Utility of cell-based vaccines as cancer therapy: Systematic review and meta-analysis.

Cell-based therapeutic cancer vaccines use autologous patient-derived tumor cells, allogeneic cancer cell lines or autologous antigen presenting cells to mimic the natural immune process and stimulate an adaptive immune response against tumor antigens. The primary objective of this study is to perform a systematic literature review with an embedded meta-analysis of all published Phase 2 and 3 clinical trials of cell-based cancer vaccines in human subjects. The secondary objective of this study is to review trials demonstrating biological activity of cell-based cancer vaccines that could uncover additional hypotheses, which could be used in the design of future studies. We performed the systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The final review included 36 studies - 16 single-arm studies, and 20 controlled trials. Our systematic review of the existing literature revealed largely negative trials and our meta-analysis did not show evidence of clinical benefit from cell-based cancer-vaccines. However, as we looked beyond the stringent inclusion criteria of our systematic review, we identified significant examples of biological activity of cell-based cancer vaccines that are worth highlighting. In conclusion, the existing literature on cell-based cancer vaccines is highly variable in terms of cancer type, vaccine therapies and the clinical setting with no overall statistically significant clinical benefit, but there are individual successes that represent the promise of this approach. As cell-based vaccine technology continues to evolve, future studies can perhaps fulfill the potential that this exciting field of anti-cancer therapy holds.

Post-migration stressors, mental health and well-being in resettled refugees from Syria: Do individuals' coping strategies matter?

BACKGROUND: The evidence is mixed as to whether individuals' coping strategies may mitigate the adverse mental health effects of post-displacement stressors in refugee populations, with some indications that the buffering effects of coping strategies are context dependent. The present study examined if problem-solving and acceptance coping strategies were effect modifiers between post-migration stressors and mental health in adult refugees from Syria resettled in Sweden. METHODS: Study aims were investigated using cross-sectional survey data from a nationwide, randomly sampled group of adult refugees from Syria granted permanent residency in Sweden between 2011 and 2013 (Nsample = 4000, nrespondents = 1215, response rate 30.4%). Post-migration stressors examined included: financial strain, social strain, host-country competency strain and discrimination. Two mental health outcomes were used: anxiety/depression, measured with the Hopkins Symptom Checklist-25; and well-being, measured with the WHO-5 Well-being Index. Both outcomes were modelled continuously. Coping strategies were measured using the BRIEF Cope scale. Interactions between coping strategies and post-migration stressors were tested in fully adjusted linear regression models using Wald test for interaction, corrected for multiple testing using the Benjamini-Hochberg procedure. RESULTS: Both problem-solving and acceptance coping strategies buffered the adverse association between financial strain and symptoms of anxiety/depression, and problem-solving coping strategies buffered the adverse association between host-country competency strain and anxiety/depression. CONCLUSIONS: The study suggests that individuals' coping strategies may to some degree buffer the adverse mental health effects of financial strain and host-country competency strain experienced by refugees in the resettlement phase. Although this pattern was only found in regard to anxiety/depression and not subjective well-being, the findings show that individual-level coping skills among refugees may contribute to adaptation in the face of post-settlement adversities. Notwithstanding the importance of attending to refugees' psychosocial conditions, refugees residing in refugee camps and newly resettled refugees might benefit from interventions aiming at enhancing individual coping resources and skills. The potential effect of increased controllability and decreased conflict-proximity also warrants further exploration in future studies.

Comprehensive Health Assessment for Children in Out-of-Home Care: An Exploratory Study of Service Needs and Mental Health in a Norwegian Population.

A comprehensive model for routine multi-disciplinary health assessment for children in out-of-home care was piloted in a Norwegian region. This paper reports on identified service needs and mental disorders among 196 children (0-17 years) receiving the assessment. Cross-sectional data was extracted from assessment reports. Results show needs across a range of services, with a mean of 2.8 recommended services for children aged 0-6 and 3.3 for children aged 7-17. Mental disorders were identified in 50% of younger children, and 70% of older children. For all children, overall service need was associated with mental disorders, in addition to male gender among younger children. Need for specialized mental health services was associated with mental disorders among younger children and increasing age among older children. The high frequency of service needs and mental disorders illustrate the importance of offering comprehensive health assessments routinely to this high-risk child population and necessitates coordinated service delivery.

