Prognosis in Patients With Cardiogenic Shock Who Received Temporary Mechanical Circulatory Support.

Background: Temporary mechanical circulatory support (MCS) is often used in patients with cardiogenic shock (CS), and the type of MCS may vary by cause of CS. Objectives: This study sought to describe the causes of CS in patients receiving temporary MCS, the types of MCS used, and associated mortality. Methods: This study used a nationwide Japanese database to identify patients receiving temporary MCS for CS between April 1, 2012, and March 31, 2020. Results: Of 65,837 patients, the cause of CS was acute myocardial infarction (AMI) in 77.4%, heart failure (HF) in 10.9%, valvular disease in 2.7%, fulminant myocarditis (FM) in 2.5%, arrhythmia in 4.5%, and pulmonary embolism (PE) in 2.0% of cases. The most commonly used MCS was an intra-aortic balloon pump alone in AMI (79.2%) and in HF (79.0%) and in valvular disease (66.0%), extracorporeal membrane oxygenation with intra-aortic balloon pump in FM (56.2%) and arrhythmia (43.3%), and extracorporeal membrane oxygenation alone in PE (71.5%). Overall in-hospital mortality was 32.4%; 30.0% in AMI, 32.6% in HF, 33.1% in valvular disease, 34.2% in FM, 60.9% in arrhythmia, and 59.2% in PE. Overall in-hospital mortality increased from 30.4% in 2012 to 34.1% in 2019. After adjustment, valvular disease, FM, and PE had lower in-hospital mortality than AMI: valvular disease, OR: 0.56 (95% CI: 0.50-0.64); FM: OR: 0.58 (95% CI: 0.52-0.66); PE: OR: 0.49 (95% CI: 0.43-0.56); whereas HF had similar in-hospital mortality (OR: 0.99; 95% CI: 0.92-1.05) and arrhythmia had higher in-hospital mortality (OR: 1.14; 95% CI: 1.04-1.26). Conclusions: In a Japanese national registry of patients with CS, different causes of CS were associated with different types of MCS and differences in survival.

Trends and impact of intravascular ultrasound and optical coherence tomography on percutaneous coronary intervention for myocardial infarction.

Background: Intravascular imaging with either intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during percutaneous coronary intervention (PCI) is associated with improved outcomes, but these techniques have previously been underutilized in the real world. We aimed to examine the change in utilization of intravascular imaging-guided PCI over the past decade in the United States and assess the association between intravascular imaging and clinical outcomes following PCI for myocardial infarction (MI). Methods: We surveyed the National Inpatient Sample from 2008 to 2019 to calculate the number of PCIs for MI guided by IVUS or OCT. Temporal trends were analyzed using Cochran-Armitage trend test or simple linear regression for categorical or continuous outcomes, respectively. Multivariable logistic regression was used to compare outcomes following PCI with and without intravascular imaging. Results: A total of 2,881,746 PCIs were performed for MI. The number of IVUS-guided PCIs increased by 309.9 % from 6,180 in 2008 to 25,330 in 2019 (P-trend < 0.001). The percentage of IVUS use in PCIs increased from 3.4 % in 2008 to 8.7 % in 2019 (P-trend < 0.001). The number of OCT-guided PCIs increased 548.4 % from 246 in 2011 to 1,595 in 2019 (P-trend < 0.001). The percentage of OCT guidance in all PCIs increased from 0.0 % in 2008 to 0.6 % in 2019 (P-trend < 0.001). Intravascular imaging-guided PCI was associated with lower odds of in-hospital mortality (adjusted odds ratio 0.66, 95 % confidence interval 0.60-0.72, p < 0.001). Conclusions: Although the number of intravascular imaging-guided PCIs have been increasing, adoption of intravascular imaging remains poor despite an association with lower mortality.

Safety of measles, mumps, and rubella vaccine in adolescents and adults in the vaccine safety Datalink.

