Background: The optimal treatment for primary spontaneous pneumothorax (PSP) remains undefined. Furthermore, the overall utilization and costs of various treatment approaches are incompletely understood. We investigated hospital charges and resource utilization by management strategy across the state of Maryland in adult and pediatric patients with PSP. Methods: We queried the Maryland Health Services Cost Review Commission database for patients aged 10-40 years admitted with PSP between 2012 and 2020. Patients managed with a chest tube alone (CT) were compared with recipients of video-assisted thoracoscopic surgery (VATS). Subsequently, we analyzed hospital charges for patients undergoing early VATS (<48 hours post-admission) vs. delayed VATS (>= 48 hours). The predicted incremental cost of early vs. delayed VATS was calculated. Results: Overall, 354 admissions were identified, with 211 (59.6%) receiving CT management and 143 (40.4%) undergoing VATS. Patients receiving VATS were more likely to be female (24% vs. 15%, p=0.030) and Black (32% vs. 20%, p=0.035) than CT recipients. The median total hospital charge for CT recipients was $6,493, compared to $20,437 for patients managed surgically (p<0.001). Delayed surgery during the index admission was associated with significantly higher total hospital charges-including operating room, room and board, radiology, and laboratory costs-than early surgery. Applying early VATS to all patients appeared more cost-efficient than delayed VATS (per-patient costs: $18,568 vs. $30,832, p<0.001), although the former had slightly higher recurrence (7.9% vs. 1.5%, Conclusion: Variations in management strategies, particularly surgical decision-making and timing, impact hospital charges and utilization for patients with PSP.

Introduction: Indications for extracorporeal membrane oxygenation (ECMO) in pediatric trauma continue to evolve. This study evaluates trends and practices in ECMO use for injured children and identifies factors associated with mortality using the National Trauma Data Bank (NTDB). Methods: We conducted a retrospective review of children <= 18 years who underwent ECMO therapy following trauma, recorded in the NTDB from 2007 to 2018. The primary outcome was in-hospital mortality. Secondary outcomes were hospital length of stay (LOS) and in-hospital complications. Multivariable regression models identified factors associated with mortality. Results: Out of 217 children cannulated onto ECMO from 2007 to 2018, 172 (79.2 %) were from 2013 to 2018. Median age was 16 years (IQR 9-17) and 158 (72.8 %) patients were male. The median injury severity score was 26 (IQR 18-38). The thorax (71.9 %) and extremities (63.6 %) were the most common sites injured. Overall, in-hospital mortality was 37.3 %. Median ICU LOS among survivors was 16 days (IQR 5-32). Common complications included acute respiratory failure (29 %), cardiac arrest (24 %) and acute renal failure (17.5 %). On multivariable analysis, higher ISS (adjusted OR [aOR] 1.04, 95%CI 1.01-1.07), the presence of burn injuries (aOR 4.35, 95%CI 1.01-18.74), ICH of unspecified type at presentation (aOR 4.22, 95%CI 1.21-14.68), and intentional injury (aOR 12.7, 95%CI 2.77-58.26) were associated with increased mortality. Conclusion: This is the largest contemporaneous study of ECMO use in injured children. Many factors such as ISS, cardiac arrest, presence of burn injuries and unspecified ICH increase the rate of in-hospital mortality following ECMO utilization post-trauma. The increase in ECMO utilization over the years support its role as a potentially effective intervention for pediatric trauma patients. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