Admission Forced Vital Capacity Adds a Predictive Physiologic Tool to Triage Patients Suffering Rib Fractures: A Prospective Observation Trial.

BACKGROUND: Patients with rib fractures are at high risk for morbidity and mortality. This study prospectively examines bedside percent predicted forced vital capacity (% pFVC) in predicting complications for patients suffering multiple rib fractures. The authors hypothesize that increased % pFVC is associated with reduced pulmonary complications. METHODS: Adult patients with =3 rib fractures admitted to a level I trauma center, without cervical spinal cord injury or severe traumatic brain injury, were consecutively enrolled. FVC was measured at admission and % pFVC values were calculated for each patient. Patient were grouped by % pFVC <30% (low), 30-49% (moderate), and =50% (high). RESULTS: A total of 79 patients were enrolled. Percent pFVC groups were similar except for pneumothorax being most frequent in the low group (47.8% vs. 13.9% and 20.0%, p = .028). Pulmonary complications were infrequent and did not differ between groups (8.7% vs. 5.6% vs. 0%, p = .198). DISCUSSION: Increased % pFVC was associated with reduced hospital and intensive care unit (ICU) length of stay (LOS) and increased time to discharge to home. Percent pFVC should be used in addition to other factors to risk stratify patients with multiple rib fractures. Bedside spirometry is a simple tool that can help guide management in resource-limited settings, especially in large-scale combat operations. CONCLUSION: This study prospectively demonstrates that % pFVC at admission represents an objective physiologic assessment that can be used to identify patients likely to require an increased level of hospital care.

Thymic adenocarcinoma presenting as an incidental mediastinal mass.

BACKGROUND: Primary thymic adenocarcinoma represents an exceptionally rare malignancy, for which the cornerstone of therapy is margin-negative resection, with radiation and systemic therapy reserved for invasive and advanced disease. Thymic adenocarcinoma has not been previously reported in the setting of a concomitant malignancy, as reported herein. CASE PRESENTATION: We present a case of a 55-year-old previously healthy male diagnosed with acute myeloid leukemia, also found to have a mediastinal mass. Evaluation of the mediastinal mass with tumor markers, biopsies, and next-generation sequencing proved non-diagnostic, while he was simultaneously treated with induction chemotherapy to prevent leukemia-related blast crisis. After completing and recovering from induction chemotherapy, he underwent successful thymectomy during a chemotherapy holiday, with a margin-negative resection of thymic adenocarcinoma. He has subsequently recovered and undergone successful allogeneic hematopoietic stem cell transplant. CONCLUSIONS: We present a case of synchronous adult acute myeloid leukemia and primary thymic adenocarcinoma requiring a tailored approach for management of simultaneous malignancies.

Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study.

BACKGROUND: Limited research exists on pain and especially the co-occurrence of pain and mental ill health in general refugee populations. The present study aimed to approximate the prevalence of chronic pain (CP) among adult refugees from Syria resettled in Norway; investigate the association between CP and mental ill health; and explore how CP and mental ill health associate with both perceived general health and functional impairment. Gender as potential effect modifier in these associations was also examined. METHODS: Cross-sectional, postal survey questionnaire. INCLUSION CRITERIA: ≥ 18 years old; refugee from Syria; and arrived in Norway between 2015 and 2017. Study sample was randomly drawn from full population registries, and n = 902 participated (participation rate ≈10%). CP was measured with 10 items on pain lasting for ≥ 3 consecutive months last year. Symptoms of anxiety, depression and PTSD were measured with the HSCL and HTQ scales, respectively. Ordered and binomial logistic regressions were used in analyses. Gender was tested as effect modifier with Wald test for interaction. RESULTS: In the sample overall, the proportion of participants who reported severe CP was 43.1%. There was strong evidence that anxiety, depression and PTSD were associated with higher levels of CP. In fully adjusted regression models, including both CP and mental health variables, CP was strongly associated with poor perceived general health whereas mental health showed much weaker associations. The association between mental health (anxiety and PTSD) and functional impairment was highly gender specific, with strong associations in men but not in women. CP was strongly associated with functional impairment with no difference across gender. CONCLUSION: The study shows a high burden of CP in a general population of adult refugees from Syria with likely substantial adverse consequences for daily functioning. The strong association between CP and mental ill health suggests personnel working with refugees' health should be attuned to their co-occurrence as both problems may need to be addressed for either to be effectively mitigated. A clear mismatch exists between the burden on health caused by pain in general refugee populations and the amount of available evidence to guide mitigating strategies. TRIAL REGISTRATION: NCT03742128.

