Characterizing the Racial Discrepancy in Hypoxemia Detection in Venovenous Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis.

PURPOSE: Skin pigmentation influences peripheral oxygen saturation (SpO2) compared to arterial saturation of oxygen (SaO2). Occult hypoxemia (SaO2 ≤ 88% with SpO2 ≥ 92%) is associated with increased in-hospital mortality in venovenous-extracorporeal membrane oxygenation (VV-ECMO) patients. We hypothesized VV-ECMO cannulation, in addition to race/ethnicity, accentuates the SpO2-SaO2 discrepancy due to significant hemolysis. METHODS: Adults (≥ 18 years) supported with VV-ECMO with concurrently measured SpO2 and SaO2 measurements from over 500 centers in the Extracorporeal Life Support Organization Registry (1/2018-5/2023) were included. Multivariable logistic regressions were performed to examine whether race/ethnicity was associated with occult hypoxemia in pre-ECMO and on-ECMO SpO2-SaO2 calculations. RESULTS: Of 13,171 VV-ECMO patients, there were 7772 (59%) White, 2114 (16%) Hispanic, 1777 (14%) Black, and 1508 (11%) Asian patients. The frequency of on-ECMO occult hypoxemia was 2.0% (N = 233). Occult hypoxemia was more common in Black and Hispanic patients versus White patients (3.1% versus 1.7%, P < 0.001 and 2.5% versus 1.7%, P = 0.025, respectively). In multivariable logistic regression, Black patients were at higher risk of pre-ECMO occult hypoxemia versus White patients (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.18-2.02, P = 0.001). For on-ECMO occult hypoxemia, Black patients (aOR = 1.79, 95% CI = 1.16-2.75, P = 0.008) and Hispanic patients (aOR = 1.71, 95% CI = 1.15-2.55, P = 0.008) had higher risk versus White patients. Higher pump flow rates (aOR = 1.29, 95% CI = 1.08-1.55, P = 0.005) and on-ECMO 24-h lactate (aOR = 1.06, 95% CI = 1.03-1.10, P < 0.001) significantly increased the risk of on-ECMO occult hypoxemia. CONCLUSION: SaO2 should be carefully monitored if using SpO2 during ECMO support for Black and Hispanic patients especially for those with high pump flow and lactate values at risk for occult hypoxemia.

Right Ventricular Sizing and Pulmonary Vascular Resistance: How Much Mass Do You Need?

OBJECTIVE: Right ventricular (RV) donor-recipient sizing has been demonstrated to be a sensitive predictor for mortality after heart transplantation. We sought to understand the relationship between donor-recipient RV mass (RVM) ratio and pulmonary vascular resistance (PVR) on outcomes after heart transplantation. METHODS: Adult heart transplant recipients from the UNOS database were included (N=42,594). The impact of RVM ratio and PVR on 1-year mortality was assessed by logistic regression after multivariable adjustment. RESULTS: Among transplant recipients, median PVR was 2.4 (1.7-3.3) WU and median RVM ratio was 1.2 (1.0-1.3). Without considering PVR, RVM ratio was highly associated with postoperative dialysis (OR=0.49, P<0.001) and 1-year mortality (OR=0.64, P<0.001). Without considering RVM ratio, PVR was highly associated with 1-year mortality (OR=1.05, P<0.001), but not postoperative dialysis (OR=0.98, P=0.156). When considering both RVM ratio and PVR, the risk associated with each remained significant, but PVR did not modify the effect of RVM ratio on 1-year mortality (RVM ratio*PVR: OR=0.99, P=0.858). In order to maintain a consistent predicted 1-year mortality, RVM ratio would need to increase by 0.12 for each WU increase in PVR. Secondary analyses found that a 1 WU change in PVR was associated with an 11% increase in mortality risk in RVM ratio mismatched patients (RVM ratio <1; P=0.001), but only a 5% increase in RVM ratio matched patients (RVM ratio ≥1; P=0.003). CONCLUSION: RVM ratio and recipient PVR are independent predictors of 1-year mortality. Still, a larger RV mass may be utilized to mediate the effects of an elevated PVR.

Racial and Ethnic Variations in Patients Undergoing Mitral and Tricuspid Valve Surgery.

