Hydrology, vegetation, and soil properties as key drivers of soil organic carbon in coastal wetlands: A high-resolution study.

Coastal wetlands are important blue carbon ecosystems that play a significant role in the global carbon cycle. However, there is insufficient understanding of the variations in soil organic carbon (SOC) stocks and the mechanisms driving these ecosystems. Here we analyze a comprehensive multi-source dataset of SOC in topsoil (0-20 cm) and subsoil (20-100 cm) across 31 coastal wetlands in China to identify the factors influencing their distribution. Structural equation models (SEMs) reveal that hydrology has the greatest overall effect on SOC in both soil layers, followed by vegetation, soil properties, and climate. Notably, the mechanisms driving SOC density differ between the two layers. In topsoil, vegetation type and productivity directly impact carbon density as primary sources of carbon input, while hydrology, primarily through seawater salinity, exerts the largest indirect influence. Conversely, in subsoil, hydrology has the strongest direct effect on SOC, with seawater salinity also influencing SOC indirectly through soil and vegetation mediation. Soil properties, particularly pH, negatively affect carbon accumulation, while climate influences SOC indirectly via its effects on vegetation and soil, with a diminishing impact at greater depths. Using Random Forest, we generate high-resolution maps (90 m × 90 m) of topsoil and subsoil carbon density (R 2 of 0.53 and 0.62, respectively), providing the most detailed spatial distribution of SOC in Chinese coastal wetlands to date. Based on these maps, we estimate that SOC storage to a depth of 1 m in Chinese coastal wetlands totals 74.58 ± 3.85 Tg C, with subsoil carbon storage being 2.5 times greater than that in topsoil. These findings provide important insights into mechanism on driving spatial pattern of blue carbon and effective ways to assess carbon status on a national scale, thus contributing to the advancement of global blue carbon monitoring and management.

Two-Centre Retrospective Analysis on Selective Sensory Denervation of Shoulder Joint by Means of Cooled Radiofrequency in Chronic Shoulder Pain.

Purpose: Radiofrequency ablation has been used to treat chronic shoulder pain with mixed results. Thanks to recent anatomical studies, the precise location of articular branches of the suprascapular, lateropectoral and axillary nerves has been determined. Cooled radiofrequency is a neuroablative modality of treatment which has been demonstrated as efficient in different anatomical locations, and targeting the aforementioned nerves could result in a complete and efficient denervation of the shoulder. The aim of this study is to assess the efficacy of a fluoroscopic guided cooled radiofrequency technique for chronic shoulder pain. Patients and Methods: This is a retrospective observational study performed in two hospital in Wales and Italy (Wrexham NHS trust and Iseo Hospital). Forty-four patients were treated between December 2019 and January 2023. Follow-up was provided at 1-, 6- and 12-months post-procedure. Pain intensity was measured with a 0-10-point Numerical Rating Scale (NRS), and was assessed at rest and during movement. Disability was assessed with the Oxford Shoulder Score (OSS). All patients were treated with cooled radiofrequency under fluoroscopic guidance targeting the articular branches of the suprascapular, axillary and lateropectoral nerves. Results: In the 44 patients treated, the mean NRS significantly decreased at all follow ups, pain relief of >50% was obtained in 70.4%, 61% and 51% of the patients at 1.6 and 12 month follow-ups, respectively. Disability improved significantly, with a mean OSS at 12 months follow up of 30 ±17.5, compared to 15 ± 3 at baseline. Medication intake (non-steroidal anti-inflammatory drugs (NSAIDS) and/or opioids) significantly decreased at all follow ups. Conclusion: Cooled radiofrequency denervation can be an effective procedure to manage chronic shoulder pain, providing sustained pain relief and functional improvement in more than 50% of the patients.

Single Institutional Cross-Sectional Phone Survey Study: Evaluation of Causes for Loss to Follow-up After Spinal Cord Stimulator Implantation.

