The Impact of COVID-19 on Racial and Ethnic Disparities in Cardiac Procedural Care.

OBJECTIVE: The primary objective of this study was to evaluate whether the COVID-19 pandemic altered the racial and ethnic composition of patients receiving cardiac procedural care. DESIGN: This was a retrospective observational study. SETTING: This study was conducted at a single tertiary-care university hospital. PARTICIPANTS: A total of 1,704 adult patients undergoing transcatheter aortic valve replacement (TAVR) (n = 413), coronary artery bypass grafting (CABG) (n = 506), or atrial fibrillation (AF) ablation (n = 785) from March 2019 through March 2022 were included in this study. INTERVENTIONS: No interventions were performed as this was a retrospective observational study. MEASUREMENTS AND MAIN RESULTS: Patients were grouped based on the date of their procedure: pre-COVID (March 2019 to February 2020), COVID Year 1 (March 2020 to February 2021), and COVID Year 2 (March 2021 to March 2022). Population-adjusted procedural incidence rates during each period were examined and stratified based on race and ethnicity. The procedural incidence rate was higher for White patients versus Black, and non-Hispanic patients versus Hispanic patients for every procedure and every period. For TAVR, the difference in procedural rates between White patients versus Black patients decreased between the pre-COVID and COVID Year 1 (12.05-6.34 per 1,000,000 persons). For CABG, the difference in procedural rates between White patients versus Black, and non-Hispanic patients versus Hispanic patients did not change significantly. For AF ablations, the difference in procedural rates between White patients versus Black patients increased over time (13.06 to 21.55 to 29.64 per 1,000,000 persons in the pre-COVID, COVID Year 1, and COVID Year 2, respectively). CONCLUSION: Racial and ethnic disparities in access to cardiac procedural care were present throughout all study time periods at the authors' institution. Their findings reinforce the continuing need for initiatives to reduce racial and ethnic disparities in healthcare. Further studies are needed to fully elucidate the effects of the COVID-19 pandemic on healthcare access and delivery.

Orthotopic Heart and Combined Heart Liver Transplantation: the Ultimate Treatment Option for Failing Fontan Physiology.

Purpose of the Review: This is a comprehensive update on failing Fontan physiology and the role of heart and combined heart and liver transplantation in the current era. Recent Findings: Single ventricle physiology encompasses a series of rare congenital cardiac abnormalities that are characterized by absence of or hypoplasia of one ventricle. This effectively results in a single ventricular pumping chamber. These abnormalities are rarely compatible with long-term survival if left without surgical palliation in the first few years of life. Surgical treatment of single ventricle physiology has evolved over the past 60 years and is characterized by numerous creative innovations. These include the development of arteriopulmonary shunts, the evolution of partial cavopulmonary connections, and the eventual development of the "Fontan" operation. Regardless of the type of Fontan modification, the long-term consequences of the Fontan operation are predominantly related to chronic central venous hypertension and the multi-organ consequences thereof. Atrial arrhythmias can further compromise this circulation.Patients with single ventricle physiology represent a special sub-segment of congenital cardiac transplants and are arguably the most challenging patients considered for transplantation. Summary: This review describes in detail the challenges and opportunities of heart and liver transplantation in Fontan patients, as viewed and managed by the experienced team at the Ahmanson/UCLA Adult Congenital Heart Center.

Epidural analgesia does not increase the rate of inpatient falls after major upper abdominal and thoracic surgery: a retrospective case-control study.

