Trends of Hospitalizations and In-Hospital Outcomes for Traumatic Cardiac Injury in United States.

Introduction: Traumatic cardiac injury (TCI) poses a significant risk of morbidity and mortality, yet there is a lack of population-based outcomes data for these patients. Methods: The authors examined national yearly trends, demographics, and in-hospital outcomes of TCI using the National Inpatient Sample from 2007 to 2014. We focused on adult patients with a primary discharge diagnosis of TCI, categorizing them into blunt (BTCI) and penetrating (PTCI) cardiac injury. Results: A total of 11,510 cases of TCI were identified, with 7,155 (62.2%) classified as BTCI and 4,355 (37.8%) as PTCI. BTCI was predominantly caused by motor vehicle collisions (66.7%), while PTCI was mostly caused by piercing injuries (67.4%). The overall mortality rate was 11.3%, significantly higher in PTCI compared to BTCI (20.3% vs. 5.9%, χ2(1, N = 11,185) = 94.9, p <0.001). Additionally, 21.5% required blood transfusion, 19.6% developed hemopericardium, and 15.9% suffered from respiratory failure. Procedures such as heart and pericardial repair were more common in PTCI patients. Length of hospitalization and cost of care were also significantly higher for PTCI patients, W(1, N = 11,015) = 88.9, p <0.001). Conclusions: Patients with PTCI experienced higher mortality rates than those with BTCI. Within the PTCI group, young men from minority racial groups and low-income households had poorer outcomes. This highlights the need for early and specialized attention from emergency and cardiothoracic providers for patients in these demographic groups.

Nationwide Trends and Outcomes for Coronary Artery Bypass Grafting in End-Stage Kidney Disease and Stable Coronary Artery Disease.

Patients with end-stage kidney disease (ESKD) on dialysis have an increased burden of coronary artery disease (CAD). This study assessed the trend and outcomes for coronary artery bypass surgery (CABG) in patients with ESKD and stable CAD. We conducted a longitudinal study using the United States Renal Data System of patients with ESKD and stable CAD who underwent CABG from the years 2009 to 2017. The outcomes included in-hospital, long-term mortality, and repeat revascularization. The follow-up was until death, end of Medicare AB coverage, or December 31, 2018. A total of 11,952 patients were identified. The mean age was 62.8 years, 68% were male, and 67% were white. The common co-morbidities included hypertension (97%), diabetes mellitus (75%), and congestive heart failure (53%). A significant decrease in CABG procedures from 2.9 to 1.3 procedures per 1,000 patients with ESKD (p <0.001) was noted during the years studied. The overall in-hospital mortality rate was 5.9%, and there was a significant decrease over the study period (p = 0.01). Although the 30-day mortality rate was 6.9% and remained steady (p = 0.14), the 1-year mortality rate was 22.8% and decreased significantly (p <0.001). At 5 years, the overall survival rate was 35%, and patients with internal mammary artery grafts showed better survival than those without (36% vs 25%). In conclusion, there has been a decrease in CABG procedures performed in patients with ESKD with stable CAD with decreasing in-hospital and 1-year mortality. Those with an internal mammary artery graft do better, but the overall long-term survival remains dismal in this population. There remains need for caution and individualization of revascularization decisions in this high-risk population.

Center-Level Variation in Hospitalization Costs of Transcatheter Aortic Valve Replacement.

BACKGROUND: Using a nationally representative database, the present study evaluated the degree of center-level variation in the cost of transcatheter aortic valve replacement (TAVR). METHODS: All adults undergoing elective, isolated TAVR were identified in the 2016 to 2018 Nationwide Readmissions Database. Multilevel mixed-effects models were used to identify patient and hospital characteristics associated with hospitalization costs. The random intercept for each hospital was generated and considered to be the baseline cost attributable to care at each center. Hospitals in the highest decile of baseline costs were classified as high-cost hospitals. The association of high-cost hospital status with in-hospital mortality and perioperative complications was subsequently assessed. RESULTS: An estimated 119,492 patients, with a mean age of 80 years and a 45.9% prevalence of female sex, met the study criteria. Analysis of random intercepts indicated that 54.3% of variability in costs was attributable to interhospital differences rather than patient factors. Perioperative respiratory failure, neurologic complications, and acute kidney injury were associated with increased episodic expenditure but did not explain the observed center-level variation. The baseline cost associated with each hospital ranged from -$26,000 to $162,000. Notably, high-cost hospital status was not linked to annual TAVR caseload or to odds of mortality (P = .83), acute kidney injury (P = .18), respiratory failure (P = .32), or neurologic complications (P = .55). CONCLUSIONS: The present analysis identified significant variation in the cost of TAVR, which was largely attributable to center-level rather than patient factors. Hospital TAVR volume and occurrence of complications were not drivers of the observed variation.