BACKGROUND: Spinal cord stimulation (SCS) is often an option of last resort for patients with post-laminectomy syndrome or an alternative option for patients with complex regional pain syndrome, chronic nonsurgical low back pain, or painful diabetic peripheral neuropathy when conservative management has failed. Although SCS is a helpful option, it is not without complications that can frequently lead to explantation of the SCS device and dissatisfaction with the treatment. Furthermore, as with any technology, SCS has potential issues that may lead to patient frustration and ultimately result in patient noncompliance and lack of follow-up visits. OBJECTIVES: The goals of this study are to explore the magnitude of and reasons for patient loss to follow-up after SCS device implantation. STUDY DESIGN: A cross-sectional phone survey. SETTING: A tertiary-care academic hospital. METHODS: A cross-sectional phone survey was performed on 49 patients who were deemed lost to follow-up when they did not return to the clinic one month after being implanted with permanent SCS devices at Beth Israel Deaconess Medical Center. Patients were administered an institutional review board-approved questionnaire exploring their reasons for not returning to the clinic. RESULTS: Over a 5-year period, 257 patients underwent full implantation of an SCS device. Of the 49 patients lost to follow-up, 24 were able to be contacted, and they completed the questionnaire. Twenty of the patients continued to use the SCS device but were lost to follow-up for the following reasons: 58% (14/24) due to improvement of pain, 13% (3/24) due to minimal improvement in pain control, 4% (1/24) due to other urgent health conditions, and 8% (2/24) due to patient noncompliance and missing follow-up appointments (4/24). Four patients discontinued using the SCS device after an average of 1.5 years +/- one year, 12% (3/24) due to inadequate pain control and 4% (1/24) due to inability to recharge the device (1/24). Of these patients, 2 of the 4 contacted their SCS representatives for help with troubleshooting prior to discontinuation. None of the patients was explanted. LIMITATIONS: The main limitation of this study was the incompletion rate, which was 51.0% (25 out of 49 patients). CONCLUSIONS: This paper, the first cross-sectional study of loss to follow-up among patients who are implanted with SCS devices, identifies that up to 19% of patients are quickly lost to follow-up after implantation. Only half of the patients in this study could be reached, with most successfully using their device for meaningful pain control, but a substantial number of patients likely required additional device optimization for pain relief.

Impact of Aficamten on Disease and Symptom Burden in Obstructive Hypertrophic Cardiomyopathy: Results From SEQUOIA-HCM.

BACKGROUND: Aficamten is a cardiac myosin inhibitor that mitigates left ventricular outflow gradients in obstructive hypertrophic cardiomyopathy (oHCM). The clinical efficacy of aficamten across multiple outcome domains in oHCM has not been fully defined. OBJECTIVES: This responder analysis from the SEQUOIA-HCM (Phase 3 Trial to Evaluate the Efficacy and Safety of Aficamten Compared to Placebo in Adults With Symptomatic oHCM) trial characterizes the clinical impact of aficamten. METHODS: Patients who were symptomatic of oHCM were randomized to aficamten (n = 142) or placebo (n = 140) daily for 24 weeks. Outcomes assessed included the proportion of patients with complete hemodynamic response (rest and Valsalva gradient <30 mm Hg and <50 mm Hg, respectively), relief in limiting symptoms (≥1 improvement in NYHA functional class and/or ≥10-point change in Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score), enhanced exercise capacity (≥1.5 mL/kg/min change in peak oxygen uptake), and ≥50% reduction in N-terminal pro-B-type natriuretic peptide. Eligibility for septal reduction therapy was also evaluated. RESULTS: At 24 weeks, patients treated with aficamten vs placebo showed significant improvement in limiting symptoms (71% vs 42%), were more likely to have complete hemodynamic response (68% vs 7%), demonstrated enhanced exercise capacity (47% vs 24%), and showed a decrease ≥50% in N-terminal pro-B-type natriuretic peptide (84% vs 8%) (P ≤ 0.002 for all). An improvement in ≥1 of these outcome measures was achieved in 97% of patients treated with aficamten (vs 59% placebo), including 23% on aficamten who achieved all 4 outcomes compared with none in placebo. Among 32 patients receiving aficamten and 29 patients receiving placebo who were eligible for septal reduction therapy, 28 (88%) from the aficamten group were no longer eligible at 24 weeks compared with 15 (52%) from the placebo group (P = 0.002). CONCLUSIONS: Treatment with aficamten was associated with substantial improvements across a broad range of clinically relevant efficacy measures. These results underscore the wide-ranging potential of aficamten for treatment of patients with symptomatic oHCM (Phase 3 Trial to Evaluate the Efficacy and Safety of Aficamten Compared to Placebo in Adults with oHCM [SEQUOIA-HCM]; NCT05186818).

