Variability in Standardized Mortality Rates Among Pediatric Traumatic Brain Injury Patients: A Comparative Analysis of Trauma Centers.

INTRODUCTION: Traumatic brain injury (TBI) causes significant morbidity and mortality in pediatric patients and care is highly variable. Standardized mortality ratio (SMR) summarizes the mortality rate of a specific center relative to the expected rates across all centers, adjusted for case-mix. This study aimed to evaluate variations in SMRs among pediatric trauma centers for TBI. METHODS: Patients aged 1-18 diagnosed with TBI within the National Trauma Data Bank (NTDB) from 2017 to 2019 were included. Center-specific SMRs and 95% confidence intervals identified centers with mortality rates significantly better or worse than the median SMR for all centers. RESULTS: 316 centers with 10,598 patients were included. SMRs were risk-adjusted for patient risk factors. Unadjusted mortality ranged from 16.5 to 29.5%. Three centers (1.5%) had significantly better SMR (SMR <1) and three centers (1.5%) had significantly worse SMR (SMR >1). Significantly better centers had a lower proportion of neurosurgical intervention (2.4% vs. 11.8%, p < 0.001), a higher proportion of supplemental oxygen administration (93.7% vs. 83.5%, p = 0.004) and venous thromboembolism prophylaxis (53.2% vs. 40.6%, p < 0.001) compared to significantly worse centers. CONCLUSIONS: This study identified centers that have significantly higher and lower mortality rates for pediatric TBI patients relative to the overall median rate. These data provide a benchmark for pediatric TBI outcomes and institutional quality improvement. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective Comparative Study.

Computation-aided Design of Rod-Shaped Janus Base Nanopieces for Improved Tissue Penetration and Therapeutics Delivery.

Despite the development of various drug delivery technologies, there remains a significant need for vehicles that can improve targeting and biodistribution in "hard-to-penetrate" tissues. Some solid tumors, for example, are particularly challenging to penetrate due to their dense extracellular matrix (ECM). In this study, we have formulated a new family of rod-shaped delivery vehicles named Janus base nanopieces (Rod JBNps), which are more slender than conventional spherical nanoparticles, such as lipid nanoparticles (LNPs). These JBNp nanorods are formed by bundles of DNA-inspired Janus base nanotubes (JBNts) with intercalated delivery cargoes. To develop this novel family of delivery vehicles, we employed a computation-aided design (CAD) methodology that includes molecular dynamics and response surface methodology. This approach precisely and efficiently guides experimental designs. Using an ovarian cancer model, we demonstrated that JBNps markedly improve penetration into the dense ECM of solid tumors, leading to better treatment outcomes compared to FDA-approved spherical LNP delivery. This study not only successfully developed a rod-shaped delivery vehicle for improved tissue penetration but also established a CAD methodology to effectively guide material design.

Impacts of microplastics and heavy metals on the earthworm Eisenia fetida and on soil organic carbon, nitrogen, and phosphorus.

Microplastics (MPs) are increasingly being studied because they have become ubiquitous in aquatic and terrestrial environments. However, little is known about the negative effects of co-contamination by polypropylene microplastic (PP MPs) and heavy metal mixtures on terrestrial environment and biota. This study assessed the adverse effects of co-exposure to PP MPs and heavy metal mixture (Cu2+, Cr6+, and Zn2+) on soil quality and the earthworm Eisenia fetida. Soil samples were collected in the Dong Cao catchment, near Hanoi, Vietnam, and analyzed for changes in extracellular enzyme activity and carbon, nitrogen, and phosphorus availability in the soil. We determined the survival rate of earthworms Eisenia fetida that had ingested MPs and two doses of heavy metals (the environmental level - 1 × - and its double - 2 ×). Earthworm ingestion rates were not significantly impacted by the exposure conditions, but the mortality rate for the 2 × exposure conditions was 100%. Metal-associated PP MPs stimulated the activities of ß-glucosidase, ß-N-acetyl glucosaminidase, and phosphatase enzymes in soil. Principle component analysis showed that these enzymes were positively correlated with Cu2+ and Cr6+ concentrations, but negatively correlated with microbial activity. Zn2+ showed no correlation with soil extracellular enzyme activity or soil microbial activity. Our results showed that co-exposure of earthworms to MPs and heavy metals had no impact on soil nitrogen and phosphorus but caused a decrease in total soil carbon content, with a possible associated risk of increased CO2 emissions.

