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Blood transfusion can have detrimental effects on the pulmonary system, leading to lung injury and respiratory decompensation with subsequent increased morbidity and mortality in surgical and critically ill patients. How much of this effect is carried from a lung donor to transplant recipient is not fully understood, raising questions regarding transplant suitability of lungs from transfused donors.United Network for Organ Sharing data were reviewed. Lung transplants from adult donors and known donor transfusion status were included; multiorgan transplants and retransplants were excluded. Recipient mortality was evaluated based on donor and recipient characteristics using a Kaplan-Meier survival estimate, Cox proportional hazards, and logistic regression models. We further assessed whether recipient mortality risk modified the donor transfusion effect.From March 1996 to June 2017, 20,294 transplants were identified. Outcome analysis based on transfusion status showed nonsignificant difference in 1-year mortality (P = .214). Ninety-day recipient mortality was significantly higher with transfusion of10 units (U) vs 1-10 U or no transfusion (8.5%, 6.1%, and 6.0%, respectively, P = .005). Multivariable analysis showed increased 90-day mortality with transfusion of10 U compared to no transfusion (odds ratio 1.62, P.001), whereas 1-10 U showed no difference (odds ratio 1.07, P = .390). When stratified by recipient transplant risk, transfusion of10 U was associated with increased mortality even with the lowest-risk recipients, while transfusion of 1-10 U showed no mortality increase even in the highest-risk recipients.Donor transfusion of10 U of blood was associated with increased 90-day recipient mortality even in low-risk transplants. This risk should be considered when evaluating donor lungs.

Purpose The intravitreal injection (IVI) of pharmacologic agents is the most commonly performed ocular procedure and is associated with a host of complications. Most IVI-related complications data are derived from randomized controlled clinical trials, which report a high adverse event rate. The nature of these protocol-driven trials limit their applicability to the diverse circumstances seen in routine clinical practice. The goal of this study was to determine the prevalence of patient-reported IVI-related complications, their risk factors, and the manner in which patients sought treatment at a tertiary eye care center. Design Retrospective, institutional review board–approved study. Participants Forty-four thousand seven hundred thirty-four injections in 5318 unique patients at the Cleveland Clinic Cole Eye Institute from 2012 through 2016. Methods Intravitreal injection. Main Outcome Measures Complication occurrence within 15 days of injection. Results From 2012 through 2016, a total of 44734 injections were performed in 5318 unique patients. Overall, complication rates were low, representing 1.9% of all injections, with 1031 unique complications in 685 patients (12.9%). The most common minor complications, or those not requiring intervention, were irritation (n = 312) and subconjunctival hemorrhage (n = 284). The most common serious complications, or those requiring intervention, were corneal abrasion (n = 46) and iritis (n = 31). Most complications (66%) were managed adequately by a telephone or Epic (Epic Systems Corp., Verona, WI) electronic message encounter only. Importantly, no injection protocol parameter, such as type of anesthesia, preparation, or post-injection medication, increased the risk of a complication. However, a patient’s gender, age, number of previous injections, and provider strongly influenced the risk of patient-reported complications. Conclusions Overall, complication rates seen in routine clinical practice were low compared with clinical trial reporting. Providers should feel confident in the safety and administration of IVI during times when follow-up office visits and resources may be limited. When performing an IVI, factors such as a patient’s gender, age, number of previous injections, and provider must be taken into account to ensure the best possible outcomes.

