Early Childhood Co-Sleeping Predicts Behavior Problems in Preadolescence: A Prospective Cohort Study.

OBJECTIVE/BACKGROUND: Co-sleeping is common practice around the globe. The relationship between early childhood co-sleeping and adolescent behavior problems remains uncertain. We aim to identify whether early childhood co-sleeping can predict behavior problems in preadolescence. PARTICIPANTS: A cohort of 1,656 Chinese preschool children were followed up in adolescence. METHODS: Prospective cohort study design involving two waves of data collection from the China Jintan Cohort (1,656 children aged 3-5 years). Co-sleeping history was collected at 3-5-years-old via parent-reported questionnaire at wave I data collection. Behavior problems were measured twice in childhood and preadolescence, respectively. Adolescent behavior problems were measured by integrating data from self-report, parent-report and teacher-report using the Achenbach System of Empirically Based Assessment. Predictions were assessed using the general linear model with mixed effects on the inverse probability weight propensity-matched sample. RESULTS: 1,656 children comprising 55.6% boys aged 4.9 ± 0.6 were initially enrolled in the first wave of data collection. In the second wave of data collection, 1,274 children were 10.99 ± 0.74 (76.9%) aged 10-13 years were retained. Early childhood co-sleeping is significantly associated with increased behavior problems in childhood (Odds Ratio [OR] 1.22-2.06, ps<0.03) and preadolescence (OR 1.40-2.27, ps<0.02). Moreover, co-sleeping history significantly predicted multiscale increase in internal (OR 1.63-2.61, ps<0.02) and external behavior problems in adolescence. CONCLUSIONS: Early childhood co-sleeping is associated with multiple behavioral problems reported by parents, teachers, and children themselves. Early childhood co-sleeping predicts preadolescent internalizing and externalizing behavior after controlling for baseline behavior problems.

The impact of surgeon and hospital procedural volume on outcomes after aortic root replacement in the United States.

OBJECTIVE: Surgeon procedural volume for complex cardiac procedures have become important quality metrics. The objective is to determine the association of surgeon and hospital case volume on patient outcomes after an aortic root replacement for aortic root aneurysms. METHODS: From 2009 to 2014, 4629 Medicare patients underwent an aortic root replacement for a root aneurysm. Procedures were performed by 1276 surgeons at 718 hospitals. Patients with endocarditis, aortic rupture, or Type-A dissection were excluded. Procedural volume was defined as mean number of cases performed each year during the study period. The impact of hospital and surgeon volume on adjusted 30-day mortality was analyzed as a continuous variable using adjusted logistic regression with cubic splines. RESULTS: After an aortic root replacement, we observed a nonlinear reduction in the adjusted odds ratio for 30-day mortality as surgeon and hospital volume increased. Surgeons that performed approximately five cases/year and hospitals that completed approximately five cases/year had the greatest reduction in the odds of perioperative death. Patients treated at high-volume hospitals (≥4.5 cases/year) had a lower risk for 30-day postoperative stroke (hazard ratio [HR] = 0.51, p = .008), myocardial infarction (HR = 0.49, p = .016), hemodialysis (HR = 0.44, p = .005), and reoperation (HR = 0.48, p = .003). Additionally, patients treated with high-volume surgeons (≥9 cases/year) had lower risk for stroke (HR = 0.65, p = .005), hemodialysis (HR = 0.65, p = .03), sepsis (HR = 0.62, p = .03), and reoperation (HR = 0.67, p = .004). CONCLUSION: Among Medicare patients undergoing an aortic root replacement, there is a strong inverse relationship between annualized surgeon and hospital case volume and postoperative outcomes. Procedural volume is an important quality metric for this high-risk procedure.

"It Hits the Spot": The Impact of a Professional Development Program on English Teacher Wellbeing in Underdeveloped Regions.

In poor and remote areas, teachers frequently encounter serious ongoing challenges and experience teacher exhaustion due to the uneven distribution of resource supply, and a shortage of professional support. Maintaining teachers' professional wellbeing in an unfavorable teaching environment has become a major challenge. The current study explores teachers' professional wellbeing in the context of a five-month-long professional development program designed for teachers in areas of deep poverty in China. This study adopted the method of narrative enquiry and collected diaries written before and after the program from 46 primary school English teachers. Based on the manually analyzed data, it was found that teachers' overall wellbeing at work was enhanced in terms of their professional meaning, engagement, and achievement. The systematic analysis of the diaries helped to better understand how the program exerted such an effect on teachers' learning experiences and their wellbeing.