Dietary potassium intake, kidney function, and survival in a nationally representative cohort.

BACKGROUND: In healthy adults, higher dietary potassium intake is recommended given that potassium-rich foods are major sources of micronutrients, antioxidants, and fiber. Yet among patients with advanced kidney dysfunction, guidelines recommend dietary potassium restriction given concerns about hyperkalemia leading to malignant arrhythmias and mortality. OBJECTIVES: Given sparse data informing these recommendations, we examined associations of dietary potassium intake with mortality in a nationally representative cohort of adults from the NHANES. METHODS: We examined associations between daily dietary potassium intake scaled to energy intake (mg/1000 kcal), ascertained by 24-h dietary recall, and all-cause mortality among 37,893 continuous NHANES (1999-2014) participants stratified according to impaired and normal kidney function (estimated glomerular filtration rates <60 and ≥60 mL · min-1 · 1.73 m-2, respectively) using multivariable Cox models. We also examined the impact of the interplay between dietary potassium, source of potassium intake (animal- compared with plant-based sources), and coexisting macronutrient and mineral consumption upon mortality. RESULTS: Among participants with impaired and normal kidney function, the lowest tertile of dietary potassium scaled to energy intake was associated with higher mortality (ref: highest tertile) [adjusted HR (aHR): 1.18; 95% CI: 1.02, 1.38 and aHR: 1.17; 95% CI: 1.06, 1.28, respectively]. Compared with high potassium intake from plant-dominant sources, participants with low potassium intake from animal-dominant sources had higher mortality irrespective of kidney function. Among participants with impaired kidney function, pairings of low potassium intake with high protein, low fiber, or high phosphorus consumption were each associated with higher death risk. CONCLUSIONS: Lower dietary potassium scaled to energy intake was associated with higher mortality, irrespective of kidney function. There was also a synergistic relation of higher potassium intake, plant-based sources, and macronutrient/mineral consumption with survival. Further studies are needed to elucidate pathways linking potassium intake and coexisting dietary factors with survival in populations with and without chronic kidney disease.

Recurrent pericardial effusion and tamponade after epicardial pacemaker lead placement: a case report.

Background: Epicardial pacemaker placement is often necessary in pacemaker-dependent patients with ongoing device pocket infection or lack of venous access. Pericardial effusion and tamponade are rare but serious complications of this procedure. Case summary: A 38-year-old woman presented with nausea, diaphoresis, and hypotension 7 days after epicardial lead placement. Echocardiography revealed a large pericardial effusion with signs of tamponade. Despite initial improvement after pericardiocentesis, she continued to develop symptomatic pericardial effusions. The patient ultimately underwent pleuro-pericardial window surgery, which resulted in sustained resolution of effusion recurrence. Discussion: Cases of recurrent pericardial effusion and tamponade following epicardial lead placement have been reported in the literature, although they are rare. While extensive partial pericardiectomy or total pericardiectomy was required to achieve adequate control of fluid accumulation in prior case reports, our patient was successfully managed with a pleuro-pericardial window.

Variation across centers in standardized mortality ratios for congenital diaphragmatic hernia receiving extracorporeal life support.

