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Introduction: We sought to produce the first nationally representative analysis of racial and income inequities by mortality and cost for patients with chronic total occlusion (CTO) of coronary arteries by the presence or absence of active cancer. Methods: Propensity score adjusted and backward propagation neural network machine learning augmented multivariable regression among patients with CTO and stratified by race and income was conducted for the above outcomes in this case-control study of the United States’ largest and most current all-payer hospitalized dataset, the 2016 National Inpatient Sample. Regression models were fully adjusted for age, geographic region, anemia, thrombocytopenia, cancer metastases, NIS-calculated mortality risk by Diagnosis Related Group (DRG), and the likelihood of undergoing PCI (in addition to length of stay [LOS] for cost). To produce nationally representative estimates, analyses were also adjusted for the complex survey design. Results: Of the 30,195,722 adult hospitalized patients, 1,159,994 (3.84%) underwent PCI (of whom 30,624 [2.64%] were in patients with active cancer), and 120,815 (0.40%) had CTO (of whom 3,068 [2.54%] had active cancer). In multivariable regression among patients with CTO, mortality was comparable across races in both PCI and cancer, but significantly increased among the lowest income quartile for patients with cancer (OR 4.09; 95%CI 1.30-12.80; p=0.016). PCI in Hispanic cancer patients unlike other races had significantly increased costs ($207,218.80; 95%CI 76,799.21-337,738.30; p=0.002) as did the lowest income quartile ($26,327.08; 95%CI 21,123.93-31,530.23; p=0.042) unlike other income groups significantly increased costs. Conclusions: This large nationally representative study suggests PCI can safely done in hospitalized patients with CTO and active cancer though its prevalence is far less than in those without cancer despite comparable risk profiles; there also appears to be significant racial and income inequities in both mortality and cost by both race and income.

Introduction: Valvular diseases, especially Mitral regurgitation (MR) confer a high cardiovascular burden in cancer survivors. Transcatheter Edge-to-Edge Repair (TEER) with the MitraClip TM system has shown promising results in the management of severe MR regardless of etiology. However, little is known about the impact of cancer history on patient outcomes. Methods: We studied 456 consecutive patients (cancer: 86; non-cancer: 370) with severe mitral regurgitation who underwent mitral valve TEER at our institution from 2005 to 2020. In addition to pre-and post-procedural characteristics, we examined imaging parameters and outcome data including all-cause mortality. We used Cox regression analysis to identify factors associated with mortality. Results: Patients were followed for a mean of 9.2 months (SD 19). Table 1 shows the baseline and follow-up characteristics for both groups. At 1-year follow-up, only 4 (5%) cancer survivors and 23 (6%) non-cancer patients had died. In a Cox regression analysis, short-term (0.05). Age and sex were also not significantly associated with mortality (p>0.05). In subgroup analyses, at 1-year follow-up, cancer survivors who had received prior radiation therapy were more likely to have died (11% vs 0; X2=5.07, p=0.024) and cancer survivors with solid tumors were more likely to have an NYHA functional class III-IV at 1-year follow-up than those with hematologic malignancies (X2=4.75, p=0.029). Conclusions: In this large retrospective study, short- and long-term all-cause mortality after mitral valve TEER were similar in both cancer survivors and non-cancer patients. Prior radiation therapy and history of solid tumors may be poor prognostic markers.

Introduction: It is unclear whether bare-metal stent (BMS) use in cancer patient is associated with similar outcome compared with drug-eluting stent (DES). We aim to compare outcome of percutaneous coronary intervention (PCI) in cancer patient who were treated with BMS versus DES. Methods: We identified cancer patients who underwent PCI using BMS or DES between 2013 and 2020. Outcome of interest was overall survival and number of revascularizations. Kaplan-Meier method was used to estimate the survival probability. Multivariate Cox regression model were utilized to compare overall survival between BMS and DES. Results: We included 347 cancer patients who underwent PCI with median follow-up of 34.1 months (95% CI, 28.4-38.7). 42 patients were treated with BMS (12.1%) and 305 with DES (87.9%). Age and gender were similar between BMS and DES groups (p = 0.08 and 0.94 respectively). DES use was more frequent in Caucasians while African American patients had more BMS (p=0.03). There was no significant difference in number of revascularizations between BMS and DES groups (p=0.36). Median survival was 46 months (95%CI, 34-66) with no significant difference in overall survival between BMS and DES groups in multivariate analysis (p = 0.37). Independent predictors for survival include age > 65 (hazard ratio [HR]:1.53 [95% CI, 1.046-2.240]), BMI > 30 (HR:0.58 [95% CI, 0.374-0.895) and hemoglobin level > 12 mg/dl (HR:0.44 [95% CI, 0.303-0.639]). Conclusions: PCI using bare-metal stent in cancer patients appears to be associated with similar overall survival and number of revascularizations compared with drug-eluting stent.

