BACKGROUND:Congenital heart disease (CHD) is one the most common congenital anomalies, with a prevalence of 8-10 cases per 1000 live births in the United States. Congenital heart disease has been recognized as a risk factor for poor perioperative and postoperative outcomes in non-cardiac surgery. We aimed to determine if documentation of CHD-related diagnosis codes was associated with similar risks for trauma surgery. METHODS:Data were acquired from the 2010-2019 American College of Surgeons' Trauma Quality Programs Participant Use Files. This study included trauma patients of all ages with one or more surgical procedures and at least one documented non-trauma (comorbidity) International Classification of Diseases code. Patients were stratified based on presence of CHD-related comorbidity codes vs any other comorbidity. Outcomes included mortality, hospital length of stay (LOS), discharge disposition, and in-hospital complications. RESULTS:Using 1:1 propensity score matching, we matched 215 cases with CHD-related comorbid diagnoses to non-CHD controls. Compared to patients with other comorbidities, patients with CHD-related comorbidites were less likely to be discharged home to self-care (odds ratio: 0.44, 95% confidence interval [CI]: 0.25, 078 P = .005) and tended to have prolonged hospital LOS (incidence rate ratio [IRR]: 1.06, 95% CI: 1.001, 1.13, P = .046). CONCLUSIONS:We present the first quantitative multicenter analysis correlating documentation of comorbid CHD-related diagnoses with higher risk of adverse outcomes after trauma surgery. These results support the need to routinely acknowledge and document CHD as comorbidity in trauma admissions that could lead to surgical intervention and for trauma centers to prepare for patients with a possible CHD comorbidity.

The Appendices can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2022.10.019] on http://www.annalsthoracicsurgery.org. The Appendices can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2022.10.019] on http://www.annalsthoracicsurgery.org. The Society of Thoracic Surgeons (STS) prioritizes the elimination of bias and disparities in cardiothoracic surgery. This statement, submitted on behalf of the STS Workforce on Health Policy, Reform, and Advocacy, outlines the scope of the challenge and highlights the efforts of the STS in this domain. Differences in prevalence exist in the conditions treated by cardiothoracic surgeons. Ischemic heart disease varies markedly along racial, ethnic, sexual orientation, and gender lines. Moreover there are stark differences in the use of therapies such as percutaneous coronary intervention and coronary artery bypass grafting (CABG). Lung cancer is highest in the most deprived neighborhoods. The disparities in access and treatment influence outcomes. Disparities also affect access to cardiothoracic surgery as a whole. This inequity is manifest in the varied access to CABG and aortic valve replacement and newer therapies such as transcatheter aortic valve replacement and mitral valve therapies. Indeed they are reflected in the enrollment in cardiovascular trials, which has disproportionately fewer female and minority patients. Disparities are prevalent in cardiac, thoracic, congenital cardiac, and transplantation patients, and the efforts to create a more equitable allocation of cardiothoracic resources require multiple stakeholders. Access is a complex interplay of patient-, provider-, and system-level factors. Geographic factors can influence all of these. Utilization rates underpin the difference between geographic availability and physical usage. The STS has supported legislative efforts to improve access to cardiothoracic surgery and promote health equity. These address resident workforce shortages, advocacy for increased diversity, and protecting vulnerable communities from an array of public health threats. The efforts also focus on reducing tobacco use by prohibiting menthol cigarettes and the targeted advertising campaign focused on minority communities. The initiative culminated in a US Food and Drug Administration effort to ban menthol cigarettes in 2022. In addition the STS is a member of the Healthy Air Coalition, which aims to reduce pollution and improve air quality to promote health outcomes. Vulnerable communities are at much higher risk of exposure. The STS Workforce on Diversity, Equity, and Inclusion was established in 2019 to nurture diversity and inclusion within the STS and the broader cardiothoracic surgical community. The Workforce aims to improve cultural competency and address health disparities in clinical, scientific, educational, and advocacy domains. There is a growing impetus to recruit underrepresented minorities and women into cardiothoracic surgical training programs and provide targeted mentorship and sponsorship efforts. The STS strongly supports advocacy initiatives that explicitly incorporate social determinants of health to improve health equity, improve awareness, and encourage training and implementation. The STS Research Center and National Database have provided meaningful insights into program outcomes and ongoing efforts at continuous improvement for over 2 decades The addition of socioeconomic status data in the form of the area deprivation index (ADI) will provide novel insight into the impact of social determinants of health on clinical