Patients with metastatic cancer have worse short-term coronary artery bypass grafting outcomes: A population-based study of National Inpatient Sample from 2015 to 2020.

BACKGROUND: Metastasis is a hallmark for cancer progression. While patients with metastatic cancer (MC) have higher risk profiles, outcomes of coronary artery bypass grafting (CABG) in these patients have not been established, likely due to their smaller representation in the CABG patient population. This study aimed to examine the short-term outcomes of patients with MC who underwent CABG. METHODS: Patients who underwent CABG were identified in National Inpatient Sample from Q4 2015-2020. Exclusion criteria included age <18 years, concomitant procedures, and non-metastatic malignancies. A 1:3 propensity-score matching was used to address differences in demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status between MC and non-MCC patients. In-hospital post-CABG outcomes were evaluated. RESULTS: There were 379 (0.23 %) patients with MC who underwent CABG. All MC patients were matched to 1161 out of 164,351 non-MC patients who underwent CABG during the same period. Patients with MC had higher risks of mortality (4.76 % vs 2.58 %, p = 0.04), pacemaker implantation (2.91 % vs 1.12 %, p = 0.03), venous thromboembolism (1.85 % vs 0.43 %, p = 0.01), and hemorrhage/hematoma (61.11 % vs 55.04 %, p = 0.04). In addition, MC patients had a longer time from admission to operation (3.35 ± 4.19 vs 2.82 ± 3.54 days, p = 0.03) and longer hospital length of stay (11.86 ± 8.17 vs 10.65 ± 8.08 days, p = 0.01). CONCLUSION: Patients with MC had higher short-term mortality and morbidities after CABG. These findings can help provide insights for clinicians in the management of patients with concurrent coronary artery disease and MC, particularly in terms of preoperative risk stratification and therapeutic decision-making.

Observed rates of surgical instrument errors point to visualization tasks as being a critically vulnerable point in sterile processing and a significant cause of lost chargeable OR minutes.

BACKGROUND: The reporting of surgical instrument errors historically relies on cumbersome, non-automated, human-dependent, data entry into a computer database that is not integrated into the electronic medical record. The limitations of these reporting systems make it difficult to accurately estimate the negative impact of surgical instrument errors on operating room efficiencies. We set out to determine the impact of surgical instrument errors on a two-hospital healthcare campus using independent observers trained in the identification of Surgical Instrument Errors. METHODS: This study was conducted in the 7 pediatric ORs at an academic healthcare campus. Direct observations were conducted over the summer of 2021 in the 7 pediatric ORs by 24 trained student observers during elective OR days. Surgical service line, error type, case type (inpatient or outpatient), and associated length of delay were recorded. RESULTS: There were 236 observed errors affecting 147 individual surgical cases. The three most common errors were Missing+ (n = 160), Broken/poorly functioning instruments (n = 44), and Tray+ (n = 13). Errors arising from failures in visualization (i.e. inspection, identification, function) accounted for 88.6% of all errors (Missing+/Broken/Bioburden). Significantly more inpatient cases (42.73%) had errors than outpatient cases (22.32%) (p = 0.0129). For cases in which data was collected on whether an error caused a delay (103), over 50% of both IP and OP cases experienced a delay. The average length of delays per case was 10.16 min. The annual lost charges in dollars for surgical instrument associated delays in chargeable minutes was estimated to be between $6,751,058.06 and $9,421,590.11. CONCLUSIONS: These data indicate that elimination of surgical instrument errors should be a major target of waste reduction. Most observed errors (88.6%) have to do with failures in the visualization required to identify, determine functionality, detect the presence of bioburden, and assemble instruments into the correct trays. To reduce these errors and associated waste, technological advances in instrument identification, inspection, and assembly will need to be made and applied to the process of sterile processing.

African Americans have worse outcomes after transcatheter and surgical aortic valve replacement: A national inpatient sample analysis from 2015 to 2020.

