Racial and Ethnic Differences in Bystander CPR for Witnessed Cardiac Arrest.

BACKGROUND: Differences in the incidence of cardiopulmonary resuscitation (CPR) provided by bystanders contribute to survival disparities among persons with out-of-hospital cardiac arrest. It is critical to understand whether the incidence of bystander CPR in witnessed out-of-hospital cardiac arrests at home and in public settings differs according to the race or ethnic group of the person with cardiac arrest in order to inform interventions. METHODS: Within a large U.S. registry, we identified 110,054 witnessed out-of-hospital cardiac arrests during the period from 2013 through 2019. We used a hierarchical logistic regression model to analyze the incidence of bystander CPR in Black or Hispanic persons as compared with White persons with witnessed cardiac arrests at home and in public locations. We analyzed the overall incidence as well as the incidence according to neighborhood racial or ethnic makeup and income strata. Neighborhoods were classified as predominantly White (>80% of residents), majority Black or Hispanic (>50% of residents), or integrated, and as high income (an annual median household income of >$80,000), middle income ($40,000-$80,000), or low income (<$40,000). RESULTS: Overall, 35,469 of the witnessed out-of-hospital cardiac arrests (32.2%) occurred in Black or Hispanic persons. Black and Hispanic persons were less likely to receive bystander CPR at home (38.5%) than White persons (47.4%) (adjusted odds ratio, 0.74; 95% confidence interval [CI], 0.72 to 0.76) and less likely to receive bystander CPR in public locations than White persons (45.6% vs. 60.0%) (adjusted odds ratio, 0.63; 95% CI, 0.60 to 0.66). The incidence of bystander CPR among Black and Hispanic persons was less than that among White persons not only in predominantly White neighborhoods at home (adjusted odds ratio, 0.82; 95% CI, 0.74 to 0.90) and in public locations (adjusted odds ratio, 0.68; 95% CI, 0.60 to 0.75) but also in majority Black or Hispanic neighborhoods at home (adjusted odds ratio, 0.79; 95% CI, 0.75 to 0.83) and in public locations (adjusted odds ratio, 0.63; 95% CI, 0.59 to 0.68) and in integrated neighborhoods at home (adjusted odds ratio, 0.78; 95% CI, 0.74 to 0.81) and in public locations (adjusted odds ratio, 0.73; 95% CI, 0.68 to 0.77). Similarly, across all neighborhood income strata, the frequency of bystander CPR at home and in public locations was lower among Black and Hispanic persons with out-of-hospital cardiac arrest than among White persons. CONCLUSIONS: In witnessed out-of-hospital cardiac arrest, Black and Hispanic persons were less likely than White persons to receive potentially lifesaving bystander CPR at home and in public locations, regardless of the racial or ethnic makeup or income level of the neighborhood where the cardiac arrest occurred. (Funded by the National Heart, Lung, and Blood Institute.).

Outcomes With Single-Site Dual-Lumen Versus Multisite Cannulation for Adults With COVID-19 Respiratory Failure Receiving Venovenous Extracorporeal Membrane Oxygenation.

OBJECTIVES: To determine whether multisite versus single-site dual-lumen (SSDL) cannulation is associated with outcomes for COVID-19 patients requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). DESIGN: Retrospective analysis of the Extracorporeal Life Support Organization Registry. Propensity score matching (2:1 multisite vs SSDL) was used to control for confounders. PATIENTS: The matched cohort included 2,628 patients (1,752 multisite, 876 SSDL) from 170 centers. The mean ( sd ) age in the entire cohort was 48 (11) years, and 3,909 (71%) were male. Patients were supported with mechanical ventilation for a median (interquartile range) of 79 (113) hours before VV-ECMO support. INTERVENTIONS: None. MEASUREMENTS: The primary outcome was 90-day survival. Secondary outcomes included survival to hospital discharge, duration of ECMO support, days free of ECMO support at 90 days, and complication rates. MAIN RESULTS: There was no difference in 90-day survival (49.4 vs 48.9%, p = 0.66), survival to hospital discharge (49.8 vs 48.2%, p = 0.44), duration of ECMO support (17.9 vs 17.1 d, p = 0.82), or hospital length of stay after cannulation (28 vs 27.4 d, p = 0.37) between multisite and SSDL groups. More SSDL patients were extubated within 24 hours (4% vs 1.9%, p = 0.001). Multisite patients had higher ECMO flows at 24 hours (4.5 vs 4.1 L/min, p < 0.001) and more ECMO-free days at 90 days (3.1 vs 2.0 d, p = 0.02). SSDL patients had higher rates of pneumothorax (13.9% vs 11%, p = 0.03). Cannula site bleeding (6.4% vs 4.7%, p = 0.03), oxygenator failure (16.7 vs 13.4%, p = 0.03), and circuit clots (5.5% vs 3.4%, p = 0.02) were more frequent in multisite patients. CONCLUSIONS: In this retrospective study of COVID-19 patients requiring VV-ECMO, 90-day survival did not differ between patients treated with a multisite versus SSDL cannulation strategy and there were only modest differences in major complication rates. These findings do not support the superiority of either cannulation strategy in this setting.

