Publications by authors named "Joseph Hadaya"

45 Publications

Impact of frailty on acute outcomes of endovascular thoracic and abdominal aneurysm repair.

Surgery 2021 Apr 30. Epub 2021 Apr 30.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA. Electronic address:

Background: While coding-based frailty tools may readily identify at-risk patients, they have not been adopted into screening guidelines for endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic repair at the national level. We aimed to characterize the impact of frailty on clinical outcomes and resource use after endovascular aneurysm repair and thoracic endovascular aortic repair using a nationally representative cohort.

Methods: The 2005 to 2018 National Inpatient Sample was queried to identify all adults undergoing elective endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic repair. Patients were considered "frail" if they suffered from any frailty-defining diagnoses in the Johns Hopkins Adjusted Clinical Groups. Multivariable regression models were used to identify independent associations with outcomes of interest including in-hospital mortality, nonhome discharge, and hospitalization costs.

Results: Of an estimated 301,869 patients, 273,415 (90.6%) underwent endovascular aneurysm repair and the remainder thoracic endovascular aortic repair. Frailty prevalence was lower in the endovascular aneurysm repair cohort (2.3%) compared with thoracic endovascular aortic repair (4.7%). After adjustment, frailty was associated with higher in-hospital mortality (endovascular aneurysm repair odds ratio 4.0; thoracic endovascular aortic repair odds ratio 2.5), nonhome discharge rates (endovascular aneurysm repair odds ratio 7.2; thoracic endovascular aortic repair odds ratio 4.2), and predicted costs (endovascular aneurysm repair ß coefficient +$10.6K; thoracic endovascular aortic repair ß coefficient +$38.2K) for both cohorts.

Conclusion: Given that frailty portends inferior outcomes for both endovascular aneurysm repair and thoracic endovascular aortic repair, its inclusion in existing risk models may better inform shared decision-making.
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http://dx.doi.org/10.1016/j.surg.2021.03.053DOI Listing
April 2021

The obesity paradox: Underweight patients are at the greatest risk of mortality after cholecystectomy.

Surgery 2021 Apr 28. Epub 2021 Apr 28.

Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, CA. Electronic address:

Background: Elevated body mass index is a risk factor for gallstone disease and cholecystectomy, but outcomes for low body mass index patients remain uncharacterized. We examined the association of body mass index with morbidity, mortality, and resource use after cholecystectomy.

Methods: The 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program was retrospectively analyzed for adult patients undergoing laparoscopic and open cholecystectomy. Patients were stratified into 5 groups: body mass index <18.5 (underweight), body mass index 18.5 to 24.9 (normal weight), body mass index 25 to 29.9 (overweight), body mass index 30 to 34.9 (class I obesity), body mass index 35 to 39.9 (class II obesity), and body mass index ≥40 (class III obesity). Multivariable regressions identified independent associations of covariates with 30-day mortality, complications, and resource use.

Results: Of 327,473 cholecystectomy patients, 1.0% were underweight, 19.5% normal weight, 30.3% overweight, 24.0% class I obesity, 13.5% class II obesity, and 11.7% class III obesity. After multivariable analysis, underweight patients had a higher risk of mortality (adjusted odds ratio = 1.53; P = .029) and postoperative bleeding (adjusted odds ratio = 1.45; P = .011) relative to normal weight patients. Conversely, class III obesity patients had lower mortality (adjusted odds ratio = 0.66; P = .005) but increased operative time (β = 10.2 minutes; P < .001), wound infection (adjusted odds ratio = 1.38; P < .001), and wound dehiscence (adjusted odds ratio = 2.20; P < .001). Hospital duration of stay and readmission rates were highest for underweight patients.

Conclusion: Underweight patients experience increased risk of mortality and readmission, while class III obesity patients have higher rates of wound infection and dehiscence as well as prolonged operative time. These findings may guide choice of intervention.
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http://dx.doi.org/10.1016/j.surg.2021.03.034DOI Listing
April 2021

Impact of Postoperative Infections on Readmission and Resource Use in Elective Cardiac Surgery.

Ann Thorac Surg 2021 Apr 18. Epub 2021 Apr 18.

Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California. Electronic address:

Background: Efforts to reduce postoperative infections have garnered national attention, leading to practice guidelines for cardiac surgical perioperative care. The present study characterized the impact of healthcare-acquired infection (HAI) on index hospitalization costs and post-discharge healthcare utilization.

Methods: Adults undergoing elective coronary artery bypass grafting (CABG) and/or valve operations were identified in the 2016-2018 Nationwide Readmissions Database. Infections were categorized into bloodstream, gastrointestinal, pulmonary, surgical site, or urinary tract infections. Generalized linear or flexible hazard models were used to assess associations between infections and outcomes. Observed-to-expected (O/E) ratios were generated to examine inter-hospital variation in HAI.

Results: Of an estimated 444,165 patients, 8.0% developed HAI. Patients with HAI were older, had a greater burden of chronic diseases, and more commonly underwent CABG/valve or multi-valve operations (all p<0.001). HAI was independently associated with mortality (odds ratio 4.02, 95% CI 3.67-4.40), non-home discharge (3.48, 95% CI 3.21-3.78), and a cost increase of $23,000 (95% CI 20,900-25,200). At 90 days, HAI was associated with greater hazard of readmission (1.29, 95% CI 1.24-1.35). Pulmonary infections had the greatest incremental impact on patient-level ($24,500, 95% CI 23,100-26,00) and annual cohort costs ($121.8 million, 95% CI 102.2-142.9 million). Significant hospital level variation in HAI was evident, with O/E ranging from 0.17 to 4.3 for cases performed in 2018.

Conclusions: Infections following cardiac surgery remain common and are associated with inferior outcomes and increased resource use. The presence of inter-hospital variation in this contemporary cohort emphasizes the ongoing need for systematic approaches in their prevention and management.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.013DOI Listing
April 2021

The Impact of Expedited Discharge on 30-Day Readmission Following Lung Resection: A National Study.

Ann Thorac Surg 2021 Apr 18. Epub 2021 Apr 18.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA. Electronic address:

Background: Expedited discharge (within 24 hours) following lung resection has received scrutiny due to concerns for higher readmissions and paradoxically increased costs. The present study examined the impact of expedited discharge on hospitalization costs and unplanned readmissions using a nationally-representative sample. In addition, we sought to determine inter-hospital practice variation.

