Virginia Mason Hospital is a 336-bed teaching hospital in Seattle, Washington, part of the Virginia Mason Medical Center. The hospital is accredited by the Joint Commission and the Commission on Accreditation of Rehabilitation Facilities (CARF). Founded in 1920, the hospital operates several accredited residency programs that train newly graduated physicians.
The Society for Healthcare Epidemiology of America, the Association of Professionals in Infection Control and Epidemiology, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society represent the core expertise regarding healthcare infection prevention and infectious diseases and have written multisociety statement for healthcare facility leaders, regulatory agencies, payors, and patients to strengthen requirements and expectations around facility infection prevention and control (IPC) programs. Based on a systematic literature search and formal consensus process, the authors advocate raising the expectations for facility IPC programs, moving to effective programs that are:• Foundational and influential parts of the facility's operational structure• Resourced with the correct expertise and leadership• Prioritized to address all potential infectious harmsThis document discusses the IPC program's leadership-a dyad model that includes both physician and infection preventionist leaders-its reporting structure, expertise, and competencies of its members, and the roles and accountability of partnering groups within the healthcare facility. The document outlines a process for identifying minimum IPC program medical director support. It applies to all types of healthcare settings except post-acute long-term care and focuses on resources for the IPC program. Long-term acute care hospital (LTACH) staffing and antimicrobial stewardship programs will be discussed in subsequent documents.
Objective:To evaluate prognostic differences between minimally invasive esophagectomy (MIE) and open esophagectomy (OE) in patients with surgery after a prolonged interval (>12 wk) following chemoradiotherapy (CRT). Background:Previously, we established that a prolonged interval after CRT before esophagectomy was associated with poorer long-term survival. Methods:This was an international multicenter cohort study involving 17 tertiary centers, including patients who received CRT followed by surgery between 2010 and 2020. Patients undergoing MIE were defined as thoracoscopic and laparoscopic approaches. Results:A total of 428 patients (145 MIE and 283 OE) had surgery between 12 weeks and 2 years after CRT. Significant differences were observed in American Society of Anesthesiologists grade, radiation dose, clinical T stage, and histologic subtype. There were no significant differences between the groups in age, sex, body mass index, pathologic T or N stage, resection margin status, tumor location, surgical technique, or 90-day mortality. Survival analysis showed MIE was associated with improved survival in univariate (P=0.014), multivariate analysis after adjustment for smoking, T and N stage, and histology (HR=1.69; 95% CI: 1.14-2.5) and propensity-matched analysis (P=0.02). Further subgroup analyses by radiation dose and interval after CRT showed survival advantage for MIE in 40 to 50 Gy dose groups (HR=1.9; 95% CI: 1.2-3.0) and in patients having surgery within 6 months of CRT (HR=1.6; 95% CI: 1.1-2.2). Conclusions:MIE was associated with improved overall survival compared with OE in patients with a prolonged interval from CRT to surgery. The mechanism for this observed improvement in survival remains unknown, with potential hypotheses including a reduction in complications and improved functional recovery after MIE.
OBJECTIVE:This international multicenter study by the Upper GI International Robotic Association aimed to gain insight in current techniques and outcomes of RAMIE worldwide.BACKGROUND:Current evidence for RAMIE originates from single-center studies, which may not be generalizable to the international multicenter experience.METHODS:Twenty centers from Europe, Asia, North-America, and South-America participated from 2016 to 2019. Main endpoints included the surgical techniques, clinical outcomes, and early oncological results of ramie.RESULTS:A total of 856 patients undergoing transthoracic RAMIE were included. Robotic surgery was applied for both the thoracic and abdominal phase (45%), only the thoracic phase (49%), or only the abdominal phase (6%). In most cases, the mediastinal lymphadenectomy included the low paraesophageal nodes (n=815, 95%), subcarinal nodes (n = 774, 90%), and paratracheal nodes (n = 537, 63%). When paratracheal lymphadenectomy was performed during an Ivor Lewis or a McKeown RAMIE procedure, recurrent laryngeal nerve injury occurred in 3% and 11% of patients, respectively. Circular stapled (52%), hand-sewn (30%), and linear stapled (18%) anastomotic techniques were used. In Ivor Lewis RAMIE, robot-assisted hand-sewing showed the highest anastomotic leakage rate (33%), while lower rates were observed with circular stapling (17%) and linear stapling (15%). In McKeown RAMIE, a hand-sewn anastomotic technique showed the highest leakage rate (27%), followed by linear stapling (18%) and circular stapling (6%).CONCLUSION:This study is the first to provide an overview of the current techniques and outcomes of transthoracic RAMIE worldwide. Although these results indicate high quality of the procedure, the optimal approach should be further defined.