OBJECTIVES:Limited data exist on outcomes in COVID-19- vs. influenza A (H1N1)-associated acute respiratory distress syndrome (ARDS) patients when supported on venovenous extracorporeal membrane oxygenation (ECMO). We aimed to compare acute brain injury (ABI) frequency, thrombotic, and hemorrhagic complications and mortality in COVID-19- vs. H1N1-associated ARDS patients on venovenous ECMO. DESIGN:Retrospective multicenter observational cohort study. SETTING:Data reported to the Extracorporeal Life Support Organization by up to 534 ECMO centers from 2009 to 2021. PATIENTS:Patients 18 years or older with COVID-19 or H1N1 requiring venovenous ECMO support. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:We conducted a retrospective analysis on 2253 venovenous ECMO patients (1916 COVID-19 and 337 H1N1). We employed propensity score matching followed by multivariable logistic regression to compare outcomes. The primary outcome was ABI and secondary outcomes were thrombosis, hemorrhage, and mortality. After matching, 674 patients (337 COVID and 337 H1N1) remained (median age = 41, 55% male). In the matched cohort, 10% of COVID-19 patients experienced ABI compared with 12% of H1N1 patients, with no significant difference between the groups (adjusted odds ratio [aOR], 0.83; 95% CI, 0.44-1.54; p = 0.53). There was no difference in thrombotic complications (aOR, 0.67; 95% CI, 0.44-1.02; p = 0.06), but COVID-19 patients had fewer hemorrhagic complications (aOR, 0.27; 95% CI, 0.17-0.42; p < 0.001) compared with H1N1. Mortality was higher in COVID patients (aOR, 2.17; 95% CI, 1.45-3.23; p < 0.001). In both groups, however, patients with ABI had higher mortality than those without, with 94% vs. 40% ( p < 0.001) for COVID and 75% vs. 29% ( p < 0.001) for H1N1, respectively. CONCLUSIONS:COVID-19 and H1N1 patients on venovenous ECMO exhibited similar ABI frequency, which was twice that observed in the general historical ARDS patients supported on venovenous ECMO population. Our findings highlight that both COVID and H1N1 ARDS increase ABI frequency in ECMO patients. Finally, the presence of ABI doubled mortality among both COVID and H1N1.

BackgroundPrehospital tourniquet (PHT) use has become widespread. However, whether it improves outcomes after penetrating proximal extremity trauma in urban settings remains unknown. We hypothesized that PHT improves mortality in this setting.Materials and MethodsThis was a post hoc analysis of a multicenter study of adults (18+ years) with penetrating torso and/or proximal extremity trauma from 25 urban trauma centers. Subjects were allocated via nearest neighbor propensity matching (chest, abdominal, or extremity injury, GSW vs stab, and vascular injuries) to compare similarly-injured PHT and non-PHT patients.ResultsAmong 2352 patients, 117 (4.9%) received PHT. Prehospital tourniquet patients had 22 (18.84%) arterial injuries, 8 (6.8%) venous injuries, and 92 (78.6%) non-vascular injuries. Most PHTs (86, 73.5%) were placed on-scene, and 22 (18.8%) en-route. Admission of systolic blood pressure was not different between PHT and non-PHT patients. Prehospital tourniquet did not impact survival on regression analysis. After propensity matching, 218 patients remained, who were primarily male (n = 182, 83.9%) with median (IQR) age 30 (23-39) years and new injury severity score 9 (3-17). Mortality was similar between PHT and non-PHT groups (6.4% vs 7.3%; P = 1.0). Matched comparison of patients with vascular injury showed similar mortality for PHT vs non-PHT (3.7% vs 3.7%, P = 1.00). The same was true for isolated extremity trauma (4.1% vs 0.0%, P = 0.25).ConclusionsPHT use for urban, penetrating proximal extremity trauma was not associated with decreased mortality or complications. Further research may determine whether modified tourniquet training improves outcomes, or whether immediate transport to a trauma center is more beneficial for these patients.

