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Fibroblasts can be directly reprogrammed via a combination of small molecules to generate induced neurons (iNs), bypassing intermediate stages. This method holds great promise for regenerative medicine; however, it remains inefficient. Recently, studies have suggested that physical cues may improve the direct reprogramming of fibroblasts into neurons, but the underlying mechanisms remain to be further explored, and the physical factors reported to date do not exhibit the full properties of the extracellular matrix (ECM). Previous in vitro studies mainly used rigid polystyrene dishes, while one of the characteristics of the native in-vivo environment of neurons is the soft nature of brain ECM. The reported stiffness of brain tissue is very soft ranging between 100 Pa and 3 kPa, and the effect of substrate stiffness on direct neuronal reprogramming has not been explored. Here, we show for the first time that soft substrates substantially improved the production efficiency and quality of iNs, without needing to co-culture with glial cells during reprogramming, producing more glutamatergic neurons with electrophysiological functions in a shorter time. Transcriptome sequencing indicated that soft substrates might promote glutamatergic neuron reprogramming through integrins, actin cytoskeleton, Hippo signalling pathway, and regulation of mesenchymal-to-epithelial transition, and competing endogenous RNA network analysis provided new targets for neuronal reprogramming. We demonstrated that soft substrates may promote neuronal reprogramming by inhibiting microRNA-615-3p-targeting integrin subunit beta 4. Our findings can aid the development of regenerative therapies and help improve our understanding of neuronal reprogramming. First, we have shown that low stiffness promotes direct reprogramming on the basis of small molecule combinations. To the best of our knowledge, this is the first report on this type of method, which may greatly promote the progress of neural reprogramming. Second, we found that microRNA (miR)-615-3p may interact with integrin subunit beta 4 (ITGB4), and the soft substrates may promote neural reprogramming by inhibiting miR-615-3p targeting ITGB4. We are the first to report on this mechanism. Our findings will provide more functional neurons for subsequent basic and clinical research in neurological regenerative medicine, and will help to improve the overall understanding of neural reprogramming. This work also provides new ideas for the design of medical biomaterials for nerve regeneration. [Display omitted] [ABSTRACT FROM AUTHOR]

Carbon cloth (CC) coupled with exogenous hydrogen (EH 2) was used to promote direct interspecies electron transfer (DIET) during anaerobic digestion of waste fat, oil, and grease (FOG). However, whether the change of EH 2 injection pattern would further enhance DIET and FOG conversion for methane production is unknown, and the underlying mechanism is not fully understood. In this study, three EH 2 injection pressures (0.2/0.4/0.6 atm) and frequencies (once/every 8 days/every 4 days) were chosen to collaborate with CC for investigating the role of EH 2 in methane yield during FOG digestion. The results show that, combined with CC, increased EH 2 injection pressure/frequency resulted in gradually enhanced DIET to increase FOG conversion rate (from 69.9% to 96.7%), leading to the highest cumulative methane production (1204.9 mL/gVS added) 58.9% higher than that of Control. During the digestion, the secretion of extracellular polymeric substances was increased by EH 2 to promote bioaggregation and electron transfer between cells for enhanced biological DIET in the digestate. The influence of EH 2 on the microbial communities on CC surface was bigger than that in suspended sludge, leading to enhanced syntrophic acetate oxidation-hydrogenotrophic methanogenesis (SAO-HM) for acetate conversion on CC. As the amount of EH 2 increased, the acetate conversion by SAO-HM via DIET was improved, which simultaneously promoted the syntrophic metabolisms between acidogens/acetogens and methanogens to achieve more efficient FOG conversion. Together, this work provides new insight into the role of EH 2 in the enhancement of DIET and methane yield during FOG digestion. [Display omitted] • Exogenous H 2 (with carbon cloth) increased methane production by 58.9%. • Increased H 2 injection gradually enhanced DIET to achieve 96.7% of lipid conversion. • High H 2 injection increased the activity of electron transfer system by 181.8%. • Exogenous H 2 significantly shifted the microbial community on carbon cloth. • Enhanced DIET by H 2 injection promoted acetate conversion in lipid degradation. [ABSTRACT FROM AUTHOR]

