Racial and ethnic disparities in the treatment and outcomes for witnessed out-of-hospital cardiac arrest in Connecticut.

BACKGROUND: Racial and ethnic disparities in the treatment and outcomes for witnessed out-of-hospital cardiac arrest (OHCA) in the United States have been previously described. We sought to characterize disparities in pre-hospital care, overall survival, and survival with favorable neurological outcomes following witnessed OHCA in the state of Connecticut. METHODS: We performed a cross-sectional study to compare pre-hospital treatment and outcomes for White versus Black and Hispanic (Minority) OHCA patients submitted from Connecticut to the Cardiac Arrest Registry to Enhance Survival (CARES) between 2013 and 2021. Primary outcomes included bystander CPR use, bystander automated external defibrillator (AED) use with attempted defibrillation, overall survival, and survival with favorable cerebral function. RESULTS: 2,809 patients with witnessed OHCA were analyzed (924 Black or Hispanic; 1885 White). Minorities had lower rates of bystander CPR (31.4% vs 39.1%, P = 0.002) and bystander AED placement with attempted defibrillation (10.5% vs 14.4%, P = 0.004), with lower rates of survival to hospital discharge (10.3% vs 14.8%, P = 0.001) and survival with favorable cerebral function (65.3% vs 80.2%, P = 0.003). Minorities were less likely to receive bystander CPR in communities with median annual household income >$80, 000 (OR, 0.56; 95% CI, 0.33-0.95; P = 0.030) and in integrated neighborhoods (OR, 0.70; 95% CI, 0.52-0.95; P = 0.020). CONCLUSIONS: Black and Hispanic Connecticut patients with witnessed OHCA have lower rates of bystander CPR, attempted AED defibrillation, overall survival, and survival with favorable neurological outcomes compared to White patients. Minorities were less likely to receive bystander CPR in affluent and integrated communities.

Racial and Ethnic Disparities in the Use of Transcatheter Aortic Valve Replacement in the State of Connecticut.

BACKGROUND: Although prior national reports have identified trends in the underutilization of transcatheter aortic valve replacement (TAVR) in Afro-American and Latino populations, racial and ethnic healthcare disparities in TAVR use in the State of Connecticut have not been previously reported. METHODS: We conducted a retrospective analysis of 1461 patients undergoing TAVR at our institute between from 2012 to 2020. Baseline demographics, procedural characteristics, clinical outcomes, median incomes and insurance coverage were compared between 1417 Caucasian and 44 minority patients, including 23 patients designated as Afro-American and 10 designated as Latino. Demographics of TAVR utilization at our institution were further compared to 6 additional Connecticut TAVR centers using Connecticut Hospital Association (CHA) ChimeData detailing hospital discharges for DRG 266 and 267. RESULTS: In comparison to Caucasian patients, minority cohorts were younger (75.7 ± 9.0 vs 81.5 ± 5.1 years, p < 0.001) and had more co-morbidities including diabetes (64% vs 34%, p < 001), coronary artery disease (95% vs 78%, p = 0.039), end stage renal disease requiring dialysis (9% vs 3%, p = 0.009) and atrial fibrillation (77% vs 62%, p = 0.041). The two groups did not differ with respect to other risk factors or co-morbidities, baseline echocardiographic or CTA findings, STS risk score, or procedural technique. Minority patients had a longer length of hospital stay (9.5 ± 9.0 vs 6.4 ± 6.9 days, p = 0.003), but did not differ with respect to procedural complications. Socioeconomic differences between the two groups included lower median incomes and higher rates of Medicaid or no insurance coverage for minority versus Caucasian patients. CHA ChimeData revealed a similar underutilization of TAVR in minority subgroups in the remaining 6 Connecticut TAVR centers. CONCLUSIONS: Despite statewide demographics describing 10.7% and 15.7% of the total population as Afro-American and Latino, respectively, only 3.0% of the total TAVR procedures performed at a large Connecticut health care facility were performed in minority subgroups. Despite having a higher burden of co-morbidities, minority patients had similar outcomes compared to Caucasian patients. Similar racial and ethnic disparities in TAVR utilization were confirmed statewide using CHA ChimeData.

An overview of a successful COVID-19 vaccination campaign at a prominent Connecticut healthcare system.