BACKGROUND:In an effort to enhance recovery after cardiac surgery, intraoperative extubation has been targeted as possibly beneficial. This multicenter cohort study aimed to assess this by evaluating the outcomes of operating room (OR) extubation versus extubation within 6 hours of intensive care unit (ICU) arrival (early ICU extubation). Furthermore, we assessed time to ICU extubation and mortality and morbidity. METHODS:Patients undergoing on-pump cardiac surgery across 79 hospitals between 2011 and 2020 were included to (1) compare outcomes among OR extubation and early ICU extubation patients and (2) assess time to overall ICU extubation and outcomes. RESULTS:The overall study cohort comprised 163,982 patients, including 95,982 patients (OR extubation: n = 2529 [2.6%] and early ICU extubation: n = 93,453 [97.4%]) who underwent comparison of OR with early ICU extubation. After overlap weighting, patients with OR extubation had longer OR times (5.6 vs 5.1 hours, P < . 0001) and greater rates of reintubation (5.2% vs 2.9%, P = .003), prolonged ventilation (3% vs 2%, P = .021), reoperation for bleeding (1.5% vs 0.7%, P < .01), pneumonia (1.9% vs 1.1%, P < .006), and greater in-hospital mortality on multivariable regression (odds ratio, 1.34, P < .001). Patients with OR extubation at centers with low OR extubation rates (<10%, n = 60) had greater mortality (odds ratio, 1.6, P = .001). Beyond 22 hours of postoperative ICU ventilation, the risk of morbidity and mortality increased significantly. CONCLUSIONS:Few patients who undergo cardiac surgery are extubated in the OR, which is associated with no clinical benefit and with increased morbidity. Cardiac surgery programs should reconsider OR extubation after cardiopulmonary bypass. In addition, increased intubation time, in particular >22 hours, is associated with an increase in adverse outcomes.

Sparse data exist on sex-related differences in extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest (rCA). We explored the role of sex on the utilization and outcomes of ECPR for rCA by retrospective analysis of the Extracorporeal Life Support Organization (ELSO) International Registry. The primary outcome was in-hospital mortality. Exploratory outcomes were discharge disposition and occurrence of any specific extracorporeal membrane oxygenation (ECMO) complications. From 1992 to 2020, a total of 7,460 adults with ECPR were identified: 30.5% women; 69.5% men; 55.9% Whites, 23.7% Asians, 8.9% Blacks, and 3.8% Hispanics. Women's age was 50.4 +/- 16.9 years (mean +/- standard deviation) and men's 54.7 +/- 14.1 (p < 0.001). Ischemic heart disease occurred in 14.6% women vs. 18.5% men (p < 0.001). Overall, 28.5% survived at discharge, 30% women vs. 27.8% men (p = 0.138). In the adjusted analysis, sex was not associated with in-hospital mortality (odds ratio [OR] = 0.93 [confidence interval {CI} = 0.80-1.08]; p = 0.374). Female sex was associated with decreased odds of neurologic, cardiovascular, and renal complications. Despite being younger and having fewer complications during ECMO, women had in-hospital mortality similar to men. Whether these findings are driven by biologic factors or disparities in health care warrants further investigation.

Objective: We sought to determine the impact of right ventricular dysfunction on the outcomes of mechanically ventilated patients with COVID-19 requiring venovenous extracorporeal membrane oxygenation. Methods: Six academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 stratified by support with veno-venous extracorporeal membrane oxygenation during the first wave of the pandemic (March to August 2020). Echocardiograms performed for clinical indications were reviewed for right and left ventricular function. Baseline characteristics, hospitalization characteristics, and survival were compared. Results: The cohort included 424 mechanically ventilated patients with COVID-19, 126 of whom were cannulated for veno-venous extracorporeal membrane oxygenation. Right ventricular dysfunction was observed in 38.1 % of patients who received extracorporeal membrane oxygenation and 27.4 % of patients who did not receive extracorporeal membrane oxygenation with an echocardiogram. Biventricular dysfunction was observed in 5.5 % of patients who received extracorporeal membrane oxygenation. Baseline patient characteristics were similar in both the extracorporeal membrane oxygenation and non - extracorporeal membrane oxygenation cohorts strati fi ed by the presence of right ventricular dysfunction. In the extracorporeal membrane oxygenation cohort, right ventricular dysfunction was associated with increased inotrope use (66.7 % vs 24.4 % , P < .001), bleeding complications (77.1 % vs 53.8 % , P = .015), and worse survival independent of left ventricular dysfunction (39.6 % vs 64.1 % , P = .012). There was no signi fi cant difference in days ventilated before extracorporeal membrane oxygenation, length of hospital stay, hours on extracorporeal membrane oxygenation, duration of mechanical ventilation, vasopressor use, inhaled pulmonary vasodilator use, infectious complications, clotting complications, or stroke. The cohort without extracorporeal membrane oxygenation cohort demonstrated no statistically signi fi cant differences in in -hospital outcomes. Conclusions: The presence of right ventricular dysfunction in patients with COVID-19 - related acute respiratory distress syndrome supported with venovenous extracorporeal membrane oxygenation was associated with increased in -hospital mortality. Additional studies are required to determine if mitigating right ventricular dysfunction in patients requiring veno-venous extracorporeal membrane oxygenation improves mortality. (J Thorac Cardiovasc Surg 2024;167:1833-41)