BACKGROUND: We sought to elucidate the degree of variation across centers by calculating center-specific standardized mortality ratios (SMRs) for infants with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS). METHODS: The Extracorporeal Life Support Organization (ELSO) registry data (2000-2019) were used to estimate SMRs. Center-specific SMRs and their 95% confidence intervals (CIs) were used to identify centers with mortality as significantly worse (SW), significantly better (SB), or not different (ND) relative to the median standardized mortality rate. RESULTS: We identified 4,223 neonates with CDH from 109 centers. SMRs were risk-adjusted for pre-ECLS case-mix (birthweight, sex, race, 5 min Apgar, blood gases, gestational age, hernia side, prenatal diagnosis, pre-ECLS arrest, and comorbidities). Observed (unadjusted) mortality rates across centers varied substantially (range: 14.3%-90.9%; interquartile range [IQR]: 42.9%-62.1%). Thirteen centers (11.9%) had SB SMRs< 1 (SMR 0.52 to 0.84), 7 centers (6.4%) had SW SMRs>1 (SMR 1.25 to 1.43), and 89 centers (81.7%) had SMRs ND relative to the median SMR rate across all centers (i.e., SMR not different from one). Descriptive analyses demonstrated that SB centers had a lower proportion of cases with renal complications, infectious complications and discontinuation of ECLS owing to complications, as well as differences in pre-ECLS treatments and timing of CDH repair, compared to SW and ND centers. CONCLUSION: This study specifically identified ECLS centers with higher and lower survival for patients with CDH, which may serve as a benchmark for institutional quality improvement. Future studies are needed to identify those specific processes at those centers that leads to favorable outcomes with the goal of improving care globally. LEVEL OF EVIDENCE: Level III.

Prior Frequent Emergency Department Use as a Predictor of Emergency Department Visits After a New Cancer Diagnosis.

PURPOSE: To determine whether emergency department (ED) visit history prior to cancer diagnosis is associated with ED visit volume after cancer diagnosis. METHODS: This was a retrospective cohort study of adults (≥ 18 years) with an incident cancer diagnosis (excluding nonmelanoma skin cancers or leukemia) at an academic medical center between 2008 and 2018 and a safety-net hospital between 2012 and 2016. Our primary outcome was the number of ED visits in the first 6 months after cancer diagnosis, modeled using a multivariable negative binomial regression accounting for ED visit history in the 6-12 months preceding cancer diagnosis, electronic health record proxy social determinants of health, and clinical cancer-related characteristics. RESULTS: Among 35,090 patients with cancer (49% female and 50% non-White), 57% had ≥ 1 ED visit in the 6 months immediately following cancer diagnosis and 20% had ≥ 1 ED visit in the 6-12 months prior to cancer diagnosis. The strongest predictor of postdiagnosis ED visits was frequent (≥ 4) prediagnosis ED visits (adjusted incidence rate ratio [aIRR]: 3.68; 95% CI, 3.36 to 4.02). Other covariates associated with greater postdiagnosis ED use included having 1-3 prediagnosis ED visits (aIRR: 1.32; 95% CI, 1.28 to 1.36), Hispanic (aIRR: 1.12; 95% CI, 1.07 to 1.17) and Black (aIRR: 1.21; 95% CI, 1.17 to 1.25) race, homelessness (aIRR: 1.95; 95% CI, 1.73 to 2.20), advanced-stage cancer (aIRR: 1.30; 95% CI, 1.26 to 1.35), and treatment regimens including chemotherapy (aIRR: 1.44; 95% CI, 1.40 to 1.48). CONCLUSION: The strongest independent predictor for ED use after a new cancer diagnosis was frequent ED visits before cancer diagnosis. Efforts to reduce potentially avoidable ED visits among patients with cancer should consider educational initiatives that target heavy prior ED users and offer them alternative ways to seek urgent medical care.

Dietary Potassium Intake and Mortality in a Prospective Hemodialysis Cohort.

