Coronavirus disease 19 in minority populations of Newark, New Jersey

BACKGROUND

The purpose of this study is to report the clinical features and outcomes of Black/African American (AA) and Latino Hispanic patients with Coronavirus disease 2019 (COVID-19) hospitalized in an inter-city hospital in the state of New Jersey.

METHODS

This is a retrospective cohort study of AA and Latino Hispanic patients with COVID-19 admitted to a 665-bed quaternary care, teaching hospital located in Newark, New Jersey. The study included patients who had completed hospitalization between March 10, 2020, and April 10, 2020. We reviewed demographics, socioeconomic variables and incidence of in-hospital mortality and morbidity. Logistic regression was used to identify predictor of in-hospital death.

RESULTS

Out of 416 patients, 251 (60%) had completed hospitalization as of April 10, 2020. The incidence of In-hospital mortality was 38.6% (n = 97). Most common symptoms at initial presentation were dyspnea 39% (n = 162) followed by cough 38%(n = 156) and fever 34% (n = 143). Patients were in the highest quartile for population's density, number of housing units and disproportionately fell into the lowest median income quartile for the state of New Jersey. The incidence of septic shock, acute kidney injury (AKI) requiring hemodialysis and admission to an intensive care unit (ICU) was 24% (n = 59), 21% (n = 52), 33% (n = 82) respectively. Independent predictors of in-hospital mortality were older age, lower serum Hemoglobin < 10 mg/dl, elevated serum Ferritin and Creatinine phosphokinase levels > 1200 U/L and > 1000 U/L.

CONCLUSIONS

Findings from an inter-city hospital's experience with COVID-19 among underserved minority populations showed that, more than one of every three patients were at risk for in-hospital death or morbidity. Older age and elevated inflammatory markers at presentation were associated with in-hospital death.

Clinical outcomes of patients with COVID-19 and HIV coinfection

Background

Patients with human immunodeficiency virus (HIV) infection may be at an increased risk for morbidity and mortality from the coronavirus disease 2019 (COVID‐19). We present the clinical outcomes of HIV patients hospitalized for COVID‐19 in a matched comparison with historical controls.

Methods

We conducted a retrospective cohort study of HIV patients admitted for COVID‐19 between March 2020 and April 2020 to Newark Beth Israel Medical Center. Data on baseline clinical characteristics and hospital course were documented and compared with that of a matched control group of COVID‐19 patients who had no history of HIV. Kaplan–Meier survival curves and the log‐rank tests were used to estimate and compare in‐hospital survival between both unmatched and matched groups.

Results

Twenty‐three patients with HIV were hospitalized with COVID‐19. The median age was 59 years. The rates of in‐hospital death, the need for mechanical ventilation, and intensive care unit (ICU) admission were 13% (n = 3), 9% (n = 2), and 9% (n = 2), respectively. The HIV infection was well‐controlled in all patients except for three patients presented with acquired immune deficiency syndrome (AIDS). All AIDS patients were discharged home uneventfully. A one‐to‐one propensity matching identified 23 COVID‐19 patients who served as a control group. In both pre‐ and post‐match cohorts, survival between HIV and control groups were comparable.

Conclusions

In our cohort of HIV‐infected patients hospitalized for COVID‐19, there was no difference in mortality, ICU admission, and the need for mechanical ventilation when compared with a matched control of COVID‐19 patients with HIV.

The impact of frailty status on clinical and functional outcomes after transcatheter aortic valve replacement in nonagenarians with severe aortic stenosis

BACKGROUND

The impact of frailty status on TAVR outcomes in nonagenarians is unknown. The present study aims to investigate the impact of frailty status on procedural outcomes and overall survival in nonagenarians after TAVR.

METHODS

A frailty score (FS) was derived by using preoperative grip strength, gait speed, serum albumin, and daily activities. Patients were divided into two groups: Frail (FS ≥ 3/4) and Non-Frail (FS <3/4). Health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ). Baseline demographic and clinical characteristics were compared in both groups. The effect of frailty status on outcomes was investigated. Cox regression analyses were performed to determine predictors of overall all-cause mortality. Kaplan-Meier survival curves were used to estimate survival.

