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There is limited research regarding the association between the mFI-5 and postoperative complications among adult spinal deformity (ASD) patients.Using the National Surgical Quality Improvement Project (NSQIP) database, patients with Current Procedural Terminology (CPT) codes for 7-level fusion or 7-level fusion with International Classification of Diseases, Ninth Revision (ICD-9) codes for ASD were identified between 2008 and 2016. Univariate analyses with post-hoc Bonferroni correction for demographics and preoperative factors were performed. Logistic regression assessed associations between mFI-5 scores and 30-day post-operative outcomes.2,120 patients met criteria. Patients with an mFI-5 score of 4 or 5 were excluded, given there were20 patients with those scores. Patients with mFI-5 scores of 1 and 2 had increased 30-day rates of pneumonia (3.5 % and 4.3 % vs 1.6 %), unplanned postoperative ventilation for 48 h (3.1 % and 4.3 % vs 0.9 %), and UTIs (4.4 % and 7.4 % vs 2.0 %) than patients with a score of 0 (all, p 0.05). Logistic regression revealed that compared to an mFI-5 of 0, a score of 1 was an independent predictor of 30-day reoperations (OR = 1.4; 95 % CI 1.1-18). A score of 2 was an independent predictor of overall (OR = 2.4; 95 % CI 1.4-4.1) and related (OR = 2.2; 95 % CI 1.2-4.1) 30-day readmissions. A score of 3 was not predictive of any adverse outcome.The mFI-5 score predicted complications and postoperative events in the ASD population. The mFI-5 may effectively predict 30-day readmissions. Further research is needed to identify the benefits and predictive value of mFI-5 as a risk assessment tool.

Whether pre left ventricular assist device (LVAD) sarcopenia is associated with higher incidence of gastrointestinal bleeding (GIB) on LVAD support remains unknown.To study the association between preoperative sarcopenia and post LVAD GIB events, we performed a retrospective, multi-centered study including patients with chest CTs performed ≤ 3 months prior to LVAD implantation at the University of Minnesota (n = 143) and Houston Methodist Hospital (n = 133). To quantify sarcopenia, unilateral pectoralis muscle mass indexed to body surface area (PMI) and attenuation (approximated by mean Hounsfield units; PHUThe study cohort included 276 LVAD recipients with 43 % designated as bridge to transplant at the time of LVAD implantation. High pectoralis muscle mass and tissue attenuation were both protective against GIB events. Each 5 unit increase in PHUPreoperative sarcopenia, as quantified by pectoralis muscle size and attenuation, was associated with the development of recurrent GI bleeding after LVAD implantation. These CT quantitative measures appear to predict not only early mortality but morbidity on LVAD as well.

Risk assessment for early, severe right heart failure (RHF) after LVAD implantation remains imperfect. We sought to define the differences in RV adaptation and load after axillary Impella support between patients who experienced RHF and those who did not. Seventeen of 18 patients included were deemed intermediate or high risk for RHF by EUROMACS-RHF score. Before Impella insertion, RV adaptation parameters (RAP, RAP:PCWP, PAPi) were worse in the non-RHF group compared to the RHF group. In both groups, RV load parameters (effective pulmonary arterial elastance, pulmonary vascular resistance, and pulmonary vascular compliance) improved after Impella insertion. Lesser improvements in RV adaptation were seen in the RHF group. Moreover, load-to-adaptation relationships (EA/RAP and EA/RAP:PCWP) worsened to a greater degree. In patients at intermediate or high risk for RHF after LVAD, assessment of RV adaptation and load during axillary Impella support may improve risk stratification.