Guest-activated quaternary ammonium salt hosts emit room temperature phosphorescence.

A novel doped system based on quaternary ammonium salts as hosts was established. Interestingly, it is the guest-activated hosts that emit room temperature phosphorescence, rather than the host-assisted guests in traditional doped systems.

Patients with Atrial Fibrillation Benefit from SAVR with Surgical Ablation Compared to TAVR Alone.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSION: Select patients with persistent non-valvular AF may benefit from SAVR-SA compared to TAVR alone.

Pulmonary artery diameter: means and normal limits-assessment by computed tomography angiography.

OBJECTIVES: Normal pulmonary artery (PA) diameter remains blurred and the definitions of PA aneurysm are heterogenous. We aimed to assess PA diameters, identify a threshold for normal diameters, define PA aneurysms, possible predictors of PA size and evaluate the correlation with mid-ascending aortic diameters. METHODS: Between April 2018 and August 2019, 497 consecutive patients who underwent whole-body computed tomographic angiography were reviewed. Clinical and imaging data were collected from our institutional database. Precise three-dimensional centreline measurements were taken. Linear regression analysis was performed to detect parameters associated with PA diameter. A two-stage model was created to identify potential predictors and the resulting statistically significant interactions were tested. Data were grouped and PA, standard deviation, and upper normal limits were calculated. RESULTS: Among 497 patients with an average age of 51.4 (20.2) (74.6% males), the mean PA diameter measured 32.0 (4.6) mm [female: 31.2 (4.7) mm vs male: 32.2 (4.5) mm; P = 0.032]. The mean PA length, left PA and right PA diameters were similar between male and female patients. We found a significant correlation (r = 0.352; P < 0.001) between the PAs and mid-ascending aortic diameters. Body surface area (P = 0.032, ß = 4.52 [0.40; 8.64] 95% CI) was the only significant influencing variable for PA diameter. CONCLUSIONS: The normal mean PA diameter in a reference cohort is 32.0 (4.6) mm. Body surface area is the only influencing variable of PA diameter. The normal diameters measured and corresponding upper limits of normal revealed that a PA aneurysm should not be considered below a threshold of 45 mm.

A Study of Student-Teachers' Emotional Experiences and Their Development of Professional Identities.

A reciprocal relation has been identified between teacher emotion and teacher professional identity. However, the underlying mechanism explaining this complex interaction remains underexamined. Moreover, limited attention has been paid to the emotional dimension of student-teachers' development of professional identity during university coursework. To bridge this gap, the present study explores how student-teachers' emotions reciprocally interact with their professional identities, drawing data from questionnaires, reflections, and interviews with students taking courses related to language teaching in a teacher-training university. Both quantitative and qualitative data delineated the intertwined trajectories of student-teachers' emotional experiences and the development of professional identity in the learning process of becoming teachers. Mainly triggered by course-related factors, student-teachers experienced a wide array of emotions, of which the polarity and intensity were determined and mediated by their goals and actions deriving from their professional identities. Those aroused emotions, in turn, signaled the developmental process of professional identity and promoted or hindered their emerging identities. This paper concludes with some implications for initial teacher education programs.

Development of Persistent Opioid Use After Cardiac Surgery.