The coronavirus disease 2019 (COVID-19) pandemic has required healthcare systems to adapt, innovate, and collaborate to protect public health through treatment, testing, and vaccination initiatives related to the virus. As the pandemic evolved, lessons learned early on through testing and treatment were applied to vaccination efforts. Hartford HealthCare (HHC) is one of the largest healthcare systems in New England and took an integral role in vaccinating patients throughout the region, thus providing one of the largest vaccination campaigns in Connecticut. Early planning for equipment and personnel, in addition to effective communication between providers and patients, was critical in accomplishing HHC's goal of rapidly providing access to COVID-19 vaccines. The efficient and effective response to the pandemic at HHC was led by the Office of Emergency Management, which worked to ensure continuity of patient care and physician excellence in the face of disaster. Initially, resources were directed to testing and treatment of the disease; as vaccine clinical trials announced successful outcomes, these efforts shifted to preparing for the storage and distribution of a mass number of vaccines. This manuscript details the factors that enabled success in HHC's vaccination campaign and serves to provide a useful template for similar healthcare systems for future pandemic response.

A Connecticut healthcare system's response to the COVID-19 pandemic.

Connecticut was impacted severely and early on by the COVID-19 pandemic due to the state's proximity to New York City. Hartford Healthcare (HHC), one of the largest healthcare systems in New England, became integral in the state's response with a robust emergency management system already in place. In this manuscript, we review HHC's prepandemic emergency operations as well as the response of the system-wide Office of Emergency Management to the initial news of the virus and throughout the evolving pandemic. Additionally, we discuss the unique acquisition of vital critical care resources and personal protective equipment, as well as the hospital personnel distribution in response to the shifting demands of the virus. The public testing and vaccination efforts, with early consideration for at risk populations, are described as well as ethical considerations of scarce resources. To date, the vaccination effort resulted in over 70 percent of the adult population being vaccinated and with 10 percent of the population having been infected, herd immunity is eminent. Finally, the preparation for reestablishing elective procedures while experiencing a second wave of the pandemic is discussed. These descriptions may be useful for other healthcare systems in both preparation and response for future catastrophic emergencies of all types.

Getting back to work: A framework and pivot plan to resume elective surgery and procedures after COVID-19.

INTRODUCTION: The COVID-19 pandemic has compelled a majority of hospital systems to reduce surgical and procedural volumes in an attempt to preserve resources. Elective surgery and procedures resumption has proven to be a calculated risk between COVID-19 exposure and resource depletion and patient morbidity and mortality from surgical deferral. METHODS: Within a few days of halting elective surgery and procedures, our 7-hospital (2427 in-patient beds, 26,647 inpatient surgeries) healthcare system developed a multidisciplinary Pivot Plan with the primary outcome of a phased resumption of elective surgery and procedures. The plan entailed the integration of our electronic medical record, order entry automatization, perioperative staff utilization, partnering with primary care providers, and a stepwise COVID-19 testing algorithm based on a predetermined hierarchy of case acuity and timeliness of patient care. RESULTS: The Pivot Plan was instituted on May 10, 2020. Since then, 22,624 patients have been tested for COVID-19 in anticipation of an elective surgery and procedures; 140 (0.62%) tested positive for COVID-19 and had their procedure deferred. As our testing capability has increased, we have been able to increase our added elective surgery and procedures capacity from 13 cases per day to 531 cases per day. In turn, we have seen the case volume increase by 52%. CONCLUSION: Our academic healthcare system located in one of the initial COVID-19 hotspots in the United States has successfully resumed elective surgery and procedures in part due to a receptive and supportive culture based upon nimbleness, agility, and rapid integration of multiple resources from a cohort of diverse disciplines applied to the perioperative services workflow.

Bile acids for non-alcoholic fatty liver disease and/or steatohepatitis.

The review is withdrawn on 09.07.2020, as it has not been updated since its first publication in 2007.

Public reporting and transparency: a primer on public outcomes reporting.

