Human placental lactogen (human chorionic somatomammotropin) and oxytocin during pregnancy: Individual patterns and associations with maternal-fetal attachment, anxiety, and depression.

Previous studies support links among maternal-fetal attachment, psychological symptoms, and hormones during pregnancy and the post-partum period. Other studies connect maternal feelings and behaviors to oxytocin and suggest that an increase in oxytocin during pregnancy may prime maternal-fetal attachment. To date, researchers have not examined a possible association between maternal-fetal attachment with human placental lactogen although animal models are suggestive. In the current study, we sought to describe oxytocin and human placental lactogen levels as related to psychological constructs across pregnancy. Seventy women participated in the study. At each of three time-points (early, mid, and late pregnancy), the women had their blood drawn to assess oxytocin and human placental lactogen levels, and they completed psychological assessments measuring maternal-fetal attachment, anxiety, and depression. Our results indicate that oxytocin levels were statistically similar across pregnancy, but that human placental lactogen significantly increased across pregnancy. Results did not indicate significant associations of within-person (comparing individuals to themselves) oxytocin or human placental lactogen levels with maternal-fetal attachment. Additionally, results did not show between-person (comparing individuals to other individuals) oxytocin or human placental lactogen levels with maternal-fetal attachment. Oxytocin levels were not associated with anxiety; rather the stage of pregnancy moderated the effect of the within-person OT level on depression. Notably, increasing levels of human placental lactogen were significantly associated with increasing levels of both anxiety and depression in between subject analyses. The current study is important because it describes typical hormonal and maternal fetal attachment levels during each stage of pregnancy, and because it suggests an association between human placental lactogen and psychological symptoms during pregnancy. Future research should further elucidate these relationships.

Mild Thrombocytopenia, a Predictor of Outcomes After Laparoscopic Cholecystectomy: Assessment of Surgical Risk in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease.

BACKGROUND: A common cause of mild thrombocytopenia is chronic liver disease, the most common etiology being metabolic dysfunction-associated steatotic liver disease (MASLD). Mild thrombocytopenia is a well-defined, independent marker of hepatic fibrosis in patients with chronic liver disease. Currently, there is a paucity of information available to characterize perioperative risk in patients with MASLD; therefore, the characterization of perioperative morbidity is paramount. We used a platelet threshold of 150×10 9 as a surrogate for fibrosis in patients undergoing laparoscopic cholecystectomy to study its effect on perioperative complications and mortality. PATIENTS AND METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database for laparoscopic cholecystectomies occurring from 2005 through 2018. Demographic differences between patients with and without thrombocytopenia were evaluated using the t test or the χ 2 test, whereas adjusted and unadjusted differences in outcome risk were evaluated using log-binomial regression models. RESULTS: We identified 437,630 laparoscopic cholecystectomies of which 6.9% included patients with thrombocytopenia. Patients with thrombocytopenia were more often males, older, and with chronic disease. Patients with thrombocytopenia and higher Aspartate Aminotransferase to Platelet Ratio Index scores had 30-day mortality rates risk ratio of 5.3 (95% CI: 4.8-5.9), with higher complication rates risk ratio of 2.4 (95% CI: 2.3-2.5). The most frequent complications included the need for transfusion, renal, respiratory, and cardiac. CONCLUSIONS: Perioperatively, patients with mild thrombocytopenia undergoing laparoscopic cholecystectomy had higher mortality rates and complications compared with patients with normal platelet counts. Thrombocytopenia may be a promising, cost-effective tool to identify patients with MASLD and estimate perioperative risk, especially if used in high-risk populations.

Video consent significantly improves patient knowledge of general surgery procedures.