Effects of COVID-19 on Irish general practice activity from 2019 to 2021: a retrospective analysis of 500,000 consultations using electronic medical record data.

BACKGROUND: General practice (GP) is crucial to primary care delivery in the Republic of Ireland and is almost fully computerised. General practice teams were the first point of contact for much COVID-19-related care and there were concerns routine healthcare activities could be disrupted due to COVID-19 and related restrictions. AIMS: The study aimed to assess effects of the pandemic on GP activity through analysis of electronic medical record data from general practice clinics in the Irish Midwest. METHODS: A retrospective, descriptive study of electronic medical record data relating to patient record updates, appointments and medications prescribed across 10 GP clinics over the period 2019-2021 inclusive. RESULTS: Data relating to 1.18 million record transactions for 32 k patients were analysed. Over 500 k appointments were examined, and demographic trends presented. Overall appointment and prescribing activity increased over the study period, while a dip was observed immediately after the pandemic's arrival in March 2020. Delivery of non-childhood immunisations increased sixfold as a result of COVID-19, childhood immunisation activity was maintained, while cervical smears decreased in 2020 as the screening programme was halted. A quarter of consultations in 2020 and 2021 were teleconsultations, and these were more commonplace for younger patients. CONCLUSIONS: General practice responded robustly to the pandemic by taking on additional activities while maintaining routine services where possible. The shift to teleconsulting was a significant change in workflow. Analysing routinely collected electronic medical record data can provide valuable insights for service planning, and access to these insights would be beneficial for future pandemic responses.

Research Priorities in Pediatric Asthma Morbidity: Addressing the Impacts of Systemic Racism on Children with Asthma in the United States. An Official American Thoracic Society Workshop Report.

Background: In the United States, Black and Latino children with asthma are more likely than White children with asthma to require emergency department visits or hospitalizations because of an asthma exacerbation. Although many cite patient-level socioeconomic status and access to health care as primary drivers of disparities, there is an emerging focus on a major root cause of disparities-systemic racism. Current conceptual models of asthma disparities depict the historical and current effects of systemic racism as the foundation for unequal exposures to social determinants of health, environmental exposures, epigenetic factors, and differential healthcare access and quality. These ultimately lead to biologic changes over the life course resulting in asthma morbidity and mortality. Methods: At the 2022 American Thoracic Society International Conference, a diverse panel of experts was assembled to identify gaps and opportunities to address systemic racism in childhood asthma research. Panelists found that to examine and address the impacts of systemic racism on children with asthma, researchers and medical systems that support biomedical research will need to 1) address the current gaps in our understanding of how to conceptualize and characterize the impacts of systemic racism on child health, 2) design research studies that leverage diverse disciplines and engage the communities affected by systemic racism in identifying and designing studies to evaluate interventions that address the racialized system that contributes to disparities in asthma health outcomes, and 3) address funding mechanisms and institutional research practices that will be needed to promote antiracism practices in research and its dissemination. Results: A thorough literature review and expert opinion discussion demonstrated that there are few studies in childhood asthma that identify systemic racism as a root cause of many of the disparities seen in children with asthma. Community engagement and participation in research studies is essential to design interventions to address the racialized system in which patients and families live. Dissemination and implementation studies with an equity lens will provide the multilevel evaluations required to understand the impacts of interventions to address systemic racism and the downstream impacts. To address the impacts of systemic racism and childhood asthma, there needs to be increased training for research teams, funding for studies addressing research that evaluates the impacts of racism, funding for diverse and multidisciplinary research teams including community members, and institutional and financial support of advocating for policy changes based on study findings. Conclusions: Innovative study design, new tools to identify the impacts of systemic racism, community engagement, and improved infrastructure and funding are all needed to support research that will address impacts of systemic racism on childhood asthma outcomes.

Target trial emulation using cohort studies: estimating the effect of antihypertensive medication initiation on incident dementia.