INTRODUCTION: Healthcare consumers seeking accurate information about where to find quality surgical care face a confusing constellation of rating systems that lack transparency or consistency of opinion. For example, a 2016 report in Health Affairs demonstrated that no hospital was rated as a high performer by all four prominent national ratings systems: Consumer Reports, Leapfrog, Healthgrades and U.S. News & World Report (Austin et al. Health Aff 34:423-430, 2015). Surgeons should have an understanding of the current state of public reporting of quality; hospital ratings and data sources; physician ratings and data sources; and transparency of reporting. METHODS: We conducted a non-systematic review of the literature. RESULTS: Hospital quality ratings remain nebulous and there is not universal opinion on the utility of voluntary participation in ranking systems, leaving the current systems largely opinion-based. Early attempts at physician ranking systems are rudimentary at best and suffer from methodological concerns. Publicly reported metrics should be easily understandable, accessible, clinically relevant, reliable, non-punitive, and shielded from legal discovery. Transparency is increasing within institutions to help align staff to institutional objectives, while specialty specific registries are helping to standardize care pathways and outcomes measures across organizations. Measuring surgical outcomes beyond 30-day morbidity and mortality has been plagued by a lack of understanding on how to create metrics that matter; the four attributes of relevance, scientific soundness, feasibility and comprehensiveness set a high bar for the development of effective and efficient quality measures in surgery. DISCUSSION: SAGES, via the Quality, Outcomes, and Safety Committee, is committed to learning how to develop meaningful quality metrics in general surgery and will continue to work in other areas that impact quality, such as opioid prescribing, and surgeon wellness.

SAGES quality initiative: an introduction.

The Medicare program has transitioned to paying healthcare providers based on the quality of care delivered, not on the quantity. In May 2015, SAGES held its first ever Quality Summit. The goal of this meeting was to provide us with the information necessary to put together a strategic plan for our Society over the next 3-5 years, and to participate actively on a national level to help develop valid measures of quality of surgery. The transition to value-based medicine requires that providers are now measured and reimbursed based on the quality of services they provide rather than the quantity of patients in their care. As of 2014, quality measures must cover 3 of the 6 available National Quality domains. Physician quality reporting system measures are created via a vigorous process which is initiated by the proposal of the quality measure and subsequent validation. Commercial, non-profit, and governmental agencies have now been engaged in the measurement of hospital performance through structural measures, process measures, and increasingly with outcomes measures. This more recent focus on outcomes measures have been linked to hospital payments through the Value-Based Purchasing program. Outcomes measures of quality drive CMS' new program, MACRA, using two formats: Merit-based incentive programs and alternative payment models. But, the quality of information now available is highly variable and difficult for the average consumer to use. Quality metrics serve to guide efforts to improve performance and for consumer education. Professional organizations such as SAGES play a central role in defining the agenda for improving quality, outcomes, and safety. The mission of SAGES is to improve the quality of patient care through education, research, innovation, and leadership, principally in gastrointestinal and endoscopic surgery.

Severe liver cirrhosis markedly reduces AhR-mediated induction of cytochrome P450 in rats by decreasing the transcription of target genes.

Although the induction of cytochrome P450 (CYP) has long been investigated in patients with cirrhosis, the question whether liver dysfunction impairs the response to CYP inducers still remains unresolved. Moreover, the mechanism underlying the possible effect of cirrhosis on induction has not been investigated. Since ethical constraints do not permit methodologically rigorous studies in humans, this question was addressed by investigating the effect of the prototypical inducer benzo[a]pyrene (BP) on CYP1A1 and CYP1A2 in cirrhotic rats stratified according to the severity of liver dysfunction. We simultaneously assessed mRNA level, protein expression and enzymatic activity of the CYP1A enzymes, as well as mRNA and protein expressions of the aryl hydrocarbon receptor (AhR), which mediates the BP effect. Basal mRNA and protein expressions of CYP1A1 were virtually absent in both healthy and cirrhotic rats. On the contrary, CYP1A2 mRNA, protein and enzyme activity were constitutively present in healthy rats and decreased significantly as liver function worsened. BP treatment markedly increased the concentrations of mRNA and immunodetectable protein, and the enzymatic activities of both CYP1A enzymes to similar levels in healthy and non-ascitic cirrhotic rats. Induced mRNA levels, protein expressions and enzymatic activities of both CYPs were much lower in ascitic rats and were proportionally reduced. Both constitutive and induced protein expressions of AhR were significantly lower in ascitic than in healthy rats. These results indicate that the inducibility of CYP1A enzymes is well preserved in compensated cirrhosis, whereas it is markedly reduced when liver dysfunction becomes severe. Induction appears to be impaired at the transcriptional level, due to the reduced expression of AhR, which controls the transcription of CYP1A genes.

Physician leadership: a health-care system's investment in the future of quality care.