Methods: Adults undergoing elective lobar or sublobar resection were identified using the 2016-2018 Nationwide Readmissions Database, while those with postoperative duration of hospitalization >5 days or experienced any perioperative complication, were excluded. Patients were classified as Expedited if postoperative hospitalization was 0 or 1 day and otherwise as Routine. Inverse probability of treatment weighing was utilized to adjust for intergroup differences. Hospitals were ranked according to risk-adjusted early discharge rates. Multivariable regression models were developed to assess the association of expedited discharge on nonelective 30-day readmissions as well as associated mortality and costs.

Results: Of an estimated 84,152 patients, 13,834 (16.4%) comprised the Expedited group. Compared to Routine, Expedited were younger, less likely to have chronic obstructive pulmonary disease and undergo open procedures. Following adjustment, early discharge was associated with lower incremental costs (β coefficient: -$3.6K, 95%CI: -4.4 - -2.8) as well as similar readmissions (odds ratio: 0.89, 95%CI: 0.70 - 1.13) and related-mortality. Nearly half (48.1%) of all hospitals performed zero early discharges.

Conclusions: Expedited discharge following lung resection is a feasible management strategy and is associated with decreased costs and similar readmission risk compared to the norm. Select individuals should be strongly considered for expedited discharge following lung resection.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.009DOI Listing
April 2021

Trends and Outcomes of Surgical Re-exploration Following Cardiac Operations in the United States.

Ann Thorac Surg 2021 Apr 17. Epub 2021 Apr 17.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles. Electronic address:

Background: Surgical re-exploration following cardiac surgery has been associated with increased in-hospital complications and mortality in limited series. The present study examined trends in reoperation and its impact on clinical outcomes and resource use in a nationally-representative cohort. We sought to determine patient and hospital factors associated with re-exploration and reoperative mortality, defined as failure-to-rescue-surgical (FTR-S).

Methods: Adult hospitalizations entailing cardiac operations (coronary artery bypass and/or valve) were identified using the 2005-2018 National Inpatient Sample. Procedures were tabulated using International Classification of Diseases codes. Hospitals were ranked into tertiles according to risk-adjusted mortality, with the lowest stratified as high-performing. Multivariable regression models examined factors associated with re-exploration as well as clinical outcomes including FTR-S and resource utilization.

Results: Of an estimated 3,490,245 hospitalizations, 78,003 (2.23%) required re-exploration with decreasing incidence over time. Valvular procedures, preoperative intra-aortic balloon pump and liver disease were associated with greater likelihood of re-exploration. Reoperation was associated with increased odds of mortality (adjusted odds ratio (AOR): 3.86, 95%CI: 3.61-4.12), perioperative complications and resource utilization. Increasing time from index operation to re-exploration was associated with higher odds of mortality (AOR:1.10/day, 95%CI: 1.07-1.12). High-performing hospitals were associated with lower odds of re-exploration (AOR: 0.88, 95%CI: 0.82-0.95) and FTR-S (AOR: 0.29, 95%CI: 0.23-0.35).

Conclusions: Surgical re-exploration following cardiac surgery has declined over time. High performing hospitals demonstrated lower rates of re-exploration and subsequent failure-to-rescue. Although unable to identify specific practices, our study highlights the presence of significant variation in takeback rates and further study of underlying factors is warranted.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.011DOI Listing
April 2021

Impact of hospital volume on resource use after elective cardiac surgery: A contemporary analysis.

Surgery 2021 Apr 10. Epub 2021 Apr 10.

Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA. Electronic address:

Background: Institutional experience has been associated with reduced mortality after coronary artery bypass grafting and valve operations. Using a contemporary, national cohort, we examined the impact of hospital volume on hospitalization costs and postdischarge resource utilization after these operations.

Methods: Adults undergoing elective coronary artery bypass grafting or valve operations were identified in the 2016 to 2017 Nationwide Readmissions Database. Institutions were grouped into volume quartiles based on annual elective cardiac surgery caseload, and comparisons were made between the lowest and highest quartiles, using generalized linear models.

Results: Of an estimated 296,510 patients, 24.8% were treated at low-volume hospitals and 25.2% at high-volume hospitals. Compared with patients treated at low-volume hospitals, patients managed at high-volume hospitals were younger, had more comorbidities, and more frequently underwent combined coronary artery bypass grafting valve (13.0% vs 12.3%, P < .001) and multivalve operations (6.2% vs 3.1%, P < .001). After adjustment, operations at high-volume hospitals were associated with a $7,600 reduction (95% confidence interval $4,700-$10,500) in costs. High-volume hospitals were also associated with reduced odds of mortality, non-home discharge, and 30-day non-elective readmission compared to low-volume hospitals.

Conclusion: Despite increased complexity at high-volume centers, greater operative volume was independently associated with reduced hospitalization costs and mortality after elective cardiac operations. Reduction in non-home discharge and readmissions suggests this effect to extend beyond acute hospitalization, which may guide value-based care paradigms.
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http://dx.doi.org/10.1016/j.surg.2021.03.004DOI Listing
April 2021

Failure to rescue after surgical re-exploration in lung resection.

Surgery 2021 Mar 25. Epub 2021 Mar 25.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA. Electronic address:

Background: Surgical re-exploration after lung resection remains poorly characterized, although institutional series have previously reported its association with greater mortality and complications. The present study sought to examine the impact of institutional lung-resection volume on the incidence of and short-term outcomes after surgical re-exploration.

Methods: The 2007 to 2018 National Inpatient Sample was used to identify all adults who underwent lobectomy or pneumonectomy. Hospitals were divided into tertiles based on institutional lung-resection caseload. Multivariable regressions were used to identify associations between independent covariates on clinical outcomes.

Results: Of an estimated 329,273 patients, 3,592 (1.09%) were re-explored with decreasing incidence over time. Open and minimal access pneumonectomy among other factors were associated with greater odds of reoperation. Those re-explored had greater odds of mortality and complications as well as increased duration of stay and adjusted costs. Although risk of re-exploration was similar across hospital tertiles, reoperative mortality was significantly lower at high-volume hospitals.

Conclusion: Re-exploration after lung resection is uncommon; however, when occurring, it is associated with worse clinical outcomes. After re-exploration, high-volume center status was associated with reduced odds of mortality relative to low volume. Failure to rescue at lower-volume centers suggests the need for optimization of perioperative factors to decrease incidence of reoperation.
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http://dx.doi.org/10.1016/j.surg.2021.02.023DOI Listing
March 2021

Impact of hospital safety-net status on clinical outcomes following carotid artery revascularization.

Surgery 2021 Mar 13. Epub 2021 Mar 13.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA. Electronic address:

Background: High hospital safety-net burden has been associated with inferior clinical outcomes. We aimed to characterize the association of safety-net burden with outcomes in a national cohort of patients undergoing carotid interventions.

