Community-Level Disadvantage of Adults With Firearm- vs Motor Vehicle-Related Injuries.

Importance: Motor vehicle crash (MVC) and firearm injuries are 2 of the top 3 mechanisms of adult injury-related deaths in the US. Objective: To understand the differing associations between community-level disadvantage and firearm vs MVC injuries to inform mechanism-specific prevention strategies and appropriate postdischarge resource allocation. Design, Setting, and Participants: This multicenter cross-sectional study analyzed prospectively collected data from the American College of Surgeons (ACS) Firearm Study. Included patients were treated either for firearm injury between March 1, 2021, and February 28, 2022, or for MVC-related injuries between January 1 and December 31, 2021, at 1 of 128 participating ACS trauma centers. Exposures: Community distress. Main outcome and Measure: Odds of presenting with a firearm as compared with MVC injury based on levels of community distress, as measured by the Distressed Communities Index (DCI) and categorized in quintiles. Results: A total of 62 981 patients were included (mean [SD] age, 42.9 [17.7] years; 42 388 male [67.3%]; 17 737 Black [28.2%], 9052 Hispanic [14.4%], 36 425 White [57.8%]) from 104 trauma centers. By type, there were 53 474 patients treated for MVC injuries and 9507 treated for firearm injuries. Patients with firearm injuries were younger (median [IQR] age, 31.0 [24.0-40.0] years vs 41.0 [29.0-58.0] years); more likely to be male (7892 of 9507 [83.0%] vs 34 496 of 53 474 [64.5%]), identified as Black (5486 of 9507 [57.7%] vs 12 251 of 53 474 [22.9%]), and Medicaid insured or uninsured (6819 of 9507 [71.7%] vs 21 310 of 53 474 [39.9%]); and had a higher DCI score (median [IQR] score, 74.0 [53.2-94.8] vs 58.0 [33.0-83.0]) than MVC injured patients. Among admitted patients, the odds of presenting with a firearm injury compared with MVC injury were 1.50 (95% CI, 1.35-1.66) times higher for patients living in the most distressed vs least distressed ZIP codes. After controlling for age, sex, race, ethnicity, and payer type, the DCI components associated with the highest adjusted odds of presenting with a firearm injury were a high housing vacancy rate (OR, 1.11; 95% CI, 1.04-1.19) and high poverty rate (OR, 1.17; 95% CI, 1.10-1.24). Among patients sustaining firearm injuries patients, 4333 (54.3%) received no referrals for postdischarge rehabilitation, home health, or psychosocial services. Conclusions and Relevance: In this cross-sectional study of adults with firearm- and motor vehicle-related injuries, we found that patients from highly distressed communities had higher odds of presenting to a trauma center with a firearm injury as opposed to an MVC injury. With two-thirds of firearm injury survivors treated at trauma centers being discharged without psychosocial services, community-level measures of disadvantage may be useful for allocating postdischarge care resources to patients with the greatest need.

Emergency department pediatric readiness of United States trauma centers in 2021: Trauma center facility characteristics and opportunities for improvement.

BACKGROUND: Emergency department (ED) pediatric readiness has been associated with lower mortality for injured children but has historically been suboptimal in non-pediatric trauma centers. Over the past decade, the National Pediatric Readiness Project (NPRP) has invested resources in improving ED pediatric readiness. This study aimed to quantify current trauma center pediatric readiness and identify associations with center-level characteristics to target further efforts to guide improvement. METHODS: The study cohort included all centers that responded to the 2021 NPRP national assessment and contributed data to the National Trauma Databank (NTDB) the same calendar year. Center characteristics and pediatric (0-15y) volume from the NTDB were linked to weighted pediatric readiness scores (wPRS) obtained from the NPRP assessment. Univariate and multivariable analyses were used to determine associations between wPRS and trauma center type as well as center-level facility characteristics. RESULTS: The wPRS was reported for 77% (749/973) of centers that contributed to the NTDB. ED Pediatric Readiness was highest in ACS level one pediatric trauma centers (PTCs), but wPRS in the highest quartile was seen among all adult and pediatric trauma center types. Independent predictors of high wPRS included ACS level one PTC verification, pediatric trauma volume, and the presence of a PICU. Higher-level adult trauma centers and pediatric trauma centers were more likely to have pediatric-specific physician requirements, pediatric emergency care coordinators, and pediatric quality improvement initiatives. CONCLUSION: ED pediatric readiness in trauma centers remains variable and is predictably lower in centers that lack inpatient resources. There is, however, no aspect of ED pediatric readiness that is constrained to high-level pediatric facilities, and a highest quartile wPRS was achieved in all types of adult centers in our study. Ongoing efforts to improve pediatric readiness for initial stabilization at non-pediatric centers are needed, particularly in centers that routinely transfer children out. LEVEL OF EVIDENCE: Epidemiologic, Level III.