The current state of health care and its reform will require physician leaders to take on greater management responsibilities, which will require a set of organizational and leadership competencies that traditional medical education does not provide. Physician leaders can form a bridge between the clinical and administrative sides of a health-care organization, serving to further the organization's strategy for growth and success. Recognizing that the health-care industry is rapidly changing and physician leaders will play a key role in that transformation, Hartford HealthCare has established a Physician Leadership Development Institute that provides advanced leadership skills and management education to select physicians practicing within the health-care system.

Relationship between bone formation markers bone alkaline phosphatase, osteocalcin and amino-terminal propeptide of type I collagen and bone mineral density in elderly men. Preliminary results.

Bone remodeling is altered in all metabolic bone diseases, especially in post-menopausal women and in the elderly. Predicting changes in bone mineral density (BMD) is useful to manage the progression of such diseases and to potentially provide interventions in reducing fracture risk. Continuous bone formation and resorption processes can be monitored by measuring biochemical markers of bone turnover (BTMs) and a relationship between BMD and BTMs has been known for long. The aim of this study was to evaluate the relationship between BMD and serum BTMs bone alkaline phosphatase (BAP), osteocalcin and amino-terminal propeptide of type I collegen (PINP) in elderly (>65 years) men. We prospectively studied 18 elderly men (median age=69, range=65-77 years) with no history of fractures, angina, stroke, myocardial infarction or diabetes mellitus. Patients who had undergone corticosteroid, calcitonin, androgen or bisphosphonate therapy were excluded from the study, as well as those who were vitamin D and calcium supplementation users. All the patients underwent lumbar-spine (L2-L4) dual-energy x-ray absorbtiometry and BMD, BAP, osteocalcin and PINP measurements. The mean BMD and body mass index (BMI) were 0.963±0.04 g/cm(2) and 24.4±1.2 kg/m(2), respectively. BAP, osteocalcin and PINP were 27.8±11.3 U/l, 25.6±7.1 ng/ml and 36.0±7.5 ng/ml, respectively. No correlation was found between BMD and BAP (R=-0.28, p=0.25), osteocalcin (R=-0.18, p=0.48) and PINP (R=-0.21, p=0.39), nor between BMI and both age (R=0.05, p=0.83) and BMD (R=0.10, p=0.67). In conclusion, we did not find any relationship between bone formation markers BAP, osteocalcin and PINP and bone density. Thus, our preliminary data suggest that BTMs are not useful in monitoring the bone mineral status of elderly men.

Expression of p53 and Ki-67 as prognostic factors for survival of men with colorectal cancer.

In patients with colorectal cancer (CRC) several independent prognostic factors are well-supported in the literature, including TNM stage, histological type and grade, and serum levels of carcinoembryonic antigen (CEA). All cancer cells express high levels of tissue proliferation markers, such as Ki-67 and p53, which are currently considered prognostic markers for patients with several types of cancers. We retrospectively studied 31 men (median age 65, range 48-75 years) with confirmed Dukes' B colorectal adenocarcinoma. The following parameters were recorded: age of the patients (years), baseline CEA serum levels (ng/ml), Ki-67 and p53 expression (%), and survival (months). The mean overall survival was 37.3 ± 13.7 months. The mean baseline CEA serum level was 79 ± 7.4 ng/ml, while the percentage positivity for Ki-67 and p53 in cancer tissues was 46.9 ± 19.2 and 48.7 ± 14.2, respectively. There was a significant correlation between Ki-67 and p53 expression (R=0.82, p<0.001) and an inverse relationship between survival and the expression of both Ki-67 (R=-0.67, p<0.001) and p53 (R=-0.64, p<0.001). No significant correlation was found between survival and age (R=0.22, p=0.22) or CEA (R=0.08, p=0.67). There was no relationship between CEA and age (R=0.34, p=0.06), Ki-67 (R=-0.021, p=0.90) or p53 (R=0.03, p=0.87). In conclusion, our preliminary results showed that both Ki-67 and p53 overexpression in CRC are associated with a worse outcome. In this selected group of patients, these prognostic markers were independent of age, and the preoperative CEA serum levels did not have any relationship with survival.

Simultaneous multianalyte immunoassay measurement of five serum tumor markers in the detection of colorectal cancer.