Methods: The 2010-2017 Nationwide Readmissions Database was used to identify adults undergoing carotid endarterectomy and carotid artery stenting. Hospitals were classified as low (LBH), medium, or high safety-net burden (HBH) based on the proportion of uninsured or Medicaid patients. Multivariable models were developed to evaluate associations between HBH and outcomes.

Results: Of an estimated 540,558 hospitalizations for a carotid intervention, 28.5% were at HBH. Patients treated at HBH were more likely to be admitted non-electively (28.7% vs 20.2%, P < .001), have symptomatic presentation (11.0% vs 7.7%, P < .001), and undergo carotid artery stenting (18.7% vs 8.9%, P < .001). After adjustment, HBH remained associated with increased odds of postoperative stroke (AOR 1.19, P = .023, Ref = LBH), non-home discharge (AOR 1.10, P = .026), 30-day readmissions (AOR 1.14, P < .001), and 31-90-day readmissions (AOR 1.13, P < .001), but not in-hospital mortality (AOR 1.18, P = .27). HBH was linked to increased hospitalization costs (β +$2,169, P = .016).

Conclusion: HBH was associated with postoperative stroke, non-home discharge, readmissions, and increased hospitalization costs after carotid revascularization. Further studies are warranted to alleviate healthcare inequality and improve outcomes at safety-net hospitals.
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http://dx.doi.org/10.1016/j.surg.2021.01.052DOI Listing
March 2021

Factors Associated with High Resource Utilization in Elective Adult Cardiac Surgery from 2005 - 2016.

Ann Thorac Surg 2021 Mar 6. Epub 2021 Mar 6.

Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: Lack of consensus remains about factors that may be associated with high resource utilization (HRU) in adult cardiac surgical patients. We aimed to identify patient, hospital, and perioperative characteristics associated with HRU admissions involving elective cardiac operations.

Methods: Data from the National Inpatient Sample was used to identify patients who underwent coronary artery bypass graft (CABG), valve replacement, and valve repair operations between 2005 and 2016. Admissions with HRU were defined as those in the highest decile for total hospital costs. Multivariable regressions were used to identify factors associated with HRU.

Results: An estimated 1,750,253 hospitalizations coded for elective cardiac operations. The median hospitalization cost was $34.7K (IQR $26.8K - $47.1K), with HRU (N=175,025) cutoff at $66,029. Although HRU patients comprised 10% of admissions, they accounted for 25% of cumulative costs. On multivariable regression, patient characteristics predictive of HRU included female sex, older age, higher comorbidity burden, non-white race, and highest income quartile. Hospital factors associated with HRU were low volume hospitals for both CABG and valvular operations. Among postoperative outcomes, mortality, infectious complication, extracorporeal membrane oxygenation use, and hospitalization > 8 days were associated with greater odds of HRU.

Conclusions: In this nationwide study of elective cardiac surgical patients, several important patient and hospital factors, including patient race, comorbidities, postoperative infectious complications, and low hospital operative volume were identified as predictors of HRU. These highly predictive factors may be used for benchmarking purposes and improvement in surgical planning.
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http://dx.doi.org/10.1016/j.athoracsur.2021.02.059DOI Listing
March 2021

Filtering Facepiece Respirator (N95 Respirator) Reprocessing: A Systematic Review.

JAMA 2021 Apr;325(13):1296-1317

Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California.

Importance: The COVID-19 pandemic has resulted in a persistent shortage of personal protective equipment; therefore, a need exists for hospitals to reprocess filtering facepiece respirators (FFRs), such as N95 respirators.

Objective: To perform a systematic review to evaluate the evidence on effectiveness and feasibility of different processes used for decontaminating N95 respirators.

Evidence Review: A search of PubMed and EMBASE (through January 31, 2021) was completed for 5 types of respirator-decontaminating processes including UV irradiation, vaporized hydrogen peroxide, moist-heat incubation, microwave-generated steam, and ethylene oxide. Data were abstracted on process method, pathogen removal, mask filtration efficiency, facial fit, user safety, and processing capability.

Findings: Forty-two studies were included that examined 65 total types of masks. All were laboratory studies (no clinical trials), and 2 evaluated respirator performance and fit with actual clinical use of N95 respirators. Twenty-seven evaluated UV germicidal irradiation, 19 vaporized hydrogen peroxide, 9 moist-heat incubation, 10 microwave-generated steam, and 7 ethylene oxide. Forty-three types of N95 respirators were treated with UV irradiation. Doses of 1 to 2 J/cm2 effectively sterilized most pathogens on N95 respirators (>103 reduction in influenza virus [4 studies], MS2 bacteriophage [3 studies], Bacillus spores [2 studies], Escherichia virus MS2 [1 study], vesicular stomatitis virus [1 study], and Middle East respiratory syndrome virus/SARS-CoV-1 [1 study]) without degrading respirator components. Doses higher than 1.5 to 2 J/cm2 may be needed based on 2 studies demonstrating greater than 103 reduction in SARS-CoV-2. Vaporized hydrogen peroxide eradicated the pathogen in all 7 efficacy studies (>104 reduction in SARS-CoV-2 [3 studies] and >106 reduction of Bacillus and Geobacillus stearothermophilus spores [4 studies]). Pressurized chamber systems with higher concentrations of hydrogen peroxide caused FFR damage (6 studies), while open-room systems did not degrade respirator components. Moist heat effectively reduced SARS-CoV-2 (2 studies), influenza virus by greater than 104 (2 studies), vesicular stomatitis virus (1 study), and Escherichia coli (1 study) and preserved filtration efficiency and facial fit for 11 N95 respirators using preheated containers/chambers at 60 °C to 85 °C (5 studies); however, diminished filtration performance was seen for the Caron incubator. Microwave-generated steam (1100-W to 1800-W devices; 40 seconds to 3 minutes) effectively reduced pathogens by greater than 103 (influenza virus [2 studies], MS2 bacteriophage [3 studies], and Staphylococcus aureus [1 study]) and maintained filtration performance in 10 N95 respirators; however, damage was noted in least 1 respirator type in 4 studies. In 6 studies, ethylene oxide preserved respirator components in 16 N95 respirator types but left residual carcinogenic by-product (1 study).

Conclusions And Relevance: Ultraviolet germicidal irradiation, vaporized hydrogen peroxide, moist heat, and microwave-generated steam processing effectively sterilized N95 respirators and retained filtration performance. Ultraviolet irradiation and vaporized hydrogen peroxide damaged respirators the least. More research is needed on decontamination effectiveness for SARS-CoV-2 because few studies specifically examined this pathogen.
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http://dx.doi.org/10.1001/jama.2021.2531DOI Listing
April 2021

Innervation and Neuronal Control of the Mammalian Sinoatrial Node a Comprehensive Atlas.

