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Williamson CG, Tran Z, Rudasill S, Hadaya J, Verma A, Bridges AW, Satou G, Biniwale RM, Benharash P. Race-based disparities in access to surgical palliation for hypoplastic left heart syndrome. Surgery 2022; 172:500-505. [PMID: 35450745 DOI: 10.1016/j.surg.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/15/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Racial disparities in outcomes have been shown to persist in many operative specialties, including the management of congenital heart disease. Using a demographic-adjusted methodology, we examined whether patient race influenced access to high-performing centers for the operative management of hypoplastic left heart syndrome. METHODS The 2005-2017 National Inpatient Sample was queried to identify all pediatric (≤5 years) hospitalizations with an operation for hypoplastic left heart syndrome. A racial disparity index was generated for each hospital and defined as the proportion of White patients receiving operative management for hypoplastic left heart syndrome divided by the proportion of White patients admitted for respiratory failure. This methodology quantified hospital-level racial variation while adjusting for the local racial makeup of each center. RESULTS Of the 17,275 patients who met inclusion criteria, 64.1% were managed at high-volume centers. Patients at high-volume centers had a similar distribution of operative type, age, and burden of comorbidities. The mean racial disparity index steadily grew from 1.06 at the lowest volume decile of operative volume to 1.51 at the highest, indicating an increasing proportion of White patients as volume increased. Using risk-adjusted analysis, each decile increase in hospital volume was associated with a 14% relative reduction in odds of mortality and a 0.06 increase in predicted racial disparity index. Increasing volume was further associated with reduced odds of non-home discharge but did not alter resource utilization. CONCLUSION We demonstrate that high-volume centers disproportionally serve White patients and have superior clinical outcomes compared to low-volume centers. This study highlights the critical importance of equitable access to expert care for high-risk conditions such as hypoplastic left heart syndrome.
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Affiliation(s)
- Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Sarah Rudasill
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Alexander W Bridges
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Gary Satou
- Division of Pediatric Cardiology, Mattel Children's Hospital, University of California, Los Angeles, CA
| | - Reshma M Biniwale
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
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Rudasill S, Negrete Manriquez JA, Benharash P, Kim D, Yetasook A, Bowens N, de Virgilio C. Association between Participation in a Preclinical Surgery Elective and Future Match into Surgical Residency. Am Surg 2022:31348221074242. [PMID: 35099317 DOI: 10.1177/00031348221074242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Since 2013, we have offered a robust "Introduction to Surgery" elective (ITS) for preclinical medical students. The present study investigates whether participants of the ITS elective were more likely to match into surgical residencies than non-ITS participants. METHODS This is a retrospective case-control study of medical students from two medical schools in Southern California who participated in the ITS elective and those who did not. Descriptive results and univariate analysis using STATA were utilized to analyze the de-identified data who matched between 2016 and 2021 were included. RESULTS Overall, 87 (8.9%) of the 982 matched students participated in the ITS elective, with an increase in participation from 1.2% in 2016 to 13.9% in 2021 (P < .001). Among ITS participants, 49.4% matched into a surgical specialty compared to only 22.9% for non-ITS students (P < .001). There was no difference between ITS and non-ITS students with regards to procedural specialty match (14.9% vs 12.6%, P = .537). CONCLUSION ITS participants were more than twice as likely to match into a surgical specialty than non-participants. Future qualitative research will help discern the relative impact of the ITS course versus a student's baseline predisposition to surgery.