Background: Measles, mumps, and rubella vaccine (MMR) is routinely administered to children; however, adolescents and adults may receive MMR for various reasons. Safety studies in adolescents and adults are limited. We report on safety of MMR in this age group in the Vaccine Safety Datalink. Methods: We included adolescents (aged 9-17 years) and adults (aged ≥ 18 years) who received ≥ 1 dose of MMR from January 1, 2010-December 31, 2018. Pre-specified outcomes were identified by diagnosis codes. Clinically serious outcomes included anaphylaxis, encephalitis/myelitis, Guillain-Barré syndrome, immune thrombocytopenia, meningitis, and seizure. Non-serious outcomes were allergic reaction, arthropathy, fever, injection site reaction, lymphadenopathy, non-specific reaction, parotitis, rash, and syncope. All serious outcomes underwent medical record review. Outcome-specific incidence was calculated in pre-defined post-vaccination windows. A self-controlled risk interval design was used to determine the relative risk of each outcome in a risk window after vaccination compared to a more distal control window. Results: During the study period, 276,327 MMR doses were administered to adolescents and adults. Mean age of vaccinees was 34.8 years; 65.8 % were female; 53.2 % of doses were administered simultaneously with ≥ 1 other vaccine. Serious outcomes were rare, with incidence ≤ 6 per 100,000 doses for each outcome assessed, and none had a significant elevation in incidence during the risk window compared to the control window. Incidence of non-serious outcomes per 100,000 doses ranged from 3.4 for parotitis to 263.0 for arthropathy. Other common outcomes included injection site reaction and rash (157.0 and 112.9 per 100,000 doses, respectively). Significantly more outcomes were observed during the risk window compared to the control window for all non-serious outcomes except parotitis. Some variability was observed by sex and age group. Conclusion: Serious outcomes after MMR are rare in adolescents and adults, but vaccinees should be counseled regarding anticipated local and systemic non-serious adverse events.

Real-world comparison of in-hospital complications after catheter ablation for atrial fibrillation between non-antivitamin K anticoagulants and warfarin: A propensity-matched analysis using nation-wide database.

Background: Few large-scale, real-world studies have compared the efficacy and safety of non-antivitamin K anticoagulants (NOACs) with that of warfarin in catheter ablation (CA) for atrial fibrillation (AF). Methods: This retrospective, cross-sectional study used a nationwide administrative claims database, to compare complication-incidence rates following CA for AF between NOAC-treated patients and warfarin-treated matched cohorts in the real-world. Among the 32,797,540 records between June 2011 and August 2020 from 426 hospitals, 41,347 patients (38,065 on NOACs and 3,282 on Warfarin) were considered eligible. After performing propensity matching, 6,564 patients (3,282 per group) were analyzed. Results: The overall complication incidence was significantly lower in the NOACs group than in the warfarin group (2.3 % vs. 4.0 %; P < 0.001, odds ratio [OR]: 0.55, 95 % confidence interval [CI]: 0.41-0.74). Although no significant differences in the incidence of cardiac tamponade (1.0 % vs. 1.1 %; P = 0.90, OR: 0.97, 95 % CI: 0.60-1.56) and major bleeding (0.6 % vs. 0.7 %; P = 0.54, OR: 0.83, 95 % CI: 0.44-1.52) were noted, blood transfusion requirements (0.6 % vs. 1.2 %; P = 0.02, OR: 0.52, 95 % CI: 0.30-0.88) and vascular complications (0.2 % vs. 0.5 %; P = 0.02, OR: 0.33, 95 % CI: 0.12-0.79) were significantly lower in the NOACs group than in the warfarin group. Furthermore, the thromboembolic event incidence was significantly lower in the NOACs group than in the warfarin group (0.5 % vs. 1.2 %; P < 0.001, OR: 0.36, 95 % CI: 0.19-0.64). Conclusions: NOACs should be considered as a first-line therapy for periprocedural anticoagulation in patients undergoing CA for AF.

Different Renal Function Equations and Dosing of Direct Oral Anticoagulants in Atrial Fibrillation.

Background: Randomized trials of direct oral anticoagulants (DOACs) adopted the Cockcroft-Gault (CG) formula to calculate estimated glomerular filtration rate (eGFR) to determine the dosages of DOACs. Objectives: The authors aimed to investigate the agreements/disagreements of eGFRs calculated using different equations (CG, Modified Diet in Renal Disease [MDRD], and Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI] formulas), and their impacts on the dosages of DOACs and clinical outcomes. Methods: Medical data from a multicenter health care provider in Taiwan including 39,239 patients with atrial fibrillation were used. Among these patients, there were 11,185 and 2,323 patients treated with DOACs and warfarin, respectively. Results: At the cutoff values of eGFR of <15, 15-50, and >50 mL/min, the agreements were 78% between MDRD and CG and 81% between CKD-EPI and CG. The disagreements among the different equations were largely due to overestimations, especially for patients aged >75 years and with a body weight of <50 kg (58.8% for MDRD and 50.9% for CKD-EPI). Among patients receiving DOACs whose dosages were defined as "on label" based on MDRD or CKD-EPI, only those whose dosages were "truly on label" based on CG were associated with a lower risk of major bleeding (adjusted HR: 0.34; 95% CI: 0.26-0.45) compared to warfarin. Conclusions: The adoptions of MDRD or CKD-EPI rather than CG would result in inappropriate dosing of DOACs (mainly overdosing), which would attenuate the advantages of DOACs compared to warfarin. The CG equation should be used as the gold standard to calculate eGFRs and guide the DOAC dosages.