Circ Res 2021 Apr 25;128(9):1279-1296. Epub 2021 Feb 25.

Department of Medicine, Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, University of California, Los Angeles (UCLA; P.H., M.J.D., M.A.S., P.S.R., S.M., J.E.H., R.L.L., J.D.T., J.L.A., K.S.).

[Figure: see text].
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http://dx.doi.org/10.1161/CIRCRESAHA.120.318458DOI Listing
April 2021

Outcomes and resource use for liver transplantation in the United States: Insights from the 2009-2017 National Inpatient Sample.

Clin Transplant 2021 Feb 22:e14262. Epub 2021 Feb 22.

Division of Liver and Pancreas Transplantation, David Geffen School of Medicine, Los Angeles, CA, USA.

Introduction: Liver transplantation (LT) is a life-saving treatment for end-stage liver disease patients that requires significant resources. We used national data to evaluate LT outcomes and factors associated with hospital resource use.

Methods: Using the National Inpatient Sample, we identified all patients undergoing LT from 2009 to 2017 and defined high-resource use (HRU) as having costs ≥ 90th percentile. Hierarchical regression models were used to assess factors associated with length of stay (LOS) and HRU.

Results: Over the study period, approximately 53,000 patients underwent LT, increasing from 5,582 in 2009 to 7,095 in 2017 (nptrend < 0.001). Morbidity and mortality were 42.2% and 3.9%, respectively, with a median post-LT LOS of 10 days. Hospitalization costs increased from $106,866 to $145,868 (nptrend < 0.001). Acute kidney injury (β:4.7 days, P < .001) and end-stage renal disease (ESRD) with dialysis (β:4.3 days, P < .001) were associated with greater LOS while the Northeast region (AOR:5.2, P < .001), ESRD with dialysis (AOR:3.4, P < .001), heart failure (AOR:2.5, P < .001), and fulminant liver disease (AOR:1.8, P = .01) were associated with HRU.

Conclusion: The cost of LT has increased over time. Renal dysfunction, regional practice patterns, and patient acuity were associated with greater resource use. Transplanting patients before health deterioration may help contain costs, mitigate resource use, and improve LT outcomes.
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http://dx.doi.org/10.1111/ctr.14262DOI Listing
February 2021

Outcomes and Resource Use Associated With Acute Respiratory Failure in Safety Net Hospitals Across the United States.

Chest 2021 Feb 19. Epub 2021 Feb 19.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA. Electronic address:

Background: Despite the frequency and cost of hospitalizations for acute respiratory failure (ARF), the literature regarding the impact of hospital safety net burden on outcomes of these hospitalizations is sparse.

Research Question: How does safety net burden impact outcomes of ARF hospitalizations such as mortality, tracheostomy, and resource use?

Study Design And Methods: This was a retrospective cohort study using the National Inpatient Sample 2007-2017. All patients hospitalized with a primary diagnosis of ARF were tabulated using the International Classification of Diseases 9th and 10th Revision codes, and safety net burden was calculated using previously published methodology. High- and low-burden hospitals were generated from proportions of Medicaid and uninsured patients. Trends were analyzed using a nonparametric rank-based test, whereas multivariate logistic and linear regression models were used to establish associations of safety net burden with key clinical outcomes.

Results: Of an estimated 8,941,334 hospitalizations with a primary diagnosis of ARF, 33.9% were categorized as occurring at low-burden hospitals (LBHs) and 31.6% were categorized as occurring at high-burden hospitals (HBHs). In-hospital mortality significantly decreased at HBHs (22.8%-12.6%; nonparametric trend [nptrend] < 0.001) and LBHs (22.0%-10.9%; nptrend < 0.001) over the study period, as did tracheostomy placement (HBH, 5.6%-1.3%; LBH, 3.5%-0.8%; all nptrend <0.001). After adjustment for patient and hospital factors, an HBH was associated with increased odds of mortality (adjusted OR [AOR], 1.11; 95% CI, 1.10-1.12) and tracheostomy use (AOR, 1.33; 95% CI, 1.29-1.37), as well as greater hospitalization costs (β coefficient, +$1,083; 95% CI, $882-$1,294) and longer lengths of stay (β coefficient, +3.3 days; 95% CI, 3.2-3.3 days).

Interpretation: After accounting for differences between patient cohorts, high safety net burden was associated independently with inferior clinical outcomes and increased costs after ARF hospitalizations. These findings emphasize the need for health-care reform to ameliorate disparities within these safety net centers, which treat our most vulnerable populations.
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http://dx.doi.org/10.1016/j.chest.2021.02.018DOI Listing
February 2021

Impact of Frailty on Clinical Outcomes after Carotid Artery Revascularization.

Ann Vasc Surg 2021 Feb 5. Epub 2021 Feb 5.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA. Electronic address:

Background: Frailty has been increasingly recognized as an important risk factor for vascular procedures. To assess the impact of frailty on clinical outcomes and resource utilization in patients undergoing carotid revascularization using a national cohort.

Methods: The 2005-2017 National Inpatient Sample was used to identify patients who underwent carotid endarterectomy (CEA) or carotid stenting (CAS). Patients were classified as frail using diagnosis codes defined by the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable regression was used to evaluate associations between frailty and in-hospital mortality, postoperative stroke, myocardial infarction (MI), hospitalization costs, and length of stay (LOS).

Results: Of 1,426,343 patients undergoing carotid revascularization, 59,158 (4.2%) were identified as frail. Among frail patients, 79.4% underwent CEA and 20.6% underwent CAS. Compared to CEA, a greater proportion of patients undergoing CAS were frail (6.0% vs. 3.8%, P < 0.001). Compared to the nonfrail cohort, frail patients had higher rates of mortality (2.2% vs. 0.5%, P < 0.001), postoperative stroke (2.6% vs. 1.0%, P < 0.001), MI (2.2% vs. 0.8%, P < 0.001), and stroke/death (4.4% vs. 1.4%, P < 0.001). After adjustment, frailty was associated with increased odds of mortality (AOR = 1.59, 95% CI: 1.30-1.80, P < 0.001), stroke (AOR = 1.66, 95% CI: 1.38-1.83 P < 0.001), MI (AOR = 1.51, 95% CI: 1.29-1.72, P < 0.001), and stroke/death (AOR = 1.62, 95% CI: 1.45-1.81, P < 0.001). Furthermore, frailty was associated with increased hospitalization costs (β = +$5,980, 95% CI: $5,490-$6,470, P < 0.001) and LOS (β = +2.6 days, 95% CI: 2.4-2.8, P < 0.001).