Elective and non-elective endomyocardial biopsy in heart transplant patients and procedural outcomes: An IMPACT registry analysis.

BACKGROUND: Endomyocardial biopsies are standard of care for transplant surveillance, however the procedural risks are not well established, especially in children. The purpose of the study was therefore to assess procedural risks and outcomes associated with elective (surveillance) biopsies and non-elective (clinically indicated) biopsies. METHODS: We used the NCDR IMPACT registry database for this retrospective analysis. Patients undergoing an endomyocardial biopsy were identified using the procedural code, with a diagnosis of heart transplantation required. Data regarding indication, hemodynamics, adverse events and outcomes was gathered and analyzed. RESULTS: A total of 32 547 endomyocardial biopsies were performed between 2012-2020; 31 298 (96.5%) elective and 1133 (3.5%) were non-elective biopsies. Non-elective biopsy was more commonly performed in infants and in those above 18 years of age, in female and in Black race patients and in those with non-private insurance (all p < .05) and showed hemodynamic derangements. Overall rate of complications was low. Combined major adverse events were more common in non-elective patients, with sicker patient profile, use of general anesthesia and femoral access with overall decline in these events over time. CONCLUSIONS: This large-scale analysis shows safety of surveillance biopsies and that non-elective biopsies carry a small but significant risk of major adverse event. Patient profile impacts the safety of the procedure. These data may serve as important comparison point for newer non-invasive tests and for bench marking, especially in children.

Cholecystectomy for Biliary Gallstone Pancreatitis Is Often Not Performed During Index Hospitalization and Is Associated With Worse Outcomes.

Guidelines recommend that patients with mild gallstone pancreatitis (GSP) without necrosis or infection should undergo cholecystectomy during the index hospitalization before discharge.1,2 However, in routine clinical practice, cholecystectomy is often performed several weeks after hospital discharge, or not performed at all.3.

Risk of Colorectal Cancer and Cancer Related Mortality After Detection of Low-risk or High-risk Adenomas, Compared With No Adenoma, at Index Colonoscopy: A Systematic Review and Meta-analysis.

BACKGROUND & AIMS: The risk of metachronous colorectal cancer (CRC) among patients with no adenomas, low-risk adenomas (LRAs), or high-risk adenomas (HRAs), detected at index colonoscopy, is unclear. We performed a systematic review and meta-analysis to compare incidence rates of metachronous CRC and CRC-related mortality after a baseline colonoscopy for each group. METHODS: We searched the PubMed, Embase, Google Scholar, and Cochrane databases for studies that reported the incidence of CRC and adenoma characteristics after colonoscopy. The primary outcome was odds of metachronous CRC and CRC-related mortality per 10,000 person-years of follow-up after baseline colonoscopy for all the groups. RESULTS: Our final analysis included 12 studies with 510,019 patients (mean age, 59.2 ± 2.6 years; 55% male; mean duration of follow up, 8.5 ± 3.3 years). The incidence of CRC per 10,000 person-years was marginally higher for patients with LRAs compared to those with no adenomas (4.5 vs 3.4; odds ratio [OR], 1.26; 95% CI, 1.06-1.51; I2=0), but significantly higher for patients with HRAs compared to those with no adenoma ( 13.8 vs 3.4; odds ratio [OR], 2.92; 95% CI, 2.31-3.69; I2=0 ) and patients with HRAs compared to LRAs (13.81 vs 4.5; OR, 2.35; 95% CI, 1.72-3.20; I2=55%). However, the CRC-related mortality per 10,000 person-years did not differ significantly for patients with LRAs compared to no adenomas (OR, 1.15; 95% CI, 0.76-1.74; I2=0) but was significantly higher in persons with HRAs compared with LRAs (OR, 2.48; 95% CI, 1.30-4.75; I2=38%) and no adenomas (OR, 2.69; 95% CI, 1.87-3.87; I2=0). CONCLUSIONS: The results of this systematic review and meta-analysis demonstrate that the risk of metachronous CRC and mortality is significantly higher for patients with HRAs, but this risk is very low in patients with LRAs, comparable to patients with no adenomas. Follow-up of patients with LRAs detected at index colonoscopy should be the same as for persons with no adenomas.