CONTEXT:Conventional MRI is incompatible with extracorporeal membrane oxygenation (ECMO) cannulas and pumps. Ultra-low-field portable MRI (ULF-pMRI) with 0.064 Tesla may provide a solution, but its safety and compatibility is unknown. HYPOTHESIS:ULF-pMRI does not cause significant displacement and heating of ECMO cannulas and does not affect ECMO pump function. METHODS AND MODELS:ECMO cannulas in various sizes were tested ex vivo using phantom models to assess displacement force and heating according to the American Society for Testing and Materials criteria. ECMO pump function was assessed by pump flow and power consumption. In vivo studies involved five female domestic pigs (20-42 kg) undergoing different ECMO configurations (peripheral and central cannulation) and types of cannulas with an imaging protocol consisting of T2-weighted, T1-weighted, FLuid-Attenuated Inversion Recovery, and diffusion-weighted imaging sequences. RESULTS:Phantom models demonstrated that ECMO cannulas, both single lumen with various sizes (15-24-Fr) and double lumen cannula, had average displacement force less than gravitational force within 5 gauss safety line of ULF-pMRI and temperature changes less than 1°C over 15 minutes of scanning and ECMO pump maintained stable flow and power consumption immediately outside of the 5 gauss line. All pig models showed no visible motion due to displacement force or heating of the cannulas. ECMO flow and the animals' hemodynamic status maintained stability, with no changes greater than 10%, respectively. INTERPRETATION AND CONCLUSIONS:ULF-pMRI is safe and feasible for use with standard ECMO configurations, supporting its clinical application as a neuroimaging modality in ECMO patients.

Objective: To determine whether allograft ischemic times affect outcomes following bilateral, single, and redo lung transplantation. Methods: A nationwide cohort of lung transplant recipients from 2005 through 2020 was examined using the Organ Procurement and Transplantation Network registry. The effects of standard (<6 hours) and extended (>= 6 hours) ischemic times on outcomes following primary bilateral (n = 19,624), primary single (n = 688), redo bilateral (n = 8461), and redo single (n = 449) lung transplantation were analyzed. A priori subgroup analysis was performed in the primary and redo bilateral-lung transplant cohorts by further stratifying the extended ischemic time group into mild (>= 6 and <8 hours), moderate (>= 8 and <10 hours), and long (>= 10 hours) subgroups. Primary outcomes included 30-day mortality, 1-year mortality, intubation at 72 hours' posttransplant, extracorporeal membrane oxygenation (ECMO) support at 72 hours' posttransplant, and a composite variable of intubation or ECMO at 72 hours' posttransplant. Secondary outcomes included acute rejection, postoperative dialysis, and hospital length of stay. Results: Recipients of allografts with ischemic times >= 6 hours experienced increased 30-day and 1-year mortality following primary bilateral-lung transplantation, but increased mortality was not observed following primary single, redo bilateral, or redo single-lung transplants. Extended ischemic times correlated with prolonged intubation or increased postoperative ECMO support in the primary bilateral, primary single, and redo bilateral-lung transplant cohorts but did not affect these outcomes following redo single-lung transplantation. Conclusions: Since prolonged allograft ischemia correlates with worse transplant outcomes, the decision to use donor lungs with extended ischemic times must consider the specific benefits and risks associated with individual recipient factors and institutional expertise.