BACKGROUND: Racial disparities in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are controversial among African Americans (AA). This study investigated racial disparities comparing AA and Caucasians undergoing aortic valve replacement. METHODS: Patients who underwent SAVR and TAVR for aortic stenosis were identified in National Inpatient Sample from Q4 2015-2020. In-hospital perioperative outcomes, length of stay, days from admission to operation, and total hospital charge, were compared between AA and Caucasians using multivariable analysis, adjusting for sex, age, socioeconomic status, comorbidity, and hospital characteristics. RESULTS: In TAVR, 51,394 (84.41 %) were Caucasians and 2433 (4.00 %) were AA. In SAVR, there were 50,080 (78.52 %) Caucasians and 3565 (5.59 %) AA. Compared to Caucasians, AA underwent TAVR had a higher risk of complications such as major adverse cardiovascular events (MACE) [adjusted odds ratio (aOR) = 1.335, p = 0.02)], respiratory complications (aOR = 1.363, p = 0.01), acute kidney injury (AKI) (aOR = 1.468, p < 0.01), pulmonary embolism (aOR = 4.65, p = 0.05), hemorrhage/hematoma (aOR = 1.202, p < 0.01), or superficial wound complication (aOR = 1.414, p = 0.04). AA who underwent SAVR had higher risks of morality (aOR = 1.184, p < 0.05) and surgical complications including MACE (aOR = 1.263, p < 0.01), pericardial complications (aOR = 1.563, p < 0.01), cardiogenic shock (aOR = 1.578, p < 0.01), respiratory complications (aOR = 1.261, p < 0.01), AKI (aOR = 1.642, p < 0.01), venous thromboembolism (aOR = 1.613, p < 0.01), hemorrhage/hematoma (aOR = 1.129, p < 0.01), infection (aOR = 1.234, p < 0.01), superficial wound complications (aOR = 1.756, p < 0.01), vascular complications (aOR = 1.592, p < 0.01), and diaphragmatic paralysis (aOR = 2.181, p = 0.02). In both TAVR and SAVR, AA had longer waiting times from admission to operation (p < 0.01), longer hospital stays (p < 0.01), and higher hospital charges (p < 0.01). CONCLUSION: AA were underrepresented, especially in TAVR. AA experienced higher in-hospital mortality post-SAVR, but not after TAVR. Furthermore, AA had more complications for both TAVR and SAVR. These findings underscore the pronounced disparities among AA in aortic valve replacement.

Asian Americans have higher 30-day surgical complications after esophagectomy: A propensity-score matched study from ACS-NSQIP database.

BACKGROUND: Despite Asian Americans having a heightened risk profile for esophageal cancer, racial disparities within this group have not been investigated. This study seeks to evaluate the 30-day postoperative outcomes for Asian Americans following esophagectomy. METHODS: A retrospective analysis was performed using ACS-NSQIP esophagectomy targeted database 2016-2021. A 1:3 propensity-score matching was applied to Asian Americans and Caucasians who underwent esophagectomy to compare their 30-day outcomes. RESULTS: There were 229 Asian Americans and 5303 Caucasians identified. Asian Americans were more likely to have squamous cell carcinoma than adenocarcinoma. After matching, 687 Caucasians were included. Asian Americans had higher pulmonary complications (22.27 â€‹% vs 16.01 â€‹%, p â€‹= â€‹0.04) especially pneumonia (16.59 â€‹% vs 11.06 â€‹%, p â€‹= â€‹0.04), renal dysfunction (2.62 â€‹% vs 0.44 â€‹%, p â€‹= â€‹0.01) especially progressive renal insufficiency (1.31 â€‹% vs 0.15 â€‹%, p â€‹< â€‹0.05), and bleeding events (18.34 â€‹% vs 9.02 â€‹%, p â€‹< â€‹0.01). In addition, Asian Americans had longer LOS (11.83 â€‹± â€‹9.39 vs 10.23 â€‹± â€‹7.34 days, p â€‹= â€‹0.03). CONCLUSION: Asian Americans were found to face higher 30-day surgical complications following esophagectomy. Continued investigation into the underlying causes and potential mitigation strategies for these disparities are needed.

Disparity among Asian Americans in transcatheter and surgical aortic valve replacement.

BACKGROUND: Racial disparities in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) outcomes have been established, but research has predominantly focused on African Americans and Hispanics, leaving a gap in Asian Americans. This study aimed to investigate disparities in aortic valve replacement outcomes among Asian Americans. METHODS: Patients who underwent SAVR and TAVR were identified in National Inpatient Sample from the last quarter of 2015-2020. A 1:2 propensity score matching was applied to Asian Americans and Caucasians. In-hospital perioperative outcomes, length of stay, days from admission to operation, and total hospital charge, were compared. RESULTS: In TAVR, 51,394 (84.41 %) were Caucasians and 795 (1.31 %) were Asian Americans. In SAVR, there were 50,080 (78.52 %) Caucasians and 1233 (1.93 %) Asian Americans. No significant difference was found in post-TAVR complications. However, Asian Americans experienced longer waiting time until operation (p = 0.03) and higher costs (p < 0.01) in TAVR. In SAVR, Asian Americans had higher risks of in-hospital mortality (3.91 % vs 2.39 %, p = 0.01), cardiogenic shock (8.71 % vs 6.74 %, p = 0.03), respiratory complications (14.08 % vs 11.2 %, p = 0.01), mechanical ventilation (13.83 % vs 9.09 %, p < 0.01), acute kidney injury (25.47 % vs 20.13 %, p < 0.01), and hemorrhage/hematoma (72.01 % vs 62.95 %, p < 0.01). Additionally, Asian Americans underwent SAVR had longer lengths of stay (p < 0.01) and higher costs (p < 0.01). CONCLUSIONS: Asian Americans were underrepresented in aortic valve replacement. Asian Americans, while having similar post-TAVR outcomes to Caucasians, faced greater risks of post-SAVR mortality and surgical complications. These disparities among Asian Americans call for targeted actions to ensure equitable health outcomes.