Use of primary bariatric surgery among patients with obesity and diabetes. Insights from the Diabetes Collaborative Registry.

Despite its cardiometabolic benefits, bariatric surgery has historically been underused in patients with obesity and diabetes, but contemporary data are lacking. Among 1,520,182 patients evaluated from 2013 to 2019 within a multicenter, longitudinal, US registry of outpatients with diabetes, we found that 462,033 (30%) met eligibility for bariatric surgery. After a median follow-up of 854 days, 6310/384,859 patients (1.6%) underwent primary bariatric surgery, with a slight increase over time (0.38% per year [2013] to 0.68% per year [2018]). Patients who underwent bariatric surgery were more likely to be female (63% vs. 56%), white (87% vs. 82%), have higher body mass indices (42.1 ± 6.9 vs. 40.6 ± 5.9 kg/m2), and depression (23% vs. 14%; p < 0.001 for all). Over a median (IQR) follow-up after surgery of 722 days (364-993), patients who underwent bariatric surgery had lost an average of 11.8 ± 18.5 kg (23% of excess body weight), 10.2% were on fewer glucose-lowering medications, and 8.4% were on fewer antihypertensives. Despite bariatric surgery being safer and more accessible over the past two decades, less than one in fifty eligible patients with diabetes receive this therapy.

Educational intervention to improve quality of care in Barrett's esophagus: the AQUIRE randomized controlled trial.

BACKGROUND AND AIMS: Despite quality measures in upper endoscopy (EGD) for Barrett's esophagus (BE), considerable variability remains in practice among gastroenterologists. This randomized controlled trial evaluated the role of structured intensive training on the quality of EGD in BE. METHODS: In this multicenter study, 8 sites (from the GI Quality Consortium) were cluster randomized (1:1) to receive AQUIRE (A Quality Improvement program in cancer care during Endoscopy) training (intervention) or continue local standard practices (control). The primary outcome was compliance with the Seattle biopsy protocol. Secondary outcomes were change in knowledge of BE detection and sampling assessed by questionnaire and dysplasia detection rate (DDR) before and after completion of the 6-month study period. RESULTS: The intervention sites (n = 4) had 31 gastroenterologists and the control sites (n = 4) had 34. There was a significant improvement in the compliance rates with the Seattle biopsy protocol from baseline to the end of the study in the intervention sites (64.8%-73.2%, P = .002) but not in the control sites (69.5%-69.4%, P = .953). The accurate response rate on the questionnaire at the intervention sites increased from 73% at baseline to 88% after AQUIRE training (difference, 14.8%; standard deviation, 18.7; P = .008). DDR did not change significantly from baseline to 6 months in either the control or intervention groups (P = .06). CONCLUSIONS: This study confirms the capacity of a structured educational intervention to improve utilization of a standard biopsy protocol and knowledge of standards of care in BE but without significant change in DDR.

Trends in invasive treatment of patients hospitalized with aortic stenosis complicated by cardiogenic shock.

BACKGROUND: Before the development of transcatheter aortic valve replacement (TAVR), balloon aortic valvuloplasty (BAV) was the only potential nonsurgical intervention for patients with aortic stenosis complicated by cardiogenic shock. Emergent TAVR is now an option and has shown acceptable outcomes compared with elective TAVR. We explored how treatment patterns for aortic stenosis and cardiogenic shock among patients received invasive intervention have shifted since TAVR was introduced. METHODS: We used the Nationwide In patients Sample to identify nonelective hospitalizations for patient with aortic stenosis complicated by cardiogenic shock who received invasive treatment (TAVR, BAV, or surgical aortic valve replacement [SAVR]). We explored the proportion treated with each treatment modality over time, the patient characteristics and in-hospital mortality associated with each treatment, and used multivariable logistic regression to examine whether changes in in-hospital mortality over time differed by treatment. RESULTS: Between 2010 and 2019, we identified 9899 hospitalizations for decompensated aortic stenosis with cardiogenic shock during which patients received invasive treatment (TAVR 17.7%, BAV 20.2%, SAVR 62.1%). Use of both TAVR and BAV has increased over time compared with SAVR (TAVR 6.6% ≥ 33.8%, BAV 8.4% ≥ 23.2%, SAVR 91.6% ≥ 43.0%; p < 0.001 for trend). The overall in-hospital mortality rate was 21.0%, which decreased over time for all treatments (TAVR 20.0% ≥ 18.8%, BAV 66.0% ≥ 25.5%, SAVR 17.7% ≥ 11.8%; linear trend p < 0.001 for each), with lower mortality for TAVR versus BAV at all time points. Patients treated with TAVR (vs. BAV) were less likely to require mechanical ventilation (36.8% vs. 46.3%, p < 0.001) or mechanical circulatory support (22.5% vs. 29.9%, p < 0.001). In the multivariable analysis, the interaction between treatment and time was not significant (p = 0.245), indicating the reduction in in-hospital mortality over time did not differ among the treatments. CONCLUSIONS: Since the introduction of TAVR, there has been a shift toward increased use of nonsurgical invasive treatments (both BAV and TAVR) for aortic stenosis and cardiogenic shock. Although in-hospital mortality has declined, it remains high in all groups, but particularly among patients treated with BAV, where the severity of cardiogenic shock appears to be higher than in those treated with other modalities.