Objective Wide interhospital variation exists in cardiac surgical postoperative transfusion rates. We aimed to compare transfusion rates at 2 hospitals and identify the institutional practice factors, unrelated to patient or operative characteristics, associated with postoperative transfusion rates. Methods Records for adult patients undergoing routine cardiac surgery at 2 hospitals (H and L) from February 2020 to August 2022 were analyzed. Patient and operative characteristics, preoperative and intensive care unit hemoglobin values, and postoperative transfusion rates were compared. Transfusion indication was recorded prospectively. Propensity matching was completed to assess comparability of patient populations. Results After propensity matching patients at H and L on age, procedure type, predicted morbidity or mortality, crossclamp time, preoperative hypertension, preoperative heart failure, and preoperative stroke, 2111 patients remained, with similar characteristics except hypertension. Matched results showed no significant differences in mortality, reoperation, or other major outcomes. Hospital H transfused 36% of patients (mean postoperative hemoglobin [Hb] 10.5) with 1483 units of packed red blood cells whereas hospital L transfused 12% of patients (mean postoperative Hb 9.4) with 198 units of packed red blood cells (P < .001). For all patients with a Hb >7.5, hospital H versus L transfused 27% versus 0.9% (P < .001). Hospital L's sole transfusion indication for pretransfusion hemoglobin trigger >7.5 was bleeding versus hospital H, which had multiple indications. When Hb concentration alone was the indication for transfusion, the threshold at hospital H was <7.5 g/dL versus <6 g/dL at hospital L. Conclusions Variation in transfusion rates between hospitals H and L resulted from strict adherence at hospital L to a transfusion trigger of <6 g/dL with narrow indications for transfusions above that Hb concentration.

Background: Anti-inflammatory effects of tranexamic acid (TXA) in reducing trauma endotheliopathy may protect from acute lung injury. Clinical data showing this benefit in trauma patients is lacking. We hypothesized that TXA administration mitigates pulmonary complications in penetrating trauma patients. Materials and Methods: This is a post-hoc analysis of a multicenter, prospective, observational study of adults (18+ years) with penetrating torso and/or proximal extremity injury presenting at 25 urban trauma centers. Tranexamic acid administration in the prehospital setting or within three hours of admission was examined. Participants were propensity matched to compare similarly injured patients. The primary outcome was development of pulmonary complication (ARDS and/or pneumonia). Results: A total of 2382 patients were included, and 206 (8.6%) received TXA. Of the 206, 93 (45%) received TXA prehospital and 113 (55%) received it within three hours of hospital admission. Age, sex, and incidence of massive transfusion did not differ. The TXA group was more severely injured, more frequently presented in shock (SBP < 90 mmHg), developed more pulmonary complications, and had lower survival (P < 0.01 for all). After propensity matching, 410 patients remained (205 in each cohort) with no difference in age, sex, or rate of shock. On logistic regression, increased emergency department heart rate was associated with pulmonary complications. Tranexamic acid was not associated with different rate of pulmonary complications or survival on logistic regression. Survival was not different between the groups on logistic regression or propensity score-matched analysis. Conclusions: Tranexamic acid administration is not protective against pulmonary complications in penetrating trauma patients.

AbstractObjectivesThe objective of this study is to compare the early oncological outcomes of delayed (>90 days) versus scheduled (≤90 days) radical prostatectomy (RP).Patients and methodsPatients with prostate cancer due to undergo surgery between March 2020 and June 2020 who were enrolled in the COVIDSurg‐Cancer international, observational study were prospectively followed up for 1 year. Time to surgery was defined as the difference between the operation date and the multi‐disciplinary team decision to offer surgery. The primary outcome was the positive surgical margin (PSM) rate. Biochemical recurrence (BCR), upgradation and upstaging were secondary oncological outcomes. The Independent t‐test and Mann Whitney U test were used to compare means between groups and regression models and were used to investigate factors associated with the primary outcome.ResultsFour hundred seventy‐six (78.7%) patients underwent RP from 605 that were eligible. Three hundred seven (64.5%) patients underwent scheduled RP, and 169 (35.5%) underwent delayed RP. A small proportion of men (n = 35, 6.8%) did not undergo RP within the 1‐year follow‐up period. More men with high‐risk disease (72.8%) underwent scheduled RP compared to men with intermediate‐risk disease (60.2%) (p < 0.05). There was no statistically significant difference in the PSM rate between the two groups (p = 0.512). Delay in surgery was not associated with an increased PSM or BCR on univariable or multivariable analyses. There was statistically significantly greater upstaging (p < 0.05) in the delayed group but no difference in upgradation.ConclusionHigh‐risk men were prioritised for surgery during the COVID‐19 pandemic. Our prospective data support previous retrospective, cancer‐registry evidence suggesting no adverse oncological impact after delaying RP across all risk groups. Our study is limited by the short follow‐up period, and therefore, longer term conclusions cannot be drawn.