Conclusions: Frailty is associated with adverse outcomes and greater resource use for those undergoing carotid revascularization. Risk models should include an assessment of frailty to guide management and improve outcomes for these high-risk patients.
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http://dx.doi.org/10.1016/j.avsg.2020.12.039DOI Listing
February 2021

Impact of the Coronavirus Disease 2019 Pandemic on Utilization of Mechanical Circulatory Support As Bridge to Heart Transplantation.

ASAIO J 2021 04;67(4):382-384

From the Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine University of California, Los Angeles, Los Angeles, California.

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http://dx.doi.org/10.1097/MAT.0000000000001387DOI Listing
April 2021

Autonomic Modulation for Cardiovascular Disease.

Front Physiol 2020 22;11:617459. Epub 2020 Dec 22.

University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, CA, United States.

Dysfunction of the autonomic nervous system has been implicated in the pathogenesis of cardiovascular disease, including congestive heart failure and cardiac arrhythmias. Despite advances in the medical and surgical management of these entities, progression of disease persists as does the risk for sudden cardiac death. With improved knowledge of the dynamic relationships between the nervous system and heart, neuromodulatory techniques such as cardiac sympathetic denervation and vagal nerve stimulation (VNS) have emerged as possible therapeutic approaches for the management of these disorders. In this review, we present the structure and function of the cardiac nervous system and the remodeling that occurs in disease states, emphasizing the concept of increased sympathoexcitation and reduced parasympathetic tone. We review preclinical evidence for vagal nerve stimulation, and early results of clinical trials in the setting of congestive heart failure. Vagal nerve stimulation, and other neuromodulatory techniques, may improve the management of cardiovascular disorders, and warrant further study.
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http://dx.doi.org/10.3389/fphys.2020.617459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783451PMC
December 2020

Frailty is Independently Associated with Worse Outcomes Following Elective Anatomic Lung Resection.

Ann Thorac Surg 2020 Nov 27. Epub 2020 Nov 27.

Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles (UCLA), Los Angeles, CA; Division of Cardiac Surgery, Department of Surgery, UCLA, Los Angeles, CA. Electronic address:

Background: Frailty has been widely recognized as a predictor of postoperative outcomes. Given the paucity of standardized frailty measurements in thoracic procedures, we aimed to determine the impact of coding-based frailty on clinical outcomes and resource utilization following anatomic lung resection.

Methods: All adults undergoing elective, anatomic lung resections (segmentectomy, lobectomy, pneumonectomy) from 2005-2014 were identified using the National Inpatient Sample. Patients were categorized as Frail or Non-Frail based on the presence of any frailty-defining diagnoses defined by the Johns Hopkins Adjusted Clinical Groups. Multivariable models were used to assess the independent association of frailty with in-hospital mortality, non-home discharge, complications, duration of stay and costs.

Results: Of an estimated 366,357 hospitalizations for elective lung resection during the study period, 4.4% were Frail. Patients who underwent pneumonectomy or were treated at low-volume hospitals were more commonly frail. Relative to Non-Frail, frailty was associated with increased unadjusted mortality (9.1% vs 1.7%, p<0.001) and non-home discharge (44.7% vs 10.5%, p<0.001). Frail patients had 3.47 increased adjusted odds of mortality across resection types (95% CI 2.94-4.09). Frailty conferred the greatest increase in mortality, complications and resource use following pneumonectomy relative to lobectomy or segmentectomy, though significant differences were evident for all three.

Conclusions: Frailty exhibits a strong association with inferior clinical outcomes and increased resource utilization following elective lung resection, particularly pneumonectomy. This readily available tool may improve preoperative risk assessment and allow for better selection of treatment modalities for frail patients with pulmonary pathologies.
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http://dx.doi.org/10.1016/j.athoracsur.2020.11.004DOI Listing
November 2020

Impact of Payer Status on Delisting Among Liver Transplant Candidates in the United States.

Liver Transpl 2021 02 31;27(2):200-208. Epub 2020 Dec 31.

Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA.

Although socioeconomic disparities persist both pre- and post-transplantation, the impact of payer status has not been studied at the national level. We examined the association between public insurance coverage and waitlist outcomes among candidates listed for liver transplantation (LT) in the United States. All adults (age ≥18 years) listed for LT between 2002 and 2018 in the United Network for Organ Sharing database were included. The primary outcome was waitlist removal because of death or clinical deterioration. Continuous and categorical variables were compared using the Kruskal-Wallis and chi-square tests, respectively. Fine and Gray competing-risks regression was used to estimate the subdistribution hazard ratios (HRs) for risk factors associated with delisting. Of 131,839 patients listed for LT, 61.2% were covered by private insurance, 22.9% by Medicare, and 15.9% by Medicaid. The 1-year cumulative incidence of delisting was 9.0% (95% confidence interval [CI], 8.3%-9.8%) for patients with private insurance, 10.7% (95% CI, 9.9%-11.6%) for Medicare, and 10.7% (95% CI, 9.8%-11.6%) for Medicaid. In multivariable competing-risks analysis, Medicare (HR, 1.20; 95% CI, 1.17-1.24; P < 0.001) and Medicaid (HR, 1.20; 95% CI, 1.16-1.24; P < 0.001) were independently associated with an increased hazard of death or deterioration compared with private insurance. Additional predictors of delisting included Black race and Hispanic ethnicity, whereas college education and employment were associated with a decreased hazard of delisting. In this study, LT candidates with Medicare or Medicaid had a 20% increased risk of delisting because of death or clinical deterioration compared with those with private insurance. As more patients use public insurance to cover the cost of LT, targeted waitlist management protocols may mitigate the increased risk of delisting in this population.
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http://dx.doi.org/10.1002/lt.25936DOI Listing
February 2021

Management of penetrating aortic arch trauma.

J Trauma Acute Care Surg 2021 02;90(2):e50-e51

From the Division of Cardiac Surgery (J.H., R.M., P.B.), and Division of General Surgery (J.H., C.P.C., A.E.-S., P.S.), Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.

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http://dx.doi.org/10.1097/TA.0000000000003015DOI Listing
February 2021

Impact of opioid use disorders on outcomes and readmission following cardiac operations.

Heart 2021 Jun 29;107(11):909-915. Epub 2020 Oct 29.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA

Objective: While opioid use disorder (OUD) has been previously associated with increased morbidity and resource use in cardiac operations, its impact on readmissions is understudied.