Reasons for discordance between positron emission tomography (PET) myocardial perfusion imaging (MPI) results and subsequent management.

BACKGROUND: Referral patterns to coronary angiography following positron emission tomography (PET) myocardial perfusion imaging (MPI) and reasons for non-referral following abnormal PET MPI are largely unknown. METHODS: Referral rates to coronary angiography within 90 days post PET MPI were determined. A random subset of 100 patients with severe (≥ 10%) ischemia on MPI between 2014-16 who were not referred for angiography were examined to better understand reasons as to why patients with high-risk MPI findings did not undergo coronary angiography. RESULTS: Among 19,282 unique patients, overall rate of 90-day coronary angiography was 18.5% (3574/19282). Among patients with severe ischemia, 64.1% (1930/3011) underwent angiography within 90 days; the rate was lower in those with mild-moderate (20.6% [1010/4898]) and no ischemia (5.6% [634/11373]). In the random sample of 100 patients, the most common physician reasons for non-referral were uncertainty regarding whether the test results were responsible for the patient's presenting symptoms, renal failure, and patient age, frailty, or cognitive status, while patient preference for medical management was by far the most common patient reason. CONCLUSION: Referral rates for coronary angiography after PET correlate with severity of ischemia. However, there appear to be opportunities to reconsider testing for instances when results will not change clinical management.

Trends and predictors of 30-day readmissions in subjects with eosinophilic esophagitis: results from a national cohort.

BACKGROUND: Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory condition causing recurrent dysphagia and may predispose patients to repeated hospitalizations. We assessed temporal trends and factors affecting readmissions in patients with EoE. METHODS: Patients with primary diagnosis of EoE and/or a complication (dysphagia, weight loss, and esophageal perforation) from EoE between 2010 and 2017 were identified from the National Readmissions Database using the International Classification of Diseases codes. The primary outcome was incidence of EoE related 30-day readmission. Independent risk factors for readmissions were evaluated using multivariable logistic regression analysis. Secondary outcomes were temporal trends of readmissions and healthcare costs. RESULTS: Of the 2,676 (mean age 45 ± 17.8 years, 1,667 males) index adult admissions, 2,103 (79%) patients underwent an upper endoscopy during the admission. The mean length of stay (LOS) was 3 ± 3.7 days. The 30-day readmission rate was steady at 6.8% from 2010 to 2017 and majority of the readmissions occurred by day 10 of index discharge. Age > 70 years was associated with a higher trend in 30-day readmission (P < 0.001). Longer LOS, history of smoking and the presence of eosinophilic gastroenteritis predicted readmission. Conversely, a history of foreign body impaction and upper endoscopy (including esophageal dilation) at index admission were negatively associated with readmission. Mean hospital charges significantly increased from $24,783 in 2010 to $40,922 in 2017. CONCLUSION: Readmissions due to EoE are more likely to occur in the first 10 days of discharge and at a lesser rate when upper endoscopies are performed at the index admission.

Contemporary national utilization of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest.

OBJECTIVE: The utilization of extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) has demonstrated promising evidence for the management of out-of-hospital cardiac arrest (OHCA). We aim to describe contemporary utilization and predictors of survival of patients receiving ECPR for OHCA. METHODS: The National Inpatient Sample (NIS) was queried to identify hospital discharge records of patients aged ≥18 years who underwent ECPR from 2012 to 2017. Patients with an International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of cardiac arrest, admitted urgently and placed on ECMO on Day 0 of hospitalization, were selected. Patients with a primary diagnosis indicative of veno-venous ECMO were excluded. Predictors of mortality were assessed using multivariable analyses. RESULTS: There were 1675 cases of ECPR, increasing from 185 cases in 2012 to 400 in 2017 (p < .001). Overall mortality was 63.3%, which remained stable over time (p = .441). Common diagnoses included ST-elevation myocardial infarction (39.1%), non-ST-elevation myocardial infarction (9.3%), and pulmonary embolism (13.7%). Percutaneous coronary intervention was performed in 495 patients (29.6%); coronary artery bypass grafting was performed in 125 patients (7.5%). In multivariable analysis, decreased age, female gender, and left ventricular (LV) decompression were associated with reduced mortality. CONCLUSION: Utilization of ECPR is increasing nationally with stable mortality rates. Younger age, female gender, and utilization of LV decompression were associated with increased survival.

