Monitoring hiring discrimination through online recruitment platforms.

Women (compared to men) and individuals from minority ethnic groups (compared to the majority group) face unfavourable labour market outcomes in many economies1,2, but the extent to which discrimination is responsible for these effects, and the channels through which they occur, remain unclear3,4. Although correspondence tests5-in which researchers send fictitious CVs that are identical except for the randomized minority trait to be tested (for example, names that are deemed to sound 'Black' versus those deemed to sound 'white')-are an increasingly popular method to quantify discrimination in hiring practices6,7, they can usually consider only a few applicant characteristics in select occupations at a particular point in time. To overcome these limitations, here we develop an approach to investigate hiring discrimination that combines tracking of the search behaviour of recruiters on employment websites and supervised machine learning to control for all relevant jobseeker characteristics that are visible to recruiters. We apply this methodology to the online recruitment platform of the Swiss public employment service and find that rates of contact by recruiters are 4-19% lower for individuals from immigrant and minority ethnic groups, depending on their country of origin, than for citizens from the majority group. Women experience a penalty of 7% in professions that are dominated by men, and the opposite pattern emerges for men in professions that are dominated by women. We find no evidence that recruiters spend less time evaluating the profiles of individuals from minority ethnic groups. Our methodology provides a widely applicable, non-intrusive and cost-efficient tool that researchers and policy-makers can use to continuously monitor hiring discrimination, to identify some of the drivers of discrimination and to inform approaches to counter it.

Postoperative acute kidney injury following intraoperative blood product transfusions during cardiac surgery.

INTRODUCTION: This study explored the nature of the association between intraoperative usage of red blood cell, fresh frozen plasma, cryoprecipitate or platelet transfusions and acute kidney injury. METHODS: A total of 1175 patients who underwent cardiac surgery between 2008 and 2013 were retrospectively analyzed. We assessed the association between: (1) preoperative patient characteristics and acute kidney injury, (2) intraoperative blood product usage and acute kidney injury, (3) acute kidney injury and 30-day mortality or re-hospitalization. RESULTS: In our cohort of 1175 patients, 288 patients (24.5%) developed acute kidney injury. This included 162 (13.8%), 69 (5.9%) and 57 (4.9%) developing stage 1, stage 2 or stage 3 acute kidney injury, respectively. Increased red blood cell, fresh frozen plasma or platelet transfusions increased the odds of developing acute kidney injury. Specifically, every unit of red blood cells, fresh frozen plasma or platelets transfused was associated with an increase in the covariate-adjusted odds ratio of developing ⩾ stage 2 kidney injury of 1.18, 1.19 and 1.04, respectively. CONCLUSIONS: Intraoperative blood product transfusions were independently associated with an increased odds of developing acute kidney injury following cardiac surgery. Further randomized studies are needed to better define intraoperative transfusion criteria.

NT5E mutations and arterial calcifications.

BACKGROUND: Arterial calcifications are associated with increased cardiovascular risk, but the genetic basis of this association is unclear. METHODS: We performed clinical, radiographic, and genetic studies in three families with symptomatic arterial calcifications. Single-nucleotide-polymorphism analysis, targeted gene sequencing, quantitative polymerase-chain-reaction assays, Western blotting, enzyme measurements, transduction rescue experiments, and in vitro calcification assays were performed. RESULTS: We identified nine persons with calcifications of the lower-extremity arteries and hand and foot joint capsules: all five siblings in one family, three siblings in another, and one patient in a third family. Serum calcium, phosphate, and vitamin D levels were normal. Affected members of Family 1 shared a single 22.4-Mb region of homozygosity on chromosome 6 and had a homozygous nonsense mutation (c.662C→A, p.S221X) in NT5E, encoding CD73, which converts AMP to adenosine. Affected members of Family 2 had a homozygous missense mutation (c.1073G→A, p.C358Y) in NT5E. The proband of Family 3 was a compound heterozygote for c.662C→A and c.1609dupA (p.V537fsX7). All mutations found in the three families result in nonfunctional CD73. Cultured fibroblasts from affected members of Family 1 showed markedly reduced expression of NT5E messenger RNA, CD73 protein, and enzyme activity, as well as increased alkaline phosphatase levels and accumulated calcium phosphate crystals. Genetic rescue experiments normalized the CD73 and alkaline phosphatase activity in patients' cells, and adenosine treatment reduced the levels of alkaline phosphatase and calcification. CONCLUSIONS: We identified mutations in NT5E in members of three families with symptomatic arterial and joint calcifications. This gene encodes CD73, which converts AMP to adenosine, supporting a role for this metabolic pathway in inhibiting ectopic tissue calcification. (Funded by the National Human Genome Research Institute and the National Heart, Lung, and Blood Institute of the National Institutes of Health.).