Long-term outcomes for hybrid aortic arch repair.

OBJECTIVE: Since its inception in the early 2000s, hybrid arch repair (HAR) has evolved from novel approach to well-established treatment modality for aortic arch pathology in appropriately selected patients. Despite this nearly 20-year history of use, long-term results of HAR remain to be determined. As such, objectives of this study are to detail the long-term outcomes for HAR within an expanded classification scheme. METHODS: From August 2005 to August 2022, 163 consecutive patients underwent HAR at a single referral institution. Operative approach was selected according to an institutional algorithm and included zone 0/1 HAR in 25% (n = 40), type I HAR in 34% (n = 56), and type II/III HAR in 41% (n = 67). Specific zone 0/1 technique was zone 1 HAR in 31 (78%), zone 0 with innominate snorkel (zone 0S HAR) in 7 (18%), and zone 0 with single side-branch endograft (zone 0B HAR) in 2 (5%). The 30-day and long-term outcomes, including overall and aortic-specific survival, as well as freedom from reintervention, were assessed. RESULTS: The mean age was 63 ± 13 years and almost one-half of patients (47% [n = 77]) had prior sternotomy. Presenting pathology included degenerative aneurysm in 44% (n = 71), residual dissection after prior type A repair in 38% (n = 62), chronic type B dissection in 12% (n = 20), and other indications in 6% (n = 10). Operative outcomes included 9% mortality (n = 14) at 30 days, 5% mortality (n = 8) in hospital, 4% stroke (n = 7), 2% new dialysis (n = 3), and 2% permanent paraparesis/plegia (n = 3). The median follow-up was 44 month (interquartile range, 12-84 months). Overall survival was 59% and 47% at 5 and 10 years, respectively, whereas aorta-specific survival was 86% and 84% at the same time points. At 5 and 10 years, freedom from major reintervention was 92% and 91%, respectively. Institutional experience had a significant impact on both early and late outcomes: comparing the first (2005-2012) and second (2013-2022) halves of the series, 30-day mortality decreased from 14% to 1% (P = .01) and stroke from 6% to 3% (P = .62). Improved operative outcomes were accompanied by improved late survival, with 78% of patients in the later era vs 45% in the earlier era surviving to 5 years. CONCLUSIONS: HAR is associated with excellent operative outcomes, as well as sustained protection from adverse aortic events as evidenced by high long-term aorta-specific survival and freedom from reintervention. However, surgeon and institutional experience appear to play a major role in achieving these superior outcomes, with a five-fold decrease in operative mortality and a two-fold decrease in stroke rate in the latter half of the series. These long-term results expand on prior midterm data and continue to support use of HAR for properly selected patients with arch disease.

Mid-term outcomes of aortic valve repair using an anatomically shaped internal annuloplasty ring.