Background: The Stop the Bleed campaign gives bystanders an active role in prehospital hemorrhage control. Whether extending bystanders' role to private vehicle transport (PVT) for urban penetrating trauma improves survival is unknown, but past research has found benefit to police and PVT. We hypothesized that for penetrating trauma in an urban environment, where prehospital procedures have been proven harmful, PVT improves outcomes compared to any EMS or advanced life support (ALS) transport.Methods: Post-hoc analysis of an EAST multicenter trial was performed on adult patients with penetrating torso/proximal extremity trauma at 25 urban trauma centers from 5/2019-5/2020. Patients were allocated to PVT and any EMS or ALS transport using nearest neighbor propensity score matching. Univariate analyses included Wilcoxon signed rank or McNemar's Test and logistic regression.Results: Of 1999 penetrating trauma patients in urban settings, 397 (19.9%) had PVT, 1433 (71.7%) ALS transport, and 169 (8.5%) basic life support (BLS) transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. PVT patients were primarily male (90.5%), Black (71.2%), and sustained gunshot wounds (68.9%). ALS transport had significantly higher ED mortality (3.9% vs 1.9%, P = 0.03). There was no difference in in-hospital mortality rate, hospital LOS, or complications for all EMS or ALS only transport patients.Conclusion: Compared to PVT, ALS, which provides more prehospital procedures than BLS, provided no survival benefit for penetrating trauma patients in urban settings. Bystander education incorporating PVT for early arrival of penetrating trauma patients in urban settings to definitive care merits further investigation.

BACKGROUND: The redundant leaflet tissue and annular pathology of Barlow disease can make surgical repair challenging. We examined perioperative and late outcomes of a large cohort of patients with Barlow disease undergoing surgical repair. METHODS: Patients included in this analysis underwent mitral valve repair from 01/2004-11/2021 by a single surgeon. RESULTS: Of 2798 patients undergoing mitral valve operations, 46% (N.-1292) had degenerative pathology and 7% (N.-184) had Barlow disease. Of the 179 Barlow patients, median age at surgery was 62 (51-70) years; 64% were male (115/179). Rates of non-resectional cordal repair and resectional repair were 86% (154/179) and 14% (25/179). Among patients undergoing non-resectional repair, the median number of cordal pairs inserted on the anterior and posterior leaflets was 2 (2-3) and 4 (3-4). Incidence of return to bypass for systolic anterior motion of the mitral valve, perioperative death, stroke, and renal failure was 2% (4/179), 1% (2/179), 0% (0/179), and 0% (0/179). Rates of clinical and echocardiographic follow-up were 93% (165/177) and 89% (157/177). Median time to latest postoperative clinical and echocardiographic follow-up was 2.4 (0.8-6.1) and 2.1 (0.6-4.7) years. Mitral regurgitation grade at latest follow-up or time of repair failure was none/trace, mild, mild to moderate, and severe in 63% (98/157), 26% (41/157), 8% (12/157), and 4% (6/157); five of six patients with severe MR underwent reoperation. Since 2011 97% (139/144) of patients underwent cordal repair without resection. CONCLUSIONS: Non-resectional artificial cordal repair is safe and feasible in almost all patients with Barlow valves and is associated with