Sex and racial disparities in non-alcoholic fatty liver disease-related cardiovascular events: National inpatient sample analysis (2019).

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) increases cardiovascular disease (CVD) risk irrespective of other risk factors. However, large-scale cardiovascular sex and race differences are poorly understood. AIM: To investigate the relationship between NAFLD and major cardiovascular and cerebrovascular events (MACCE) in subgroups using a nationally representative United States inpatient sample. METHODS: We examined National Inpatient Sample (2019) to identify adult hospitalizations with NAFLD by age, sex, and race using ICD-10-CM codes. Clinical and demographic characteristics, comorbidities, and MACCE-related mortality, acute myocardial infarction (AMI), cardiac arrest, and stroke were compared in NAFLD cohorts by sex and race. Multivariable regression analyses were adjusted for sociodemographic characteristics, hospitalization features, and comorbidities. RESULTS: We examined 409130 hospitalizations [median 55 (IQR 43-66) years] with NFALD. NAFLD was more common in females (1.2%), Hispanics (2%), and Native Americans (1.9%) than whites. Females often reported non-elective admissions, Medicare enrolment, the median age of 55 (IQR 42-67), and poor income. Females had higher obesity and uncomplicated diabetes but lower hypertension, hyperlipidemia, and complicated diabetes than males. Hispanics had a median age of 48 (IQR 37-60), were Medicaid enrollees, and had non-elective admissions. Hispanics had greater diabetes and obesity rates than whites but lower hypertension and hyperlipidemia. MACCE, all-cause mortality, AMI, cardiac arrest, and stroke were all greater in elderly individuals (P < 0.001). MACCE, AMI, and cardiac arrest were more common in men (P < 0.001). Native Americans (aOR 1.64) and Asian Pacific Islanders (aOR 1.18) had higher all-cause death risks than whites. CONCLUSION: Increasing age and male sex link NAFLD with adverse MACCE outcomes; Native Americans and Asian Pacific Islanders face higher mortality, highlighting a need for tailored interventions and care.

Characteristics of Firearm Injury by Injury Intent: The Need for Tailored Interventions.

INTRODUCTION: While the U.S. has high quality data on firearm-related deaths, less information is available on those who arrive at trauma centers alive, especially those discharged from the emergency department. This study sought to describe characteristics of patients arriving to trauma centers alive following a firearm injury, postulating that significant differences in firearm injury intent might provide insights into injury prevention strategies. METHODS: This was a multi-center prospective cohort study of patients treated for firearm-related injuries at 128 U.S. trauma centers from 3/2021-2/2022. Data collected included patient-level sociodemographic, injury and clinical characteristics, community characteristics, and context of injury. The outcome of interest was the association between these factors and the intent of firearm injury. Measures of urbanicity, community distress, and strength of state firearm laws were utilized to characterize patient communities. RESULTS: 15,232 patients presented with firearm-related injuries across 128 centers in 41 states. Overall, 9.5% of patients died, and deaths were more common among law enforcement and self-inflicted (SI) firearm injuries (80.9% and 50.5%, respectively). These patients were also more likely to have a history of mental illness. SI firearm injuries were more common in older White men from rural and less distressed communities, whereas firearm assaults were more common in younger, Black men from urban and more distressed communities. Unintentional injuries were more common among younger patients and in states with lower firearm safety grades whereas law enforcement-related injuries occurred most often in unemployed patients with a history of mental illness. CONCLUSIONS: Injury, clinical, sociodemographic, and community characteristics among patients injured by a firearm significantly differed between intents. With the goal of reducing firearm-related deaths, strategies and interventions need to be tailored to include community improvement and services that address specific patient risk factors for firearm injury intent. LEVEL OF EVIDENCE: Level III, Prognostic/Epidemiological.

Rural/urban disparities in the trends and outcomes of peripartum cardiomyopathy in delivery hospitalizations.