outcomes. The STS supports efforts to recruit, train, and retain a diverse physician workforce. This includes making training programs more amenable to a diverse group of trainees, addressing issues such as parental leave, and making family expansion less disruptive to trainees and early-career physicians. The commitment to expanding diversity in the physician workforce is well recognized. By increasing racial and gender concordance between physicians and patients, there can be an improvement in care quality and cultural competency. Other major medical societies and organizations have well recognized the effect of structural racism on patient outcomes. The STS joins the emphatic voices of the American College of Cardiology and American College of Surgeons to acknowledge the role that structural racism has in exacerbating health disparities and the need to actively work to eliminate structural racism in all its manifestations in health care. Moreover the STS supports the disaggregation of health data by race and ethnicity to appreciate more considerable differences that may exist within different racial and ethnic categories in health care. In addition the STS supports policies that advance equity in payment models and organ transplantation programs to better reduce inequities. The collective STS efforts in multiple areas of promoting diversity, equity, and inclusion are an ongoing commitment by the organization with active engagement of its membership in this regard. The STS is committed to eliminating bias and disparities in cardiothoracic surgery specifically and in health care in general. Equitable access facilitates the optimization of patient outcomes across all patient demographics. The purpose of this article is to review existing disparities in cardiac and pulmonary diseases and access to cardiothoracic surgical care and outcomes. In addition we explore past policy efforts and outline STS positions on crucial policies aimed at mitigating health inequities along the continuum of care. The 2 most common conditions treated by cardiothoracic surgeons in the United States are ischemic heart disease and lung cancer.1Grover A. Gorman K. Dall T.M. et al.Shortage of cardiothoracic surgeons is likely by 2020.Circulation. 2009; 120: 488-494Crossref PubMed Scopus (157) Google Scholar These 2 conditions are the leading causes of disease burden in the United States as measured by disability-adjusted life years.2Mokdad A.H. Ballestros K. Echko M. et al.The state of US health, 1990-2016: burden of diseases, injuries, and risk factors among US states.JAMA. 2018; 319: 1444-1472Crossref PubMed Scopus (894) Google Scholar The third leading cause is chronic obstructive pulmonary disease.2Mokdad A.H. Ballestros K. Echko M. et al.The state of US health, 1990-2016: burden of diseases, injuries, and risk factors among US states.JAMA. 2018; 319: 1444-1472Crossref PubMed Scopus (894) Google Scholar Risk factors for each condition frequently overlap and include various combinations of smoking, hypertension, obesity, and hypercholesterolemia. These risk factors are highly linked to social determinants of health and often fall along racial, gender, and socioeconomic demographic lines that are typically manifest in disparities in incidence, treatment, and patient outcomes. Data from the American Heart Association highlight the racial, ethnic, and gender differences in the prevalence of coronary artery disease. The highest rates are in White men (8.7%), followed by Hispanic men (6.8%), Black men (6.7%), and Asian men (5.0%).3Grines C.L. Klein A.J. Bauser-Heaton H. et al.Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease.Cath Cardiovasc Interv. 2021; 98: 277-294Crossref PubMed Scopus (13) Google Scholar Although women typically have lower rates of coronary artery disease, Black women have higher rates of disease (7.2%) compared with Hispanic (6.4%), White (6.0%), and Asian women (3.2%).3Grines C.L. Klein A.J. Bauser-Heaton H. et al.Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease.Cath Cardiovasc Interv. 2021; 98: 277-294Crossref PubMed Scopus (13) Google Scholar Recent reports demonstrate marked discrepancies in the frequency with which percutaneous coronary intervention and CABG is performed in different racial and ethnic groups in the United States, with Black patients less likely to receive CABG with poorer risk-adjusted outcomes.4Zea-Vera R. Asokan S. Shah R.M. et al.Racial/ethnic differences persist in treatment choice and outcomes in isolated intervention for coronary artery disease.J Thorac Cardiovasc Surg. Published online February 3, 2022; https://doi.org/10.1016/j.jtcvs.2022.01.034Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Evidence also shows that LGBTQ+ adults experience disparities across several cardiovascular health metrics.5Caceres B.A. Streed C.G. Corliss H.L. et al.Assessing and addressing cardiovascular health in LGBTQ adults: a scientific statement from the American Heart Association.Circulation. 2020; 142: e321-e332Crossref PubMed Scopus (97) Google Scholar The prevalence of cardiovascular disease may be underestimated given the comparatively lower rates of hospital admissions, invasive testing, and revascularizations among minority populations, which provides a basis on which prevalence is most frequently characterized.6Jones D.W. Chambless L.E. Folsom A.R. et al.Risk factors for coronary heart disease in African Americans: the atherosclerosis risk in communities study, 1987-1997.Arch Intern Med. 2002; 162: 2565-2571Crossref PubMed Scopus (124) Google Scholar,7Cram P. Bayman L. Popescu I. Vaughan-Sarrazin M.S. Racial disparities in revascularization rates among patients with similar insurance coverage.J Natl Med Assoc. 