BACKGROUND: Observational studies link high midlife systolic blood pressure to increased dementia risk. However, synthesis of evidence from randomized controlled trials has not definitively demonstrated that antihypertensive medication use reduces dementia risk. Here, we emulate target trials of antihypertensive medication initiation on incident dementia using three cohort studies, with attention to potential violations of necessary assumptions. METHODS: We emulated trials of antihypertensive medication initiation on incident dementia using data from the Atherosclerosis Risk in Communities (ARIC) study, Cardiovascular Health Study (CHS), and Health and Retirement Study (HRS). We used data-driven methods to restrict participants to initiators and non-initiators with overlap in propensity scores and positive control outcomes to look for violations of positivity and exchangeability assumptions. RESULTS: Analyses were limited by the small number of cohort participants who met eligibility criteria. Associations between antihypertensive medication initiation and incident dementia were inconsistent and imprecise (ARIC: HR = 0.30 [0.05, 1.93]; CHS: HR = 0.66 [0.27, 1.64]; HRS: HR = 1.09 [0.75, 1.59]). More stringent propensity score restriction had little effect on findings. Sensitivity analyses using a positive control outcome unexpectedly suggested antihypertensive medication initiation increased risk of coronary heart disease in all three samples. CONCLUSIONS: Positive control outcome analyses suggested substantial residual confounding in effect estimates from our target trials, precluding conclusions about the impact of antihypertensive medication initiation on dementia risk through target trial emulation. Formalized processes for identifying violations of necessary assumptions will strengthen confidence in target trial emulation and avoid inappropriate confidence in emulated trial results.

Scalable incident detection via natural language processing and probabilistic language models.

Post marketing safety surveillance depends in part on the ability to detect concerning clinical events at scale. Spontaneous reporting might be an effective component of safety surveillance, but it requires awareness and understanding among healthcare professionals to achieve its potential. Reliance on readily available structured data such as diagnostic codes risks under-coding and imprecision. Clinical textual data might bridge these gaps, and natural language processing (NLP) has been shown to aid in scalable phenotyping across healthcare records in multiple clinical domains. In this study, we developed and validated a novel incident phenotyping approach using unstructured clinical textual data agnostic to Electronic Health Record (EHR) and note type. It's based on a published, validated approach (PheRe) used to ascertain social determinants of health and suicidality across entire healthcare records. To demonstrate generalizability, we validated this approach on two separate phenotypes that share common challenges with respect to accurate ascertainment: (1) suicide attempt; (2) sleep-related behaviors. With samples of 89,428 records and 35,863 records for suicide attempt and sleep-related behaviors, respectively, we conducted silver standard (diagnostic coding) and gold standard (manual chart review) validation. We showed Area Under the Precision-Recall Curve of ~ 0.77 (95% CI 0.75-0.78) for suicide attempt and AUPR ~ 0.31 (95% CI 0.28-0.34) for sleep-related behaviors. We also evaluated performance by coded race and demonstrated differences in performance by race differed across phenotypes. Scalable phenotyping models, like most healthcare AI, require algorithmovigilance and debiasing prior to implementation.

Artificial intelligence and machine learning applications for cultured meat.

Cultured meat has the potential to provide a complementary meat industry with reduced environmental, ethical, and health impacts. However, major technological challenges remain which require time-and resource-intensive research and development efforts. Machine learning has the potential to accelerate cultured meat technology by streamlining experiments, predicting optimal results, and reducing experimentation time and resources. However, the use of machine learning in cultured meat is in its infancy. This review covers the work available to date on the use of machine learning in cultured meat and explores future possibilities. We address four major areas of cultured meat research and development: establishing cell lines, cell culture media design, microscopy and image analysis, and bioprocessing and food processing optimization. In addition, we have included a survey of datasets relevant to CM research. This review aims to provide the foundation necessary for both cultured meat and machine learning scientists to identify research opportunities at the intersection between cultured meat and machine learning.

Invasive Candidiasis in Pediatric Hematologic Malignancy: Increased Risk of Dissemination With Candida tropicalis.