OBJECTIVES: The Hemispherical Aortic Annuloplasty Reconstructive Technology (HAART) ring is a rigid, internal and geometric device. The objective of this article is to assess the mid-term outcomes of aortic valve repair (AVr) using this prosthesis. METHODS: A prospectively maintained database was used to obtain outcomes for adult patients undergoing AVr using the HAART ring between September 2017 and June 2023. All aortic patients at our institution undergo life-long surveillance with regular assessment and valve imaging. RESULTS: Seventy-one patients underwent AVr using the HAART device: 53 had a trileaflet valve and 18 a bicuspid valve. The median age was 54 years, and most were male (79%). Many required concomitant intervention: 46% had a root procedure and 77% an arch repair. There were no in-hospital deaths, and the median postoperative stay was 5 days. At a mean follow-up of 3.9 (±1.1) years, freedom from reoperation was 94%. Late imaging demonstrated: zero trace (25%), 1+ (54%), 2+ (15%) and 4+ (6%) aortic insufficiency (AI). Eleven patients have ≥moderate AI under surveillance, all of whom have a trileaflet valve (21% of trileaflet patients). Four patients required reoperation: 3 for ring dehiscence and 1 for endocarditis. CONCLUSIONS: Although early results using the HAART device are encouraging, mid-term results raise concern as 21% of trileaflet patients developed recurrent ≥moderate AI by 4 years post-repair. We experienced 3 incidences of ring dehiscence requiring reoperation. Based on this, we recommend caution using the sub-annular approach for stabilization in patients with trileaflet aortic valves. Long-term results are needed to assess outcomes against established techniques.

Effectiveness and diurnal variations of vegetative environmental buffers (VEBs) for mitigating NH3 and PM emissions from poultry houses.

Air pollutants from poultry production, such as ammonia (NH3) and particulate matter (PM), have raised concerns due to their potential negative impacts on human health and the environment. Vegetative environmental buffers (VEBs), consisting of trees and/or grasses planted around poultry houses, have been investigated as a mitigation strategy for these emissions. Although previous research demonstrated that VEBs can reduce NH3 and PM emissions, these studies used a limited number of samplers and did not examine concentration profiles. Moreover, the differences between daytime and nighttime emissions have not been investigated. In this study, we characterized emission profiles from a commercial poultry house using an array with multiple sampling heights and explored the differences between daytime and nighttime NH3 and PM profiles. We conducted three sampling campaigns, each with ten sampling events (five daytime and five nighttime), at a VEB-equipped poultry production facility. NH3 and PM samples were collected downwind from the ventilation tunnel fans before, within, and after the VEB. Results showed that ground-level concentrations beyond the VEB decreased to 8.0% ± 2.7% for NH3, 13% ± 4% for TSP, 13% ± 4% for PM10, and 2.4% ± 2.8% for PM2.5 of the original concentrations from the exhaust tunnel fan, with greater reduction efficiency during daytime than nighttime. Furthermore, pollutant concentrations were positively intercorrelated. These findings will be valuable for developing more effective pollutant remediation strategies in poultry house emissions.

Influence of center surgical aortic valve volume on outcomes of transcatheter aortic valve replacement.

Objective: The utilization of transcatheter aortic valve replacement (TAVR) technology has exceeded that of traditional surgical aortic valve replacement (SAVR). In addition, the role of minimum surgical volume requirements for TAVR centers has recently been disputed. The present work evaluated the association of annual institutional SAVR caseload on outcomes following TAVR. Methods: The 2012-2018 Nationwide Readmissions Database was queried for elective TAVR hospitalizations. The study cohort was split into early (Era 1: 2012-2015) and late (Era 2: 2016-2018) groups. Based on restricted cubic spline modeling of annual hospital SAVR caseload, institutions were dichotomized into low-volume and high-volume centers. Multivariable regressions were used to determine the influence of high-volume status on in-hospital mortality and perioperative complications following TAVR. Results: An estimated 181,740 patients underwent TAVR from 2012 to 2018. Nationwide TAVR volume increased from 5893 in 2012 to 49,983 in 2018. After adjustment for relevant patient and hospital factors, high-volume status did not alter odds of TAVR mortality in Era 1 (adjusted odds ratio, 0.94; P = .52) but was associated decreased likelihood of mortality in Era 2 (adjusted odds ratio, 0.83; P = .047). High-volume status did not influence the risk of perioperative complications during Era 1. However, during Era 2, patients at high-volume centers had significantly lower odds of infectious complications, relative to low-volume hospitals (adjusted odds ratio, 0.78; P = .002). Conclusions: SAVR experience is associated with improved TAVR outcomes in a modern cohort. Our findings suggest the need for continued collaboration between cardiologists and surgeons to maximize patient safety.