Serious aortic complications in a patient with Turner syndrome.

An asymptomatic young woman was discovered to have life-threatening aneurysms and dissection of the thoracic aorta during routine evaluation in a Turner syndrome (TS) study. The presence of a heart murmur and hypertension had led to diagnosis and surgical repair of an atrial septal defect at age 5 and of aortic coarctation at age 12. The diagnosis of TS was made at 16 years of age due to short stature and delayed pubertal development. She was treated with growth hormone from age 16 to 18 and with atenolol, thyroid hormone, and estrogen. She discontinued her medications and was lost to medical follow-up at age 20. Upon presenting here at age 26, she reported a very active lifestyle, including vigorous exercise and an acting career, with no symptoms of chest or back pain or shortness of breath. Cardiovascular imaging revealed aortic regurgitation, an unsuspected dissection of a severely dilated ascending aorta, and a large descending aortic aneurysm. She required surgical replacement of her aortic valve and ascending aorta, followed by endovascular repair of the descending aortic aneurysm. This patient illustrates the importance of considering the diagnosis of TS in girls with congenital aortic defects and the absolute necessity for close, expert follow-up of these patients who are at high risk for complications after surgical repair due to an underlying aortopathy, hypertension, and metabolic disorders. This patient also emphasizes the need to publicize and follow screening guidelines as there is an increasing number of patients with congenital defects who need transition to adult care.

Left Ventricular Pseudoaneurysm in a Patient With an Apical Aneurysm.

Left ventricular pseudoaneurysm is a potentially life-threatening complication of acute myocardial infarction. Timely diagnosis is crucial to improve the patient's prognosis. We describe a multimodality diagnostic approach with emphasis on cardiac magnetic resonance imaging for a left ventricular pseudoaneurysm found surreptitiously in 72-year-old man 2 weeks following an acute myocardial infarction. (Level of Difficulty: Beginner.).

COVID-19 financial support to small businesses in Switzerland: evaluation and outlook.

We analyse small businesses' recourse to public support measures during the COVID-19 crisis using a survey of 1011 self-employed workers and small business owners in Switzerland. We find that "objective" measures of lockdown affectedness and economic structure explain fairly well how businesses availed of support measures to cover labour costs. Recourse to government-backed corona loans, however, appears to be driven to a larger extent by behavioural idiosyncrasies across firms. Specifically, previously indebted businesses took out corona loans more readily than those who had been debt-free before the pandemic. Since uptake is not well in line with firm fundamentals, we propose making loan repayments contingent on future profits. This will more effectively target and sustain businesses that are in trouble today but would be viable in the absence COVID-19.

Repair of a Syphilitic Aneurysm of the Noncoronary Sinus.

About one-tenth of patients with untreated chronic syphilis and tertiary syphilis develop structural complications involving the coronary ostia, ascending aorta, or aortic root. We describe a unique case of a large aortic root aneurysm of the noncoronary sinus with extrinsic compression of the right coronary artery, a complication of tertiary syphilis. Surgical intervention involved valve-sparing aortic root reconstruction with right coronary ostia reimplantation (hemi-Yacoub). The patient's postoperative course was uneventful; he is healthy approximately 2 years later.

Physiologic coarctation of the aorta resulting from proximal protrusion of thoracic aortic stent grafts into the arch.

Graft collapse is a known complication of thoracic aortic stent grafting, particularly in cases of traumatic thoracic aortic transection, when a typically smaller diameter aorta is repaired with a relatively large diameter device. In contrast, obstruction of the aorta from a stent graft that protrudes into the aortic arch but does not collapse is a less common complication of thoracic aortic stent grafting that can present as a functional aortic coarctation. We describe here two cases of physiologic coarctation of the aorta caused by stent graft protrusion into the arch that were successfully treated with stent graft explantation and open aortic reconstruction.