Revascularization of acute inferior vena cava thrombosis and atresia in an adolescent.

Inferior vena cava (IVC) anomalies will remain silent until collateralized venous drainage has been lost. The initial signs can be subtle, including back pain, and are often missed initially until progressive changes toward motor weakness, phlegmasia cerulea dolens, and/or renal impairment have occurred. We have presented a case of acute occlusion of an atretic IVC and infrarenal collateral drainage in an adolescent patient, who had been treated with successful thrombolysis, thrombectomy, and endovascular revascularization for IVC stenting and reconstruction.

Post-Migration Stressors and Health-Related Quality of Life in Refugees from Syria Resettled in Sweden.

The link between post-migration stressors and mental ill health is well documented in refugees resettled in high-income host countries, but the consequences of these stressors on refugees' health-related quality of life (HRQoL) are less known. This study examined the association between post-migration stressors and HRQoL among Syrian adult refugees resettled in Sweden using a preference-based value set obtained from the general Swedish population. A total of 1215 Syrian adults, ages 18-64 years, granted residency in Sweden, responded to a postal questionnaire in 2016 regarding various aspects of their resettlement. The European Quality of Life Five Dimensions Five Level (EQ-5D-5L) questionnaire was used to assess HRQoL through an EQ-5D-5L index score (range; 0=dead to 1=full health). The index score was preference weighted using a Swedish population value set. Predictors were four self-reported post-migration stressors related to daily living in the host country: financial strain, social strain, competency strain and perceived discrimination divided into low, medium and high levels of experienced stress. Multivariable linear regression models were employed to assess the association between post-migration stressors and HRQoL index score, adjusting for potentially traumatic events in the pre- and peri-migration phase as well as sociodemographic confounders/covariates (sex, age, education, civil status, immigration year). The Syrian refugees had a mean EQ-5D-5L index score of 0.863 (SD = 0.145). There was strong evidence of a negative dose-response association in both unadjusted and adjusted models between HRQoL and the post-migration stressors financial strain and social strain-i.e., there was a stepwise, and statistically significant, decrease in HRQoL when going from low to medium to high strain. Competency strain and discrimination were only associated with lower HRQoL when experienced at high levels in fully adjusted models. High exposure to potentially traumatic experiences before or during flight was also associated with lower HRQoL. Syrian refugees resettled in Sweden reported a lower HRQoL than the general Swedish population and lower than age-matched Swedish adults. The present study results point to the possible adverse effects of post-migration stressors on HRQoL.

The Effect of COVID-19 on Adult Cardiac Surgery in the United States in 717 103 Patients.

BACKGROUND: COVID-19 has changed the world as we know it, and the United States continues to accumulate the largest number of COVID-related deaths worldwide. There exists a paucity of data regarding the effect of COVID-19 on adult cardiac surgery trends and outcomes on regional and national levels. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried from January 1, 2018, to June 30, 2020. The Johns Hopkins COVID-19 database was queried from February 1, 2020, to January 1, 2021. Surgical and COVID-19 volumes, trends, and outcomes were analyzed on a national and regional level. Observed-to-expected ratios were used to analyze risk-adjustable mortality. RESULTS: The study analyzed 717 103 adult cardiac surgery patients and more than 20 million COVID-19 patients. Nationally, there was a 52.7% reduction in adult cardiac surgery volume and a 65.5% reduction in elective cases. The Mid-Atlantic region was most affected by the first COVID-19 surge, with 69.7% reduction in overall case volume and 80.0% reduction in elective cases. In the Mid-Atlantic and New England regions, the observed-to-expected mortality for isolated coronary bypass increased as much as 1.48 times (148% increase) pre-COVID rates. After the first COVID-19 surge, nationwide cardiac surgical case volumes did not return to baseline, indicating a COVID-19-associated deficit of cardiac surgery patients. CONCLUSIONS: This large analysis of COVID-19-related impact on adult cardiac surgery volume, trends, and outcomes found that during the pandemic, cardiac surgery volume suffered dramatically, particularly in the Mid-Atlantic and New England regions during the first COVID-19 surge, with a concurrent increase in observed-to-expected 30-day mortality.

