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Background: Cardiovascular disease (CVD) in pregnancy is a leading cause of maternal morbidity and mortality in the United States, with an increasing prevalence., Objectives: This study aimed to examine risk factors for adverse maternal cardiac, maternal obstetric, and neonatal outcomes as well as costs for pregnant people with CVD at delivery., Methods: Using the National Inpatient Sample 2010-2019 and the Internal Classification of Diseases diagnosis codes, all pregnant people admitted for their delivery hospitalization were included. CVD diagnoses included congenital heart disease, cardiomyopathy, ischemic heart disease, arrhythmias, and valvular disease. Multivariable regressions were used to analyze major adverse cardiovascular events (MACE), maternal and fetal complications, length of stay, and resource utilization., Results: Of the 33,639,831 birth hospitalizations included, 132,532 (0.39%) had CVD. These patients experienced more frequent MACE (8.5% vs 0.4%, P  < 0.001), obstetric (24.1% vs 16.6%, P  < 0.001), and neonatal complications (16.1% vs 9.5%, P  < 0.001), and maternal mortality (0.16% vs 0.01%, P  < 0.001). Factors associated with MACE included cardiomyopathy (adjusted OR [aOR]: 49.9, 95% CI: 45.2-55.1), congenital heart disease (aOR: 13.8, 95% CI: 12.0-15.9), Black race (aOR: 1.04, 95% CI: 1.00-1.08), low income (aOR: 1.06, 95% CI: 1.02-1.11), and governmental insurance (aOR: 1.03, 95% CI: 1.00-1.07). On adjusted analysis, CVD was associated with higher odds of maternal mortality (aOR: 9.28, 95% CI: 6.35-13.56), stillbirth (aOR: 1.66, 95% CI: 1.49-1.85), preterm birth (aOR: 1.33, 1.27-1.39), and congenital anomalies (aOR: 1.84, 95% CI: 1.69-1.99). CVD was also associated with an increase of $2,598 (95% CI: $2,419-2,777) per patient during admission for delivery., Conclusions: CVD in pregnancy is associated with higher rates of adverse outcomes. Our study highlights the association of key clinical and demographic factors with CVD during pregnancy to emphasize those at highest risk for complications., Competing Interests: Dr Afshar is supported by the 10.13039/100000002National Institute of Health K12 HD000849, the 10.13039/100009633Eunice Kennedy Shriver National Institute of Child Health & Human Development, and the 10.13039/100002575American College of Obstetricians and Gynecologists as part of the Reproductive Scientist Development Program; and is a consultant for Mirvie and has an investigator-initiated project with Natera. Dr Benharash has received consultation fees from Atricure as a proctor. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Understanding the capacity of temperate trees to acclimate to limited soil water has become essential in the face of increasing drought risk due to climate change. We documented seasonal - or phenological - patterns in acclimation to water deficit stress in stems and leaves of tree species spanning the angiosperm phylogeny. Over 3 yr of field observations carried out in two US arboreta, we measured stem vulnerability to embolism (36 individuals of 7 Species) and turgor loss point (119 individuals of 27 species) over the growing season. We also conducted a growth chamber experiment on 20 individuals of one species to assess the mechanistic relationship between soil water restriction and acclimation. In three-quarters of species measured, plants became less vulnerable to embolism and/or loss of turgor over the growing season. We were able to stimulate this acclimatory effect by withholding water in the growth chamber experiment. Temperate angiosperms are capable of acclimation to soil water deficit stress, showing maximum vulnerability to soil water deficits following budbreak and becoming more resilient to damage over the course of the growing season or in response to simulated drought. The species-specific tempo and extent of this acclimatory potential constitutes preadaptive climate change resilience., (© 2024 The Authors. New Phytologist © 2024 New Phytologist Foundation.)