BACKGROUND: Rural-urban disparities in peripartum cardiomyopathy (PPCM) are not well known. We examined rural-urban differences in maternal, fetal, and cardiovascular outcomes in PPCM during delivery hospitalizations. METHODS: We used 2003-2020 data from the National Inpatient Sample for delivery hospitalizations in individuals with PPCM. The 9th and 10th editions of the International Classification of Diseases were used to identify PPCM and cardiovascular, maternal, and fetal outcomes. Rural and urban hospitalizations for PPCM were 1:1 propensity score-matched using relevant clinical and sociodemographic variables. Odds of in-hospital mortality were assessed using logistic regression. RESULTS: Among 72,880 delivery hospitalizations with PPCM, 4,571 occurred in rural locations, while 68,309 occurred in urban locations. After propensity matching, there were a total of 4,571 rural-urban pairs. There was significantly higher in-hospital mortality in urban compared to rural hospitalizations (adjusted OR 1.54, 95% CI 1.10-1.89). Urban PPCM hospitalizations had significantly higher cardiogenic shock (2.9% vs. 1.3%), mechanical circulatory support (1.0% vs. 0.6%), cardiac arrest (2.3% vs. 0.9%), and VT/VF (4.5% vs. 2.1%, all p <.05). Additionally, urban PPCM hospitalizations had worse maternal and fetal outcomes as compared to rural hospitalizations, including higher preterm delivery, gestational diabetes, and fetal death (all p<.05). Notably, significantly more rural individuals were transferred to a short-term hospital (including tertiary care centers) compared to urban individuals (13.5% vs. 3.2%, p<.0001). CONCLUSIONS: There are significant rural-urban disparities in delivery hospitalizations with PPCM. Worse outcomes were associated with urban hospitalizations, while rural PPCM hospitalizations were associated with increased transfers, suggesting inadequate resources and advanced sickness.

Association of Prediabetes and Recurrent Stroke in Atrial Fibrillation Patients: A Population-Based Analysis of Hospitalizations and Outcomes.

Prediabetes is a risk factor for ischemic stroke in atrial fibrillation (AF) patients, yet, its impact on recurrent stroke in AF patients remains understudied. Using the 2018 National Inpatient Sample, we investigated the link between Prediabetes and recurrent stroke in AF patients with prior stroke or transient ischemic attack (TIA). Among 18,905 non-diabetic AF patients, 480 (2.5%) had prediabetes. The prediabetic group, with a median age of 78, exhibited a two-fold higher risk of recurrent stroke compared to the non-prediabetic cohort (median age 82), as evidenced by both unadjusted (OR 2.14, 95% CI 1.72-2.66) and adjusted (adjusted for socio-demographics/comorbidities, OR 2.09, 95% CI 1.65-2.64, p < 0.001). The prediabetes cohort, comprising more male and Black patients, demonstrated associations with higher Medicaid enrollment, admissions from certain regions, and higher rates of hyperlipidemia, smoking, peripheral vascular disease, obesity, and chronic obstructive pulmonary disease (all p < 0.05). Despite higher rates of home health care and increased hospital costs in the prediabetes group, the adjusted odds of all-cause mortality were not statistically significant (OR 0.55, 95% CI 0.19-1.56, p = 0.260). The findings of this study suggest that clinicians should be vigilant in managing prediabetes in AF patients, and strategies to prevent recurrent stroke in this high-risk population should be considered.

Firearm injuries in Missouri.

Firearm deaths continue to be a major public health problem, but the number of non-fatal firearm injuries and the characteristics of patients and injuries is not well known. The American College of Surgeons Committee on Trauma, with support from the National Collaborative on Gun Violence Research, leveraged an existing data system to capture lethal and non-lethal injuries, including patients treated and discharged from the emergency department and collect additional data on firearm injuries that present to trauma centers. In 2020, Missouri had the 4th highest firearm mortality rate in the country at 23.75/100,000 population compared to 13.58/100,000 for the US overall. We examined the characteristics of patients from Missouri with firearm injuries in this cross-sectional study. Of the overall 17,395 patients, 1,336 (7.7%) were treated at one of the 11 participating trauma centers in Missouri during the 12-month study period. Patients were mostly male and much more likely to be Black and uninsured than residents in the state as a whole. Nearly three-fourths of the injuries were due to assaults, and overall 7.7% died. Few patients received post-discharge services.

Firearm Injuries treated at Trauma Centers in the United States.