Objectives: Although many studies have addressed such disparities caused by COVID-19, to our knowledge, no study has focused on the association of race on outcomes for patients with COVID-19 requiring venovenous extracorporeal membrane oxygenation support. The goal of this study was to assess association of race on death and duration on venovenous extracorporeal membrane oxygenation in both the pre-COVID-19 and COVID-19 eras. Methods: We retrospectively reviewed the Extracorporeal Life Support Organization registry and included adults (>= 18 years) who required venovenous extracorporeal membrane oxygenation between January 2019 and April 2021. We performed descriptive statistics and multivariable logistic regression. Our primary outcomes were death and extracorporeal membrane oxygenation duration. Results: A total of 7477 patients were included after excluding 340 patients (4.3%) who were missing race data. In the COVID-19 era, 1474 of 2777 COVID-19-positive patients (53.1%) died. Our regression model suggested somewhat of a protective effect on death for Black and multiple race patients. Additionally, a diagnosis of COVID-19 and patients in the COVID-19 era in general, irrespective of COVID-19 diagnosis, had higher odds of death. Hispanic patients had the longest average venovenous extracorporeal membrane oxygenation run times. Conclusions: Our study using data from the international Extracorporeal Life Support Organization Registry provides updated data on patients supported with venovenous extracorporeal membrane oxygenation in the pre-COVID-19 and COVID-19 eras between 2019 and 2021 with a focus on race. Patients in the COVID-19 era group also had higher mortality compared with those in the pre-COVID-19 era even after being adjusted for COVID-19 diagnosis. Black and multiple races appeared somewhat protective in terms of death. Hispanic race was associated with longer venovenous extracorporeal membrane oxygenation duration.

AbstractObjectiveThe objective of this study was to report the 12‐month oncological outcomes for patients with non‐muscle‐invasive bladder cancer (NMIBC) within the prospective, international COVIDSurg Cancer study.Patients and methodsEligible patients were aged ≥18 years and scheduled for elective surgical management of NMIBC with curative intent (transurethral resection of bladder tumour [TURBT] or bladder biopsy) from 21 January to 14 April 2020. The primary outcome was disease recurrence within 12 months of previous elective TURBT/bladder biopsy. Secondary outcomes included disease progression within 12 months of previous elective TURBT/bladder biopsy, site‐declared delay to surgery from diagnosis as a consequence of COVID‐19 and deviation in standard care due to COVID‐19. Comparisons were made to cohorts from the pre‐pandemic era.ResultsBladder cancer accounted for 2.2% (n = 446) of patients in the COVIDSurg Cancer study, with data contributed by 27 centres across 12 countries internationally. Within this included cohort, 229 patients had NMIBC and 12‐month follow‐up data available. On application of National Institute for Health and Care Excellence (NICE) criteria, 47.2% were classified as having high‐risk disease. Overall disease recurrence and progression rates were 29.3% and 9.7% at 12 months, respectively. In purely high‐risk pre‐pandemic cohorts, the International Bladder Cancer Group (IBCG) estimates a recurrence rate of 25% at 12 months, and the European Association of Urology (EAU) NMIBC 2021 scoring model estimates a 12‐month progression rate of 3.5%. As a consequence of the COVID‐19 pandemic, 10.9% of patients had site‐declared delay to TURBT/bladder biopsy; 7.4% did not undergo intravesical therapy or had early discontinuation of this; 9.2% did not undergo early repeat resection for high‐risk disease; and 18.3% had a delay to cystoscopic follow‐up surveillance.ConclusionsThis prospective study indicates that there were widespread deviations in usual care for NMIBC during the pandemic and that 12‐month oncological outcomes appear to be impaired compared to published pre‐pandemic outcomes.