Staged versus concomitant transcatheter aortic valve replacement and percutaneous coronary intervention: A national analysis.

Objective: Although patients with significant coronary artery disease and aortic stenosis have traditionally undergone open valve replacement and bypass grafting, percutaneous coronary intervention (PCI) and transcatheter aortic valve replacement (TAVR) are increasingly considered. Because of the lack of data regarding timing of PCI/TAVR, in the present study we evaluated associations of staged and concomitant PCI/TAVR on outcomes in a nationally representative cohort. Methods: Adults who underwent TAVR and PCI were identified using the 2016 to 2018 Nationwide Readmissions Database. If PCI/TAVR occurred on the same day, patients were considered Concomitant and otherwise considered Staged. Staged were further classified as Early-Staged if both occurred in the same hospitalization or Late-Staged if TAVR ensued PCI in a subsequent hospitalization. Multivariable regression models were developed to evaluate the association of TAVR timing on outcomes. The primary end point was in-hospital mortality whereas perioperative complications including acute kidney injury and hospitalization costs were secondarily considered. Results: Of an estimated 5843 patients, 843 (14.4%) were Concomitant and 745 (12.7%) and 4255 (72.8%) were Early-Staged and Late-Staged, respectively. Although age and TAVR access were similar, Concomitant had a lower proportion of chronic kidney disease and more commonly underwent single-vessel PCI. Staged showed similar risk-adjusted mortality but greater odds of acute kidney injury (Early-Staged adjusted odds ratio: 2.68; 95% CI, 1.57-4.55 and Late-Staged: 1.97; 95% CI, 1.29-2.99) compared with Concomitant. Although post-TAVR hospitalization duration was similar, total length of stay and costs were increased in Staged. Conclusions: Concomitant PCI/TAVR was associated with similar rates of in-hospital mortality but reduced rates of acute kidney injury and lower resource utilization. While evaluating patient-specific factors, concomitant PCI/TAVR might be reasonable in select individuals.

Hybrid repair of acute type B dissection with aberrant right subclavian artery and bicarotid trunk.

Patients with type B aortic dissection (TBAD) often present as an emergency. Operative repair of TBAD can be indicated for selected patients in the setting of hemodynamic instability or rupture. Thoracic endovascular aortic repair of TBAD has achieved significant popularity. Variant aortic arch anatomy can present a significant clinical challenge in patients with an inadequate proximal landing zone for thoracic endovascular aortic repair. A three-stage, hybrid aortic arch debranching and endovascular repair of a ruptured TBAD in a patient with a bicarotid trunk and an aberrant right subclavian artery was successfully performed using a unique technical approach.

Impact of Postoperative Infections on Readmission and Resource Use in Elective Cardiac Surgery.

BACKGROUND: Efforts to reduce postoperative infections have garnered national attention, leading to practice guidelines for cardiac surgical perioperative care. The present study characterized the impact of health care-acquired infection (HAI) on index hospitalization costs and postdischarge health care utilization. METHODS: Adults undergoing elective coronary artery bypass graft surgery (CABG) or valve operations were identified in the 2016 to 2018 Nationwide Readmissions Database. Infections were categorized into bloodstream, gastrointestinal, pulmonary, surgical site, or urinary tract infections. Generalized linear or flexible hazard models were used to assess associations between infections and outcomes. Observed-to-expected ratios were generated to examine interhospital variation in HAI. RESULTS: Of an estimated 444,165 patients, 8% had HAI. Patients with HAI were older, had a greater burden of chronic diseases, and more commonly underwent CABG/valve or multivalve operations (all P < .001). HAI was independently associated with mortality (odds ratio 4.02; 95% confidence interval [CI], 3.67 to 4.40), non-home discharge (odds ratio 3.48; 95% CI, 3.21 to 3.78), and a cost increase of $23,000 (95% CI, $20,900 to $25,200). At 90 days, HAI was associated with greater hazard of readmission (1.29; 95% CI, 1.24 to 1.35). Pulmonary infections had the greatest incremental impact on patient-level costs ($24,500; 95% CI, $23,100 to $26,000) and annual cohort costs ($121.8 million; 95% CI, $102.2 to $142.9 million). Significant hospital level variation in HAI was evident, with observed-to-expected ratios ranging from 0.17 to 4.30 for cases performed in 2018. CONCLUSIONS: Infections after cardiac surgery remain common and are associated with inferior outcomes and increased resource use. Interhospital variation in this contemporary cohort emphasizes the ongoing need for systematic approaches in their prevention and management.