BACKGROUND There is little insight into which patients can be weaned off right ventricular (RV) acute mechanical circulatory support (AMCS) after left ventricular assist device (LVAD) implantation. We hypothesize that concomitant RV AMCS insertion instead of postoperative implantation will improve 1-year survival and increase the likelihood of RV AMCS weaning. METHODS A multicenter retrospective database of 826 consecutive patients who received a HeartMate II or HVAD between January 2007 and December 2016 was analyzed. We identified 91 patients who had early RV AMCS on index admission. Cox proportional-hazards model was constructed to identify predictors of 1-year mortality post-RV AMCS implantation and competing risk modeling identified RV AMCS weaning predictors. RESULTS There were 91 of 826 patients (11%) who required RV AMCS after CF-LVAD implantation with 51 (56%) receiving a concomitant RV AMCS and 40 (44%) implanted with a postoperative RV AMCS during their ICU stay; 48 (53%) patients were weaned from RV AMCS support. Concomitant RV AMCS with CF-LVAD insertion was associated with lower mortality (HR 0.45 [95% CI 0.26-0.80], p = 0.01) in multivariable model (which included age, BMI, angiotensin-converting enzyme inhibitor use, and heart transplantation as a time-varying covariate). In the multivariate competing risk analysis, a TPG < 12 (SHR 2.19 [95% CI 1.02-4.70], p = 0.04) and concomitant RV AMCS insertion (SHR 3.35 [95% CI 1.73-6.48], p < 0.001) were associated with a successful wean. CONCLUSIONS In patients with RVF after LVAD implantation, concomitant RV AMCS insertion at the time of LVAD was associated with improved 1-year survival and increased chances of RV support weaning compared to postoperative insertion.

BACKGROUND Multicenter data on long term survival following LVAD implantation that make use of contemporary definitions of RV failure are limited. Furthermore, traditional survival analyses censor patients who receive a bridge to heart transplant. Here we compare the outcomes of LVAD patients who develop post-operative RV failure accounting for the transitional probability of receiving an interim heart transplantation. METHODS We use a retrospective cohort of LVAD patients sourced from multiple high-volume centers based in the United States. Five- and ten-year survival accounting for transition probabilities of receiving a heart transplant were calculated using a multi-state Aalen Johansen survival model. RESULTS Of the 897 patients included in the study, 238 (26.5%) developed post-operative RV failure at index hospitalization. At 10 years the probability of death with post-op RV failure was 79.28% vs 61.70% in patients without (HR 2.10; 95% CI 1.72 - 2.57; p = < .001). Though not significant, patients with RV failure were less likely to be bridged to a heart transplant (HR 0.87, p = .4). Once transplanted the risk of death between both patient groups remained equivalent; the probability of death after a heart transplant was 3.97% in those with post-operative RV failure shortly after index LVAD implant, as compared to 14.71% in those without. CONCLUSIONS AND RELEVANCE Long-term durable mechanical circulatory support is associated with significantly higher mortality in patients who develop post-operative RV failure. Improving outcomes may necessitate expeditious bridge to heart transplant wherever appropriate, along with critical reassessment of organ allocation policies.

Objectives This study presents the largest clinical experience of percutaneously placed axillary intra-aortic balloon pump (IABP) in patients with advanced heart failure. Background Transfemoral placement of IABP limits mobility and recuperation in patients who need prolonged support. We had previously reported a novel percutaneous method of IABP placement in the axillary artery and now present our expanded experience with this technique. Methods We performed a retrospective chart review of patients with advanced heart failure with percutaneous axillary IABP placement from November 2007 to June 2018 at Houston Methodist Hospital. We defined successful cardiac replacement therapy as heart transplant or left ventricular assist device implantation. We compared patients who had successful cardiac replacement with those who died and those who needed unplanned escalation of mechanical circulatory support. Results Of the 195 patients identified, 133 (68%) underwent successful cardiac replacement (120 transplants and 13 left ventricular assist device) as planned. End-organ function improved on IABP support in patients bridged to next therapy. There were 16 patients that died while on IABP support and 18 needed escalation of support. Higher right atrial/wedge ratio, higher right atrial pressure, smaller left ventricular end diastolic dimension, and ischemic cardiomyopathy were associated with death on the IABP in multivariate analysis. Post-transplant and post left ventricular assist device survival for those bridged successfully was 87% and 62%, respectively. Although bedside repositioning was frequent, 37% needed replacement for malfunction. Vascular complications occurred in a minority. Conclusions Percutaneous axillary approach for IABP placement is a feasible strategy for prolonged mechanical circulatory support in patients with advanced heart failure.