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Affiliation(s)
- Sarah Rudasill
- Department of Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Jose A Negrete Manriquez
- David Geffen School of Medicine, 5140University of California, Los Angeles, CA, USA.,College of Medicine, 21640Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, 12222University of California, Los Angeles, CA, USA
| | - Dennis Kim
- Department of Surgery, 21640Harbor UCLA Medical Center, Torrance, CA, USA
| | - Amy Yetasook
- Department of Surgery, 21640Harbor UCLA Medical Center, Torrance, CA, USA
| | - Nina Bowens
- Department of Surgery, 21640Harbor UCLA Medical Center, Torrance, CA, USA
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Madrigal J, Rudasill S, Tran Z, Bergman J, Benharash P. Sexual and gender minority identity in undergraduate medical education: Impact on experience and career trajectory. PLoS One 2021; 16:e0260387. [PMID: 34797881 PMCID: PMC8604342 DOI: 10.1371/journal.pone.0260387] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/08/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The wellbeing of sexual and gender minority (SGM) medical students and the impact of their experiences on career trajectory remain poorly understood. The present study aimed to characterize the incidence of mistreatment in SGM trainees as well as general perspectives on the acceptance of SGM individuals across medical and surgical specialties. METHODS This was a cross sectional survey study of all actively enrolled medical students within the six University of California campuses conducted in March 2021. An online, survey tool captured incidence of bullying, discrimination, and suicidal ideation as well as perceived acceptance of SGM identities across specialties measured by slider scale. Differences between SGM and non-SGM respondents were assessed with two-tailed and chi-square tests. Qualitative responses were evaluated utilizing a multi-stage, cutting-and-sorting technique. RESULTS Of approximately 3,205 students eligible for participation, 383 submitted completed surveys, representing a response rate of 12.0%. Of these respondents, 26.9% (n = 103) identified as a sexual or gender minority. Overall, SGM trainees reported higher slider scale scores when asked about being bullied by other students (20.0 vs. 13.9, P = 0.012) and contemplating suicide (14.8 vs. 8.8, P = 0.005). Compared to all other specialties, general surgery and surgical subspecialties had the lowest mean slider scale score (52.8) in perceived acceptance of SGM identities (All P < 0.001). In qualitative responses, students frequently cited lack of diversity as contributing to this perception. Additionally, 67.0% of SGM students had concerns that disclosure of identity would affect their future career with 18.5% planning to not disclose during the residency application process. CONCLUSIONS Overall, SGM respondents reported higher incidences of bullying and suicidal ideation as well as increased self-censorship stemming from concerns regarding career advancement, most prominently in surgery. To address such barriers, institutions must actively promote diversity in sexual preference and gender identity regardless of specialty.
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Affiliation(s)
- Josef Madrigal
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Jonathan Bergman
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- * E-mail:
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Mandelbaum AD, Rudasill S, Williamson CG, Hadaya J, Sanaiha Y, De Virgilio C, Benharash P. Impact of hospital safety-net status on clinical outcomes following carotid artery revascularization. Surgery 2021; 169:1544-1550. [PMID: 33726952 DOI: 10.1016/j.surg.2021.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/24/2021] [Accepted: 01/29/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND High hospital safety-net burden has been associated with inferior clinical outcomes. We aimed to characterize the association of safety-net burden with outcomes in a national cohort of patients undergoing carotid interventions. METHODS The 2010-2017 Nationwide Readmissions Database was used to identify adults undergoing carotid endarterectomy and carotid artery stenting. Hospitals were classified as low (LBH), medium, or high safety-net burden (HBH) based on the proportion of uninsured or Medicaid patients. Multivariable models were developed to evaluate associations between HBH and outcomes. RESULTS Of an estimated 540,558 hospitalizations for a carotid intervention, 28.5% were at HBH. Patients treated at HBH were more likely to be admitted non-electively (28.7% vs 20.2%, P < .001), have symptomatic presentation (11.0% vs 7.7%, P < .001), and undergo carotid artery stenting (18.7% vs 8.9%, P < .001). After adjustment, HBH remained associated with increased odds of postoperative stroke (AOR 1.19, P = .023, Ref = LBH), non-home discharge (AOR 1.10, P = .026), 30-day readmissions (AOR 1.14, P < .001), and 31-90-day readmissions (AOR 1.13, P < .001), but not in-hospital mortality (AOR 1.18, P = .27). HBH was linked to increased hospitalization costs (β +$2,169, P = .016). CONCLUSION HBH was associated with postoperative stroke, non-home discharge, readmissions, and increased hospitalization costs after carotid revascularization. Further studies are warranted to alleviate healthcare inequality and improve outcomes at safety-net hospitals.