Background: Although failure to rescue (FTR) is increasingly recognized as a quality metric, studies in congenital cardiac surgery remain sparse. Within a national cohort of children undergoing cardiac operations, we characterized the presence of center-level variation in FTR and hypothesized a strong association with mortality but not complications., Methods: All children undergoing congenital cardiac operations were identified in the 2013 to 2019 Nationwide Readmissions Database. FTR was defined as in-hospital death after cardiac arrest, ventricular tachycardia/fibrillation, prolonged mechanical ventilation, pneumonia, stroke, venous thromboembolism, or sepsis, among other complications. Hierarchical models were used to generate hospital-specific, risk-adjusted rates of mortality, complications, and FTR. Centers in the highest decile of FTR were identified and compared with others., Results: Of an estimated 74,070 patients, 1.9% died before discharge, at least 1 perioperative complication developed in 43.0%, and 4.1% experienced FTR. After multilevel modeling, decreasing age, nonelective admission, and increasing operative complexity were associated with greater odds of FTR. Variations in overall mortality and FTR exhibited a strong, positive relationship (r = 0.97), whereas mortality and complications had a negligible association (r = -0.02). Compared with others, patients at centers with high rates of FTR had similar distributions of age, sex, chronic conditions, and operative complexity., Conclusions: In the present study, center-level variations in mortality were more strongly explained by differences in FTR than complications. Our findings suggest the utility of FTR as a quality metric for congenital heart surgery, although further study is needed to develop a widely accepted definition and appropriate risk-adjustment models., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background Guidelines for choice of prosthetic heart valve in people of reproductive age are not well established. Although biologic heart valves (BHVs) have risk of deterioration, mechanical heart valves (MHVs) require lifelong anticoagulation. This study aimed to characterize the association of prosthetic valve type with maternal and fetal outcomes in pregnant patients. Methods and Results Using the 2008 to 2019 National Inpatient Sample, we identified all adult patients hospitalized for delivery with prior heart valve implantation. Multivariable regressions were used to analyze the primary outcome, major adverse cardiovascular events, and secondary outcomes, including maternal and fetal complications, length of stay, and costs. Among 39 871 862 birth hospitalizations, 4152 had MHVs and 874 had BHVs. Age, comorbidities, and cesarean birth rates were similar between patients with MHVs and BHVs. The presence of a prosthetic valve was associated with over 22-fold increase in likelihood of major adverse cardiovascular events (MHV: adjusted odds ratio, 22.1 [95% CI, 17.3-28.2]; BHV: adjusted odds ratio, 22.5 [95% CI, 13.9-36.5]) as well as increased duration of stay and hospitalization costs. However, patients with MHVs and BHVs had no significant difference in the odds of any maternal outcome, including major adverse cardiovascular events, hypertensive disease of pregnancy, and ante/postpartum hemorrhage. Similarly, fetal complications were more likely in patients with valve prostheses, including a 4-fold increase in odds of stillbirth, but remained comparable between MHVs and BHVs. Conclusions Patients hospitalized for delivery with prior valve replacement carry substantial risk of adverse maternal and fetal events, regardless of valve type. Our findings reveal comparable outcomes between MHVs and BHVs.

Background: With a large body of literature demonstrating positive volume-outcome relationships for most major operations, minimum volume requirements have been suggested for concentration of cases to high-volume centers (HVCs). However, data are limited regarding disparities in access to these hospitals for pancreatectomy patients., Methods: The 2005-2018 National Inpatient Sample (NIS) was queried for all elective adult hospitalizations for pancreatectomy. Hospitals performing more than 20 annual cases were classified as HVCs. Mixed-multivariable regression models were developed to characterize the impact of demographic factors and case volume on outcomes of interest., Results: Of an estimated 127,527 hospitalizations, 79.8% occurred at HVCs. Patients at these centers were more frequently white (79.0 vs 70.8%; p < 0.001), privately insured (39.4 vs 34.2%; p < 0.001), and within the highest income quartile (30.5 vs 25.0%; p < 0.001). Adjusted analysis showed that operations performed at HVCs were associated with reduced odds of in-hospital mortality (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.34-0.55), increased odds of discharge to home (AOR, 1.17; 95% CI, 1.04-1.30), shorter hospital stay (β, -0.81 days; 95% CI, -1.2 to -0.40 days), but similar costs. Patients who were female (AOR, 0.88; 95% CI, 0.79-0.98), non-white (black: AOR, 0.66; 95% CI, 0.59-0.75; Hispanic: AOR, 0.56; 95% CI, 0.47-0.66; reference, white), insured by Medicaid (AOR, 0.63; 95% CI, 0.56-0.72; reference, private), and within the lowest income quartile (AOR, 0.73; 95% CI, 0.59-0.90; reference, highest) had decreased odds of treatment at an HVC., Conclusions: For those undergoing pancreatectomies, HVCs realize superior clinical outcomes but treat lower proportions of female, non-white, and Medicaid populations. These findings may have implications for improving access to high-quality centers., (© 2023. The Author(s).)

