Trends in MitraClip, mitral valve repair, and mitral valve replacement from 2000 to 2016.

OBJECTIVE: The dissemination of mitral valve repair as the first-line treatment and the introduction of MitraClip for patients who have a prohibitive risk for surgery have changed the landscape of mitral valve intervention. The aim of this study is to provide current and generalizable data regarding the trend of mitral valve interventions and outcomes from 2000 to 2016. METHODS: Patients ≥18 years of age who underwent mitral-valve interventions were identified using the National Inpatient Sample database. National estimates were generated by means of discharge weights; comorbid conditions were identified using Elixhauser methods. All trends were analyzed with JoinPoint software. RESULTS: A total of 656,030 mitral valve interventions (298,102 mitral valve replacement, 349,053 mitral valve repair, and 8875 MitraClip) were assessed. No changes in rate of procedures (per 100,000 people in the United States) were observed over this period (annual percent change, -0.4; 95% confidence limit, -1.1 to 0.3; P = .3). From 2000 to 2010, the number of replacements decreased by 5.6% per year (P < .001), whereas repair increased by 8.4% per year from 2000 to 2006 (P < .001). MitraClip procedures increased by 84.4% annually from 2013 to 2016 (P < .001). The burden of comorbidities increased throughout the study for all groups, with the greatest score for MitraClip recipients. Overall, length of stay has decreased for all interventions, most significantly for MitraClip. In-hospital mortality decreased from 8.5% to 3.7% for all interventions, with MitraClip having the most substantial decrease from 3.6% to 1.5%. CONCLUSIONS: Over a 17-year period, mitral-valve interventions were associated with improved outcomes despite being applied to an increasingly sicker population.

Granulosa cell proliferation is inhibited by PGE2 in the primate ovulatory follicle.

Prostaglandin E2 (PGE2) is a key paracrine mediator of ovulation. Few specific PGE2-regulated gene products have been identified, so we hypothesized that PGE2 may regulate the expression and/or activity of a network of proteins to promote ovulation. To test this concept, Ingenuity Pathway Analysis (IPA) was used to predict PGE2-regulated functionalities in the primate ovulatory follicle. Cynomolgus macaques underwent ovarian stimulation. Follicular granulosa cells were obtained before (0 h) or 36 h after an ovulatory dose of human chorionic gonadotropin (hCG), with ovulation anticipated 37-40 h after hCG. Granulosa cells were obtained from additional monkeys 36 h after treatment with hCG and the PTGS2 inhibitor celecoxib, which significantly reduced hCG-stimulated follicular prostaglandin synthesis. Granulosa cell RNA expression was determined by microarray and analyzed using IPA. No granulosa cell mRNAs were identified as being significantly up-regulated or down-regulated by hCG + celecoxib compared with hCG only. However, IPA predicted that prostaglandin depletion significantly regulated several functional pathways. Cell cycle/cell proliferation was selected for further study because decreased granulosa cell proliferation is known to be necessary for ovulation and formation of a fully-functional corpus luteum. Prospective in vivo and in vitro experiments confirmed the prediction that hCG-stimulated cessation of granulosa cell proliferation is mediated via PGE2. Our studies indicate that PGE2 provides critical regulation of granulosa cell proliferation through mechanisms that do not involve significant regulation of mRNA levels of key cell cycle regulators. Pathway analysis correctly predicted that PGE2 serves as a paracrine mediator of this important transition in ovarian structure and function.

Using Electronic Health Records to Enhance Predictions of Fall Risk in Inpatient Settings.

BACKGROUND: Falls are the most common adverse events of hospitalized adults. Traditional validated assessment tools have limited ability to accurately detect patients at high risk for falls. The researchers aim to develop an automated comprehensive risk score to enhance the identification of patients at high risk for falls and examine its effectiveness. METHODS: The enhanced fall algorithm (EFA) was developed from 171,515 hospitalizations and 2,659 falls, in an academic medical center, using hierarchical logistic regression. Routine nursing assessments, labs, medications, demographics, and patients' location during their hospitalization were gathered from the electronic health record (EHR). RESULTS: The fall rate was 2.8 per 1,000 patient-days. Morse fall score was the strongest predictor of falls (odds ratio = 7.16, 95% confidence interval = 6.48-7.91), with a model discrimination c-statistic of 0.687. By adding patient demographics, chronic conditions, lab values, and medications, and controlling for patient clustering within units, predication was enhanced and model discrimination increased to 0.805. By applying the enhanced model, we observed redistribution of patient by risk: low-risk group increased from 52.8% to 66.5%, and the high-risk group decreased from 28.0% to 16.2%, with an increase of fall detection from 3.1% to 5.1%. CONCLUSION: The EFA redistributes and identifies patients at high risk more accurately than the Morse score alone, decreasing the population of high-risk patients without increasing the rate of falls over time. The EFA requires no addition data collection and automatically updates the patient's fall risk based on new inputs in the EHR.

