Refractory postoperative vasoplegia following cardiac surgery and left ventricular assist device (LVAD) implantation predicts poor outcomes. We aimed to investigate outcomes and predictors of postoperative vasoplegia. We retrospectively reviewed a single-center cohort of 190 patients who received LVADs from January 2015 through March 2022 at The Ohio State Wexner Medical Center. Primary outcomes included duration of ICU stay, development of right heart failure (RHF), and mortality. Secondary outcomes included pre-implant medications and post-implant blood products. Vasoplegia was defined as physician documentation of vasoplegia with patients requiring ≥1 intravenous vasopressors within 48-hours following LVAD implantation to maintain a mean arterial pressure >65 mmHg for >24 hours. Overall, 55 (29%) patients developed vasoplegia following LVAD implantation. Our sample was stratified into two cohorts: patients with vasoplegia and without vasoplegia. Baseline characteristics, LVAD indication, creatinine clearance, and comorbidities did not vary significantly between cohorts. Patients without vasoplegia were more likely to have prior implantable cardiac defibrillators (p = 0.02) and were more commonly prescribed pre-operative inotropes (p = 0.03). Blood-product administration within the first 48-hours postoperatively did not differ. While patients with vasoplegia required a longer ICU stay post-op (5 vs 7 days, p = 0.03), there were no significant differences in development of RHF (39% vs 44%), 30-day (7% vs 13%), 1-year (31% vs 29%), and 2-year mortality (39% vs 33%) in patients without and with vasoplegia, respectively. Overall, our vasoplegia rates were consistent with previous literature (29%) and vasoplegia did not confer inferior outcomes for mortality or developing RHF.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementNo external funding was received### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Prior to data collection the study protocol was evaluated and approved by the institutional review board at The Ohio State University Medical Center (#2019H0328).I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesData available in the manuscript is available for review upon request

The intercondylar notch of the knee is a relatively small area. However, numerous rare pathologies can arise in this region. A majority of the existing literature has focused on the cruciate ligament injuries, yet there are several other entities that can cause knee pain from within the intercondylar notch. This review focuses on identifying the various diagnostic and treatment options for rare benign and malignant lesions including ganglion cyst formation, mucoid degeneration, benign proliferative conditions, and intra-articular tumors. These entities are most often diagnosed with advanced imaging studies and treated arthroscopically. While rare, these pathologies are important to identify in patients with ongoing vague knee pain.

BACKGROUND Cerebrovascular diseases are a major cause of morbidity and mortality worldwide and are the fifth leading cause of death in the United States. Understanding demographic differences in mortality rate trends can raise awareness of demographic disparities. We sought to investigate age‐adjusted mortality trends due to cerebrovascular diseases and ischemic stroke for demographic disparities in trend from 1999 to 2020. METHODS We used the publicly accessible Centers for Disease Control and Prevention Wide‐Ranging Online Data for Epidemiologic Research database to gather mortality data to determine trends in cerebrovascular diseases and cerebral infarction mortality in the United States from 1999 to 2020. Using the Joinpoint program, temporal trends for cerebrovascular diseases and cerebral infarction mortality were calculated for each demographic group and reported as both annual percentage changes (APCs) or average APC from 1999 to 2020. In addition, trends were compared between groups for significant differences. RESULTS We found an overall decrease in mortality rate for cerebrovascular diseases with average APC −1.9%. In 2020, age‐adjusted mortality rates due to cerebrovascular diseases in the Black population was 1031 per 1 000 000 compared with 679 in the White population. Similarly in 2020, cerebral infarction for the Black population had an age‐adjusted mortality rate of 256.3 compared with the White population's 170.4. When assessing overall trends by race and ethnic group: American Indian/Alaska Native had average APC −2.5%, Asian Pacific Americans had 2.4%, White population had −1.9%, and the Black population had −1.8%. We found a statistically significant difference in trend of decline between the Black and White population cerebrovascular diseases age‐adjusted mortality rates. No significant average APCs were found for cerebral infarction. The results of this study showcase disparities in cerebrovascular diseases mortality in the United States and where additional effort, research, and care should be focused. CONCLUSION The results of this study showcase disparities in mortality in the United States and where additional effort, research, and care should be focused.

