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This is the first use of combined MPI and PET for cell tracking and shows the complementary benefits of MPI for sensitive detection of MSCs early after implantation and PET for longer-term measurements of cell viability.

Metastasis is the leading cause of cancer-related death. However, it remains a poorly understood aspect of cancer biology, and most preclinical cancer studies do not examine metastasis, focusing solely on the primary tumor. One major factor contributing to this paradox is a gap in available tools for accurate spatiotemporal measurements of metastatic spread in vivo. Here, our objective was to develop an imaging reporter system that offers sensitive three-dimensional (3D) detection of cancer cells at high resolutions in live mice. An organic anion-transporting polypeptide 1b3 (oatp1b3) was used as an MRI reporter gene, and its sensitivity was systematically optimized for in vivo tracking of viable cancer cells in a spontaneous metastasis model. Metastases with oatp1b3-MRI could be observed at the single lymph node level and tracked over time as cancer cells spread to multiple lymph nodes and different organ systems in individual animals. While initial single lesions were successfully imaged in parallel via bioluminescence, later metastases were largely obscured by light scatter from the initial node. Importantly, MRI could detect micrometastases in lung tissue comprised on the order of 1,000 cancer cells. In summary, oatp1b3-MRI enables longitudinal tracking of cancer cells with combined high resolution and high sensitivity that provides 3D spatial information and the surrounding anatomical context.Significance:An MRI reporter gene system optimized for tracking metastasis in deep tissues at high resolutions and able to detect spontaneous micrometastases in lungs of mice provides a useful tool for metastasis research.

Coronary endarterectomy (CE) is an uncommon and often unplanned technique used to approach difficult targets during coronary artery bypass grafting (CABG). We evaluated the outcomes of CABG with CE (CE-CABG) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database.All isolated, first-time, elective or urgent CABG cases from July 2011 to September 2019 in the Adult Cardiac Surgery Database were retrospectively reviewed. Because of a higher risk profile in the patients undergoing CE-CABG, we performed propensity score matching. Primary outcomes included operative mortality and postoperative myocardial infarction. For patients ≥65 years, long-term mortality and rehospitalization were evaluated using linked data from Centers for Medicare and Medicaid Services.Of the total 1 111 792 patients included, 32 164 (2.9%) had CE-CABG and 1 079 628 (97.1%) underwent CABG alone. The majority of CE-CABG involved a single-vessel endarterectomy (86.9%; n = 27 945); the left anterior descending was most common (40.9%; n = 13 161). Compared with propensity score-matched CABG, CE-CABG had increased operative mortality (3.2% vs 1.7%; P.0001; odds ratio, 1.81; 95% CI, 1.63-2.01) and postoperative myocardial infarction (6.8% vs 3.9%; P.0001; odds ratio, 1.80; 95% CI, 1.68-1.93). CE-CABG had higher risk of mortality in the first year and rehospitalization for myocardial infarction in the first 3 years but was comparable to CABG alone thereafter. Subgroup analysis showed no difference between CE-CABG of the left anterior descending compared with CE-CABG of other coronary arteries.This analysis demonstrates that CE-CABG has acceptable long-term outcomes and serves as a benchmark for what can be expected when this rare procedure is used.

Metastasis is the leading cause of cancer-related death. However, it remains a poorly understood aspect of cancer biology, and most preclinical cancer studies do not examine metastasis, focusing solely on the primary tumor. One major factor contributing to this paradox is a gap in available tools for accurate spatiotemporal measurements of metastatic spread in vivo. Here, our objective was to develop an imaging reporter system that offers sensitive three-dimensional (3D) detection of cancer cells at high resolutions in live mice. An organic anion-transporting polypeptide 1b3 (oatp1b3) was used as an MRI reporter gene, and its sensitivity was systematically optimized for in vivo tracking of viable cancer cells in a spontaneous metastasis model. Metastases with oatp1b3-MRI could be observed at the single lymph node level and tracked over time as cancer cells spread to multiple lymph nodes and different organ systems in individual animals. While initial single lesions were successfully imaged in parallel via bioluminescence, later metastases were largely obscured by light scatter from the initial node. Importantly, MRI could detect micrometastases in lung tissue comprised on the order of 1,000 cancer cells. In summary, oatp1b3-MRI enables longitudinal tracking of cancer cells with combined high resolution and high sensitivity that provides 3D spatial information and the surrounding anatomical context.Significance:An MRI reporter gene system optimized for tracking metastasis in deep tissues at high resolutions and able to detect spontaneous micrometastases in lungs of mice provides a useful tool for metastasis research.

The integrity of a cell's proteome depends on correct folding of polypeptides by chaperonins. The chaperonin TCP-1 ring complex (TRiC) acts as obligate folder for >10% of cytosolic proteins, including he cytoskeletal proteins actin and tubulin. Although its architecture and how it recognizes folding substrates are emerging from structural studies, the subsequent fate of substrates inside the TRiC chamber is not defined. We trapped endogenous human TRiC with substrates (actin, tubulin) and cochaperone (PhLP2A) at different folding stages, for structure determination by cryo-EM. The already-folded regions of client proteins are anchored at the chamber wall, positioning unstructured regions toward the central space to achieve their native fold. Substrates engage with different sections of the chamber during the folding cycle, coupled to TRiC open-and-close transitions. Further, the cochaperone PhLP2A modulates folding, acting as a molecular strut between substrate and TRiC chamber. Our structural snapshots piece together an emerging model of client protein folding within TRiC. Tagging of the endogenous type II chaperonin TRiC complex using CRISPR knock-in enables its purification for cryo-EM. A series of structures reveal the fate of substrates and co-chaperones inside the TRiC chamber to uncover its inner workings.