Background: While the impact of socioeconomic status (SES) on surgical outcomes has been examined in limited series, it remains a significant determinant of healthcare outcomes at the national level. Therefore, the current study aims to determine SES disparities at three time-points: hospital accessibility, in-hospital outcomes, and post-discharge consequences., Methods: The Nationwide Readmissions Database 2010-2018 was used to isolate major elective operations. SES was assigned using previously coded median income quartiles as defined by patient zip-code, with low SES defined as the lowest quartile and high SES as the highest., Results: Of an estimated 4,816,837 patients undergoing major elective operations, 1,037,689 (21.3 %) were categorized as low SES and 1,288,618 (26.5 %) as high . On univariate analysis and compared to those of low SES, high SES patients were more frequently treated at high-volume centers (70.9 vs 55.6 %, p < 0.001), had lower rates of in-hospital complications (24.0 vs 29.0 %, p < 0.001) and mortality (0.4 vs 0.9 %, p < 0.001) as well as less frequent urgent readmissions at 30- (5.7 vs 7.1 %, p < 0.001) and 90-day timepoints (9.4 vs 10.7 %, p < 0.001). On multivariable analysis, high SES patients had higher odds of treatment at high-volume centers (Odds: 1.87, 95 % CI: 1.71-2.06), and lower odds of perioperative complications (Odds: 0.98, 95 % CI: 0.96-0.99), mortality (Odds: 0.70, 95 % CI: 0.65-0.75), and urgent readmissions at 90-days (Odds: 0.95, 95 % CI: 0.92-0.98)., Conclusion: This study fills a much-needed gap in the current literature by establishing that all of the aforementioned timepoints include significant disadvantages for those of low socioeconomic status. Therefore, a multidisciplinary approach may be required for intervention to improve equity for surgical patients., Competing Interests: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this manuscript., (© 2023 The Authors.)

A body of literature has previously highlighted the impact of health insurance on observed disparities in congenital cardiac operations. With aims of improving access to healthcare for all patients, the Affordable Care Act (ACA) expanded Medicaid coverage to nearly all eligible children in 2010. Therefore, the present population-based study aimed to examine the association of Medicaid coverage with clinical and financial outcomes in the era the ACA. Records for pediatric patients (≤ 18 years) who underwent congenital cardiac operations were abstracted from the 2010-2018 Nationwide Readmissions Database. Operations were stratified using the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Category. Multivariable regression models were developed to evaluate the association of insurance status on index mortality, 30-day readmissions, care fragmentation, and cumulative costs. Of an estimated 132,745 hospitalizations for congenital cardiac surgery from 2010 to 2018, 74,925 (56.4%) were insured by Medicaid. The proportion of Medicaid patients increased from 57.6 to 60.8% during the study period. On adjusted analysis, patients with Medicaid insurance were at an increased odds of mortality (1.35, 95%CI: 1.13-1.60) and 30-day unplanned readmission (1.12, 95%CI: 1.01-1.25), experienced longer lengths of stay (+ 6.5 days, 95%CI 3.7-9.3), and exhibited higher cumulative hospitalization costs (+ $21,600, 95%CI: $11,500-31,700). The total hospitalization cost-burden for patients with Medicaid and private insurance were $12.6 billion and $8.06 billion, respectively. Medicaid patients exhibited increased mortality, readmissions, care fragmentation, and costs compared to those with private insurance. Our results of outcome variation by insurance status indicate the necessity of policy changes to attempt to approach equality in surgical out comes for this high-risk cohort. Baseline characteristics, trends, and outcomes by insurance status over the ACA rollout period 2010-2018., (© 2023. The Author(s).)