RESULTS

Seventy-five patients >90 years underwent full assessment for frailty status. There was a significant improvement in overall health status of non-frail patients (mean difference: 11.03, P = 0.032). Unadjusted 30-day and 2-year mortality rates were higher in the frail group than the non-frail group. (14% vs. 2% P = 0.059; 31% vs. 9% P = 0.018). Kaplan-Meier estimated all-cause mortality to be significantly higher in the frail group (log-rank test; P = 0.042). Frailty status was independently associated with increased mortality (hazard ratio: 1.84, 95% C.I: 1.06-3.17; P = 0.028) after TAVR.

CONCLUSION

Among nonagenarians selected to undergo TAVR for severe aortic stenosis, a considerable number are frail. Nonfrail patients report a significant improvement in overall health status in the short term. Worse frailty is strongly associated with diminished long-term survival. © 2017 Wiley Periodicals, Inc.

Ambulatory Electrocardiographic Monitoring Following Minimalist Transcatheter Aortic Valve Replacement

OBJECTIVES

The aim of this study was to determine the impact of delayed high-degree atrioventricular block (HAVB) or complete heart block (CHB) after transcatheter aortic valve replacement (TAVR) using a minimalist approach followed by ambulatory electrocardiographic (AECG) monitoring.

BACKGROUND

Little is known regarding the clinical impact of HAVB or CHB in the early period after discharge following TAVR.

METHODS

A prospective, multicenter study was conducted, including 459 consecutive TAVR patients without permanent pacemaker who underwent continuous AECG monitoring for 14 days (median length of hospital stay 2 days; IQR: 1-3 days), using 2 devices (CardioSTAT and Zio AT). The primary endpoint was the occurrence of HAVB or CHB. Patients were divided into 3 groups: 1) no right bundle branch block (RBBB) and no electrocardiographic (ECG) changes; 2) baseline RBBB with no further changes; and 3) new-onset ECG conduction disturbances.

RESULTS

Delayed HAVB or CHB episodes occurred in 21 patients (4.6%) (median 5 days postprocedure; IQR: 4-6 days), leading to PPM in 17 (81.0%). HAVB or CHB events were rare in group 1 (7 of 315 [2.2%]), and the incidence increased in group 2 (5 of 38 [13.2%]; P < 0.001 vs group 1) and group 3 (9 of 106 [8.5%]; P = 0.007 vs group 1; P = 0.523 vs group 2). No episodes of sudden or all-cause death occurred at 30-day follow-up.

CONCLUSIONS

Systematic 2-week AECG monitoring following minimalist TAVR detected HAVB and CHB episodes in about 5% of cases, with no mortality at 1 month. Whereas HAVB or CHB was rare in patients without ECG changes post-TAVR, baseline RBBB and new-onset conduction disturbances determined an increased risk. These results would support tailored management using AECG monitoring and the possibility of longer hospitalization periods in patients at higher risk for delayed HAVB or CHB.

Hemobilia as a result of right hepatic artery pseudoaneurysm rupture: An unusual complication of laparoscopic cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy has many complications which may be seen due to anatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficient exposure of the surgical field; including vascular injuries. Here we present a case of pseudoaneurysm of the right hepatic artery leading to hemobilia after rupturing into the biliary system.

PRESENTATION OF CASE

A 43-year-old male patient presented to our clinic 3 weeks post laparoscopic cholecystectomy with right upper quadrant pain, melena and hematemesis. After stabilizing the patient, Doppler ultrasonography, abdominal computer tomography and selective right hepatic artery angiography were performed and a pseudoaneurysm was established on the anterior posterior bifurcation of right hepatic artery. Right hepatic artery ligation and a T-tube placement after choledocotomy were performed. The patient recovered completely.

DISCUSSION

Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic cholecystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be precipitating factors. Today, transarterial embolization (TAE) is the gold standard for the management of hemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic or gallbladder bleeding, and for TAE failure.

CONCLUSION

In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicion of hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CT angiography should be performed for early diagnosis and management in such patients.

Percutaneous Axillary Access for Placement of Microaxial Ventricular Support Devices: The Axillary Access Registry to Monitor Safety (ARMS)

Supplemental Digital Content is available in the text.