Objective: To determine the impact of delayed surgical intervention following chemoradiotherapy (CRT) on survival from esophageal cancer.Background: CRT is a core component of multimodality treatment for locally advanced esophageal cancer. The timing of surgery following CRT may influence the probability of performing an oncological resection and the associated operative morbidity.Methods: This was an international, multicenter, cohort study, including patients from 17 centers who received CRT followed by surgery between 2010 and 2020. In the main analysis, patients were divided into 4 groups based upon the interval between CRT and surgery (0-50, 51-100, 101-200, and >200 days) to assess the impact upon 90-day mortality and 5-year overall survival. Multivariable logistic and Cox regression provided hazard ratios (HRs) with 95% CIs adjusted for relevant patient, oncological, and pathologic confounding factors.Results: A total of 2867 patients who underwent esophagectomy after CRT were included. After adjustment for relevant confounders, prolonged interval following CRT was associated with an increased 90-day mortality compared with 0 to 50 days (reference): 51 to 100 days (HR=1.54, 95% CI: 1.04-2.29), 101 to 200 days (HR=2.14, 95% CI: 1.37-3.35), and >200 days (HR=3.06, 95% CI: 1.64-5.69). Similarly, a poorer 5-year overall survival was also observed with prolonged interval following CRT compared with 0 to 50 days (reference): 101 to 200 days (HR=1.41, 95% CI: 1.17-1.70), and >200 days (HR=1.64, 95% CI: 1.24-2.17).Conclusions: Prolonged interval following CRT before esophagectomy is associated with increased 90-day mortality and poorer long-term survival. Further investigation is needed to understand the mechanism that underpins these adverse outcomes observed with a prolonged interval to surgery.
Objective To estimate the gonadal doses irradiated from urine- contaminated diapers during diuretic renal scintigraphy. Methods Images of 31 patients (18 males and 13 females) with urine-contaminated diapers during 99mTc-MAG3 renal scintigraphy were analyzed. The count rate of the diapers was converted into a time-activity curve based on the calibrated factor of the gamma camera system. The cumulative activity was determined from the area under the curve. By incorporating dose per unit cumulative activity pre-calculated from Monte Carlo simulation with 0-year phantom, the gonadal dose irradiated from diaper was calculated. To assess the degree of this additionally introduced dose from diapers, the calculated gonadal dose was compared to the internal gonadal dose from injected radiotracer activity. Results The cumulative activities irradiated from urine-contaminated diapers were 1.12 E04 ± 1.29E04 MBq.s in male infants, which was nearly half of the 1.94 E04 ± 1.80E04 MBq.s (P = 0.15) in female infants. However, the absorbed doses for testes in male infants were 7.37E-01 ± 8.50E-01 mGy, which was approximately 10 times the 6.38E-02 ± 5.94E-02 mGy for ovaries in female infants (P < 0.01). The diaper-introduced dose for testes and ovaries was 91.7% and 3.9% of the gonadal doses from the injected activity in patients with normal renal function, and 99.0% and 4.3% of those in patients with abnormal renal function. Conclusion Urine-contaminated diapers introduced additional radiation doses to infant patients during 99mTc-MAG3 renal scintigraphy. The gonadal doses were of significance in male infants who had nearly double the absorbed dose for the testes.