INTRODUCTION: Informed consent is essential in ensuring patients' understanding of their medical condition, treatment, and potential risks. The objective of this study was to investigate the impact of utilizing a video consent compared to standard consent for patient knowledge and satisfaction in selected general surgical procedures. METHODS AND PROCEDURES: We included 118 patients undergoing appendectomy, cholecystectomy, inguinal hernia repair, and fundoplication at two hospitals in Omaha, NE. Patients were randomized to either a standard consent or a video consent. Outcomes included a pretest and posttest objective knowledge assessment of their procedure, as well as a satisfaction survey which was completed immediately after consent and following discharge. Given the pre-post design, a linear mixed-effect model was estimated for both outcomes. A two-way interaction effect was of primary interest to assess whether pre-to-post change in the outcome differed between patients randomized to standard or video consent. RESULTS: Baseline characteristics were mostly similar between groups except for patient sex, p = 0.041. Both groups showed a statistically significant increase in knowledge from pretest to posttest (standard group: 0.25, 95% CI 0.01 to 0.51, p = 0.048; video group: 0.68, 95% CI 0.36 to 1.00, p < 0.001), with the video group showing significantly greater change (interaction p = 0.043) indicating that incorporating a video into the consent process resulted in a better improvement in patient's knowledge of the proposed procedure. Further, both groups showed a decrease in satisfaction post-discharge, but no statistically significant difference in the magnitude of decrease between the groups (interaction p = 0.309). CONCLUSION: Video consent lead to a significant improvement in a patient's knowledge of the proposed treatment. Although the patient satisfaction survey didn't show a significant difference, it did show a trend. We propose incorporating videos into the consent process for routine general surgical procedures.

Correlation Between ECT Quality Measures and Likelihood to Transition From Acute to Continuation and Maintenance ECT.

OBJECTIVES: To evaluate the association between 3 ECT quality measures (seizure duration, Postictal Suppression Index [PSI], and heart rate response) and therapeutic compliance as indicated by transitioning from acute to continuation to maintenance phases of ECT. METHODS: This was a retrospective chart review of patients who received ECT between July 2016 and July 2019. ECT quality measures were lagged by 1 ECT session to examine the effect of the prior session's quality measure on progressing to a higher ECT phase at the subsequent ECT session. Associations with therapeutic compliance were analyzed using mixed-effects ordinal regression and mixed-effects partial proportional odds models. RESULTS: Seizure duration was associated with 8% higher adjusted odds of progressing to out of the acute phase (95% confidence interval [CI]: 2% to 15%, P = 0.007) and 18% higher adjusted odds of progressing to the maintenance phase (95% CI: 10% to 28%, P < 0.001); PSI was associated with 9% higher adjusted odds of progressing out of the acute phase (95% CI: 3% to 16%, P = 0.005), whereas heart rate response was not statistically associated with therapeutic compliance. Greater therapeutic compliance was also associated with bilateral electrode placement and older age. CONCLUSIONS: Longer seizure duration was associated with greater therapeutic compliance across all ECT phases, PSI was associated with progressing out of the acute phase, and heart rate response was not associated with therapeutic compliance. Our findings assist ECT psychiatrists in optimizing ECT quality measures to promote better compliance with ECT.

Efficient interspecies transmission of synthetic prions.

Prions are comprised solely of PrPSc, the misfolded self-propagating conformation of the cellular protein, PrPC. Synthetic prions are generated in vitro from minimal components and cause bona fide prion disease in animals. It is unknown, however, if synthetic prions can cross the species barrier following interspecies transmission. To investigate this, we inoculated Syrian hamsters with murine synthetic prions. We found that all the animals inoculated with murine synthetic prions developed prion disease characterized by a striking uniformity of clinical onset and signs of disease. Serial intraspecies transmission resulted in a rapid adaptation to hamsters. During the adaptation process, PrPSc electrophoretic migration, glycoform ratios, conformational stability and biological activity as measured by protein misfolding cyclic amplification remained constant. Interestingly, the strain that emerged shares a strikingly similar transmission history, incubation period, clinical course of disease, pathology and biochemical and biological features of PrPSc with 139H, a hamster adapted form of the murine strain 139A. Combined, these data suggest that murine synthetic prions are comprised of bona fide PrPSc with 139A-like strain properties that efficiently crosses the species barrier and rapidly adapts to hamsters resulting in the emergence of a single strain. The efficiency and specificity of interspecies transmission of murine synthetic prions to hamsters, with relevance to brain derived prions, could be a useful model for identification of structure function relationships between PrPSc and PrPC from different species.

Catching Up on Multilevel Modeling.