INTRODUCTION: Prior investigations assessing the impact of race/ethnicity on outcomes after mitral valve (MV) surgery have reported conflicting findings. This analysis aimed to examine the association between race/ethnicity and operative presentation and outcomes of patients undergoing MV and tricuspid valve (TV) surgery. METHODS: We retrospectively analyzed 5984 patients (2730 female, median age 63 y) who underwent MV (n = 4,534, 76%), TV (n = 474, 8%) or both MV and TV (n = 976, 16%) surgery in a statewide collaborative from 2012 to 2021. The influence of race/ethnicity on preoperative characteristics, MV and TV repair rates, and postoperative outcomes was assessed for White (n = 4,244, 71%), Black (n = 1,271, 21%), Hispanic (n = 144, 2%), Asian (n = 171, 3%), and mixed/other race (n = 154, 3%) patients. RESULTS: Black patients, compared to White patients, had higher Society of Thoracic Surgeons predicted risk of morbidity/mortality (24.5% versus 13.1%; P < 0.001) and more comorbid conditions. Compared to White patients, Black and Hispanic patients were less likely to undergo an elective procedure (White 71%, Black 55%, Hispanic 58%; P < 0.001). Degenerative MV disease was more prevalent in White patients (White 62%, Black 41%, Hispanic 43%, Asian 51%, mixed/other 45%; P < 0.05), while rheumatic disease was more prevalent in non-White patients (Asian 28%, Hispanic 26%, mixed/other 25%, Black 17%, White 10%;P < 0.05). After multivariable adjustment, repair rates and adverse postoperative outcomes, including mortality, did not differ by racial/ethnic group. CONCLUSIONS: Patient race/ethnicity is associated with a higher burden of comorbidities at operative presentation and MV disease etiology. Strategies to improve early detection of valvular heart disease and timely referral for surgery may improve outcomes.

Non-resectional cordal repair for Barlow mitral valve disease.

BACKGROUND: The redundant leaflet tissue and annular pathology of Barlow disease can make surgical repair challenging. We examined perioperative and late outcomes of a large cohort of patients with Barlow disease undergoing surgical repair. METHODS: Patients included in this analysis underwent mitral valve repair from 01/2004-11/2021 by a single surgeon. RESULTS: Of 2798 patients undergoing mitral valve operations, 46% (N.=1292) had degenerative pathology and 7% (N.=184) had Barlow disease. Of the 179 Barlow patients, median age at surgery was 62 (51-70) years; 64% were male (115/179). Rates of non-resectional cordal repair and resectional repair were 86% (154/179) and 14% (25/179). Among patients undergoing non-resectional repair, the median number of cordal pairs inserted on the anterior and posterior leaflets was 2 (2-3) and 4 (3-4). Incidence of return to bypass for systolic anterior motion of the mitral valve, perioperative death, stroke, and renal failure was 2% (4/179), 1% (2/179), 0% (0/179), and 0% (0/179). Rates of clinical and echocardiographic follow-up were 93% (165/177) and 89% (157/177). Median time to latest postoperative clinical and echocardiographic follow-up was 2.4 (0.8-6.1) and 2.1 (0.6-4.7) years. Mitral regurgitation grade at latest follow-up or time of repair failure was none/trace, mild, mild to moderate, and severe in 63% (98/157), 26% (41/157), 8% (12/157), and 4% (6/157); five of six patients with severe MR underwent reoperation. Since 2011 97% (139/144) of patients underwent cordal repair without resection. CONCLUSIONS: Non-resectional artificial cordal repair is safe and feasible in almost all patients with Barlow valves and is associated with excellent mid-term results.

Scoring systems, expert assessment, and identification of risk factors for the emergence of delirium in paediatric patients: Prospective cohort study.