A hypersonic inlet/isolator acts as the "compressor" for scramjet engines through a series of shocks, which induces complex internal flows. This paper comprehensively reviews the recent research achievements, focusing on the shock-dominated internal flow of an inlet/isolator. Considering the specific geometrical feature of the hypersonic inlet, the shock wave/boundary layer interactions (SWBLIs) are characterized by multiple successive shocks. Three types of couplings have been observed between adjacent interaction regions. Moreover, shock and expansion waves, which are induced by the SWBLIs and named "background wave", are reflected in an isolator, forming a background wave/shock train interaction flow. The shock train behavior significantly differs from that in direct-connect facilities under uniform incoming flow conditions, and energy-level-transition-like phenomenon is observed when the shock train intersects with the background wave. Four types of quasi-steady background wave/shock train interactions have been reported, and three types of dynamic transitions have been observed when the shock train passes across the reflection point of the background shock. After the shock train is expelled from the internal duct, the inlet/isolator falls into unstart, and the unsteady shock-dominated flow with violent low-frequency shock oscillation occurs. A typical unstart period contains several stages, including the motion of the shock train in the isolator, large-scale separation in the inlet, and shock oscillation at the external part of the inlet. The flow mechanics of the hypersonic inlet/isolator unstart differs from that of a supersonic inlet. An unstart loop for a hypersonic inlet/isolator has been proposed, including convection wave, shock train, and acoustic wave. Once the induced factor of the unstart is removed, the unstarted shock retreats and the inlet experiences restart with the rebuilding of the supersonic flow. The restart process is highly dependent on the initial flow state and the historical effect. An instantaneous buzz arises before the unstarted shock retreats into the internal duct. Finally, the related passive (e.g., micro-vortex generator, bump, boundary layer bleed and self-circulation secondary flow control method) and active flow control methods (e.g., air jet vortex generator, plasma jet flow control, and solid-particle injection) for weakening the unfavorable impact of these shock-dominated flows are reviewed. Furthermore, the control mechanics and control effects of these flow control methods are analyzed. [ABSTRACT FROM AUTHOR]

Background Dumbbell-shaped tumor is a type of inner and outer cervical spinal canal tumor, and most of these are neurogenic. Desmoid tumors are rare, and, to the best of our knowledge, no case of desmoid tumors involving intervertebral foramen formed dumbbell-shaped tumors in the cervical spine have been reported before in English literature. Here we report a case of a desmoid tumor occurring in the cervical spine that is presented as a typical dumbbell-shaped tumor. Case Description A 47-year-old woman was admitted to our department with a mass in the left side of her neck. The tumor was initially thought to be a neurogenic cervical dumbbell tumor based on physical and radiologic examination. Postoperative hematoxylin-eosin staining and immunohistochemical staining verified the diagnosis of a cervical dumbbell desmoid tumor, which, to our knowledge, had never been reported before. We report our experience and reviewed literature regarding desmoid tumor to share our experience and explore proper treatment options of such lesions. Conclusions Desmoid tumors in the head and neck may present as cervical dumbbell-shaped tumors. Before the treatment plan was made, thorough examinations, including surgical pathology, were necessary. [ABSTRACT FROM AUTHOR]

Abstract The trinomial coefficient (n k) 2 is given by ∑ k = − n n (n k) 2 x k = (1 + x + x − 1) n. In this paper, we obtain the explicit formulas for the lacunary sum ∑ − n ≤ k ≤ n k ≡ r (mod m) (n k) 2. For example, ∑ − n ≤ k ≤ n k ≡ 1 (mod 12) (n k) 2 = 2 n + 3 n − (− 1) n + 6 H n 12 , where H 0 = 0 , H 1 = 1 and H n = 2 H n − 1 + 2 H n − 2 for n ≥ 2. [ABSTRACT FROM AUTHOR]

Background The Society of Thoracic Surgeons (STS) uses statistical models to create risk-adjusted performance metrics for Adult Cardiac Surgery Database (ACSD) participants. Because of temporal changes in patient characteristics and outcomes, evolution of surgical practice, and additional risk factors available in recent ACSD versions, completely new risk models have been developed. Methods Using July 2011 to June 2014 ACSD data, risk models were developed for operative mortality, stroke, renal failure, prolonged ventilation, mediastinitis/deep sternal wound infection, reoperation, major morbidity or mortality composite, prolonged postoperative length of stay, and short postoperative length of stay among patients who underwent isolated coronary artery bypass grafting surgery (n = 439,092), aortic or mitral valve surgery (n = 150,150), or combined valve plus coronary artery bypass grafting surgery (n = 81,588). Separate models were developed for each procedure and endpoint except mediastinitis/deep sternal wound infection, which was analyzed in a combined model because of its infrequency. A surgeon panel selected predictors by assessing model performance and clinical face validity of full and progressively more parsimonious models. The ACSD data (July 2014 to December 2016) were used to assess model calibration and to compare discrimination with previous STS risk models. Results Calibration in the validation sample was excellent for all models except mediastinitis/deep sternal wound infection, which slightly underestimated risk and will be recalibrated in feedback reports. The c-indices of new models exceeded those of the last published STS models for all populations and endpoints except stroke in valve patients. Conclusions New STS ACSD risk models have generally excellent calibration and discrimination and are well suited for risk adjustment of STS performance metrics. [ABSTRACT FROM AUTHOR]