Thoracic endovascular stent grafting inhibits aortic growth: an experimental study.

OBJECTIVE: Dilatation of the aorta at the landing zone site may be exaggerated by the radial force of stent grafts potentially limiting long-term results of endovascular therapy. We evaluated growth patterns and morphology of the thoracic aorta in young piglets after thoracic stent-graft placement. METHODS: Eight domestic piglets (37+/-2 kg) had an endovascular stent graft placed in the proximal descending thoracic aorta using retroperitoneal access. At implantation, the stent was oversized by 10%. Aortic size was documented after thoracotomy by intraoperative measurement and angiography. Subsequently the piglets were grown to adult size (181+/-42 kg). At explantation 6-15 months later, CT scan and surgical evaluation for endoleaks, defined as perigraft flow, was performed. Histopathological assessment of the explanted aorta was performed in stented and non-stented segments and compared to five normal porcine aortas. RESULTS: No endoleak (perigraft flow) or stent migration occurred even in 230kg pigs. The stent grafts expanded to full size, but there was no further growth in the stented area. The aortic diameter increased significantly by 32+/-9% 1cm proximal to the stents (p=0.0012) and by 45+/-13% 1cm distal to the stents (p=0.0033). The stented area grew less than the proximal (p=0.0011) and distal aorta (p<0.0001). In all pigs, the distal aorta was larger than the proximal overstented segment. Histology of the stented aorta showed significant thickening of the intima (p=0.018) and media (p=0.006) with neointimal formation and segmental fibrosis of the inner 1/3 of the media with loss of smooth muscle cells and compression of the elastic fibers but normal architecture in the outer 2/3 of the media. CONCLUSIONS: Endovascular stent grafting may inhibit growth of the nonatherosclerotic normal aorta and lead to intimal hyperplasia and focal fibrosis in the inner media part adjacent to the stent. Stent-graft interaction with aortic tissue over time is important and should receive more detailed evaluation. Testing this interaction in an animal model of nonatherosclerotic dilative aortic disease could be of great interest.

Incidence of neurological complications following overstenting of the left subclavian artery.

OBJECTIVE: Aortic endovascular stent-graft implantation is associated with low morbidity and mortality rates. Overstenting of the left subclavian artery may be necessary to create a satisfactory proximal 'landing zone' for the stent-graft. Few cases have been published reporting adverse neurological events after overstenting of the left subclavian artery. We thus evaluated whether this procedure is associated with a higher rate of neurological complications by focusing on the management of the supra-aortic vessels. METHODS: Twenty patients suffering from aortic arch aneurysms (n=3), descending aortic aneurysms (n=7), acute (n=6) and chronic (n=4) type-B aortic dissections underwent stent-graft repair with complete (n=14) or partial (n=6) overstenting of the left subclavian artery. Three patients underwent overstenting of the entire aortic arch with ascending aortic-bi-carotid bypass grafting. One patient with right carotid and vertebral artery occlusion underwent initial carotid-to-subclavian bypass. All patients subsequently underwent neurological examination and Doppler ultrasound for detection of neurological and peripheral vascular complications. RESULTS: Aortic stent-graft repair was successful in all patients without acute neurologic complications. Two patients developed late central adverse neurological events: right-sided vertebral artery occlusion with brainstem infarction (n=1) and impaired binocular vision combined with dizziness (n=1), necessitating secondary subclavian transposition in one patient. Peripheral symptoms related to occlusion of the left subclavian artery were observed in five patients as sensory and motoric deficits of the left hand and arm. CONCLUSIONS: Overstenting of the left subclavian artery as treatment of aortic pathologies in high-risk patients is feasible but associated with the risk of neurological complications and peripheral symptoms. Side effects were mild or transient in most of our patients. Detailed preoperative exploration of vascular anatomy and pathology via Doppler ultrasound, CT- or MRI scan is mandatory to avoid adverse neurological events. Prior surgical revascularization of the left subclavian artery is essential in patients with high-grade stenoses, occlusions, or anatomic variants of the supra-aortic branches. Delayed surgical revascularization is necessary only in patients with relevant subclavian steal syndrome or severe peripheral vascular symptoms.

Neurophysiological monitoring during thoracoabdominal aortic endovascular stent graft implantation.