2009; 101: 1132-1139Crossref PubMed Scopus (47) Google Scholar The incidence of lung cancer is highest among male patients living in the most deprived neighborhoods.8Singh G.K. Jemal A. Socioeconomic and racial/ethnic disparities in cancer mortality, incidence, and survival in the United States, 1950-2014: over six decades of changing patterns and widening inequalities.J Environ Public Health. 2017; 2017: 2819372Crossref PubMed Scopus (441) Google Scholar The age-adjusted lung cancer incidence among Black men, for example, is approximately 30% higher than that in White men despite comparatively lower overall exposure to cigarette smoke.9The American Lung Association. Lung cancer fact sheet: racial/ethnic differences [updated 2020; cited 2020]. Accessed October 8, 2022. https://www.lung.org/lung-health-diseases/lung-disease-lookup/lung-cancer/resource-library/lung-cancer-fact-sheetGoogle Scholar Similarly for women with lung cancer, the incidence rate is equal for Black and White women despite disproportionately lower smoking rates among Black women.9The American Lung Association. Lung cancer fact sheet: racial/ethnic differences [updated 2020; cited 2020]. Accessed October 8, 2022. https://www.lung.org/lung-health-diseases/lung-disease-lookup/lung-cancer/resource-library/lung-cancer-fact-sheetGoogle Scholar The starkest example of lung cancer disparity, nevertheless, is in patients identifying as lesbian, gay, bisexual, or unsure (LGBTQ+). These patients often endure an extra burden of societal and environmental constraints that are poorly understood and are poorly studied.10Matthews A.K. McCabe S.E. Lee J.G.L. Veliz P. Differences in smoking prevalence and eligibility for low-dose computed tomography (LDCT) lung cancer screening among older U.S. adults: role of sexual orientation.Cancer Causes Control. 2018; 29: 769-774Crossref PubMed Scopus (10) Google Scholar,11Veliz P. Matthews A.K. Arslanian-Engoren C. et al.LDCT lung cancer screening eligibility and use of CT scans for lung cancer among sexual minorities.Cancer Epidemiol. 2019; 60: 51-54Crossref PubMed Scopus (17) Google Scholar The following section shows relevant reports and key references in the literature coupled with their respective key findings. •Becker ER, Granzotti AM. Trends in in-hospital coronary artery bypass surgery mortality by gender and race/ethnicity—1998-2015: why do the differences remain? J Natl Med Assoc. 2019;111:527-539.12Becker E.R. Granzotti A.M. Trends in in-hospital coronary artery bypass surgery mortality by gender and race/ethnicity—1998-2015: why do the differences remain?.J Natl Med Assoc. 2019; 111: 527-539Crossref PubMed Scopus (20) Google Scholar•Key Findings (Nationwide Inpatient Sample, N = 5,032,985): Although overall CABG mortality has been reduced, Black men still have the highest risk-adjusted mortality, which has persisted.•Benedetto U, Kamel MK, Khan FM, et al. Are racial differences in hospital mortality after coronary artery bypass graft surgery real? A risk-adjusted meta-analysis. J Thorac Cardiovasc Surg. 2019;157:2216-2225.13Benedetto U. Kamel M.K. Khan F.M. et al.Are racial differences in hospital mortality after coronary artery bypass graft surgery real? A risk-adjusted meta-analysis.J Thorac Cardiovasc Surg. 2019; 157: 2216-2225Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar•Key Findings (meta-analysis of 28 studies, N = 3,990,519): Despite lower mortality rates for CABG across most racial and ethnic groups over time, the relative disadvantage for non-White groups persisted.•Chatterjee S, LeMaire SA, Amarasekara HS, et al. Differential presentation in acuity and outcomes based on socioeconomic status in patients who undergo thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg. 2022;163:1990-1998.e1.14Chatterjee S. LeMaire S.A. Amarasekara H.S. et al.Differential presentation in acuity and outcomes based on socioeconomic status in patients who undergo thoracoabdominal aortic aneurysm repair..J Thorac Cardiovasc Surg. 2022; 163: 1990-1998.e1Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar•Key Findings (single-center report, N = 832): Socioeconomic status differences did not result in differences in early mortality or late survival in a single-center, high-volume series. Lower socioeconomic status patients presented with higher degrees of acuity.•Matthew Brennan J, Leon MB, Sheridan P, et al. Racial differences in the use of aortic valve replacement for treatment of symptomatic severe aortic valve stenosis in the transcatheter aortic valve replacement era. J Am Heart Assoc. 2020;9:e015879.15Matthew Brennan J. Leon M.B. Sheridan P. et al.Racial differences in the use of aortic valve replacement for treatment of symptomatic severe aortic valve stenosis in the transcatheter aortic valve replacement era.J Am Heart Assoc. 2020; 9e015879Crossref PubMed Scopus (28) Google Scholar•Key Findings (Optum Health Record Database, N = 32,853): Transcatheter aortic valve replacement rates are less common in Black patients than White patients with symptomatic severe aortic stenosis.