Importance: The overuse of opioids for acute pain management has led to an epidemic of persistent opioid use. Objective: To determine the proportion of opioid-naive patients who develop persistent opioid use after cardiac surgery and investigate the association between the initial amount of opioids prescribed at discharge and the likelihood of developing new persistent opioid use. Design, Setting, and Participants: This retrospective cohort study used data from a national administrative claims database from January 1, 2004, to December 31, 2016 and included 35 817 patients who underwent coronary artery bypass grafting (CABG) (25 673 [71.7%]) and heart valve (10 144 [28.3%]) procedures. All patients were opioid-naive within 180 days before the index procedure and filled an opioid prescription within 14 days after surgery. Exposures: Opioid medications after cardiac surgery. Main Outcomes and Measures: The proportion of opioid-naive patients who developed new persistent opioid use within 90 to 180 days after surgery was determined. Oral morphine equivalents (OMEs) were calculated for the first opioid prescription filled after discharge. A multivariable logistic regression with cubic splines was used to analyze the association among the OMEs at discharge and likelihood of developing persistent opioid use. Results: Of the 25 673 patients who underwent CABG, the mean (SD) age for those without (n = 23 064) vs with (n = 2609) persistent opioid use was 62.9 (9.8) years vs 61.6 (9.7) years, respectively, and the number who were men were 18 758 (81.3%) vs 1998 (76.6%). Of the 10 144 patients who underwent heart valve surgery, the mean (SD) age for those without (n = 9343) vs with (n = 821) persistent opioid use was 63.2 (12.4) years vs 61.2 (12.5) years, respectively, and the number who were men were 6378 (68.3%) vs 511 (62.2%). Persistent opioid use is a substantial concern after cardiac surgery and occurred in 2609 patients undergoing CABG (10.2%) and 821 valve surgery patients (8.1%; P = .001). The likelihood for developing persistent opioid use was decreased among heart valve surgery recipients (odds ratio [OR], 0.78; P < .001) and increased for patients who were women; younger; with preoperative congestive heart failure, chronic lung disease, diabetes, kidney failure, chronic pain, and alcoholism; and those taking preoperative benzodiazepines and muscle relaxants (women: OR, 1.15 [95% CI, 1.03-1.26]; younger age: OR, 1.02 [95% CI, 1.01-1.02]; congestive heart failure: OR, 1.17 [95% CI, 1.06-1.30]; chronic lung disease: OR, 1.32 [95% CI, 1.19-1.45]; diabetes: OR, 1.27 [95% CI, 1.15-1.40]; kidney failure: OR, 1.17 [95% CI, 1.00-1.37]; chronic pain: OR, 2.71 [95% CI, 2.10-3.56]; alcoholism: OR, 1.56 [95% CI, 1.23-2.00]; benzodiazepines: OR, 1.71 [95% CI, 1.52-1.91]; muscle relaxants: OR, 1.74 [95% CI, 1.51-2.02]; all P < .001). Furthermore, we found that when patients were prescribed more than approximately 300 mg of OMEs at discharge, they had a significantly increased risk of new persistent opioid use than with lower opioid prescriptions. Conclusions and Relevance: Opioids are used extensively after cardiothoracic surgery and nearly 1 of 10 patients will continue to use opioids over 90 days after surgery. Furthermore, higher OMEs prescribed at discharge were significantly associated with developing persistent use. Centers must adopt protocols to increase patient education and limit opioid prescriptions after discharge.

Aortic reinterventions after the frozen elephant trunk procedure.

OBJECTIVE: The frozen elephant trunk (FET) procedure has emerged as a potential single-step treatment for pathologies of the thoracic aorta, but the procedure's true potential to be a single-step treatment remains unclear. The aim of this study was to evaluate the need and outcomes of aortic reinterventions after previous FET implantation. METHODS: Patient characteristics and follow-up data of 107 patients following the FET procedure were evaluated and compared between patients with and without aortic reinterventions. A competing risk regression model was analyzed to identify independent predictors of aortic reintervention and to predict the risk for reintervention. RESULTS: Intended completion, anticipated reinterventions, and unexpected reinterventions were performed in 35 patients (33%). There was no difference in the underlying pathology between patients with or without aortic reintervention. An endovascular reintervention was performed in 24 patients (69%), open surgery in 7 patients (20%) and a hybrid approach in 4 patients (11%). No stroke or permanent spinal cord injuries were observed. In-hospital mortality after reintervention was 14% (5 patients), but there was no difference in survival during follow-up after FET implantation (log rank test, P = .58). No risk factors for aortic reinterventions were identified. The risk for aortic reintervention was 31% (95% confidence interval [CI], 21%-42%), 49% (95% CI, 35%-62%), and 64% (95% CI, 44%-79%) after 12, 24, and 36 months, respectively. CONCLUSIONS: Aortic reinterventions are common and likely after FET implantation, but this study did not identify independent predictors. Reinterventions are associated with acceptable morbidity and mortality. Close follow-up of all patients undergoing FET procedure is paramount.

Predictors of 30-day readmission and resource utilization after thoracic endovascular aortic repair.

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.

Effects of Frailty on Outcomes and 30-day Readmissions After Surgical Mitral Valve Replacement.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Thoracic Endovascular Aneurysm Repair Trends and Outcomes in Over 27,000 Medicare Patients for Descending Thoracic Aneurysms.