Background The last published version of The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) risk models were developed in 2008 based on patient data from 2002 to 2006 and have been periodically recalibrated. In response to evolving changes in patient characteristics, risk profiles, surgical practice, and outcomes, the STS has now developed a set of entirely new risk models for adult cardiac surgery. Methods New models were estimated for isolated coronary artery bypass grafting surgery (CABG [n = 439,092]), isolated aortic or mitral valve surgery (n = 150,150), and combined valve plus CABG procedures (n = 81,588). The development set was based on July 2011 to June 2014 STS ACSD data; validation was performed using July 2014 to December 2016 data. Separate models were developed for operative mortality, stroke, renal failure, prolonged ventilation, reoperation, composite major morbidity or mortality, and prolonged or short postoperative length of stay. Because of its low occurrence rate, a combined model incorporating all operative types was developed for deep sternal wound infection/mediastinitis. Results Calibration was excellent except for the deep sternal wound infection/mediastinitis model, which slightly underestimated risk because of higher rates of this endpoint in the more recent validation data; this will be recalibrated in each feedback report. Discrimination (c-index) of all models was superior to that of 2008 models except for the stroke model for valve patients. Conclusions Completely new STS ACSD risk models have been developed based on contemporary patient data; their performance is superior to that of previous STS ACSD models. [ABSTRACT FROM AUTHOR]

Treatment-related toxicity following stereotactic ablative radiotherapy (SABR) in patients with central and ultracentral non-small cell lung cancer (NSCLC) is of potential concern, and the best regimens are still being explored. This study aimed to evaluate the clinical outcomes and toxicities of the patients with ultracentral and central NSCLC treated with SABR at our institution. This retrospective study included patients with central and ultracentral NSCLC treated with SABR to prescription doses of 50 Gy in five fractions, 56 Gy in seven fractions, or 60 Gy in ten fractionsat Jiangsu Cancer Hospital between May 2013 and October 2018. The patients were grouped as central or ultracentral tumors.Overall survival (OS), progression-free survival (PFS), and grade ≥3 toxicities were analyzed. Forty patients (31 male, nine female) were included. Median follow-up was 41 (5-81) months. The 1-, 2-, and 3-year OS rates were 90.0%, 83.6%, and 66.0%, respectively, and the 1-, 2-, and 3-year PFS rates were 82.5%, 62.9%, and 54.2%, respectively. OS in the ultracentral group was inferior compared with the central group (median, 52.0 months, 95%CI: 43.0-61.0 vs. not reached, P=0.03).The median PFS was 38.0 months in the ultracentral group (95%CI: 19.8-56.2) vs. not reached in the central group, although this difference was not statistically significant (P= 0.06). The overall incidence of grade ≥3 toxicity was five (12.5%) patients, (5 in the ultracentralgroup vs. 0 in the central group; P=0. 11), including one patient with grade 3 pneumonitis, two with grade 3 bronchial obstruction, one with grade 5 bronchial obstruction, and one with grade 5 esophageal perforation. Worse outcomes were obseverd in patients with ultracentral NSCLC than those with central tumors after SABR. Higher rate of treatment-related grade 3 or more toxicity was observed in the ultracentral group. [ABSTRACT FROM AUTHOR]