•Loehrer AP, Hawkins AT, Auchincloss HG, Song Z, Hutter MM, Patel VI. Impact of expanded insurance coverage on racial disparities in vascular disease: insights from Massachusetts. Ann Surg. 2016;263:705.16Loehrer A.P. Hawkins A.T. Auchincloss H.G. Song Z. Hutter M.M. Patel V.I. Impact of expanded insurance coverage on racial disparities in vascular disease: insights from Massachusetts.Ann Surg. 2016; 263: 705-711Crossref PubMed Scopus (41) Google Scholar•Key Findings (Healthcare Cost and Utilization Project State Inpatient Databases of 4 states, N = 20,295): Insurance expansion in 2006 resulted in elimination of racial disparities in those states that expanded but no improvement in those that did not. •Farjah F, Wood DE, Yanez ND, et al. Racial disparities among patients with lung cancer who were recommended operative therapy. Arch Surg. 2009;144:14-18.17Farjah F. Wood D.E. Yanez N.D. et al.Racial disparities among patients with lung cancer who were recommended operative therapy.Arch Surg. 2009; 144: 14-18Crossref PubMed Scopus (111) Google Scholar•Key Findings (Surveillance, Epidemiology, and End Results Medicare database, N = 17,739): Black patients underwent resection for lung cancer less frequently than White patients among patients recommended for surgery.•Ebner PJ, Ding L, Kim AW, et al. The effect of socioeconomic status on treatment and mortality in non-small cell lung cancer patients. Ann Thorac Surg. 2020;109:225-232.18Ebner P.J. Ding L. Kim A.W. et al.The effect of socioeconomic status on treatment and mortality in non-small cell lung cancer patients.Ann Thorac Surg. 2020; 109: 225-232Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar•Key Findings (National Cancer Database; n = 69,168): Socioeconomic status factors increased the likelihood of no treatment in stage 1 non-small cell lung cancer, reducing survival.•Savitch SL, Grenda TR, Scott W, et al. Racial disparities in rates of surgery for esophageal cancer: a study from the National Cancer Database. J Gastrointest Surg. 2021;25:581-592.19Savitch S.L. Grenda T.R. Scott W. et al.Racial disparities in rates of surgery for esophageal cancer: a study from the National Cancer Database.J Gastrointest Surg. 2021; 25: 581-592Crossref PubMed Scopus (22) Google Scholar•Key Findings (National Cancer Database, N = 60,041): Black patients with esophageal cancer had a higher risk of mortality compared with Whites patients and were less likely to receive surgical intervention. •Anderson BR, Fieldston ES, Newburger JW, Bacha EA, Glied SA. Disparities in outcomes and resource use after hospitalization for cardiac surgery by neighborhood income. Pediatrics. 2018;141:e20172432.20Anderson B.R. Fieldston E.S. Newburger J.W. Bacha E.A. Glied S.A. Disparities in outcomes and resource use after hospitalization for cardiac surgery by neighborhood income.Pediatrics. 2018; 141: e20172432Crossref PubMed Scopus (81) Google Scholar•Key Findings (Pediatric Health Information System database, N = 101,013): Children from lower-income neighborhoods have higher risk-adjusted mortality and resource use after cardiac surgery.•Oster ME, Strickland MJ, Mahle WT. Racial and ethnic disparities in post-operative mortality following congenital heart surgery. J Pediatr 2011;159:222-226.21Oster M.E. Strickland M.J. Mahle W.T. Racial and ethnic disparities in post-operative mortality following congenital heart surgery.J Pediatr. 2011; 159: 222-226Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar•Key Findings (Pediatric Health Information System database, N = 44,017): Risk-adjusted mortality for Black and Hispanic patients was higher than for White patients even after adjusting for access to care after cardiac surgery. •ClerkinKJ, Garan AR, Wayda B, et al. Impact of socioeconomic status on patients supported with a left ventricular assist device: an analysis of the UNOS database (United Network for Organ Sharing). Circ Heart Fail. 2016;9:e003215.22Clerkin K.J. Garan A.R. Wayda B. et al.Impact of socioeconomic status on patients supported with a left ventricular assist device: an analysis of the UNOS database (United Network for Organ Sharing).Circ Heart Fail. 2016; 9: e003215Crossref PubMed Scopus (17) Google Scholar•Key Findings (United Network for Organ Sharing database, N = 3361): Waitlist mortality was not found to be affected by socioeconomic status. Low socioeconomic status was associated with worse post-orthotopic heart transplantation outcomes in patients bridged with left ventricular assist devices.•Chan EG, Hayanga JWA, Tuft M, Morrell MR, Sanchez PG. Access to lung transplantation in the United States: the potential impact of access to a high-volume center. Transplantation. 2020;104:e199-e207.23Chan E.G. Hayanga J.W.A. Tuft M. Morrell M.R. Sanchez P.G. Access to lung transplantation in the united states: the potential impact of access to a high-volume center.Transplantation. 2020; 104: e199-e207Crossref PubMed Scopus (4) Google Scholar•Key Findings (United Network for Organ Sharing database, N = 13,374): Socioeconomic status differences did not result in inferior outcomes after lung transplantation.