Objective: To assess the impact of congenital heart disease (CHD) on resource utilisation and clinical outcomes in patients undergoing major elective non-cardiac operations., Background: Due to advances in congenital cardiac management in recent years, more patients with CHD are living into adulthood and are requiring non-cardiac operations., Methods: The 2010-2018 Nationwide Readmissions Database was used to identify all adults undergoing major elective operations (pneumonectomy, hepatectomy, hip replacement, pancreatectomy, abdominal aortic aneurysm repair, colectomy, gastrectomy and oesophagectomy). Multivariable regression models were used to categorise key clinical outcomes., Results: Of an estimated 4 941 203 adults meeting inclusion criteria, 5234 (0.11%) had a previous diagnosis of CHD. Over the study period, the incidence of CHD increased from 0.06% to 0.17%, p<0.001. CHD patients were on average younger (63.3±14.8 vs 64.4±12.5 years, p=0.004), had a higher Elixhauser Comorbidity Index (3.3±2.2 vs 2.3±1.8, p<0.001) and received operations at high volume centres more frequently (66.6% vs 62.0%, p=0.003). Following risk adjustment, these patients had increased risk of in-hospital mortality (adjusted risk ratio (ARR): 1.76, 95% CI 1.25 to 2.47), experienced longer hospitalisation durations (+1.6 days, 95% CI 1.3 to 2.0) and cost more (+$8370, 95% CI $6686 to $10 055). Furthermore, they were more at risk for in-hospital complications (ARR: 1.24 95% CI 1.17 to 1.31) and endured higher adjusted risk of readmission at 30 days (ARR: 1.32 95% CI 1.13 to 1.54)., Conclusions: Adults with CHD are more frequently comprising the major elective operative cohort for non-cardiac cases. Due to the inferior clinical and financial outcomes suffered by this population, perioperative risk stratification may benefit from the inclusion of CHD as a factor that portends unfavourable outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Racial disparities in extracorporeal membrane oxygenation (ECMO) outcomes in patients with a broad set of indications are not well documented., Methods: Adults requiring ECMO were identified in the 2016-2019 National Inpatient Sample. Patient and hospital characteristics, including mortality, clinical outcomes, and resource utilization were analyzed using multivariable regressions., Results: Of 43,190 adult ECMO patients, 67.8% were classified as White, 18.1% Black, and 10.4% Hispanic. Although mortality for Whites declined from 47.5 to 41.0% (P = 0.002), it remained steady for others. Compared to White, Asian/Pacific Islander (PI) race was linked to increased odds of mortalty (AOR = 1.4, 95% CI = 1.1-2.0). Black race was associated with increased odds of acute kidney injury (AOR = 1.4, 95%-CI: 1.2-1.7), while Hispanic race was linked to neurologic complications (AOR 21.6; 95% CI 1.2-2.3). Black and Hispanic race were also associated with increased incremental costs., Conclusions: Race-based disparities in ECMO outcomes persist in the United States. Further work should aim to understand and mitigate the underlying reasons for such findings., Competing Interests: Declaration of competing interest The authors have no financial disclosures or conflicts of interest to report., (Copyright © 2022. Published by Elsevier Inc.)

Background: This study used a national cohort to characterize the impact of inter-hospital transfer status on outcomes following nonelective cholecystectomy for cholecystitis., Methods: Nonelective cholecystectomies were identified using the 2016-2019 National Inpatient Sample. Multivariable models adjusting for patient and hospital characteristics were utilized to assess outcomes of interest., Results: Of an estimated 530,696 patients, 5.3% were transferred. Transferred patients were older, more often male, and more likely to report income in the 0 th -25th percentile, compared to others. After adjustment, transfer was associated with increased odds of infectious complications (AOR 1.31, 95%CI 1.06-1.60) and non-home