Mental health in adult refugees from Syria resettled in Norway between 2015 and 2017: a nationwide, questionnaire-based, cross-sectional prevalence study.

Background: The number of forcibly displaced people globally has never been higher, with refugees from Syria constituting the largest displaced population worldwide. Many studies have documented elevated levels of mental health problems in refugee populations, though prevalence estimates of common mental disorders vary considerably between studies, explained both by methodological and contextual factors. Objective: Using questionnaire-based screening checklists to approximate the prevalence of and investigate risk factors for post-traumatic stress disorder (PTSD), anxiety and depression among adult refugees from Syria resettled in Norway and to compare estimates with a sister-study in Sweden. Method: Cross-sectional survey of a randomly selected sample from the National Population Register in Norway of adult refugees from Syria who were granted residency rights in Norway between 2015 and 2017 (Nsample = 9,990; nrespondents = 902). Above-threshold scores on the Harvard Trauma Questionnaire (HTQ) and Hopkins Symptoms Checklist (HSCL-25) defined caseness for PTSD (HTQ>2.06); anxiety (HSCLanxitey>1.75); and depression (HSCLdepression>1.80). Results: Weighted, checklist-positive prevalence estimates for PTSD, anxiety and depression were 29.7% (25.4%-34.4%), 30.1% (25.7%-34.9%), and 45.2% (40.6%-49.8%), respectively. Cumulative exposure to potentially traumatic experiences before or during flight was a clear risk factor for all outcomes, and female gender was a risk factor for anxiety and depression, though only in adjusted analyses. The choice of HTQ cut-off to define PTSD caseness (2.5 vs. 2.06) had a notable effect on prevalence estimates. Conclusion: In line with prior evidence, the present study suggests adult refugees from Syria resettled in Norway have higher rates of anxiety and depression and markedly higher rates of PTSD compared to general, non-refugee populations, and that this is clearly linked to past traumatic experiences. Prevalence estimates were highly consistent with estimates from the sister-study in Sweden, which used almost identical methodology. Findings underline the importance of screening for and intervening on mental health problems in newly arrived refugees.

Antecedentes: El número de personas desplazadas forzosamente a nivel global nunca ha sido más alto, con los refugiados de Siria constituyendo la mayor población desplazada del mundo. Muchos estudios han documentado elevados niveles de problemas de salud mental en poblaciones refugiadas, aunque las estimaciones de prevalencia de trastornos de salud mental comunes varían considerablemente entre estudios, explicadas tanto por factores metodológicos y contextuales.Objetivo: Utilizar listas de tamizaje en formato de cuestionarios para estimar la prevalencia e investigar factores de riesgo para el trastorno de estrés postraumático (TEPT), la ansiedad y la depresión entre adultos refugiados de Siria reinstalados en Noruega, y para comparar estimaciones con un estudio hermano en Suecia.Método: Encuesta transaccional en una muestra seleccionada aleatoriamente del Registro de Población Nacional en Noruega de adultos refugiados de Siria que obtuvieron derechos de residencia entre 2015 y 2017 (N muestral = 9990, n de encuestados = 902). Puntajes por sobre el puntaje de corte del Cuestionario de Trauma de Harvard (HTQ en su sigla en inglés) y la Lista de chequeo de síntomas de Hopkins (HSCL-25 en su sigla en inglés) definió como caso clínico para el TEPT (HTQ>2.06); ansiedad (HSCL ansiedad > 1.75); y depresión (HSCL depresión> 1.80).Resultados: Las estimaciones ponderadas de prevalencia de positivos en lista de chequeo para TEPT, ansiedad y depresión fueron 29.7% (25.4%­34.4%), 30.1% (25.7%­34.9%), and 45.2% (40.6%- 49.8%), respectivamente. La exposición acumulativa a experiencias potencialmente traumáticas antes o durante el vuelo fue un claro factor de riesgo para todos los resultados, y el género femenino fue un factor de riesgo para ansiedad y depresión, aunque solo en análisis ajustados. La elección del puntaje de corte del HTQ para definir caso clínico de TEPT (2.5 versus 2.06) tuvo un efecto notable en las estimaciones de prevalencia.Conclusión: En línea con evidencia previa, el presente estudio sugirió que los adultos de Siria refugiados y reinstalados en Noruega tienen tasas más altas de ansiedad y depresión, y tasas marcadamente más altas de TEPT comparadas con poblaciones generales no refugiadas, y esto está ligado directamente a experiencias traumáticas anteriores. Las estimaciones de prevalencia fueron altamente consistentes con las estimaciones del estudio hermano en Suecia, el cual utilizó metodología casi idéntica. Los hallazgos subrayan la importancia de tamizar e intervenir en problemas de salud mental en refugiados recién llegados.