Objectives Determine whether D-dimer concentration in the absence of imaging can differentiate patients that require anti-coagulation from patients who do not require anti-coagulation. Methods Data was obtained retrospectively from 366 hemodynamically stable adult ED patients with suspected pulmonary embolism (PE). Patients were categorized by largest occluded artery and aggregated into: ‘Require anti-coagulation’ (main, lobar, and segmental PE), ‘Does not require anti-coagulation’ (sub-segmental and No PE), ‘High risk of deterioration’ (main and lobar PE), and ‘Not high risk of deterioration’ (segmental, sub-segmental, and No PE) groups. Wilcoxon rank-sum test was used for 2 sample comparisons of median D-dimer concentrations. Receiver operating characteristic (ROC) curve analysis was utilized to determine a D-dimer cut-off that could differentiate ‘Require anti-coagulation’ from ‘Does not require anti-coagulation’ and ‘High risk of deterioration’ from ‘Low risk of deterioration’ groups. Results The ‘Require anti-coagulation’ group had a maximum area under the curve (AUC) of 0.92 at an age-adjusted D-dimer cut-off of 1540 with a specificity of 86% (95% CI, 81–91%), and sensitivity of 84% (79–90%). The ‘High risk of deterioration’ group had a maximum AUC of 0.93 at an age-adjusted D-dimer cut-off of 2500 with a specificity of 90% (85–93%) and sensitivity of 83% (77–90%). Conclusions An age-adjusted D-dimer cut-off of 1540 ng/mL differentiates suspected PE patients requiring anti-coagulation from those not requiring anti-coagulation. A cut-off of 2500 differentiates those with high risk of clinical deterioration from those not at high risk of deterioration. When correlated with clinical outcomes, these cut-offs can provide an objective method for clinical decision making when imaging is unavailable., Highlights • ED providers are faced with risks and benefits when empirically administering anti-coagulation for suspected PE patients. • We show that D-dimer concentration can be used as a clinical decision making tool to minimize these risks. • A D-dimer cut-off of 1540 ng/mL can be used to minimize unnecessary anti-coagulation exposure in patients who do not need it. • A D-dimer cut-off of 2500 ng/mL can be used to minimize risk of withholding treatment for patients at risk of clinical deterioration. • Together these cut-offs provide an objective measure that can be combined with clinical gestalt to weight the risks and benefits of empiric anti-coagulation.

BACKGROUND CONTEXT Anterior lumbar interbody fusion (ALIF) exposes the anterior aspect of the spine through a retroperitoneal approach. Access to the anterior spine requires mobilization of intra-abdominal viscera/vasculature, which can become complicated as scarring and/or adhesions develop from prior abdominal surgical interventions, increasing risk of intraoperative complications. The literature suggests that “significant prior abdominal surgery” is a relative contraindication of ALIF surgery; however, there is no consensus within the literature as to what defines “major/significant” abdominal surgeries. Additionally, the association between the number of prior abdominal surgeries and perioperative complications in ALIF surgery has not been explored within the literature. PURPOSE This study seeks to explore the association between perioperative complications of ALIF surgery and the type (major and/or minor) and number of prior abdominal surgeries. DESIGN A retrospective cohort study was performed to examine perioperative complications in ALIF patients with or without prior history of abdominal surgery. PATIENT SAMPLE All consecutive patients undergoing ALIF with or without a history of prior abdominal surgery from 2008 to 2018 at a single tertiary center were evaluated. Patients under the age of 18, patients with spinal malignancy, or patients who had ALIF above L3 were excluded. OUTCOME MEASURES Perioperative complications included intraoperative complications during ALIF surgery and postoperative complications within 90 days of ALIF surgery. Intraoperative complications include vascular injury, ureter injury, retroperitoneal hematoma, etc. Postoperative complications include urinary tract infection, revision of abdominal scar, ileus, deep vein thrombosis, pulmonary embolism, etc. Other outcome measures include readmission within 90 days, length of ALIF surgery, and length of hospital stay. METHODS Electronic medical records of 660 patients who underwent ALIF between 2008 and 2018 were retrospectively reviewed. Patient demographics, Charleston Comorbidity Index (CCI), level of fusion, past abdominal surgical history, use of access surgeon during exposure, intraoperative, and postoperative complications were collected. Predictors of intraoperative and postoperative complications were analyzed using simple and multivariable logistic regression. Statistical analysis was performed using JMP 14.0 (SAS, Cary, NC, USA) software. RESULTS After controlling for age, length of ALIF, gender, multilevel ALIF, and the use of an access surgeon, there was no significant association between the type of prior abdominal surgery (major and/or minor) and intraoperative complications on multivariable logistic regression analysis (Minor: odds ratio [OR]=1.68; 95% confidence interval [CI]: 0.58–4.86 & Major: OR=1.99; 95% CI: 0.80–4.91). On multivariable logistic regression, the odds of developing an intraoperative complication increases by 52% for each additional prior abdominal surgery after adjusting for age, length of ALIF, gender, multilevel ALIF, and the use of an access surgeon (OR=1.52, 95% CI: 1.10–2.11). Iliac vein laceration was the most common intraoperative complication (n=27, 4%). Neither the type (major and/or minor) nor the number of prior abdominal surgeries were significant predictors of postoperative complications (Minor: OR=1.29; 95% CI: .72–2.31, Major: OR=1.24; 95% CI: 0.77–2.00, & Number: OR=1.03; 95% CI: .84–1.26). CONCLUSION With each additional prior abdominal surgery, accumulation of scarring and adhesions can likely obscure anatomical landmarks and increase the risk of developing an intraoperative complication. Therefore, the number of prior abdominal surgeries should be taken into consideration during planning and operative exposure of the anterior spine via a retroperitoneal approach.