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Affiliation(s)
- Ava D Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA. https://twitter.com/Sarah_Rudasill
| | - Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA. https://twitter.com/YasSanaiha
| | - Christian De Virgilio
- Department of Surgery, Harbor UCLA Medical Center, Torrance, CA. https://twitter.com/drdevirgilio
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
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Karunungan KL, Sanaiha Y, Hernandez RA, Wilhalme H, Rudasill S, Hadaya J, DiNorcia J, Benharash P. Impact of Payer Status on Delisting Among Liver Transplant Candidates in the United States. Liver Transpl 2021; 27:200-208. [PMID: 33185336 PMCID: PMC8281984 DOI: 10.1002/lt.25936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/23/2020] [Accepted: 11/05/2020] [Indexed: 12/24/2022]
Abstract
Although socioeconomic disparities persist both pre- and post-transplantation, the impact of payer status has not been studied at the national level. We examined the association between public insurance coverage and waitlist outcomes among candidates listed for liver transplantation (LT) in the United States. All adults (age ≥18 years) listed for LT between 2002 and 2018 in the United Network for Organ Sharing database were included. The primary outcome was waitlist removal because of death or clinical deterioration. Continuous and categorical variables were compared using the Kruskal-Wallis and chi-square tests, respectively. Fine and Gray competing-risks regression was used to estimate the subdistribution hazard ratios (HRs) for risk factors associated with delisting. Of 131,839 patients listed for LT, 61.2% were covered by private insurance, 22.9% by Medicare, and 15.9% by Medicaid. The 1-year cumulative incidence of delisting was 9.0% (95% confidence interval [CI], 8.3%-9.8%) for patients with private insurance, 10.7% (95% CI, 9.9%-11.6%) for Medicare, and 10.7% (95% CI, 9.8%-11.6%) for Medicaid. In multivariable competing-risks analysis, Medicare (HR, 1.20; 95% CI, 1.17-1.24; P < 0.001) and Medicaid (HR, 1.20; 95% CI, 1.16-1.24; P < 0.001) were independently associated with an increased hazard of death or deterioration compared with private insurance. Additional predictors of delisting included Black race and Hispanic ethnicity, whereas college education and employment were associated with a decreased hazard of delisting. In this study, LT candidates with Medicare or Medicaid had a 20% increased risk of delisting because of death or clinical deterioration compared with those with private insurance. As more patients use public insurance to cover the cost of LT, targeted waitlist management protocols may mitigate the increased risk of delisting in this population.
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Affiliation(s)
- Krystal L. Karunungan
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Holly Wilhalme
- Department of Medicine Statistics Core, University of California, Los Angeles, CA
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joseph DiNorcia
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Khoury H, Ragalie W, Sanaiha Y, Boutros H, Rudasill S, Shemin RJ, Benharash P. Readmission After Surgical Aortic Valve Replacement in the United States. Ann Thorac Surg 2020; 110:849-855. [DOI: 10.1016/j.athoracsur.2019.11.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 11/05/2019] [Accepted: 11/27/2019] [Indexed: 12/01/2022]
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Emami S, Rudasill S, Bellamkonda N, Sanaiha Y, Cale M, Madrigal J, Christian-Miller N, Benharash P. Impact of Malnutrition on Outcomes Following Transcatheter Aortic Valve Implantation (from a National Cohort). Am J Cardiol 2020; 125:1096-1101. [PMID: 31959432 DOI: 10.1016/j.amjcard.2019.12.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 11/27/2022]
Abstract
Malnutrition is associated with increased mortality in open cardiac surgery, but its impact on transcatheter aortic valve implantation (TAVI) is unknown. This study utilized the National Readmissions Database to evaluate the impact of malnutrition on mortality, complications, length of stay (LOS), 30-day readmission, and total charges following TAVI. Adult patients undergoing isolated TAVI for severe aortic stenosis were identified using the 2011 to 2016 National Readmissions Database, which accounts for 56.6% of all US hospitalizations. The malnourished cohort included patients with nutritional neglect, cachexia, protein calorie malnutrition, postsurgical nonabsorption, weight loss, and underweight status. Multivariable models were utilized to evaluate the impact of malnutrition on selected outcomes. Of 105,603 patients, 5,280 (5%) were malnourished. Malnourished patients experienced greater mortality (10.4% vs 2.2%, p <0.001), postoperative complications (49.2% vs 22.6%, p <0.001), 30-day readmission rates (21.4 vs 14.9%, p <0.001), index hospitalization charges ($331,637 vs $208,082, p <0.001), and LOS (16.4 vs 6.2 days, p <0.001) relative to their nourished counterparts. On multivariable analysis, malnutrition remained a significant, independent predictor of increased index mortality (Adjusted odds ratio (AOR) = 2.68, p <0.001), complications (AOR = 2.09, p <0.001), and 30-day readmission rates (AOR = 1.34, p <0.001). Malnutrition was most significantly associated with infectious complications at index hospitalization (AOR = 3.88, p <0.001) and at 30-day readmission (AOR = 1.43, p <0.027). In conclusion, malnutrition is independently associated with increased mortality, complications, readmission, and resource utilization in patients undergoing TAVI. Preoperative risk stratification and malnutrition modification may improve outcomes in this vulnerable population.