OBJECTIVE:Patients with inflammatory bowel disease (IBD) prescribed immunosuppressive therapies including antitumor necrosis factor (aTNF) therapies are at increased risk of histoplasmosis. We aim to evaluate the presentation, management, and outcomes of youth with IBD and concurrent histoplasmosis. METHODS:Single center, retrospective review of youth with IBD diagnosed with histoplasmosis from January 12, 2007 to January 1, 2022. Management and outcomes were followed for up to 2 years after diagnosis. RESULTS:Nineteen patients (10 male, median age 16 years, range 8-22) with IBD were diagnosed with histoplasmosis: disseminated (N = 15/19; 79%), pulmonary (N = 3/19; 16%), lymph node (N = 1/19; 5%). At the time of histoplasmosis diagnosis, patients were predominantly receiving aTNF therapy (N = 17/19; 89%, median duration 21.9 months (interquartile range 8.5-52.0). Thirteen (13/19, 68%) patients required hospitalization and 2/19 (11%) required intensive care. All achieved antigen clearance with no recurrences. At the time of histoplasmosis diagnosis, aTNF was stopped in 15/17 (88%) patients and the following IBD therapies were initiated: 5-aminosalicylates (N = 4/19; 21%), 6-mercaptopurine (N = 3/19; 16%), enteral therapy (N = 2/19; 11%), and vedolizumab (N = 2/19; 11%); 6 of 19 (32%) received no IBD therapy and 2 of 19 (11%) patients continued aTNF. During follow-up, 6 of 19 (32%) patients had an emergency department (ED) visit and/or hospitalization for symptoms attributed to active IBD, all of whom had discontinued aTNF; one patient required colectomy. CONCLUSIONS:Severe histoplasmosis infection in youth with IBD was rare. IBD treatment was modified by reducing immunosuppression. Histoplasmosis outcomes were favorable, but multiple patients required hospitalization or ED visits for IBD symptoms. The optimal approach to managing IBD during histoplasmosis treatment is challenging and requires further study.

Background: Patients undergoing heart transplantation are at significant risk of the developing post-operative vasoplegia, which is associated with poor outcomes. Despite significant burden to these patients, risk factors for development of vasoplegia are poorly understood. We assess these risk factors and outcomes in patients undergoing orthotopic heart transplant at our high-volume academic center. Methods: 173 patients underwent cardiac transplantation between January 1 st , 2015 and February 28 th 2022 at the Ohio State University Wexner Medical Center. Baseline demographics, operative characteristics, peri-operative management, and long-term follow-up data were obtained. Vasoplegia was defined as provider documentation of vasoplegia for patients with persistent hypotension requiring the use of one or more vasopressors to maintain mean arterial pressures >65 mmHg in the absence of other explainable causes (cardiogenic shock, sepsis, etc.) The two primary endpoints assessed were development of vasoplegia in the 48 hours post-transplant and all-cause mortality. Statistical significance was assessed using Chi-squared, analysis of variance, or Kruskal-Wallis where appropriate. Results: In total, 173 patients underwent cardiac transplantation. 89 (51.4%) developed vasoplegia in the post-operative period. 130 (75.1%) were males. The average age at transplant was 56 years. Patients with vasoplegia were more likely to have history of atrial fibrillation (p=0.01) and had higher BMI (p<0.01) compared to those without. There were otherwise no significant differences in demographic data such as past medical history and medication history in those with and without vasoplegia. Patients with vasoplegia had significantly higher cardiopulmonary bypass times (p=0.01), aortic cross-clamp times (p<0.01) and need for red blood cell transfusion peri-operatively (p=0.02). Patients with vasoplegia had higher 30-day mortality (p=0.03), however there was no significant difference in 1-year mortality for those with and without vasoplegia. Conclusions: Vasoplegia is common following orthotopic heart transplant, and short-term mortality is high. Appropriate risk-stratification is paramount in caring for these high-risk patients.