Introduction Investigation into right and left-sided primary colon liver metastasis (CLM) has revealed differences in the tumor biology and prognosis. This indicates that preoperative and operative factors may affect outcomes of right-sided primary CLM differently than left. This retrospective analysis investigated the effects of resection margin stratified by left and right-sided primary CLM on overall survival (OS) for patients undergoing hepatectomy. Methods A total of 732 patients undergoing hepatic resection for CLM at the Cleveland Clinic and Johns Hopkins were identified between 2002 and 2016. Clinically significant variables were analyzed using Cox proportional hazard regression. The cohort was then divided into patients with right and left-sided CLM and analyzed separately using Kaplan Meier analysis and Cox proportional hazard regression. Results Cox proportional hazard regression showed that left-sided CLM with an R0 margin was a statistically significant predictor of OS even after controlling for other important factors (HR = 0.629, P = 0.024) but right-sided CLM with R0 margin was not (HR = 0.788, P = 0.245). Kaplan–Meier analysis demonstrated that patients with a left-sided CLM and R0 margin had the best prognosis (P = 0.037). Conclusion Surgical margin is an important prognostic factor for left-sided primary CLM but tumor biology may override surgical technique for right-sided CLM.

Background One of the ultimate goals of bariatric and metabolic surgery is to decrease cardiovascular morbidity and mortality. Obese individuals who smoke tobacco are at an increased risk of cardiovascular events and may benefit the most by positive effects of bariatric surgery on cardiometabolic risk factors. The safety profile of sleeve gastrectomy in patients who smoke has not yet been characterized. Objectives To investigate the independent effect of smoking on early postoperative morbidity and mortality of laparoscopic sleeve gastrectomy. Setting American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Methods All patients undergoing primary laparoscopic sleeve gastrectomy from 2010 to 2014 were identified within the NSQIP database. Thirty-day postoperative outcomes for smokers, defined as patients who smoked within the year before surgery, were compared with nonsmokers. Results A total of 33,714 people underwent sleeve gastrectomy; 30,418 (90.2%) patients were nonsmokers, whereas 3296 (9.8%) patients smoked within a year before surgery. Among the 17 examined individual adverse events, patients who smoked were more likely to experience an unplanned reintubation (odds ratio [OR] = 1.88, 95% confidence interval [CI]: 1.01–3.50). Patients in the smoking group were significantly more likely to experience a composite morbidity event (4.3% versus 3.7%, P = .04), serious morbidity event (.9% versus .6%, P = .003), and 30-day mortality (0.2% versus .1%, P = .0004). The length of hospital stay, unplanned readmission, and readmission rates were comparable between the 2 groups. These differences in the composite morbidity event, serious morbidity event, and mortality persisted even when those patients with chronic obstructive pulmonary disease, used as a surrogate for end-stage pulmonary effects of smoking, were excluded from the analysis. Conclusion Sleeve gastrectomy is a well-tolerated procedure in nonsmokers and smokers. However, patients who have smoked within a year before sleeve gastrectomy are at an increased, albeit still very low, risk for 30-day morbidity and mortality compared with nonsmokers. Additional studies are needed to determine if long-term improvement in co-morbidities can offset this initial modest increased perioperative risk.