BACKGROUND: Since United States Food and Drug Administration approval in 2005, thoracic endovascular aneurysm repair (TEVAR) has replaced open surgery to become the preferred treatment for descending thoracic aneurysms (DTAs). This study investigated TEVAR trends during the previous 15 years regarding patient and hospital characteristics and their effect on survival. METHODS: Between 2000 and 2014, 27,079 Medicare patients underwent TEVAR for DTA. We analyzed TEVAR trends during this period and stratified hospitals based on the number of cases completed during the previous 5 years: low (0-19 cases), medium (20-99 cases), and high (≥100 cases) volume. Trends over time were calculated using Poisson regression to determine the average annual percentage changes (aAPC). Survival was calculated using a multivariate Cox regression and adjusted logistic regression with a restricted cubic spline. RESULTS: TEVAR volume significantly increased from 81 cases in 2000 to 3478 cases in 2014 (aAPC, 16.2%; P < .001). During the study period, the proportion of cases performed at medium-volume centers increased (aAPC, 5.2%; P < .001). Thirty-day mortality after TEVAR increased in the recent period (2013-2014) to 8.8% as compared with 6.6% in the early years (2004-2006) of TEVAR (P < .001), and a significant contribution was due to increased patient comorbidity score (aAPC, 1.6%; P < .001). Lastly, TEVAR center volume was significantly associated with 30-day survival when fewer than 33 cases were done in the prior 5 years. CONCLUSIONS: From 2000 to 2014, TEVAR volume accelerated, and centers are gaining more experience. TEVAR patients have become more acute, and mortality has increased over this period. Patient selection and procedural experience are critical to improving outcomes.

Outcomes after thoracic endovascular aortic repair in patients with chronic kidney disease in the Medicare population.

OBJECTIVE: Thoracic endovascular aortic repair has been increasingly performed in higher-risk patients with renal failure. The objective was to compare Medicare patients with preoperative chronic kidney disease with patients with normal renal function to determine differences in postoperative survival and complications. METHODS: From 2000 to 2014, 27,079 Medicare fee-for service patients underwent thoracic endovascular aortic repair. Patients were stratified by kidney function, and 23,375 patients (86%) had no chronic kidney disease, 2957 patients (11%) had chronic kidney disease stage I/IV, and 747 patients (3%) had end-stage renal disease or hemodialysis. Groups were then compared with determined differences in adjusted all-cause mortality and rates of postoperative complications. RESULTS: Overall survival was significantly worse among patients with chronic kidney disease and end-stage renal disease or hemodialysis compared with patients with no chronic kidney disease (1-year survival no chronic kidney disease: 78%; chronic kidney disease I/II: 77%; chronic kidney disease III: 67%; chronic kidney disease IV: 58%; and end-stage renal disease or hemodialysis: 48%, P < .001). Mortality was significantly increased among patients with chronic kidney disease III (hazard ratio [HR], 1.29; P < .001), chronic kidney disease IV (HR, 1.74; P < .001), and end-stage renal disease or hemodialysis (HR, 2.03; P < .001). No mortality difference was found between patients with no chronic kidney disease and patients with chronic kidney disease stage I/II. At 30 days after thoracic endovascular aortic repair, sepsis was increased for patients with chronic kidney disease stage III/IV (HR, 1.7; P < .001) and end-stage renal disease or hemodialysis (HR, 2.7; P < .001). CONCLUSIONS: In this elderly Medicare population undergoing thoracic endovascular aortic repair, patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis had poor survival and increased morbidity compared with those with normal kidney function. These data may suggest that patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis should be more cautiously evaluated for thoracic endovascular aortic repair, weighing the benefits of the procedure against the high expected mortality.

Distal Stent Graft-Induced New Entries After the Frozen Elephant Trunk Procedure.