OBJECTIVES: Among hemodialysis patients, clinical practice guidelines recommend dietary potassium restriction given concerns about potential hyperkalemia leading to malignant arrhythmias and mortality. However, there are sparse data informing recommendations for dietary potassium intake in this population. We thus sought to examine the relationship between dietary potassium intake and death risk in a prospective cohort of hemodialysis patients. DESIGN AND METHODS: Among 415 hemodialysis patients from the prospective "Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease" cohort recruited across 16 outpatient dialysis clinics, information regarding dietary potassium intake was obtained using Food Frequency Questionnaires administered over October 2011 to March 2015. We first examined associations of baseline dietary potassium intake categorized as tertiles with mortality risk using Cox regression. We then examined clinical characteristics associated with low dietary potassium intake (defined as the lowest tertile) using logistic regression. RESULTS: In expanded case-mix Cox analyses, patients whose dietary potassium intake was in the lowest tertile had higher mortality (ref: highest tertile) (adjusted hazard ratio 1.74, 95% confidence interval 1.14-2.66). These associations had even greater magnitude of risk following adjustment for laboratory and nutritional covariates (adjusted hazard ratio 2.65, 95% confidence interval 1.40-5.04). In expanded case-mix restricted cubic spline analyses, there was a monotonic increase in mortality risk with incrementally lower dietary potassium intake. In expanded case-mix logistic regression models, female sex; higher serum bicarbonate; and lower dietary energy, protein, and fiber intake were associated with low dietary potassium intake. CONCLUSIONS: In a prospective cohort of hemodialysis patients, lower dietary potassium intake was associated with higher mortality risk. These findings suggest that excessive dietary potassium restriction may be deleterious in hemodialysis patients, and further studies are needed to determine the optimal dietary potassium intake in this population.

Effects of Catalyst Pretreatment on Carbon Nanotube Synthesis from Methane Using Thin Stainless-Steel Foil as Catalyst by Chemical Vapor Deposition Method.

Synthesis of carbon nanotubes (CNTs) was carried out using methane as a carbon source via the chemical vapor deposition (CVD) method. A thin stainless-steel foil was used as catalyst for CNT growth. Our results revealed that pretreatment step of the stainless-steel foil as a catalyst plays an important role in CNT formation. In our experiments, a catalyst pretreatment temperature of 850 °C or 950 °C was found to facilitate the creation of Fe- and Cr-rich particles are active sites on the foil surface, leading to CNT formation. It is noted that the size of metallic particles after pretreatment is closely related to the diameter of the synthesized CNTs. It is interesting that a shorter catalyst pretreatment brings the growth of semiconducting typed CNTs while a longer pretreatment creates metallic CNTs. This finding might lead to a process for improving the quality of CNTs grown on steel foil as catalyst.

Progressive Left Ventricular Hypertrophy After Ozaki Procedure: A Case Report.

We describe a 57-year-old man with symptomatic severe aortic stenosis who underwent aortic valve reconstruction with glutaraldehyde-treated autologous pericardium with the Ozaki technique (Ozaki procedure). Seven months later, he rapidly developed progressive left ventricular hypertrophy with a left ventricular outflow tract obstruction. This required a reoperation for septal myectomy.

Predictors of long ECMO runs for congenital diaphragmatic hernia.

BACKGROUND: Although longer ECMO run times for patients with congenital diaphragmatic hernia (CDH) have been associated with worse outcomes, a large study has not been conducted to examine the risk factors for long ECMO runs. METHODS: The Extracorporeal Life Support Organization (ELSO) Registry from 2000 to 2015 was used to identify predictors of long ECMO runs in CDH patients. A long run was any duration of ≥14 days. Multivariable logistic regression models were used to examine the association between demographics, pre-ECMO blood gas/ventilator settings, comorbid conditions, and therapies on long ECMO runs. RESULTS: There were 4730 CDH-infants examined. The largest association with long ECMO runs was on-ECMO repair (OR: 3.72, 95% CI: 3.013-4.602, p < 0.001) and the use of THAM (OR: 1.463, 95% CI: 1.062-2.016, p = 0.02). Each drop in pH quartile was associated with an increased risk of long ECMO run: pH ≥ 7.3 (reference), pH 7.2-7.9 (OR 1.24, 95% CI: 0.98-1.57, p = 0.07), pH 7.08-7.19 (OR 1.46, 95% CI: 1.17-1.84, p = 0.001), pH ≤ 7.07 (OR 1.64, 95% CI: 1.29-2.07, p < 0.001). CONCLUSIONS: We found a correlation between both pre-ECMO demographics/timing of repair and the subsequent risk of long ECMO runs, providing insight for both providers and parents about the risk factors for longer runs. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.