This review focuses on the use of multilevel models in psychology and other social sciences. We target readers who are catching up on current best practices and sources of controversy in the specification of multilevel models. We first describe common use cases for clustered, longitudinal, and cross-classified designs, as well as their combinations. Using examples from both clustered and longitudinal designs, we then address issues of centering for observed predictor variables: its use in creating interpretable fixed and random effects of predictors, its relationship to endogeneity problems (correlations between predictors and model error terms), and its translation into multivariate multilevel models (using latent-centering within multilevel structural equation models). Finally, we describe novel extensions-mixed-effects location-scale models-designed for predicting differential amounts of variability.

Information Sources and Attitudes Toward COVID-19 Vaccination at a Free Clinic in the State of Nebraska, USA.

The full impacts of the COVID-19 pandemic are yet to be determined. While highly effective vaccines are available to prevent and decrease the severity of COVID-19 infection, significant COVID-19 vaccine hesitancy remains. Understanding motivations, discouraging factors, opinions, and information sources regarding COVID-19 is essential to targeting vaccine hesitancy and improving vaccine uptake. A 25 question survey was administered to the patients of a free clinic in the Midwest to assess patient demographic data, opinions about and experience with COVID-19, the COVID-19 vaccines, and information sources. The main outcome of interest was if vaccination status influenced information sources and opinions regarding COVID-19. This study also analyzed motivating and discouraging factors for vaccination. The study had a total of 104 participants with 7 being excluded. There were a total of 97 survey responses included in this study, there were 79 vaccinated patients and 18 unvaccinated patients. This survey study found differences in information sources between vaccinated and unvaccinated groups. Opinions surrounding the COVID-19 vaccine, public health agencies, and perceived severity of COVID-19 also varied between vaccinated and unvaccinated groups. The differential information sources and opinions between vaccinated and unvaccinated groups emphasizes the importance of access to high-quality sources and educating the community to improve public health.

In-hospital mortality and readmission after ST-elevation myocardial infarction in nonagenarians: A nationwide analysis from the United States.

OBJECTIVES: To assess readmission rates in nonagenarians (age ≥ 90 years) with ST-elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (pPCI) versus no pPCI. BACKGROUND: There are limited data exploring readmissions following STEMI in nonagenarians undergoing pPCI versus no pPCI. METHODS: We retrospectively analyzed the Nationwide Readmissions Database to identify nonagenarians hospitalized with STEMI. We divided the cohort into two groups based on pPCI status. We compared mortality during index hospitalization and during 30-day readmission, readmission rates, and causes of readmissions. RESULTS: We identified 58,231 nonagenarian STEMI hospitalizations between 2010 and 2018, of which 18,809 (32.3%) included pPCI, and 39,422 (67.7%) had no pPCI. Unadjusted unplanned 30-day readmission was higher in pPCI cohort (21.0% vs. 15.4%, p < 0.001). However, mortality during index hospitalization and during 30-day readmission were significantly lower in pPCI cohort (15.8% vs. 32.2%, p < 0.001; 7.4% vs. 14.2%, p < 0.001, respectively). After adjusting for baseline characteristics, hospitalizations that included pPCI had 25% greater odds of unplanned 30-day readmission (adjusted odds ratio [aOR]: 1.25, 95% confidence interval [CI]: 1.12-1.39, p < 0.001) and 49% lower odds of in-hospital mortality during index hospitalization (aOR: 0.51, 95% CI: 0.46-0.56, p < 0.001). Heart failure was the most common cause of readmission in both cohorts followed by myocardial infarction. CONCLUSIONS: In nonagenarians with STEMI, pPCI is associated with slightly higher 30-day readmission but significantly lower mortality during index hospitalization and during 30-day readmission than no pPCI. Given the overwhelming mortality benefit with pPCI, further research is necessary to optimize the utilization of pPCI while reducing readmissions following STEMI in nonagenarians.

Impact of delirium on mortality in patients hospitalized for heart failure.