Background Although recruiting highly qualified, diverse applicants into cardiothoracic surgery remains a national priority, their characteristics remain unknown. This study aims to describe current and future applicants in cardiothoracic surgery. Methods Aspiring cardiothoracic surgeons (students interested in matriculating in a North American training program) were voluntarily enrolled in the study through Twitter and email outreach. A 33-question survey evaluated their backgrounds, research experiences, attitudes, and interests within cardiothoracic surgery. Standard descriptive statistics were used. Results There were 111 participants, 40 of whom were female (36.0%) and 27 of whom identified as an underrepresented minority (24.3%). Of the total, 63 belonged to an institution with a cardiothoracic surgery training program (56.8%). A total of 91 students envisioned having a mostly operative career (82.0%) and 75 envisioned pursuing educational roles (67.6%). The most popular surgical specialties were heart transplantation (50.5%) and aortic surgery (47.8%). Participants selected having a high-intensity operative environment (81.2%) and an innovative academic environment (58.8%) as the most attractive qualities. Perceived lack of work–life balance (46%) and toxic training or work environment (28%) were the greatest deterrents. Finances during the application process were perceived as a potential barrier by 41 students (36.9%). Approximately 75% of students (83 of 111) had faculty as mentors; 46.8% (56 of 111) thought that cardiothoracic surgery faculty were approachable but had limited time for mentorship. Conclusions This survey study characterized a nationally selected pool of aspiring cardiothoracic surgeons using social media. Future studies involving larger and more diverse cohorts are warranted to find areas for improvement in recruitment, retention, and diversity.

The coronavirus disease 2019 (COVID-19) pandemic continues to pose a significant threat to patients receiving advanced heart failure therapies. The current study was undertaken to better understand the relationship between obesity and outcomes of SARS-CoV-2 infection in patients with a left ventricular assist device (LVAD) or heart transplant. We performed a retrospective review of patients with a heart transplant or LVAD who presented to one of the participating 11 institutions between April 1 and November 30, 2020. Patients were grouped by body mass index (BMI) into obese (BMI ≥ 30 k/m2) and nonobese cohorts (BMI30 kg/m2). Multivariable logistic regression models were used to estimate effects of obesity on outcomes of interest. Across all centers, 162 heart transplant and 81 LVAD patients were identified; 54 (33%) and 38 (47%) were obese, respectively. Obese patients tended to have more symptoms at presentation. No differences in rates of hospitalization or ICU admission were noted. Obese patients with LVADs were more likely to require mechanical ventilation (39% vs. 8%, p0.05). No differences in renal failure or secondary infection were noted. Mortality was similar among heart transplant patients (11% [obese] vs. 16% [nonobese], p = 0.628) and LVAD patients (12% vs. 15%, p = 1.0). BMI was not associated with increased adjusted odds of mortality, ICU admission, or mechanical ventilation (all p0.10). In summary, acute presentations of SARS-CoV-2 among heart transplant and LVAD recipients carry a significantly higher mortality than the general population, although BMI does not appear to impact this. Further studies on the longer-term effects of COVID-19 on this population are warranted.

OBJECTIVES In 2018, the United Network for Organ Sharing modified their heart allocation policy to reduce waitlist mortality and prioritize patients with the greatest acuity. Considering declining rates of combined heart-lung transplantation, this study sought to investigate the impact of the new allocation system on waitlist and post-transplant outcomes of patients listed for combined heart-lung transplantation. METHODS Adult patients listed for combined heart-lung transplant between 2012 and 2021 were included. Patients were stratified according to listing era. Competing risk regression was used to assess waitlist outcomes. Cox proportional hazards regression was used to establish risk factors for post-transplant mortality. RESULTS A total of 511 patients were included, of whom 295 (57.8%) were listed in era 1 and 216 (42.2%) in era 2. Era 2 was associated with increased likelihood of transplant (adjusted standard hazard ratio (aSHR): 1.60 [1.23–2.07]; P CONCLUSIONS The allocation policy change has led to improvements in waitlist outcomes in patients listed for heart-lung transplantation. Despite increased ischaemic times and use of ECMO, early post-transplant survival was equivalent.

In October 2018, the United States implemented a change in the donor heart allocation policy from a three-tiered to a six-tiered status system. The purpose of the current study was to examine changes in waitlist patterns among patients listed for concomitant heart-liver transplantation with implementation of the new allocation system.Patients listed for heart-liver transplantation between January 1, 2012, and June 30, 2021, were identified from the United Network for Organ Sharing database. Patients were grouped by era according to initial list date before or after October 18, 2018. Competing risks regression for mortality, transplantation, removal from waitlist due to illness was performed according to the method of Fine and Gray. Waitlist data were censored at 3 years from initial listing.Overall, 523 patients were identified, of whom 310 were listed before (era 1, 59%) and 213 after (era 2, 41%) allocation change. Patients in era 1 were older, had more restrictive cardiomyopathy, and more preoperative inotrope use (all P.05). However, patients in era 2 has longer ischemic times (3.5 ± 1.1 vs 3.1 ± 1.1 hours, P.01) and more intraaortic balloon pump use (8.9% vs 3.9%, P = .016). Era 2 was associated with lower subdistribution hazard for death (hazard ratio 0.37; 95% CI, 0.13-1.02; P = .054) and increased transplantation (hazard ratio 1.35; 95% CI, 1.06-1.72; P = .015).The implementation of the US donor heart allocation policy was associated with more preoperative intraaortic balloon pump use for patients listed for heart-liver transplantation. Despite that, the modern era was associated with lower waitlist mortality and more frequent transplantation, without increased risk of delisting due to illness.