Survival and readmission among patients with advanced cardiomyopathy undergoing transcatheter edge-to-edge mitral valve repair: Are we applying COAPT findings too broadly?

OBJECTIVE: Transcathether edge-to-edge mitral valve repair (TEER) has been shown to be an effective treatment for secondary mitral regurgitation (MR). However, the outcomes of TEER in patients with severe cardiomyopathy is less clear. The objective of this study is to determine the outcomes of such patients who underwent TEER at our institution. METHODS: A retrospective review of patients with severe cardiomyopathy, defined as ejection fraction ≤30% or the requirement of inotropic support preoperatively, undergoing TEER for secondary MR at our institution from 11/2016 to 11/2020 was performed. Univariate analysis associating preoperative characteristics with our primary endpoint of 1-year death or orthotopic heart transplant (OHT) was performed. Kaplan-Meier analysis was conducted for the composite outcome of death or OHT, as well as for heart failure-related readmission. Finally, an assessment of changes in MR severity from the preoperative, to immediate postoperative period, to 30-day postoperative period was conducted. RESULTS: There were 48 patients identified. Median age was 74.5 years (IQR 65.5-79.5), median ejection fraction was 21.5% (IQR 16.0-27.5), and 81.4% of patients had severe or torrential mitral regurgitation preoperatively. The composite endpoint of 1-year mortality or OHT occurred in 15 of 48 patients (31.3%, 14 deaths and 1 OHT). One-year heart failure readmission rate was 47.9%. Mortality or OHT at 2 years occurred in 45.8%. CONCLUSION: Patients at extremes of heart failure who underwent TEER had poor outcomes when assessed at 1-year. Our study may suggest that the results of cardiovascular outcomes assessment of the mitraclip percutaneous therapy for heart failure patients with secondary mitral regurgitation may not be applicable to patients with severe cardiomyopathy.

Use of a Smart-Phone Mobile Application is Associated With Improved Compliance and Reduced Length of Stay in Patients Undergoing Primary Total Joint Arthroplasty of the Hip and Knee.

BACKGROUND: Patient compliance with perioperative protocols is paramount to improving outcomes and reducing adverse events in total joint arthroplasty (TJA) of the hip and knee. Given the widespread use of smartphones, mobile applications (MAs) may present an opportunity to improve outcomes in TJA. We aim to determine whether the use of a mobile application platform improves compliance with standardized pre-operative protocols and outcomes in TJA. METHODS: A non-randomized, prospective cohort study was conducted in adult patients undergoing primary elective TJA to determine whether the use of an MA with timed reminders starting 5 days pre-operatively, to perform a chlorhexidine gluconate (CHG) shower and oral hydration protocol improves compliance with these protocols. OUTCOME MEASURES: compliance, length of stay (LOS), surgical site infection (SSI), 90-day readmission. RESULTS: App-users had increased adherence to the hydration protocol (odds ratio [OR] = 3.17 [95% confidence interval {CI} = 1.42, 7.09: P = .003]). App-use was associated with shorter LOS (Median Interquartile ranges [IQR] 2.0 days [1.0, 2.0 days]) for App-users vs 2.0 days ([1.0, 3.0] for non-App users, P = .031), younger age, (63.3 vs 67.9 years, P = .0001), Caucasian race (OR = 3.32 [95% CI = 1.59, 6.94 P = .0009]) and male gender (48.2% vs 35.0%, P = .02). There was no difference in adherence to chlorhexidine gluconate (CHG), readmission, or surgical site infection (SSI) (2.2% App-users vs 2.9% non-App users; P = .74). CONCLUSION: Use of a mobile application was associated with increased compliance with a hydration protocol and reduced LOS. App-users were more likely to be younger, male and Caucasian. These disparities may reflect inequity of access to the requisite technology and warrant further study.

Comparative Safety of Endoscopic vs Radiological Gastrostomy Tube Placement: Outcomes From a Large, Nationwide Veterans Affairs Database.