OBJECTIVE: Heart Failure (HF) is one of the leading causes of hospitalization in the United States accounting for ≈800,000 hospital discharges and $11 billion in annual costs. Delirium occurs in approximately 30% of elderly hospitalized patients and its incidence is significantly higher among those admitted to the critical care units. Despite this, there has been limited exploration of the clinical and economic impact of delirium in patients hospitalized with acute HF. We hypothesized that delirium in HF is associated with excess mortality and hospital costs. METHODS: We queried the 2001-2014 Nationwide Inpatient Sample to identify hospitalizations that included a primary discharge diagnosis of HF (ICD-9-CM: 428.xx) and stratified them by presence or absence of delirium (ICD-9-CM: 239.0, 290.41, 293.0, 293.1, 348.31). Differences in in-hospital mortality, length of stay (LOS), and hospital costs were assessed using propensity-score matched cohorts. RESULTS: Major predictors of delirium included advanced age, Caucasian race, underlying dementia or psychiatric diagnoses, higher Elixhauser Comorbidity Index, renal failure, cardiogenic shock, and coronary artery bypass surgery. In the propensity-score matched analysis of 76,411 hospitalization with delirium compared to 76,612 without delirium, in-hospital mortality (odds ratio: 1.67, 95% CI: 1.51-1.77), LOS (rate ratio [RR]: 1.47, 95% CI: 1.45-1.51), and hospital costs (RR: 1.44, 95% CI: 1.41-1.48) were all statistically higher in the presence of delirium (all p < 0.001). CONCLUSION: In patients hospitalized with HF, delirium is an independent predictor of increased in-hospital mortality, longer LOS, and excess hospital costs despite adjustment for baseline characteristics.

Impact of gender on in-hospital mortality and 90-day readmissions in patients undergoing transcatheter edge-to-edge mitral valve repair: Analysis from the National Readmission Database.

BACKGROUND: Patients undergoing transcatheter edge-to-edge mitral valve repair (TEER) carry a high risk of rehospitalization due to disease, procedure, patient, hospital, and system related factors. AIMS: We aimed to explore the impact of gender on in-hospital mortality and 90-day readmissions in patients undergoing TEER. METHODS: We utilized the National Readmission Database from 2012 to 2018 to identify individuals who underwent TEER for mitral regurgitation. Gender-based differences in in-hospital mortality and 90-day readmissions were explored using multivariable logistic regression models. RESULTS: Between 2012 and 2018, an estimated 21,415 TEER procedural hospitalizations were identified, of which 9893 (46.2%) were in women and 11,522 (53.8%) were in men. Compared with men, women were older, from a lower socioeconomic status but had a lower co-morbidity burden. In-hospital mortality rate during the index hospitalization was similar in women and men (2.1% vs. 2.1%, p = 0.908). Ninety-day all-cause and heart failure readmission rates were significantly higher in women compared to men (30.2% vs. 25.4%; p < 0.001 and 28.1% vs. 23.9%; p = 0.020 respectively). In a multivariable analysis, women had 36% greater odds of 90-day readmission compared to men (adjusted odds ratio [aOR] 1.36, 95% CI: 1.22-1.52; p < 0.001). Trend analysis revealed no significant improvement in rates of 90-day readmission during the observation period for men or women (p = 0.245, p = 0.429, respectively). CONCLUSIONS: Following TEER, there has been no significant improvement in 90-day readmission rates between 2012 and 2018. Female gender is associated with higher 90-day all-cause and heart failure readmission rates.

ST-elevation myocardial infarction in nonagenarians: A nationwide analysis of trends and outcomes in the United States.