OBJECTIVES The purpose of this study was to evaluate the association between left ventricular (LV) dilation and outcomes following valve-sparing root reimplantation. METHODS Patients with an indexed LV internal diameter during systole of ≥2.0 cm/m2 were categorized as having LV dilation. Outcomes were postoperative aortic insufficiency (AI), reintervention and all-cause mortality. The cumulative incidence of each outcome was computed using the Kaplan–Meier estimator. Adjusted comparisons between strata were performed for each outcome using a Cox proportional-hazards model. Where possible, the competing risk of death was accounted for. Multilevel mixed-effects ordered logistic regression was performed for AI grade at follow-up. RESULTS There were 295 patients of whom 52 had LV dilation. Operative outcomes were excellent; there were no significant differences between groups. Patients with LV dilation demonstrated significant improvement in indexed LV internal diameter during systole overtime. There was no association between LV dilation and postoperative AI grade >2 [hazard ratio 0.88, 95% confidence interval (CI) 0.21–3.67, P = 0.89] or odds of increased AI grade overtime (odds ratio = 0.76, 95% CI 0.30–1.93, P = 0.57). There were no re-interventions among those with LV dilation. Adjusted mortality was significantly higher among those with LV dilation (hazard ratio 5.56, 95% CI 1.56–19.9); however, deaths were unrelated to aortic valve dilation. CONCLUSIONS LV dilation is not associated with poorer operative outcomes, postoperative AI or reintervention. It is associated with an increased risk of mortality, though not from valvular dysfunction. LV dilation should not deter valve-sparing root reimplantation when otherwise indicated.

The channel-forming glycoprotein Pannexin 3 (PANX3) functions in cutaneous wound healing and keratinocyte differentiation, but its role in skin homeostasis through aging is not yet understood. We found that PANX3 is absent in newborn skin but becomes upregulated with age. We characterized the skin of globalPanx3knockout mice (KO) and found that KO dorsal skin showed sex-differences at different ages, but generally had reduced dermal and hypodermal areas compared to aged-matched controls. Transcriptomic analysis of KO epidermis revealed reduced E-cadherin stabilization and Wnt signaling compared to WT, consistent with the inability of primary KO keratinocytes to adhere in culture, and diminished epidermal barrier function in KO mice. We also observed increased inflammatory signaling in KO epidermis and higher incidence of dermatitis in aged KO mice compared to wildtype controls. These findings suggest that during skin aging, PANX3 is critical in the maintenance of dorsal skin architecture, keratinocyte cell-cell and cell-matrix adhesion and inflammatory skin responses.

Background and Purpose: Early detection of large vessel occlusion (LVO) stroke optimizes endovascular therapy and improves outcomes. Clinical stroke severity scales used for LVO identification have variable accuracy. We investigated a portable LVO-detection device (PLD), using electroencephalography and somatosensory-evoked potentials, to identify LVO stroke. Methods: We obtained PLD data in suspected patients with stroke enrolled prospectively via a convenience sample in 8 emergency departments within 24 hours of symptom onset. LVO discriminative signals were integrated into a binary classifier. The National Institutes of Health Stroke Scale was documented, and 4 prehospital stroke scales were retrospectively calculated. We compared PLD and scale performance to diagnostic neuroimaging. Results: Of 109 patients, there were 25 LVO (23%), 38 non-LVO ischemic (35%), 14 hemorrhages (13%), and 32 stroke mimics (29%). The PLD had higher sensitivity (80% [95% CI, 74–85]) and similar specificity (80% [95% CI, 77–83]) to all prehospital scales at their predetermined high probability LVO thresholds. The PLD had high discrimination for LVO ( C -statistic=0.88). Conclusions: The PLD identifies LVO with superior accuracy compared with prehospital stroke scales in emergency department suspected stroke. Future studies need to validate the PLD’s potential as an LVO triage aid in prehospital undifferentiated stroke populations.

The University of Pennsylvania classification system (Penn class) of acute type A aortic dissection (aTAAD) is used to evaluate the impact of malperfusion on surgical outcomes. The purpose of this analysis was to determine the validity of Penn class in a larger and more contemporary cohort and to compare its performance with other classification systems.This was a retrospective study of patients who underwent aTAAD repair at our institution from 1993 to 2020. Patients were assigned to Penn class on the basis of burden of preoperative malperfusion syndrome. The association of Penn class and 30-day mortality was evaluated by multivariable regression. The discriminatory ability of Penn class for mortality was determined by a bootstrapped C statistic.There were 1192 patients, of whom 50% were assigned to Penn class A (no ischemia), 21% (253/1192) to class B (local ischemia), 14% (171/1192) to class C (generalized ischemia), and 14% (167/1192) to class B-C (combined ischemia). The incidence of mortality rose significantly with increasing Penn class from 5% (31/601) in class A to 35% (59/167) in class B-C (P.001). After adjustment, 30-day mortality increased significantly with class B (odds ratio [OR], 2.43; 95% CI, 1.38-4.27), class C (OR, 3.39; 95% CI, 1.90-6.03), and class B-C (OR, 13.08; 95% CI, 7.90-22.15) compared with class A. The C statistic was 0.77 (95% CI, 0.72-0.80) and was significantly higher than for models featuring alternative classification systems (P.05).Penn class provides excellent discrimination for 30-day mortality after repair of aTAAD.

Microplastic is a contaminant of concern in freshwater ecosystems worldwide. Microplastic particles within aquatic habitats are colonized by dense microbial biofilms, and previous studies h...