Purpose of review The population of kidney transplant recipients with advanced chronic kidney disease is growing but their outcomes are poor and care is not standardized. There has been wide variety of research in recent years on different aspects of care in failing allografts, and these research findings may help the providers in optimizing care. The purpose of the review is to outline the challenges and opportunities in management of failing allograft, and provide tools for improvement. Recent findings This review summarizes the recent research in field of failing allograft including outcomes, immunosuppression, risk factor management, multidisciplinary CKD care, dialysis initiation, nephrectomy and re-transplantation. Summary Kidney allograft failure is a period of higher risk of mortality compared with other transition periods for patients with ESRD. Risk mitigation is a complex challenge for patients and their care teams. In addition to summarizing the recent literature, we propose a checklist approach to the various issues, medical, surgical, psychological and nutritional as patients approach kidney transplant failure while they consider initiation of dialysis and possible repeat transplantation. Once standard algorithms are instituted, studies can be conducted to identify those high-value interventions that actually reduce morbidity and mortality risk during this transition period.

OBJECTIVES Comparison of demographic, clinical, microbiological, and utility profile of the corneas obtained through hospital corneal retrieval program (HCRP) and voluntary eye donation (VED) program. METHODS Donor corneas retrieved during a 14 months period at National eye bank, India were included in the study. The donor cornea grading was done according to the cornea donor study. The corneal swabs were taken from the donor eyes and were sent for microbiological evaluation. The quality of the donor corneas and their utility was assessed. RESULTS Out of 1,014 donor corneas collected (700 through HCRP, 314 through VED), 455 were of optical grade (91.2% [415/455] through the HCRP and 8.7% [40/455] through the VED). HCRP had a higher proportion of donors in younger age (81.6% vs. 21%, P

Purpose To describe a new surgical modality, "Bowman membrane tuck-in," for management of small to medium sized corneal perforation of a noninfectious etiology. Methods Two patients with corneal perforation of a noninfectious etiology and less than 4 mm in size underwent Bowman membrane tuck-in, a new surgical procedure. In this technique, Bowman membrane harvested from the donor cornea was tucked inside the stromal pocket of host tissue, which was prepared by 360-degree anterior stromal lamellar dissection. Patients were followed up for 6 months and were examined for best-corrected visual acuity, epithelialization time, anterior chamber stability, and graft-related complications. Results During 6-month follow-up, best-corrected visual acuity improved from PL+ (positive) to 20/120 and 20/200 in patient 1 and patient 2, respectively, and epithelialization was completed within a 2-week period in both patients. Surgery was uneventful in both cases; however, anterior chamber re-formation and graft repositioning were performed in patient 1. None of the patients showed signs of rejection or graft failure at 6-month follow-up. Conclusions Bowman membrane tuck-in is an effective sutureless and glueless technique for management of corneal perforation of a noninfectious etiology, which may be used in emergency settings for the management of noninfectious corneal perforation of size less than 4 mm.

Background The purpose of this study was to compare functional outcomes between nerve grafting and nerve transfer procedures in the setting of isolated, posttraumatic axillary nerve injuries. Methods A systematic review was performed using the PubMed, Scopus, and Cochrane databases to identify all cases of isolated, posttraumatic axillary nerve injuries in patients aged 18 years or older. Patients who underwent axillary nerve reconstruction were included and categorized by technique: graft or transfer. Demographics were recorded, including age, time to operation, and presence of concomitant injuries. Functional outcomes were evaluated, including British Medical Research Council strength and range of motion for shoulder abduction. Results Ten retrospective studies met criteria, for a total of 66 patients (20 nerve grafts and 46 nerve transfers). Median time from injury to operation was equivalent across the nerve graft and nerve transfer groups (8.0 months versus 7.0 months; p = 0.41). Postoperative follow-up was 24.0 months for nerve grafting versus 18.5 months for nerve transfer (p = 0.13). Clinically useful shoulder abduction, defined as British Medical Research Council grade M3 or greater, was obtained in 100 percent of nerve graft patients versus 87 percent of nerve transfer patients (p = 0.09). Grade M4 or better strength was obtained in 85 percent of nerve graft patients and 73.9 percent of nerve transfer patients (p = 0.32). Conclusions Significant differences in functional outcomes between nerve graft and transfer procedures for posttraumatic axillary nerve injuries are not apparent at this time. Prospective outcomes studies are needed to better elucidate whether functional differences do exist. Clinical question/level of evidence Therapeutic, IV.