OBJECTIVE: The aim of this study was to evaluate the benefit of neurophysiological monitoring during thoracic and thoracoabdominal endovascular stent graft implantation. METHODS: The spinal cords of 21 patients undergoing endovascular stent graft implantation on the thoracic and thoracoabdominal aorta were monitored with transcranial motor-evoked potentials (tcMEP) and somatosensory-evoked potentials (SSEP). All patients underwent mild systemic hypothermia (34-35 degrees C), constant cerebrospinal fluid (CSF) pressure and vital parameter monitoring. If CSF pressure exceeded 15 mmHg, CSF-drainage was carried out. RESULTS: Three of the 21 patients (14%) exhibited short-term loss of tcMEP and SSEP after the deployment of the self-expanding endoprosthesis. We observed an intraoperative recovery of the evoked potentials in all cases. CSF-drainage was necessary in three of them. One patient, whose potentials were stable intraoperatively, developed paraparesis 3 weeks after the intervention. CONCLUSIONS: Neurophysiological monitoring has proved to be an ideal monitoring method to detect spinal cord ischemia during thoracic and thoracoabdominal endovascular stent graft implantation. Due to the advantages of endovascular therapy (no aortic cross-clamping, continuous distal perfusion, and no reperfusion injury), changes in potentials were seldom observed.

Implantation of the permanent Jarvik-2000 left ventricular assist device: a single-center experience.

OBJECTIVES: We sought to evaluate the surgical results and effects of continuous support with the permanent Jarvik-2000 left ventricular assist device (LVAD). We report the early outcomes. BACKGROUND: A shortage of transplant donors necessitates the testing of alternative treatments. The Jarvik-2000 is an axial flow pump with a percutaneous retro-auricular power connector, designed for permanent use. METHODS: Patients with severe heart failure (HF), unsuitable for heart transplantation or conventional LVAD support, were offered implantation. The surgical approach included a left lateral thoracotomy. The device was implanted into the left ventricular apex on femoro-femoral bypass. It is set to allow pulsatile flow with an aortic valve opening. Anticoagulation is adjusted the same as for patients with a heart valve. RESULTS: Between May 2001 and August 2001, we implanted the Jarvik-2000 in two patients with dilated cardiomyopathy and in one with cardiac amyloidosis, all with severe HF (cardiac index 1.8 +/- 0.3 l/m(2) per min). One patient required preoperative inotropic support. All patients did well, with no repeat operations or infections. Patients received 4.3 +/- 3.2 packed red blood cells and were intubated at 14 +/- 3 h, and the intensive care unit stay was 7.0 +/- 0.5 days. The cardiac index increased from 3.7 +/- 1.5 l/min per m(2) at 8,000 rpm to 5.9 +/- 2.9 l/min per m(2) at 12,000 rpm. All patients currently have mild hemolysis not requiring transfusion. The following postoperative events were recorded: a transient ischemic attack with complete recovery, a short re-intubation due to ventricular arrhythmia, loss of consciousness with a battery change while standing, knee-joint effusion after ergometry training, a minor wound problem and a short hospital re-admission due to dehydration. Patients were discharged home after 49 +/- 7 days; one has returned to work. All quality-of-life scores have improved. CONCLUSIONS: The permanent Jarvik-2000 appears safe. It can be used for dilative or restrictive disease. The Jarvik-2000 might prove a valid option for the long-term treatment of patients with severe HF.

Implantation of the Jarvik 2000 left-ventricular-assist-device: role of the maxillofacial surgeon.

The Jarvik 2000 system of axial-flow LVAD-is implanted for permanent mechanical circularly support in patients with end-stage heart failure waiting to undergo heart transplantation. The battery is connected with a power plug to the percutaneous skull-mounted footplate, which is monocortically fixated to the retro auricular bone. Patient selection should be highly specific, including careful preoperative evaluation. No device failures have been published so far, but complications can occur due to heparinisation. We describe the procedure from the perspective of the maxillofacial surgeon and give suggestions to prevent surgical complications.

Implantable left ventricular assist device for treatment of pulmonary hypertension in candidates for orthotopic heart transplantation-a preliminary study.