•Eberly LA, Richterman A, Beckett AG, et al. Identification of racial inequities in access to specialized inpatient heart failure care at an academic medical center. Circ Heart Fail. 2019;12:e006214.24Eberly L.A. Richterman A. Beckett A.G. et al.Identification of racial inequities in access to specialized inpatient heart failure care at an academic medical center.Circ Heart Fail. 2019; 12e006214Crossref PubMed Scopus (83) Google Scholar•Key Findings (single-center study, N = 1967): Black and Latino patients were less likely to be evaluated by heart failure cardiology. Several studies have confirmed the disparities in patient access to cardiothoracic surgery in the United States from 2011 to 2016. For instance the overall rate of aortic valve replacement increased by 17%, but Black patients were 8.2% less likely than White patients to undergo aortic valve replacement.15Matthew Brennan J. Leon M.B. Sheridan P. et al.Racial differences in the use of aortic valve replacement for treatment of symptomatic severe aortic valve stenosis in the transcatheter aortic valve replacement era.J Am Heart Assoc. 2020; 9e015879Crossref PubMed Scopus (28) Google Scholar Moreover Black, Hispanic, and lower socioeconomic status patients have been shown to be less likely to receive transcatheter aortic valve replacement. The variation in access is further exacerbated in the use of transcatheter edge-to-edge mitral valve repair, ranging from 38.0 per 100,000 in White patients compared with 29.7 per 100,000 in Black patients and 30.5 per 100,000 in Hispanic patients.25Sparrow R.T. Sanjoy S.S. Lindman B.R. et al.Racial, ethnic and socioeconomic disparities in patients undergoing transcatheter mitral edge-to-edge repair.Int J Cardiol. 2021; 344: 73-81Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Studies have also revealed that enrollment in cardiovascular trials of female and minority patients is low in the United States.26Preventza O. Critsinelis A. Simpson K. et al.Sex, racial, and ethnic disparities in U.S. cardiovascular trials in more than 230,000 patients.Ann Thorac Surg. 2021; 112: 726-735Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar,27Mayor J.M. Preventza O. McGinigle K. et al.Persistent under-representation of female patients in United States trials of common vascular diseases from 2008 to 2020.J Vasc Surg. 2022; 75: 30-36Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Engagement of industry and surgical leadership to address these disparities is likely necessary to achieve durable solutions.26Preventza O. Critsinelis A. Simpson K. et al.Sex, racial, and ethnic disparities in U.S. cardiovascular trials in more than 230,000 patients.Ann Thorac Surg. 2021; 112: 726-735Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Factors contributing to healthcare disparities in cardiothoracic surgery are depicted in Figure 1.14Chatterjee S. LeMaire S.A. Amarasekara H.S. et al.Differential presentation in acuity and outcomes based on socioeconomic status in patients who undergo thoracoabdominal aortic aneurysm repair..J Thorac Cardiovasc Surg. 2022; 163: 1990-1998.e1Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,28Vervoort D. Meuris B. Meyns B. Verbrugghe P. Global cardiac surgery: access to cardiac surgical care around the world.J Thorac Cardiovasc Surg. 2020; 159: 987-996Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 29Peterson J.K. Chen Y. Nguyen D.V. Setty S.P. Current trends in racial, ethnic, and healthcare disparities associated with pediatric cardiac surgery outcomes.Congenit Heart Dis. 2017; 12: 520-532Crossref PubMed Scopus (33) Google Scholar, 30Vinck E.E. Ebels T. Hittinger R. Peterson T.F. Cardiothoracic surgery in the Caribbean.Braz J Cardiovasc Surg. 2021; 36: 599-606Crossref PubMed Scopus (6) Google Scholar, 31Ferraris V.A. Pezzella A.T. Worldwide disparities in cardiac surgical care: thinking globally not locally to solve problems of limited resources and access to specialized care [Commentary].J Thorac Cardiovasc Surg. 2020; 159: 997-999Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 32Erkmen C.P. Ortmeyer K.A. Pelletier G.J. Preventza O. Cooke D.T. Society of Thoracic Surgeons Workforce on Diversity and Inclusion. An approach to diversity and inclusion in cardiothoracic surgery.Ann Thorac Surg. 2021; 111: 747-752Abstract Full Text Full Text PDF PubMed Google Scholar The evaluation of access in the healthcare setting is a product of both the individual and the environment. The individual is influenced by an intersection of patient-, provider-, and system-level factors, including the interplay of social determinants of health aSocial determinants of health are conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks.33Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human ServicesSocial determinants of health.https://health.gov/healthypeople/objectives-and-data/social-determinants-healthDate: 2021Google Scholar that may work for and against access in varying magnitudes.34Mannoh I. Hussien M. Commodore-Mensah Y. Michos E.D. Impact of social determinants of health on cardiovascular disease prevention.Curr Opin Cardiol. 2021; 36: 572-579Crossref PubMed Scopus (37) Google Scholar Access itself can be broadly classified into geographic availability and utilization. Geographic factors often exacerbate the effect of these determinants. Residential deprivation, diversity index, residential segregation, racial clustering, and Gini index (measure of income across a population to reflect the degree of income inequality), for example, each proffer a quantitative influence that may be analyzed using contemporary online tools.23Chan E.G. Hayanga J.W.A. Tuft M. Morrell M.R. Sanchez P.G. Access to lung transplantation in the united states: the potential impact of access to a high-volume center.Transplantation. 