INTRODUCTION: A gastrostomy is generally performed in patients who are unable to maintain volitional intake of food. We compared outcomes of percutaneous endoscopic gastrostomy (PEG) and interventional radiologist-guided gastrostomy (IRG) using an integrated nationwide database. METHODS: Using the VA Informatics and Computing Infrastructure database, patients who underwent PEG or IRG from 2011 through 2021 were selected using Current Procedural Terminology and International Classification of Diseases codes. The primary outcome was the comparative incidence of adverse events between PEG and IRG. Secondary outcomes included all-cause mortality. Comorbidities were identified using International Classification of Diseases codes, and adjusted odds ratio (OR) for adverse events were calculated using multivariate logistic regression analysis. RESULTS: A total of 23,566 (70.7 ± 10.2 years) patients underwent PEG and 9,715 (69.6 ± 9.7 years) underwent IRG. Selected frequent indications for PEG vs IRG were as follows: stroke, 6.8% vs 5.3%, P < 0.01; aspiration pneumonia, 10.9% vs 6.8%, P < 0.001; feeding difficulties, 9.8% vs 6.3%, P < 0.01; and upper aerodigestive tract malignancies 58.8% vs 79.8%, P < 0.01. Across all subtypes of malignancies of the head and neck and foregut, the proportion of patients undergoing IRG was greater than those undergoing PEG (P < 0.001). The all-cause 30-day mortality and overall incidence of adverse events were significantly lower for PEG compared with those for IRG (PEG vs IRG): all-cause 30-day mortality, 9.35% vs 10.3% (OR 0.80; 95% confidence interval [CI] 0.74-0.87; P < 0.01); perforation of the colon, 0.12% vs 0.24% (OR 0.50; 95% CI 0.29-0.86; P = 0.04); peritonitis, 1.9% vs 2.7% (OR 0.68; 95% CI 0.58-0.79; P < 0.01); and hemorrhage 1.6% vs 1% (OR 1.47; 95% CI 1.18-1.83; P < 0.01). DISCUSSION: In a large nationwide database of more than 33,000 gastrostomy procedures, PEG was associated with a lower incidence of adverse outcomes and the 30-day mortality than IRG.

Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment.

BACKGROUND AND AIMS: A gastrostomy tube is often required for inpatients requiring long-term nutritional access. We compared the safety and outcomes of 3 techniques for performing a gastrostomy: percutaneous endoscopic gastrostomy (PEG), fluoroscopy-guided gastrostomy by an interventional radiologist (IR-gastrostomy), and open gastrostomy performed by a surgeon (surgical gastrostomy). METHODS: Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent a gastrostomy from 2016 to 2017. They were identified using the International Classification of Diseases, 10th Revision, Procedure Coding System. The selected patients were divided into 3 cohorts: PEG (0DH64UZ), IR-gastrostomy (0DH63UZ), and open surgical gastrostomy (0DH60UZ). Adjusted odds ratios for adverse events associated with each technique were calculated using multivariable logistic regression analysis. RESULTS: Of the 184,068 patients meeting the selection criteria, the route of gastrostomy tube placement was as follows: PEG, 16,384 (53.7 ± 29.0 years); IR-gastrostomy, 154,007 (67.2 ± 17.5 years); and surgical gastrostomy, 13,677 (57.9 ± 24.3 years). Compared with PEG, the odds for colon perforation using IR-gastrostomy and surgical gastrostomy, respectively, were 1.90 (95% confidence interval [CI], 1.26-2.86; P = .002) and 6.65 (95% CI, 4.38-10.12; P < .001), for infection of the gastrostomy 1.28 (95% CI, 1.07-1.53; P = .006) and 1.61 (95% CI, 1.29-2.01; P < .001), for hemorrhage requiring blood transfusion 1.84 (95% CI, 1.26-2.68; P = .002) and 1.09 (95% CI, .64-1.86; P = .746), for nonelective 30-day readmission 1.07 (95% CI, 1.03-1.12; P = .0023) and 1.13 (95% CI, 1.06-1.2; P = .0002), and for inpatient mortality 1.09 (95% CI, 1.02-1.17; P = .0114) and 1.55 (95% CI, 1.42-1.69; P < .0001). CONCLUSIONS: Placement of a gastrostomy tube (PEG) endoscopically is associated with a significantly lower risk of inpatient adverse events, mortality, and readmission rates compared with IR-gastrostomy and open surgical gastrostomy.

Development and validation of a predictive model for bleeding after peripheral vascular intervention: A report from the National Cardiovascular Data Registry Peripheral Vascular Interventions Registry.