Timing of Coronary Artery Bypass Grafting in Acute Coronary Syndrome: A National Analysis.

BACKGROUND: Timing of surgical revascularization for acute coronary syndrome remains debated. We assessed the impact of timing to coronary artery bypass grafting (CABG) on mortality and resource utilization in a national cohort. METHODS: Adults admitted for acute coronary syndrome in the 2009-2018 National Inpatient Sample were grouped by time from coronary angiography to CABG (Δt): 0, 1-3, 4-7, and >7 days. Generalized linear models were fit to evaluate associations between Δt and in-hospital mortality and hospitalization costs. Timing and mortality of CABG for acute coronary syndrome were compared between high-performing hospitals (below the median risk adjusted mortality for all CABG and valve operations) and others. RESULTS: Of 444,065 patients, Δt = 0 days in 12.3%, Δt = 1-3 days in 57.3%, Δt = 4-7 days in 26.3%, and Δt > 7 days in 4.2%. Risk-adjusted mortality was greatest at Δt = 0 days (4.5%, 95% confidence interval [CI], 4.1%-4.9%) and Δt > 7 days (4.0%, 95% CI 3.4%-4.7%), but similar for operations performed at Δt = 1-3 days (1.8%, 95% CI 1.7%-1.9%) and Δt = 4-7 days (2.1%, 95% CI 1.9%-2.3%). Compared to Δt = 1-3 days, hospitalization costs were greater by $6,400 (95% CI $5,900-$6,900) for Δt = 4-7 days and $21,200 (95% CI $19,800-$22,600) for Δt > 7 days. High-performing hospitals had similar time to CABG as others (2 vs 2 days, P = .17), but lower mortality (0.9% vs 3.3%, P < .001). CONCLUSIONS: Revascularization on days 1-3 and 4-7 led to comparable in-hospital mortality, with greater rates on day 0 and after day 7. Costs were greater for revascularization at days 4-7 compared with days 1-3. These findings support the reduction of time to revascularization to 1-3 days when deemed clinically appropriate and feasible.

Surgical explantation of a failed transcatheter aortic valve.

With transcatheter aortic valve replacement being increasingly utilized in a younger and lower risk population, we can expect to see larger numbers of patients presenting with structural deterioration of aortic valves replaced by the transcatheter route that now require explantation and surgical replacement.   Surgical aortic valve replacement after transcatheter aortic valve replacement is associated with operative morbidity and mortality rates significantly higher than those seen in the setting of surgical replacement of the native valve, which had a 30-day mortality of 12-20% in recent series. Centers performing transcatheter aortic valve replacement in lower risk patients with longer expected lifespans and a higher probability of late structural deterioration of the transcatheter aortic valve replacement should carefully consider their choice of valve type (balloon-expandable versus self-expanding) and patient anatomy, including annulus and root diameter, at the time of the initial valve intervention. Further, one should not forget the mechanical surgical aortic valve replacement option in younger patients with risk factors for early structural valve deterioration such as obesity, metabolic syndrome, and chronic kidney disease. The objectives of this tutorial are to describe the preoperative workup for a patient with late structural valve deterioration after transcatheter aortic valve replacement, detail the explantation approach specific to self-expanding valves, and illustrate the key decisions and techniques needed for subsequent surgical aortic valve replacement.

Continuous Lighting Promotes Plant Growth, Light Conversion Efficiency, and Nutritional Quality of Eruca vesicaria (L.) Cav. in Controlled Environment With Minor Effects Due to Light Quality.