discharge (AOR 1.59, 95%CI 1.45-1.74), but not mortality. Transfer was linked to a $600 cost decrement at the operating hospital (95%CI -$880-330)., Conclusions: Transfer status is associated with greater postoperative infection, but not mortality. Given that disparities may play a role in transfer decisions, more work must be done to identify transfer drivers and improve patient outcomes., Competing Interests: Declaration of competing interest The authors have no financial disclosures or conflicts of interest to report., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Whereas the association between surgical volume and outcomes has been well established, the potential impact of specialized pediatric centers on outcomes of cardiac operations for adults with congenital heart disease has not been elucidated., Methods: The 2010-2017 Nationwide Readmissions Database was queried to identify all adults with congenital heart disease. High-volume centers were designated the highest tertile of operative case volume annually for both pediatric and adult cardiac operations. Multivariable regression models adjusting for demographic and clinical characteristics were used to evaluate adjusted odds ratios for select outcomes., Results: Of an estimated 52 357 hospitalizations meeting inclusion criteria, 6074 (11.7%) received an operation at a pediatric high-volume center (pHVC) and 45 652 (87.2%) at an adult high-volume center (aHVC). Compared with an aHVC, patients at a pHVC were on average younger, had a similar Elixhauser Comorbidity Index, and underwent higher risk operations. They more commonly carried private insurance and were categorized within the top income quartile. On multivariable analysis, operations at a pHVC were associated with reduced odds of perioperative complications (adjusted odds ratio [AOR], 0.85; 95% CI, 0.72-0.99), nonhome discharge (AOR, 0.64; 95% CI, 0.55-0.73), and 90-day emergent readmissions (AOR, 0.73; 95% CI, 0.60-0.89) but similar risk of death (AOR, 0.74; 95% CI, 0.43-1.28)., Conclusions: Compared with high-volume hospitals for adult cardiac operations, congenital heart disease operations at high-volume pediatric cardiac centers were associated with reduced odds of complications, nonhome discharges, and urgent readmissions. Our findings may better inform appropriate referral of this cohort of complex patients and regionalization of their care., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Practices in surgical repair of uncomplicated gastroschisis are varied. Data regarding hospital volume, surgical technique, clinical outcomes, and costs remain limited. Neonatal patients with uncomplicated gastroschisis were identified using the 2015-2019 National Readmissions Database. Hospital volume tertiles were determined, and sutureless or fascial repair techniques were enumerated. High volume centers (HVC) comprised the top tertile. Hospital-level variability in surgical technique was determined. Adjusted multivariable analysis was performed to compare clinical outcomes and costs among HVC and lower-volume centers and among repair techniques. Of an estimated 2903 hospitalizations meeting inclusion criteria, 23.5% occurred at HVC. There was 42.4% variation among sutureless and fascial repair techniques across all hospitals. Among HVC and lower-volume centers, there were no significant differences in rates of 30-day readmission or complication; however, HVC were associated with greater cost and length of stay. Those with codes for fascial repair technique experienced greater lengths of stay, costs, and rates of complication. Codes for surgical repair technique for uncomplicated gastroschisis vary widely, while outcomes are equivalent across strata of hospital volume. Those with codes for sutureless technique were associated with favorable clinical outcomes, irrespective of hospital volume. Guidelines for management of uncomplicated gastroschisis should account for hospital volume, variation in technique, outcomes, and resource utilization.