Methods: Patients undergoing coronary artery bypass grafting and valve repair or replacement, excluding infective endocarditis, were identified in the 2010-16 Nationwide Readmissions Database. Using International Classification of Diseases 9/10, we tabulated OUD and other characteristics. Multivariable regression was used to adjust for differences.

Results: Of an estimated 1 978 276 patients who had cardiac surgery, 5707 (0.3%) had OUD. During the study period, the prevalence of OUD increased threefold (0.15% in 2010 vs 0.53% in 2016, parametric trend<0.001). Patients with OUD were more likely to be younger (54.0 vs 66.0 years, p<0.001), insured by Medicaid (28.2 vs 6.2%, p<0.001) and of the lowest income quartile (33.6 vs 27.1%, p<0.001). After multivariable adjustment, OUD was associated with decreased mortality (1.5 vs 2.7%, p=0.001). Although these patients had similar rates of overall complications (36.1 vs 35.1%, p=0.363), they had increased thromboembolic (1.3 vs 0.8%, p<0.001) and infectious (4.1 vs 2.8%, p<0.001) events, as well as readmission at 30 days (19.0 vs 13.2%, p<0.001). While patients with OUD had similar hospitalisation costs ($50 766 vs $50 759, p=0.994), they did have longer hospitalisations (11.4 vs 10.3 days, p<0.001).

Conclusion: The prevalence of OUD among cardiac surgical patients has steeply increased over the past decade. Although the presence of OUD was not associated with excess mortality at index hospitalisation, it was predictive of 30-day readmission. Increased attention to predischarge interventions and care coordination may improve outcomes in this population.
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http://dx.doi.org/10.1136/heartjnl-2020-317618DOI Listing
June 2021

Postoperative Physician Phone Calls as a Method to Decrease Urgent Care and Emergency Department Returns After Ambulatory General Surgery.

Am Surg 2020 Oct 25;86(10):1373-1378. Epub 2020 Oct 25.

Southern California Kaiser Permanente Medical Group, Woodland Hills, CA, USA.

Unplanned returns after ambulatory surgery pose a burden to patients and health care providers alike. We hypothesized that a postoperative phone call by a physician would decrease avoidable returns to urgent care (UC) or the emergency department (ED) in the week after anorectal (AR), laparoscopic cholecystectomy (LC), inguinal hernia repair (IHR), and umbilical hernia repair (UHR) operations. A retrospective analysis from 1/2011 to 12/2015 across 14 Kaiser hospitals was conducted to determine baseline UC/ED return rates of patients pre-call. Between 10/2017 and 06/2019, physicians placed phone calls to patients within postoperative days (PODs) 1-4. The cohorts were compared using chi-squared analysis with significance determined at < .05. In total, 276 patients received a call, with the majority placed on PODs 1-3. There were no statistically significant differences in return rates between the pre- and post-call groups. All of the AR, 50.0% of LC, 66.7% of IHR, and 50.0% of UHR patients returned prior to phone call placement. Our data indicate that a physician phone call does not help in decreasing UC/ED returns. However, it is noteworthy that many of the returns occurred pre-call placement. Future directions should be aimed at placing earlier postoperative phone calls.
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http://dx.doi.org/10.1177/0003134820964463DOI Listing
October 2020

Impact of Frailty on Clinical and Financial Outcomes Following Minor Lower Extremity Amputation: A Nationwide Analysis.

Am Surg 2020 Oct 25;86(10):1312-1317. Epub 2020 Oct 25.

Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Frailty has been shown to portend worse outcomes in surgical patients. Our goal was to identify the impact of frailty on outcomes and resource utilization among patients undergoing minor lower extremity amputation in the United States. Using the Nationwide Readmission Database, we identified all adults undergoing a minor amputation between 2010 and 2015, and assessed 90-day outcomes, including readmission, reamputation, mortality, and cumulative hospitalization costs. Frailty was defined by International Classification of Diseases codes consistent with the ten frailty clusters as defined by the Johns Hopkins Adjusted Clinical Group System. Multivariable regression models were developed for risk adjustment. An estimated 302 798 patients (mean age = 61.8 years) were identified, of which 15.2% were categorized as . Before adjustment, frailty was associated with increased rates of readmission (44% vs. 36%, < .001) and in-hospital mortality (4% vs. 2%, < .001). Frailty was also associated with increased cumulative costs of care ($39 417 vs. $27 244, < .001). After risk adjustment, frailty remained an independent predictor of readmission (Adjusted odds ratio [AOR] 1.18, CI 1.14-1.23), in-hospital mortality (AOR 1.48, CI 1.34-1.65), and incremental costs (+$7 646, CI $6927-$8365). Frailty is an independent marker of worse outcomes following minor foot amputation, and may be utilized to direct quality improvement efforts.
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http://dx.doi.org/10.1177/0003134820964230DOI Listing
October 2020

Rapid measurement of cardiac neuropeptide dynamics by capacitive immunoprobe in the porcine heart.

Am J Physiol Heart Circ Physiol 2021 01 23;320(1):H66-H76. Epub 2020 Oct 23.

Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio.

Sympathetic control of regional cardiac function occurs through postganglionic innervation from stellate ganglia and thoracic sympathetic chain. Whereas norepinephrine (NE) is their primary neurotransmitter, neuropeptide Y (NPY) is an abundant cardiac cotransmitter. NPY plays a vital role in homeostatic processes including angiogenesis, vasoconstriction, and cardiac remodeling. Elevated sympathetic stress, resulting in increased NE and NPY release, has been implicated in the pathogenesis of several cardiovascular disorders including hypertension, myocardial infarction, heart failure, and arrhythmias, which may result in sudden cardiac death. Current methods for the detection of NPY in myocardium are limited in their spatial and temporal resolution and take days to weeks to provide results [e.g., interstitial microdialysis with subsequent analysis by enzyme-linked immunosorbent assay (ELISA), high performance liquid chromatography (HPLC), or mass spectrometry]. In this study, we report a novel approach for measurement of interstitial and intravascular NPY using a minimally invasive capacitive immunoprobe (C.I. probe). The first high-spatial and temporal resolution, multichannel measurements of NPY release in vivo are provided in both myocardium and transcardiac vascular space in a beating porcine heart. We provide NPY responses evoked by sympathetic stimulation and ectopic ventricular pacing and compare these to NE release and hemodynamic responses. We extend this approach to measure both NPY and vasoactive intestinal peptide (VIP) and show differential release profiles under sympathetic stimulation. Our data demonstrate rapid and local changes in neurotransmitter profiles in response to sympathetic cardiac stressors. Future implementations include real-time intraoperative determination of cardiac neuropeptides and deployment as a minimally invasive catheter. The sympathetic nervous system regulates cardiac function through release of neurotransmitters and neuropeptides within the myocardium. Neuropeptide Y (NPY) acts as an acute cardiac vasoconstrictor and chronically to regulate angiogenesis and cardiac remodeling. Current methodologies for the measure of NPY are not capable of providing rapid readouts on a single-sample basis. Here we provide the first in vivo methodology to report dynamic, localized NPY levels within both myocardium and vascular compartments in a beating heart.
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http://dx.doi.org/10.1152/ajpheart.00674.2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847069PMC
January 2021

Assessing the Burden of Nodal Disease for Breast Cancer Patients with Clinically Positive Nodes: Hope for More Limited Axillary Surgery.