2020; 104: e199-e207Crossref PubMed Scopus (4) Google Scholar,35Hayanga A.J. Waljee A.K. Kaiser H.E. Chang D.C. Morris A.M. Racial clustering and access to colorectal surgeons, gastroenterologists, and radiation oncologists by African Americans and Asian Americans in the United States: a county-level data analysis.Arch Surg. 2009; 144: 532-535Crossref PubMed Scopus (49) Google Scholar,36Hayanga A.J. Kaiser H.E. Sinha R. Berenholtz S.M. Makary M. Chang D. Residential segregation and access to surgical care by minority populations in US counties.J Am Coll Surg. 2009; 208: 1017-1022Crossref PubMed Scopus (64) Google Scholar Utilization depends on a multitude of factors as patient-, system-, and provider-level inputs influence the ability to use the health infrastructure. In addition levels of trust for the healthcare system by the individual and the community at large are also important influencing factors.37White R.M. Misinformation and misbeliefs in the Tuskegee Study of Untreated Syphilis fuel mistrust in the healthcare system.J Natl Med Assoc. 2005; 97: 1566-1573PubMed Google Scholar These social determinants of health are complex, often interrelated, and may influence clinical outcomes to a greater extent than the actual treatment provided, particularly in underserved populations. Clinical research using the tools at the disposal of the STS may provide greater insight. The STS has supported legislation advocating for improved access to cardiothoracic surgery and health equity for all patients. The initiatives include support of the South Asian Heart Health Awareness and Research Act of 2017, Women and Lung Research and Preventive Services Act of 2018, Ensuring Children's Access to Specialty Care Act of 2015, and Resident Physician Shortage Reduction Act of 2021. Moreover legislation supporting increased funding for the Centers for Disease Control and Prevention's Climate and Health Program has also been encouraged. These efforts address resident shortages, advocate for increased diversity, and seek to protect vulnerable communities from public health threats. In a similar vein the STS supports administrative and regulatory efforts to improve health equity. In addition to other tobacco-focused advocacy efforts, the STS supported coalition efforts to prohibit menthol cigarettes. Menthol cigarettes posed a public health threat and impacted health equity because of manufacturer advertising practices that specifically targeted Black consumers.38Stopping menthol, saving lives: ending big tobacco's predatory marketing to black communitiesTobacco Free Kids.https://www.tobaccofreekids.org/assets/content/what_we_do/industry_watch/menthol-report/2021_02_tfk-menthol-report.pdfDate: 2021Google Scholar Initiation with menthol cigarettes was higher among Black smokers (93.1%) than White smokers (43.9%).39Chetty R. Stepner M. Abraham S. et al.The association between income and life expectancy in the United States, 2001-2014.JAMA. 2016; 315: 1750-1766Crossref PubMed Scopus (1413) Google Scholar In April 2021 the US Food and Drug Administration announced the intention to ban menthol cigarettes, aiming to propose regulation by April 2022.40US Food and Drug AdministrationFDA commits to evidence-based actions aimed at saving lives and preventing future generations of smokers.https://www.fda.gov/news-events/press-announcements/fda-commits-evidence-based-actions-aimed-saving-lives-and-preventing-future-generations-smokersDate: 2021Google Scholar The STS is a member of the Healthy Air Coalition, which aims to improve air quality in all communities. Given the impact of pollution and climate on heart and lung disease incidence, the STS has supported advocacy efforts to enhance the air quality and improve equitable health outcomes. Chronic exposure to air pollution increases the risk of cardiovascular disease, including increased risk of ischemic heart disease, heart failure, and ischemic/thrombotic stroke.41Air pollution: healthy neighborhoods are free of pollution and toxins that undermine safety, health, and well-being.https:

BACKGROUND Because of the limited published information on complications that obstructive sleep apnea (OSA) patients experience during and after cardiac surgery, we investigated OSA as a risk factor for postoperative outcomes. METHODS This project used the Northern New England Cardiovascular Disease Study Group's data collected between 2011 and 2017 based on The Society of Thoracic Surgeons Adult Cardiac Surgery Database Data Collections form. A retrospective analysis of 1555 patients with OSA and 10,450 patients without OSA across 5 medical centers undergoing isolated coronary artery bypass grafting, isolated valve surgery, and combined coronary artery bypass grafting valve surgery was conducted. We used 1:1 nearest-neighbor propensity score matching with no replacement to balance characteristics among patients with and without OSA. RESULTS There was a statistically significant increased risk of postoperative pneumonia, increased length of total and postoperative stay, and time to initial extubation. Two outcomes trended toward significance: intra-and postoperative intraaortic