Carbonaceous materials are usually used to improve the electrochemical performance of GeO x for lithium-ion batteries (LIBs). Preparing a material in which GeO x is ultra-dispersed in carbon nanofibers via a simple process has rarely been reported. Here we design and prepare a three-dimensional (3D) composite in which amorphous GeO x is ultra-uniformly distributed in one-dimensional (1D) microporous carbon nanofibers (GeO x -mCNFs) via high energy ball milling combined with carbonization-amorphization reactions. When directly used as a binder-free anode material for LIBs, the as-synthesized GeO x -mCNFs hybrid shows a highly reversible specific capacity, a good rate performance, and an excellent cycling stability (i.e., 621 mA h g −1 at 1.2 A g −1 after 300 cycles), which is attributed to the synergistic effects of the ultra-uniform amorphous GeO x , a 1D interconnected carbon nanostructure, and micropores. It is expected that the GeO x -mCNFs hybrid could be utilized as a binder-free anode material in high-current rechargeable lithium-ion batteries. [ABSTRACT FROM AUTHOR]

Sleep deprivation (SD) is a common condition associated with a variety of nervous system diseases, and has a negative impact on emotional and cognitive function. Continuous theta burst stimulation (cTBS) is known to improve cognition and emotion function in normal situations as well as in various types of dysfunction, but the mechanism remains unknown. We used two-photon in vivo imaging to explore the effect of cTBS on glymphatic pathway clearance in normal and SD C57BL/6J mice. Aquaporin-4 (AQP4) polarization was detected by immunofluorescence. Anxiety-like behaviors was measured using open field tests. We found that SD reduced influx efficiency along the peri-vascular space (PVS), disturbed AQP4 polarization and induced anxiety-like behaviors. CTBS significantly attenuated the decrease in efficiency of solute clearance usually incurred with SD, restored the loss of AQP4 polarization and improved anxiety-like behavior in SD animals. Our results implied that cTBS had the potential to protect against neuronal dysfunction induced by sleep disorders. [ABSTRACT FROM AUTHOR]

Background The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed a composite performance measure for mitral repair/replacement (MVRR) with concomitant coronary artery bypass grafting (CABG). Methods Data were acquired from the STS Adult Cardiac Surgery Database for 26,463 patients undergoing MVRR + CABG operations between July 1, 2011, and June 30, 2014. Established STS risk models were applied, along with modifications enabling the inclusion of patients with concomitant closures of atrial septal defects and patent foramen ovale, surgical ablation for atrial fibrillation, and tricuspid valve repair (TVR). Participants with fewer than 10 eligible cases over 3 years were excluded. The MVRR + CABG composite consisted of two domains: risk-adjusted mortality and the any-or-none occurrence of major morbidity (prolonged ventilation, deep sternal infection, permanent stroke, renal failure, and reoperation). Composite performance scores were calculated with the use of hierarchic regression models, and high-performing and low-performing outliers were determined with the use of 95% Bayesian credible intervals. Results There were 24,740 patients at 703 participant sites after exclusions. Two percent (14/703) of programs were classified as 1-star (lower than expected performance), 95% (666/703) were classified as 2-star (as-expected performance), and 3% (23/703) were classified as 3-star (higher than expected performance). The average unadjusted operative mortality was 6.2% (1,532/24,740), and a monotonic decline in both mortality and morbidity was observed as star rating scores increased. Conclusions An STS composite performance measure was developed for MVRR + CABG operations. This measure may be useful for outcome assessment, quality improvement, patient counseling, clinical research, and public reporting. [ABSTRACT FROM AUTHOR]

Amnestic mild cognitive impairment (aMCI) is a high-risk precursor to Alzheimer's disease (AD). Acupuncture has been shown to improve cognitive function and regulate the brain function in patients with aMCI. Nevertheless, acupuncture's underlying cerebral mechanism in patients with aMCI is incompletely revealed. Therefore, this study proposes to investigate acupuncture's effect and cerebral mechanism for aMCI. This study will be a randomized, parallel, and controlled trial. The trial will consist of a 12-week treatment period along with a 12-week follow-up period. The study will enrol 72 patients who have been diagnosed with aMCI. They will be randomly assigned to one of two groups, acupuncture and waiting list, in a 1:1 ratio. Each subject in either group will receive health education about improving cognitive function for 24 weeks. In addition, 20 healthy subjects will be included in the control group. The primary outcome will be an assessment of changes in global cognitive function that will be evaluated using Alzheimer's Disease Assessment Scale-Cognitive at baseline to 12 and 24 weeks after randomization. Acupuncture's neuroimaging mechanism will be investigated by detecting changes in cerebral functional connectivity at baseline and treatment endpoint. Furthermore, the imaging data will be correlated with clinical variables to investigate the possible relationship between acupuncture effect and functional connectivity. This study is envisaged to provide high-quality evidence from a clinical randomized controlled trial of the effect of acupuncture on the treatment of aMCI. Meanwhile, our results will partially illuminate the neuroimaging mechanism to understand how acupuncture exerts its effective role. Chinese Clinical Trials Register ChiCTR2200062062. [ABSTRACT FROM AUTHOR]