BACKGROUND: While firearm injuries and deaths continue to be a major public health problem, the number of non-fatal firearm injuries and the characteristics of patients is not well known. The American College of Surgeons (ACS) Committee on Trauma leveraged an existing data system to collect additional data on fatal and non-fatal firearm injuries presenting to trauma centers. This report provides an overview of this initiative and highlights the challenges associated with capturing actionable data on firearm-injured patients. METHODS: 128 trauma centers that are part of the ACS Trauma Quality Improvement Program (TQIP) collected data on individuals of any age arriving alive between March 1, 2021 and February 28, 2022 with a firearm injury. In addition to the standard data collected for TQIP, abstractors also extracted additional data specific to this study. We linked data from the Distressed Community Index (DCI) to patient records using zip code of residence. RESULTS: A total of 17,395 patients were included, with mean (SD) age of 30.2 (13.5) years, 82.5% were male and the majority were Black and non-Hispanic. The mean proportion of variables with missing data varied among trauma centers, with a mean of 20.7% missing data. Injuries occurred most commonly in homes (31.2%) or on the street (26.6%); 70.4% of injuries were due to assaults. Nearly one-third of patients were discharged from the ED, 25.9% were admitted directly to the operating room, 10.9% to the ICU; 5.9% died in the ED and 10.3% died overall during their course of care. Nearly two-thirds of patients lived in the two highest distressed categories of communities; only 7.5% lived in the least distressed quintile. CONCLUSIONS: Utilizing trauma center data can be a valuable tool to improve our knowledge of firearm injuries if clinical practices and documentation of patient risks and circumstances are standardized. LEVEL OF EVIDENCE: III Level, epidemiological.

The Association between Pediatric Readiness and Mortality for Injured Children Treated at US Trauma Centers.

OBJECTIVE: To use updated 2021 weighted Pediatric Readiness Score (wPRS) data to identify a threshold level of trauma center emergency department (ED) pediatric readiness. SUMMARY BACKGROUND DATA: Most children in the US receive initial trauma care at non-pediatric centers. The National Pediatric Readiness Project (NPRP) aims to ensure that all EDs are prepared to provide quality care for children. Trauma centers reporting the highest quartile of wPRS on the 2013 national assessment have been shown to have lower mortality. Significant efforts have been invested to improve pediatric readiness in the past decade. STUDY DESIGN: A retrospective cohort of trauma centers that completed the NPRP 2021 national assessment and contributed to the National Trauma Data Bank (NTDB) in 2019-21 was analyzed. Center-specific observed-to-expected mortality estimates for children (0-15y) were calculated using Pediatric TQIP models. Deterministic linkage was used for transferred patients to account for wPRS at the initial receiving center. Center-specific mortality odds ratios were then compared across quartiles of wPRS. RESULTS: 66,588 children from 630 centers with a median [IQR] wPRS of 79 [66-93] were analyzed. The average observed-to-expected odds of mortality (1.02 [0.97-1.06]) for centers in the highest quartile (wPRS≥93) was lower than any of the lowest three wPRS quartiles (1.19 [1.14-1.23](Q1), 1.29 [1.24-1.33](Q2), and 1.28 [1.19-1.36](Q3), all P <0.05). The presence of a pediatric-specific quality improvement plan was the domain with the strongest independent association with mortality (standardized beta -0.095 [-0.146--0.044]). CONCLUSION: Trauma centers should address gaps in pediatric readiness to include a pediatric-specific quality improvement plan and aim to achieve wPRS ≥93.

Clinical and Radiographic Evaluation of Autologous Platelet-Rich Fibrin With or Without Demineralized Bone Matrix in the Treatment of Grade II Furcation Defects.

Introduction This study aims to differentiate the employment of demineralized bone matrix (DMBM; Osseograft, Advanced Biotech Products (P) Ltd, Chennai, India) and platelet-rich fibrin (PRF) alone to a composite graft consisting of both materials in the surgical actions toward the anomalies of the human periodontal furcation imperfection. Methods In a split-mouth study, 30 patients with mandibular molars affected by the furcation were allocated without conscious choice to test (PRF + DMBM, n = 30) or control (PRF, n = 30) categories. At the starting point, three months after surgery, and six months later, the following modifiable factors were evaluated: probing pocket depth (PPD), full-mouth plaque scores, full-mouth gingival scores, radiographic defect depth, relative vertical clinical attachment level (RVCAL), and relative horizontal clinical attachment level (RHCAL). Results Results at three and six months demonstrated substantial differences between baseline values for both treatment methods in clinical and X-ray imaging appraisal. Nonetheless, the PRF/DMBM group manifests statistically significantly soaring changes observed in comparison to the PRF group. Overall, the probing depth (PD) in the test site was significantly lower than that in the control site, showing a reduction of 68% (95% CI=41%, 95%, p<0.001). Conclusion Clinical indications significantly improved with PRF and DMBM combined instead of PRF alone. On radiographs, the test group also showed higher bone fill.