BACKGROUND:Transcatheter aortic valve replacement (TAVR) is an increasingly used but relatively expensive procedure with substantial associated readmission rates. It is unknown how cost-constrictive payment reform measures, such as Maryland's All Payer Model, impact TAVR utilization given its relative expense. This study investigated the impact of Maryland's All Payer Model on TAVR utilization and readmissions among Maryland Medicare beneficiaries.METHODS:This was a quasi-experimental investigation of Maryland Medicare patients undergoing TAVR between 2012 and 2018. New Jersey data were used for comparison. Longitudinal interrupted time series analyses were used to study TAVR utilization and difference-in-differences analyses were used to investigate post-TAVR readmissions.RESULTS:During the first year of payment reform (2014), TAVR utilization among Maryland Medicare beneficiaries dropped by 8% (95% confidence interval [CI]: -9.2% to -7.1%; p < 0.001), with no concomitant change in TAVR utilization in New Jersey (0.2%, 95% CI: 0%-1%, p = 0.09). Longitudinally, however, the All Payer Model did not impact TAVR utilization in Maryland compared to New Jersey. Difference-in-differences analyses demonstrated that implementation of the All Payer Model was not associated with significantly greater declines in 30-day post-TAVR readmissions in Maryland versus New Jersey (-2.1%; 95% CI: -5.2% to 0.9%; p =0.1).CONCLUSIONS:Maryland's All Payer Model resulted in an immediate decline in TAVR utilization, likely a result of hospitals adjusting to global budgeting. However, beyond this transition period, this cost-constrictive reform measure did not limit Maryland TAVR utilization. In addition, the All Payer Model did not reduce post-TAVR 30-day readmissions. These findings may help inform expansion of globally budgeted healthcare payment structures.

Introduction: Global burn injury burden disproportionately impacts low- and middle-income countries. Surgery is a mainstay of burn treatment, yet access to surgical care appears to be inequitably distributed for women. This study sought to identify gender disparities in mortality and access to surgery for burn patients in the World Health Organization Global Burn Registry (GBR). Methods: We queried the World Health Organization GBR for a retrospective cohort (20162021). Patients were stratified by sex. Outcomes of interest were in-hospital mortality and surgical treatment. Patient demographics, injury characteristics, outcomes, and health facility resources were compared between sexes with Wilcoxon rank sum test for nonparametric medians, and chi-squared or Fisher's exact test for nonparametric proportions. Multivariable logistic regressions were performed to assess the relationships between sex and mortality, and sex and surgery. Results: Of 8445 patients in the GBR from 20 countries (10 low resource), 40% of patients were female, with 51% of all patients receiving surgical treatment during their hospitalization. Female patients had a higher incidence of mortality (24% versus 15%, P < 0.001) and a higher median total body surface area (20% versus 15%, P < 0.001), yet a lower incidence of surgery (47% versus 53%, P < 0.001) following burn injury when compared to males. In multivariable analysis, female sex was independently associated with mortality after controlling for age, time to presentation, smoke injury, percent total body surface area, surgery, and country income status. Female sex was independently associated with surgical care (odds ratio 0.86, P = 0.001). Conclusions: Female burn patients suffer higher mortality compared to males and are less likely to receive surgery. Further study into this gender disparity in burns is warranted. (c) 2022 Elsevier Inc. All rights reserved.

OBJECTIVE:Cardiac sympathetic denervation (CSD) is a surgical antiadrenergic procedure that can reduce sustained ventricular tachyarrhythmia (VT). Video-assisted thoracoscopic surgery (VATS) is currently the standard approach used in CSD, and the practicality for robot-assisted thoracoscopic surgery (RATS) has yet to be investigated.METHODS:We conducted a single-center retrospective study of all adult patients (N = 67) who underwent CSD from 2015 to 2021. We compared short-term outcomes of those treated with RATS versus VATS thoracic sympathectomy. For patients with VT, we examined the effectiveness of a RATS approach in reducing implantable cardioverter defibrillator (ICD) shock burden.RESULTS:A total of 34 patients underwent RATS cardiac denervation, and 33 underwent VATS cardiac denervation. Those undergoing RATS denervation had a significantly shorter procedure duration with a median of 129 min (P = 0.008). Patients receiving the VATS approach were significantly more complicated by pneumothorax (P = 0.004) and overall complications (P = 0.01) when compared with the RATS approach. At 1 year after surgery, both groups had significant reductions in ICD shocks compared with before surgery, both decreasing from a median of 4 to 0 shocks (P < 0.001). In addition, at 1 year after surgery, the percentage of patients with persistent ICD shocks and the median of ICD shocks were similar between the groups.CONCLUSIONS:The RATS approach to cardiac denervation has similar 1-year follow-up outcomes in reducing recurrent VT as the VATS approach. However, patients undergoing RATS denervation experienced better perioperative outcomes. This shows promise for robotic CSD to be an effective and safe therapeutic option for patients with malignant arrhythmias.