The incidence and prevalence of babesiosis in animals and humans is increasing, yet prevention, control, or treatment measures remain limited and ineffective. Despite a growing body of new knowledge of the biology, pathogenicity, and virulence of Babesia parasites, there is still no well-defined, adequately effective and easily deployable vaccine. While numerous published studies suggest that the development of such anti-Babesia vaccines should be feasible, many others identify significant challenges that need to be overcome in order to succeed. Here, we review historic and recent attempts in babesiosis vaccine discovery to avoid past pitfalls, learn new lessons, and provide a roadmap to guide the development of next-generation babesiosis vaccines.

New technologies can do more than just digitize health information; they can support multimedia platforms for patient education and health decision support. Technology can simplify the way health decisions are made by offering quick access to a vast amount of information that can be tailored to specific populations. Digital tools can increase knowledge and assist consumers in comparing health care alternatives. They are well received by patients because of the myriad features that render them visually appealing and entertaining, including audiovisual and interactive elements. To be effective, however, digital tools must be evidence based and developed following quality standards.

Social networking has been shown to improve health outcomes in certain patient populations. While patients with rheumatoid arthritis (RA) increasingly use social networking to communicate with peers, the effects of these interactions are largely unknown.In a randomized controlled trial, we compared RA patients who participated in a social networking group moderated by peer leaders and who had access to a static website offering RA materials with a control group, who only had access to the website. The primary outcomes were patients' RA knowledge, self-efficacy and empowerment. Secondary outcomes included participation in desired health behaviors, and satisfaction with peer support, among others. Follow-up assessments were conducted at 3 and 6 months. Participants who never signed in were excluded from the primary analysis.105 participants were randomized to each group. Mean age was 52 (±12.4) and 92.4% were females. Knowledge scores improved in both groups, but only in the control group the differences observed at 3 and 6 months were significant (p≤0.02). Self-efficacy scores also improved in both groups, but only the differences observed at 6 months in the Facebook group were significant (p=0.02). When comparing groups, at 3 months the knowledge improvements observed in the control group were greater compared with those observed in the Facebook group (mean difference 0.4 versus 0.1; respectively, p=0.03). No other differences were observed in secondary outcomes between the 2 groups, except in peer support satisfaction. The Facebook® group reported greater peer support satisfaction in 3 out 5 subscales compared with the control group (p≤0.04).Peer support satisfaction was higher in participants using an online social network, but this was not translated into greater disease knowledge or empowerment.

Objectives Immune checkpoint inhibitors (ICIs) can successfully treat cancer, but their use can be hindered by serious immune-related adverse events. We report six patients receiving ICIs who presented with de novo myositis. Methods We identified patients with myositis who were receiving ICIs between January 2004 and September 2016 at The University of Texas MD Anderson Cancer Center. Results Six patients developed de novo myositis. The mean age was 64.3 years and five patients were male. Cancer types included melanoma, urothelial carcinoma, renal cell carcinoma, and prostate cancer. ICI regimens included single-agent ipilimumab (n = 1), pembrolizumab (n = 1), or atezolizumab (n = 1); nivolumab and ipilimumab (n = 3). The median time to development of de novo myositis from first infusion was 5.4 weeks (range: 2.1–17.1 weeks). All patients with myositis had elevated levels of creatinine kinase, ranging from 514 to 13,710 U/L. Two of them developed rhabdomyolysis, one with concurrent myocarditis. Five patients were treated with 1–2 mg/kg corticosteroids, with variable response rates; one patient received nonsteroidal anti-inflammatory drugs. Two patients with myositis died as a result of cancer progression. Conclusion We found several occurrences of de novo myositis following ICI therapy. These preliminary data suggest that myositis can occur early after onset of ICI therapy with serious adverse outcomes.