balloon pump use. Outcomes that failed to show statistical significance were surgical site infection, atrial fibrillation, cerebrovascular accident, permanent pacemaker placement, and blood products given. A chart review conducted on a subset of the study cohort revealed that more than 40% of OSA patients did not receive continuous positive airway pressure or bilevel positive airway pressure therapy postoperatively during their hospitalization. CONCLUSIONS Our study aligns with the literature in concluding that OSA has deleterious effects on postoperative outcomes of cardiac surgery patients. Further research to better stratify OSA patients by severity are still needed. Additionally heightened awareness of the need to screen, diagnose, and properly treat patients for OSA is needed. (c) 2022 by The Society of Thoracic Surgeons

INTRODUCTION:IFN lambda (type III-IFN-λ1) is a molecule primarily produced by epithelial cells that provides an important first-line defence against viral respiratory infections and has been linked to the pathogenesis of viral-induced wheezing in early life. The goal of this study was to better understand the regulation of innate IFN-lambda responses in vitro in primary human infant airway epithelial cells (AECs) and in vivo using nasal aspirates during viral respiratory infections. METHODS:IFN-lambda protein levels were quantified: (a) in human infant AECs exposed to (poly(I:C) dsRNA) under different experimental conditions (n = 8 donors); and (b) in nasal aspirates of young children (≤3 years) hospitalized with viral respiratory infection (n = 138) and in uninfected controls (n = 74). In vivo IFN-lambda airway levels during viral infections were correlated with individual characteristics and respiratory disease parameters. RESULTS:Our in vitro experiments showed that the poly(I:C)-induced innate production of IFN lambda in human infant AECs is regulated by (a) p38-MAPK/NF-kB dependent mechanism; and (b) exposure to pro-inflammatory signals such as IL1β. Our in vivo studies demonstrated that (a) infants (<18 months) had higher virus-induced IFN-lambda airway secretion; (b) subjects with RSV infection showed the highest IFN-lambda airway levels; and (c) individuals with the highest virus-induced IFN-lambda levels (>90th percentile) had higher viral loads and were more likely to have respiratory sick visits within 12 months of discharge (OR = 5.8). CONCLUSION:IFN-lambda responses to dsRNA in the human infant airway epithelium are regulated by p38-MAPK and NF-kB signalling. High in vivo IFN-lambda production is influenced by virus type and associated with recurrent respiratory sick visits in young children.

Objectives Otitis media (OM) is a ubiquitous pediatric disease leading to a significant health care burden. There is no medication beneficial to resolving COM fluid, highlighting the need for research in the field. Crucially, current human middle ear epithelial cell models are transformed cells not recapitulating physiological functions. Herein, we describe a new method to proliferate and differentiate pediatric primary middle ear epithelial cells (pMEEC) from patients as a physiological model for the study of OM. Methods We adapted a cell reprogramming protocol using irradiated fibroblast feeder medium in addition to Rho kinase inhibitor to proliferate pMEEC collected during cochlear implant surgery. Cells were plated on transwell membranes, proliferated with conditionally reprogrammed culture medium, and transferred to air–liquid interface (ALI). Cultures were maintained for 4 weeks at ALI, photos were taken and cell lysates and secretions were collected over time for characterization analysis using quantitative polymerase chain reaction, Western bolt, and proteomics. Keratins, MUC5B and MUC5AC mucins, and beta tubulin (TUBB) were analyzed at the mRNA and protein level. Results Cultures took a mean of 2 weeks to proliferate before transwell plating and forming a tight epithelium at ALI from 2 to 4 weeks. Although mRNA expression of MUC5B, MUC5AC, TUBB, and keratin 5 (KRT5) were variable depending on the differentiation stage and the patient, both TUBB and KRT5 proteins were detected until week 2. Conclusion We demonstrate a novel method to proliferate and differentiate pMEECs that express epithelial markers and that are able to secrete mucins for the study of OM. Level of Evidence NA

The quantity, accessibility and focus on child-targeted programming has exponentially increased since it entered American households in the early 1900s. It may have started with the television (TV), but technology has evolved and now fits in our pockets; as of 2017, 95% of American families own a smartphone. Availability and child-tailored content has subsequently led to a decrease in the age at initial screen exposure. The negative effects that accompany the current culture of early screen exposure are extensive and need to be considered as technology continues to enter the home and inundate social interactions. Increased levels of early screen exposure have been associated with decreased cognitive abilities, decreased growth, addictive behavior, poor school performance, poor sleep patterns, and increased levels of obesity. Research on the adverse effects of early screen exposure is mounting, but further epidemiological studies are still needed to inform prevention and regulation policies.

