discuss efforts specific to each of the most common infections and a philosophical approach to prevention that strives to achieve zero potentially preventable hospital-acquired infections.
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