OBJECTIVE: To assess ST elevation myocardial infarction (STEMI) trends and outcomes in nonagenarians undergoing primary percutaneous coronary intervention (pPCI) compared to medical management. BACKGROUND: Although nonagenarians (age greater than 90 years) represent the fast-growing age decade of the US population, limited evidence is available regarding trends and outcomes of treatment strategies for STEMI in this population cohort. METHODS: We performed a retrospective analysis using the National Inpatient Sample (NIS) database to identify nonagenarians presenting with STEMI and treated with either pPCI or medical management. In-hospital mortality, in-hospital complications, length of stay and in-hospital costs were analyzed. RESULTS: Between 2010-2017, 41,042 STEMI hospitalizations were identified in nonagenarians, of which 11, 155 (27.2%) included pPCI whereas 29, 887 (72.8%) included medical management. STEMI hospitalizations among nonagenarians decreased over the study period. Overall unadjusted in-hospital mortality was 21.6%, and the hospitalizations that included pPCI had significantly lower mortality compared to the medical management (13.6% vs. 24.5%, p < .001). After adjusting for baseline characteristics, hospitalizations that included pPCI had 42.1% lower odds of in-hospital mortality (adjusted OR: 0.58, 95% CI: 0.50 to 0.67, p < .001). Altogether, in-hospital cardiac, bleeding and vascular complications, length of stay and in-hospital costs were higher in pPCI hospitalizations. CONCLUSION: In nonagenarians, STEMI mortality is high, but pPCI is associated with superior outcomes compared to medical management alone. Therefore, pPCI can be considered an acceptable treatment strategy in this population.

Esophagogastric Junction Morphology on Hill's Classification Predicts Gastroesophageal Reflux with Good Accuracy and Consistency.

INTRODUCTION: Hill's classification provides a reproducible endoscopic grading system for esophagogastric junction morphology and competence, specifically whether the gastroesophageal flap valve (GEFV) is normal (grade I/II) or abnormal (grades III/IV). However, it is not routinely used in clinical practice. We report a systematic review and meta-analysis to determine association between abnormal GEFV and gastroesophageal reflux disorder (GERD). METHODS: A comprehensive literature search of MEDLINE and Scopus databases was conducted to identify studies that reported the association between abnormal GEFV and GERD. The search and quality assessment were performed independently by two authors. Fixed- and random-effects meta-analyses were conducted using symptomatic GERD and erosive esophagitis as outcomes. RESULTS: A total of 11 studies met inclusion criteria that included a total of 5054 patients. In the general population, patients with abnormal GEFV had greater risk of symptomatic GERD compared to patients with a normal GEFV (risk ratio [RR] 1.88, 95% CI 1.57-2.24). Further, in patients with symptomatic GERD, patients with abnormal GEFV had greater risk of erosive esophagitis compared to patients with normal GEFV (RR 2.17, 95% CI 1.40-3.36). Finally, the specificity of abnormal GEFV for symptomatic GERD was 73.3% (95% CI 69.3-77.0%) and 75.7% (95% CI 65.9-83.4%) for erosive esophagitis in symptomatic GERD. CONCLUSION: Our systematic review and meta-analysis showed consistent association between abnormal GEFV indicated by Hill's classification III/IV and symptomatic GERD and erosive esophagitis. Our recommendation is to include Hill's classification in routine endoscopy reports and workup for GERD.

Sustainable and replicable clinical and financial outcomes in an interprofessional education and collaborative practice nexus.

Our Interprofessional Education and Collaborative Practice (IPECP) Nexus previously reported significant reductions in Emergency Department (ED) visits, hospitalizations, hemoglobin A1c levels, and patient charges. This study examines sustainability of these results over two additional years and replication in two subsequent independent patient cohorts. Participants in the sustainability cohort (N = 276) met ≥1 of the following criteria: (a) ≥3 ED visits in first or second half of the year, (b) hemoglobin A1c level ≥ 9, or (c) Length of Stay, Acuity, Comorbidities, and ER (Emergency Room) Visits (LACE) score ≥ 10. Participants in two replicability cohorts (N = 255) and (N = 160) met the same criteria, but the LACE criterion was changed to ≥3 hospitalizations in baseline years. The Nexus, housed in a family medicine (FM) residency clinic, included professionals and students from multiple disciplines. IPECP skills and interventions included communication, team building, and conflict engagement skills training, daily huddles and pre-visit planning, immediate consultations, small teamlet IPECP interactions, and weekly IPECP case conferences for complex patients. Original health improvements and charge reductions were sustained for two additional years for ED visits, hospitalizations, A1c, and patient charges, and replicated in two additional patient cohorts. The IPECP Nexus interventions were associated with Quadruple Aim outcomes while training the next generation of health care professionals.

Sepsis and the Obesity Paradox: Size Matters in More Than One Way.