Objectives: Expedited discharge after coronary artery bypass grafting (CABG) has been postulated as a possible solution for reducing hospitalization costs. This study aimed to evaluate the impact of expedited postoperative discharge on readmissions and costs in patients undergoing isolated CABG., Design: Adults (≥18 years) who underwent isolated CABG were identified using the 2016-to-2019 Nationwide Readmission Database. Patients were classified as expedited or routine, with expedited patients being discharged on or before postoperative day 4. Those who experienced perioperative complications were excluded., Setting: The Nationwide Readmissions Database., Participants: Patients ≥18 years old who underwent isolated CABG., Measurements and Main Results: Of an estimated 187,591 patients meeting study criteria, 37.2% (n = 69,861) experienced expedited discharge. Expedited patients experienced lower index hospitalization costs ($28,543 v $34,114, p < 0.001), and were less likely to experience 30-day nonelective readmission (4.6% v 7.3%, p < 0.001) and 90-day nonelective readmission (5.6% v 8.7%, p < 0.001). After adjustment, expedited discharge remained independently associated with reduced odds of both 30-day (adjusted odds ratio [AOR]: 0.78, 95% CI: 0.71-0.85) and 90-day (AOR: 0.80, 95% CI: 0.74-0.87) nonelective readmission. In addition, expedited discharge was associated with an incremental decrease in index hospitalization costs (β: -5,661, 95% CI: -5,894 to -5,429)., Conclusions: Expedited discharge immensely decreases costs of care for patients undergoing isolated CABG, as well as readmission risks. Expedited discharge may be considered a strategy to both improve postoperative patient care and reduce hospitalization costs within the United States healthcare system., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Racial disparities in outcomes have been shown to persist in many operative specialties, including the management of congenital heart disease. Using a demographic-adjusted methodology, we examined whether patient race influenced access to high-performing centers for the operative management of hypoplastic left heart syndrome., Methods: The 2005-2017 National Inpatient Sample was queried to identify all pediatric (≤5 years) hospitalizations with an operation for hypoplastic left heart syndrome. A racial disparity index was generated for each hospital and defined as the proportion of White patients receiving operative management for hypoplastic left heart syndrome divided by the proportion of White patients admitted for respiratory failure. This methodology quantified hospital-level racial variation while adjusting for the local racial makeup of each center., Results: Of the 17,275 patients who met inclusion criteria, 64.1% were managed at high-volume centers. Patients at high-volume centers had a similar distribution of operative type, age, and burden of comorbidities. The mean racial disparity index steadily grew from 1.06 at the lowest volume decile of operative volume to 1.51 at the highest, indicating an increasing proportion of White patients as volume increased. Using risk-adjusted analysis, each decile increase in hospital volume was associated with a 14% relative reduction in odds of mortality and a 0.06 increase in predicted racial disparity index. Increasing volume was further associated with reduced odds of non-home discharge but did not alter resource utilization., Conclusion: We demonstrate that high-volume centers disproportionally serve White patients and have superior clinical outcomes compared to low-volume centers. This study highlights the critical importance of equitable access to expert care for high-risk conditions such as hypoplastic left heart syndrome., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Contemporary large-scale studies examining demographic and surgical factors associated with perioperative cardiac arrest and its associated outcomes are sparse., Methods: Adults undergoing elective pancreatectomy, hepatectomy, lung resection, colectomy, gastrectomy, esophagectomy, abdominal aortic aneurysm repair, or hip replacement were identified between 2005 and 2018 using the National Inpatient Sample. Factors associated with cardiac arrest were of primary interest, while failure to rescue was also considered. Risk-adjusted outcomes were analyzed using logistic regressions to ascertain adjusted odds ratios as selected with Elastic Net methodology., Results: Of an estimated 7,216,531 hospitalizations for major elective operations, 21,496 (0.3%) had cardiac arrest. The incidence of cardiac arrest decreased from 0.4% in 2005 to 0.3% in 2018, as did failure to rescue (65.4%-53.2%, P < .001). Factors including increased age (adjusted odds ratios: 1.02/year; 95% confidence interval, 1.01-1.02), higher Elixhauser comorbidity score (adjusted odds ratios: 1.46/point; 95% confidence interval, 1.44-1.49), abdominal aortic aneurysm repair (adjusted odds ratios: 1.67, 95% confidence interval, 1.25-2.23, reference: esophagectomy), and Black race (adjusted odds ratios: 1.60; 95% confidence interval, 1.43-1.80, reference: White) were independently associated with increased cardiac arrest. Furthermore, private insurance (private: adjusted odds ratios: 0.78; 95% confidence interval, 0.66-0.93, reference: Medicaid) and the highest income quartile (highest: adjusted odds ratios: 0.83; 95% confidence interval, 0.75-0.92, reference: lowest) were associated with lower adjusted odds of cardiac arrest. After cardiac arrest, Black race (adjusted odds ratios: 1.26; 95% CI, 1.02-1.56, reference: White) maintained increased adjusted odds of failure to rescue., Conclusion: Despite a reduction in the incidence of cardiac arrest and an associated improvement in survival, racial and socioeconomic disparities influence outcomes. These findings may advise policy changes to encourage equity in outcomes for those undergoing major elective operations., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: Vocal fold paralysis (VFP) has proven to increase resource use in several surgical fields. However, its burden in congenital cardiac surgery, a specialty known to be associated with high resource use, has not yet been examined. The authors aimed to assess the impact of VFP on costs, lengths of stay, and readmissions following congenital cardiac surgery., Design: A retrospective analysis of administrative data., Setting: The 2010-2017 National Readmissions Database., Participants: All pediatric patients undergoing congenital cardiac surgery., Interventions: None., Measurements