BACKGROUND: This study sought to evaluate the incidence of and identify risk factors for distal stent graft-induced new entries (dSINEs) after the frozen elephant trunk (FET) procedure. METHODS: Patient characteristics and radiographic and follow-up data on 126 patients treated for aortic dissections with the Thoraflex (Vascutek Ltd, Inchinnan, United Kingdom) FET device in 2 centers between November 2013 and December 2018 were evaluated. Stress-strain behavior and load-displacement curves of the Thoraflex and the E-Vita Open (Jotec Inc, Hechingen, Germany) FET prosthesis were evaluated by applying axial load to the most distal ring of the prostheses. RESULTS: dSINEs were diagnosed in 16 patients (13%). There was no difference in the underlying disease, aortic features, or FET stent graft dimension between patients with and without dSINEs. No predictors for dSINE occurrence in patients treated with the Thoraflex device were identified. The risk for dSINE development was 14% (95% confidence interval [CI], 0% to 22%), 16% (95% CI, 0% to 24%), and 25% (95% CI, 0% to 45%) after 12, 24, and 36 months, respectively. When prostheses were loaded axially to 2-mm maximal displacement, the Thoraflex prosthesis exhibited strongly nonlinear behavior with maximal stiffness for minimal displacements, whereas the E-Vita prosthesis showed nearly constant stiffness. In addition, the Thoraflex prosthesis showed an increase in stiffness when confined. CONCLUSIONS: dSINEs may develop at any time after the FET procedure, and the risk for dSINE development is high. No clinical or patient-specific risk factors were identified in this study. The design of the Thoraflex graft with a stiff distal ring may be a potential reason for the occurrence of dSINEs.

Optimal timing for heart transplantation in patients bridged with left ventricular assist devices: Is timing of the essence?

OBJECTIVES: Due to the scarcity of donor hearts to meet recipient demands, more than 40% of heart transplants are performed in patients bridged to transplant (BTT) with a left ventricular assist device (LVAD). The objective of this study was to determine the effect of BTT duration with an LVAD on posttransplant outcomes. METHODS: From 2009 to 2014, we identified 2639 fee-for-service Medicare patients who underwent a primary heart transplants with 1186 (45%) patients BTT with an LVAD. The LVAD patients were stratified as BTT ≤31 days (n = 28 [2.4%]), BTT 31-365 days (n = 748 [63.1%]), and BTT >365 days (n = 409 [34.5%]). Patients went directly to heart transplantation and were not bridged in 1453 cases (55%). LVAD duration was analyzed dichotomously and as a continuous variable with adjusted overall survival as the primary end point. RESULTS: All-cause mortality was significantly worse in patients who were BTT <31 days. Survival at 30 days was 81.5% for BTT <31 days, 94% for BTT 31 to 365 days, 95% for BTT >365 days, and 94% for no BTT. At 1 year, survival was 74% for BTT <31 days, 85% for BTT 31 to 365 days, 88% for BTT >365 days, and 89% for no BTT (P = .018). When LVAD duration was analyzed as a continuous variable, patients BTT with an LVAD <34 days had significantly increased mortality. CONCLUSIONS: Patients who underwent heart transplantation within the first month of BTT with an LVAD had significantly increased mortality. However, there was no survival difference among patients who were BTT with an LVAD longer than 31 days.

Causes, Risk Factors, and Costs of 30-Day Readmissions After Mitral Valve Repair and Replacement.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Management of Patients With Coronary Artery Malperfusion Secondary to Type A Aortic Dissection.

BACKGROUND: This study reviewed our experience with coronary artery (CA) malperfusion secondary to type A aortic dissection. METHODS: Between 2002 and 2017, 76 patients presented with CA malperfusion, with a dissection flap limited to the aorta in the region of the coronary ostium (type A lesion) in 26 (34%), with a dissection flap involving the CA itself (type B lesion) in 32 (42%), or with complete avulsion of the CA (type C lesion) in 18 (24%). RESULTS: Ostial repair was successfully performed in 23 type A patients (88%), in 20 type B patients (63%), and in no type C patient (0%). CA bypass grafting was performed when antegrade cardioplegia could not be applied in all 18 type C patients (100%) and in 5 type B patients (16%) because of a primary entry at the coronary ostium and in 7 patients (type A: 3 patients [12%], type B: 4 patients [13%]) with evidence of CA disease (p < 0.001). Perioperative mortality in patients with CA malperfusion was high (18 patients [24%]), but there was no difference in short-term (p = 0.153) or long-term survival (log-rank p = 0.542). Also, a landmark analysis showed equal survival of discharged patients with and without CA malperfusion (log-rank p = 0.645). CONCLUSIONS: We recommend CA bypass grafting in patients with type C lesions or in patients with underlying CA disease for optimal delivery of cardioplegia and ostial pledgetted suture repair in patients with type A lesions or type B lesions when the administration of antegrade cardioplegia is successful.