Background Left ventricular assist devices (LVADs) are used as a bridge to transplant or as a destination therapy for patients with end-stage heart failure. LVADs are associated with increased stroke risk, and many patients on LVAD are treated with ACE/ARBs and vasodilators to keep their mean arterial pressure (MAP) at goal to minimize the risk of stroke. We hypothesized that ACE/ARBs and vasodilators can reduce the 5-year risk of stroke in patients with LVAD. Methods We retrospectively analyzed the effect of ACE/ARBs and vasodilators on 5-year risk of developing stroke in patients (n = 250) who have received LVADs at the Ohio State University Wexner Medical Center (OSUWMC). This study was approved by IRB at OSUWMC. After LVAD placement, dates of stroke as well as duration of ACE/ARBs and vasodilators over next 5 years were recorded. In addition, MAP and INR at clinic visits were recorded every 3 months. Results We found that taking ACE/ARBs or vasodilators at any point during the 5-year window did not significantly change the risk of developing stroke. However, we found that duration of ACE/ARBs is positively associated with time-to-stroke after LVAD placement (correlation coefficient = 0.75; P value < 0.001). We further divided stroke patients into two etiologies: ischemic and hemorrhagic strokes. Interestingly, duration of ACE/ARBs was positively correlated with time-to-ischemic strokes only (correlation coefficient = 0.92; P value < 0.001), but not with time-to-hemorrhagic strokes (correlation coefficient = 0.36; P value = 0.39). In addition, duration of vasodilators was not strongly correlated with time-to-stroke (correlation coefficient = 0.4; P value = 0.5). There were no significant differences in MAP and INR in patients on ACE/ARBs, vasodilators, both, or none. Conclusions The mechanism via which ACE/ARBs can delay the occurrence of ischemic stroke is unclear and necessitates further investigation. Importantly, our study suggests that ACE/ARBs may be preferred over vasodilators when managing hypertension in patients with LVADs as ACE/ARBs, especially when taken over an extensive period, may be protective against ischemic strokes. Left ventricular assist devices (LVADs) are used as a bridge to transplant or as a destination therapy for patients with end-stage heart failure. LVADs are associated with increased stroke risk, and many patients on LVAD are treated with ACE/ARBs and vasodilators to keep their mean arterial pressure (MAP) at goal to minimize the risk of stroke. We hypothesized that ACE/ARBs and vasodilators can reduce the 5-year risk of stroke in patients with LVAD. We retrospectively analyzed the effect of ACE/ARBs and vasodilators on 5-year risk of developing stroke in patients (n = 250) who have received LVADs at the Ohio State University Wexner Medical Center (OSUWMC). This study was approved by IRB at OSUWMC. After LVAD placement, dates of stroke as well as duration of ACE/ARBs and vasodilators over next 5 years were recorded. In addition, MAP and INR at clinic visits were recorded every 3 months. We found that taking ACE/ARBs or vasodilators at any point during the 5-year window did not significantly change the risk of developing stroke. However, we found that duration of ACE/ARBs is positively associated with time-to-stroke after LVAD placement (correlation coefficient = 0.75; P value < 0.001). We further divided stroke patients into two etiologies: ischemic and hemorrhagic strokes. Interestingly, duration of ACE/ARBs was positively correlated with time-to-ischemic strokes only (correlation coefficient = 0.92; P value < 0.001), but not with time-to-hemorrhagic strokes (correlation coefficient = 0.36; P value = 0.39). In addition, duration of vasodilators was not strongly correlated with time-to-stroke (correlation coefficient = 0.4; P value = 0.5). There were no significant differences in MAP and INR in patients on ACE/ARBs, vasodilators, both, or none. The mechanism via which ACE/ARBs can delay the occurrence of ischemic stroke is unclear and necessitates further investigation. Importantly, our study suggests that ACE/ARBs may be preferred over vasodilators when managing hypertension in patients with LVADs as ACE/ARBs, especially when taken over an extensive period, may be protective against ischemic strokes.

The purpose of this study was to evaluate the relationship between the number of all-inside meniscal repair implants placed and the risk of repair failure. We hypothesized that the use of higher numbers of all-inside meniscus repair implants would be associated with increased failure risk. A retrospective chart review identified 351 patients who underwent all-inside meniscus repair between 2006 and 2013 by a sports medicine fellowship-trained orthopaedic surgeon at a single institution. Patient demographics (age, body mass index [BMI], sex) and surgical data (number of implants used, concomitant anterior cruciate ligament reconstruction [cACLR], and tear type/size/location) were recorded. Patients who received repairs in both menisci or who had follow-up < 1-year postoperatively were excluded. Repair failure was identified through chart review or patient interviews defined as a revision surgery on the index knee such as partial meniscectomy, total knee arthroplasty, meniscus transplant, or repeat repair. Logistic regression modeling was utilized to evaluate the relationship between the number of implants used and repair failure. A total of 227 all-inside meniscus repairs were included with a mean follow-up of 5.0 ± 3.0 years following surgery. Repair failure was noted in 68 knees (30.3%)-in 28.1% of knees with fewer than four implants and in 35.8% of knees with four or more implants (p = 0.31). No significant increase in failure was observed with increasing number of all-inside medial (odds ratio [OR]: 1.15; 95% confidence interval [CI]: 0.79-1.7; p = 0.46) or lateral (OR: 0.86; 95% CI: 0.47-1.57; p = 0.63) implants after controlling for patient age, BMI, cACLR, tear type, or size. Tears of the lateral meniscus located in the red-white and white-white zones had lower odds of failure (OR: 0.14; 95% CI: 0.02-0.88; p = 0.036) than tears within the red-red zone, and patients with cACLR had lower odds of repair failure (OR: 0.40; 95% CI: 0.18-0.86, p = 0.024) than those without. The number of all-inside implants placed during meniscus tear repair did not affect the likelihood of repair failure leading to reoperation after controlling for BMI, age, tear type, size, location, and cACLR. LEVEL OF EVIDENCE:  III.