Summary Background Patients previously infected with hepatitis B virus (HBV; indicated by positivity for anti-HBc) can experience HBV reactivation during cancer chemotherapy. Intravenous immunoglobulin infusion, which is frequently used in supportive care, might facilitate passive transfer of anti-HBc. We aimed to estimate the probability of passive transfer of anti-HBc after intravenous immunoglobulin infusion in patients with cancer. Methods We reviewed institutional databases to identify adult patients who received outpatient chemotherapy between Jan 1, 2004, and Dec 31, 2011, at the University of Texas MD Anderson Cancer Center, Houston, TX, USA. Eligible patients had received intravenous immunoglobulin therapy, had tested negative for both anti-HBc and HBsAg before infusion, and had been tested for anti-HBc after infusion. The primary endpoint was the proportion of patients who became positive for anti-HBc after intravenous immunoglobulin infusion. Findings 950 of 18 874 patients who underwent chemotherapy within the study time frame received intravenous immunoglobulin, of whom 870 had been tested for anti-HBc before infusion. 199 patients who were negative for anti-HBc before receiving intravenous immunoglobulin were retested after infusion, of whom 29 (15% [95% CI 10–20]) became positive for anti-HBc. The probability of anti-HBc conversion at 1 week after intravenous immunoglobulin infusion was 34% (95% CI 22–48) and at 12 weeks was 4% (2–7). Interpretation Conversion of patients from anti-HBc negativity to anti-HBc positivity was common after intravenous immunoglobulin administration. However, the probability of a positive test decreased with time since infusion. Positive anti-HBc tests done shortly after intravenous immunoglobulin infusion should be interpreted with caution because they might indicate passive transfer instead of true infection. Funding None.

Purpose Prediction of right heart failure (RHF) after left ventricular assist device (LVAD) implant is a crucial step to improve outcomes. The EUROMACS Right-Sided Heart Failure (EUROMACS-RHF) risk score is one of the most recent derived scores for RHF prediction after LVAD but it lacks external validation. The aim of our study was to validate the EUROMACS-RHF risk score. Methods From 01/2007 to 12/2017, 878 continuous-flow LVADs were implanted at three tertiary care centers. We calculated the EUROMACS-RHF score in 662 patients with complete data. We evaluated the predictive performance of the score for early RHF defined as need for short- or long-term right-sided circulatory support, continuous inotropic support for ≥14 days or nitric oxide ventilation for ≥48 hours post-operatively. Results RHF occurred in 211 patients (32%). RHF patients had higher creatinine, bilirubin and right atrial pressure, more echocardiographic RV dysfunction and were more critically ill reflected in lower INTERMACS class (p Conclusion In an external validation, the EUROMACS-RHF had similar discrimination predicting RHF compared to the original derivation cohort, which was better than other published scores. The clinical utility of these scores in the decision to implant LVAD in prospective studies remains to be determined.

Purpose Deciding which patients can be weaned from an RVAD placed after LVAD implantation could help triage advanced heart failure device strategy. Therefore, we set out to determine the predictors of RVAD weaning. Methods A multi-center retrospective study of 826 consecutive patients who received either a HeartMate2 or HVAD between 1/2007 an 12/2007. We identified 91 patients who received an early RVAD insertion during their LVAD implant index admission. A Cox Proportional hazard model was constructed to identify predictors of RVAD weaning. Results There were 91 patients (11%) who required an RVAD after LVAD with 48 (52%) weaned from RVAD support and 43 (48%) not weaned. Patients who were weaned had a lower prevalence of hypertension, higher pre-operative ACE-inhibitor use, and lower pre-operative transpulmonary gradient (TPG), RA-PCWP ratio, and RVSWI; they were also more likely to receive concomitant RVAD at time of LVAD insertion and ultimately transplanted more often (Table 1). Our multivariable model for predictors of RVAD weaning included pre-operative creatinine (HR 0.32 [0.15, 0.70], p = 0.004), PVR (HR 1.23 [1.02, 1.48], p = 0.03), non-white ethnicity (HR 2.56 [1.19, 5.54], p = 0.02), COPD (HR 4.63 [1.32, 16.25], p = 0.02), and concomitant RVAD insertion (HR 2.87 [1.00, 8.21], p-value = 0.05) with a model c-statistic of 0.84. The survival curve demonstrates that patients who are weaned from RVAD have significantly improved 1-year mortality (Figure 1, p Conclusion In a multi-institutional continuous-flow LVAD cohort, we show novel predictors of RVAD weaning that can help triage mechanical support strategy.