Stroke is a major cause of mortality after left ventricular assist device (LVAD) placement.Prospectively collected data of patients with HeartMate II (n = 332) and HeartWare (n = 70) LVADs from October 21, 2004, to May 19, 2015, were reviewed. Predictors of early (during index hospitalization) and late (post-discharge) ischemic and hemorrhagic stroke and association of stroke subtypes with mortality were assessed.Of 402 patients, 83 strokes occurred in 69 patients (17%; 0.14 events per patient-year [EPPY]): early ischemic stroke in 18/402 (4%; 0.03 EPPY), early hemorrhagic stroke in 11/402 (3%; 0.02 EPPY), late ischemic stroke in 25/402 (6%; 0.04 EPPY) and late hemorrhagic stroke in 29/402 (7%; 0.05 EPPY). Risk of stroke and death among patients with stroke was bimodal with highest risks immediately post-implant and increasing again 9-12 months later. Risk of death declined over time in patients without stroke. Modifiable stroke risk factors varied according to timing and stroke type, including tobacco use, bacteremia, pump thrombosis, pump infection, and hypertension (all p0.05). In multivariable analysis, early hemorrhagic stroke (adjusted odds ratio [aOR] 4.3, 95% confidence interval [CI] 1.0-17.8, p = 0.04), late ischemic stroke (aOR 3.2, 95% CI 1.1-9.0, p = 0.03), and late hemorrhagic stroke (aOR 3.7, 95% CI 1.5-9.2, p = 0.005) predicted death, whereas early ischemic stroke did not.Stroke is a leading cause and predictor of death in patients with LVADs. Risk of stroke and death among patients with stroke is bimodal, with highest risk at time of implant and increasing risk again after 9-12 months. Management of modifiable risk factors may reduce stroke and mortality rates.

Purpose Evaluating marginal donor lungs for transplant suitability in acellular ex-vivo lung perfusion (EVLP) can be challenging. Relying on a single parameter for evaluation can be misleading and may result in unfavorable outcomes following lung transplantation (LTx). This study aimed to establish a comprehensive scoring system incorporating important evaluation parameters in a simple reproducible way. Methods The comp rehensive l ung e valua t ion E VLP ( COMPLETE ) score is the composite result of ten evaluation parameters including: lung weight measurement, ultrasound evaluation, airway pressure, lung compliance, P/F ratio, lactate level, deflation, palpation, bronchoscopy, and x-ray. Each parameter is scored from 0 to 3, 3 being the worst, then the COMPLETE score is calculated by the summation of the individual parameter scores. Data was collected prospectively, then analyzed retrospectively utilizing receiver operating characteristic (ROC) analysis to inform the cut off values for each parameter scoring. Results Seventy-three EVLP cases were performed resulting in 48 lung transplants with 100% 30-day survival and 96% 1-year survival. Median time to extubation was 1 day and median ICU stay was 7 days. The incidence of primary graft dysfunction (PGD) grades 0, 1, 2, and 3 at 72 hours were 23%, 61%, 9%, and 7%, respectively. The COMPLETE score was significantly higher in lungs non-suitable for LTx compared to transplanted lungs (17 [15-20] vs 7 [4-8], P Conclusion The COMPLETE scoring system is a comprehensive system that can facilitate decision making in EVLP in a protocolized manner. The COMPLETE score was significantly higher in EVLP lungs deemed non-suitable for transplant and, in those transplanted after EVLP, the COMPLETE score had a significant correlation with time to extubation, ICU stay, and incidence of PGD3. Consideration should be given to the routine use of the COMPLETE score during EVLP evaluation.

Background Rifampin is recommended as adjunctive treatment for staphylococcal prosthetic valve endocarditis (PVE). It is unclear whether this should hold for surgically treated patients. The purpose of this study was to examine whether adjunctive rifampin treatment in addition to cell wall active antimicrobial agents in patients with surgically treated staphylococcal infective endocarditis (IE) results in better outcomes. Methods Patients operated on for staphylococcal IE from April 1, 2008, to July 1, 2014, were identified from our institution's IE registry. Rifampin treatment was defined as 3 or more days of rifampin postoperatively. Cox proportional hazards regression was used to compare a composite outcome of death or reoperation for IE relapse, between patients treated and not treated with rifampin, adjusted for propensity to be treated with rifampin, methicillin resistance, all-purpose refined diagnosis related group (APR-DRG) severity score, and APR-DRG mortality risk. Results In all, 273 patients were identified. The mean age was 56 years, 66% were male, 50% had PVE, 60% had S. aureus or S. lugdunensis infection, 89% had left side involvement, and 57% had invasive disease. Fifty-one (27%) received 3 or more days of rifampin postoperatively. Ninety-two patients died or underwent reoperation for IE relapse at a median of 205 days (interquartile range 56 to 718 days). In a multivariable model, patients treated with rifampin had a similar hazard of death or reoperation for IE relapse as those not treated (hazard ratio 0.76, 95% confidence interval 0.44 to 1.32, p value 0.34). The results were robust to varying definitions of rifampin treatment. Conclusions Among patients with surgically treated staphylococcal IE there was insufficient evidence to claim a reoperation-free survival benefit from treatment with rifampin. Rifampin should not be used as adjunctive therapy for staphylococcal IE in patients who have undergone surgical procedures for its treatment.