OBJECTIVES: To develop a model to predict risk of in-hospital bleeding following endovascular peripheral vascular intervention. BACKGROUND: Peri-procedural bleeding is a common, potentially preventable complication of catheter-based peripheral vascular procedures and is associated with increased mortality. We used the National Cardiovascular Data Registry (NCDR) Peripheral Vascular Interventions (PVI) Registry to develop a novel risk-prediction model to identify patients who may derive the greatest benefit from application of strategies to prevent bleeding. METHODS: We examined all patients undergoing lower extremity PVI at 76 NCDR PVI hospitals from 2014 to 2017. Patients with acute limb ischemia (n = 1600) were excluded. Major bleeding was defined as overt bleeding with a hemoglobin (Hb) drop of ≥ 3 g/dl, any Hb decline of ≥ 4 g/dl, or a blood transfusion in patients with pre-procedure Hb ≥ 8 g/dl. Hierarchical multivariable logistic regression was used to develop a risk model to predict major bleeding. Model validation was performed using 1000 bootstrapped replicates of the population after sampling with replacement. RESULTS: Among 25,382 eligible patients, 1017 (4.0%) developed major bleeding. Predictors of bleeding included age, female sex, critical limb ischemia, non-femoral access, prior heart failure, and pre-procedure hemoglobin. The model demonstrated good discrimination (optimism corrected c-statistic = 0.67), calibration (corrected slope = 0.98, intercept of -0.04) and range of predicted risk (1%-18%). CONCLUSIONS: Post-procedural PVI bleeding risk can be predicted based upon pre- and peri-procedural patient characteristics. Further studies are needed to determine whether this model can be utilized to improve procedural safety through developing and targeting bleeding avoidance strategies.

Ultrasound-guided transthoracic needle biopsy of the lung: sensitivity and safety variables.

OBJECTIVES: Variables affecting the performance of ultrasound-guided transthoracic needle biopsy (US-TTNB) are not well established. We examined clinical and imaging variables affecting the sensitivity and the complication rates of US-TTNB. METHODS: We retrospectively reviewed a consecutive series of 528 US-TTNBs performed from 2008 to 2017. Univariate analyses were used to assess the influence of clinical and imaging variables on sensitivity and complication rates. Multivariate logistic regression was used to account for possible confounding variables. RESULTS: In 397 malignant lesions, the sensitivity of US-TTNB was 72% (95% CI 68-77%; 285/397). The overall pneumothorax rate was 15% (95% CI 12-18%; 77/528), leading to a chest tube in 2% (95% CI 1-3%; 9/528). Multivariate analysis showed that increasing pleural contact length (up to 30 mm) was associated with increased sensitivity (OR 1.08 per mm; 95% CI 1.04-1.12; p < 0.001), and pleural contact length (OR 0.98 per mm; 95% CI 0.97-0.99; p = 0.013), lesion size (OR 0.98 per mm; 95% CI 0.96-0.99; p = 0.006), and core needle diameter of 18G (OR 0.47 as compared with 20G; 95% CI 0.26-0.83; p = 0.010) were associated with a decreased pneumothorax rate. Graphical inspection of cubic splines showed that the probability of a positive biopsy rose sharply with increasing pleural contact length up to 30 mm and was stable thereafter. A similar, but inverse, relationship was observed for the probability of a pneumothorax. CONCLUSION: Pleural contact length is a key variable predicting the sensitivity of US-TTNB and pneumothorax rate after US-TTNB. Lesion size also predicts pneumothorax rates. KEY POINTS: • US-TTNB has a high sensitivity and a low complication rate for pleural and pulmonary lesions with pleural contact. • Pleural contact length is a key variable predicting the sensitivity of US-TTNB and pneumothorax rate after US-TTNB. • This study suggests that relying on US-TTNB may not be optimal for lesions < 10 mm for which the risk of pneumothorax is as high as the chance of obtaining diagnosis.

Global patterns of comprehensive cardiovascular risk factor control in patients with type 2 diabetes mellitus: Insights from the DISCOVER study.

AIM: To investigate global patterns of cardiovascular risk factor control in patients with type 2 diabetes mellitus (T2D). METHODS: DISCOVER is an international, observational cohort study of patients with T2D beginning second-line glucose-lowering therapy. Risk factor management was examined among eligible patients (ie, those with the risk factor) at study baseline. Inter-country variability was estimated using median odds ratios (MORs). RESULTS: Among 14 343 patients with T2D from 34 countries, the mean age was 57.4 ± 12.0 years and the median (interquartile range) duration of T2D was 4.2 (2.0-8.0) years; 11.8% had documented atherosclerotic cardiovascular disease (ASCVD). Among eligible patients, blood pressure was controlled in 67.5% (9284/13756), statins were prescribed in 43.7% (5775/13208), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers were prescribed in 55.6% (5292/9512), aspirin was prescribed in 53.3% of those with established ASCVD (876/1645), and 84.4% (12 102/14343) were non-smoking. Only 21.5% of patients (3088/14343) had optimal risk factor management (defined as control of all eligible measures), with wide inter-country variability (10%-44%), even after adjusting for patient and site differences (MOR 1.47, 95% confidence interval 1.24-1.66). CONCLUSION: Globally, comprehensive control of ASCVD risk factors is not being achieved in most patients, with wide variability among countries unaccounted for by patient and site differences. Better country-specific strategies are needed to implement comprehensive cardiovascular risk factor control consistently in patients with T2D to improve long-term outcomes.