All-cause 30- and 90-day inpatient readmission costs associated with 4 minimally invasive colon surgery approaches: A propensity-matched analysis using Medicare and commercial claims data.

Background: The purpose of this study is to assess which minimally invasive colon surgery approach may be associated with the least 30- and 90-day inpatient readmission costs from a payer perspective. Methods: This retrospective claims analysis included adult Medicare and commercially insured beneficiaries who underwent minimally invasive sigmoid, left, or right colon surgery between January 2016 and December 2019. Two cohorts were created based on the use of near-infrared fluorescence (NIF) and were propensity-score matched 1 NIF:5 NoNIF. Four subgroups were then created based on the presence of robotics (R): NIF-NoR, NIF-R, NoNIF-R, and NoNIF-NoR. Results: A total of 50,148 patients were identified, of which 165 (0.3%) indicated the use of NIF and 49,983 (99.7%) did not. After propensity score matching, 990 patients were included (NIF cohort: 165; NoNIF cohort: 825). Of the 165 NIF patients, 87 were robotic-assisted and 78 were conventional laparoscopy. Of the 825 NoNIF patients, 136 were robotic-assisted and 689 were conventional laparoscopy. Postindex inpatient readmission costs were significantly different between the NIF and NoNIF cohorts with the NIF cohort having the lowest 30- and 90-day postindex readmission costs. Postindex readmission costs were also significantly different across the 4 subgroups at 30 and 90 days, with the NIF-NoR group having the lowest postindex readmission costs (all P < .05). Conclusion: Using NIF without the robot during minimally invasive colon surgery is associated with the least 30- and 90-day inpatient readmission costs compared to the other 3 approaches. Hospitals may want to consider these potential cost savings when evaluating technologies for laparoscopic colon surgery. Key Message: Near-infrared fluorescence (NIF) imaging without the robot during minimally invasive colon surgery may significantly save hospitals 30- and 90-day inpatient readmission costs compared to NIF with the robot, NoNIF with the robot, and NoNIF without the robot. This is important as hospitals may want to consider these cost findings in addition to capital equipment and disposable costs when evaluating technologies for laparoscopic colon surgery.

Comparing the Clinical Frailty Scale and an International Classification of Diseases-10 Modified Frailty Index in Predicting Long-Term Survival in Critically Ill Patients.

The Clinical Frailty Scale (CFS) is the most used frailty measure in intensive care unit (ICU) patients. Recently, the modified frailty index (mFI), derived from 11 comorbidities has also been used. It is unclear to what degree the mFI is a true measure of frailty rather than comorbidity. Furthermore, the mFI cannot be freely obtained outside of specific proprietary databases. OBJECTIVE: To compare the performance of CFS and a recently developed International Classification of Diseases-10 (ICD-10) mFI (ICD-10mFI) as frailty-based predictors of long-term survival for up to 1 year. DESIGN: A retrospective multicentric observational study. SETTING AND PARTICIPANTS: All adult (≥16 yr) critically ill patients with documented CFS scores admitted to sixteen Australian ICUs in the state of Victoria between April 1, 2017 to June 30, 2018 were included. We used probabilistic methods to match de-identified ICU admission episodes listed in the Australia and New Zealand Intensive Care Society Adult Patient Database with the Victorian Admission Episode Dataset and the Victorian Death Index via the Victorian Data Linkage Centre. MAIN OUTCOMES AND MEASURES: The primary outcome was the longest available survival following ICU admission. We compared CFS and ICD-10mFI as primary outcome predictors, after adjusting for key confounders. RESULTS: The CFS and ICD-10mFI were compared in 7,001 ICU patients. The proportion of patients categorized as frail was greater with the CFS than with the ICD-10mFI (18.9% [n = 1,323] vs. 8.8% [n = 616]; p < 0.001). The median (IQR) follow-up time was 165 (82-276) days. The CFS predicted long-term survival up to 6 months after adjusting for confounders (hazard ratio [HR] = 1.26, 95% CI, 1.21-1.31), whereas ICD-10mFI did not (HR = 1.04, 95% CI, 0.98-1.10). The ICD-10mFI weakly correlated with the CFS (Spearman's rho = 0.22) but had a poor agreement (kappa = 0.06). The ICD-10mFI more strongly correlated with the Charlson comorbidity index (Spearman's rho 0.30) than CFS (Spearman's rho = 0.25) (p < 0.001). CONCLUSIONS: CFS, but not ICD-10mFI, predicted long-term survival in ICU patients. ICD-10mFI correlated with co-morbidities more than CFS. These findings suggest that CFS and ICD-10mFI are not equivalent. RELEVANCE: CFS and ICD-10mFI are not equivalent in screening for frailty in critically ill patients and therefore ICD-10mFI in its current form should not be used.