Background:

There has been increasing utilization of short-term mechanical circulatory support devices for a variety of clinical indications. Many patients have suboptimal iliofemoral access options or reasons why early mobilization is desirable. Axillary artery access is an option for these patients, but little is known about the utility of this approach to facilitate short-term use for circulatory support with microaxial pump devices.

Methods:

The Axillary Access Registry to Monitor Safety (ARMS) was a prospective, observational multicenter registry to study the feasibility and acute safety of mechanical circulatory support via percutaneous upper-extremity access.

Results:

One hundred and two patients were collected from 10 participating centers. Successful device implantation was 98% (100 of 102). Devices were implanted for a median of 2 days (interquartile range, 0–5 days; range, 0–35 days). Procedural complications included 10 bleeding events and 1 stroke. There were 3 patients with brachial plexus–related symptoms all consisting of C8 tingling and all arising after multiple days of support. Postprocedural access site hematoma or bleeding was noted in 9 patients. Device explantation utilized closure devices alone in 61%, stent grafts in 17%, balloon tamponade facilitated closure in 15%, and planned surgical explant in 5%. Duration of support appeared to be independently associated with a 1.1% increased odds of vascular complication per day ([95% CI, 0.0%–2.3%] P=0.05).

Conclusions:

Percutaneous axillary access for use with microaxial support pumps appears feasible with acceptable rates of bleeding despite early experience. Larger studies are necessary to confirm the pilot data presented here.

Tocilizumab use in COVID-19-associated pneumonia

BACKGROUND

We sought to evaluate the effect of tocilizumab (TCB), a recombinant humanized monoclonal antibody against soluble interleukin-6 receptors, in patients hospitalized for coronavirus disease 2019 (COVID-19).

METHODS

We included all patients with laboratory-confirmed COVID-19 who had completed hospitalization between March 10, 2020 and April 10, 2020 with follow-up through April 20, 2020. Patients who received TCB in addition to standard of care within 48 h of admission were matched in a 1:2 fashion to a similar cohort who received standard of care alone. Clinical outcomes were compared between matched groups. The primary outcome was de-escalation in oxygen therapy. Secondary outcomes were in-hospital death, septic shock, and acute kidney injury (AKI) requiring hemodialysis.

RESULTS

Out of 77 patients who received TCB in addition to standard of care, 34% (n = 26) received TCB within 48 h of admission. One-to-two propensity matching identified 20 versus 40 patients in the TCB and no-TCB treatment arms. In the TCB group, an improvement in oxygenation was observed in 80% (n = 16) of the patients by 7 days post TCB administration. After matching, there was no difference in clinical outcomes between TCB and no-TCB patients. In-hospital death: 10% versus 8%; p = .823, septic shock: 10% versus 11%, p = .912, AKI requiring hemodialysis (10% vs. 13%; p = .734).

CONCLUSIONS

Early treatment with TCB in patients admitted for COVID-19 led to an improvement in their oxygen status during hospitalization. This change however did not translate into improved survival when compared to a matched cohort with a similar clinical profile.

The top 100 Twitter influencers in cardiology

Importance

Twitter represents a growing aspect of the social media experience and is a widely used tool for public education in the 21^st century. In the last few years, there has been concern about the dissemination of false health information on social media. It is therefore important that we assess the influencers of this health information in the field of cardiology.

Objective

We sought to identify the top 100 Twitter influencers within cardiology, characterize them, and examine the relationship between their social media activity and academic influence.

Design

Twitter topic scores for the topic search “cardiology” were queried on May 01, 2020 using the Right Relevance application programming interface (API). Based on their scores, the top 100 influencers were identified. Among the cardiologists, their academic h-indices were acquired from Scopus and these scores were compared to the Twitter topic scores.

Result

We found out that 88/100 (88%) of the top 100 social media influencers on Twitter were cardiologists. Of these, 63/88 (72%) were males and they practiced mostly in the United States with 50/87 (57%) practicing primarily in an academic hospital. There was a moderately positive correlation between the h-index and the Twitter topic score, r = +0.32 (p-value 0.002).

Conclusion

Our study highlights that the top ranked cardiology social media influencers on Twitter are board-certified male cardiologists practicing in academic settings in the US. The most influential on Twitter have a moderate influence in academia. Further research should evaluate the relationship between other academic indices and social media influence.