A Multipathway Phosphopeptide Standard for Rapid Phosphoproteomics Assay Development.

Recent advances in methodology have made phosphopeptide analysis a tractable problem for many proteomics researchers. There are now a wide variety of robust and accessible enrichment strategies to generate phosphoproteomes while free or inexpensive software tools for quantitation and site localization have simplified phosphoproteome analysis workflow tremendously. As a research group under the Association for Biomolecular Resource Facilities umbrella, the Proteomics Standards Research Group has worked to develop a multipathway phosphopeptide standard based on a mixture of heavy-labeled phosphopeptides designed to enable researchers to rapidly develop assays. This mixture contains 131 mass spectrometry vetted phosphopeptides specifically chosen to cover as many known biologically interesting phosphosites as possible from seven different signaling networks: AMPK signaling, death and apoptosis signaling, ErbB signaling, insulin/insulin-like growth factor-1 signaling, mTOR signaling, PI3K/AKT signaling, and stress (p38/SAPK/JNK) signaling. Here, we describe a characterization of this mixture spiked into a HeLa tryptic digest stimulated with both epidermal growth factor and insulin-like growth factor-1 to activate the MAPK and PI3K/AKT/mTOR pathways. We further demonstrate a comparison of phosphoproteomic profiling of HeLa performed independently in five labs using this phosphopeptide mixture with data-independent acquisition. Despite different experimental and instrumentation processes, we found that labs could produce reproducible, harmonized datasets by reporting measurements as ratios to the standard, while intensity measurements showed lower consistency between labs even after normalization. Our results suggest that widely available, biologically relevant phosphopeptide standards can act as a quantitative "yardstick" across laboratories and sample preparations enabling experimental designs larger than a single laboratory can perform. Raw data files are publicly available in the MassIVE dataset MSV000090564.

Surgical Outcomes of Septal Myectomy With and Without Mitral Valve Surgeries in Hypertrophic Cardiomyopathy: a National Propensity-Matched Analysis (2005 to 2020).

The management of concomitant mitral valve (MV) disease in patients with hypertrophic cardiomyopathy (HCM) remains controversial. The 2020 American Heart Association/American College of Cardiology HCM guidelines recommend that MV replacement (MVR) at the time of myectomy should not be performed for the sole purpose of relieving outflow obstruction. At the national level, limited data exist on the surgical outcomes of MV repair/replacement in patients with HCM who underwent septal myectomy (SM). Hospitalizations of patients with HCM who underwent SM between 2005 and 2020 were identified using International Classification of Diseases, Ninth and Tenth Revision codes (International Classification of Diseases, Ninth and Tenth Revision Clinical Modification/Procedure Coding System). The 3 comparison cohorts were SM alone, MV repair, and MVR with concomitant SM. After propensity matching, 2 cohorts, SM + MVR versus SM + MV repair, were studied for surgical outcomes. Demographic characteristics, baseline co-morbidities, procedural complications, inpatient mortality, length of stay, and cost of hospitalization were compared between the propensity-matched cohorts. A total of 16,797 SM procedures were identified from 2005 to 2020. Among them, 11,470 hospitalizations had SM alone (68.2%), SM + MVR was seen in 3,101 (18.4%), and SM + MV repair comprised 2,226 (13.2%). After propensity matching, the MVR and MV repair formed the matched cohorts of 1,857. There were no significant differences in the odds of cardiogenic shock (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.63 to 1.24, p = 0.49), mechanical circulatory support requirement (aOR 0.58, 95% CI 0.37 to 0.90, p = 0.015), stroke (aOR 1.27, 95% CI 0.81 to 1.99, p = 0.29), and major bleeding (aOR 0.52, 95% CI 0.34 to 0.79, p = 0.0026) between the comparison groups. MVR, compared with MV repair, was associated with a higher risk of procedural mortality (8.02% vs 3.18%, aOR 2.98, 95% CI 2.05 to 4.33, p <0.0001), complete heart block (16.36% vs 12.15%, aOR 1.76, 95% CI 1.44 to 2.12, p <0.0001), and the need for permanent pacemaker (16.39% vs 10.62%, aOR 1.83, 95% CI 1.41 to 2.38, p <0.0001). The total length of hospital stay and median hospitalization cost was higher in the MVR group. SM in HCM concomitant with MVR is associated with higher procedural mortality and in-hospital complication risk. These real-world data support the 2020 American Heart Association/American College of Cardiology guidelines that in patients who are candidates for surgical myectomy, MVR should not be performed as part of the operative strategy for relieving outflow obstruction in HCM.