OBJECTIVES: Multiple studies have demonstrated an obesity paradox such that obese ICU patients have lower mortality and better outcomes. We conducted this study to determine if the mortality benefit conferred by obesity is affected by baseline serum lactate and mean arterial pressure. DESIGN: Retrospective analysis of prospectively collected clinical data. SETTING: Five community-based and one academic medical center in the Omaha, NE. PATIENTS: 7,967 adults hospitalized with sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were categorized by body mass index as underweight, normal weight, overweight, or obese. Multivariable logistic regression models were used to estimate the odds of in-hospital death by body mass index category; two-way interactions between body mass index and each covariate were also evaluated. Subgroup and sensitivity analyses were conducted using an ICU cohort and Acute Physiology and Chronic Health Evaluation III scores, respectively. The overall unadjusted mortality rate was 12.1% and was consistently lower in higher body mass index categories (all comparisons, p < 0.007). The adjusted mortality benefit observed in patients with higher body mass index was smaller in patients with higher lactate levels with no mortality benefit in higher body mass index categories observed at lactate greater than 5 mmol/L. By contrast, the association between lower MAP and higher mortality was constant across body mass index categories. Similar results were observed in the ICU cohort. Finally, the obesity paradox was not observed after including Acute Physiology and Chronic Health Evaluation III scores as a covariate. CONCLUSIONS: Our retrospective analysis suggests that although patient size (i.e., body mass index) is a predictor of in-hospital death among all-comers with sepsis-providing further evidence to the obesity paradox-it adds that illness severity is critically important whether quantified as higher lactate or by Acute Physiology and Chronic Health Evaluation III score. Our results highlight that the obesity paradox is more than a simple association between body mass index and mortality and reinforces the importance of illness severity.

Obesity is Associated with Significantly More Anastomotic Leaks After Minimally Invasive Esophagectomy: A NSQIP Database Study.

BACKGROUND: This study assessed the association between obesity status and postoperative outcomes for patients who underwent transthoracic esophagectomy (TTE) or transhiatal esophagectomy (THE) via an open or minimally invasive (MIE) surgical approach. METHODS: The 2016-2018 national surgical quality improvement program esophagectomy-targeted database was used to identify adult patients who underwent TTE or THE, with stratification of patients by obesity status and surgical approach. Using a multivariable regression model for each outcome, the study evaluated whether the adjusted difference between obese and non-obese patients varied between the open and MIE approaches. RESULTS: In this study, 1260 patients underwent TTE (28.1% obese; 51.7% MIE), and 386 patients underwent THE (29.3% obese; 43.0% MIE). The obese patients in the TTE cohort who underwent MIE had 3.4 times higher odds of failing to wean from mechanical ventilation within 48 h (95% confidence interval [CI] 1.8-6.4), 1.7 times greater odds of returning to the operating room (95% CI 1.1- 3.0), 2.4 times greater odds of having an index hospital stay longer than 30 days, (95% CI 1.0-6.0), and 2.5 times greater odds of experiencing a grade 3 anastomotic leak (95% CI 1.3-4.9). No differences between obese and non-obese patients were observed among those who underwent TTE via an open approach or THE. CONCLUSIONS: The findings showed that obese patients undergoing TTE via an MIE approach had greater odds of failing to wean from mechanical ventilation within 48 h, returning to the operating room, having an index hospital stay longer than 30 days, and having a grade 3 anastomotic leak. These results are in contrast to the previously published literature and require replication as additional data become available.

Immediate dilation in esophageal food impaction is safe and effective but performed infrequently: observations from a large Midwest US cohort.