INTRODUCTION: Emergence delirium (ED) is a transient irritative and dissociative state that arises after the cessation of anaesthesia in patients who do not respond to calming measures. There are many risk factors for ED, but the exact cause and underlying mechanism have not been determined because the definition of ED is still unclear in consensus. This study aims to determine ED incidence, identify ED risk factors and external validation of Watcha, Cravero and expert assessment to Pediatric Anesthesia Emergence Delirium (PAED) scoring system in ED prediction. MATERIALS AND METHODS: This study is a prospective cohort study on 79 paediatrics who underwent elective surgery with general anaesthesia. Parameter measures include the incidence of ED, ED risk factors, and the relationship between PAED, Watcha, Cravero score and expert assessment. The ED risk factor was analysed using univariate and multivariate analysis. The relationship between PAED, Watcha, Cravero score, and expert assessment was determined using Receiver Operating Characteristic (ROC) curve analysis. RESULTS: The incidence of ED was 22.8%. All parameters examined in this study showed p < 0.05. Watcha's scoring correlates with the PAED scoring and shows the highest discrimination ability with AUC 0.741 and p < 0.05. CONCLUSION: The incidence of ED in paediatrics is relatively high. Compared to others, Watcha score are more reliable for ED prediction. However, some demographic and perioperative factors are not the risk factor of ED.

Breast Implant Associated Anaplastic Large Cell Lymphoma: Evidence-Based Consensus Conference Statement From The American Association of Plastic Surgeons.

BACKGROUND: In the absence of high-quality evidence, there is a need to provide guidelines and multidisciplinary consensus recommendations on Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). The purpose of this expert consensus conference was to evaluate the existing evidence regarding the diagnosis, and management of BIA-ALCL caused by textured implants. The aim is to provide evidence-based recommendations regarding the management and prevention of BIA-ALCL. METHODS: A comprehensive search was conducted in the MEDLINE, Cochrane Library, and Embase databases, supplemented by manual searches of relevant English language articles and "related articles" sections. Studies focusing on breast surgery and lymphoma associated with breast implants were included for analysis. Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons by a Delphi consensus method. RESULTS: 840 articles between January 2011 and January 2023 were initially identified and screened. Full-text of 188 articles were assessed. An additional 43 articles were excluded for focus, and 145 articles were included in the synthesis of results, with 105 of them being case reports or case series. The analysis encompassed a comprehensive examination of the selected articles to determine the incidence, risk factors, clinical presentation, diagnostic approaches, and treatment modalities related to BIA-ALCL. CONCLUSIONS: Plastic surgeons should be aware of the elevated risks by surface type, implement appropriate patient surveillance, and follow the recommendations outlined in this statement to ensure patient safety and optimize outcomes. Ongoing research on pathogenesis, genetic drivers, and preventative and prophylactic measures is crucial for improving patient care.

Statewide data on surgical ablation for atrial fibrillation: The data provide a path forward.

OBJECTIVE: Atrial fibrillation (AF), if left untreated, is associated with increased intermediate and long-term morbidity/mortality. Surgical treatment for AF is lacking standardization in patient selection and lesion set, despite clear support from multi-society guidelines. The aim of this study was to analyze a statewide cardiac surgery registry to establish whether or not there is an association between center volume and type of index procedure with performance of surgical ablation (SA) for AF, the lesion set chosen, and ablation technology used. METHODS: Adult, first-time, nonemergency patients with preoperative AF between 2014 and 2022 excluding standalone SA procedures from a statewide registry of Society of Thoracic Surgeons data were included (N = 4320). AF treatment variability by hospital volume (ordered from smallest to largest) and surgery type were examined with χ2 analyses. Hospital-level Spearman correlations compared hospital volume with proportion of AF patients treated with SA. RESULTS: Overall, 37% of patients with AF were ablated at the time of surgery (63% of mitral procedures, 26% of non-mitrals) and 15% had left atrial appendage management only. There was a significant temporal trend of increasing performance of SA for AF over time (Cochran-Armitage = 27.8; P < .001). Hospital cardiac surgery volume did not correlate with the proportion of AF patients treated with SA (rs = 0.19; P = .603) with a rate of SA below the state average for academic centers. Of cases with SA (n = 1582), only 43% had a biatrial lesion set. Procedures that involved mitral surgery were more likely to include a biatrial lesion set (χ2 = 392.3; P < .001) for both paroxysmal and persistent AF. Similarly, ablation technology use was variable by type of concomitant operation (χ2 = 219.0; P < .001) such that radiofrequency energy was more likely to be used in non-mitral procedures. CONCLUSIONS: These results indicate an increase in adoption of SA for AF over time. No association between greater hospital volume or academic status and performance of SA for AF was established. Similar to national data, the type of index procedure remains the most consistent factor in the decision to perform SA with a disconnect between AF pathophysiology and decision making on the type of SA performed. This analysis demonstrates a gap between evidence-based guidelines and real-world practice, highlighting an opportunity to confer the benefits of concomitant SA to more patients.