Background Delayed sternal closure (DSC) is commonly used to optimize hemodynamic stability after neonatal and infant heart surgery. We hypothesized that duration of sternum left open (SLO) was associated with rate of infection complications, and that location of sternal closure may mitigate infection risk. Methods Infants (age ≤365 days) undergoing index operations with cardiopulmonary bypass and DSC at STS Congenital Heart Surgery Database centers (from 2007 to 2013) with adequate data quality were included. Primary outcome was occurrence of infection complication, defined as one or more of the following: endocarditis, pneumonia, wound infection, wound dehiscence, sepsis, or mediastinitis. Multivariable regression models were fit to assess association of infection complication with: duration of SLO (days), location of DSC procedure (operating room versus elsewhere), and patient and procedural factors. Results Of 6,127 index operations with SLO at 100 centers, median age and weight were 8 days (IQR, 5-24) and 3.3 kg (IQR, 2.9-3.8); 66% of operations were STAT morbidity category 4 or 5. At least one infection complication occurred in 18.7%, compared with 6.6% among potentially eligible neonates and infants without SLO. Duration of SLO (median, 3 days; IQR, 2-5) was associated with an increased rate of infection complications ( p < 0.001). Location of DSC procedure was operating room (16%), intensive care unit (67%), or other (17%). Location of DSC was not associated with rate of infection complications ( p = 0.45). Conclusions Rate of occurrence of infectious complications is high among infants with sternum left open following cardiac surgery. Longer duration of SLO is associated with increased infection complications. [ABSTRACT FROM AUTHOR]

[Display omitted] • Adsorption of unsaturated LCFAs on GAC led to 10–57% decreased methane production. • Unsaturated LCFAs adsorbed on GAC were hardly biodegraded and hindered DIET via GAC. • Big microbial aggregates had high tendency to outcompete GAC for LCFA adsorption. • LCFAs adsorbed on GAC changed the community structures on GAC/in suspended sludge. • Premixing of GAC with inoculum could lessen LCFA adsorption on GAC. To investigate the effect of granular activated carbon (GAC) adsorption and size of microbial aggregates in inoculum on stimulating direct interspecies electron transfer (DIET) during anaerobic digestion of fat, oil, and grease (FOG), seed sludge was divided into two inocula (big (>0.85 mm)/small (0.15–0.85 mm)) for FOG digestion with/without GAC. More long-chain fatty acids (LCFAs) were adsorbed on GAC in the reactor with small aggregates than that with big aggregates, corresponding to 57 % and 10 % decreased methane production, respectively. Adsorption of unsaturated LCFAs (e.g., oleic acid) on GAC was found to reduce LCFA bioavailability, hinder DIET via GAC, and change community structure. Compared to pre-adsorption of oleic acid on GAC, pre-attachment of microbes on GAC resulted in 5.6-fold higher methane yield for oleic acid digestion. Together, competition of LCFA adsorption between GAC and microbial aggregates is essential for enhanced methane recovery from FOG digestion via GAC-induced DIET. [ABSTRACT FROM AUTHOR]

[Display omitted] • CMs + EH 2 was used to enhance anaerobic digestion of FOG. • CMs + EH 2 resulted in 59–84 % incremental methane production than that of the control. • CMs + EH 2 led to enhanced DIET compared to CMs only or EH 2 only. • Electrogenic microorganisms were highly enriched in the reactors with CMs + EH 2. • CMs + EH 2 caused the changes of metabolic pathways during FOG digestion. To investigate the combination of carbon-based conductive materials and exogenous hydrogen (EH 2) on methane recovery from fat, oil, and grease (FOG), granular activated carbon (GAC) and carbon cloth (CC) were chosen to collaborate with EH 2 , resulting in increased methane production by 59 % and 84 %, respectively. Further digestion of long chain fatty acids (LCFAs) confirms that enhanced direct interspecies electron transfer (DIET) was achieved in the reactors with GAC/CC + EH 2 than those with GAC/CC only. Other evidences (such as increased microbial population and rapid degradation of volatile fatty acids) were found to support the role of GAC/CC + EH 2 in promotion of DIET. Significant change of microbial community was observed using GAC/CC + EH 2 , which was mainly attributed to the enrichment of electrogenic species (such as Spirochaetaceae , Syntrophomonas palmitatica , and Methanosaeta), leading to some changes in metabolic pathways during acidogenesis and methanogenesis. Together, enhanced DIET was achieved by GAC/CC + EH 2 , thus improving the methane recovery from FOG. [ABSTRACT FROM AUTHOR]