Background: Airway epithelial cells (AEC) are quite difficult to access in newborns and infants. It is critically important to develop robust life-extended models to conduct translational studies in this age group. We propose the use of a recently described cell culture technology (conditionally reprogrammed cells-CRC) to generate continuous primary cell cultures from nasal and bronchial AEC of young children. Methods: We collected nasal and/or bronchial AEC from a total of 23 subjects of different ages including newborns/infants/toddlers (0-2years; N=9), school-age children (4-11years; N=6), and a group of adolescent/adult donors (N=8). For CRC generation, we used conditioned medium from mitotically inactivated 3T3 fibroblasts and Rho-associated kinase (ROCK) inhibitor (Y-27632). Antiviral immune responses were studied using 25 key antiviral genes and protein production of type III epithelial interferon (IFN lambda 1) after double-stranded (ds) RNA exposure. Results: CRC derived from primary AEC of neonates/infants and young children exhibited: (i) augmented proliferative capacity and life extension, (ii) preserved airway epithelial phenotype after multiple passages, (iii) robust immune responses characterized by the expression of innate antiviral genes and parallel nasal/bronchial production of IFN lambda 1 after exposure to dsRNA, and (iv) induction of airway epithelial inflammatory and remodeling responses to dsRNA (eg, CXCL8 and MMP9). Conclusion: Conditional reprogramming of AEC from young children is a feasible and powerful translational approach to investigate early-life airway epithelial immune responses in humans.

BACKGROUND:Defensive symbionts can provide significant fitness advantages to their hosts. Facultative symbionts can protect several species of aphid from fungal pathogens, heat shock, and parasitism by parasitoid wasps. Previous work found that two of these facultative symbionts can also indirectly protect pea aphids from predation by the lady beetle Hippocampus convergens. When aphids reproduce asexually, there is extremely high relatedness among aphid clone-mates and often very limited dispersal. Under these conditions, symbionts may indirectly protect aphid clone-mates from predation by negatively affecting the survival of a predator after the consumption of aphids harboring the same vertically transmitted facultative symbionts. In this study, we wanted to determine whether this indirect protection extended to another lady beetle species, Harmonia axyridis.RESULTS:We fed Ha. axyridis larvae aphids from one of four aphid sub-clonal symbiont lines which all originated from the same naturally symbiont free clonal aphid lineage. Three of the sub-clonal lines harbor different facultative symbionts that were introduced to the lines via microinjection. Therefore these sub-clonal lineages vary primarily in their symbiont composition, not their genetic background. We found that aphid facultative symbionts affected larval survival as well as pupal survival in their predator Ha. axyridis. Additionally, Ha. axyridis larvae fed aphids with the Regiella symbiont had significantly longer larval developmental times than beetle larvae fed other aphids, and females fed aphids with the Regiella symbiont as larvae weighed less as adults. These fitness effects were different from those previously found in another aphid predator Hi. convergens suggesting that the fitness effects may not be the same in different aphid predators.CONCLUSIONS:Overall, our findings suggest that some aphid symbionts may indirectly benefit their clonal aphid hosts by negatively impacting the development and survival of a lady beetle aphid predator Ha. axyridis. By directly affecting the survival of predatory lady beetles, aphid facultative symbionts may increase the survival of their clone-mates that are clustered nearby and have significant impacts across multiple trophic levels. We have now found evidence for multiple aphid facultative symbionts negatively impacting the survival of a second species of aphid predatory lady beetle. These same symbionts also protect their hosts from parasitism and fungal infections, though these fitness effects seem to depend on the aphid species, predator or parasitoid species, and symbiont type. This work further demonstrates that beneficial mutualisms depend upon complex interactions between a variety of players and should be studied in multiple ecologically relevant contexts.

Heritable symbionts have been found to mediate interactions between host species and their natural enemies in a variety of organisms. Aphids, their facultative symbionts, and their potential fitness effects have been particularly well-studied. For example, the aphid facultative symbiont Regiella can protect its host from infection from a fungal pathogen, and aphids with Hamiltonella are less likely to be parasitized by parasitic wasps. Recent work has also found there to be negative fitness effects for the larvae of two species of aphidophagous lady beetles that consumed aphids with facultative symbionts. In both species, larvae that consumed aphids with secondary symbionts were significantly less likely to survive to adulthood. In this study we tested whether adult Harmonia axyridis and Hippodamia convergens lady beetles avoided aphids with symbionts in a series of choice experiments. Adults of both lady beetle species were as likely to choose aphids with symbionts as those without, despite the potential negative fitness effects associated with consuming aphids with facultative symbionts. This may suggest that under natural conditions aphid secondary symbionts are not a significant source of selection for predatory lady beetles.