Periprocedural Complications After Transcatheter Aortic Valve Replacement and Their Impact on Resource Utilization

BACKGROUND

To examine the incidence and trends of peri-procedural complications after TAVR and their impact on resource utilization.

METHODS

The incidence of complications by type [acute kidney injury (AKI), permanent pacemaker (PPM), vascular, paravalvular leak, in-hospital mortality, others] was calculated for TAVR patients at a high-volume center between 2012 and 2018. Clinical data were matched with hospital-billing data of patients. Trends in high resource utilization (discharge to a rehabilitation facility or PLOS >7 days) (HRU) and complication rates were assessed. Multivariable logistic regression models were used to determine predictors of HRU.

RESULTS

Out of 1163 patients, 966 (83%) had no complications, others in 95 (8%), PPM in 56 (5%), AKI alone in 32 (3%), vascular in 31 (3%), in-hospital mortality in 28 (2%) and PVL in 10 (1%). A significant decreasing trend in the incidence of complications (29% vs 10%; p trend <0.001) and HRU (75% vs 12%; p trend <0.001) was observed between 2012 and 2018 respectively. Mean ± SD direct procedure cost of having a complication was $58,234 ± $24,568, was associated with an incremental cost of $10, 649 and a prolonged stay of 3-days. On multivariable logistic regression analysis, PPM, vascular complications, high STS risk score, NYHA class III/IV, frailty and ≥ moderate tricuspid regurgitation were significantly associated with HRU. TAVR year was protective against HRU.

CONCLUSIONS

We established that, post-TAVR resource utilization and morbidity is high among frail and patients with higher STS risk scores. However, these rates decrease over time with experience.

Early Discharge After Minimally Invasive Aortic and Mitral Valve Surgery

BACKGROUND

We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery.

METHODS

All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve surgery at a single center between 2012 and 2019 were classified by postoperative length of stay: early discharge (≤3 days) or late discharge (>3 days). The trend in early discharge was investigated over the study period, predictors of early discharge were identified using multivariate logistic regression modeling, and 1:1 propensity score matching was used to determine which patients in the late-discharge cohort had similar health to patients discharged early. Adjusted outcomes of 30-day mortality, readmission, and direct costs were analyzed.

RESULTS

Among 1262 consecutive patients undergoing minimally invasive valve surgery, 618 were elective and uncomplicated, 25% (n = 162) of whom were discharged early. The proportion of early-discharge patients increased over time (P for trend < .05). A history of congestive heart failure, stroke, or smoking and higher Society of Thoracic Surgeons predictive risk of mortality score negatively predicted early discharge (P < .05). Propensity score matching identified 101 (22%) late-discharge patients comparable with early-discharge patients. Adjusted 30-day mortality and readmission rates were comparable between cohorts. The median direct costs per patient ($20,046 vs $22,124, P < .05) were significantly lower in the early-discharge cohort.

CONCLUSIONS

In well-selected patients early discharge after minimally invasive valve surgery was associated with lower costs but comparable postoperative outcomes. About one-fifth of patients who remain in the hospital beyond postoperative day 3 may be candidates for earlier discharge.

Effect of Transcatheter Aortic Valve Implantation on Renal Function in Patients With Previous Renal Dysfunction

The study aims to investigate the incidence of immediate renal function improvement in renal dysfunction patients who had transcatheter aortic valve implantation (TAVI). TAVI patients with ≥ moderate reduced renal function [estimated GFR ≤ 60 ml/min/1.73 m²] at baseline were identified from a prospectively maintained database. Patients were divided into 3 groups based on percent change [(discharge eGFR - baseline eGFR/baseline GFR) × 100] in eGFR post-TAVR. Improvement ≥ 10%, no change, Decline ≥ 10%. Multivariable logistic regression was performed to identify factors that predicted improvement/decline in GFR postprocedure. Out of 677 patients, 359 (53%) had eGFR ≤ 60 ml/min/1.73 m². Of these, 188 (52%) had an improvement in eGFR ≥ 10%, 125 (34%) had no change and 48 (14%) observed decline ≥ 10%. All groups had similar proportions of females and age was comparable in patient groups. Patients in whom a decline in eGFR was observed had significantly higher Society of thoracic Surgeons scores (10.7 vs 8.2 vs 8.2; p = 0.007) and incidence of liver disease (6% vs, 0% vs 2%; p = 0.014) than the no-change or improved groups respectively. On multivariable analysis, independent predictors of decline/improvement in eGFR were being female, low left ventricular ejection fraction and baseline liver dysfunction. In conclusion, over half of patients with compromised renal function who underwent TAVI experience an immediate improvement in kidney function post-TAVI. Being female, baseline liver dysfunction and a low left ventricular ejection fraction is associated with an immediate decline in eGFR.