Ann Surg Oncol 2021 May 21;28(5):2609-2618. Epub 2020 Oct 21.

Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.

Background: Omission of axillary lymph node dissection (ALND) is accepted for patients with one or two positive sentinel nodes, and studies are focusing on clinically node-positive patients who have been downstaged with neoadjuvant chemotherapy (NAC). Evidence is lacking for patients with positive nodes who undergo surgery upfront. These patients are assumed to have a higher burden of nodal disease such that ALND remains the standard of care.

Methods: Patients who underwent ALND for breast cancer between 2010 and 2019 at the authors' institution were retrospectively identified. Those with clinical N1 disease were included in the study. Patients who received NAC and those who had surgery for sentinel node positive disease or axillary recurrence were excluded. Clinical and pathologic factors associated with nodal stage were evaluated.

Results: Of 111 patients who met the inclusion criteria, 61.3% had a palpable node on exam, and 41.4% ultimately had pN1 disease. Most of the tumors were estrogen receptor (ER)-positive (91.5%), and 21.7% of the tumors were invasive lobular cancers. Lobular histology, tumor size, and metastasis size were associated with higher nodal stage. In the multivariable analysis, the patients with nodal metastasis larger than 10 mm had significantly lower odds of having pN1 disease (odds ratio 0.12; 95% confidence interval 0.02-0.69; p = 0.02). In a subset analysis of patients with palpable nodes, tumor size and histology remained significantly associated with nodal stage.

Conclusion: More than 40% of breast cancer patients with clinically positive nodes had minimal nodal disease (pN1) at surgery. Additionally, palpable nodes on exam did not predict higher nodal stage. A subset of patients with clinically positive nodes may be identified who can potentially be spared the morbidity of ALND.
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http://dx.doi.org/10.1245/s10434-020-09228-5DOI Listing
May 2021

The Pragmatic Impact of Frailty on Outcomes of Coronary Artery Bypass Grafting.

Ann Thorac Surg 2020 Oct 17. Epub 2020 Oct 17.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California. Electronic address:

Background: Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. Using administrative coding, we evaluated the impact of frailty on in-hospital death, complications, and resource use in a nationally representative cohort of patients undergoing isolated coronary artery bypass grafting (CABG).

Methods: Patients aged 18 years and older who underwent isolated CABG across the United States were identified using the 2005 to 2016 National Inpatient Sample. Frailty was defined using a derivative of the validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Mortality, length of stay, inflation-adjusted costs, and postoperative complications were evaluated using multilevel multivariable regression.

Results: Of an estimated 2,137,618 patients undergoing isolated CABG, 85,879 (4.0%) were considered frail. The proportion of frail patients increased over the study period (nonparametric test for trend P = .002), while annual mortality rates declined (nonparametric test for trend P <.001). Frail patients were older (68.9 ± 10.7 years vs 65.0 ± 10.6 years, P < .001), and more commonly female (32.8% vs 26.2%, P < .001). After adjustment, frailty was associated with increased odds of in-hospital death (adjusted odds ratio [AOR], 2.49; 95% confidence interval [CI], 2.30-2.70; P < .001), major complications (AOR, 2.55; 95% CI, 2.39-2.71; P < .001), increased length of stay (AOR, 1.40; 95% CI, 1.09-2.11; P < .001), and costs (AOR, 1.03; 95% CI, 1.02-1.07; P < .001).

Conclusions: Frailty, as identified by administrative coding, serves as a strong independent predictor of death and complications after CABG. Incorporation of frailty into risk models may aid in counseling patients about operative risk and benchmarking outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.028DOI Listing
October 2020

Impact of Early Tracheostomy on Outcomes After Cardiac Surgery: A National Analysis.

Ann Thorac Surg 2021 05 24;111(5):1537-1544. Epub 2020 Sep 24.

Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California. Electronic address:

Background: Despite evidence supporting its early use in respiratory failure, tracheostomy is often delayed in cardiac surgical patients given concerns for sternal infection. This study assessed national trends in tracheostomy creation among cardiac patients and evaluated the impact of timing to tracheostomy on postoperative outcomes.

Methods: We used the 2005 to 2015 National Inpatient Sample to identify adults undergoing coronary revascularization or valve operations and categorized them based on timing of tracheostomy: early tracheostomy (ET) (postoperative days 1-14) and delayed tracheostomy (DT) (postoperative days 15-30). Temporal trends in the timing of tracheostomy were analyzed, and multivariable models were created to compare outcomes.

Results: An estimated 33,765 patients (1.4%) required a tracheostomy after cardiac operations. Time to tracheostomy decreased from 14.8 days in 2005 to 13.9 days in 2015, sternal infections decreased from 10.2% to 2.9%, and in-hospital death also decreased from 23.3% to 15.9% over the study period (all P for trend <.005). On univariate analysis, the ET cohort had a lower rate of sternal infection (5.2% vs 7.8%, P < .001), in-hospital death (16.7% vs 22.9%, P < .001), and length of stay (33.7 vs 43.6 days, P < .001). On multivariable regression, DT remained an independent predictor of sternal infection (adjusted odds ratio, 1.35; P < .05), in-hospital death (odds ratio, 1.36; P < .001), and length of stay (9.1 days, P < .001), with no difference in time from tracheostomy to discharge between the 2 cohorts (P = .40).

Conclusions: In cardiac surgical patients, ET yielded similar postoperative outcomes, including sternal infection and in-hospital death. Our findings should reassure surgeons considering ET in poststernotomy patients with respiratory failure.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.027DOI Listing
May 2021

Predictors and In-Hospital Outcomes Among Patients Using a Single Versus Bilateral Mammary Arteries in Coronary Artery Bypass Grafting.