Corticosteroid use with extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A nationwide observational study.

Aim: Several studies have reported that corticosteroid administration for cardiac arrest patients may improve outcomes. However, these previous studies have not examined the effect of corticosteroid use in out-of-hospital cardiac arrest (OHCA) patients administered extracorporeal cardiopulmonary resuscitation (ECPR). Therefore, we aimed to examine the effectiveness of corticosteroids in OHCA patients administered ECPR. Methods: Using the Japanese Diagnosis Procedure Combination inpatient database, we included OHCA patients who were administered ECPR on the day of admission between July 2010 and March 2019. The patients were categorized into the corticosteroid and control groups according to whether they received corticosteroids on the day of admission or not. The primary outcome was in-hospital mortality and the secondary outcomes included percentages of neurologically favorable survival, major bleeding complications, and infection-related complications. We compared the outcomes using a propensity score matching analysis. Results: We identified 6,142 eligible patients (459 vs 5,683, the corticosteroid and control group, respectively). One-to-four propensity score matching analysis (457 vs 1,827) showed in-hospital mortality was significantly higher in the corticosteroid group compared with the control group (82.1% vs 76.6%; risk difference, 5.5%; 95% CI, 1.5 to 9.5%). Neurologically favorable outcomes did not differ between the two groups (13.6% vs 16.9%; risk difference, -3.3%; 95% CI, -6.9 to 0.3%). The percentage of major bleeding complications and infection-related complications did not significantly differ between the two groups. Conclusions: The results of this study demonstrated that administration of corticosteroids on the day of admission to OHCA patients administered ECPR was associated with increased in-hospital mortality.

Age, sex, and contemporary outcomes in surgical repair of type A aortic dissection: Insights from the National Inpatient Sample.

Objective: Acute type A aortic dissection (ATAAD) is a surgical emergency with significant morbidity and mortality, as well as significant center-level variation in outcomes. Our study aims to leverage a nationally representative database to assess contemporary in-hospital outcomes in surgical repair of ATAAD, as well as the association of age and sex with outcomes. Methods: The National Inpatient Sample was queried to identify hospital discharge records of patients aged ≥18 years who underwent urgent surgical repair of ATAAD between 2017 and 2018. Patients with a diagnosis of thoracic aortic dissection, who underwent surgical intervention of the ascending aorta, were identified. Patient demographics were assessed, and predictors of in-hospital mortality were identified. Results: We identified 7805 weighted cases of surgically repaired ATAAD nationally, with an overall mortality of 15.3%. Mean age was 60.0 ± 13.6 years. There was a male predominance, although female subjects made up a larger proportion of older age groups-female subjects up 18.4% of patients younger than 40 years with ATAAD but 53.6% of patients older than 80 years. In multivariable analysis controlling for sex, race, comorbidities, and malperfusion, age was a significant predictor of mortality. Patients aged 71 to 80 years had a 5.3-fold increased risk of mortality compared with patients ≤40 years old (P < .001), and patients aged >80 years had a 6.8-fold increased risk of mortality (P < .001). Sex was not significantly associated with mortality. Conclusions: Surgical repair of ATAAD continues to carry high risk of morbidity and mortality, with outcomes impacted significantly by patient age, regardless of patient comorbidity burden.

Defining value in cardiac surgery: A contemporary analysis of cost variation across the United States.

Objective: Isolated coronary artery bypass grafting and aortic valve replacement are common cardiac operations performed in the United States and serve as platforms for benchmarking. The present national study characterized hospital-level variation in costs and value for coronary artery bypass grafting and aortic valve replacement. Methods: Adults undergoing elective, isolated coronary artery bypass grafting or aortic valve replacement were identified in the 2016-2018 Nationwide Readmissions Database. Center quality was defined by the proportion of patients without an adverse outcome (death, stroke, respiratory failure, pneumonia, sepsis, acute kidney injury, and reoperation). High-value hospitals were defined as those with observed-to-expected ratios less than 1 for costs and greater than 1 for quality, whereas the converse defined low-value centers. Results: Of 318,194 patients meeting study criteria, 71.9% underwent isolated coronary artery bypass grafting and 28.1% underwent aortic valve replacement. Variation in hospital-level costs was evident, with median center-level cost of $36,400 (interquartile range, 29,500-46,700) for isolated coronary artery bypass grafting and $38,400 (interquartile range, 32,300-47,700) for aortic valve replacement. Observed-to-expected ratios for quality ranged from 0.2 to 10.9 for isolated coronary artery bypass grafting and 0.1 to 11.7 for isolated aortic valve replacement. Hospital factors, including volume and quality, contributed to approximately 9.9% and 11.2% of initial cost variation for isolated coronary artery bypass grafting and aortic valve replacement. High-value centers had greater cardiac surgery operative volume and were more commonly teaching hospitals compared to low-value centers, but had similar patient risk profiles. Conclusions: Significant variation in hospital costs, quality, and value exists for 2 common cardiac operations. Center volume was associated with value and partly accounts for variation in costs. Our findings suggest the need for value-based care paradigms to reduce expenditures and optimize outcomes.