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Khoury H, Lyons R, Sanaiha Y, Rudasill S, Shemin RJ, Benharash P. Deep Venous Thrombosis and Pulmonary Embolism in Cardiac Surgical Patients. Ann Thorac Surg 2019; 109:1804-1810. [PMID: 31706868 DOI: 10.1016/j.athoracsur.2019.09.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 08/12/2019] [Accepted: 09/12/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Deep venous thrombosis and pulmonary embolism are life-threatening complications after surgery, warranting prophylaxis. However prophylaxis is not uniformly practiced among cardiac surgical patients. This study aimed to characterize the national incidence, mortality, and costs associated with thromboembolism after cardiac surgery. METHODS The 2005 to 2015 National Inpatient Sample was used to identify all adult patients undergoing coronary artery bypass grafting or valve surgery. International Classification of Disease codes were used to identify patients with deep venous thrombosis and pulmonary embolism. RESULTS Of approximately 3 million patients undergoing cardiac surgery, 1.62% developed deep venous thrombosis and 0.38% pulmonary embolism. Those with deep venous thrombosis and pulmonary embolism were more commonly women (33.2% and 36.2 vs 31.2%, P < .001), older (68.1 and 66.0% vs 65.7 years, P < .001), and had a higher Elixhauser comorbidity index (4.0 and 4.7 vs 3.7, P < .001). Deep venous thrombosis and pulmonary embolism were associated with increased mortality (4.95% and 14.8% vs 2.67%, P < .001). After adjustment for baseline differences, deep venous thrombosis was associated with an incremental increase in cost of $12,308, whereas pulmonary embolism was associated with $13,879 cost increase after cardiac surgery. Pulmonary embolism was an independent predictor of mortality (adjusted odds ratio, 3.39; 95% confidence interval, 2.74-4.18). CONCLUSIONS The mortality and financial burden related to thromboembolism in cardiac surgery are significant. Prophylaxis may be indicated in cardiac surgery patients to improve quality of care and reduce healthcare costs. Future controlled randomized trials investigating the benefit of thromboembolism prophylaxis in cardiac surgery are warranted.
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Affiliation(s)
- Habib Khoury
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California
| | - Robert Lyons
- Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, California
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California
| | - Richard J Shemin
- Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, California.
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Sanaiha Y, Xing H, Morchi R, Seo YJ, Rudasill S, Benharash P. National Study of Immediate and Delayed Readmissions After Colostomy Creation. J Surg Res 2019; 246:457-463. [PMID: 31706537 DOI: 10.1016/j.jss.2019.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 08/17/2019] [Accepted: 09/13/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy. METHODS The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission. RESULTS Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively. CONCLUSIONS Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, Los Angeles, California
| | - Hanning Xing
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Ravi Morchi
- Department of General Surgery, University of California, Irvine, Orange, California
| | - Young Ji Seo
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, Los Angeles, California.