Purpose Early insertion of an RVAD may help to mitigate post-LVAD implantation morbidity and mortality. We hypothesize that concomitant RVAD insertion at time of LVAD implantation improves 1-year mortality in comparison to post-operative insertion. Methods A multi-center retrospective study of 826 consecutive patients who received either a HeartMate2 or HVAD between 1/2007 an 12/2017. We identified 91 patients who either had an unplanned or planned early RVAD on index admission. A Cox proportional hazard model was constructed to identify predictors of 1-year mortality. Results There were 91 patients (11%) who required an RVAD after LVAD implantation with 51 (56%) receiving a concomitant RVAD and 40 (43%) post-operatively (Table 1). Concomitant RVAD with LVAD insertion was associated with lower mortality (HR 0.45 [0.27, 0.76], p-value = 0.002, Figure 1). Our multivariable model (which included age, BMI, and ACE-i use) found receiving transplant (HR 0.04 [0.01, 0.29], p = 0.001) and concomitant RVAD (HR 0.51 [0.29, 0.90], p = 0.004) to be independent predictors of 1-year mortality with a final model C-statistic of 0.77. Stratifying concomitant RVAD by intended approach, planned versus unplanned RVAD insertion had a similar survival rate as unplanned approach at 1 year (42.8% versus 28.6%, p-value = 0.08). Conclusion We show in a continuous-flow and multi-institutional cohort that concomitant RVAD insertion at time of LVAD is associated with improved survival at 1 year compared to post-operative insertion.

Theileria equi is a tick-borne hemoparasite that may cause severe illness in equids. Intrauterine transmission of T. equi can occur and may result in abortion, stillbirth, or neonatal piroplasmosis of foals. Theileria equi and Babesia caballi infection are present in Israel, and subclinical infection with T. equi is highly prevalent. Here, we describe a case of a neonatal piroplasmosis that manifested with diffuse and cerebral T. equi infection. A Quarter Horse filly was born to a mare chronically infected with T. equi. The filly was born weak, could not stand and suckle, and had jaundice, pigmenturia, and died within hours from parturition. High T. equi parasitemia was detected in stained blood smears and imprint smears of different organs, further confirmed by polymerase chain reaction and sequence analysis. Intraerythrocytic parasites were also found in brain capillaries. Theileria equi infection in brain, to our knowledge, has never been reported previously. In vitro culture from the mare's blood enabled isolation of T. equi parasites. Phylogenetic analysis of the T. equi 18S rRNA gene from the dam's isolate and from the filly was identical and showed high similarity to previously reported T. equi sequences from Israel. Further studies should be done to determine whether the cerebral infection observed here was caused by the phenotypic particularities of the T. equi strain involved or resulted from intrinsic/unique characteristics of the immune responses elicited by the parasite in the infected foal.

Introduction Whiplash associated disorders are currently a common musculoskeletal problem. Besides the high incidence in western countries, the costs derived from prolonged treatment and medicolegal compensation, make this entity a challenging problem for clinicians and insurance companies. To date, no conservative treatment has shown clear superiority in the management of acute cases. Hypothesis Percutaneous needle electrolysis (PNE) is an effective approach for the treatment of Quebec type II acute whiplash syndrome (AWS). PNE consists in the application of brief galvanic currents into a damaged structure, producing a local controlled inflammatory response, with subsequent tissular healing enhancement. Materials and methods One hundred AWS patients were randomized into: (a) standard physiotherapy intervention for AWS; (b) a standardized PNE protocol for AWS. Both groups were assessed for treatment outcome at the 5th week mark. Results Both groups showed a statistically significant improvement according to the Northwick Park Neck Questionnaire, visual analogic scale and pressure pain threshold. The improvement was similar in both groups, except for the pain pressure threshold, with a 56.6% reduction vs. 44.4% reduction in favour of the PNE group (P = 0.035). In addition, the physio group consumed a mean treatment time of 20 hours, while the PNE intervention averaged less than 1 hour in total. Discussion PNE can be considered as an effective treatment option for AWS. Importantly, the technique is highly cost-effective, with limited equipment required and a notable treatment time reduction, compared to more comprehensive physiotherapy protocols. Type of study Randomized controlled trial. Level of proof 1b.