Association between metabolic overweight/obesity phenotypes and readmission risk in patients with lung cancer: A retrospective cohort study.

Background: Increased body mass index (BMI) and metabolic abnormalities are controversial prognostic factors of lung cancer. However, the relationship between metabolic overweight/obesity phenotypes and hospital readmission in patients with lung cancer is rarely reported. Methods: We established a retrospective cohort using the United States (US) Nationwide Readmissions Database (NRD). We included adult patients diagnosed with lung cancer from January 1, 2018 to November 30, 2018 and excluded patients combined with other cancers, pregnancy, died during hospitalization, low body weight, and those with missing data. The cohort was observed for hospital readmission until December 31, 2018. We defined and distinguished four metabolic overweight/obesity phenotypes: metabolically healthy with normal weight (MHNW), metabolically unhealthy with normal weight (MUNW), metabolically healthy with overweight or obesity (MHO), and metabolically unhealthy with overweight or obesity (MUO). The relationship between metabolic overweight/obesity phenotypes and 30-day readmission risk was assessed by multivariable Cox regression analysis. Findings: Of the 115,393 patients included from the NRD 2018 (MHNW [58214, 50.4%], MUNW [44980, 39.0%], MHO [5044, 4.4%], and MUO [7155, 6.2%]), patients with the phenotype MUNW (6531, 14.5%), MHO (771, 15.3%), and MUO (1155, 16.1%) had a higher readmission rate compared to those with MHNW (7901, 13.6%). Compared with patients with the MHNW phenotype, those with the MUNW (hazard ratio [HR], 1.10; 95% CI, 1.06-1.14), MHO (HR, 1.15; 95% CI, 1.07-1.24), and MUO (HR, 1.28; 95% CI, 1.20-1.36) phenotypes had a higher risk of readmission, especially in men, those without surgical intervention, or those aged >60 years. In women, similar results with respect to readmission were observed in people aged >60 years (MUNW [HR, 1.07; 95% CI, 1.01-1.13], MHO [HR, 1.19; 95% CI, 1.06-1.35], and MUO [HR, 1.28; 95% CI, 1.16-1.41]). We also found increased costs for 30-day readmission in patients with MHO (OR, 1.18; 95% CI, 1.07-1.29) and MUO (OR, 1.11; 95% CI, 1.02-1.20). Interpretation: Increased BMI and metabolic abnormalities are independently associated with higher readmission risks in patients with lung cancer, whereas increased BMI also increases the readmission costs. Follow-up and intervention method targeting increased BMI and metabolic abnormalities should be considered for patients with lung cancer. Funding: The National Key Research and Development Program of China (2017YFC1309800).

Exploring Age and Sex Patterns for Rehabilitation Referrals After a Concussion: A Retrospective Analysis.

Objective: To explore patterns of postconcussion care at a level 1 trauma center. Design: Retrospective cohort study. Setting: U.S. level 1 trauma center and local satellite units. Participants: Patients of any age with a concussion diagnosis that reported to level 1 trauma center and local satellite units between 2016 and 2018 (N=2417). Intervention: Not applicable. Main Outcome Measures: Age, sex, point of entry, rehabilitation referrals, and pre-existing comorbidity diagnosis. Results: Patient age (mean [SD]) significantly differed among points of entry, from youngest to oldest: 26.0 (14.0) years in sports medicine, 29.3 (23.0) years in the emergency department, 34.6 (23.6) years at primary care providers, and 46.0 (19.7) years at specialty care departments. Sex also significantly differed among points of entry; emergency departments reported more men (55.6%), whereas the other points of entry reported more women (59.3%-65.6%). Patients were more likely to receive a referral from sports medicine (odds ratio [OR]unadjusted=75.05, P<.001), primary care providers (ORunadjusted=7.98, P<.001), and specialty care departments (ORunadjusted=7.62, P<.001) than from the emergency department. Women were more likely to receive a referral (ORunadjusted=1.92, P<.0001), regardless of point of entry. Lastly, patients with a preexisting comorbidity were more likely (ORadjusted=2.12, P<.001) to get a rehabilitation referral than patients without a comorbidity. Conclusions: Point of entry, age, sex, and preexisting comorbidities are associated with postconcussion care rehabilitation referral patterns. Improving concussion education dissemination across all entry points of a level 1 trauma center may standardize the postconcussion rehabilitation referral patterns, potentially improving the time to recovery from a concussion.