The Impact of a Workplace Terrorist Attack on the Psychosocial Work Environment: A Longitudinal Study From Pre- to Post-disaster.

The psychosocial work environment is of great importance for regaining health and productivity after a workplace disaster. Still, there is a lack of knowledge about the impact of a disaster on the psychosocial work environment. The purpose of this study was to examine whether employees' perceptions of role clarity, role conflicts, and predictability in their work situation changed from before to after a workplace terrorist attack. We combined data from two prospective work environment surveys of employees in three governmental ministries that were the target of the 2011 Oslo terrorist attack. A first two-wave survey was conducted 4-5 years and 2-3 years before the attack, and a second three-wave survey took place 10 months, 2 years, and 3 years after the attack. Of 504 individuals who were employed at the time of the bombing, 220 were employed in both pre- and post-disaster periods, participated in both the first and the second survey, and consented to the linking of data from the two surveys. We found no significant changes in levels of role clarity, role conflict, and predictability from before to after the terrorist attack. Adjusting for sex, age and education had no effect on the results. The findings suggest that perceptions of the psychosocial working environment are likely to be maintained at previous levels in the aftermath of a workplace disaster. Considering the importance of the psychosocial work environment for regaining health and productivity, the findings are important for the preparation for, and management of, future crises.

Psychosocial work factors and sick leave risk after a terrorist bomb attack: a survey and registry-based longitudinal study of governmental employees in Norway.

OBJECTIVES: Studies show that social support may reduce the negative psychological effects of terror. The aim was to explore the effects of the psychosocial work environment on sick leave risk among governmental employees after a workplace bomb attack. DESIGN: We linked longitudinal survey data collected at 10 and 22 months after the bombing with registry data on doctor-certified sick leave collected from 42 months before the attack to 33 months after the attack. ORs and rate ratios were estimated with mixed effects hurdle models. SETTING: The bombing of the government ministries in Oslo, Norway, 22 July 2011. PARTICIPANTS: We identified 1625 participants from a cohort of 3520 employees working in the ministries during the bombing in 2011. RESULTS: After adjustment for confounders, social support from coworkers reduced the odds of sick leave (OR 0.80, 95% CI 0.68 to 0.93), and there was marginal evidence for reduced odds with support from superior (OR 0.87, 95% CI 0.87 to 1.03). A social work climate, an innovative climate and a human resource primacy climate (HRP) reduced the sick leave risk (eg, HRP OR 0.77, 95% CI 0.66 to 0.90). The hurdle model found no associations between psychosocial support at work and the duration of sick leave. CONCLUSIONS: Psychosocial support at work can enhance employees' work ability after terror and reduce the sick leave risk by more than 20%. However, a supportive psychosocial work environment did not reduce the duration of sickness absence. The protective role of psychosocial work factors on sick leave may be most significant when employees are at work and interact with their work environment.

Investigating the frequency of intrusive memories after 24 hours using a visuospatial interference intervention: a follow-up and extension.