Background Previous analyses of The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database have demonstrated a reduction over time of risk-adjusted operative mortality after coronary artery bypass grafting. The STS Congenital Heart Surgery Database (STS CHSD) was queried to assess multiinstitutional trends over time in discharge mortality and postoperative length of stay (PLOS). Methods Since 2009, operations in the STS CHSD have been classified according to STAT (The Society of Thoracic Surgeons—European Association for Cardio-Thoracic Surgery) Congenital Heart Surgery Mortality Categories. The five STAT Mortality Categories were chosen to be optimal with respect to minimizing variation within categories and maximizing variation between categories. For this study, all index cardiac operations from 1998 to 2014, inclusive, were grouped by STAT Mortality Category (exclusions: patent ductus arteriosus ligation in patients weighing less than or equal to 2.5 kg and operations that could not be assigned to a STAT Mortality Category). End points were discharge mortality and PLOS in survivors for the entire period and for 4-year epochs. The Cochran-Armitage trend test was used to test the null hypothesis that the mortality was the same across epochs, by STAT Mortality Category. Results The analysis encompassed 202,895 index operations at 118 centers. The number of centers participating in STS CHSD increased in each epoch. Overall discharge mortality was 3.4% (6,959 of 202,895) for 1998 to 2014 and 3.1% (2,308 of 75,337) for 2011 to 2014. Statistically significant improvement in discharge mortality was seen in STAT Mortality Categories 2, 3, 4, and 5 ( p values for STAT Mortality Categories 1 through 5 are 0.060, <0.001, 0.015, <0.001, and <0.001, respectively). PLOS in survivors was relatively unchanged over the same time intervals. Sensitivity analyses reveal that the finding of declining risk-stratified rates of discharge mortality over time is not simply attributable to the addition of more centers to the cohort over time. Conclusions This 16-year analysis of STS CHSD reveals declining discharge mortality over time, especially for more complex operations. [ABSTRACT FROM AUTHOR]

Background Previous studies have demonstrated the effect of adult nursing skill mix, staffing ratios, and level of education on patient deaths, complication rates, and failure to rescue (FTR). To date, only one known study had examined the effect of nursing experience and education on postoperative pediatric cardiac operations. Methods Nursing survey data were linked to The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database for patients undergoing cardiac operations (2010 to 2011). Logistic regression models were used to estimate associations of nursing education and years of clinical experience with in-hospital mortality rates, complication rates, and FTR. Generalized estimating equations and robust standard error estimates were used to account for within-center correlation of outcomes. Results Among 15,463 patients (29 hospitals), the in-hospital mortality rate was 2.8%, postoperative complications occurred in 42.4%, and the FTR rate was 6.4%. After covariate adjustment, pediatric critical care units with a higher proportion of nurses with a Bachelor of Science degree or higher had lower odds of complication (odds ratio for 10% increase, 0.85; 95% confidence interval, 0.76 to 0.96; p = 0.009). Units with a higher proportion of nurses with more than 2 years of experience had lower mortality rates (odds ratio for 10% increase, 0.92; 95% confidence interval, 0.85 to 0.99; p = 0.025). Conclusions This is the first study to demonstrate that higher levels of nursing education and experience are significantly associated with fewer complications after pediatric cardiac operations and aligns with our previous findings on their association with reduced deaths. These results provide data for pediatric hospital leaders and reinforce the importance of organization-wide mentoring strategies for new nurses and retention strategies for experienced nurses. [ABSTRACT FROM AUTHOR]