Using passive extraction of real-world data from eConsent, electronic patient reported outcomes (ePRO) and electronic health record (EHR) data loaded to an electronic data capture (EDC) system for a multi-center, prospective, observational study in diabetic patients.

As clinical trial complexity has increased over the past decade, using electronic methods to simplify recruitment and data management have been investigated. In this study, the Optum Digital Research Network (DRN) has demonstrated the use of electronic source (eSource) data to ease subject identification, recruitment burden, and used data extracted from electronic health records (EHR) to load to an electronic data capture (EDC) system. This study utilized electronic Informed Consent, electronic patient reported outcomes (SF-12) and included three sites using 3 different EHR systems. Patients with type 2 diabetes with an HbA1c ≥ 7.0% treated with metformin monotherapy were recruited. Endpoints consisted of changes in HbA1c, medications, and quality of life measures over 12-weeks of study participation using data from the subjects' eSources listed above. The study began in June of 2020 and the last patient last visit occurred in January of 2021. Forty-eight participants were consented and enrolled. HbA1c was repeated for 33 and ePRO was obtained from all subjects at baseline and 28 at 12-week follow-up. Using eSource data eliminated transcription errors. Medication changes, healthcare encounters and lab results were identified when they occurred in standard clinical practice from the EHR systems. Minimal data transformation and normalization was required. Data for this observational trial where clinical outcomes are available using lab results, diagnoses, and encounters may be achieved via direct access to eSources. This methodology was successful and could be expanded for larger trials and will significantly reduce staff effort and exemplified clinical research as a care option.

Lower extremity physeal fractures and post-traumatic surgical deformities; National Trauma Data Bank and institutional cohorts.

Background: Pediatric lower extremity physeal fractures carry a risk of developing deformities. Most epidemiological evidence is over 25 years old, single institution, and lacks follow-up, while recent studies report variable results. Understanding their epidemiology and deformity risk is important for patient counseling and follow-up. Methods: The National Trauma Data Bank (NTDB) from 2016 was queried to describe the modern epidemiology of physeal fractures. This was contrasted with our 10-year experience of surgically treated deformities. Basic descriptive statistics, Chi-square analysis, prevalence ratios and multivariable linear regression were used to interpret results. Results: The NTDB contained 22,048 non-physeal and 1,929 physeal fractures of the femur, tibia, and fibula. Physeal fracture prevalence rose after 8 years of age but decreased for girls 2 years sooner than boys. Salter Harris (SH) type 2 fractures predominated. Physeal fractures were more commonly associated with lower energy mechanisms of injury. Distal tibia fractures were more prevalent in the NTDB cohort, while distal femur and SH-1 fractures were more prevalent in the operative cohort. Over 10 years, only 52 (5.3%) of the deformity-correcting surgeries at our institution were for physeal fracture sequelae. Age at injury and intraarticular fractures were associated with shorter times from injury to deformity correction. Conclusion: Lower extremity physeal fractures are uncommon. Fracture pattern prevalence differs from an operative cohort. Proximal tibia physeal fractures appear to be an underappreciated source of deformity. The risk of developing deformity requiring operative intervention appears to be low and is generally treated within 2 years of initial injury.

Clinical and prognostic implications of high-sensitivity cardiac troponin T concentrations in type 2 non-ST elevation myocardial infarction.