Objective Endometrial carcinoma (EC), the most common gynecologic malignancy in the United States, affects European American (EA) women more frequently than African-American (AA) women. Yet, AA women are more likely to die from EC. Proposed etiologies for this racial disparity, such as socioeconomic status, aggressive, non-endometrioid tumor histology, and comorbid conditions, do not account for the entire disparity experienced by AA women, suggesting an unexplored genetic component. Germline mutations in PTEN cause Cowden syndrome (CS), which increases lifetime risk of endometrial cancer. In addition, somatic PTEN silencing is one of the most common initiating events in sporadic EC. Therefore, we hypothesized that specific PTEN haplotypes in the AA population may directly predispose AA women to unfavorable tumor characteristics when diagnosed with EC. Methods We conducted a case–control association study of germline variations in and around the PTEN /10q region between 53 EA and 51 AA EC cases and ethnic controls. Results Eighteen tag SNPs with minor allele frequency ≥0.1, were genotyped and used to reconstruct haplotypes. Forty-eight ancestry informative markers were genotyped control for population stratification. Two haplotypes were overrepresented in AA, and there was a trend towards tumors with higher stage and grade in patients with these haplotypes. One haplotype was overrepresented in the EA population with a trend towards more endometrioid tumors. Conclusions We show that specific PTEN /10q haplotypes are significantly different between EA and AA individuals ( p ≤0.02), and specific haplotypes may increase the risk of unfavorable tumor phenotypes in AA women diagnosed with EC.

Background Patients with epilepsy or multiple sclerosis (MS) have high risks of depression and increased risks of suicide, but little is known about their risks of suicidal ideation. Objective We sought to (1) estimate the prevalence of thoughts of being better off dead or of self-harm among patients with epilepsy or MS, (2) identify risk factors for such thoughts, and (3) determine whether any risk factors interact with depression to predict such thoughts. Methods A Cleveland Clinic database provided information on 20,734 visits of 6586 outpatients with epilepsy or MS. Outcome measures were thoughts of death or self-harm (Patient Health Questionnaire [PHQ] item-9), and total score ≥10 for the 8 remaining PHQ items (probable major depression). Generalized estimating equations accounted for repeat visits in tests of associations of PHQ item-9 responses with depression, age, sex, race, household income, disease severity, and quality of life. Results Prevalence of thoughts of death or self-harm averaged 14.4% overall (epilepsy, 14.0% and MS, 14.7%). Factors associated with positive PHQ item-9 responses in epilepsy were depression and male sex, modified by poor quality of life. Factors associated with positive PHQ item-9 in MS were depression, male sex, medical comorbidity, and poor quality of life; the effect of depression was worse with greater MS severity and being unmarried. Conclusions Among patients with common neurologic disorders (epilepsy or MS), 14%–15% reported thoughts of death or self-harm associated with illness severity, depression, quality of life, male sex, and being unmarried. Such patients require further evaluation of clinical outcomes and effects of treatment.

Background context Posterior cervical fusion (PCF) has been shown to be an effective treatment for cervical spondylosis, but is associated with a 9% complication rate and high costs. To limit such complications and costs, it is imperative that proper selection of surgical candidates occur for those most likely to do well with the surgery. Affective disorders, such as depression, are associated with worsened outcomes after lumbar surgery; however, this effect has not been evaluated in patients undergoing cervical spine surgery. Purpose To assess the predictive value of preoperative depression and the health state on 1-year quality of life (QOL) outcomes after PCF. Study design A retrospective cohort analysis. Patient sample Eighty-eight patients who underwent PCF for cervical spondylosis were reviewed. Outcome measures Preoperative and 1-year postoperative health outcomes were assessed based on the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire-9 (PHQ-9), and the EuroQol five-dimensions (EQ-5D) questionnaire. Methods Univariable and multivariable regression analyses were performed to assess for preoperative predictors of 1-year change in health status. Results Compared with preoperative health states, the PCF cohort showed statistically significant improved PDQ (87.8 vs. 73.6), PHQ-9 (7.7 vs. 6.6), and EQ-5D (0.50 vs. 0.60) scores at 1 year postoperatively. Only 10/88 (11%) patients achieved or surpassed the minimum clinically important difference for the PHQ-9 (5). Multiple linear and logistic regression analyses showed that increasing PHQ-9 and EQ-5D preoperative scores were associated with reduced 1-year postoperative improvement in health status (EQ-5D index). Conclusions Of patients who undergo PCF, those with a greater degree of preoperative depression have lower improvements in postoperative QOL compared with those with less depression. Additionally, patients with better preoperative health states also attain lower 1-year QOL improvements.