Characterizing the Racial Discrepancy in Hypoxemia Detection in VV-ECMO: An ELSO Registry Analysis.

Importance: Skin pigmentation influences peripheral oxygen saturation (SpO2) measured by pulse oximetry compared to the arterial saturation of oxygen (SaO2) measured via arterial blood gas analysis. However, data on SpO2-SaO2 discrepancy are limited in venovenous-extracorporeal membrane oxygenation (VV-ECMO) patients. Objective: To determine whether there is racial/ethnical discrepancy between SpO2 and SaO2 in patients receiving VV-ECMO. We hypothesized VV-ECMO cannulation, in addition to race/ethnicity, accentuates the SpO2-SaO2 discrepancy due to significant hemolysis. Design: Retrospective cohort study of the Extracorporeal Life Support Organization Registry from 1/2018-5/2023. Setting: International, multicenter registry study including over 500 ECMO centers. Participants: Adults (≥ 18 years) supported with VV-ECMO with concurrently measured SpO2 and SaO2 measurements. Exposure: Race/ethnicity and ECMO cannulation. Main outcomes and measures: Occult hypoxemia (SaO2 ≤ 88% with SpO2 ≥ 92%) was our primary outcome. Multivariable logistic regressions were performed to examine whether race/ethnicity was associated with occult hypoxemia in pre-ECMO and on-ECMO SpO2-SaO2 calculations. Covariates included age, sex, temporary mechanical circulatory support, pre-vasopressors, and pre-inotropes for pre-ECMO analysis, plus single-lumen versus double-lumen cannulation, hemolysis, hyperbilirubinemia, ECMO pump flow rate, and on-ECMO 24h lactate for on-ECMO analysis. Results: Of 13,171 VV-ECMO patients (median age = 48.6 years, 66% male), there were 7,772 (59%) White, 2,114 (16%) Hispanic, 1,777 (14%) Black, and 1,508 (11%) Asian patients. The frequency of on-ECMO occult hypoxemia was 2.0% (N = 233). Occult hypoxemia was more common in Black and Hispanic versus White patients (3.1% versus 1.7%, P < 0.001 and 2.5% versus 1.7%, P = 0.025, respectively).In multivariable logistic regression, Black patients were at higher risk of pre-ECMO occult hypoxemia versus White patients (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.18-2.02, P = 0.001). For on-ECMO occult hypoxemia, Black patients (aOR = 1.79, 95%CI = 1.16-2.75, P = 0.008) and Hispanic patients (aOR = 1.71, 95%CI = 1.15-2.55, P = 0.008) had higher risk versus White patients. Furthermore, higher pump flow rate (aOR = 1.29, 95%CI = 1.08-1.55, P = 0.005) and higher on-ECMO 24h lactate (aOR = 1.06, 95%CI = 1.03-1.10, P < 0.001) significantly increased the risk of on-ECMO occult hypoxemia. Conclusions and Relevance: Hispanic and Black VV-ECMO patients experienced occult hypoxemia more than White patients. SaO2 should be carefully monitored during ECMO support for Black and Hispanic patients especially for those with high pump flow and lactate values at risk for occult hypoxemia.

Unexpected impact of preoperative anemia in low-risk isolated coronary artery bypass grafting or single-valve surgical patients: Do not overlook these patients in anemia management!

OBJECTIVE: Preoperative anemia is prevalent in cardiac surgery and independently associated with increased risk for short-term and long-term mortality. The purpose of this study was to examine the effect of preoperative hematocrit (Hct) on outcomes in cardiac surgical patients and whether the effect is comparable across levels of Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM). METHODS: The study consisted of adult, isolated coronary artery bypass grafting (CABG) or single-valve surgical patients in a statewide registry from 2011 to 2022 (N = 29,828). Regressions were used to assess effect of preoperative Hct on STS-defined major morbidity/mortality including the interaction of Hct and STS PROM as continuous variables. RESULTS: Median age was 66 years (58-73 years), STS PROM was 1.02% (0.58%-1.99%), and preoperative Hct was 39.5% (35.8%-42.8%). The sample consisted of 78% isolated CABG (n = 23,261), 10% isolated mitral valve repair/replacement (n = 3119), 12% isolated aortic valve replacement (n = 3448), and 29% were female (n = 8646). Multivariable analyses found that greater Hct was associated with reduced risk of STS-defined morbidity/mortality (odds ratio, 0.96; P < .001). These effects for Hct persisted even after adjustment for intraoperative blood transfusion. The interaction of Hct and STS PROM was significant for morbidity/mortality (odds ratio, 1.01; P < .001). There was a stronger association between Hct levels and morbidity/mortality risk in the patients with the lowest STS risk compared with patients with the greatest STS risk. CONCLUSIONS: Patients with lower risk had a greater association between preoperative Hct and major morbidity and mortality compared with patients with greater risk. Preoperative anemia management is essential across all risk groups for improved outcomes.