Several serum tumor markers (STMs) have been proposed for the diagnosis of colorectal cancer (CRC), but their detection should be combined to increase accuracy. The measurement of a serum biomarker panel may improve the diagnostic value of single STM and a multianalyte immunoassay approach can shorten assay time and lower sample consumption. The aim of this study was to determine whether the simultaneous multianalyte immunoassay is useful for early detection of CRC. We measured a panel of five STMs namely, carcinoembryonic antigen (CEA), cancer antigen (CA) 19-9 and 72-4, cytokeratin fragment (CYFRA) 21-1, and osteopontin, in a selected homogeneous population of 102 consecutive patients (median age 66 years, range 42-75 years) with Dukes B, G1-2, colorectal adenocarcinoma (cases) and in a group of 99 age- and sex-matched patients suffering from confirmed benign colorectal diseases (controls). Overall, 141 (70.1%) men and 60 (29.9%) women were studied. The highest sensitivity was 45.1% (osteopontin), while the highest specificity was 90.9% (CEA). The accuracy was lower, ranging from 24.9% (CA 19-9) to 67.2% (CEA). CYFRA 21-1 and CA 72-4 had similar sensitivity (35.3% and 31.4%, respectively), but a significantly different specificity (37.4% vs. 89.9%). A combination of the five markers achieved 74.1% sensitivity and 94.3% specificity. In conclusion, in patients with CRC all single STMs show low sensitivity and specificity, while the simultaneous measurement of a panel of STMs may increase the diagnostic accuracy. When the sample volume is limited, the multianalyte immunoassay can be a reliable tool for studying patients undergoing laboratory screening for CRC.

Splenomegaly as risk factor of liver cirrhosis. A retrospective cohort study of 2,525 patients who underwent laparoscopy.

The aim of this study was to evaluate the meaning of laparoscopic splenomegaly and its relationship with the severity and evolution of liver cirrhosis. Medical records of 2,525 consecutive patients with chronic liver diseases who underwent laparoscopy and video-guided hepatic biopsy were reviewed. There were 1,610 (63.8%) men and 915 (36.2%) women. All patients underwent gastroscopy to diagnose esophageal varices. The diagnosis of cirrhosis was made in 910 (36.0%) patients, while 620 (24.6%) had hepatic fibrosis, and 995 (39.4%) chronic active hepatitis. Splenomegaly was present in 460 out of 910 patients (50.5%) with cirrhosis. Among the 1,615 patients without cirrhosis, splenomegaly was present in 80 (4.9%), and esophageal varices were present in 70 out of 910 (7.6%) cirrhotic patients. In patients without cirrhosis, esophageal varices were present in 30 out of 1,615 (1.2%) at the time of laparoscopy. Statistical analysis showed significant differences between patients with cirrhosis and without cirrhosis for splenomegaly (χ(2)=717.03, p<0.001) and esophageal varices (χ(2)=50.57, p<0.001). In conclusion, laparoscopic splenomegaly seems to be an important prognostic factor in liver cirrhosis, which represents a risk factor for portal hypertension.

Amiodarone impairs trafficking through late endosomes inducing a Niemann-Pick C-like phenotype.

Patients treated with amiodarone accumulate lysobisphosphatidic acid (LBPA), also known as bis(monoacylglycero)phosphate, in airway secretions and develop in different tissues vacuoles and inclusion bodies thought to originate from endosomes. To clarify the origin of these changes, we studied in vitro the effects of amiodarone on endosomal activities like transferrin recycling, Shiga toxin processing, ESCRT-dependent lentivirus budding, fluid phase endocytosis, proteolysis and exosome secretion. Furthermore, since the accumulation of LBPA might point to a broader disturbance in lipid homeostasis, we studied the effect of amiodarone on the distribution of LBPA, unesterified cholesterol, sphingomyelin and glycosphyngolipids. Amiodarone analogues were also studied, including the recently developed derivative dronedarone. We found that amiodarone does not affect early endosomal activities, like transferrin recycling, Shiga toxin processing and lentivirus budding. Amiodarone, instead, interferes with late compartments of the endocytic pathway, blocking the progression of fluid phase endocytosis and causing fusion of organelles, collapse of lumenal structures, accumulation of undegraded substrates and amassing of different types of lipids. Not all late endocytic compartments are affected, since exosome secretion is spared. These changes recall the Niemann-Pick type-C phenotype (NPC), but originate by a different mechanism, since, differently from NPC, they are not alleviated by cholesterol removal. Studies with analogues indicate that basic pKa and high water-solubility at acidic pH are crucial requirements for the interference with late endosomes/lysosomes and that, in this respect, dronedarone is at least as potent as amiodarone. These findings may have relevance in fields unrelated to rhythm control.