Background context Cervical disc arthroplasty (CDA) is a motion-preserving procedure that is an alternative to fusion. Proponents of arthroplasty assert that it will maintain cervical motion and prevent or reduce adjacent segment degeneration. Accordingly, CDA, compared with fusion, would have the potential to improve clinical outcomes. Published studies have varying conclusions on whether CDA reduces complications and/or improves outcomes. As many of these previous studies have been funded by CDA manufacturers, we wanted to ascertain whether there was a greater likelihood for these studies to report positive results. Purpose To critically assess the available literature on cervical arthroplasty with a focus on the time of publication and conflict of interest (COI). Study design/setting Review of the literature. Methods All clinical articles about CDA published in English through August 1, 2013 were identified on Medline. Any article that presented CDA clinical results was included. Study design, sample size, type of disc, length of follow-up, use of statistical analysis, quality-of-life (QOL) outcome scores, COI, and complications were recorded. A meta-analysis was conducted stratifying studies by COI and publication date to identify differences in complication rates reported. Results Seventy-four studies were included that investigated 8 types of disc prosthesis and 22 met the criteria for a randomized controlled trial (RCT). All Level Ib RCTs reported superior quality-of-life outcomes for CDA versus anterior cervical discectomy and fusion (ACDF) at 24 months. Fifty of the 74 articles (68%) had a disclosure section, including all Level Ib RCTs, which had significant COIs related to the respective studies. Those studies without a COI reported mean weighted average adjacent segment disease rates of 6.3% with CDA and 6.2% with ACDF. In contrast, the reverse was reported by studies with a COI, for which the averages were 2.5% with CDA and 6.3% with ACDF. Those studies with a COI (n=31) had an overall weighted average heterotopic ossification rate of 22%, whereas those studies with no COI (n=43) had a rate of 46%. Conclusions Associated COIs did not influence QOL outcomes. Conflicts of interest were more likely to be present in studies published after 2008, and those with a COI reported greater adjacent segment disease rates for ACDF than CDA. In addition, heterotopic ossification rates were much lower in studies with COI versus those without COI. Thus, COIs did not affect QOL outcomes but were associated with lower complication rates.

C5 nerve root palsy (C5P) is a relatively rare complication after anterior and posterior cervical decompression surgery that leads to a variety of debilitating symptoms. The precise etiology remains obscure, and a clear understanding of preoperative risk factors for C5P development does not exist.To determine whether postoperative C5P can be predicted from preoperative anteroposterior diameter (APD), foraminal diameter (FD), and/or cord-lamina angle (CLA).Retrospective review.Consecutive patients who underwent either anterior or posterior decompression surgery at C4-C5 for cervical spondylotic myelopathy.Development of C5P.Blinded reviewers retrospectively assessed magnetic resonance images for each included patient's C4-C5 interspace, including the midline APD, the left and right FDs, and the left and right CLA. Multivariable logistic regression was used to model the probability of palsy on the basis of one or more predictors. A jackknife validation was performed to internally validate the model and assess its generalizability.A total of 98 patients fit the inclusion criteria; 12% had developed symptoms of C5 palsy postoperatively. Using the three variables in a predictor-model, we found that the odds ratio of having palsy for APD, FD, and CLA was 0.3, 0.02, and 1.4, respectively. For every 1-mm increase in APD and FD, the odds of developing palsy decrease 69% (p.0001) and decrease 98% (p.0003), respectively. In contrast, for every 1-degree increase in CLA, the odds of developing palsy increase by 43% (p.0001). The receiver-operating characteristic curve for this three-variable model predicting development of palsy has an area under the curve (concordance index) of 0.97. After implementing a jackknife validation, the area under the curve was 95%.This study is the first to use the combination of APD, FD, and CLA to predict development of postoperative C5 palsy after decompression surgery for patients with spondylotic myelopathy. This prediction formula may allow for better patient selection and to prepare patients that have an increased probability of developing this complication.