Weekend Admission is Associated with Higher Kidney Failures after Thoracic Endovascular Aneurysm Repair for Stanford Type B Aortic Dissection.

BACKGROUND: Weekend effect characterized by worse perioperative outcomes has been demonstrated in some surgery patients admitted on weekends, as opposed to weekdays. This study aimed to examine weekend effect on open surgical repair or thoracic endovascular aneurysm repair (TEVAR) for Stanford Type B Aortic Dissection (TBAD). METHODS: Patients who underwent TBAD repair were identified in National/Nationwisde Inpatient Sample from Q4 2015-2020. Open surgery and TEVAR were examined separately. Multivariable analyses were performed comparing in-hospital perioperative outcomes of patients under weekday and weekend admission. Adjusted preoperative variables included sex, age, race, socioeconomic status, hospital characteristics, clinical symptoms, comorbidities, and elective/non-elective admission. Also, length of stay, days from admission to operation, and total hospital charge were compared. RESULTS: Among patients who underwent open TBAD repair, 1321 were admitted on weekdays and 340 on weekends. Among patients who underwent TEVAR for TBAD, 2018 were admitted on weekdays and 440 wereadmitted on weekends. There was no difference in open repair outcomes between those admitted on weekdays vs weekends. In TEVAR, weekend admission was associated with higher post-procedural kidney failure (1.14% vs .20%, aOR = 4.11, P = .04) and superficial wound complications (2.73% vs 1.49%, aOR = 2.2, P = .03) but lower respiratory complications (5.80% vs 3.64%, aOR = .47, P = .01). Also, in TEVAR, weekend admission was associated with longer time from admission to operation (3.92 ± .27 vs 2.35 ± .09 days, P < .01). CONCLUSIONS: Renal malperfusion was a common indication for TBAD repair. TBAD patients admitted over the weekend and underwent TEVAR had higher post-procedural kidney failure, which may be due to delayed diagnosis and treatment.

Smoker's paradox in transcatheter aortic valve replacement: A National Inpatient Sample analysis from 2015 to 2020.

BACKGROUND: While smoking is recognized as a risk factor for multiple cardiovascular conditions, prior research has identified a smoker paradox, wherein smokers had better post-procedural outcomes following transcatheter aortic valve replacement (TAVR) in the initial years of its introduction among high-risk patients only. In recent years, TAVR has expanded to significant larger groups of low-risk patients and became the dominate approach for aortic valve replacement. Consequently, the study cohort from the previous research can no longer represent the current patient populations undergoing TAVR. This study aimed to examine the impact of smoking on TAVR outcomes in the later post-TAVR era. METHODS: Patients who underwent TAVR were identified in the National Inpatient Sample (NIS) database from the last quarter of 2015-2020 by ICD-10-PCS. Patients were stratified into two cohorts based on smoker status. Multivariable analysis was performed comparing in-hospital post-TAVR outcomes. Adjusted pre-procedural variables included sex, age, race, socioeconomic status, comorbidities, and hospital characteristics. RESULTS: A total number of 58,934 patients who underwent TAVR were identified including 23,683 smokers and 35,251 non-smokers. Compared to non-smokers, smokers had lower in-hospital mortality (aOR 0.589, p < 0.01), MACE (aOR 0.678, p < 0.01), MI (aOR 0.719, p < 0.01), stroke (aOR 0.599, p < 0.01), neurological complications (aOR 0.653, p < 0.01), pacemaker implantation (aOR 0.911, p < 0.01), cardiogenic shock (aOR 0.762, p < 0.01), respiratory complications (aOR 0.822, p < 0.01), mechanical ventilation (aOR 0.669, p < 0.01), AKI (aOR 0.745, p < 0.01), VTE (aOR 0.578, p < 0.01), hemorrhage/hematoma (aOR 0.921, p < 0.01), infection (aOR 0.625, p < 0.01), vascular complications (aOR 0.802, p < 0.01), reopen surgery (aOR 0.453), and transfer out to another facility (aOR 0.79, p < 0.01). In addition, cigarette smokers had shorter LOS (p < 0.01), and less hospital charge (p < 0.01). CONCLUSION: This study identified the smoker paradox in the later post-TAVR era with remarkably broad protection from many complications and lower mortality. The reasons underlying this apparent smoker paradox merit deeper investigation.