and Main Results: Vocal fold paralysis was defined using International Classification of Diseases, Ninth and Tenth Revisions, diagnosis codes. The primary outcome of interest was 30-day nonelective readmissions and 90-day readmissions; costs, length of stay, and discharge status also were considered. Of an estimated 124,486 patients meeting study criteria, 2,868 (2.3%) were identified with VFP. Incidence of VFP increased during the study period (0.7% in 2010 to 3.2% in 2017, nptrend < 0.001). Rates of nonhome discharge (30.0% v 16.4%, p < 0.001), 30-day readmission (23.9% v 12.4%, p < 0.001), and 90-day readmission (8.3% v 4.4%, p = 0.03) were increased in the VFP cohort, as were lengths of stay (42.1 v 27.0 days, p < 0.001) and costs ($196,000 v $128,000, p < 0.001). After adjustment for patient and hospital factors, VFP was independently associated with greater odds of nonhome discharge (adjusted odds ratios [AOR], 1.66, 95% CI, 1.14-2.40), 30-day readmission (AOR, 1.58, 95% CI, 1.03-2.42), 90-day readmission (AOR, 2.07, 95% CI, 1.22-3.52), longer lengths of stay (+ 6.1 days, 95% CI, 1.3-10.8), and higher hospitalization costs (+$22,000, 95% CI, 3,000-39,000)., Conclusions: Readmission rates after congenital cardiac surgery are significantly greater among those with VFP, as are costs, lengths of stay, and nonhome discharges. Therefore, further efforts are necessary to increase awareness and reduce the incidence of VFP in this vulnerable population to minimize the financial burden of congenital cardiac surgery on the US medical system., Competing Interests: Conflict of Interest The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this manuscript., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To characterize the relationship between surgical volume and postoperative outcomes in congenital heart surgery, we used a national cohort to assess the costs, readmissions, and complications in children undergoing cardiac operations., Study Design: The Nationwide Readmissions Database was used to identify pediatric patients (≤18 years) undergoing congenital cardiac surgery from 2010 to 2017. Hospitals were categorized based on deciles and tertiles of annual caseload with high-volume categorized as the highest tertile of volume. Multivariable regression models adjusting for patient and hospital characteristics were used to study the impact of volume on 30-day nonelective readmission, mortality, home discharge, and resource use., Results: Of an estimated 69 448 hospitalizations included for analysis, 56 672 (82%) occurred at high-volume centers. After adjustment for key clinical factors, each decile increase in volume was associated with a 25% relative decrease in the odds of mortality, a 14% decrease in the odds of nonhome discharge, and a 4% relative decrease in the likelihood of 30-day nonelective readmission. After risk adjustment, each incremental increase in volume decile was associated with a one-half-day decrease in the hospital length of stay, but did not alter costs of the index hospitalization. However, after including all readmissions within 30 days of the index discharge, high-volume centers were associated with significantly lower costs compared with low-volume hospitals., Conclusions: Increased congenital cardiac surgery volume is associated with improved mortality, reduced duration of hospitalization, 30-day readmissions, and resource use. These findings demonstrate the inverse relationship between hospital volume and resource use and may have implications for the centralization of care for congenital cardiac surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The present study examined the impact of donor hypertension on recipient survival and offer acceptance practices in the United States. This was a retrospective study of all patients undergoing OHT from 1995 to 2019 using the United Network for Organ Sharing and Potential Transplant Recipient file databases. Hypertensive donors were stratified by Short (0-5 years) and Prolonged (> 5 years) hypertension. Multivariable logistic regression was used to analyze offer acceptance practices while Cox proportional-hazards models were used to compare mortality across groups. Of 38,338 heart transplants meeting study criteria, 5662 were procured from hypertensive donors (69% Short and 31% Prolonged). After adjustment, Prolonged donor hypertension was associated with increased mortality (hazard ratio, HR, 1.31, 95% confidence interval, CI, 1.04-1.64), while recipients of Short donors experienced no decrement in post-transplant survival. Both Short and Prolonged hypertension were independently associated with decreased odds of offer acceptance (odds ratio, OR .92 95%CI: .88-.96 and OR .93 95%CI: .88-.99, respectively). While prolonged untreated hypertension in OHT donors is associated with a slight decrement in recipient survival, donors with ≤5 years of hypertension yielded similar outcomes. Donor hypertension was associated with reduced organ offer acceptance, highlighting a potential source of organ underutilization., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Retained surgical foreign bodies (RFB) are associated with inferior clinical and financial outcomes. The present work examined a nationally representative sample of all major operations to identify factors associated with RFB., Study Design: The 2005-2017 National Inpatient Sample was used to identify adults undergoing cardiac, neurosurgical, orthopedic, genitourinary, gastrointestinal, vascular, and thoracic operations. International Classifications of Diseases 9th-10th Revisions diagnosis codes were used to identify instances of RFB., Results: Of an estimated 71,445,042 hospitalizations, .02% had a diagnosis of RFB, with decreasing incidence from .03 to .02% over the study period (NPtrend < .001). Relative to vascular operations, gastrointestinal (adjusted odds ratio [AOR] 2.12), thoracic (AOR 1.80), and multi-cavity (AOR 2.17) were associated with greater odds of RFB. Laparoscopic approach (AOR .33) and trauma-associated admission (AOR .52, all P < .001) were associated with reduced odds of RFB. Despite similar mortality, RFB was associated with increased odds of pulmonary infection (AOR 1.62), sepsis (AOR 1.26), and wound infection (AOR 5.15), as well as a 2.3-day increment in length of stay and $7700 in hospitalization costs (all P < .001)., Conclusion: The development of novel mitigation strategies may reduce the incidence of RFB in high-risk populations, such as those undergoing gastrointestinal, thoracic, and multi-cavity operations.