Low Risk of Progression of Barrett's Esophagus to Neoplasia in Women.

BACKGROUND AND AIMS: Men are at a higher risk for Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC), but little is known about BE progression to dysplasia and EAC in women. We performed a retrospective, multicenter cohort study to assess risk of BE progression to dysplasia and EAC in women compared with men. We also investigated comorbidities, medication use, and endoscopic features that contribute to sex differences in risk of BE progression. METHODS: We collected data from large cohort of patients with BE seen at 6 centers in the United States and Europe, followed for a median 5.7 years. We obtained demographic information (age, sex, ethnicity), clinical history (tobacco use, body mass index, comorbidities), endoscopy results (procedure date, BE segment length), and histopathology findings. Neoplasia was graded as low-grade dysplasia, high-grade dysplasia (HGD), or EAC. Rates of disease progression between women and men were compared using χ2 analysis and the Student t test. Multivariable logistic regression was used to assess the association between sex and disease progression after adjusting for possible confounding variables. RESULTS: Of the total 4263 patients in the cohort, 2145 met the inclusion criteria, including 324 (15%) women. There was a total of 34 (1.6%) incident EACs, with an overall annual incidence of 0.3% (95% confidence interval: 0.2%-0.4%). We found significant differences between women and men in annual incidence rates of EAC (0.05% for women vs. 0.3% in men; P=0.04) and in the combined endpoint of HGD or EAC (0.1% for women vs. 1.1% for men; P<0.001). Female gender was an independent predictor for reduced progression to HGD or EAC when rates of progression were adjusted for body mass index, smoking history, race, use of aspirin, nonsteroidal anti-inflammatory drugs, proton-pump inhibitors, or statins, hypertriglyceridemia, BE length, and histology findings at baseline (hazard ratio: 0.11; 95% confidence interval: 0.03-0.45; P=0.002). CONCLUSIONS: In a multicenter study of men versus women with BE, we found a significantly lower risk of disease progression to cancer and HGD in women. The extremely low risk of EAC in women with BE (0.05%/y) indicates that surveillance endoscopy may not be necessary for this subgroup of patients with BE.

Stress myocardial perfusion imaging in patients presenting with syncope: Comparison of PET vs. SPECT.

BACKGROUND: The role of myocardial perfusion imaging (MPI) in patients with suspected coronary artery disease (CAD) presenting with syncope is controversial. We aimed to determine diagnostic yield of MPI for evaluation of syncope in patients without known CAD, as a function of pre-test patient risk and test modality (PET vs SPECT). METHODS: Between 1/2010 and 12/2016, 1324 consecutive patients presenting with syncope without known CAD underwent MPI with PET (n = 640) or SPECT (n = 684). Rates of abnormal MPI (summed difference score (SDS) > 2 or left ventricular ejection fraction (LVEF) reserve ≤ 0 for PET and SDS > 2 or post-stress LVEF ≤ 45% for SPECT) were determined among patients stratified by pre-test risk. In patients who were referred for coronary angiography, diagnostic yield of obstructive CAD was calculated in the overall cohort as well as in a propensity-matched cohort compared to patients without syncope. RESULTS: Abnormal MPI was noted in 36.5% (201/551) of patients who had PET compared with 13.0% (87/671) who had SPECT (P < 0.001), which is largely related to higher comorbidity burden and greater pre-test CAD risk in the PET population. Among patients who had an abnormal MPI, 8.5% (47/551) with PET and 0.7% (5/671) with SPECT were found to have obstructive CAD if referred for coronary angiography. Patients at intermediate-high pre-test risk had a higher proportion of abnormal MPIs and obstructive CAD as compared to those at low risk in both the PET and SPECT cohorts. The rate of abnormal testing and diagnostic yield of PET MPI was similar and proportionate to pre-test likelihood among matched patients with and without syncope. CONCLUSIONS: Among patients referred for PET MPI with syncope at an intermediate-high pre-test CAD risk, 1 in 3 had an abnormal MPI and 1 in 10 had obstructive CAD. The value of MPI was related to pre-test risk as opposed to the presence of syncope, and MPI testing with PET or SPECT in the low-risk population was low value.