PURPOSE: Postoperative epidural analgesia for major upper abdominal and thoracic surgery can provide significant benefits, including superior analgesia and reduced pulmonary dysfunction. Nevertheless, epidural analgesia may also be associated with decreased muscle strength, sympathetic tone, and proprioception that could possibly contribute to falls. The purpose of this retrospective case-control study was to search a large national database in order to investigate the possible relationship between postoperative epidural analgesia and the rate of inpatient falls. METHODS: Data from the nationwide inpatient sample for 2007-2011 were queried for adult patients who underwent elective major upper abdominal and thoracic surgery. Multiple International Classification of Diseases, Ninth Revision, Clinical Modification codes for inpatient falls and accidents were combined into one binary variable. Univariate analyses were used for initial statistical analysis. Logistic regression analyses and McNemar's tests were subsequently used to investigate the association of epidural analgesia with inpatient falls in a 1:1 case-control propensity-matched sample after adjustment of patients' demographics, comorbidities, and hospital characteristics. RESULTS: Forty-two thousand six hundred fifty-eight thoracic and 54,974 upper abdominal surgical procedures were identified. The overall incidence of inpatient falls in the thoracic surgery group was 6.54% with an increasing trend over the study period from 4.95% in 2007 to 8.11% in 2011 (P < 0.001). Similarly, the overall incidence of inpatient falls in the upper abdominal surgery group was 5.30% with an increasing trend from 4.55% in 2007 to 6.07% in 2011 (P < 0.001). Postoperative epidural analgesia was not associated with an increased risk for postoperative inpatient falls in the thoracic surgery group (relative risk [RR], 1.18; 95% confidence interval [CI], 0.95 to 1.47; P = 0.144) and in the upper abdominal surgery group (RR, 0.84; 95% CI 0.64 to 1.09; P = 0.220). Inpatient falls compared with non-falls were associated with a longer median (interquartile range) length of hospital stay in both the thoracic surgery group (11 [7-17] days vs 9 [6-16] days, respectively; P < 0.001) and the upper abdominal surgery group (12 [7-20] days vs 10 [6-17] days, respectively; P < 0.001). CONCLUSION: Our study suggests that postoperative epidural analgesia for patients undergoing major upper abdominal and thoracic surgery is not associated with an increased risk of inpatient falls.

Genome analysis of a highly virulent serotype 1 strain of Streptococcus pneumoniae from West Africa.

Streptococcus pneumoniae is a leading cause of pneumonia, meningitis, and bacteremia, estimated to cause 2 million deaths annually. The majority of pneumococcal mortality occurs in developing countries, with serotype 1 a leading cause in these areas. To begin to better understand the larger impact that serotype 1 strains have in developing countries, we characterized virulence and genetic content of PNI0373, a serotype 1 strain from a diseased patient in The Gambia. PNI0373 and another African serotype 1 strain showed high virulence in a mouse intraperitoneal challenge model, with 20% survival at a dose of 1 cfu. The PNI0373 genome sequence was similar in structure to other pneumococci, with the exception of a 100 kb inversion. PNI0373 showed only 15 lineage specific CDS when compared to the pan-genome of pneumococcus. However analysis of non-core orthologs of pneumococcal genomes, showed serotype 1 strains to be closely related. Three regions were found to be serotype 1 associated and likely products of horizontal gene transfer. A detailed inventory of known virulence factors showed that some functions associated with colonization were absent, consistent with the observation that carriage of this highly virulent serotype is unusual. The African serotype 1 strains thus appear to be closely related to each other and different from other pneumococci despite similar genetic content.

Subtle genetic changes enhance virulence of methicillin resistant and sensitive Staphylococcus aureus.

BACKGROUND: Community acquired (CA) methicillin-resistant Staphylococcus aureus (MRSA) increasingly causes disease worldwide. USA300 has emerged as the predominant clone causing superficial and invasive infections in children and adults in the USA. Epidemiological studies suggest that USA300 is more virulent than other CA-MRSA. The genetic determinants that render virulence and dominance to USA300 remain unclear. RESULTS: We sequenced the genomes of two pediatric USA300 isolates: one CA-MRSA and one CA-methicillin susceptible (MSSA), isolated at Texas Children's Hospital in Houston. DNA sequencing was performed by Sanger dideoxy whole genome shotgun (WGS) and 454 Life Sciences pyrosequencing strategies. The sequence of the USA300 MRSA strain was rigorously annotated. In USA300-MRSA 2658 chromosomal open reading frames were predicted and 3.1 and 27 kilobase (kb) plasmids were identified. USA300-MSSA contained a 20 kb plasmid with some homology to the 27 kb plasmid found in USA300-MRSA. Two regions found in US300-MRSA were absent in USA300-MSSA. One of these carried the arginine deiminase operon that appears to have been acquired from S. epidermidis. The USA300 sequence was aligned with other sequenced S. aureus genomes and regions unique to USA300 MRSA were identified. CONCLUSION: USA300-MRSA is highly similar to other MRSA strains based on whole genome alignments and gene content, indicating that the differences in pathogenesis are due to subtle changes rather than to large-scale acquisition of virulence factor genes. The USA300 Houston isolate differs from another sequenced USA300 strain isolate, derived from a patient in San Francisco, in plasmid content and a number of sequence polymorphisms. Such differences will provide new insights into the evolution of pathogens.