Light-emitting diode lamps can allow for the optimization of lighting conditions in artificial growing environments, with respect to light quality, quantity, and photoperiod extension, to precisely manage resources and crop performance. Eruca vesicaria (L.) Cav. was hydroponically cultured under three light treatments to investigate the effect on yield and nutritional properties of rocket plants. A treatment of (W-12h) having a12/12 h light/dark at 600 µmol m-2 s-1 provided by LEDs W:FR:R:B = 12:2:71:15 was compared with two treatments of continuous lighting (CL), 24 h light at 300 µmol m-2 s-1 provided by cool white LEDs (W-CL), and by LED R:B = 73:27 (RB-CL). CL enhanced the growth of the rocket plants: total fresh biomass, leaf fresh weight, and shoot/root ratio increased in W-CL, and leaf dry weight, leaf dry matter %, root fresh and dry weight, and specific leaf dry weight (SLDW) increased in RB-CL. Total carbon content was higher in RB-CL, whereas total nitrogen and proteins content increased in W-12h. Both W-CL and RB-CL increased carbohydrate content in the rocket leaves, while W-CL alone increased the sugar content in the roots. Fibers, pigments, antioxidant compounds, and malic acid were increased by CL regardless of the light spectrum applied. Nitrate was significantly reduced in the rocket leaves grown both in W-CL and RB-CL. Thus, the application of CL with low light intensity can increase the yield and quality value of rocket, highlighting that careful scheduling of light spectrum, intensity, and photoperiod can improve the performance of the crop.

Supercritical-CO2 extraction, identification and quantification of polyprenol as a bioactive ingredient from Irish trees species.

This study ascertained the accumulation of polyprenol from four Irish conifer species Picea sitchensis, Cedrus atlantica 'Glauca', Pinus sylvestris and Taxus baccata and one flowering tree Cotoneaster hybrida using supercritical fluid extraction with carbon dioxide (SFE-CO2) and solvent extraction. The effects of SFE-CO2 parameters such as temperature (ranged from 40 to 70 [Formula: see text]), pressure (ranged from 100 to 350 bars) and dynamic time (from 70 min to 7 h) were analysed on the extraction efficiency of polyprenol. Qualitative and quantitative analysis of polyprenol was examined using high-performance liquid chromatography. Results showed that P. sylvestris accumulated the highest polyprenol yield of 14.00  ± [Formula: see text]mg g-1 DW when extracted with hexane:acetone (1:1 v/v). However, with SFE-CO2 conditions of 200 bars, 70 [Formula: see text], 7 h, with absolute ethanol as a cosolvent with a flow rate of 0.05 ml min-1, P. sitchensis accumulated the highest polyprenol yield of 6.35 ± [Formula: see text] mg g-1DW. This study emphasised the potential application of SFE-CO2 in the extraction of polyprenol as an environmentally friendly method to be used in pharmaceutical and food industries.

Trends in utilization, mortality, and resource use after implantation of left ventricular assist devices in the United States.

OBJECTIVES: Adoption of implantable left ventricular assist devices has dramatically improved survival and quality of life in suitable patients with end-stage heart failure. In the era of value-based healthcare delivery, assessment of clinical outcomes and resource use associated with left ventricular assist devices is warranted. METHODS: Adult patients undergoing left ventricular assist device implantation from 2008 to 2016 were identified using the National Inpatient Sample. Hospitals were designated as low-volume, medium-volume, or high-volume institutions based on annual institutional left ventricular assist device case volume. Multivariable logistic regression was used to evaluate adjusted odds of mortality across left ventricular assist device volume tertiles. RESULTS: Over the study period, an estimated 23,972 patients underwent left ventricular assist device implantation with an approximately 3-fold increase in the number of annual left ventricular assist device implantations performed (P for trend <.001). In-hospital mortality in patients with left ventricular assist devices decreased from 19.6% in 2008 to 8.1% in 2016 (P for trend <.001) and was higher at low-volume institutions compared with high-volume institutions (12.0% vs 9.2%, P < .001). Although the overall adjusted mortality was higher at low-volume compared with high-volume institutions (adjusted odds ratio, 1.66; 95% confidence interval, 1.28-2.15), this discrepancy was only significant for 2008 and 2009 (low-volume 2008 adjusted odds ratio, 5.5; 95% confidence interval, 1.9-15.8; low-volume 2009 adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.8). CONCLUSIONS: Left ventricular assist device use has rapidly increased in the United States with a concomitant reduction in mortality and morbidity. With maturation of left ventricular assist device technology and increasing experience, volume-related variation in mortality and resource use has diminished. Whether the apparent uniformity in outcomes is related to patient selection or hospital quality deserves further investigation.