AXL Mediates Cetuximab and Radiation Resistance Through Tyrosine 821 and the c-ABL Kinase Pathway in Head and Neck Cancer.

PURPOSE: Radiation and cetuximab are therapeutics used in management of head and neck squamous cell carcinoma (HNSCC). Despite clinical success with these modalities, development of both intrinsic and acquired resistance is an emerging problem in the management of this disease. The purpose of this study was to investigate signaling of the receptor tyrosine kinase AXL in resistance to radiation and cetuximab treatment. EXPERIMENTAL DESIGN: To study AXL signaling in the context of treatment-resistant HNSCC, we used patient-derived xenografts (PDXs) implanted into mice and evaluated the tumor response to AXL inhibition in combination with cetuximab or radiation treatment. To identify molecular mechanisms of how AXL signaling leads to resistance, three tyrosine residues of AXL (Y779, Y821, Y866) were mutated and examined for their sensitivity to cetuximab and/or radiation. Furthermore, reverse phase protein array (RPPA) was employed to analyze the proteomic architecture of signaling pathways in these genetically altered cell lines. RESULTS: Treatment of cetuximab- and radiation-resistant PDXs with AXL inhibitor R428 was sufficient to overcome resistance. RPPA analysis revealed that such resistance emanates from signaling of tyrosine 821 of AXL via the tyrosine kinase c-ABL. In addition, inhibition of c-ABL signaling resensitized cells and tumors to cetuximab or radiotherapy even leading to complete tumor regression without recurrence in head and neck cancer models. CONCLUSIONS: Collectively, the studies presented herein suggest that tyrosine 821 of AXL mediates resistance to cetuximab by activation of c-ABL kinase in HNSCC and that targeting of both EGFR and c-ABL leads to a robust antitumor response.

A novel bipartite UNC-101/AP-1 µ1 binding signal mediates KVS-4/Kv2.1 somatodendritic distribution in Caenorhabditis elegans.

Potassium channels such as Kv2.1 are targeted to specific subcellular compartments to fulfill various functions. However, the mechanisms for their localization are poorly understood. Here, we show that KVS-4/Kv2.1 somatodendritic localization in Caenorhabditis elegansDA9 neuron requires UNC-101(AP-1 µ subunit). We define a bipartite sorting signal within KVS-4 consisting of a C-terminal EQMIL and N-terminal WNIIE motifs. The bipartite signal is sufficient to target nonpolarized transmembrane protein MIG-13 into DA9 somatodendritic compartments. Furthermore, we found that AP-1 interacts with the bipartite signal through UNC-101/AP-1 µ N-terminal predicted Longin-like domain. Our results provide new insight into the mechanisms of Kv2.1 post-Golgi sorting and targeting.

[Clinical research of Bite-bumper combined with fixed appliance in treatment of lingual tipping deep bite].

OBJECTIVE: To study the mechanism and applicability of Bite-bumper combined with fixed appliance in treatment of lingual tipping deep bite. METHODS: 14 children aged 12-16 years old with lingual tipping deep bite participated in the experiment. Bite-bumper combined with fixed appliance was used to correct the deep bite. Clinic effect was observed. Lateral cephalograms were taken before treatment and after bite opening. The related hard tissues were estimated through the cephalograms. RESULTS: 1) The average duration for bite-opening with Bite-bumper and fixed appliance of 14 patients was 28 days. 2) After bite-opening, the changes in length direction of jaw (SNA, SNB, ANB) had no statistical variances. Anterior and posterior facial height (S-Go, ANS-Me) were increased. No significant changes were observed in the ratio of posterior facial height to anterior facial height (S-Go/N-Me), angle of mandibular plane (SN-MP) and Y axis. Labial incline in upper and lower incisors (U1-SN, L1-MP) and interincisa angle (U1-L1) were decreased. The posterior teeth (U6-PP, L6-MP) were extruded and the upper incisors (U1-PP) were intruded. The overbite was decreased. CONCLUSION: Bite-bumper combined with fixed appliance can be used effectively for deep bite correction and improve the short face of patients with lingual tripping deep overbite.