Pulmonary Cryoablation Outcomes in Octogenarians and Nonagenarians with Primary Lung Cancer.

PURPOSE: To characterize the effectiveness, safety, and length of stay (LOS) associated with pulmonary cryoablation for management of primary lung malignancies in patients aged ≥80 years. MATERIALS AND METHODS: A retrospective single-center database was compiled of all consecutive patients aged ≥80 years who underwent percutaneous computed tomography-guided cryoablation using modified triple-freeze protocol (1-3 ablation probes) for Stage IA-IIB primary lung malignancies between March 2017 and March 2020 (n = 19; 53% women; mean age, 85 years ± 3.5; range, 80-94 years). Follow-up imaging was assessed for local recurrence. Adverse events and LOS were recorded from chart review. Kaplan-Meier analysis was performed to assess both overall and local recurrence-free survival. RESULTS: Mean patient follow-up period was 21.6 months ± 10.8, and mean imaging follow-up period was 19.2 months ± 9.6. Overall survival at 3 years was 94% (95% CI, 81%-100%). Local recurrence-free survival was 100% throughout the imaging follow-up period. Intraprocedural pneumothorax occurred in 37% (7 of 19) of patients; pneumothorax risk was significantly associated with increased tumor distance from pleura (odds ratio, 1.2; P = .018). Sixty-three percent (12 of 19) of patients were discharged on the day of the procedure, with a mean LOS of 7.7 hours ± 1.6, whereas 37% of patients required overnight observation (2 of 19) or admission (5 of 19), with a mean LOS of 48.1 hours ± 19.4. Overall LOS for all patients was 22.6 hours ± 22.9. CONCLUSIONS: Percutaneous cryoablation of primary pulmonary malignancies can be performed in select octogenarians and nonagenarians with high 3-year overall and recurrence-free survival. Despite nonnegligible risk of pneumothorax, most patients are discharged on the day of the procedure.

Association between Trauma Center Type and Mortality for Injured Children with Severe Traumatic Brain Injury.

BACKGROUND: There is conflicting evidence regarding the relationship between trauma center type and mortality for children with traumatic brain injuries. Identification of mortality differences following brain injury across differing trauma center types may result in actionable quality improvement initiatives to standardize care for these children. METHODS: We utilized Trauma Quality Improvement Program data from 2017-2020 to identify children with severe traumatic brain injury managed at level I and II state- or American College of Surgeon-verified trauma centers. We used a random intercept multilevel logistic regression model to assess the relationship between exposure (trauma center type either adult, pediatric or mixed) and outcome (in-hospital mortality). Several secondary analyses were performed to assess the influence of trauma center volume, age strata and traumatic brain injury heterogeneity. RESULTS: There were 10,105 patients identified across 512 trauma centers. Crude mortality was 25.2%, 36.2% and 28.9% for pediatric, adult, and mixed trauma centers respectively. After adjustment for confounders, odds of mortality were higher for children managed at adult trauma centers (OR 1.67; 95% CI: 1.30 - 2.13) compared to pediatric trauma centers. Male sex, self-pay insurance status, and interfacility transfers, motor vehicle, pedestrian/ cyclist and firearm injury mechanisms, presence of concomitant abdomen, lower extremity, or chest injuries, midline shift >5 mm within 24 hours, presence of age-adjusted hypotension and either pupil asymmetry or non-reactivity were all associated with a greater odds of death. Adjustment for trauma volume and subgroup analysis using a homogenous traumatic brain injury subgroup did not change the demonstrated associations. CONCLUSIONS: Our results suggest mortality was higher at adult trauma centers compared to mixed and pediatric trauma centers for children with traumatic brain injuries. Importantly, there exists the potential for unmeasured confounding. We aim for these findings to direct continuing quality improvement initiatives to improve outcomes for brain injured children. LEVEL OF EVIDENCE: III; Type of study: Prognostic/ epidemiological.