Indexed donor cardiac output for improved size matching in heart transplantation: A United Network for Organ Sharing database analysis.

Objective: Implantation of an appropriately sized donor heart is critical for optimal outcomes after heart transplantation. Although predicted heart mass has recently gained consideration, there remains a need for improved granularity in size matching, particularly among small donor hearts. We sought to determine if indexed donor cardiac output is a sensitive metric to assess the adequacy of a donor heart for a given recipient. Methods: A retrospective analysis was performed (2003-2021) in isolated orthotopic heart transplant recipients from the United Network for Organ Sharing database. Donor cardiac output was divided by recipient body surface area to compute cardiac index (donor cardiac index). Predicted heart mass ratio was computed as donor/recipient predicted heart mass. The primary outcome was mortality 1 year after transplant. Results: Among transplant recipients, median donor cardiac output was 7.3 (5.8-9.0) liters per minute and donor cardiac index was 3.7 (3.0-4.6) liters per minute/m2. Predicted heart mass ratio was 1.01 (0.91-1.13). After multivariable adjustment, higher donor cardiac index was associated with lower 1-year mortality risk (odds ratio, 0.92, P = .042). Recipients with predicted heart mass ratio less than 0.80 (n = 255) had a lower median donor cardiac index than those with a predicted heart mass ratio of 0.80 or greater (3.2 vs 3.7, P < .001). As predicted, heart mass ratio became smaller and the association between donor cardiac index and 1-year mortality became progressively stronger. Conclusions: Higher donor cardiac index was associated with a lower probability of 1-year mortality among patients undergoing heart transplantation and served to further quantify mortality risk among those with a small predicted heart mass ratio. Donor cardiac index appears to be an effective tool for size matching and may serve as an adjunctive strategy among small donor hearts with a low predicted heart mass ratio.

Institutional Variability in Red Blood Cell Transfusion With Coronary Bypass in a Statewide Database.

BACKGROUND: The decision to perform transfusion is common but varies among centers and surgeons. This study looked at variables associated with red blood cell (RBC) transfusion in a statewide database. The study aimed to understand discrepancies in transfusion rates among hospitals and to establish whether the hospital itself was a significant variable in transfusion, independent of variables known to affect transfusion in patients undergoing cardiac surgical procedures. METHODS: The Maryland Cardiac Surgery Quality Initiative is a consortium of centers in the state. Patients undergoing isolated coronary artery bypass grafting from January 2018 to June 2020 from 10 centers in Maryland were included. Multivariable logistic regression was used to determine probability of RBC transfusion with covariates, including age, preoperative hemoglobin value, The Society of Thoracic Surgeons predicted risk of mortality, emergency status, preoperative adenosine diphosphate receptor blocker use, sex, body mass index, and off-pump status. RESULTS: A total of 5343 patients were included and had an overall RBC transfusion rate of 30.3% (range, 11.3%-55.8%). There was significant variability in the incidence of RBC transfusion among hospitals (χ2 = 604.7; P < .001). After covariate adjustment, a significant effect of hospital on transfusion remained (Wald = 547.3; P < .001). Hospital variation in RBC transfusion was not correlated with hospital variation in median age (P = .467), hemoglobin (P 0 855), The Society of Thoracic Surgeons predicted risk of mortality (P = .855), or sex (P = .726). CONCLUSIONS: In a statewide analysis, wide variability in transfusion rates was observed, with hospital-specific management strongly associated with RBC transfusion. This study suggests that RBC transfusion may be affected by the culture and practices of an institution independent of clinical and demographic variables.