Am J Cardiol 2020 11 15;134:41-47. Epub 2020 Aug 15.

Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California. Electronic address:

The benefit of bilateral mammary artery (BIMA) use during coronary artery bypass grafting (CABG) continues to be debated. This study examined nationwide trends in BIMA use and factors influencing its utilization. Using the National Inpatient Sample, adults undergoing isolated multivessel CABG between 2005 and 2015 were identified and stratified based on the use of a single mammary artery or BIMA. Regression models were fit to identify patient and hospital level predictors of BIMA use and characterize the association of BIMA on outcomes including sternal infection, mortality, and resource utilization. An estimated 4.5% (n = 60,698) of patients underwent CABG with BIMA, with a steady increase from 3.8% to 5.0% over time (p<0.001). Younger age, male gender, and elective admission, were significant predictors of BIMA use. Moreover, private insurance was associated with higher odds of BIMA use (adjusted odds ratio 1.24) compared with Medicare. BIMA use was not a predictor of postoperative sternal infection, in-hospital mortality, or hospitalization costs. Overall, BIMA use remains uncommon in the United States despite no significant differences in acute postoperative outcomes. Several patient, hospital, and socioeconomic factors appear to be associated with BIMA utilization.
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http://dx.doi.org/10.1016/j.amjcard.2020.08.011DOI Listing
November 2020

Mechanism of Ventricular Premature Beats Elicited by Left Stellate Ganglion Stimulation During Acute Ischemia of the Anterior Left Ventricle.

Cardiovasc Res 2020 Aug 27. Epub 2020 Aug 27.

Amsterdam UMC, University of Amsterdam, Heart Center, Dept of Medical Biology, Dept of Experimental Cardiology, Meibergdreef 9 Amsterdam, The Netherlands.

Aims: Enhanced sympathetic activity during acute ischemia is arrhythmogenic, but the underlying mechanism is unknown. During ischemia, a diastolic current flows from the ischemic to the non-ischemic myocardium. This "injury" current can cause ventricular premature beats originating in the non-ischemic myocardium, especially during a deeply negative T wave in the ischemic zone. We reasoned that shortening of repolarization in myocardium adjacent to ischemic myocardium increases the "injury" current and causes earlier deeply negative T waves in the ischemic zone, and re-excitation of the normal myocardium. We tested this hypothesis by activation and repolarization mapping during stimulation of the left stellate ganglion (LSGS) during left anterior descending coronary artery (LAD) occlusion.

Methods And Results: In 9 pigs, five subsequent episodes of acute ischemia, separated by 20 min of reperfusion, were produced by occlusion of the LAD and 121 epicardial local unipolar electrograms were recorded. During the third occlusion, LSGS was initiated after 3 min for a 30-sec period, causing a shortening of repolarization in the normal myocardium by about 100 msec. This resulted in more negative T waves in the ischemic zone and more ventricular premature beats (VPBs) than during the second, control, occlusion. Following decentralization of the LSG (including removal of the right stellate ganglion and bilateral cervical vagotomy), fewer VPBs occurred during ischemia without LSGS. During LSGS, the number of VPBs was similar to that recorded before decentralization.

Conclusion: LSGS, by virtue of shortening of repolarization in the non-ischemic myocardium by about 100 msec, causes deeply negative T waves in the ischemic tissue and VPBs originating from the normal tissue adjacent to the ischemic border. In this setting, decentralization of the LSG is antiarrhythmic.

Translational Perspective: Cardiac sympathetic denervation is a promising therapy for reducing arrhythmias during acute ischemia. Currently it is not clear which patients with ischemic heart disease would benefit from cardiac sympathetic denervation and for which patients it is unlikely to have an effect. This is important because cardiac sympathetic denervation by removing the stellate ganglia often results in severe side effects and morbidity. Our results indicate that left stellate ganglion activity is pro-arrhythmic and that left stellectomy is beneficial for the prevention of arrhythmias during anterior wall ischemia. When the ischemic zone is in the lateral and posterior wall, the effects of LSGS will be different because it will directly affect the ischemic myocardium, and might even be antiarrhythmic. Thus, the effect of left stellate stimulation can be pro or antiarrhythmic, depending on the location of myocardial ischemia.
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http://dx.doi.org/10.1093/cvr/cvaa253DOI Listing
August 2020

Prone Positioning for Acute Respiratory Distress Syndrome (ARDS).

JAMA 2020 10;324(13):1361

Department of Surgery, University of California, Los Angeles.

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http://dx.doi.org/10.1001/jama.2020.14901DOI Listing
October 2020

National Trends and Cost Burden of Surgically Treated Gunshot Wounds in the US.

J Am Coll Surg 2020 10 10;231(4):448-459.e4. Epub 2020 Aug 10.

Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA. Electronic address:

Background: Gun violence remains a major burden on the US healthcare system, with annual cost exceeding $170 billion. Literature on the national trends in cost and survival of gun violence victims requiring operative interventions is lacking.

Study Design: All adults admitted with a diagnosis of gunshot wound requiring operative intervention were identified using the 2005-2016 National Inpatient Sample. The ICD Injury Severity Score, a validated prediction tool, was used to quantify the extent of traumatic injuries. Survey-weighted methodology was used to provide national estimates. Hospitalizations exceeding the 66th percentile of annual cost were considered as high-cost tertile. Multivariable logistic regressions with stepwise forward selection were used to identify factors associated with mortality and high-cost tertile.

Results: During the study period, 262,098 admissions met inclusion criteria with a significant increase in annual frequency and decrease in ICD Injury Severity Scores. A decline in mortality (8.6% to 7.6%; parametric test of trend = 0.03) was accompanied by increasing mean cost ($25,900 to $33,000; nonparametric test of trend < 0.001). After adjusting for patient and hospital characteristics, head and neck (adjusted odds ratio 31.2; 95% CI, 11.0 to 88.4; p < 0.001), vascular operations (adjusted odds ratio 24.5; 95% CI, 19.2 to 31.1; p < 0.001), and gastrointestinal (adjusted odds ratio 27.8; 95% CI, 17.2 to 44.8; p < 0.001) were independently associated with high-cost tertile designation compared with patients who did not undergo these operations.

Conclusions: During the past decade, the increase in gun violence and severity has resulted in higher cost. Operations involving selected surgical treatments incurred higher in-hospital cost. Given the profound economic and social impact of surgically treated gunshot wounds, policy and public health efforts to reduce gun violence are imperative.
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http://dx.doi.org/10.1016/j.jamcollsurg.2020.06.022DOI Listing
October 2020