The development of multiorgan dysfunction in CDH-ECMO neonates is associated with the level of pre-ECMO support.

PURPOSE: Congenital diaphragmatic hernia (CDH) is the most common indication for neonatal extracorporeal membrane oxygenation (ECMO), but mortality remains at 50%. Multiorgan failure can occur in 25% and has been linked to worse outcomes. We sought to examine the factors that would increase the risk of multiorgan dysfunction (MOD). METHODS: The Extracorporeal Life Support Organization (ELSO) database was used to identify infants with CDH (2000-2015). The primary outcome was MOD, which was defined as the presence of organ failure in ≥2 organ systems. We used a multivariable logistic regression to examine the effect of demographics, pre-ECMO respiratory status, comorbidities, and therapies on MOD. RESULTS: There were a total of 4374 CDH infants who were treated with ECMO. Overall mortality was 52.4%. The risk models demonstrated that pre-ECMO cardiac arrest (OR 1.458, CI: 1.146-1.861, p = 0.002) and hand-bagging (OR 1.461, CI: 1.094-1.963, p = 0.032) had the strongest association with MOD. In addition, other pre-ECMO indicators of disease severity (pH, HFOV, MAP, 5-min APGAR) and pre-ECMO therapies (bicarb, neuromuscular [NM] blockers) were also associated with MOD. CONCLUSIONS: The level of pre-ECMO support has a significant association with the development of MOD, and initiation of ECMO prior to arrest seems to be critical to avoid complications. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level III.

Novel Health Information Technology to Aid Provider Recognition and Treatment of Major Depressive Disorder and Posttraumatic Stress Disorder in Primary Care.

BACKGROUND: Millions of traumatized refugees worldwide have resettled in the United States. For one of the largest, the Cambodian community, having their mental health needs met has been a continuing challenge. A multicomponent health information technology screening tool was designed to aid provider recognition and treatment of major depressive disorder and posttraumatic stress disorder (PTSD) in the primary care setting. METHODS: In a clustered randomized controlled trial, 18 primary care providers were randomized to receive access to a multicomponent health information technology mental health screening intervention, or to a minimal intervention control group; 390 Cambodian American patients empaneled to participating providers were assigned to the providers' randomized group. RESULTS: Electronic screening revealed that 65% of patients screened positive for depression and 34% screened positive for PTSD. Multilevel mixed effects logistic models, accounting for clustering structure, indicated that providers in the intervention were more likely to diagnose depression [odds ratio (OR), 6.5; 95% confidence interval (CI), 1.48-28.79; P=0.013] and PTSD (OR, 23.3; 95% CI, 2.99-151.62; P=0.002) among those diagnosed during screening, relative to the control group. Providers in the intervention were more likely to provide evidence-based guideline (OR, 4.02; 95% CI, 1.01-16.06; P=0.049) and trauma-informed (OR, 15.8; 95% CI, 3.47-71.6; P<0.001) care in unadjusted models, relative to the control group. Guideline care, but not trauma-informed care, was associated with decreased depression at 12 weeks in both study groups (P=0.003), and neither was associated with PTSD outcomes at 12 weeks. CONCLUSIONS: This innovative approach offers the potential for training primary care providers to diagnose and treat traumatized patients, the majority of whom seek mental health care in primary care (ClinicalTrials.gov number, NCT03191929).

Potential survival benefit with repair of congenital diaphragmatic hernia (CDH) after extracorporeal membrane oxygenation (ECMO) in select patients: Study by ELSO CDH Interest Group.