Safety of catheter ablation for atrial fibrillation in patients with cancer: a nationwide cohort study.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia in patients with cancer, especially breast, gastrointestinal, respiratory, urinary tract, and hematological malignancies. Catheter ablation (CA) is a well-established, safe treatment option in healthy patients; however, literature regarding safety of CA for AF in patients with cancer is limited and confined to single centers. OBJECTIVE: We aimed to assess the outcomes and peri-procedural safety of CA for AF in patients with certain types of cancer. METHODS: The NIS database was queried between 2016 and 2019 to identify primary hospitalizations with AF and CA. Hospitalizations with secondary diagnosis of atrial flutter and other arrhythmias were excluded. Propensity score matching was used to balance the covariates between cancer and non-cancer groups. Logistic regression was used to analyze the association. RESULTS: During this period, 47,765 CA procedures were identified, out of which 750 (1.6%) hospitalizations had a diagnosis of cancer. After propensity matching, hospitalizations with cancer diagnosis had higher in-hospital mortality (OR 3.0, 95% CI 1.5-6.2, p = 0.001), lower home discharge rates (OR 0.7, 95% CI 0.6-0.9, p < 0.001) as well as other complications such as major bleeding (OR 1.8, 95% CI 1.3-2.7, p = 0.001) and pulmonary embolism (OR 6.1, 95% CI 2.1-17.8, p < 0.001) but not associated with any major cardiac complications (OR 1.2, 95% CI 0.7-1.8, p = 0.53). CONCLUSION: Patients with cancer who underwent CA for AF had significantly higher odds of in-hospital mortality, major bleeding, and pulmonary embolism. Further larger prospective observational studies are needed to validate these findings.

Rising trend of acute myocardial infarction among young cannabis users: A 10-year nationwide gender and race stratified analysis.

Background: The use of cannabis has massively increased among younger patients due to increasing legalization and availability. Methods: We performed a retrospective nationwide study using the Nationwide inpatient sample (NIS) database to analyze the trends of acute myocardial infarction (AMI) in young cannabis users and related outcomes among patients aged 18-49 years from 2007 to 2018, using ICD-9 and ICD-10 codes. Results: Out of 819,175 hospitalizations, 230,497 (28%) admissions reported using cannabis. There was a significantly higher number of males (78.08% vs. 71.58%, p < 0.0001) and African Americans (32.22% vs. 14.06%, p < 0.0001) admitted with AMI and reported cannabis use. The incidence of AMI among cannabis users consistently increased from 2.36% in 2007 to 6.55% in 2018. Similarly, the risk of AMI in cannabis users among all races increased, with the biggest increase in African Americans from 5.69% to 12.25%. In addition, the rate of AMI in cannabis users among both sexes showed an upward trend, from 2.63% to 7.17% in males and 1.62%-5.12% in females. Conclusion: The incidence of AMI in young cannabis users has increased in recent years. The risk is higher among males and African Americans.

Characteristics and Outcomes of Early vs Late Initiation of Mechanical Circulatory Support in Non-Acute Myocardial Infarction related Cardiogenic Shock: An Analysis of the National Inpatient Sample Database.

Cardiogenic shock (CS) is significant cause of mortality. The use of mechanical circulatory support (MCS) in patients with non-acute myocardial infarction (Non-AMI) CS is lacking. We inquired data regarding the trends and outcomes early vs late initiation of MCS in non-AMI CS. We investigated National Inpatient Sample database between October 2015-December 2018, identifying hospitalizations with CS, either complicated by AMI or Non-AMI. Patients were divided into 2 cohorts, early initiation of MCS (<48 hours) and late initiation of MCS (>48 hours). The primary analysis included death within first 24 hours. A secondary analysis was adjusted after excluding patients who died in first 24 hours. A total of 85,318 patients with non-AMI-related CS with MCS placement were identified. Among this cohort, 54.6% (n=46,579) underwent early initiation of MCS within 48 hours, and 45.4% (n=38,739) underwent late initiation of MCS after 48 hours. In primary analysis, early MCS initiation was associated with more in-hospital mortality in primary outcome of all-cause hospital mortality (35.72% vs 27.63%, P<0.0001, OR 1.44, 95% CI: 1.40-1.49, P<0.0001), however, adjusted secondary analysis showed a statistically significant decrease in all-cause hospital mortality (23.63% vs 27.63%, P<0.0001, OR 0.80, 95% CI: 0.78-0.83, P<0.0001). In non-AMI-related CS and based on survival to 24 hours after admission, early initiation of MCS had statistically significant decrease in all-cause hospital mortality, with less incidence of vascular and renal complications, and shorter hospital stay. Late initiation of MCS was associated with a higher incidence of advanced therapies, including LVAD and transplant.