Multidrug-resistant (MDR) organisms in ventilator-associated pneumonia were found in 49 of 107 patients and were associated with home antibiotics, pre-ventilator-associated pneumonia hospital stay, and health care exposure. Overall, MDR organisms were associated with increased mortality ( P = .006). On multivariate analysis, MDR status was modulated by organism class. In nonfermenting gram-negative rods, no association between MDR and mortality was found, but, in all other organisms, MDR was associated with increased mortality risk (hazard ratio, 6.15; 95% confidence interval: 1.80-21.05, P = .004).

Ventricular assist devices (VADs) are increasingly being used as a bridge to transplantation and have been implicated as a risk factor for allosensitization to human leukocyte antigens (HLA). We investigate the association between VAD and allosensitization to human leukocyte antigens (HLA) and major-histocompatibility-complex (MHC) class I-related Chain A (MICA) antigens.We considered all patients who received a VAD at our institution between 2000 and 2009; 89 of them had pre-VAD and post-VAD (≤6 months after implant) HLA antibody screening. A control group of non-VAD heart transplant candidates was constructed with at least 2 pre-transplant panel-reactive antibody (PRA) tests within 8 months. Two controls were randomly selected/VAD patient matched for year (n = 178). Patients and controls with available sera from these time-points were tested by Luminex/flow PRA single-antigen beads and by MICA antibody Luminex single-antigen beads. Medical records were reviewed for comparison of pre-transplant immunologic risk factors and post-transplant outcomes between the 2 groups.Compared with controls, VAD patients had greater Class I differences between peak and initial PRA (18% vs. 0%, p0.0001) and higher peak PRA (24% vs. 6%, p0.0001). The differences between the 2 groups in Class II were less pronounced than in Class I. Of patients who had single-antigen testing, VAD implantation was significantly associated with development of new HLA antibody specificities (Class I and/or Class II) post-VAD with an increase in calculated PRA (cPRA) post-VAD compared with controls (16% vs. 0%, p0.0001). This risk was still present after adjusting for age, gender, pre-VAD PRA, transfusion and duration of follow-up in a multivariate analysis (p0.0001 and 0.02, respectively). There were no differences in development of MICA antibodies between the 2 groups (14% in both). There was no significant difference in the incidence of pre-transplant positive T-cell crossmatch, pre-transplant donor-specific HLA antibodies, rejection episodes or graft survival between the 2 groups.Our results suggest that VAD is associated with significant HLA allosensitization independent of common risk factors.

Background: Patients with prosthetic valve endocarditis (PVE) who are not treated surgically have poor clinical outcomes. This study was undertaken to compare outcomes of non-surgical with surgical treatment for PVE. Methods: Patients admitted to Cleveland Clinic with PVE from April 1, 2008 to

Aim In this study, we investigate the distribution of MICA 129 genotypes and characterized MICA-HLA-B haplotype in two major North American populations. Methods We retrospective reviewed our laboratory electronic database for individuals with high resolution HLA-B and MICA typing and known ethnicity. Total 724 individuals [692 Caucasians (C) and 32 African Americans (AA)] were identified. Typing was performed by PCR-Sequence Specific Oligonucleotide Probes and/or Sequence Based Typing. MICA 129-MM, MV, and VV genotype distribution was investigated. Two-locus haplotype frequencies (HF) and LD between MICA and HLA-B alleles were estimated using the ELB algorithm on haplotypes that reached HF ⩾ 0.5% and p-value Results Compared to C, AA had higher incidence of MM (30% AA vs. 12% C), similar percentage of MV (43% AA vs. 40% C), and lower incidence of VV (27% AA vs. 48% C), p − value Conclusions There is a significant difference of MICA129 genotype distribution between C and AA. MICA 129-M allele more frequently distributed among the MICA and HLA-B haplotype shared in both C and AA populations.