OBJECTIVES: Elevated pulmonary vascular resistance (PVR) unresponsive to pharmacological intervention is a major limitation in heart transplantation (HTX). The post-operative course of these patients is associated with an increased risk of life-threatening right heart failure. We evaluated the efficiency of an implantable left ventricular assist device (LVAD) to decrease PVR by unloading the left ventricle and to lower the risk of later orthotopic HTX. METHODS: Six patients with end-stage heart failure (NYHA class IV) and 'fixed' pulmonary hypertension (PVR 5.7+/-0.7, range 4.4-6.5 Wood units) were analyzed. Despite maximal pharmacological intervention at initial evaluation (oxygen inhalation, nitrates, alprostadil infusion) PVR could not be reduced to under 2.5 Wood units. Four patients received a TCI Heartmate, one patient a Novacor, and one patient a Jarvik 2000. RESULTS: All patients survived the LVAD implantation, four patients could be discharged from hospital. Cardiac index and pulmonary artery pressure values returned to normal during the early post-operative phase. After a mean support time of 191+/-86 days PVR had fallen to 2.0+/-1.2 (range 0.8-3.6) Wood units. All patients could be bridged to transplantation, one patient died 3 months after transplant, five patients are still alive after a mean follow-up of 16.2+/-10.5 months. CONCLUSIONS: Mechanical support using an implantable LVAD is a very efficient approach with an acceptable risk to treat severe pulmonary hypertension in end-stage heart failure patients before HTX. Adequate reduction of PVR can be expected within 3-6 months. Subsequent HTX is associated with a good outcome.

The Jarvik 2000 Heart. Clinical validation of the intraventricular position.

OBJECTIVE: Heart failure is now a public health epidemic. Donor hearts are severely restricted in availability. Permanent mechanical circulatory support or bridge to myocardial recovery are emerging alternatives. After extensive laboratory experience we sought to evaluate the intraventricular Jarvik 2000 Heart in patients with endstage heart failure. METHODS: The Jarvik 2000 Heart is a novel thumb-sized left ventricular assist device (LVAD) which is fitted within the apex of the native left ventricle. A vascular graft off loads this to the descending thoracic aorta. The pump rotor spins at between 8000 and 12,000 rpm providing 5-6 litres blood flow per minute. We have used the device with skull-mounted power delivery for seven permanent implants and trans-abdominal drive line for ten bridge-to-transplant patients. RESULTS: All patients survived the operation. Three died from non-device related complications. Survivors had early resolution of heart failure with return to NYHA I/II. All had pulsatile circulation. The device was user-friendly and imperceptible to the patient. Both the pump and native left ventricle contributed to the cardiac output during exercise. Seven patients have been transplanted successfully. All explanted devices were free from thrombus formation. Two permanent implant patients left hospital as early as 3 weeks postoperatively. CONCLUSIONS: The Jarvik 2000 is an effective user-friendly LVAD which allows early discharge from hospital. The intraventricular position has distinct advantages especially through absence of an inflow cannula. Synergy develops between the LVAD and native left ventricle. Early experience suggests that this may be a realistic LVAD to treat heart failure routinely in the outpatient setting.

A complicated case of vascular Pythium insidiosum infection treated with limb-sparing surgery.

INTRODUCTION: Pythiosis is a serious life- and limb-threatening infection endemic to Thailand, but rarely seen in the Western hemisphere. Here, we present a unique case of vascular pythiosis initially managed with limb-sparing vascular bypass grafts complicated by a pseudoaneurysm in our repair. PRESENTATION OF CASE: The patient is a 17 year-old Jamaican male with severe aplastic anemia. He sustained a minor injury to his left leg while fishing in Jamaica, which evolved to become an exquisitely tender inguinal swelling. His physical exam and imaging were significant for arteriovenous fistula with limb ischemia. Pathology obtained during surgery for an extra-anatomic vascular bypass showed extensive invasion by Pythium insidiosum. He later developed a pseudoaneurysm at the site of proximal anastomosis and required urgent intervention. DISCUSSION: This patient presented with a rare, but classic case of vascular pythiosis, which was unrecognized at the time of presentation. A variety of therapeutic modalities have been used to treat this disease, including antibiotics, antifungals, and immunotherapy, but the ultimate management of vascular pythiosis is surgical source control. CONCLUSION: A high index of suspicion in susceptible patients is needed for timely diagnosis of vascular pythiosis to achieve optimal source control.