BACKGROUND: Candida species are the most common cause of invasive fungal disease, and children with hematologic malignancy are at increased risk. Non-albicans Candida (NAC) now account for more than half of all invasive candidiasis (IC) and carry a worse prognosis. We aimed to compare the epidemiology, risk factors, organ dissemination, biomarkers and outcomes in IC based on the species implicated and evaluate trends in antifungal resistance over time. METHODS: Patients 0-18 years of age with hematologic malignancy and IC at 2 centers were included. Fifty-three patients from 2011 to 2022 were identified. Information related to demographics, host and risk factors, Candida species and antifungal susceptibilities, treatment and outcomes was collected via retrospective chart review. Data were analyzed at the species level. RESULTS: The incidence rate of IC was 29 per 1000 patients with leukemia and lymphoma. The median time to infection from diagnosis of malignancy was 38 days. Candida tropicalis (n = 17; 30%) was the most identified species followed by Candida albicans (n = 14; 25%). Patients with C. tropicalis infection were more likely to have dissemination to the eyes (P = 0.035), spleen (P = 0.001) and skin (P = 0.003) than patients with C. albicans or other NAC. Of the 34 patients who underwent dilated retinal examination, 24% (n = 8) had evidence of intraocular candidiasis. Seven of the 8 patients with intraocular disease had prolonged candidemia (3 or more days; P = 0.003). The 12-week crude mortality rate was 16.9%. CONCLUSIONS: NAC, specifically C. tropicalis, accounted for most of the IC in children with hematological malignancies. Screening for intraocular candidiasis continues to play an important role in patients with IC, and future studies are needed to determine if screening can be limited to patients with select risk factors.

Surgically treated brain metastases of gastric origin: a case series and systematic review.

BACKGROUND: The incidence of brain metastases from gastric origin is less than 1% in those with primary gastric cancer. Given this exceedingly rare presentation, there is limited literature describing the outcomes of their neurosurgical treatment. We wish to identify the role of surgical intervention for brain lesions in metastatic gastric cancer via institutional case series and systematic review. METHODS: This study was divided into two sections: (1) a retrospective, single-center patient series assessing outcomes of neurosurgical treatment modalities in patients with malignancy arising from the stomach with brain metastases and (2) a systematic review abiding by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines between the years of 1980 and 2021 assessing outcomes of patients with primary stomach cancer with metastasis to the brain treated with surgery. RESULTS: Four patients with gastric brain metastases were treated at our institution, and 16 patients were identified in literature from a total of 9 studies and case reports. The mean age at the time of stomach cancer diagnosis was 57.3 years, with a mean time to brain metastases of 14.8 months. The primary gastric cancer was most commonly adenocarcinoma (70%). Patients most presented with single lesions (58%) and were treated with multimodal neurosurgical intervention (65%). Mean overall survival following neurosurgery was 12.45 months. CONCLUSION: Brain metastases from gastric origin are extremely rare. Surgical resection of metastatic brain lesions should be considered as a treatment modality in surgical candidates. Future attention should be given to the effect of adjuvant therapies and surgical techniques on survival and quality of life.

Strategic Implementation of a New Robotic Mitral Repair Program: Early Experience and Outcomes.

BACKGROUND: Despite numerous reported benefits of robotic mitral repair, the absolute number of procedures performed remain low in part to uncertainties about the necessary steps to launch a program. In this report, we describe our early outcomes and strategy with launching a successful new robotic mitral repair program. METHODS: Our multimodal strategic plan emphasized team education, hands-on technical preparation, stepwise advancement, and careful patient selection. Consultant service analytics and team debriefings allowed for iterative improvements. RESULTS: Between March 2022 through February 2024, 50 patients underwent robotic mitral repair at our institution. Average age at time of operation was 62 with an STS risk score of 0.58. Successful repairs were performed in 98% of patients. There was one conversion to sternotomy. There were no deaths and minimal perioperative morbidity. On both predischarge and follow-up echocardiography, no patients had greater than mild mitral regurgitation. CONCLUSIONS: Our work provides a model for establishing a successful robotic mitral program. An upfront emphasis on team education, careful preparation, proper patient selection, and feedback-driven improvements can accelerate the attainment of standards set by high-volume centers.

Baseline Neck Disability Index and Patient-Reported Outcomes Measurement Information System Physical Function Predict Postoperative Return to Normal in Cervical Spine Surgery.