Utility of the Psychosocial Assessment of Candidates for Transplantation (PACT) Scale in Patients Undergoing Mechanical Circulatory Support Meghana Halkar, Amy S. Nowacki, Kay Kendall, Nader Moazami, Eiran Z. Gorodeski, W.H. Wilson Tang, Randall C. Starling, James B. Young, Sangjin Lee; Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Cleveland, OH

Purpose Ventricular assist device (VAD) is implicated in HLA-sensitization. We investigate the association between VAD and HLA & MICA sensitization. Methods and Materials Of VAD patients in our institute (00-09); 89 had pre-VAD antibody testing and another in 6 months post-VAD. The comparison group was no-VAD heart transplant candidates; 2 randomly selected/VAD patient matched for year of initial PRA. Results Follow-up was longer in the non-VADs to increase capturing non-VAD increases in PRA (53 vs. 28 days, p=0.001). The number of transfusions was higher in VADs (15 vs. 2), p Table 1 ). In patients with single antigen testing, VAD was associated with new HLA antibody specificities and increased cPRA (16 (0-41)% vs. 0%, p Figure 1 ). Conclusions VAD is associated with HLA sensitization independent of other risk factors. It was not significantly associated with differences in rejection or allograft survival, but may represent a barrier to transplant by limiting donors and lengthening of wait time. Table 1 VAD nonVAD p Class I Pk % 24 (7-72) 6 (2-26) Class I Diff 18 (3-52) 0 (0-1) Class II Pk % 4 (1-16) 2 (1-5) .04 Class II Diff 2 (0-13) 0 .0001

Aim Natural killer (NK) cells are key players in immune surveillance against malignancies. Major histocompatibility complex (MHC) class I related chain A (MICA) is a cognate ligand for the activating receptor NKG2D expressed on the surface of NK, NKT, CD8+ and TCR γδ+ T cells. Allelic variants of MICA due to a single amino acid substitution at position 129 with a methionine (M) or valine (V) in the alpha2 domain have been reported to result in large differences in NKG2D binding, which may be related to acute and chronic GvHD. The utility of MICA-129 genotype as a genetic marker in association with clinical outcomes is linked to whether a sizable proportion of the population is represented in different genotypes. Methods We investigated the MICA 129 genotype distribution among two cohorts. Cohort I consisted of 388 bone marrow and solid organ donors (351 Cauc and 37 AF) as a random sample of the population. Cohort II consisted of 530 sequential BMT recipients (507 Cauc & 23 AF). The genotype distribution of both cohorts is shown in Table 1 , Table 2 . Results Our analysis indicated that at least 8% of cohorts analyzed represented the least frequent genotype (MM) and a racial difference in genotype distribution among Cauc and AF in cohort I (p-value Conclusions These results indicate a sizable representation of MICA-129 genotypes in different populations which increases its clinical utility as a candidate biomarker. Observed differences among Cauc vs. AF and HSCT recipients vs. random population samples warrant further investigation on larger cohorts including other races.

Aim VADs are increasingly used as a bridge to transplantation and are implicated as a risk factor for allosensitization. We investigated in a matched case-control study the association between VAD and PRA changes (peak & significant increase ⩾20%). Methods We analyzed records of VAD recipients at our institute from 00-09 (n = 384) and included patients with pre-VAD PRA testing and another PRA test within 6 months post-VAD (n = 100). PRA testing was performed by screening flowPRA beads (One Lambda, CA). A control group was constructed from heart transplant candidates evaluated in the same time frame with no VAD (n = 830) for whom we had ⩾3 PRA tests within 8 months pre-transplant (n = 445). Two controls were randomly matched for each VAD case based on yr of initial PRA test. Results Follow-up was longer in the controls (median:103 vs 33; p Table 1 ). Multivariable models adjusted for gender, race, pre-VAD PRA, duration of VAD and blood transfusion yet the associations remained unchanges. Of VAD patients, that had a significant increase in C1 PRA and single antigen testing performed 81% (35/43) showed development of new HLA antibody specificities post-VAD. Conclusions Our results suggest that VAD is associated with CI allosensitization independent of other risk factors. These findings have important clinical implications and warrant prospective studies to better understand VAD associated allosensitization.

Higher Incidence of Class II Human Leukocyte Antigen (HLA)Allosensitization in Patients Supported with Pulsatile Ventricular Assist Devices (VAD) M. Askar, A. Zhang, L. Klingman, M. Mastroianni, A. Nowacki, P. Reville, J. Gatto, S. Bakdash, N. Smedira, R. Starling, G. Gonzalez-Stawinski. Allogen Laboratoires, Cleveland Clinic; Doisey College of Health Sciences, St. Louis University; Department of Quantitative Health Sciences, Cleveland Clinic; College of Arts and Sciences, The Ohio State University; Clinical Pathology, Cleveland Clinic; Cardiothoracic Surgery, Cleveland Clinic; Cardiovascular Medicine, Cleveland Clinic.