Incremental cost-effectiveness of extracorporeal membranous oxygenation as a bridge to cardiac transplant or left ventricular assist device placement in patients with refractory cardiogenic shock.

Objective: Emerging literature has described using venoarterial extracorporeal membranous oxygenation (ECMO) as a bridge to transplant or left ventricular assist device (LVAD) placement. We sought to identify the incremental cost-effectiveness ratio (ICER) of ECMO used as a bridge to cardiac transplant or LVAD. Methods: Patients with refractory cardiogenic shock who received venoarterial ECMO and were bridged to either cardiac transplant (n = 7) or a HeartMate 3 LVAD (n = 6) placement were included. Markov modeling was used, comparing ECMO bridging with non-ECMO-bridged patients. Cohorts entered the model alive and at every 1-year cycle, were exposed to risk of death, and ran forward for 20 years after transplant or LVAD. Results: Patients bridged with ECMO to cardiac transplant were stratified as group 1 whereas those bridged with ECMO to LVAD were stratified as group 2. The average ECMO run was 3 days in group 1 versus 11 days in group 2. Among group 1 patients, the ICER was $246,629 but was paired with a longer life expectancy. The ICER of group 2 patients was -$107,088 and was not paired with a longer life expectancy. The average inpatient cost for group 1 was found to be $636,023 versus $769,471 for group 2 patients. The average inpatient costs for patients not bridged to ECMO who received cardiac transplant or LVAD was $538,928 and $325,242, respectively. Conclusions: Using ECMO to bridge to transplant or LVAD placement is not cost effective. However, patients bridged to transplant are paired with longer life expectancy in contrast to patients bridged to LVAD.

Post-traumatic Splenic Injury Outcomes for Nonoperative and Operative Management: A Systematic Review.

BACKGROUND: Splenectomies are widely performed, but there exists controversy regarding care for splenic injury patients. The purpose of this study is to provide a comprehensive review of the literature over the last 20 years for operative management (OM) versus nonoperative management (NOM) versus splenic artery embolization (SAE) for traumatic splenic injuries and associated outcomes. METHODS: A review of literature was performed following the PRISMA guidelines through a search of PubMed, EMBASE, Cochrane Library, JAMA Network, and SAGE journals from 2000 to 2020 regarding splenic injury in trauma patients and their management. Articles were then selected based on inclusion/exclusion criteria with GRADE criteria used on the included articles to assess quality. RESULTS: Twenty retrospective cohorts and one prospective cohort assessed patients who received OM versus NOM or SAE. Multiple studies indicated that NOM, in properly selected patients, provided better outcomes than its operative counterpart. CONCLUSION: This review provides additional evidence to support the NOM of splenic injuries for hemodynamically stable patients with benign abdomens as it accounts for consistently shorter hospital length of stay, fewer complications, and lower mortality than OM. For hemodynamically unstable patients, management continues to be intervention with surgery. More studies are needed to further investigate outcomes of post-splenectomy patients based on grade of injury, hemodynamic status, type of procedure (i.e., SAE), and failure of NOM in order to provide additional evidence and improve outcomes for this patient population.

Advancing the use of Lactobacillus acidophilus surface layer protein A for the treatment of intestinal disorders in humans.

Intestinal immunity is subject to complex and fine-tuned regulation dictated by interactions of the resident microbial community and their gene products with host innate cells. Deterioration of this delicate process may result in devastating autoinflammatory diseases, including inflammatory bowel disease (IBD), which primarily comprises Crohn's disease (CD) and ulcerative colitis (UC). Efficacious interventions to regulate proinflammatory signals, which play critical roles in IBD, require further scientific investigation. We recently demonstrated that rebalancing intestinal immunity via the surface layer protein A (SlpA) from Lactobacillus acidophilus NCFM potentially represents a feasible therapeutic approach to restore intestinal homeostasis. To expand on these findings, we established a new method of purifying bacterial SlpA, a new SlpA-specific monoclonal antibody, and found no SlpA-associated toxicity in mice. Thus, these data may assist in our efforts to determine the immune regulatory efficacy of SlpA in humans.