PURPOSE: Studying the timing of repair in CDH is prone to confounding factors, including variability in disease severity and management. We hypothesized that delaying repair until post-ECMO would confer a survival benefit. METHODS: Neonates who underwent CDH repair were identified within the ELSO Registry. Patients were then divided into on-ECMO versus post-ECMO repair. Patients were 1:1 matched for severity based on pre-ECMO covariates using the propensity score (PS) for the timing of repair. Outcomes examined included mortality and severe neurologic injury (SNI). RESULTS: After matching, 2,224 infants were included. On-ECMO repair was associated with greater than 3-fold higher odds of mortality (OR 3.41, 95% CI: 2.84-4.09, p<0.01). The odds of SNI was also higher for on-ECMO repair (OR 1.49, 95% CI: 1.13-1.96, p<0.01). A sensitivity analysis was performed by including the length of ECMO as an additional matching variable. On-ECMO repair was still associated with higher odds of mortality (OR 2.38, 95% CI: 1.96-2.89, p<0.01). Results for SNI were similar but were no longer statistically significant (OR 1.33, 95% CI: 0.99-1.79, p=0.06). CONCLUSIONS: Of the infants who can be liberated from ECMO and undergo CDH repair, there is a potential survival benefit for delaying CDH repair until after decannulation. TYPE OF STUDY: Treatment Study LEVEL OF EVIDENCE: III.

Management preferences in ECMO mode for congenital diaphragmatic hernia.

PURPOSE: The purpose of this study was to identify management preferences that may exist in the care of infants with CDH receiving ECMO with emphasis on VV-ECMO. METHODS: A survey was created to measure treatment preferences regarding ECMO use in CDH. The survey was distributed to all APSA and ELSO/Euro-ELSO members via e-mail. Survey results were summarized using descriptive statistics. RESULTS: The survey had 230 respondents. The survey participants were surgeons (75%), neonatologists/intensivists (23%), and "other" (2%). The mean annual center volume was 11.6(±9.6) CDH cases, and the average number treated with ECMO was 4.5 (±6.4) cases/yr. The most agreed upon criteria for ECMO initiation were preductal O2 saturation <80% refractory to ventilator manipulation and medical therapy (89%), oxygenation index >40 (80%), severe air-leak (79%), and mixed acidosis (75%). Over 60% of respondents agreed the VV-ECMO would be optimum for average risk neonates. However, this preference diminished as the pre-ECMO level of cardiac support increased. When asked about why each respondent would choose VA-ECMO over VV-ECMO, the responses varied significantly between surgeons and non-surgeons. CONCLUSION: While there seem to be areas of consensus among practitioners, such as criteria for initiation of ECMO, this survey revealed substantial variation in individual practice patterns regarding the use of ECMO for CDH. TYPE OF STUDY: Qualitative, Survey. LEVEL OF EVIDENCE: IV.

Outcomes of infants with congenital diaphragmatic hernia treated with venovenous versus venoarterial extracorporeal membrane oxygenation: A propensity score approach.

