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Surgical site infections after cesarean delivery.
No full textSurgical site infections represent a persistent and clinically relevant complication of cesarean delivery, contributing substantially to postpartum morbidity, hospital readmission, and pregnancy-related mortality. As cesarean delivery has escalated to the most common major operation worldwide-now comprising 21% of global births and 32% in the United States-the burden of postcesarean surgical site infections, reported in 3% to 15% of cases, remains unacceptably high despite advances in perioperative antisepsis, antibiotic prophylaxis, and prevention bundles. This review provides an updated comprehensive overview of postcesarean SSIs, including their definitions, risk factors, microbiology, clinical presentation, evaluation, prevention strategies, and management. Postcesarean surgical site infections are classified as superficial incisional, deep incisional, organ/space infections such as postpartum endometritis, and necrotizing soft tissue infections. The microbiologic spectrum varies by infection type and includes both monomicrobial and polymicrobial pathogens. Clinical presentations range from localized incisional symptoms to systemic signs, with necrotizing soft tissue infections requiring urgent recognition due to their aggressive clinical course and high mortality. Key risk factors include prolonged rupture of membranes, labor, higher body mass index, intra-amniotic infection, and longer operative time. Prevention necessitates a multifaceted approach. In the preoperative phase, interventions include patient preparation and operative field antisepsis. Intraoperative strategies focus on surgical technique. Postoperative care centers on appropriate antibiotic prophylaxis and wound management. For established surgical site infections, the cornerstone of management is timely incision and drainage. Meticulous wound care, often involving serial dressing changes or negative pressure wound therapy, supports appropriate healing. Targeted antibiotic therapy is initiated when systemic signs or extensive local findings are present and is tailored to the specific clinical scenario. Addressing surgical site infections associated with cesarean delivery requires a comprehensive, multidisciplinary, and evidence-based approach. A sustained commitment to optimizing and implementing refined protocols is imperative to improve maternal infectious outcomes
Opioid Prescribing Patterns of Board-Certified Emergency Physicians Compared With Other Physicians Practicing Emergency Medicine Among Medicare Part-D Beneficiaries Between 2018 and 2020 in the United States.
No full textOBJECTIVES: There is limited knowledge regarding whether board-certified emergency medicine (EM) physicians have different opioid prescribing rates compared to other physicians working in emergency departments (EDs). This study aims to determine if opioid prescribing rates differ based on board-certification status compared with other physicians practicing in an ED setting.
METHODS: An IRB-approved, cross-sectional analysis was performed on the Medicare Part D Prescribers by Provider and Drug datasets from 2018 to 2020 to determine prescribing rates of EM physicians by board-certification status with the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine. EM physicians prescribing opioids to 11 or more Medicare beneficiaries per calendar year in EDs were included. The average total day supply (TDS) of opioids per beneficiary for the 4 most common opioids (acetaminophen/codeine, hydrocodone/acetaminophen, oxycodone/acetaminophen, tramadol) was estimated using generalized linear models with Poisson distribution, log-link, and individual clustering and compared by board certification in EM status. Incident rate ratios (IRR) were used to describe the association between board certification in EM and the average TDS of opioids.
RESULTS: A total of 29,144 physicians were included in the study, with 23,720 (81.4%) board-certified by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine and 5424 (18.6%) certified by another specialty board (eg, family medicine [48.6%], internal medicine [17.3%]). Physicians working in EDs, who were not board-certified in EM, prescribed a higher average TDS compared with board-certified EM physicians: acetaminophen/codeine (TDS, 10.8 vs 4.0; IRR, 2.7 [95% CI, 2.3-3.2]); hydrocodone/acetaminophen (TDS, 15.2 vs 3.8; IRR, 4.0 [95% CI, 3.7-4.4]); oxycodone/acetaminophen (TDS, 19.8 vs 4.4; IRR, 4.5 [95% CI, 3.8-5.3]); tramadol (TDS, 20.1 vs 5.3; IRR, 3.8 [95% CI, 3.5-4.1]).
CONCLUSIONS: Board certification in EM was associated with lower opioid prescribing rates. The average TDS of opioids per Medicare beneficiary was lower for board-certified EM physicians compared to non-EM board-certified physicians staffing EDs between 2018 and 2020
Invasive versus conservative strategy in older adults ≥70 years of age with non-ST-segment-elevation myocardial infarction: a GRADE-assessed systematic review and meta-analysis of randomized controlled trials with trial sequential analysis.
No full textBACKGROUND: Older adults with Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) are often undertreated invasively due to concerns about risks and comorbidities, despite potential benefits. Their limited inclusion in clinical trials leaves a gap in evidence-based management. This meta-analysis compared invasive versus conservative strategies in elderly NSTEMI patients.
METHODS: A systematic search was conducted across PubMed, CENTRAL, Web of Science, Scopus, and Embase through December 2024. Pooled results were reported using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes with 95% confidence intervals (CI).
RESULTS: A total of 11 randomized controlled trials involving 4114 patients were included. Invasive treatment significantly reduced the composite of all-cause mortality and non-fatal MI (RR: 0.82; 95% CI: 0.68-0.99;
CONCLUSION: In NSTEMI patients aged ≥70, invasive management reduces the risk of MI and revascularization without increasing mortality risk. More elderly-focused trials are warranted.
PROTOCOL REGISTRATION: https://www.crd.york.ac.uk/prospero identifier is CRD42025633157
Scary Head and Neck Infections: From Necrotizing Fasciitis, Malignant Otitis Externa, to Osteoradionecrosis.
No full text
EQIP 2023-2025: Increased Usability and Sustainability.
No full textOBJECTIVE: To describe the collaborative efforts that improved the Educational Quality Improvement Program (EQIP) between 2023 and 2025.
DESIGN: EQIP was formed by the Association of Program Directors in Surgery (APDS) in 2018 as a continuous educational quality improvement program. After a successful proof-of-concept completed in 2021 to 2022, EQIP\u27s underlying infrastructure was transitioned to the Society for Improving Medical Professional Learning (SIMPL). A data-ingestion process and reporting platform were iteratively developed over 2 years in collaboration with participating programs. User-centered design strategies were used to develop both data-ingestion and reporting tools.
SETTING & PARTICIPANTS: Ten surgical training programs provided design ideas and iterative feedback on data upload and reporting processes.
RESULTS: EQIP was sustainably strengthened in the 2023 to 2025 academic years. Data from the Accreditation Council of Graduate Medical Education (ACGME), the American Board of Surgery (ABS), and the Electronic Resident Application Service (ERAS) were merged with manually entered data for 36 programs. Feedback from participating programs emphasized the ease of the data upload process. Previously documented challenges with identifying trainees across different transition points (e.g., UME to GME) and between organizations were experienced. Lastly, an additional emphasis around allowing program directors to explore their own data was identified. While a founding premise of EQIP was to generate benchmark data that individual programs could use to set goals, additional data analysis and reporting needs around understanding trainees across multiple data points were identified.
CONCLUSIONS: The APDS, in partnership with SIMPL, demonstrated that a secure database to support continuous quality improvement in surgical education can be successfully deployed. EQIP will continue to improve and hopes to increase the number of programs who can participate in iterative, collaborative improvement work