Background Failure to rescue (FTR) is increasingly recognized as an important quality indicator in surgery. The Society of Thoracic Surgeons National Database was used to develop FTR metrics and a predictive FTR model for coronary artery bypass grafting (CABG). Methods The study included 604,154 patients undergoing isolated CABG at 1,105 centers from January 2010 to January 2014. FTR was defined as death after four complications: stroke, renal failure, reoperation, and prolonged ventilation. FTR was determined for each complication and a composite of the four complications. A statistical model to predict FTR was developed. Results FTR rates were 22.3% for renal failure, 16.4% for stroke, 12.4% for reoperation, 12.1% for prolonged ventilation, and 10.5% for the composite. Mortality increased with multiple complications and with specific combinations of complications. The multivariate risk model for prediction of FTR demonstrated a C index of 0.792 and was well calibrated, with a 1.0% average difference between observed/expected (O/E) FTR rates. With centers grouped into mortality terciles, complication rates increased modestly (11.4% to 15.7%), but FTR rates more than doubled (6.8% to 13.9%) from the lowest to highest terciles. Centers in the lowest complication rate tercile had an FTR O/E of 1.14, whereas centers in the highest complication rate tercile had an FTR O/E of 0.91. Conclusions CABG mortality rates vary directly with FTR, but complication rates have little relation to death. FTR rates derived from The Society of Thoracic Surgeons data can serve as national benchmarks. Predicted FTR rates may facilitate patient counseling, and FTR O/E ratios have promise as valuable quality metrics. [ABSTRACT FROM AUTHOR]

Background The Society of Thoracic Surgeons (STS) Quality Measurement Task Force is developing a portfolio of composite performance measures for the most commonly performed procedures in adult cardiac surgery. We now describe the fourth in this series, the STS composite measure for mitral valve repair/replacement (MVRR). Methods We examined all patients undergoing isolated MVRR, with or without concomitant performance of tricuspid valve repair, surgical arrhythmia ablation, or repair of atrial septal defect, between July 1, 2011, and June 30, 2014. In this two-domain model, risk-adjusted mortality and any-or-none major morbidity were combined into a composite score using 3 years of STS data and 95% Bayesian credible intervals to estimate composite scores and star ratings. Results There were 61,201 MVRR patients studied at 867 participant sites. Mitral valve repair was performed in 57.4% (35,114 of 61,201) and mitral valve replacement in 42.6% (26,087 of 61,201). Mortality was 2.9% (1,773 of 61,201), and occurrence of any major morbidity was 17.0% (10,381 of 61,201). The median composite score was 93.2% (interquartile range, 92.3% to 94.2%). Star rating classifications included 23 of 867 (2.6%) 1-star programs (lower-than-expected performance), 795 of 867 (91.7%) 2-star programs (as-expected or average performance), and 49 of 867 (5.7%) 3-star programs (higher-than-expected performance). Conclusions STS has developed an MVRR composite performance measure that will be used for participant feedback, quality performance assessment and improvement, and voluntary public reporting. [ABSTRACT FROM AUTHOR]

The Society of Thoracic Surgeons Congenital Heart Surgery Database is the largest congenital and pediatric cardiac surgical clinical data registry in the world. It is the platform for all activities of The Society of Thoracic Surgeons related to the analysis of outcomes and the improvement of quality in this subspecialty. This article summarizes current aggregate national outcomes in congenital and pediatric cardiac surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency. The reported data about aggregate national outcomes are exemplified by an analysis of 10 benchmark operations performed from January 2011 to December 2014 and documenting overall discharge mortality (interquartile range among programs with more than 9 cases): off-bypass coarctation, 1.0% (0.0% to 0.9%); ventricular septal defect repair, 0.7% (0.0% to 1.1%); tetralogy of Fallot repair, 1.0% (0.0% to 1.7%); complete atrioventricular canal repair, 3.2% (0.0% to 6.5%); arterial switch operation, 2.7% (0.0% to 5.6%); arterial switch operation plus ventricular septal defect, 5.3% (0.0% to 6.7%); Glenn/hemiFontan, 2.1% (0.0% to 3.8%); Fontan operation, 1.4% (0.0% to 2.4%); truncus arteriosus repair, 9.6% (0.0 % to 11.8%); and Norwood procedure, 15.6% (10.0% to 21.4%). [ABSTRACT FROM AUTHOR]