PURPOSE: Previous studies comparing extracorporeal membrane oxygenation (ECMO) modality for congenital diaphragmatic hernia (CDH) have not accounted for confounding by indication. We therefore hypothesized that using a propensity score (PS) approach to account for selection bias may identify outcome differences based on ECMO modality for infants with CDH. METHODS: We utilized ELSO Registry data (2000-2016). Patients with CDH were divided to either venoarterial (VA) or venovenous (VV) ECMO. Patients were matched by PS to control for nonrandom treatment assignment. Subgroup analyses were conducted based on timing of CDH repair relative to ECMO. Primary analysis was the "intent-to-treat" cohort based on the initial ECMO mode. Mortality was the primary outcome, and severe neurologic injury (SNI) was a secondary outcome. RESULTS: PS matching (3:1) identified 3304 infants (VA = 2470, VV = 834). In the main group, mortality was not different between VA and VV ECMO (OR = 1.01, 95% CI: 0.86-1.18) and there was no difference in SNI between VA and VV (OR = 0.80; 95% CI: 0.63-1.01). For the pre-ECMO CDH repair subgroup, 175 VA cases were matched to 70 VV. In these neonates, mortality was higher for VV compared to VA (OR = 2.10, 95% CI: 1.19-3.69), without any difference in SNI (OR = 1.48; 95% CI: 0.59-3.71). For the subgroup that did not have pre-ECMO CDH repair, 2030 VA cases were matched to 683 VV cases. In this subgroup, VV was associated with 27% lower risk of SNI relative to VA (OR = 0.73, 95% CI: 0.56-0.95) without any difference in mortality (OR = 0.94, 95% CI: 0.79-1.11). CONCLUSION: This study revalidates that ECMO mode does not significantly affect mortality or SNI in infants with CDH. In the subset of infants who require pre-ECMO CDH repair, VA favors survival, whereas, in the subgroup of infants that did not have pre-ECMO CDH repair, VV favors lower rates of SNI. We conclude that neither mode appears consistently superior across all situations, and clinical judgment should remain a multifactorial decision. LEVEL OF EVIDENCE: Level III.

One-Year Mortality after Contemporary Laparoscopic Bariatric Surgery: An Analysis of the Bariatric Outcomes Longitudinal Database.

BACKGROUND: Contemporary mortality after bariatric surgery is low and has been decreasing over the past 2 decades. Most studies have reported inpatient or 30-day mortality, which may not represent the true risk of bariatric surgery. The objective of this study was to examine 1-year mortality and factors predictive of 1-year mortality after contemporary laparoscopic bariatric surgery. STUDY DESIGN: Using the 2008 to 2012 Bariatric Outcomes Longitudinal Database (BOLD), data from 158,606 operations were analyzed, including 128,349 (80.9%) laparoscopic Roux-en-Y gastric bypass (LRYGB) and 30,257 (19.1%) laparoscopic sleeve gastrectomy (LSG) operations. Multivariate logistic regression was used to determine independent risk factors associated with 1-year mortality for each type of procedure. RESULTS: The 30-day and 1-year mortality rates for LRYGB were 0.13% and 0.23%, respectively, and for LSG were 0.06% and 0.11%, respectively. Risk factors for 1-year mortality included older age (LRYGB: adjusted odds ratio [AOR] 1.05 per year, p < 0.001; LSG: AOR 1.08 per year, p < 0.001); male sex (LRYGB: AOR 1.88, p < 0.001); higher BMI (LRYGB: AOR 1.04 per unit, p < 0.001; LSG: AOR 1.05 per unit, p = 0.009); and the presence of 30-day leak (LRYGB: AOR 25.4, p < 0.001; LSG: AOR 35.8, p < 0.001), 30-day pulmonary embolism (LRYGB: AOR 34.5, p < 0.001; LSG: AOR 252, p < 0.001), and 30-day hemorrhage (LRYGB: AOR 2.34, p = 0.001). CONCLUSIONS: Contemporary 1-year mortality after laparoscopic bariatric surgery is much lower than previously reported, at <0.25%. It is important to continually refine techniques and perioperative management in order to minimize leaks, hemorrhage, and pulmonary embolus after bariatric surgery because these complications contribute to a higher risk of mortality.

Antibiotic prophylaxis in clean-contaminated head and neck cases with microvascular free flap reconstruction: A systematic review and meta-analysis.