Method to Evaluate the Age of Groundwater Inputs to Surface Waters by Determining the Chirality Change of Metolachlor Ethanesulfonic Acid (MESA) Captured on a Polar Organic Chemical Integrative Sampler (POCIS).

We previously discovered a method to estimate the groundwater mean residence time using the changes in the enantiomeric ratio of metolachlor ethanesulfonic acid (MESA), (2-[(2-ethyl-6-methylphenyl)(2-methoxy-1-methylethyl)amino]-2-oxoethanesulfonic acid), a metabolite of the herbicide metolachlor. However, many grab samples would be needed for each watershed over an extended period, and this is not practical. Thus, we examined the use of a polar organic chemical integrative sampler (POCIS) deployed for 28 days combined with a modified liquid chromatography-mass spectrometry LC-MS/MS method to provide a time-weighted average of the MESA enantiomeric ratio. POCISs equipped with hydrophilic-lipophilic-balanced (HLB) discs were deployed at five sites across the United States where metolachlor was used before and after 1999 and compared the effectiveness of the POCIS to capture MESA versus grab samples. In addition, an in situ POCIS sampling rate (Rs) for MESA was calculated (0.15 L/day), the precision of MESA extraction from stored POCIS discs was determined, and the effectiveness of HLB to extract MESA was examined. Finally, using molecular modeling, the influence of the asymmetric carbon of metolachlor degradation on the MESA enantiomeric ratio was predicted to be negligible. Results of this work will be used in projects to discern the groundwater mean residence times, to evaluate the delivery of nitrate-N from groundwater to surface waters under various soil, agronomic, and land use conditions, and to examine the effectiveness of conservation practices.

National Study of Index and Readmission Mortality and Costs for Thoracic Endovascular Aortic Repair in Patients With Renal Disease.

BACKGROUND: In the current era of value-based health care delivery, an understanding of patient populations at greatest risk for mortality, complications, and readmissions after thoracic endovascular aortic repair (TEVAR) is warranted. Thus, the present study aimed to evaluate outcomes after TEVAR for patients with varying degrees of renal dysfunction. METHODS: All patients who underwent TEVAR from 2010 to 2015 in the Nationwide Readmissions Database were identified. These patients were further stratified into four groups: no chronic kidney disease (NCKD), chronic kidney disease (CKD) stages 1 to 3 (CKD1-3), CKD 4 to 5 (CKD4-5), and end-stage renal disease (ESRD) requiring dialysis. Multivariable regression analysis was used to study index mortality, early (30 days) and intermediate (31-90 days) readmissions, costs, and length of stay. Kaplan-Meier analyses were performed to compare readmission performance among all four groups. RESULTS: An estimated 121,046 patients underwent TEVAR with 26,653 (22.1%) being elective. Patients with ESRD comprised 2.7% of elective and 5.4% of nonelective TEVAR operations. Patients with CKD4-5 (17.8%; P = .01) and with ESRD (21.1%; P < .001), but not with CKD1-3 (14.1%; P = .12), had remarkably higher early readmission rate than the NCKD cohort (9.2%). Patients with ESRD had remarkably higher hospitalization costs than the NCKD group ($7456; 95% confidence interval, $2629-$12,283). Cardiovascular, infectious, and vascular complications were the most prevalent diagnoses on readmission, with no remarkable difference among the NCKD and CKD4-5/ESRD groups. CONCLUSIONS: Nearly 10% of all patients with TEVAR have evidence of chronic kidney disease of varying severity. Only patients with ESRD are at risk of substantially higher odds of mortality, readmissions, index length of stay, and costs compared with the non-CKD cohort.