Objective We performed an environmental scan of currently available websites providing educational information about rheumatoid arthritis (RA) and evaluated the quality of these websites. Methods We searched three separate search engines, Google, Bing, and Ask.com, on August 27, 2015, using two search terms, "arthritis" and "rheumatoid." Only patient education websites were included. Two independent investigators evaluated the accuracy, completeness, technical elements, design and esthetics, readability, usability, and accessibility of the websites. The navigation experience was also evaluated by an adult training expert. Results We identified 46 websites. Nearly all websites (98%) provided accurate information. However, no website covered all essential RA topics. Common essential topics not covered included epidemiology, pathogenesis, treatment and disease monitoring, complications, self-management, risks and benefits of treatment, prognosis, treatment adherence, questions for patients to ask their doctors, and costs. For the technical elements, all websites disclosed their ownership, but the date that the content was last updated was mentioned in only 10 websites, ranging from 2007 to 2015. The mean reading level was grade 12.1 (standard deviation ±2.3). Most websites (78%) were easy to navigate but only 33% were friendly for people with visual and/or hearing impairments. The navigation experience was rated fair or poor in 41% of the websites. Conclusion Current patient information on the Internet does not comprehensively address all educational needs of patients with RA, and is often outdated. The findings from our study highlight potential areas for improvement in online education materials for patients with RA.

Purpose The 2016 ISHLT revised cardiac transplantation listing criteria has recommended patients to achieve a body mass index (BMI) 35 show poorer outcome post-transplant, there is limited data on the BMI group of 35-39.9. This study aims to determine the relationship between post-transplant outcomes and a pre-transplant listing BMI of 35-39.9 as compared to a BMI Methods A retrospective cohort analysis of patients stratified by BMI subgroup was performed of 23,009 adult heart transplant patients from 2009-2018 using the United Network for Organ sharing database. Patients with BMI of 35-39.9 post-transplant outcomes were compared to patients with BMI Results Patients with a BMI 35.0-39.9 had post-transplant survival of 92.4% at 90 days, 89.3% at 1 year and 74.5% at 5 years, compared to patients with a BMI Conclusion Although a statistically significant increase in mortality was observed between the BMI

Introduction Heart transplant candidates with allosensitization face higher waitlist mortality and may have inferior post-transplant outcomes. We present our experience with a multi-drug desensitization regimen including daratumumab, an anti-CD38 monoclonal antibody, in a 51-year-old female listed for heart transplant. Case Report The patient presented with heart failure due to NICMP with LMNA mutation. She was listed for heart transplant with 94% class I PRAs and 98% class II PRAs. Given level of sensitization, the decision was made to desensitize with plasmapheresis (5 sessions), IVIG (2 g/kg), bortezomib (4 doses), and tocilizumab (1 dose). During this treatment she experienced neutropenia requiring bortezomib dose reduction. Following these therapies her class I PRA decreased to 36%, but her class II PRA persisted at 99%. Immunodominant HLA antibodies are trended in Figure 1. She subsequently received additional plasmapheresis (6 sessions) with IVIG (2 g/kg) and rituximab (1 dose). PRAs remained consistent; HLA MFIs remained high (Figure 1). She was then treated with daratumumab weekly. She received 8 doses; the last dose was received the day prior to transplant. Her class I PRA decreased to 13% and class II PRA was 99% at the time of transplant. Her crossmatch was negative, and she received steroid induction alone. Maintenance immunosuppression consisted of tacrolimus, mycophenolate, and prednisone. Her tacrolimus was therapeutic by POD6 with a goal of 10-15 mcg/mL. By month 11 post-transplant she has had no episodes of cellular or antibody-mediated rejection. Graft function has been stable with ejection fraction >60%. All DSA screening has been negative and she has not developed any significant infections post-transplant. Summary Daratumumab, as part of a desensitization regimen, appears to be safe and effective in sensitized patients awaiting heart transplant and was not associated with post-op complications, and may have contributed to prevention of antibody-mediated rejection post-transplant.