Chlorogenic acid may improve memory function and decrease inflamation of frontal lobe in diabetic rat.

INTRODUCTION: Diabetes Mellitus (DM) is a chronic disease with many complications, one of which is diabetic encephalopathy which is characterised by memory dysfunction. Hyperglycaemia that occurs in DM will activate inflammatory pathways in neurons, including NF-κB pathway. Activation of this pathway produce proinflammatory agents such as MCP-1 and IL-6, which activate glial cells. Activation of glial cells is characterised by Glial Fibrillary Acid Protein (GFAP). Chlorogenic acid (CGA) has been reported to have anti-inflammatory effects and can improve memory function. This research aimed to determine the effect of CGA as anti-inflammation, its effect on memory function, mRNA expression of NF-κB, MCP-1, IL- 6, and GFAP of frontal lobe. MATERIALS AND METHODS: A total of 24 male rats were randomly divided into six groups: control, DM 1.5 month (DM1.5), DM 2 months (DM2) and the group with three different doses of CGA 12.5 (CGA1), 25 (CGA2), and 50 (CGA3) mg/KgBW. Frontal lobe tissue is taken for analysis of mRNA expression for NF-κB, MCP-1, IL-6, and GFAP using Reverse Transcriptase PCR (RT-PCR). Samples were also taken for histopathology preparation and stained by immunohistochemistry method using anti-GFAP antibodies to observe glial cell activation in frontal lobe tissue. RESULTS: The group that was given CGA at all doses have statistically significant better memory function, i.e. DM2 versus CGA1 (p = 0.036), CGA2 (p = 0.040), and CGA3 (p = 0.021). The result of mRNA expression in NF-κB was lower in the group given CGA, i.e. DM2 compared to CGA2 (p = 0.007). mRNA expression of MCP-1 was significantly lower in all CGA treatment groups compared to the non-CGA group (p = 0.000). IL-6 mRNA expression was lower than the group not given CGA, DM compared to CGA2 (p = 0.028). GFAP mRNA expression was lower than the group given CGA in DM, DM2 group compared to CGA1 (p = 0.04) and CGA3 (p = 0.004). CONCLUSION: Administration of CGA can improve memory function at all doses given, and can reduce brain inflammatory activity, especially in the CGA2 group.

The differences in development between stunting and normal children at the age of 3-72 months.

INTRODUCTION: Globally, there were around 22% of children under the age of 5 suffer from stunting. The Asian region contributes around 21.8% of the world's stunting cases. This study aims to looked at the differences in development between stunted and normal children at the age of 3-72 months. MATERIALS AND METHODS: This type of research used an analytic observational approach with a cross-sectional design. The research variables were the child development and stunting. The sample were 130 respondents. Data were analysed with chi-square test. RESULTS: The results showed that stunted children were 5.525 times more at risk of getting "deviated/doubtful" development screening results than normal children (OR= 5.525; 95% CI= 2.488-12.268; p-value <0.001). CONCLUSION: It can be concluded that there were developmental differences between stunted children and normal children.

Racial and ethnic disparities in telemental health usage among veterans.

It is essential for mental health services to be equitably accessible and utilized. The literature on mental health service utilization has, to date, been focused largely on in-person care. This quality assurance project evaluated telemental health (TMH) utilization rates among Veterans by race and ethnicity. Following the rapid expansion of TMH in response to the COVID-19 pandemic, we also explored whether TMH use across racial and ethnic Veteran groups changed after the onset of the pandemic. Using chi-square analyses, we compared the observed race and ethnicity of Veterans receiving TMH to the expected race and ethnicity of Veterans receiving TMH, controlling for rurality. We found that TMH was not being utilized by all racial and ethnic groups within the Veteran population as would be expected, both before and during the pandemic. Improvements were noted during the pandemic when much of outpatient mental health care was converted to telehealth. The strengths and limitations of this project, recommendations for TMH, and potential future directions are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Rising Mortality in Coronavirus-19 Patients Supported With Extracorporeal Membrane Oxygenation.