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Sanaiha Y, Kavianpour B, Dobaria V, Mardock AL, Rudasill S, Lyons R, Benharash P. Acute kidney injury is independently associated with mortality and resource use after emergency general surgery operations. Surgery 2019; 167:328-334. [PMID: 31668777 DOI: 10.1016/j.surg.2019.07.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/04/2019] [Accepted: 07/25/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The incidence of severe perioperative renal dysfunction in high-acuity patients has not been well-explored at the national level. The present study aimed to evaluate the trends in the incidence of perioperative acute kidney injury and renal replacement therapy as well as associated mortality among patients undergoing an emergency general surgery operation. METHODS This was a retrospective cohort study using the National Inpatient Sample to identify all adult patients (>18 y) without chronic kidney disease who underwent an emergency general surgery procedure from 2008 to 2016. The study cohort was stratified based on presence of acute kidney injury and need for renal replacement therapy postoperatively. A multivariable logistic regression model was developed to predict the odds of mortality and composite morbidity. Nonparametric trend analyses of acute kidney injury and renal replacement therapy incidence and associated mortality were performed. RESULTS Of an estimated 5,862,657 patients who underwent an emergency general surgery procedure during the study period, 7.4% patients developed an acute kidney injury and 0.48% patients required renal replacement therapy. Overall, the incidence of acute kidney injury (5.3%-19.4%) and renal replacement therapy (0.43%-0.93%) increased (P < .0001) over the study period. Even without need for renal replacement therapy, acute kidney injury was associated with greater odds of mortality and composite morbidity (adjusted odds ratio 5.2, 95% confidence interval [CI] 5.1-5.3) and mortality (adjusted odds ratio = 2.20, 95% CI 2.3-2.4), as well as greater costs of hospitalization and duration of stay. CONCLUSION In this national study, we found that the incidence of acute kidney injury and renal replacement therapy after an emergency general surgery operation has increased. Both acute renal failure and hemodialysis were associated with much greater odds of morbidity and mortality. The apparent increase in the rate of acute kidney injury and renal replacement therapy warrant further investigation of mechanisms for monitoring and limiting the impact of organ malperfusion associated with emergency general surgery operations.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Behdad Kavianpour
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Alexandra L Mardock
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Robert Lyons
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
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Sanaiha Y, Rudasill S, Sareh S, Mardock A, Khoury H, Ziaeian B, Shemin R, Benharash P. Impact of hospital safety-net status on failure to rescue after major cardiac surgery. Surgery 2019; 166:778-784. [PMID: 31307773 PMCID: PMC7700062 DOI: 10.1016/j.surg.2019.05.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/23/2019] [Accepted: 05/31/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hospitals with safety-net status have been associated with inferior surgical outcomes and higher costs. The mechanism of this discrepancy, however, is not well understood. We hypothesized that discrepant rates of failure to rescue after complications of routine cardiac surgery would explain the observed inferior outcomes at safety-net hospitals. METHODS The National Inpatient Sample was used to identify adult patients who underwent elective coronary artery bypass grafting and isolated or concomitant valve operations between January 2005 and December 2016. Hospitals were stratified into low-, medium-, or high-burden categories based on the proportion of uninsured or Medicaid patients to emulate safety-net status as defined by the Institute of Medicine. Failure to rescue was defined as mortality after occurrence of neurologic, cardiovascular, respiratory, renal, or infectious complications (major and minor complications). Multivariable regression was used to perform risk-adjusted comparisons of the rate of complications, failures to rescue, and resource use for high-burden hospitals versus low-burden and medium-burden hospitals. RESULTS Of an estimated 2,012,104 patients undergoing elective major cardiac operations, 2% died, whereas 36% suffered major and minor complications. Safety-net hospitals had higher odds of failure to rescue after major comorbidity (adjusted odds ratio 1.12, 95% confidence interval 1.01-1.23). Occurrence of major and minor complications at safety-net hospitals was associated with increased costs ($2,480 [95% confidence interval $1,178-$3,935]) compared with low-burden hospitals. CONCLUSION Safety-net hospitals were associated with higher rates of failure to rescue after occurrence of tamponade, septicemia, and respiratory complications. Implementation of care bundles to tackle cardiovascular, respiratory, and renal complications may affect the discrepancy in incidence of and rescue from complications at safety-net institutions.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Sohail Sareh
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Alexandra Mardock