Background: There is a need for effective, low-cost, readily available measures for reducing trauma symptoms so that people exposed to potentially traumatic events can receive help more quickly. A previous study reported that performing an intervention including a visuospatial task shortly after a reminder of a series of unpleasant film clips seen 24 hours earlier reduced the number of intrusive memories over the following week. Objective: This study reports a follow-up and extension of the earlier promising finding. The prediction was that participants performing the visuospatial task immediately after the reminder would report fewer intrusions compared to three other groups who 1) performed no task, and novel conditions who 2) performed the task before the reminder, and 3) performed the task 90 minutes after the reminder. Method: A trauma-analogue method was used, where students (N = 200) watched a series of short films with unpleasant material. Over the following week, they were asked to write down any intrusive memories they experienced in a diary. On the second day they returned to the lab and saw static reminders of the films. They were then randomly allocated to condition, recorded intrusive memories over the following days and returned to the lab for final testing on Day 8. Results: A total of 49 participants did not report any intrusions and were excluded from the analyses. Two more participants were excluded as outliers, leaving a final sample of n = 149. Despite using largely the same materials as the original study there were no significant differences in the number of intrusive memories between the four groups post intervention. Conclusions: Possible explanations include the effect not being as robust as expected, a low number of intrusions across groups, baseline differences in attention, and minor but potentially important differences in procedure between this and the original study.

Antecedentes: Existe la necesidad de medidas efectivas de bajo costo y fácilmente disponibles para reducir los síntomas del trauma, de modo que las personas expuestas a eventos potencialmente traumáticos puedan recibir ayuda más rápidamente. James y cols. (2015) reportaron que realizar una intervención que incluye una tarea viso-espacial poco después de un recordatorio consistente en una serie de clips de películas desagradables vistos 24 horas antes, redujo el número de recuerdos intrusivos durante la semana siguiente.Objetivo: Este estudio reporta un seguimiento y extensión del prometedor hallazgo de James y cols. La predicción fue que los participantes que realizaran la tarea viso-espacial inmediatamente después del recordatorio reportarían menos intrusiones en comparación con otros tres grupos que: 1) no realizaron ninguna tarea, y en condiciones novedosas que 2) realizaron la tarea antes del recordatorio y 3) realizaron la tarea 90 minutos después del recordatorio.Método: Se utilizó un método analógico de trauma, donde los estudiantes (N = 200) vieron una serie de cortometrajes con material desagradable. Durante la semana siguiente, se les pidió que escribieran cualquier recuerdo intrusivo que experimentaran en un diario. El segundo día regresaron al laboratorio y vieron recordatorios estáticos de las películas. Luego fueron asignados aleatoriamente a la condición, registraron recuerdos intrusivos durante los días siguientes y regresaron al laboratorio para la prueba final el día 8.Resultados: Un total de 49 participantes no reportó ninguna intrusión y fueron excluidos de los análisis. Se excluyeron dos participantes adicionales como valores atípicos, dejando una muestra final de n = 149. A pesar de utilizar en gran parte los mismos materiales que el estudio original, no hubo diferencias significativas en el número de recuerdos intrusivos entre los cuatro grupos después de la intervención.Conclusiones: Las posibles explicaciones incluyen que el efecto no es tan robusto como se esperaba, un número bajo de intrusiones entre los grupos, diferencias basales de atención y diferencias menores pero potencialmente importantes en el procedimiento entre éste y el estudio original.

Coping in Limbo? The Moderating Role of Coping Strategies in the Relationship between Post-Migration Stress and Well-Being during the Asylum-Seeking Process.

Asylum seekers are faced with high levels of post-migratory stress due to uncertainty and uncontrollability of the application process, resulting in higher levels of mental health problems. Little is known about the coping strategies utilized by asylum seekers in this context. Structural equation modeling and the stepwise modeling approach were utilized on cross-sectional data from a cohort of asylum seekers in Sweden (N = 455) to examine whether adaptive coping in the form of problem-focused and cognitive-based coping would buffer the impact of post-migratory stressors by moderating the relationship between the stressors and well-being. Fit indices showed good to excellent fit of the final model that regressed well-being on selected post-migratory stressors and coping (CFI = 0.964, RMSEA = 0.043 (90% CI = 0.035-0.051), SRMR = 0.044). Well-being was negatively and significantly regressed on both perceived discrimination (B = -0.42, SE = 0.11, p < 0.001) and distressing family conflicts (B = -0.16, SE = 0.07, p = 0.037), and positively and significantly regressed on cognitive restructuring (B = 0.71, SE = 0.33, p = 0.030). There was, however, no evidence that coping strategies modified the adverse associations between the two post-migratory stressors and well-being. Interventions and policies should prioritize improving contextual factors inherent in the asylum-seeking process in order to reduce stress and enable coping.