Outcome after aortic, axillary, or femoral cannulation for acute type A aortic dissection.

OBJECTIVE: The optimal method for arterial cannulation in acute aortic dissection type A (ADA) remains controversial. The aim of this study was to compare central ascending aortic, axillary, and femoral cannulation in patients who underwent surgery for acute ADA. METHODS: Between 2006 and 2017, 584 patients were operated on for acute ADA. Of those, 355 (61%) underwent ascending aortic, 101 (17%) right axillary, and 128 (22%) femoral cannulation for arterial inflow. Clinical features and outcomes were compared after inverse probability weighting. RESULTS: After inverse probability weighting there were no statistical differences in preoperative characteristics. Operative details differed significantly among the 3 groups: hemiarch replacement was performed more often in the central aortic and the femoral group (P < .001), whereas total arch replacement was performed more often in the axillary group (P < .001). Cardiopulmonary bypass (P = .022) and aortic cross-clamp (P = .021) times were shortest in the aortic cannulation group and longest in the femoral cannulation group. Postoperative morbidities were similar; procedure-related stroke (P = .783) and the need for renal replacement therapy (P = .446). In-hospital mortality (P = .680) and long-term survival were similar (log rank, P = .704). Multilevel multivariate mixed effect logistic regression showed that the cannulation strategy was not associated with in-hospital mortality. CONCLUSIONS: Central ascending aortic cannulation in patients with ADA can be used as safely as axillary or femoral cannulation, providing another option for quick and easy establishment of cardiopulmonary bypass.

Influence of Age and the Burden of Ischemic Injury on the Outcome of Type A Aortic Dissection Repair.

BACKGROUND: This study evaluated operative details and postoperative outcomes in elderly patients according to the burden of ischemic injury. METHODS: Between 2002 and 2017, 1187 patients in 2 centers were operated on for aortic dissection type A (ADA). Patients were grouped according to the Penn classification: class A, 628 patients; class B, 196; class C, 224; and class BC, 139. The perioperative conditions and outcomes were analyzed. RESULTS: The likelihood of presenting in a Penn class changed significantly with age (P = .02). Also, the probability of ADA extension into the supraaortic vessels (P < .001) or the distal aorta (P < .001) decreased significantly over age. Nevertheless, there was no significant difference in the distal aortic repair between younger and older patients. The probability of in-hospital mortality increased significantly in all Penn classes with age (P < .001). Yet, predicted mortality remained below 15% for any age in class A patients but increased up to 25% in class B and C patients and beyond 50% in class BC patients. Class A or B were not predictive of in-hospital mortality in septuagenarians or octogenarians. CONCLUSIONS: Age by itself is not a rational criterion to select patients for surgical treatment, and a surgical approach is very reasonable in all class A patients independent of age. The predicted mortality in classes B, C, and particularly class BC is dismal in the elderly. Those patients may benefit from alternative, evolving therapeutic options such as ascending endovascular treatments.

Cohort Profile Update: The China Jintan Child Cohort Study.

The China Jintan Child Cohort study began in 2004 with 1656 pre-school participants and a research focus on studying the impact of environmental exposures, such as lead, on children's neurobehavioural outcomes. This population cohort now includes around 1000 of the original participants, who have been assessed three times over a period of 10 years. Since the original IJE cohort profile publication in 2010, participants have experienced a critical developmental transition from pre-school to school age and then adolescence. The study has also witnessed an increase in breadth and depth of data collection from the original aim of risk assessment. This cohort has added new directions to investigate the mechanisms and protective factors for the relationship between early health factors and child physical and mental health outcomes, with an emphasis on neurobehavioural consequences. The study now encompasses 11 domains, composed of repeated measures of the original variables and new domains of biomarkers, sleep, psychophysiology, neurocognition, personality, peer relationship, mindfulness and family dynamics. Depth of evaluation has increased from parent/teacher report to self/peer report and intergenerational family report. Consequently, the cohort has additional directions to include: (i) classmates of the original cohort participants for peer relationship assessment; and (ii) parental and grandparental measures to assess personality and dynamics within families. We welcome interest in our study and ask investigators to contact the corresponding author for additional information on data acquisition.