This study aimed to determine the rate and safety of immediate esophageal dilation for esophageal food bolus impaction (EFBI) and evaluate its impact on early recurrence (i.e. prior to interval esophageal dilation) from a large Midwest US cohort. We also report practice patterns among community and academic gastroenterologists practicing in similar settings. We identified adult patients with a primary discharge diagnosis for EFBI from January 2012 to June 2018 using our institutional database. Pregnant patients, incarcerated patients, and patients with esophageal neoplasm were excluded. The primary outcome measured was rate of complications with immediate esophageal dilation after disimpaction of EFBI. Secondary outcomes were recurrence of food bolus impaction prior to scheduled interval endoscopy for dilation, practice patterns between academic and private gastroenterologists, and adherence to follow-up endoscopy. Two-hundred and fifty-six patients met our inclusion criteria. Esophageal dilation was performed in 46 patients (18%) at the time of disimpaction. A total of 45 gastroenterologists performed endoscopies for EFBI in our cohort. Twenty-five (62%) did not perform immediate esophageal dilation, and only 5 (11%) performed immediate dilation on greater than 50% of cases. Academic gastroenterologists performed disimpaction of EFBI for 102 patients, immediate dilation as performed in 20 patients and interval dilation was recommended in 82 patients. Of these 82, only 31 patients (38%) did not return for interval dilation. Four patients who did not undergo immediate dilation, presented with recurrent EFBI prior to interval dilation, within 3 months. None of the patients had complications. Complications with immediate esophageal dilation after disimpaction of EFBI are infrequent but are rarely performed. Failure of immediate dilation increases the risk of EFBI recurrence. Given poor patient adherence to interval dilation, immediate dilation is recommended.

Early vs late cardiac surgery in patients with native valve endocarditis-United States Nationwide Inpatient database.

OBJECTIVE: Although the standard treatment of infective endocarditis (IE) is antimicrobial therapy, surgical intervention is required in some cases. However, the optimal timing of surgery remains unclear. Hence, we conducted a population-based analysis using the National Inpatient Sample (NIS) database to assess the outcomes of early versus late surgery in patients with native valve IE. METHODS: We queried the NIS database for all hospitalized patients between 2006 and 2016 with a primary diagnosis of IE who had cardiac surgery. We stratified surgery as early ≤7 or late >7 days of admission. Multivariable logistic regression models were used to assess in-hospital mortality and postoperative complications. Length of stay (LOS) and total hospital cost (HC) were evaluated using multivariable log-normal regression models. RESULTS: A total of 13 056 patients (57.6% in the early group and 42.4% in the late group) were included. The in-hospital mortality rate in the early group was 5.0% compared to 5.4% in the late intervention group (adjusted odds ratio, 1.20, 95% confidence interval [CI] 0.79-1.81). Overall median LOS was reduced in the early group by 48.2% (95% CI, 46.5%-49.9%, 12.4 days in the early group and 25.9 days in late group), as well as HC which was reduced in the early group by 28.3% (95% CI, 26.0%-30.6%). CONCLUSION: Among patients with native valve IE who needed cardiac surgery, the time of surgical intervention did not affect the in-hospital mortality. However, early surgery was associated with significantly shorter LOS and lower HC.

Trends in use of echocardiography in hospitalized patients with syncope.

PURPOSE: We sought to assess the trends in use, predictors of echocardiography, and its impact on in-hospital mortality in patients admitted with syncope using a large national database. METHODS: Utilizing the Nationwide Inpatient Sample (NIS) database from 2001 to 2014, we identified adult patients (>18 years) with a primary discharge diagnosis of syncope and use of echocardiogram was ascertained. RESULTS: A total of 3 174 619 patients with a primary discharge diagnosis of syncope were identified, of which 184 167 (5.8%) underwent an echocardiogram. The rate of syncope hospitalization remained constant between 2001 and 2009 (1.1/1000 US population) but has since decreased steadily to about 0.5/1000 US population in 2014. After adjusting for patient and hospital characteristics, the rate of echocardiogram use increased significantly from 5.1% in 2001 to 6.8% in 2014 (2.7% relative increase per year [Ptrend  = 0.024]). Predictors of use were cardiac disorders, hypertension, diabetes, peripheral vascular disease, and renal failure. After adjusting for baseline risk, use of echocardiography was not associated with in-hospital mortality (OR = 0.827, P = 0.155), but was associated with a 14.6% increase in adjusted length of stay and a 22.6% increase in adjusted hospital cost compared to no echocardiography use (both P < 0.001). CONCLUSIONS: The admission rates for syncope are decreasing and use of echocardiography in hospitalized patients with syncope is appropriately low. Given the lack of any favorable impact on mortality and the association with increased costs, there is a continued need to emphasize evidence-based use of echocardiography in patients presenting with syncope.

