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A subset of patients with Takotsubo Cardiomyopathy (TCM) develops hemodynamic instability requiring temporary mechanical circulatory support (tMCS). We examined the National Inpatient Sample (NIS), a large national registry of hospitalized patients in the United States, to identify temporal trends in the utilization of tMCS in TCM patients along with clinical outcomes and cost. All adult hospitalizations of TCM from the National Inpatient Sample Database between 2007 to 2015 using ICD-9-CM codes were identified. We compared baseline characteristics, co-morbidities, mortality, length of stay and hospitalization costs among TCM patients with and without the need for tMCS. Propensity score matching to mitigate the differences was used. SAS 9.4 software was used for statistical analysis. Of 44,842 TCM hospitalizations, 1,120 (2.5%) received tMCS. Table 1 summarizes the baseline characteristics of this study population. Intra-aortic balloon pump (IABP) (1049/1120, 94%) was the most commonly utilized followed by extracorporeal oxygenation (66/1120, 5.8%) and paracorporeal ventricular assist device (20/1120, 0.2%) without any temporal trend in utilization pattern during the study period. After propensity matching, patients requiring tMCS for TCM as primary diagnosis were significantly younger (64.1±12.2 vs 66.3 ±12.9, P<0.0001) and more likely to be male. In-hospital mortality (9.3 % vs. 8.4 %; P = 0.73) was indifferent between the groups. However, the cost incurred during hospitalization and length of stay were higher in patients who underwent tMCS. The use of tMCS in patients with TCM and hemodynamic instability resulted in significantly higher cost, and length of hospital stay without positive impact on survival. This may be secondary to higher utilization of IABP contributing to worsening dynamic left ventricular outflow obstruction, systemic studies are needed. [ABSTRACT FROM AUTHOR]

Purpose/objective(s): Medulloblastoma is the most common malignant pediatric brain neoplasm, but its pattern of care among adult patients has not been standardized. Recent studies demonstrated that disparity in socioeconomic factors could influence treatment decision and prognosis in many cancers. This study aims to analyze the impact of insurance and socioeconomic status on the clinical outcome of adult patients with medulloblastoma in the United States.Materials/methods: Adult patients (age 18 or older) with medulloblastoma in the brain diagnosed from 2004 to 2016 were identified from the National Cancer Database (NCDB). Patients with unknown status for race, insurance, income quartile, treatment status of radiation or chemotherapy, or overall survival (OS) were excluded. OS was evaluated with the Kaplan-Meier and Cox proportional hazards methods. Logistic regression was performed to assess the effect on dichotomized dependent variable.Results: A total of 1,282 adult patients with medulloblastoma were identified. The median follow-up time was 6.9 years. The mean age was 29 years (range 18-85). 30.9% of patients were uninsured or had Medicaid, 83.2% were white, 81.9% received radiation therapy, and 59.9% received chemotherapy. Using univariate analysis, insurance status, radiation, and chemotherapy were statistically associated with OS. Uninsured/Medicaid patients were associated with poorer OS (hazards ratio [HR] 1.36, 95% CI 1.08-1.71, P < 0.01) compared to those with private insurance. Treatment with radiation therapy (HR 0.43, 95% CI 0.34-0.55, P < 0.01) or chemotherapy (HR 0.51, 95% CI 0.41-0.62, P < 0.01) portended improved OS. After adjusting for age, sex, race, and Charlson-Deyo comorbidity score, statistically significant differences in OS were seen for patients with no insurance/Medicaid (HR 1.48, 95% CI 1.17-1.86, P < 0.01). Using multivariate logistic regression, patients with either no insurance or Medicaid were less likely to receive radiation therapy (odds ratio [OR] 0.69, 95% CI 0.51-0.95, P = 0.02) compared to patients with private insurance, suggesting the mechanistic link between insurance status and pattern of care.Conclusion: Using a large national cohort of adult medulloblastoma patients, this study demonstrated the statistically significant disparity of patient outcomes with insurance status. An effort to address healthcare disparity and increase access to cancer care may improve the clinical outcome for adult patients with medulloblastoma. [ABSTRACT FROM AUTHOR]

Background: Most guidelines recommend both pelvic packing (PP) and angioembolization for hemodynamically unstable pelvic fractures, however their sequence varies. Some argue to use PP first because orthopaedic surgeons are more available than interventional radiologists; however, there is no data confirming this. Methods: This cross-sectional survey of 158 trauma medical directors at US Level I trauma centers collected the availability of orthopaedic surgeons and interventional radiologists, the number of orthopaedic trauma surgeons trained to manage pelvic fractures, and priority treatment sequence for hemodynamically unstable pelvic fractures. The study objective was to compare the availability of orthopaedic surgeons to interventional radiologists and describe how the availability of orthopaedic surgeons and interventional radiologists affects the treatment sequence for hemodynamically unstable pelvic fractures. Fisher's exact, chi-squared, and Kruskal-Wallis tests were used, alpha = 0.05. Results: The response rate was 25% (40/158). Orthopaedic surgeons (86%) were on-site more often than interventional radiologists (54%), p = 0.003. Orthopaedic surgeons were faster to arrive 39% of the time, and interventional radiologists were faster to arrive 6% of the time. There was a higher proportion of participants who prioritized PP before angioembolization at centers with above the average number (> 3) of orthopaedic trauma surgeons trained to manage pelvic fractures, as among centers with equal to or below average, p = 0.02. Arrival times for orthopaedic surgeons did not significantly predict prioritization of angioembolization or PP. Conclusions: Our results provide evidence that orthopaedic surgeons typically are more available than interventional radiologists but contrary to anecdotal evidence most participants used angioembolization first. Familiarity with the availability of orthopaedic surgeons and interventional radiologists may contribute to individual trauma center's treatment sequence. [ABSTRACT FROM AUTHOR]