We aimed to describe practice patterns and outcomes in patients with extracorporeal membrane oxygenation (ECMO) support throughout the coronavirus 2019 (COVID-19) pandemic, with the hypothesis that mortality would improve as we accumulated knowledge and experience. We included 48 patients supported on veno-venous ECMO (VV-ECMO) at a single institution between April 2020 and December 2021. Patients were categorized into three waves based on cannulation date, corresponding to the wild-type (wave 1), alpha (wave 2), and delta (wave 3) variants. One hundred percent of patients in waves 2 and 3 received glucocorticoids, compared with 29% in wave 1 ( p < 0.01), and the majority received remdesivir (84% and 92% in waves 2 and 3, vs . 35% in wave 1; p < 0.01). Duration of pre-ECMO noninvasive ventilation was longer in waves 2 and 3 (mean 8.8 days and 3.9 days, vs . 0.7 days in wave 1; p < 0.01), as was time to cannulation (mean 17.2 and 14.6 days vs . 8.8 days in wave 1; p < 0.01) and ECMO duration (mean 55.7 days and 43.0 days vs . 28.4 days in wave 1; p = 0.02). Mortality in wave 1 was 35%, compared with 63% and 75% in waves 2 and 3 ( p = 0.05). These results suggest an increased prevalence of medically refractory disease and rising mortality in later variants of COVID-19.

Multiple Arterial Graft Use in Coronary Artery Bypass Surgery: Surgeon Perspective vs Practice.

BACKGROUND: Despite supportive evidence and guidelines, the use of multiple arterial grafts (MAGs) in coronary artery bypass grafting remains low. We sought to determine surgeon perception of personal MAG use and compare this with actual MAG use. METHODS: We conducted a statewide surgeon survey of MAG use, presence of a hospital MAG protocol, and barriers for MAG use, with a response rate of 78% (n = 25). Surgeon survey responses were compared with actual Society of Thoracic Surgeons patient data from January 1, 2017, to December 31, 2020 using χ2 or Fisher's exact tests. RESULTS: Of 5299 patients who had first-time, nonemergent, isolated coronary artery bypass grafting (≥2 grafts) by responding surgeons, 16% received MAG (n = 825). MAG use in patients whose surgeons self-designated as "routine" MAG users was 21% vs 7% for "nonroutine" users. Surgeons with a hospital protocol for MAG use utilized MAG more often (18% vs 14%, P = .001). Surgeons who were unconvinced by the data on the benefits of MAGs used MAGs in 11% vs 22% in surgeons who were convinced. MAG use increased over time, particularly from before to after the survey (13.1% vs 30.5%, P < .001). CONCLUSIONS: Although MAG use increased over time, barriers to routine use remain. In surgeons who reported routine use, only 21% of their patients received MAGs. Hospital protocols, education, and increased awareness may reduce barriers to use and encourage evidence-based clinical practice.

Hospital variability in modifiable factors driving coronary artery bypass charges.

OBJECTIVE: Coronary artery bypass grafting is associated with significant interhospital variability in charges. Drivers of hospital charge variability remain elusive. We identified modifiable factors associated with statewide interhospital variability in hospital charges for coronary artery bypass grafting. METHODS: Charge data were used as a surrogate for cost. Society of Thoracic Surgeons data from Maryland institutions and charge data from the Maryland Health Care Commission were linked to characterize interhospital charge variability for coronary artery bypass grafting. Multivariable linear regression was used to identify perioperative factors independently related to coronary artery bypass grafting charges. Of the factors independently associated with charges, we analyzed which factors varied between hospitals. RESULTS: A total of 10,337 patients underwent isolated coronary artery bypass grafting at 9 Maryland hospitals from 2012 to 2016, of whom 7532 patients were available for analyses. Mean normalized charges for isolated coronary artery bypass grafting varied significantly among hospitals, ranging from $30,000 to $57,000 (P < .001). Longer preoperative length of stay, operating room time, and major postoperative morbidity including stroke, renal failure, prolonged ventilation, reoperation, and deep sternal wound infection were associated with greater hospital charges. Incidence of major postoperative events, except stroke and deep sternal wound infection, was variable between hospitals. In a univariate linear regression model, patient risk profile only accounted for approximately 10% of statistical variance in charges. CONCLUSIONS: There is significant charge variability for coronary artery bypass grafting among hospitals within the same state. By targeting variation in preoperative length of stay, operating room time, postoperative renal failure, prolonged ventilation, and reoperation, cardiac surgery programs can realize cost savings while improving quality of care for this resource-intense patient population.