BACKGROUND: While the clinical importance of cardiac troponin is well-known in type 1 myocardial infarction (MI), evidence on this topic in type 2 MI is limited. We assessed the clinical and prognostic implications of high-sensitivity cardiac troponin (hs-cTnT) concentrations in a large sample of patients with type 2 MI. METHODS: Retrospective registry-based cohort study (SWEDEHEART) including 4607 patients with type 2 MI and 43,405 patients with type 1 MI, used for comparisons. Patients with ST-elevation MI were excluded. Multivariable-adjusted regressions were applied to investigate the associations of hs-cTnT concentrations (highest measured value during each hospitalization) with clinical variables and prognosis during a median follow-up of up to 1.9 years. RESULTS: Hs-cTnT concentrations (median 264 [25th, 75th percentiles 112-654] ng/L) were significantly associated with various cardiovascular risk factors and comorbidities in type 2 non-ST elevation MI (NSTEMI) but only weakly with the underlying triggering condition. Most of these findings including the magnitude of hs-cTn release were similar to type 1 NSTEMI. Hs-cTnT (ln) independently predicted all-cause mortality (hazard ratio 1.13 [95% confidence interval 1.09-1.17]) and major adverse events (hazard ratio 1.13 [95% confidence interval 1.10-1.17]) in type 2 NSTEMI, similar as for type 1 NSTEMI according to interaction analysis. The associations of hs-cTnT (ln) with poor prognosis tended to be stronger in type 2 NSTEMI patients without known cardiovascular disease. CONCLUSIONS: Hs-cTnT concentrations independently predict adverse outcome in type 2 NSTEMI. The similarities to type 1 NSTEMI however, are striking and emphasize the difficulty to distinguish both MI types.

Incidence of hepatocellular carcinoma in a community-based Taiwanese population without chronic HBV/HCV infection.

BACKGROUND & AIMS: In addition to HBV/HCV causing hepatocellular carcinoma (HCC), other risk factors including obesity and alcohol drinking also increase risk. We describe the cumulative risk of HCC and mortality from liver-related disease by selected modifiable risk factors among a non-hepatitis virus-infected population. METHODS: For a community-based cohort, residents aged 30-65 years living in 7 townships in Taiwan were recruited, and have been followed up since 1991. A total of 18,541 individuals were seronegative for markers of chronic infection of HBV/HCV and with no history of HCC at baseline. New non-HBV/HCV HCC cases and liver-related deaths were ascertained through data linkage to the National Cancer Registry and Death Certification System from 1 January 1991 through 31 December 2017. RESULTS: There were 207 HCC cases and 215 liver-related deaths identified. The incidence rate of non-HBV/HCV HCC was 47.2 per 100,000 person-years. The mortality rate of liver-related death was 49.0 per 100,000 person-years. Baseline information on alcohol consumption, heart disease, diabetes, elevated aspartate aminotransferase, and alanine aminotransferase predicted higher risks of HCC, with hazard ratios (HRs) (95% CIs) of 1.7 (1.1-2.5), 2.2 (1.1-4.1), 1.9 (1.0-3.5), 1.7 (1.1-2.4), and 1.6 (1.0-2.4), respectively. The HRs (95% CIs) of liver-related death were 2.3 (1.6-3.2) for alcohol consumption, 1.4 (1.1-1.9) for BMI ≥25 kg/m2, 2.2 (1.4-3.3) for elevated aspartate aminotransferase, and 1.5 (1.0-2.4) for elevated alanine aminotransferase. The HR (95% CI) was 8.1 (3.6-18.5) for those with diabetes and elevated aspartate aminotransferase. CONCLUSIONS: Individuals with elevated liver enzymes are at high risk of liver disease. Prevention and treatment of diabetes and heart disease are critical for non-hepatitis B, non-hepatitis C (NonB/C)-HCC. LAY SUMMARY: We followed up individuals with no chronic HBV or HCV infection and described the risk of hepatocellular carcinoma (HCC, the most common form of primary liver cancer) and mortality from liver-related disease by modifiable risk factors. This study estimated the incidence rate of HCC by selected lifestyle risk factors and chronic diseases conditions. Alcohol consumption, heart disease, diabetes, and abnormal blood liver function tests showed a strong association with HCC risk and mortality.

Trends of utilization and perioperative outcomes of robotic and video-assisted thoracoscopic surgery in patients with lung cancer undergoing minimally invasive resection in the United States.

Objective: The objective of this study was to evaluate utilization and perioperative outcomes of video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS) for lung cancer in the United States using a nationally representative database. Methods: Hospital admissions for lobectomy or sublobar resection (segmentectomy or wedge resection) using VATS or RATS in patients with nonmetastatic lung cancer from October 2015 through December 2018 in the National Inpatient Sample were studied. Patient and hospital characteristics, perioperative complications and mortality, length of stay (LOS), and total hospital cost were compared. Logistic regression was used to assess whether the surgical approach was independently associated with adverse outcomes. Results: There were 83,105 patients who had VATS (n = 65,375) or RATS (n = 17,710) for lobectomy (72.7% VATS) or sublobar resection (84.2% VATS). Utilization of RATS for lobectomy and sublobar resection increased from 19.2% to 34% and 7.3% to 22%, respectively. Mortality, LOS, and conversion rates were comparable. The cost was higher for RATS (P <.01). Multivariate analyses showed comparable RATS and VATS complications with no independent association between the minimally invasive surgery approach used and adverse surgical outcomes, except for a decreased risk of pneumonia with RATS, relative to VATS sublobar resection (P <.01). Thoracic complication rates and LOS decreased after RATS lobectomy in 2018, compared with previous years (P <.005). Conclusions: The utilization of robotic-assisted lung resection for cancer has increased in the United States between 2015 and 2018 for sublobar resection and lobectomy. In adjusted regression analysis, compared with VATS, patients who underwent RATS had similar complication rates and LOS. The robotic approach was associated with increased total hospital cost. LOS and thoracic complication rates trended down after RATS lobectomy.