Hemodynamic Consequences of Hypertrophic Cardiomyopathy with Midventricular Obstruction: Apical Aneurysm and Thrombus Formation.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) with midventricular hypertrophy is an uncommon phenotypic variant of the disease. Midventricular hypertrophy predisposes to intracavitary obstruction and downstream hemodynamic sequelae. CASE REPORT: We present a case of HCM with midventricular hypertrophy and obstruction diagnosed after a CT scan of the abdomen incidentally revealed a filling defect in the left ventricular apex. Transthoracic echocardiography demonstrated mid left ventricular hypertrophy and obstruction, as well as an aneurysmal apex containing a large thrombus. Cardiovascular MRI showed a spade-shaped left ventricle with midcavitary obliteration, an infarcted apex and regions of myocardial fibrosis. Due to the risk of embolization and a relative contraindication to anticoagulation, the patient underwent surgery including thrombectomy, septal myectomy and aneurysmal ligation. CONCLUSIONS: Hypertrophic cardiomyopathy with midventricular hypertrophy leads to cavity obstruction, increased apical wall tension, ischemia and ultimately fibrosis. Over time, patchy apical fibrosis can develop into a confluent scar resembling a transmural myocardial infarction in the left anterior descending coronary artery distribution. Aneurysmal remodeling of the left ventricular apex potentiates thrombus formation and risk of cardioembolism. For these reasons, hypertrophic cardiomyopathy with midventricular obstruction portends a particularly poor prognosis and should be recognized early in the disease process.

The universal bed model for patient care improves outcome and lowers cost in cardiac surgery.

OBJECTIVE: With the escalating demands to increase the efficiency and decrease the cost, innovations in postoperative cardiac surgical patient care are needed. The universal bed model is an innovative care delivery system that allows patient care to be managed in one setting from postoperation to discharge. We hypothesized that the universal bed model in the context of cardiac surgery would improve outcomes and efficacy. METHODS: A total of 610 consecutive patients were admitted to the universal bed unit and prospectively entered into the Society of Thoracic Surgeons National Cardiac Database. Intensive care unit level of care was determined by acuity and staffing needs. Telemetry was employed from admission to discharge, and multidisciplinary rounds were conducted twice daily. Postoperative outcomes were recorded during hospital stay, and comparisons were made with the Society of Thoracic Surgeons National Cardiac Database using identical variables over the same period of time. RESULTS: Decreased ventilation time, intensive care unit and hospital stay, and reduction in the incidence of atrial fibrillation and infectious complications yielded a financial benefit in the universal bed group compared with the traditional model of admission. Stroke rate and in-hospital mortality were the same compared with regional and national centers. Compared with regional centers, there was an average cost savings between $6200 and $9500 per patient depending on the operation. Patient care satisfaction by independent survey was in the 99th percentile. CONCLUSIONS: The universal bed patient care model allows for expedient and efficacious care as measured by decreased length of intensive care unit and hospital stay, improved postoperative outcomes, patient satisfaction, and cost savings.

Minimally invasive approach to thoracic effusions in patients with ventricular assist devices.

The aim of this study was to compare our experience between open and video-assisted thoracic surgery (VATS) approaches to the management of thoracic effusions in ventricular assist device (VAD) patients. This was a retrospective review of a prospectively collected database of VAD patients at a single institution. Patients who were operated on for pericardial and/or pleural effusions were included. Primary outcomes included operative mortality and morbidity as well as effusion recurrence. From 1993 to 2009, 360 adult patients underwent VAD placement. Twenty-three patients (11.9%) required operative management of pleural (n = 24), pericardial (n = 13) or both pleural and pericardial (n = 6) effusions [open = 20 (47%); VATS = 23 (53%)]. Drainage with decortication was performed in five patients, with the remaining undergoing drainage alone. Open and VATS patients were similar in age, gender and indication for VAD support. Conversion from VATS to open was necessary in four patients (17%). There was no operative mortality and no difference in perioperative complications between approaches. The open and VATS approaches had similar rates of pleural (open = 63%; VATS = 41%; P = 0.42) and pericardial (open = 31%; VATS = 17%; P = 1) effusion recurrences. In spite of apparent challenges, the VATS approach may be as safe and effective as open surgery for the management of pleural and pericardial effusions in VAD patients in centres with significant minimally invasive thoracic experience.