Background Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with substantial mortality. We evaluated outcomes of patients in The Society of Thoracic Surgeons Adult Cardiac Surgery Database who underwent coronary artery bypass graft surgery (CABG) in the setting of AMI-CS. Methods All patients with AMI-CS who underwent nonelective CABG or CABG with ventricular assist device implantation within 7 days after myocardial infarction were enrolled. The primary analysis sample consisted of patients who underwent surgery between June 2011 and December 2013. Baseline characteristics, operative findings, outcomes, and the utilization of mechanical circulatory support (MCS) were assessed in detail in this population. We also evaluated trends in unadjusted mortality for all patients undergoing CABG or CABG with ventricular assist device for AMI-CS from January 2005 to December 2013. Results A total of 5,496 patients met study criteria, comprising 1.5% of all patients undergoing CABG during the study period. Overall operative mortality was 18.7%, decreasing from 19.3% in 2005 to 18.1% in 2013 ( p < 0.001). Use of MCS increased from 5.8% in 2011 to 8.8% in 2013 ( p = 0.008). Patients receiving MCS had a high proportion of cardiovascular risk factors or high clinical acuity. Patients requiring preoperative and patients requiring intraoperative or postoperative MCS had operative mortality of 37.2% and 58.4%, respectively. Patients undergoing CABG as a salvage procedure had an operative mortality of 53.3%, and a high incidence of reoperation (21.8%), postoperative respiratory failure requiring prolonged ventilation (59.7%), and renal failure (18.5%). Conclusions Most patients undergoing CABG for AMI-CS have a sizeable but not prohibitive risk. Patients who require MCS and those undergoing operation as a salvage procedure reflect higher risk populations. [ABSTRACT FROM AUTHOR]

Background The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) has been successfully linked to the Centers for Medicare and Medicaid (CMS) Medicare database, thereby facilitating comparative effectiveness research and providing information about long-term follow-up and cost. The present study uses this link to determine contemporary completeness, penetration, and representativeness of the STS ACSD. Methods Using variables common to both STS and CMS databases, STS operations were linked to CMS data for all CMS coronary artery bypass graft (CABG) surgery hospitalizations discharged between 2000 and 2012, inclusive. For each CMS CABG hospitalization, it was determined whether a matching STS record existed. Results Center-level penetration (number of CMS sites with at least one matched STS participant divided by the total number of CMS CABG sites) increased from 45% in 2000 to 90% in 2012. In 2012, 973 of 1,081 CMS CABG sites (90%) were linked to an STS site. Patient-level penetration (number of CMS CABG hospitalizations done at STS sites divided by the total number of CMS CABG hospitalizations) increased from 51% in 2000 to 94% in 2012. In 2012, 71,634 of 76,072 CMS CABG hospitalizations (94%) occurred at an STS site. Completeness of case inclusion at STS sites (number of CMS CABG cases at STS sites linked to STS records divided by the total number of CMS CABG cases at STS sites) increased from 88% in 2000 to 98% in 2012. In 2012, 69,213 of 70,932 CMS CABG hospitalizations at STS sites (98%) were linked to an STS record. Conclusions Linkage of STS and CMS databases demonstrates high and increasing penetration and completeness of the STS database. Linking STS and CMS data facilitates studying long-term outcomes and costs of cardiothoracic surgery. [ABSTRACT FROM AUTHOR]

Background Adjustment for case mix is critical to accurate outcomes analysis in congenital heart surgery. Established tools encompass all age groups and are not specific to the growing population of adults undergoing congenital heart operations. We derived an empirically based adult congenital heart surgery (ACHS) mortality score. Methods In-hospital mortality was analyzed for the 152 most common procedures/procedural groups in adults 18 years of age and older in The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) (2000–2013). Procedure-specific adult mortality rate estimates were calculated using Bayesian methods adjusting for small denominators for procedures with 30 cases or more (N = 52). Each procedural group was assigned an ACHS mortality score ranging from 0.1 to 3.0 based on the estimated mortality rate. Discrimination was assessed using the c-index in a separate validation sample. Results A total of 12,513 procedures (116 centers) were analyzed. Overall unadjusted mortality was 1.8%. Significant differences in mortality rates in adults compared with all ages were seen for several procedures, including Ebstein’s repair (0.7% versus 4.9%; p = 0.003) and Fontan operations (6.8% versus 1.4%; p < 0.01). The procedure with the lowest model-based estimate of mortality and accompanying ACHS mortality score was atrial septal defect repair (0.2%, 0.1), and the highest was Fontan revision (9.7%, 3.0). The c-index for the ACHS mortality score was 0.809 versus 0.777 for the “non–age-specific” Society of Thoracic Surgeons–European Association for Cardio-thoracic Surgery (STAT) mortality score applied to adults. Conclusions Risk estimation based on the aggregate of all age groups is suboptimal when analyzing outcomes specifically among adults. An empirically based ACHS mortality score can facilitate case-mix adjustment by providing accurate estimation of mortality risk for adults. [ABSTRACT FROM AUTHOR]