Resection and replacement of thoracic aortic graft infections.

OBJECTIVES: Thoracic aortic graft infection (TAGI) presents a formidable challenge with high mortality. We evaluated our 22-year experience managing TAGI with extensive debridement, graft replacement, vascularized tissue coverage, and aggressive antibiotics. METHODS: We reviewed all consecutive patients with TAGI from 1991 to 2013. We also compared infected cases versus noninfected reoperative controls using a case-control design. Standard statistical methods were used for descriptive analysis, and Kaplan-Meier for survival analysis. RESULTS: We treated 32 TAGI patients, involving 19 ascending/arch (A/A) and 13 descending/thoracoabdominal (D/TAA) grafts, including 4 endografts. In total, 19 (59.4%) presented with pseudoaneurysm and 11 (34.4%) with aortic fistula. Vascularized tissue (omentum or muscle) coverage was possible in 22 (71.0%) patients. Thirty-day mortality occurred in 3 (9.4%) patients, with no 30-day mortality among those receiving vascularized graft coverage (P = .018). During follow-up, reinfection occurred in 8 patients (25% [4 A/A and 4 D/TAA]). Five-year overall (A/A 45.4% vs D/TAA 28.9%, P = .434) and reinfection-free (A/A 19.2%, D/TAA 27%, P = .409) survival was similar between groups. Long-term mortality was greater after endograft infection (100% vs 25% at 2.5 months, P = .0007) or aortobronchial fistulization (100% vs 37.9% at 6 months, P = .026). Time to reintervention was shorter in infected versus non-infected reoperative cases (31 vs 83 months, P < .0001), but there were no significant differences in long-term mortality after reoperation. CONCLUSIONS: TAGI continues to represent a highly morbid surgical challenge. Prompt antimicrobial coverage, debridement, graft replacement, and vascularized graft coverage, yielded best long-term results. Endograft infection and aortobronchial fistula had very poor prognoses.

Less Invasive Mitral Surgery Versus Conventional Sternotomy Stratified by Mitral Pathology.

BACKGROUND: Our objective was to compare national mitral repair rates and outcomes after less invasive mitral surgery (LIMS) vs conventional sternotomy across the spectrum of mitral pathologies and repair techniques. METHODS: Patients undergoing isolated primary mitral valve surgery in The Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 2014 to December 2018 were evaluated. Propensity score models were constructed nonparsimoniously, and prediction models used to compute adjusted effects of surgical approach. Hypothesis tests were adjusted for propensity score with inverse-probability weighting. RESULTS: A total of 41,082 patients met inclusion criteria; comprising 10,238 (24.9%) LIMS and 30,844 (75.1%) conventional sternotomy, with increased LIMS adoption annually. Surgeons reporting LIMS cases had higher annual median mitral case volumes than those who did not (23 vs 8, P < .001). Groups were well-balanced after propensity adjustment including mitral pathology. Propensity score-adjusted outcomes showed increased procedural volume (odds ratio 1.030 [95% confidence interval: 1.028-1.031]) and LIMS (odds ratio 2.139 [95% confidence interval 2.032-2.251]) were independently associated with higher mitral repair rates. Propensity-adjusted outcomes included reduced stroke (P < .001), atrial fibrillation (P < .001), pacemaker (P < .001), renal failure (P < .001), and length of stay (P < .001) for LIMS vs sternotomy, without differences in mortality. Operative volume influenced outcomes in both groups. CONCLUSIONS: LIMS was associated with higher mitral repair rates, and lower morbidity. Further studies regarding the impact of surgeon volume on choice of operative approach are necessary.