Discharge disposition of older patients undergoing trans-catheter aortic valve replacement and its impact on survival

BACKGROUND

Patients undergoing transcatheter aortic valve replacement (TAVR) are likely to be discharged to a location other than home. We aimed to assess the association between discharge disposition after TAVR and patient survival at 1 year.

METHODS

Patients admitted from home and survived till discharge after TAVR were divided into two groups based on discharge disposition (home discharge vs. non-home discharge). Pre-operative factors predicting the odds of not being discharged home were identified by using multivariable logistic regression analysis. Study patients were matched one-to-one via a propensity scoring method. Differences in procedural outcomes were compared. Survival of both unmatched and matched pairs was evaluated by using the Kaplan-Meier method with the Kleine-Moesch-Berger stratified log-rank test.

RESULTS

Out of 1,160 TAVR patients, 851 were admitted from home and survived till discharge. The incidence non-home discharge was 19% (n = 159). Factors that were significantly associated with non-home discharge were older age, non-transfemoral approach, female sex, frailty status, history of chronic lung disease, pacemaker placement and insulin-dependent diabetes mellitus. One-to-one propensity score matching resulted in 141 patient pairs with similar age, operative risk, frailty and functional status. At 1-year follow-up, all-cause mortality rates were significantly higher in the non-home group than their home counterparts (18% vs. 3%, P = 0.006; stratified log rank test: P = 0.006).

CONCLUSIONS

A considerable number of TAVR patients are discharged to a location other than home after the procedure. Not being discharged home after TAVR is associated with a high mortality risk at 1 year.

Trends in the utilization and reimbursement of coronary revascularization in the United States Medicare population from 2010 to 2018

OBJECTIVE

To determine utilization and reimbursement trends of coronary revascularization procedures in the US Medicare population from 2000 to 2018.

BACKGROUND

US Medicare population is increasing, and coronary revascularization decreased in the 2000s.

METHODS

This is a population-based, cross sectional study of US Medicare beneficiaries from 2010 to 2018. The Centers for Medicare and Medicaid Services' database was queried for revascularization procedures using the coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) current procedural terminology (CPT) codes. Trends in Medicare enrollees, PCIs, CABGs, and physician reimbursements were analyzed.

RESULTS

Total utilization and reimbursement decreased for both revascularization procedures. The national CABG and PCI utilization per enrollee has decreased by 40.7% (best fit line: b coefficient, 95% CI; -0.297, -0.358 to -0.235) and 26.4% (best fit line: -0.229, -0.373 to -0.0858), respectively. For CABG, annual Medicare payout per enrollee and physician compensation per procedure has decreased by 49.3% (best fit line: -0.250, -0.315 to -0.185) and 14.5% (best fit line: -11.54, -15.62 to -7.452), respectively, and for PCI, decreased by 53.3% (best fit line: -0.373, -0.560 to -0.186) and 36.6% (best fit line: -34.15, -49.35 to -18.95), respectively. Amongst the states, there was significant variability in procedure utilization, and CABG reimbursement rates but minimal variability in PCI reimbursement rates.

CONCLUSION

Even though the US population has aged, revascularization utilization and reimbursement continue to decline. Advancement in medical intervention strategies, particularly non-surgical management, may account for these trends. Further understanding of these trends will allow health systems to tailor resources to the aging population.