Use of Indoor Tanning Diagnosis Codes in Claims Data.

The International Classification of Diseases: 10th Revision (effective from October 2015) included indoor tanning diagnosis codes for the first time. The majority of data on indoor tanning is self-reported. We used a large claims dataset to investigate the patients and settings in which indoor tanning International Classification of Diseases: 10th Revision codes are being used. We included encounters with the International Classification of Diseases: 10th Revision indoor tanning codes in Truven Health MarketScan data 2016-2018, which contain deidentified commercial insurance claims data for approximately 43 million patients. We used descriptive statistics to evaluate patient and encounter characteristics and normalized results using outpatient dermatology encounters. A total of 4,550 encounters were identified, 99.0% of which were outpatient, and 72.3% were with dermatology. Patients were majority female (85.0%) with ages ranging from 7 to 93. The Midwest region had the most indoor tanning encounters. Destruction of a premalignant lesion was performed in 15.1%, and biopsies were performed in 18.4% of encounters, suggesting that encounters may have been for skin cancer surveillance. Increased usage of indoor tanning International Classification of Diseases: 10th Revision codes in the coming years may strengthen the indoor tanning literature. Claims data are a potential tool to better understand patients who have a history of exposure to indoor tanning and their associated risk factors, comorbidities, behaviors, and healthcare utilization.

A data-driven methodology towards evaluating the potential of drug repurposing hypotheses.

Drug repurposing has become a widely used strategy to accelerate the process of finding treatments. While classical de novo drug development involves high costs, risks, and time-consuming paths, drug repurposing allows to reuse already-existing and approved drugs for new indications. Numerous research has been carried out in this field, both in vitro and in silico. Computational drug repurposing methods make use of modern heterogeneous biomedical data to identify and prioritize new indications for old drugs. In the current paper, we present a new complete methodology to evaluate new potentially repurposable drugs based on disease-gene and disease-phenotype associations, identifying significant differences between repurposing and non-repurposing data. We have collected a set of known successful drug repurposing case studies from the literature and we have analysed their dissimilarities with other biomedical data not necessarily participating in repurposing processes. The information used has been obtained from the DISNET platform. We have performed three analyses (at the genetical, phenotypical, and categorization levels), to conclude that there is a statistically significant difference between actual repurposing-related information and non-repurposing data. The insights obtained could be relevant when suggesting new potential drug repurposing hypotheses.

Risk of Atrial Fibrillation According to Cancer Type: A Nationwide Population-Based Study.

BACKGROUND: Patients with cancer have an increased risk of atrial fibrillation (AF). However, there is a paucity of information regarding the association between cancer type and risk of AF. OBJECTIVES: This study sought to evaluate the risk of AF according to the type of cancer. METHODS: We enrolled 816,811 patients who were diagnosed with cancer from the Korean National Health Insurance Service database between 2009 and 2016. Age- and sex-matched noncancer control subjects (1:2; n = 1,633,663) were also selected. Newly diagnosed AF was identified based on the type of cancer. RESULTS: During a median follow-up of 4.5 years, AF was newly diagnosed in 25,356 patients with cancer (6.6 per 1,000 person-years). In multivariable Fine and Gray's regression analysis, cancer was an independent risk factor for incident AF (adjusted subdistribution hazard ratio [aHR]: 1.63; 95% confidence interval [CI]: 1.61 to 1.66). Multiple myeloma showed a higher association with incident AF (aHR: 3.34; 95% CI: 2.98 to 3.75). Esophageal cancer showed the highest risk among solid cancers (aHR: 2.69; 95% CI: 2.45 to 2.95), and stomach cancer showed the lowest association with AF risk (aHR: 1.27; 95% CI 1.23 to 1.32). CONCLUSIONS: Although patients with cancer were found to have a higher risk of AF, the impact on AF development varied by cancer type.