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Habib Khoury
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Boback Ziaeian
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; Division of Cardiology, Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Richard Shemin
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
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Sanaiha Y, Kavianpour B, Mardock A, Khoury H, Downey P, Rudasill S, Benharash P. Rehospitalization and resource use after inpatient admission for extracorporeal life support in the United States. Surgery 2019; 166:829-834. [PMID: 31277884 DOI: 10.1016/j.surg.2019.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/22/2019] [Accepted: 05/09/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND With increasing dissemination and improved survival after extracorporeal life support, also called extracorporeal membrane oxygenation, the decrease in readmissions after hospitalization involving extracorporeal life support is an emerging priority. The present study aimed to identify predictors of early readmission after extracorporeal life support at a national level. METHODS This was a retrospective cohort study using the Nationwide Readmissions Database. All patients ≥18 years who underwent extracorporeal life support from 2010 to 2015 were identified. Patients were stratified into the following categories of extracorporeal life support: postcardiotomy, primary cardiogenic shock, cardiopulmonary failure, respiratory failure, transplantation, and miscellaneous. The primary outcome of the study was the rate of 90-day rehospitalization after extracorporeal life support admission. A multivariable logistic regression model was developed to predict the odds of unplanned 90-day readmission. Kaplan-Meier analyses were also performed. RESULTS An estimated 18,748 patients received extracorporeal life support with overall mortality of 50.2%. Of the patients who survived hospitalization, 30.2% were discharged to a skilled nursing facility, and 21.1% were readmitted within 90 days after discharge. After adjusting for patient and hospital characteristics, cardiogenic shock was associated with the greatest odds of mortality (adjusted odds ratio 1.6; 95% confidence interval, 1.09-1.46; C-statistic, 0.64). The cohort with respiratory failure had decreased odds of readmission (adjusted odds ratio 0.76; 95% confidence interval, 0.58-0.99). Discharge to skilled nursing facility (adjusted odds ratio 1.64; 95% confidence interval, 1.36-1.97) was independently associated with readmission. Cardiac and respiratory-related readmissions comprised the majority of unplanned 90-day rehospitalizations. CONCLUSION In this large analysis of readmissions after extracorporeal life support in adults, 21% of extracorporeal life support survivors were rehospitalized within 90 days of discharge. Disposition to a skilled nursing facility, but not advanced age nor female sex, was associated with readmission.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Behdad Kavianpour
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Alexandra Mardock
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Habib Khoury
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Peter Downey
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
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Rudasill S, Gittings DJ, Elkassabany NM, Liu J, Nelson CL, Kamath AF. Preoperative Risk Factor Score Predicts Malnutrition in Total Joint Arthroplasty Patients. J Surg Orthop Adv 2019; 28:97-103. [PMID: 31411953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Malnutrition is a modifiable risk factor for poor outcomes in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). The purpose of this study is to highlight risk factors for hypoalbuminemia and develop a predictive model that identifies patients at risk for this condition before THA or TKA. The study retrospectively reviewed the National Surgical Quality Improvement Program database to analyze preoperative independent risk factors for a diagnosis of hypoalbuminemia in adult patients who underwent THA or TKA. These factors were used to create a preoperative risk model to predict hypoalbuminemia. Individuals with three or more risk factors in the seven-point model are predicted to have hypoalbuminemia in 20.4% of THA or 10.5% of TKA cases. Accurate identification of hypoalbuminemic patients may allow preoperative nutrition interventions to improve postoperative outcomes. (Journal of Surgical Orthopaedic Advances 28(2):97-103, 2019).
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Affiliation(s)
- Sarah Rudasill
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel J Gittings
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nabil M Elkassabany
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jiabin Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York
| | - Charles L Nelson
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Atul F Kamath