OBJECTIVES The introduction and expansion of thoracic endovascular aortic repair (TEVAR) have revolutionized the treatment of a variety of thoracic aortic diseases. We sought to evaluate the incidence, causes, predictors and costs associated with 30-day readmission after TEVAR in a nationally representative cohort. METHODS Adult patients undergoing isolated TEVAR were identified in the National Readmissions Database from 2010 to 2014. Hospital costs were estimated by converting individual hospital charge data adjusted to 2014 consumer price indices. Multivariable logistic regression was utilized to determine hospital- and patient-level factors associated with readmissions. RESULTS A total of 24 983 TEVARs were noted during the study period; the average age of the patients was 65 ± 16 years; 40% were women. The most common indication was an intact thoracic aneurysm (43.5%), followed by aortic dissection (30.5%). The average cost of the index admission was $63 644 ± $52 312; the average hospital stay was 11 ± 14 days; the index mortality rate was 6.7%. Readmissions within 30 days occurred in 17.4% of patients. Indications for readmission were varied; the most common aetiologies were cardiac (17.8%), infectious (16.0%) and pulmonary (12.1%). On multivariable analysis, the strongest predictor of readmission was the diagnosis, with a ruptured thoraco-abdominal aneurysm having the highest readmission burden (adjusted odds ratio 2.23, 1.17–4.24; P = 0.015). Notably, hospital volume did not predict index hospital length of stay, costs or 30-day readmissions (all P > 0.10). CONCLUSIONS Annual TEVAR volume was not associated with any of the outcomes assessed. Rather, indication for TEVAR was the strongest predictor for many outcomes. As TEVAR becomes increasingly utilized, a focus on cardiac and vascular diseases may reduce readmissions and improve quality of care.

Introduction Despite growth in hand/upper extremity investigation, impactful studies have not been thoroughly identified. Previous studies have been limited in scope. This study sought to identify and characterize the most impactful orthopaedic papers in hand/upper extremity over the past 25 years. Materials and Methods The top 1,000 hand/upper extremity orthopaedic studies published from 1992 to 2017 were identified with Web of Science. After screening for relevance in order of decreasing citation number, the top 100 articles were identified for bibliometric analysis. Results The mean number of authors and citations were 4.51 (range, 1–21) and 169.4 (range, 105–863). Common study types included, case series (n = 52), randomized controlled trial (n = 17), and prospective cohort (n = 16), which predominantly covered topics related to shoulder (n = 34), wrist/forearm (n = 21), and hand (n = 17). Among wrist/forearm and hand studies, distal radius fractures (n = 12) and nerve-related topics (n = 10) were most frequently analyzed. Most studies were of level IV (n = 51) and level II (n = 16) evidence. Recent studies had greater impact (mean citations/year: 2011, 82.7/year vs. 1992, 16.1/year). Conclusion Most of the 100 top orthopaedic articles in hand/upper extremity were of level IV or II evidence, retrospective, and nonrandomized. Despite an observed recent increase in level I studies, a lack of prospective, randomized trials is apparent.

Frailty is increasingly recognized as an important prognostic marker in surgical populations. The effects of frailty on outcomes after mitral valve replacement (MVR) is less clear given the inherent complexity of this patient population. We evaluated the influences of frailty on outcomes and readmission rates after MVR.Adult patients undergoing isolated MVR were queried from the National Readmissions Database from 2010 to 2014. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator, a validated instrument developed for use in health administrative data. Multivariable logistic regression was used to determine hospital- and patient-level risk factors for readmission, postoperative complications, and death.Among 50,410 patients who underwent MVR, 7.9% met frailty criteria. Frail patients were more likely to be older, have nonprivate insurance, an index admission from the emergency department, and teaching hospital care (all P.001). Frail patients had significantly more postoperative complications (77% vs 47%, P.001), more discharges to a facility (50% vs 21%, P.001), and higher in-hospital mortality (12% vs 4%, P.001). Index hospitalization costs were almost doubled in frail patients, and of those who survived to discharge, 30-day readmissions were more frequent (28% vs 20%, P.001). Frailty independently increased the risk of index hospitalization composite complications (adjusted odds ratio [AOR], 3.28; 95% confidence interval [CI], 2.61-4.12), in-hospital mortality (AOR, 2.35; 95% CI, 1.90-2.92), and 30-day readmission (AOR, 1.47; 95% CI, 1.20-1.78).Frailty is an independent predictor of morbidity, death, and increased costs after MVR. Frailty metrics should be increasingly understood among patients requiring mitral valve intervention as percutaneous approaches for intervention become increasingly used.

In 2018, a United Network for Organ Sharing (UNOS) policy change increased prioritization of patients bridged with temporary mechanical circulatory support devices, such as venoarterial ECMO, for cardiac transplantation. Considering increased waitlist acuity, we sought to characterize whether this was associated with an increased risk for development of postoperative acute renal failure requiring dialysis (AKI-D) and risk of death after transplantation.Dialysis-naive adults receiving single-organ heart transplant between November 2009 and February 2020 were stratified by receipt of AKI-D. Era 1 and era 2 were defined by the periods of UNOS allocation before and after policy change, respectively. Multivariable logistic regression was performed to determine risk factors for AKI-D. Rates of AKI-D were compared by propensity score-matched cohorts. Survival was compared by Kaplan-Meier analysis.A total of 20 698 patients were included. Venoarterial ECMO use significantly increased in era 2 (5.6% vs 0.58%; P.01). Overall prevalence of AKI-D was greater in era 2 (13.5% vs 10.2%; P.01). Use of preoperative ECMO, intra-aortic balloon pump, and ventilators and longer ischemia times were identified as independent risk factors for development of AKI-D. Five- and 10-year survival rates were significantly decreased for patients with AKI-D. There was no short-term survival difference of patients with AKI-D between era 2 and the more contemporary era 1.Patients in whom AKI-D develops after transplantation have significantly worse short- and long-term outcomes. Preoperative use of ECMO, preoperative ventilator support, and longer ischemia times are risk factors for development of AKI-D, and their prevalence has increased since the allocation policy change.