BACKGROUND: Recent studies assessing the importance of various preoperative factors on postoperative outcomes following spine surgery have uncovered several important variables that influence subjective and objective outcomes following cervical spine surgery, but it is still unclear which patients are most likely to benefit from operative management. PURPOSE: The objective of this study was to assess whether preoperative patient-reported outcome measures (PROMs) can be used to predict which patients achieve "normal" levels of pain and function after surgery. STUDY DESIGN: This was a prospective cohort study. PATIENT SAMPLE: This study included all adult patients undergoing cervical spine surgery by 1 of 7 senior spine surgeons at our institution between 2016 and 2018. Of the 164 patients who were eligible for 6-month follow-up at the time that study data were collected, 139 had available follow-up data and were included in our analysis. OUTCOMES MEASURES: Patients completed the Neck Disability Index (NDI) as well as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference computer adaptive tests preoperatively and at 6 months postoperatively. METHODS: Patients who achieved postoperative patient-acceptable symptom state (PASS) for NDI (≤17) and the normative mean (50) for PROMIS were identified. The relationship between preoperative PROMs and the probability of achieving PASS and the normative mean was assessed. RESULTS: One hundred thirty-nine patients met inclusion criteria with diagnoses of myelopathy (n = 36), radiculopathy (n = 48), and myeloradiculopathy (n = 49). For NDI, a 1-point worsening in the preoperative score resulted in an OR of achieving PASS of 0.96 (P < 0.001) in the overall population. This association held true for patients with radiculopathy (OR 0.96; P = 0.022) but not myelopathy (OR 0.98; P = 0.35). For PROMIS PF, a 1-point improvement in the preoperative score resulted in an OR of achieving the normative mean of 1.10 (P < 0.001). This association held true for patients with radiculopathy (OR 1.14; P = 0.033) but did not reach statistical significance for patients with myelopathy (OR 1.03; P = 0.515). CONCLUSIONS: Preoperative PROMs can predict postoperative benefit for patients undergoing cervical spine surgery, with worse baseline function associated with a lower likelihood of attaining PASS for NDI and the normative mean for PROMIS PF, especially for patients with radiculopathy. CLINICAL RELEVANCE: Baseline symptoms and function, including myelopathy or radiculopathy-dominant symptoms and preoperative PROMs, may predict postoperative outcomes.

The FDA Sentinel Real World Evidence Data Enterprise (RWE-DE).

PURPOSE: The US Food and Drug Administration's Sentinel Innovation Center aimed to establish a query-ready, quality-checked distributed data network containing electronic health records (EHRs) linked with insurance claims data for at least 10 million individuals to expand the utility of real-world data for regulatory decision-making. METHODS: In this report, we describe the resulting network, the Real-World Evidence Data Enterprise (RWE-DE), including data from two commercial EHR-claims linked assets collectively termed the Commercial Network covering 21 million lives, and four academic partner institutions collectively termed the Development Network covering 4.5 million lives. RESULTS: We discuss provenance and completeness of the data converted in the Sentinel Common Data Model (SCDM), describe patient populations, and report on EHR-claims linkage characterization for all contributing data sources. Further, we introduce a standardized process to store free-text notes in the Development Network for efficient retrieval as needed. CONCLUSIONS: Finally, we outline typical use cases for the RWE-DE where it can broaden the reach of the types of questions that can be addressed by the Sentinel system.

DNA polymerase ζ is a robust reverse transcriptase.

Cell biology and genetic studies have demonstrated that DNA double strand break (DSB) repair can be performed using an RNA transcript that spans the site of the DNA break as a template for repair. This type of DSB repair requires a reverse transcriptase to convert an RNA sequence into DNA to facilitate repair of the break, rather than copying from a DNA template as in canonical DSB repair. Translesion synthesis (TLS) DNA polymerases (Pol) are often more promiscuous than DNA Pols, raising the notion that reverse transcription could be performed by a TLS Pol. Indeed, several studies have demonstrated that human Pol η has reverse transcriptase activity, while others have suggested that the yeast TLS Pol ζ is involved. Here, we purify all seven known nuclear DNA Pols of Saccharomyces cerevisiae and compare their reverse transcriptase activities. The comparison shows that Pol ζ far surpasses Pol η and all other DNA Pols in reverse transcriptase activity. We find that Pol ζ reverse transcriptase activity is not affected by RPA or RFC/PCNA and acts distributively to make DNA complementary to an RNA template strand. Consistent with prior S. cerevisiae studies performed in vivo , we propose that Pol ζ is the major DNA Pol that functions in the RNA templated DSB repair pathway.

Development of a Novel Society of Thoracic Surgeons Aortic Surgery Mortality and Morbidity Risk Model.