Trends in the use of echocardiography in patients with Staphylococcus aureus bacteremia: an analysis using the Nationwide Inpatient Sample data.

BACKGROUND: Infective endocarditis occurs in approximately 10%-30% of patients with Staphylococcus aureus bacteremia (SaB). Guidelines recommend echocardiography in patients with SaB and risk factors for infective endocarditis in the absence of any obvious source of infection. Herein, we explored the trends in the use of echocardiography in patients with SaB and its relationship to outcomes using a large national database. METHOD: All patients with a principal discharge diagnosis of SaB were identified using the National Inpatient Sample database from 2001 to 2014. Procedure code 88.72 was used to identify echocardiography. Logistic regression models were estimated to identify the year-over-year trends in echocardiogram, predictors of use, and association with mortality. RESULTS: From 2001 to 2014, there were 668 423 hospitalizations with SaB diagnosis and 86 387 (12.9%) had echocardiogram. The rate of echocardiography increased from 10.7% in 2001 to 15.2% in 2014 (ptrend  < 0.001). Major predictors of echocardiogram usage were younger age, male gender, presence of sepsis, valvular or congenital heart disease, prosthetic heart valve (PHV), cardiac implantable electronic device (CIED), hemodialysis, and drug abuse. The adjusted rates of echocardiography increased from approximately 10% to 15% in hospitalizations without risk factors for IE while for high-risk groups like PHV and CIED it remained constant at 30% and 19%, respectively. Echocardiography was associated with 31% lower odds of in-hospital mortality. CONCLUSION: The increase in echocardiography rate was largely attributable to increased use in those without risk factors while usage in those with PHV and CIED remained much lower than expected. Echocardiography use was associated with lower risk-adjusted mortality. These findings require further study and confirmation.

A subgroup analysis of penetrating injuries to the pancreas: 777 patients from the National Trauma Data Bank, 2010-2014.

BACKGROUND: This study is the first to analyze penetrating injuries to the pancreas within subgroups of severe traumatic brain injury (TBI), early deaths, and potential survivors. Our objectives were to identify national patterns of injury, predictors of mortality, and to validate the American Association for Surgery of Trauma Organ Injury Scale (AAST-OIS) pancreas injury grades by mortality. Secondary outcomes included hospital and intensive care unit length of stay and days on mechanical ventilation. METHODS: Using the Abbreviated Injury Scale 2005 and ICD-9-CM E-codes, we identified 777 penetrating pancreatic trauma patients from the National Trauma Data Bank that occurred between 2010 and 2014. Severe TBI was identified by ICD-9-CM diagnosis codes and Glasgow Coma Score (GCS; n = 7), early deaths were those that occurred within 24 h of admission (n = 82), and potential survivors included patients without severe TBI who survived longer than 24 h following admission (n = 690). We estimated multivariable generalized linear mixed models to predict mortality to account for the nesting of potential survivors within trauma centers. RESULTS: Our results indicated that overall mortality decreased from 16.9% to 6.8% after excluding severe TBI and early deaths. Approximately, 11% of patients died within 24 h of admission, of whom 78% died in the first 6 h. Associated injuries to the stomach, liver, and major vasculature occurred in approximately 50% of patients; rates of associated injuries were highest in patients who died within 6 h of admission. In potential survivors, mortality increased by AAST-OIS grade: 3.5% I/II; 8.3% III; 9.6% IV; and 13.8% V. Predictors of mortality with significantly increased odds of death were patients with increasing age, lower admission GCS, higher admission pulse rate, and more severe injuries as indicated by Organ Injury Scale grade. CONCLUSIONS: From 777 patients, we identified national patterns of injury, predictors of outcome, and mortality by AAST-OIS grade within the subgroups of severe TBI, early deaths, and potential survivors. Because AAST-OIS is not a reported element in the National Trauma Data Bank, we correlated Abbreviated Injury Scale 2005 codes to injury grade and identified an increase in mortality. After controlling for covariance, we found that greater age, lower GCS in stab wounds, higher pulse, and presence of a grade V pancreatic injury independently predicted the likelihood of death in patients surviving beyond 24 h following penetrating injuries to the pancreas.