Metastasis remains a poorly understood aspect of cancer biology and the leading cause of cancer-related death, yet most preclinical cancer studies do not examine metastasis, focusing solely on the primary tumor. One major factor contributing to this paradox is a gap in available tools for accurate spatiotemporal measurements of metastatic spread in vivo. Our objective was to develop an imaging reporter system that offers sensitive three-dimensional detection of cancer cells at high resolutions in live mice. We utilized organic anion-transporting polypeptide lb3 (oatp1b3) as a magnetic resonance imaging (MRI) reporter gene to this end, and systematically optimized its framework for in vivo tracking of viable cancer cells in a spontaneous metastasis model. We were able to image metastasis on oatp1b3-MRI at the single lymph node level and continued to track its progression over time as cancer cells spread to multiple lymph nodes and different organ systems in single animals. While initial single lesions were successfully imaged in parallel via bioluminescence, later metastases were obscured by light scatter from the initial node. Importantly, we demonstrate and validate that 100-μm isotropic resolution MR images could detect micrometastases in lung tissue estimated to contain fewer than 103 cancer cells. In summary, oatp1b3-MRI enables precise determination of lesion size and location over time and offers a path towards deep-tissue tracking of any oatp1b3-engineered cell type with combined high resolution, high sensitivity, 3D spatial information, and surrounding anatomical context.

INTRODUCTION Outcomes after anterior cervical diskectomy and fusion (ACDF) and cervical total disk arthroplasty (TDA) are satisfactory, but related morbidity and revision surgery rates are notable. This study sought to determine complication variations among ACDF, TDA, and combined ACDF-TDA as well as predictors of postoperative complications. METHODS Patients undergoing 1- to 2-level ACDF and/or TDA with at least a 2-year follow-up from 2009 to 2011 were identified from the Statewide Planning and Research Cooperative System database. Patient demographics, hospital-related parameters, mortality, and postoperative outcomes were compared, and their predictors were identified using multivariate logistic regression. RESULTS A total of 16,510 and 449 individuals underwent ACDF and cervical TDA, respectively, and 201 underwent ACDF-TDA. ACDF-TDA patients had the highest rates of cardiac complications and pulmonary embolism (PE) (P ≤ 0.006), whereas TDA patients had higher individual surgical and device/implant/internal fixation complications (P ≤ 0.025). ACDF-TDA patients experienced the lowest rate of revisions. Cervical TDA increased the odds of any surgical complications (OR = 2.5, P = 0.002), overall complications (OR = 1.57, P = 0.034), and revisions (OR = 2.29, P < 0.001). Deyo index predicted any medical/surgical complications (OR = 1.43 and 1.19, respectively). Female sex was associated with increased odds of readmission (OR 1.30, P < 0.001) but was protective against medical complications (OR = 0.81, P = 0.013). DISCUSSION Combined ACDF-TDA procedures were not associated with increases in 2-year individual or overall complications, readmissions, or revisions. LEVEL OF EVIDENCE Level 3-Therapeutic study.

Postsurgical readmissions are an increasingly scrutinized marker of health care quality. We sought to estimate the risk factors and costs associated with readmissions after mitral valve (MV) surgery in a large, nationally representative cohort.Adult patients undergoing MV repair or replacement were queried from the National Readmissions Database from 2010 to 2014. Data were collected on the prevalence and indications for readmission within 30 days as well as the hospital-, procedure, and patient-level risk factors as determined by multivariable logistic regression.Among 76,342 patients undergoing MV surgery, the rate of 30-day readmission was 17.0%. Those undergoing replacement procedures had significantly higher readmission rates (20.7% vs 13.1%; P.001) compared with repair. Significant independent predictors of readmission after both MV repair and replacement included length of stay ≥8 days, chronic lung disease, chronic renal disease, and low hospital procedural volume for MV surgery. Readmissions to nonindex hospitals accounted for 26.6% of all readmissions. The most common indications for readmission were heart failure (21.4%), arrhythmia (17.0%) and respiratory diagnoses (15.0%), and infections (10.2%). The mean cost per readmission was $15,397, and among readmitted patients, the cost of readmission accounted for 17.8% of the total cost of the episode of care.Nearly 1 in 5 patients undergoing MV surgery are readmitted within 30 days. Treatment at a low-volume center was strongly associated with readmission, and much of the readmission burden falls on nonindex hospitals. Further characterization of readmissions may improve the quality of care associated with MV surgery.