BACKGROUND: The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD) was expanded in 2017 to include more granular detail on thoracic aortic surgeries. We describe the first validated risk model in thoracic aortic surgery from the STS-ACSD. METHODS: The study population consisted of patients undergoing non-emergent isolated ascending aortic aneurysm repair using open or clamped distal anastomoses, including those requiring aortic root or valve replacement. Model outcomes included operative mortality, 30-day major morbidity (cardiac reoperation, deep sternal wound infection, stroke, prolonged ventilation, renal failure) and a composite of both. To select the predictors, univariate associations and clinical face validity of models were examined. Models were evaluated by their ability to distinguish between patients with and without specific outcomes (discrimination) and their predictive accuracy (calibration). RESULTS: Between 2017 and 2021, 24,051 eligible patients underwent ascending aortic aneurysm surgery at 905 hospitals. Procedures included 8,913 aortic root replacements, 2,135 valve-sparing root replacements, 7,545 ascending aortic replacements with AVR, and 5,458 ascending aortic replacements. Circulatory arrest was performed in 7,316 (30.4%) of cases. Operative mortality was 1.9%, and 12.2% of patients experienced major morbidity including 2.4% incidence of stroke. The adjusted C-statistics for the model were 0.74, 0.67 and 0.67 for mortality, morbidity and the composite, respectively. Previous stroke and circulatory arrest were associated with new stroke. Genetic aortopathy was associated with less mortality. CONCLUSIONS: A new STS-ACSD risk model to predict mortality and morbidity after ascending aneurysm surgery has been developed, and predictors of better and worse outcomes have been identified.

Minimally Invasive CABG Is The Future: Pro.

Coronary artery bypass grafting (CABG) remains one of the most commonly performed operations worldwide. However, most CABG operations performed today are as invasive -apart from saphenous vein harvesting- as they were 50 years ago. While heart valve operations have become less invasive, CABG faces formidable challenges in doing so. Valve surgery requires a single surgical exposure to the valve intervened on, but less invasive CABG necessitates multiple surgical exposures to harvest internal thoracic artery conduits, source their inflow plus that of other grafts, and expose each coronary target to be grafted -including anterior, lateral, posterior, and inferior vessels. In this article, we rationalize why we believe that conventional CABG remains unduly invasive, associated with morbidity and prolonged recovery, and why less invasive CABG in its many forms, which we describe, represents a safe, practical, diffusible, and less invasive alternative to sternotomy CABG. Centers of excellence in coronary artery surgery should dedicate resources and expertise to developing high-quality, safe, durable, and advanced forms of lesser invasive CABG.

Effect of automated identification of antimicrobial stewardship opportunities for suspected urinary tract infections.

Objective: We aimed to determine whether automated identification of antibiotic targeting suspected urinary tract infection (UTI) shortened the time to antimicrobial stewardship (AS) intervention. Design: Retrospective before-and-after study. Setting: Tertiary and quaternary care academic medical center. Patients: Emergency department (ED) or admitted adult patients meeting best practice alert (BPA) criteria during pre- and post-BPA periods. Methods: We developed a BPA to alert AS pharmacists of potential ASB triggered by the following criteria: ED or admitted status, antibiotic order with genitourinary indication, and a preceding urinalysis with ≤ 10 WBC/hpf. We evaluated the median time from antibiotic order to AS intervention and overall percent of UTI-related interventions among patients in pre-BPA (01/2020-12/2020) and post-BPA (04/15/2021-04/30/2022) periods. Results: 774 antibiotic orders met inclusion criteria: 355 in the pre- and 419 in the post-BPA group. 43 (35 UTI-related) pre-BPA and 117 (94 UTI-related) post-BPA interventions were documented. The median time to intervention was 28 hours (IQR 18-65) in the pre-BPA group compared to 16 hours (IQR 2-34) in the post-BPA group (P < 0.01). Despite absent pyuria, there were six cases with gram-negative bacteremia presumably from a urinary source. Conclusions: Automated identification of antibiotics targeting UTI without pyuria on urinalysis reduced the time to stewardship intervention and increased the rate of UTI-specific interventions. Clinical decision support aided in the efficiency of AS review and syndrome-targeted impact, but cases still required AS clinical review.