Laparoscopic and robotic adrenal surgery: transperitoneal approach

Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality, articulating instruments, and stable surgical platform. The safety and efficacy of robotic adrenalectomy (RA) have been demonstrated by several reports. In addition, RA has been shown to provide similar outcomes compared to LA. Development of adrenal surgery has involved the description of several surgical approaches including the anterior transperitoneal, lateral transperitoneal (LT) and posterior retroperitoneal (PR). Among these, the most frequently preferred technique is LT adrenalectomy, primarily due to the surgeon's familiarity of the operative field, wider working space and visibility. The LT technique is suitable for the resection of larger, unilateral tumors and in scenarios where conversion to an open transperitoneal approach is warranted, it offers a lesser burden. Also, the larger view of the entire abdominal cavity and excellent exposure of both adrenal glands and surrounding structures provided by the LT technique render it safe and feasible in pediatric and pregnant individuals.

Impact of frailty on outcomes in acute ST-elevated myocardial infarctions undergoing percutaneous coronary intervention

AIMS

We analyzed the impact of frailty on readmission rates for ST-elevated myocardial infarctions (STEMIs) and the utilization of percutaneous coronary intervention (PCI) in STEMI admissions.

METHODS AND RESULTS

The 2016-2019 Nationwide Readmission Database was analyzed for patients admitted with an acute STEMI. Patients were categorized by frailty risk and analyzed for 30-day readmission risk after acute STEMIs, PCI utilization and outcomes, and healthcare resource utilization. Qualifying index admissions were found in 584,918 visits. Low risk frailty was noted in 78.20%, intermediate risk in 20.67%, and high risk in 1.14% of admissions. Thirty-day readmissions occurred in 7.74% of index admissions, increasing with frailty (p < 0.001). Readmission risk increased with frailty, 1.37 times with intermediate and 1.21 times with high-risk frailty. PCI was performed in 86.40% of low-risk, 66.03% of intermediate-risk, and 58.90% of high-risk patients (p < 0.001). Intermediate patients were 55.02% less likely and high-risk patients were 61.26% less likely to undergo PCI (p < 0.001). Length of stay means for index admissions were 2.96, 7.83, and 16.32 days for low, intermediate, and high-risk groups. Intermediate and high-risk frailty had longer length of stay, higher total cost, and were more likely to be discharged to a skilled facility (p < 0.001).

CONCLUSION

Among adult, all-payer inpatient visits, frailty discerned by the hospital frailty risk score was associated with increased readmissions, increased healthcare resource utilization, and lower PCI administration.

National Trends and Outcomes of Patients Bridged to Transplant With Continuous Flow Left Ventricular Assist Devices

BACKGROUND

Continuous flow left ventricular assist devices (CF-LVAD) are widely used as a bridge to transplantation (BTT) among patients with advanced heart failure. The primary outcome of the current study was to study the incidence of waitlist mortality and morbidity of CF-LVAD patients bridged to heart transplantation in the current BTT era and to determine the factors that increased their risk of delisting.

METHODS

Patients who were bridged to heart transplant with a CF-LVAD between April 2008 and September 2015 were identified from the United Network for Organ Sharing heart transplant registry. They were then categorized based on the development of complications. Cox proportional hazards and Kaplan-Meier survival curves were used for time-to-event analysis for the primary outcome.

RESULTS

Out of 7070 patients who were bridged to heart transplant, 2510 (36%) developed device-related complications. The primary outcome was present in 1631 of 7070 patients (23%). Independent predictors of primary outcome were age, ABO blood group, etiology of cardiomyopathy, and history of diabetes mellitus. Developing one device-related complication was associated with a hazard ratio (HR) of 2.59 of having the primary outcome. The HR increased to 3.45 when ≥2 of the defined complications occurred. In patients who developed the primary outcome, they most likely had a device infection (odds ratio 2.51).

CONCLUSION

Findings from the current study add to the existing literature about the incidence of morbidity and mortality in the current BTT era. Development of one device-related complication increases the risk of death or delisting among patients on the heart transplant waitlist; however, this risk almost doubles when 2 or more complications occur.

Association between increased-risk donor social behaviors and recipient outcomes after heart transplantation

BACKGROUND

This study aims to investigate the association between social behaviors of increased-risk donors (IRD) and recipient outcomes after heart transplantation.