The impact of specific patient comorbidities on outcomes in craniosynostosis surgical repair is not well defined. The aim of this retrospective review was to evaluate the short-term 30-day reoperation rate, unplanned readmission rate, and overall morbidity of craniosynostosis surgical repair using the 2012 through 2014 American College of Surgeons National Surgical Quality Improvement Program-Pediatrics (ACS NSQIP-Pediatric) database. Overall morbidity included pneumonia, wound occurrence, shock/sepsis, venous thromboembolism, cardiac complication, renal and urinary complications, or nerve injury. The authors identified patients undergoing craniosynostosis repair by CPT code resulting in 2,037 patients. A univariate and multivariate analysis was performed to identify risk factors for reoperation, readmission, and morbidity. The reoperation rate was 2.4%, the overall morbidity rate was 2.8%, and readmission rate was 3.4%.Regression analysis identified age, high American Society of Anesthesiologists (ASA) classification, and history of either neurologic or pulmonary disorders as associated with unplanned reoperations within 30 days. High ASA classification also demonstrated significant correlation with unplanned 30-day readmission, and a history of neurologic disorders was associated with overall morbidity. The most common reason for readmission was wound complications (n = 15) followed by respiratory complications (n = 7). Gender, gastrointestinal comorbidities, blood disorders, cardiac risk factors, and prior operation within 30 days did not show significant association with any outcome. Craniosynostosis surgical repair is safe and associated with low complication and readmission rates. Careful patient selection and preoperative optimization of these factors should be sought to reduce detrimental outcomes.

Clinical features A middle-aged man with history of kidney transplantation was diagnosed with multiple myeloma (MM); he was treated with cyclophosphamide, bortezomib, and dexamethasone (CyBorD) for induction therapy. However, a repeat bone marrow biopsy after treatment revealed 10% clonal plasma cell involvement. Given residual disease, his treatment regimen was changed to daratumumab, bortezomib, and dexamethasone in an attempt to achieve minimal residual disease. Therapeutic challenge Daratumumab was recently approved for treatment of relapsed or refractory MM; there are no data regarding the safety and effectiveness in solid organ transplant patients. Solution Our patient was treated with a daratumumab-based regimen for MM. His renal function was monitored closely along with donor-specific antibody to assess for risk of graft rejection. His renal function remained stable with minimal proteinuria and negative donor-specific antibody during the treatment course.

Syncope is defined as a transient loss of consciousness due to cerebral hypoperfusion followed by spontaneous recovery. Common causes of syncope include vasovagal syncope, situational syncope, orthostatic hypotension, carotid sinus hypersensitivity, left- and right-sided obstructive cardiac lesions, and cardiac arrhythmias. History and physical examination often provide valuable clues about the underlying etiology of syncope. Admission decisions in the emergency department can be guided by various risk prediction scores. Evaluation of a patient with syncope involves a large battery of diagnostic tests that include a 12-lead electrocardiogram, Holter monitoring, echocardiogram, tilt table testing, ischemia evaluation, electrophysiologic studies, and other imaging tests. Despite the availability of these advanced diagnostic tests, a significant proportion of patients with syncope remain undiagnosed. Therapy should be tailored based on the underlying etiology of syncope.

Summary:. Sensory nerve trauma at the level of the wrist can lead to debilitating neuromas. Targeted muscle reinnervation (TMR) is an effective therapy for the treatment of neuromas. Here we propose the use of the terminal anterior interosseous nerve (AIN) as a viable recipient for TMR. All superficial sensory nerves around the wrist, including the dorsal ulnar sensory nerve, the distal lateral antebrachial cutaneous nerve, the distal branches of the superficial branch of the radial nerve, and the palmar cutaneous branch of the median nerve were dissected in 2 cadaver specimens. The AIN branch to pronator quadratus was divided just distal to the final branch of flexor pollicis longus to preserve adequate length for TMR. The sensory nerves at the wrist were fully dissected to identify a viable location for coaptation to the AIN. After the cadaveric concept was demonstrated, the technique was successfully used in a clinical case. In summary, the distal AIN is a versatile recipient for TMR as a treatment of painful sensory neuromas at the level of the wrist, with minimal donor-site morbidity.

Van Nes rotationplasty is a limb-salvage used for reconstruction after resection of a distal femoral or proximal tibial osteosarcoma in the pediatric patient. After resection, the distal leg is reapproximated to the level of tumor resection. The goal is to optimize extremity functionality such that the ankle functions as a knee joint. Traditionally, the vessels and nerves around the tumor are preserved within the distal leg. In the first case of our series, this method resulted in thrombosis, flap loss, and ultimately amputation secondary to venous torsion and thrombosis. In the following 2 cases, the intervening vasculature was resected along with the tumor, and the distal pedicles were anastomosed to their proximal counterparts using microvascular techniques. In addition to expediting resection of the tumor as well as allowing wider tumor resection margins, this technique also precludes thrombosis and subsequent flap loss.