In patients with preoperative atrial fibrillation (AF) undergoing aortic valve replacement, the addition of surgical ablation to surgical aortic valve replacement (SAVR-SA) is efficacious and a Class I guideline. We hypothesized that this subgroup may benefit from SAVR-SA compared to transcatheter aortic valve replacement (TAVR) alone.Medicare beneficiaries with persistent non-valvular AF who underwent SAVR-SA or TAVR alone between 2012 and 2018 were included. Patients with high-risk surgical comorbidities were excluded. Groups were matched using inverse probability weighting. The primary outcome was all-cause mortality. Secondary outcomes were stroke, transient ischemic attack, permanent pacemaker implantation, bleeding, rehospitalization for atrial arrhythmias, and rehospitalization for heart failure. Kaplan-Meier estimates and Cox proportional-hazards regression were used to compare outcomes. Outcomes were adjusted for variables with a standardized mean difference greater than 0.1.Of 439,492 patients who underwent aortic valve replacement, 2591 underwent SAVR-SA and 1494 underwent TAVR alone. Weighting resulted in adequately matched groups. Compared to TAVR alone, SAVR-SA was associated with a significant reduction in all-cause mortality (HR 0.65, 95% CI 0.53-0.79), permanent pacemaker implantation (HR 0.62, 95% CI 0.44-0.87), bleeding (HR 0.63, 95% CI 0.39-1.00), and rehospitalization for heart failure (HR 0.49 (0.36-0.65). There was no difference in the incidence of stroke (HR 1.07, 95% CI 0.74-1.54), transient ischemic attack (HR 1.05, 95% CI 0.75-1.47), or rehospitalization for atrial arrhythmia.Select patients with persistent non-valvular AF may benefit from SAVR-SA compared to TAVR alone.

A significant decrease in emergency presentations of acute cardiac conditions has been observed during the COVID-19 pandemic. We aimed to understand perceptions that influence people's decisions whether to present to the emergency department (ED) with symptoms related to acute cardiovascular events to inform necessary medical communication.We recruited users of Amazon Mechanical Turk (Seattle, WA) to participate in a survey to elucidate perceptions of COVID-19 risk associated with a visit to the ED. A conjoint analysis was designed based on commonly reported factors associated with people's decisions to present to the ED during the pandemic to calculate preference utilities.After exclusions, 1003 participants completed the survey between 12/5/2020 and 12/6/2020. Participants ranked the perceived risk of contracting COVID-19 at the ED as one of the highest, only second to that at bars and restaurants. Only 68% (685/1003) were willing to present to the ED immediately with severe chest pain. Fear of further transmitting the virus to loved ones was the most frequently cited reason for not presenting. Conjoint analysis demonstrated severe chest pain to be the dominant factor in the decision to present to the ED.The risk of contracting COVID-19 while presenting to the ED for a life-threatening cardiovascular symptom is overestimated and is strongly affected by social factors.

There is a tremendous need for affordable and accessible surgical simulators in the United States and abroad. Our group developed a portable, modular, inexpensive surgical simulator designed for all levels of surgical trainees, from medical students to cardiothoracic surgery fellows, and adaptable to a variety of surgical specialties. Our goal is to provide a platform for innovative surgery simulation that applies to any learner or resource setting. We describe the development, assembly, and future directions for this simulator.

Intracranial Masson tumor (intravascular papillary endothelial hyperplasia, IPEH) is a benign lesion that is thought to originate from a reactionary process in response to compromised blood flow. IPEH may be classified into one of three subtypes based on etiology as it may result from the excessive proliferation of endothelial cells within a normal vessel (primary), vascular malformation (type II), or organized hematoma (type III). We report the case of a 79-year-old woman who presented with confusion, gait instability, and urinary incontinence. Neuroimaging revealed a hemorrhagic lesion within the right lateral ventricle, which was successfully resected. To our knowledge, this is the first reported case of an intraventricular IPEH and 33rd case of primary intracranial IPEH. We further performed a systematic review of the literature on all prior type I intracranial IPEH cases and discuss the importance of long-term follow-up in intracranial IPEH.

Subacute groin complications associated with extracorporeal membrane oxygenation (ECMO) cannulation are well recognized, yet their effects on clinical outcomes remain unknown. This single-center, retrospective study reviewed all patients receiving venoarterial ECMO from 01/2017 to 02/2020. Cohorts analyzed included transplanted patients (TPs) and non-transplanted patients (N-TPs) who did or did not develop ECMO-related subacute groin complications. Standard descriptive statistics were used for comparisons. Logistic regressions identified associated risk factors. Overall, 82/367 (22.3%) ECMO patients developed subacute groin complications, including 25/82 (30.5%) seromas/lymphoceles, 32/82 (39.0%) hematomas, 18/82 (22.0%) infections, and 7/82 (8.5%) non-specified collections. Of these, 20/82 (24.4%) underwent surgical interventions, most of which were muscle flaps (14/20, 70.0%). TPs had a higher incidence of subacute groin complications than N-TPs (14/28, 50.0% vs. 68/339, 20.1%, P = 0.001). Seromas/lymphoceles more often developed in TPs than N-TPs (10/14, 71.4% vs. 15/68, 22.1%, P = 0.001). Most patients with subacute groin complications survived to discharge (60/68, 88.2%). N-TPs who developed subacute groin complications had longer post-ECMO lengths of stay than those who did not (34 days, IQR 16-53 days vs. 17 days, IQR 8-34 days, P 0.001). Post-ECMO length of stay was also longer among patients who underwent related surgical interventions compared to those who did not (50 days, IQR 35-67 days vs. 29 days, IQR 16-49 days, P = 0.007). Transplantation was the strongest risk factor for developing subacute groin complications (OR 3.91, CI

Objective To assess societal preferences regarding allocation of extracorporeal membrane oxygenation (ECMO) as a rescue option for select patients with coronavirus disease 2019 (COVID-19). Design Cross-sectional survey of a nationally representative sample. Setting Amazon Mechanical Turk platform. Participants In total, responses from 1,041 members of Amazon Mechanical Turk crowd-sourcing platform were included. Participants were 37.9 ± 12.6 years old, generally white (65%), and college-educated (66.1%). Many reported working in a healthcare setting (22.5%) and having a friend or family member who was admitted to the hospital (43.8%) or died from COVID-19 (29.9%). Measurements and Main Results Although most reported an unwillingness to stay on ECMO for >one week without signs of recovery, participants were highly supportive of ECMO utilization as a life-preserving technique on a policy level. The majority (96.7%) advocated for continued use of ECMO to treat COVID patients during periods of resource scarcity but would prioritize those with highest likelihood of recovery (50%) followed by those who were sickest regardless of survival chances (31.7%). Patients >40 years old were more likely to prefer distributing ECMO on a first-come first-served basis (21.5% v 13.3%, p Conclusion Even though participants expressed hesitation regarding ECMO in personal circumstances, they were uniformly in support of using ECMO to treat COVID patients at a policy level for others who might need it, even in the setting of severe scarcity.