Incidence and Risk Factors for Permanent Pacemaker Implantation Following Mitral or Aortic Valve Surgery.

BACKGROUND: Risk factors for post-operative conduction disturbances after cardiac valve surgery requiring a permanent pacemaker (PPM) are poorly characterized. OBJECTIVES: The aim of this study was to investigate the timing and risk factors for PPM implantation after mitral or aortic valve surgery. METHODS: All patients who underwent open aortic or mitral valve surgery between January 1996 and December 2014 were reviewed using New York State's mandatory hospital discharge database. Patients with prior cardiac surgery or pre-existing PPM were excluded. The primary endpoint was PPM implantation within 1 year. RESULTS: Among 77,882 patients, 63.8% (n = 49,706) underwent aortic valve replacement (AVR), 18.9% (n = 14,686) underwent mitral valve replacement (MVR), 10.5% (n = 8,219) underwent mitral valve repair (MVr), 5.4% (n = 4,202) underwent AVR plus MVR, and 1.4% (n = 1,069) underwent AVR plus MVr. The 1-year PPM implantation rate was 4.5% after MVr, 6.6% after AVR, 9.3% after AVR plus MVr, 10.5% after MVR, and 13.3% after AVR plus MVR (p < 0.001). Across all groups, the majority of PPMs were implanted during the index hospitalization (79.9%). MVr was associated with the lowest risk for PPM and AVR plus MVR with the highest risk. Older age, history of arrhythmias, pre-operative conduction disturbances, and concomitant index procedures were associated with increased risk for PPM during the index hospitalization. Conversely, beyond 30 days, chronic comorbidities were associated with increased risk for PPM. CONCLUSIONS: Conduction disturbances requiring PPM remain a common adverse event after valve surgery. Identifying patients at risk for PPM will help facilitate perioperative planning and inform clinical decision making regarding post-operative rhythm surveillance.

Quality of Life after Open or Minimally Invasive Esophagectomy in Patients With Esophageal Cancer-A Systematic Review.

Although esophageal cancer is rare in the United States, 5-year survival and quality of life (QoL) are poor following esophageal cancer surgery. Although esophageal cancer has been surgically treated with esophagectomy through thoracotomy, an open procedure, minimally invasive surgical procedures have been recently introduced to decrease the risk of complications and improve QoL after surgery. The current study is a systematic review of the published literature to assess differences in QoL after traditional (open) or minimally invasive esophagectomy. We hypothesized that QoL is consistently better in patients treated with minimally invasive surgery than in those treated with a more traditional and invasive approach. Although global health, social function, and emotional function improved more commonly after minimally invasive surgery compared with open surgery, physical function and role function, as well as symptoms including choking, dysphagia, eating problems, and trouble swallowing saliva, declined for both surgery types. Cognitive function was equivocal across both groups. The potential small benefits in global and mental health status among those who experience minimally invasive surgery should be considered with caution given the possibility of publication and selection bias.

Review of malignant pleural mesothelioma survival after talc pleurodesis or surgery.

Malignant pleural mesothelioma (MPM) is an aggressive tumor and the prognosis is still dismal despite the various proposed multimodal treatment plans. Currently, new palliative treatments, such as talc pleurodesis, are being explored besides traditional surgery. This review reports survival rates after talc pleurodesis in comparison to surgery in patients with malignant pleural mesothelioma. A systematic literature search yielded 49 articles eligible for this review. The mean survival in the talc pleurodesis group was 14 months compared to 17 and 24 months for the pleurectomy decortication (P/D) group and extrapleural pneumonectomy (EPP) group, respectively. Few studies reported on the 1-, 2-year overall survival for the talc pleurodesis group and the results were very heterogeneous. The pooled 1-year overall survival for the P/D and EPP groups were 55% [credibility limits (CL): 21-87%] and 67% (CL: 3-89%), the pooled 2-year overall survival were 32% (CL: 8-63%) and 36% (CL: 8-54%), respectively. The pooled 1- and 2-year survival for surgery independently from the type of surgery were 62% (CL: 38-84%) and 34% (CL: 16-54%). There was significant heterogeneity in all the analyses. This review shows that there is limited research on the survival rate after talc pleurodesis compared to surgery in the treatment of malignant pleural mesothelioma. A comparison study is necessary to accurately assess the best way to treat MPM patients, including assessment of the quality of life after treatment as an outcome measure.