METHODS

The United Network for Organ Sharing (UNOS) database was queried to identify patients who received a heart transplant between 2004 and 2015. Patients were grouped based on donor's risk status (IRD vs standard risk donor [SRD]). Recipients of IRD were categorized based on donor social behaviors (SB), and recipient survival was assessed. Cox regression analysis was used to identify associations between SB of donors and recipient survival.

RESULTS

Out of 22 333 heart transplantations performed during the study period, 2769 (12%) received an IRD graft with the following SB: Unprofessional tattoos or piercings (n = 1722) (63%), cocaine use (n = 916) (33%), heavy smoking (n = 437) (16%), and heavy alcohol abuse (n = 610) (22%). Viral screens detected 72(3%) hepatitis B virus (HBV) positive and 12 (0.4%) hepatitis C virus (HCV) positive at donation. There was no difference in recipient survival based on both donor risk and their social behaviors. Cox regression analysis found only donor HCV infection and non-identical ABO mismatch to be associated with poor recipient survival among recipients of IR grafts.

CONCLUSION

Cardiac allografts from IRD, serologically negative for viruses, can safely be used. There is no association between social behaviors of IRD and recipient survival.

Health and Healthcare Disparities: Impact on Resource Utilization and Costs After Transcatheter Aortic Valve Replacement

OBJECTIVE

We investigated health and healthcare disparities in the treatment of aortic stenosis with transcatheter aortic valve replacement (TAVR) and how they affect resource utilization and costs.

METHODS

We retrospectively reviewed all patients who were discharged alive after TAVR between 2012 and 2017 from the National Inpatient Sample. Patients were stratified by race and outcomes investigated were in-hospital complications, total procedural costs, and resource utilization. High resource utilization (HRU) was defined as length of stay (LOS) ≥7 days or discharge to a nonhome location. Multivariable regression models were used to identify predictors of HRU.

RESULTS

TAVR patients (N = 29,464) were stratified into Caucasians (n = 25,691), others (n = 1,274), Hispanics (n = 1,267), and African Americans (AA, n = 1,232). More AA and Hispanics had TAVR at urban teaching centers (P = 0.003) and were less likely to be Medicare beneficiaries (P < 0.001). Distribution of TAVR patients in the lowest income quartile showed AA (50%) versus Caucasian (20%) versus Hispanic (33%, P < 0.001). In-hospital complications were higher among Hispanics and AA than Caucasians with prolonged LOS, procedural costs, and HRU. On multivariable analysis, independent predictors of HRU were TAVR year (P < 0.001), advanced age (P < 0.001), female sex (P < 0.001), non-Caucasian race (P = 0.038), history of coronary artery bypass grafting (P < 0.001), smoking (P < 0.001), chronic lung disease (P = 0.003), stroke (P < 0.001), and lowest income quartile (P = 0.002).

CONCLUSIONS

There exist significant healthcare and health disparities among patients undergoing TAVR in the United States. Consequently, this unequal access to care and determinants of heath translate into higher resource utilization and costs.

The prognostic value of pro-calcitonin, CRP and thyroid hormones in secondary peritonitis: a single-center prospective study

BACKGROUND

Infections and sepsis remain the leading cause of morbidity and mortality in secondary peritonitis. Clinicians are still challenged with the task of finding an early and reliable diagnosis of septic complications. The role of inflammatory markers (Procalcitonin (PCT), C-reactive Protein (CRP) and thyroid hormones in determining the severity of secondary peritonitis was evaluated in this study.

METHODS

On the preoperative and first, third, fifth, seventh, and fourteenth postoperative days, PCT, CRP, and thyroid hormone concentrations were measured in serum taken from eighty-four consecutive patients who were operated on for secondary peritonitis between January 2008 and January 2010. All data was entered and analyzed using the Statistical Package for Social Sciences, version 15.0 and clinical parameters were compared using the student's t-test.

RESULTS

For the groups diagnosed with perforated viscus, PCT concentrations were significantly low in contrast to high thyroid hormone levels in patients who developed postoperative complications or died when compared to patients whose postoperative course was uneventful or discharged. The PCT concentration significantly correlated with the CRP concentration and WBC count.

CONCLUSION

In the absence of postoperative complications, PCT is a better predictor of outcome than CRP in secondary peritonitis. Our study showed that a low thyroid hormone level can serve as an important prognostic parameter of disease severity in secondary peritonitis.