Background The COVID‐19 pandemic has disrupted all aspects of healthcare, including cardiothoracic surgery (CTS). We sought to determine the pandemic's impact on CTS trainees' educational experiences. Methods A survey was developed and distributed to members of the Thoracic Surgery Residents Association and other international CTS trainees. Trainees were asked to evaluate their cumulative experiences and share their overall perceptions of how CTS training had been impacted during the earliest months of the COVID‐19 pandemic (i.e., since March 01, 2020). Surveys were distributed and responses were recorded June 25–August 05, 2020. In total, 748 surveys were distributed and 166 responses were received (overall response rate 22.2%). Of these, 126 of 166 responses (75.9%) met inclusion criteria for final analysis. Results Final responses analyzed included 45 of 126 (35.7%) United States (US) and 81 of 126 (64.3%) international trainees, including 101 of 126 (80.2%) senior and 25 of 126 (19.8%) junior trainees. Most respondents (76/126, 43.2%) lost over 1 week in the hospital due to the pandemic. Juniors (12/25, 48.0%) were more likely than seniors (20/101, 19.8%) to be reassigned to COVID‐19‐specific units (p, Cardiothoracic surgery trainees in the United States and abroad have been significantly impacted by the COVID‐19 pandemic in the form of lost time in the hospital, decreased operative volumes, and frequent reassignment to COVID‐19‐specific care settings

Biochar has been promoted as a soil amendment that enhances soil quality and agronomic productivity and reduces greenhouse gas production. However, these benefits are not always realized. A major hurdle to the beneficial use of biochar is our limited knowledge regarding the mechanisms directing its effects on soil systems. This project aimed to eliminate some of this uncertainty by examining the biological responses (plant productivity, greenhouse gas production, soil microbial community structure) of a suite of soils (10) to the addition of biochars produced by different processes (pyrolysis, gasification, burning) from a range of feedstocks (corn stalks, hardwood, grass). Results indicated that these three responses were not significantly impacted by the addition of pyrolysis biochars from different feedstocks at 1 and 5% (w/w) addition levels. On the other hand, both an open-air burned corn stalk (5%) and raw corn stalks (1 and 5%) additions did alter the measured soil functionality. For example, the 5% burnt corn stalks addition reduced total above ground plant biomass (∼30%), increased observed N2O production by an order of magnitude, and altered soil bacterial community structure. The bacterial groups that increased in relative abundance in the burnt corn stalks-amended soils included families associated with cellulose decomposition (Chitinophagaceae), plant pathogens (Xanthomonadaceae), and biochar/charcoal-amended media (Gemmatimonadetes). In contrast, the abundance of these bacterial groups was not impacted by the pyrolysis biochars. Therefore, this research suggests that pyrolysis biochar represents a stabilized form of carbon that is resistant to microbial mineralization and has negligible effects on soil biological responses.

Background Currently, the functional status of patients undergoing spine surgery is assessed with quality-of-life questionnaires, and a more objective and quantifiable assessment method is lacking. Dr. Jean Dubousset conceptually proposed a four-component functional test, but to our knowledge, reference values derived from asymptomatic individuals have not yet been reported, and these are needed to assess the test's clinical utility in patients with spinal deformities. Questions/purposes (1) What are the reference values for the Dubousset Functional Test (DFT) in asymptomatic people? (2) Is there a correlation between demographic variables such as age and BMI and performance of the DFT among asymptomatic people? Methods This single-institution prospective study was performed from January 1, 2018 to May 31, 2018. Asymptomatic volunteers were recruited from our college of medicine and hospital staff to participate in the DFT. Included participants did not report any musculoskeletal problems or trauma within 5 years. Additionally, they did not report any history of lower limb fracture, THA, TKA, or patellofemoral arthroplasty. Patients were also excluded if they reported any active medical comorbidities. Demographic data collected included age, sex, BMI, and self-reported race. Sixty-five asymptomatic volunteers were included in this study. Their mean age was 42 ± 15 years; 27 of the 65 participants (42%) were women. Their mean BMI was 26 ± 5 kg/m. The racial distribution of the participants was 34% white (22 of 65 participants), 25% black (16 of 65 participants), 15% Asian (10 of 65 participants), 9% subcontinental Indian (six of 65 participants), 6% Latino (four of 65 participants), and 10% other (seven of 65 participants). In a controlled setting, participants completed the DFT after verbal instruction and demonstration of each test, and all participants were video recorded. The four test components included the Up and Walking Test (unassisted sit-to-stand from a chair, walk forward/backward 5 meters [no turn], then unassisted stand-to-sit), Steps Test (ascend three steps, turn, descend three steps), Down and Sitting Test (stand-to-ground, followed by ground-to-stand, with assistance as needed), and Dual-Tasking Test (walk 5 meters forwards and back while counting down from 50 by 2). Tests were timed, and data were collected from video recordings to ensure consistency. Reference values for the DFT were determined via a descriptive analysis, and we calculated the mean, SD, 95% CI, median, and range of time taken to complete each test component, with univariate comparisons between men and women for each component. Linear correlations between age and BMI and test components were studied, and the frequency of verbal and physical pausing and adverse events was noted. Results The Up and Walking Test was completed in a mean of 15 seconds (95% CI, 14-16), the Steps Test was completed in 6.3 seconds (95% CI, 6.0-6.6), the Down and Sitting Test was completed in 6.0 seconds (95% CI, 5.4-6.6), and the Dual-Tasking Test was performed in 13 seconds (95% CI, 12-14). The length of time it took to complete the Down and Sitting (r = 0.529; p = 0.001), Up and Walking (r = 0.429; p = 0.001), and Steps (r = 0.356; p = 0.014) components increased with as the volunteer's age increased. No correlation was found between age and the time taken to complete the Dual-Tasking Test (r = 0.134; p = 0.289). Similarly, the length of time it took to complete the Down and Sitting (r = 0.372; p = 0.005), Up and Walking (r = 0.289; p = 0.032), and Steps (r = 0.366; p = 0.013) components increased with increasing BMI; no correlation was found between the Dual-Tasking Test's time and BMI (r = 0.078; p = 0.539). Conclusions We found that the DFT could be completed by asymptomatic volunteers in approximately 1 minute, although it took longer for older patients and patients with higher BMI. Clinical relevance We believe, but did not show, that the DFT might be useful in assessing patients with spinal deformities. The normal values we calculated should be compared in future studies with those of patients before and after undergoing spine surgery to determine whether this test has practical clinical utility. The DFT provides objective metrics to assess function and balance that are easy to obtain, and the test requires no special equipment.