Objective: To characterize hospitalization costs attributable to gun-related injuries in children across the US., Study Design: The 2005-2017 National Inpatient Sample was used to identify all pediatric admissions for gunshot wounds (GSW). Patients were stratified by International Classification of Diseases procedural codes for trauma-related operations. Annual trends in GSW hospitalizations and costs were analyzed with survey-weighted estimates. Multivariable regressions were used to identify factors associated with high-cost hospitalizations., Results: During the study period, an estimated 36 283 pediatric patients were admitted for a GSW, with 43.1% undergoing an operative intervention during hospitalization. Admissions for pediatric firearm injuries decreased from 3246 in 2005 to 3185 in 2017 (NPtrend < .001). The median inflation-adjusted cost was $12 408 (IQR $6253-$24 585). Median costs rose significantly from $10 749 in 2005 to $16 157 in 2017 (P < .001). Compared with those who did not undergo surgical interventions, operative patients incurred increased median costs ($18 576 vs $8942, P < .001). Assault and self-harm injuries as well as several operations were independently associated with classification in the highest cost tertile., Conclusions: Admissions for pediatric firearm injuries were associated with a significant socioeconomic burden in the US, with increasing resource use over time. Pediatric gun violence is a major public health crisis that warrants further research and advocacy to reduce its prevalence and social impact., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: The effect of the 2018 adult heart allocation policy change at an institution-level remains unclear. The present study assessed the impact of the policy change by transplant center volume., Methods: The United Network for Organ Sharing database was queried for all adults undergoing isolated heart transplantation from November 2016 to September 2020. Era 1 was defined as the period before the policy change and Era 2 afterwards. Hospitals were divided into low-(LVC) medium-(MVC) and high-volume (HVC) tertiles based on annual transplant center volume. Competing-risks regressions were used to determine changes in waitlist death/deterioration, while post-transplant mortality was assessed using multivariable Cox proportional-hazards models., Results: A total of 3531 (47.0%) patients underwent heart transplantation in Era 1 and 3988 (53.0%) in Era 2. At LVC, Era 2 patients were less likely to experience death/deterioration on the waitlist (subhazard ratio .74, 95% CI .63-.88), while MVC and HVC patients experienced similar waitlist death/deterioration across eras. After adjustment, transplantation in Era 2 was associated with worse 1-year mortality at MVC (hazard ratio, HR, 1.42 95% CI 1.02-1.96) and HVC (HR 1.42, 95% CI 1.02-1.98) but not at LVC., Conclusion: Early analysis shows that LVC may be benefitting under the new allocation scheme., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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] < .001) and LBHs (22.0%-10.9%; nptrend < .001) over the study period, as did tracheostomy placement (HBH, 5.6%-1.3%; LBH, 3.5%-0.8%; all nptrend <.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., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Competing Interests: Disclosure: The authors have no conflicts of interest to report.

Background: Extracorporeal life support (ECLS) has been used for >30 years as a life-sustaining therapy in critically ill patients for a variety of indications. In the current study, we aimed to examine trends in use, mortality, length of stay (LOS), and costs for pediatric ECLS hospitalizations., Methods: We performed a retrospective cohort study of pediatric patients (between the ages of 28 days and <21 years) on ECLS using the 2008-2015 National Inpatient Sample, the largest all-payer inpatient hospitalization database generated from hospital discharges. Nonparametric and Cochran-Armitage tests for trend were used to study in-hospital mortality, LOS, and hospitalization costs., Results: Of the estimated 5847 patients identified and included for analysis, ECLS was required for respiratory failure (36.4%), postcardiotomy syndrome (25.9%), mixed cardiopulmonary failure (21.7%), cardiogenic shock (13.1%), and transplanted graft dysfunction (2.9%). The rate of ECLS hospitalizations increased 329%, from 11 to 46 cases per 100 000 pediatric hospitalizations, from 2008 to 2015 ( P < .001). Overall mortality decreased from 50.3% to 34.6% ( P < .001). Adjusted hospital costs increased significantly ($214 046 ± 11 822 to 324 841 ± 25 621; P = .002) during the study period despite a stable overall hospital LOS (46 ± 6 to 44 ± 4 days; P = .94)., Conclusions: Use of ECLS in pediatric patients has increased with substantially improved ECLS survival rates. Hospital costs have increased significantly despite a stable LOS in this group. Dissemination of this costly yet life-saving technology warrants ongoing analysis of use trends to identify areas for quality improvement., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Calcium ions are essential to signal transduction in virtually all cells, where they coordinate processes ranging from embryogenesis to neural function. Although optical probes for intracellular calcium imaging have been available for decades, the development of probes for noninvasive detection of intracellular calcium signaling in deep tissue and intact organisms remains a challenge. To address this problem, we synthesized a manganese-based paramagnetic contrast agent, ManICS1-AM, designed to permeate cells, undergo esterase cleavage, and allow intracellular calcium levels to be monitored by magnetic resonance imaging (MRI). Cells loaded with ManICS1-AM show changes in MRI contrast when stimulated with pharmacological agents or optogenetic tools; responses directly parallel the signals obtained using fluorescent calcium indicators. Introduction of ManICS1-AM into rodent brains furthermore permits MRI-based measurement of neural activation in optically inaccessible brain regions. These results thus validate ManICS1-AM as a calcium sensor compatible with the extensive penetration depth and field of view afforded by MRI.