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Khoury H, Sanaiha Y, Rudasill S, Xing H, Benharash P, Ebrahimi R. TCT-608 Effect of Chronic Liver Disease on the Outcomes, Readmissions, Length of Stay and Cost of Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement. J Am Coll Cardiol 2018. [DOI: 10.1016/j.jacc.2018.08.1807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Rudasill S, Sanaiha Y, Khoury H, Xing H, Jaman R, Ebrahimi R, Benharash P. TCT-298 Autoimmune Connective Tissue Diseases are Associated With Increased Infectious Complications After TAVR. J Am Coll Cardiol 2018. [DOI: 10.1016/j.jacc.2018.08.1436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rudasill S, Sanaiha Y, Xing H, Khoury H, Yazdani S, Ebrahimi R, Benharash P. TCT-607 Protein Caloric Malnutrition is Associated With Adverse Outcomes Following TAVR. J Am Coll Cardiol 2018. [DOI: 10.1016/j.jacc.2018.08.1806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Xing H, Sanaiha Y, Rudasill S, Khoury H, Mardock A, Yazdani S, Gowland L, Ebrahimi R, Benharash P. TCT-143 Higher Institutional TAVR Volume Reduces Index Mortality but Does Not Impact Readmission Outcomes. J Am Coll Cardiol 2018. [DOI: 10.1016/j.jacc.2018.08.1251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Xing H, Sanaiha Y, Rudasill S, Khoury H, Mardock A, Yazdani S, Gowland L, Ebrahimi R, Benharash P. TCT-573 Inter-hospital Transfer of TAVR Patients is Associated With Index Complications but Not Readmission Outcomes. J Am Coll Cardiol 2018. [DOI: 10.1016/j.jacc.2018.08.1764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Rudasill S, Dattilo JR, Liu J, Clements A, Nelson CL, Kamath AF. Using Illness Rating Systems to Predict Discharge Location Following Total Knee Arthroplasty. Knee Surg Relat Res 2018; 30:50-57. [PMID: 29482304 PMCID: PMC5853174 DOI: 10.5792/ksrr.17.079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/15/2017] [Accepted: 01/05/2018] [Indexed: 01/16/2023] Open
Abstract
Purpose Total knee arthroplasty (TKA) is increasing in frequency and cost. Optimization of discharge location may reduce total expenditure while maximizing patient outcomes. Although preoperative illness rating systems—including the American Society for Anesthesiologists Physical Classification System (ASA), severity of illness scoring system (SOI), and Mallampati rating scale (MP)—are associated with patient morbidity and mortality, their predictive value for discharge location, length of stay (LOS), and total costs remains unclear. Materials and Methods We conducted a retrospective analysis of 677 TKA patients (550 primary and 127 revision) treated at a single institution. The influence of ASA, SOI, and MP scores on discharge locations, LOS, and total costs was assessed using multivariable regression analyses. Results None of the systems were significant predictors of discharge location following TKA. SOI scores of major or higher (β=2.08 days, p<0.001) and minor (β=−0.25 days, p=0.009) significantly predicted LOS relative to moderate scores. Total costs were also significantly predicted by SOI scores of major or higher (β=$6,155, p=0.022) and minor (β=−$1,163, p=0.007). Conclusions SOI scores may be harnessed as a predictive tool for LOS and total costs following TKA, but other mechanisms are necessary to predict discharge location.
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Affiliation(s)
| | - Jonathan R Dattilo
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jiabin Liu
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ari Clements
- University of Pennsylvania, Philadelphia, PA, USA
| | - Charles L Nelson
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Sabin K, Santos-Ferreira T, Essig J, Rudasill S, Echeverri K. Dynamic membrane depolarization is an early regulator of ependymoglial cell response to spinal cord injury in axolotl. Dev Biol 2015; 408:14-25. [PMID: 26477559 DOI: 10.1016/j.ydbio.2015.10.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 10/08/2015] [Accepted: 10/08/2015] [Indexed: 11/29/2022]
Abstract
Salamanders, such as the Mexican axolotl, are some of the few vertebrates fortunate in their ability to regenerate diverse structures after injury. Unlike mammals they are able to regenerate a fully functional spinal cord after injury. However, the molecular circuitry required to initiate a pro-regenerative response after spinal cord injury is not well understood. To address this question we developed a spinal cord injury model in axolotls and used in vivo imaging of labeled ependymoglial cells to characterize the response of these cells to injury. Using in vivo imaging of ion sensitive dyes we identified that spinal cord injury induces a rapid and dynamic change in the resting membrane potential of ependymoglial cells. Prolonged depolarization of ependymoglial cells after injury inhibits ependymoglial cell proliferation and subsequent axon regeneration. Using transcriptional profiling we identified c-Fos as a key voltage sensitive early response gene that is expressed specifically in the ependymoglial cells after injury. This data establishes that dynamic changes in the membrane potential after injury are essential for regulating the specific spatiotemporal expression of c-Fos that is critical for promoting faithful spinal cord regeneration in axolotl.
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Affiliation(s)
- Keith Sabin
- Dept. of Genetics, Cell Biology and Development, University of Minnesota, USA
| | - Tiago Santos-Ferreira
- CRTD/DFG-Center for Regenerative Therapies Dresden, Technische Universität Dresden, Dresden, Germany
| | - Jaclyn Essig
- Dept. of Genetics, Cell Biology and Development, University of Minnesota, USA
| | - Sarah Rudasill
- Dept. of Genetics, Cell Biology and Development, University of Minnesota, USA
| | - Karen Echeverri
- Dept. of Genetics, Cell Biology and Development, University of Minnesota, USA.
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