This study sought to assess comorbidity profiles unique to early-onset-scoliosis (EOS) patients by employing cluster analytics and to determine the influence of isolated comorbidity clusters on perioperative complications, morbidity and mortality using a high powered administrative database. The KID database was queried for ICD-9 codes pertaining to congenital and idiopathic scoliosis from 2003, 2006, 2009, 2012. Patients10 y/o (EOS group) were included. Demographics, incidence and comorbidity profiles were assessed. Comorbidity profiles were stratified by body systems (neurological, musculoskeletal, pulmonary, cardiovascular, renal). K-means cluster and descriptive analyses elucidated incidence and comorbidity relationships between frequently co-occurring comorbidities. Binary logistic regression models determined predictors of perioperative complication development, mortality, and extended length-of-stay (≥75th percentile). 25,747 patients were included (Age: 4.34, Female: 52.1%, CCI: 0.64). Incidence was 8.9 per 100,000 annual discharges. 55.2% presented with pulmonary comorbidities, 48.7% musculoskeletal, 43.8% neurological, 18.6% cardiovascular, and 11.9% renal; 38% had concurrent neurological and pulmonary. Top inter-bodysystem clusters: Pulmonary disease (17.2%) with epilepsy (17.8%), pulmonary failure (12.2%), restrictive lung disease (10.5%), or microcephaly and quadriplegia (2.1%). Musculoskeletal comorbidities (48.7%) with renal and cardiovascular comorbidities (8.2%, OR: 7.9 [6.6-9.4], p 0.001). Top intra-bodysystem clusters: Epilepsy (11.7%) with quadriplegia (25.8%) or microcephaly (20.5%). Regression analysis determined neurological and pulmonary clusters to have a higher odds of perioperative complication development (OR: 1.28 [1.19-1.37], p 0.001) and mortality (OR: 2.05 [1.65-2.54], p 0.001). Musculoskeletal with cardiovascular and renal anomalies had higher odds of mortality (OR: 1.72 [1.28-2.29], p 0.001) and extLOS (OR: 2.83 [2.48-3.22], p 0.001). EOS patients with musculoskeletal conditions were 7.9x more likely to have concurrent cardiovascular and renal anomalies. Clustered neurologic and pulmonary anomalies increased mortality risk by as much as 105%. These relationships may benefit pre-operative risk assessment for concurrent anomalies and adverse outcomes. Level of Evidence: III - Retrospective Prognostic Study.

Background Stroke is a serious complication after transcatheter aortic valve replacement (TAVR), yet predictive models are not available. A new risk model for in-hospital stroke after TAVR was developed and used to estimate site-specific performance. Methods We included 97,600 TAVR procedures from 521 sites in The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry from July 2014 to June 2017. Association between baseline covariates and in-hospital stroke was estimated by logistic regression. Discrimination was evaluated by C-statistic. Calibration was tested internally via cross-validation. Hierarchical modeling was used to estimate risk-adjusted site-specific performance. Results Median age was 82 years, 44,926 (46.0%) were women, and 1,839 (1.9%) had in-hospital stroke. Covariates associated with stroke (odds ratio) included transapical access (1.44), access excluding transapical and transfemoral (1.77), prior stroke (1.57), prior transient ischemic attack (1.50), preprocedural shock, inotropes or mechanical assist device (1.48), smoking (1.28), porcelain aorta (1.23), peripheral arterial disease (1.21), age per 5 years (1.11), glomerular filtration rate per 5 mL/min (0.97), body surface area per m2 (0.55 male; 0.43 female), and prior aortic valve (0.78) and nonaortic valvular (0.42) procedures. The C-statistic was 0.622. Calibration curves demonstrated agreement between observed and expected stroke rates. Hierarchical modeling showed 10 (1.9%) centers with significantly higher odds ratios for in-hospital stroke than their peers. Conclusions A risk model for in-hospital stroke after TAVR was developed from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry and used to estimate site-specific stroke performance. This model can serve as a valuable resource for quality improvement, clinical decision making, and patient counseling.