BACKGROUND: Optimal antibiotic prophylaxis duration in head and neck clean-contaminated free-flap cases is unknown. METHODS: A systematic review/meta-analysis was conducted using PubMed/MEDLINE, Cochrane Library, Web-of-Science, and Scopus databases. RESULTS: Of the 3755 searched articles, 5 articles were included for a total of 861 patients. The recipient surgical site infection risk was significantly higher in patients receiving prophylactic antibiotics for ≤24 hours compared to >24 hours (relative risk [RR] 1.56; 95% confidence interval [CI] 1.13-2.14). In the post hoc multivariate analysis based on available individual-level data on 697 patients from 3 studies, the risk of surgical site infection for ≤24 hours versus >24 hours was not significant after adjusting for antibiotic type (RR 1.09; 95% CI 0.78-1.55). When compared to ampicillin-sulbactam, patients who received clindamycin prophylaxis had an increased likelihood of recipient surgical site infection (RR 2.85; 95% CI 1.95-4.17). CONCLUSION: Less than or equal to 24 hours of antibiotic prophylaxis in head and neck clean-contaminated free-flap is likely sufficient but a strong conclusion remains elusive. Clindamycin prophylaxis increases the risk of recipient surgical site infection. Further prospective trials are necessary to clarify.

Cannulating the contraindicated: effect of low birth weight on mortality in neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation.

BACKGROUND/PURPOSE: Restrictions for ECMO in neonates include birth weight less than 2kg (BW <2kg) and/or gestational age less than 34weeks (GA <34weeks). We sought to describe their relationship on mortality. METHODS: Neonates with a primary diagnosis code of CDH were identified in the Extracorporeal Life Support Organization (ELSO) registry, and logistic regression models were used to examine the effect of BW <2kg and GA <34weeks on mortality. RESULTS: We identified 7564 neonates with CDH. The overall mortality was 50%. There was a significantly higher risk of death with unadjusted odds ratio (OR) 2.39 (95% confidence interval [CI]: 1.53-3.74; P<0.01) for BW <2kg neonates. The adjusted OR of death for BW <2kg neonates remained significantly high with over two-fold increase in the odds of mortality when adjusted for potential confounding variables (OR 2.11, 95% CI: 1.30-3.43; P<0.01). However, no difference in mortality was observed in neonates with GA <34weeks. CONCLUSIONS: While mortality among CDH neonates with a BW <2kg was substantially increased, GA <34weeks was not significantly associated with mortality. Effort should be made to identify the best candidates for ECMO in this high-risk group and develop treatment strategies to optimize their survival. TYPE OF STUDY: Case-Control Study, Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Current trends in racial, ethnic, and healthcare disparities associated with pediatric cardiac surgery outcomes.

OBJECTIVE: Despite overall improvements in congenital heart disease outcomes, racial and ethnic disparities have continued. The purpose of this study is to examine the effect of race and ethnicity, as well as other risk factors on congenital heart surgery length of stay and in-hospital mortality. DESIGN: From the 2012 Healthcare Cost and Utilization Project Kids Inpatient Database (KID), we identified 13 130 records with Risk Adjustment in Congenital Heart Surgery complexity score-eligible procedures. Multivariate logistic and linear regression modeling with survey weights, stratification and clustering was used to examine the relationships between predictor variables and length of stay as well as in-hospital mortality. RESULTS: No significant mortality differences were found among all race and ethnicity groups across each age group. Black neonates and black infants had a longer length of stay (neonatal estimate = 8.73 days, P = .0034; infant estimate 1.10 days, P = .0253), relative to whites. Government-sponsored insurance was associated with increased odds of neonatal mortality (odds ratio = 1.51, P = .0055), increased length of stay in neonates (estimate = 4.26 days, P = .0009) and infants (estimate = 1.52 days, P = .0181), relative to private insurance. Government-sponsored insurance was associated with increased number of chronic conditions, which were also associated with increased LOS (estimate 8.39 days, P < .001 in neonates; estimate 3.60 days, P < .001 in infants; estimate 1.87 days, P < .001 children). CONCLUSIONS: Racial/ethnic disparities in congenital heart surgical outcomes may be changing compared with previous studies using the KID database. Increased length of stay in children with government-sponsored insurance may reflect expansion of individual states government-sponsored insurance eligibility criteria for children with complex chronic medical conditions. These findings warrant cautious optimism regarding racial and ethnic disparities in congenital heart surgery outcomes.