Trend, Predictors, and Outcomes of Transcatheter Aortic Valve Implantation in Patients With End-Stage Renal Disease: Insights From the Nationwide Readmissions Database.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is the standard of care for patients with severe aortic valve stenosis (AS). However, evidence on its safety in patients with end-stage renal disease (ESRD) is limited. METHODS: The Nationwide Readmissions Database (NRD) from 2015 to 2019 was queried to identify patients undergoing TAVI in ESRD versus patients with no ESRD. The in-hospital, 30-day and 180-day outcomes were assessed using a propensity-score matched (PSM) analysis to calculate adjusted odds ratios (aOR). RESULTS: A total of 198,816 underwent TAVI, of which 34,546 patients (TAVI-ESRD 16,986 vs. non-ESRD 17,560) were selected using PSM analysis. The adjusted odds of net adverse cardiovascular events (NACE) (aOR 1.65, 95 % CI 1.49-1.82), in-hospital mortality (aOR 2.99, 95 % CI 2.52-3.55), major bleeding (aOR 1.21, 95 % CI 1.05-1.40), postprocedural cardiogenic shock (aOR 1.54, 95 % CI 1.11-2.13), and need for permanent pacemaker implantation (PPM) (aOR 1.24, 95 % CI 1.15-1.38) were significantly higher in TAVI-ESRD patients compared with non-ESRD patients at index admission. There was no significant difference in the odds of stroke (aOR 1.09, 95 % CI 0.86-1.34) and cardiac tamponade (aOR 1.06, 95 % CI 0.78-1.45) between the two groups. At 30- and 180-day follow-up, the odds of readmission, NACE, and mortality remained high in TAVI-ESRD patients. CONCLUSION: ESRD patients undergoing TAVI have a high risk of NACE, in-hospital mortality, and major bleeding compared with patients with no ESRD.

Impact of Chronic Kidney Disease on In-Hospital Outcomes of Hospitalizations With Acute Limb Ischemia Undergoing Endovascular Therapy.

PURPOSE: Studies on outcomes related to endovascular treatment (EVT) in advanced stages of chronic kidney disease (CKD) and end-stage renal disease (ESRD) among hospitalizations with acute limb ischemia (ALI) are limited. METHODS: The Nationwide Inpatient Sample was quarried from October 2015 to December 2017 to identify the hospitalizations with ALI and undergoing EVT. The study population was subdivided into 3 groups based on their CKD stages: group 1 (No CKD, stage I, stage II), group 2 (CKD stage III, stage IV), and group 3 (CKD stage V and ESRD). The primary outcome was all-cause in-hospital mortality. RESULTS: A total of 51 995 hospitalizations with ALI undergoing EVT were identified. The in-hospital mortality was significantly higher in group 2 (OR = 1.17; 95% CI 1.04 - 1.32, p=0.009) and group 3 (OR = 3.18; 95% CI 2.74-3.69, p<0.0001) compared with group 1. Odds of minor amputation, vascular complication, atherectomy, and blood transfusion were higher among groups 2 and 3 compared with group 1. Group 2 had higher odds of access site hemorrhage compared with groups 1 and 3, whereas group 3 had higher odds of major amputation, postprocedural infection, and postoperative hemorrhage compared with groups 1 and 2. Besides, groups 2 and 3 had lower odds of discharge to home compared with group 1. Finally, the length of hospital stay and cost of care was significantly higher with the advancing CKD stages. CONCLUSION: Advanced CKD stages and ESRD are associated with higher mortality, worse in-hospital outcomes and higher resource utilization among ALI hospitalizations undergoing EVT. CLINICAL IMPACT: Current guidelines are not clear for the optimum first line treatment of acute limb ischemia, especially in patients with advanced kidney disease as compared to normal/mild kidney disease patients. We found that advanced kidney disease is a significant risk factor for worse in-hospital morbidity and mortality. Furthermore, patients with acute limb ischemia and advanced kidney disease is associated with significantly higher resource utilization as compared to patients with normal/mild kidney disease. This study suggests shared decision making between treating physician and patients when considering endovascular therapy for the treatment of acute limb ischemia in patients with advanced kidney disease.