Introduction Sensitization is a challenge in heart transplant recipients, often increasing wait time and decreasing access to acceptable organs. We present a case of a highly sensitized 47-year-old female listed for re-do heart and kidney transplant who was desensitized utilizing ofatumumab and tocilizumab. Case Report The patient received her first heart transplant in 1992 (induction muromonab-CD3) for viral cardiomyopathy at an outside hospital; in 2015 she was treated for antibody mediated rejection with plasma exchange (PLEX), intravenous immunoglobulin (IVIG), and bortezomib. She later developed cardiac allograft vasculopathy. In 2018 she was brought to our center with cardiogenic shock and worsening renal function, required dual inotropic support, and evaluated and listed for a re-do heart and kidney transplant. Her peak PRA was 90% with several class I and II antibodies. She underwent desensitization therapy with PLEX, IVIG (2 g/kg), ofatumumab (1 dose), and monthly tocilizumab (3 doses). No adverse drug events were reported during therapy. Her PRA remained persistently ∼90%; MFI trends of her antibodies are presented in Figure 1. After her 3rd tocilizumab dose she received an offer which was crossmatch negative and no pre-existing antibodies. She received basiliximab induction and maintenance immunosuppression of tacrolimus, mycophenolate, and prednisone. During the 1 year follow-up post-transplant, she had excellent graft function with ejection fraction >60%, serum creatinine Summary Desensitization with ofatumumab and tocilizumab resulted in successful heart and kidney transplantation. Although PRA and MFI of pre-existing antibodies were not significantly altered, this regimen may have been helpful in reducing de novo donor specific antibodies and preventing acute rejection post-transplant.

In Mexico, agave constitutes a natural waste that comes from many different industries. This situation creates an opportunity area for the research, exploitation, and use of these agro-industrial wastes. Present work compared color, mechanical, and functional properties of PVA/cellulose/Alginate, PVA/cellulose/chitosan, and PVA films. Milox process and high-energy ball milling were used to purify agave waste for the later obtaining of cellulose nanoparticles (CNP). Addition of CNP to the films reinforced and increased the tensile strength of them.

Study Objective To evaluate the rate of vaginal cuff dehiscence (VCD) after endoscopic hysterectomy using absorbable vs delayed absorbable suture. Design Retrospective cohort study. Setting Academic center, Mayo Clinic Phoenix, Arizona. Patients or Participants 586 consecutive patients undergoing endoscopic hysterectomy (499 robotic, 87 laparoscopic) with a specific cuff closure technique. Interventions Specific vaginal cuff closure technique with delayed absorbable (PDS and V-loc) or absorbable (Vicryl) suture. Measurements and Main Results The mean age was 50.8 years (SD 12.6) with a mean BMI of 30 kg/m2 (SD 8.4). Most patients were premenopausal (59%) and 4.6% were on or had previously received chemotherapy. Of the hysterectomies performed, 75% were for benign indications, 94.5% were simple hysterectomies and 5.5% were radical or modified radical hysterectomies. Mean estimated blood loss was 93.4 ml (SD 137.7ml). Vicryl was used in 152 patients, PDS in 161 patients and V loc in 273 patients. The 3 groups were similar in demographics except for uterine pathology (benign in 80.9% vs. 72.7% vs 73.2% respectively, p= 0.038), median blood loss (115.7 (SD 134.7) vs 87.9 (SD= 90.5) vs 96.9 (SD 161.2) ml respectively, p= 0.034). After a mean follow up period of 586.6 days (SD 725.7), vaginal cuff dehiscence occurred in 1.2% of patients (2.6% Vicryl, 0.6% PDS and 0.7% V loc, p= 0.165). VCD rate with delayed absorbable suture (PDS or V loc) vs absorbable suture (Vicryl), was 0.7% vs. 2.6%, p= 0.058. respectively. Logistic regression analysis revealed younger age and lower BMI are risk factors for VCD (OR: 0.91 95% CI 0.83-0.99 vs OR 0.76, 95% CI 0.61-0.94 respectively). Conclusion Delayed absorbable suture is preferable for vaginal cuff closure at endoscopic hysterectomy as compared to absorbable suture. Risk factors for vaginal cuff dehiscence are younger age and lower BMI.

Introduction Left ventricular assist device (LVAD) has shown to improve hemodynamics (HD). Right heart catheterization (RHC) and echocardiogram (ECHO) are used to define the optimal LVAD speed. This study evaluates the instantaneous effect of speed change on the HD and ECHO parameters in HeartWare (HVAD) and HeartMate 3 (HM3). Methods Patients with LVAD between January 2016 to March 2020, who had undergone speed optimization using RHC and ECHO, were included in this study. Generalized estimating equation or multilevel ordered logistic regression models were used to examine the effect of speed on all parameters to account for the correlation within conditions. Speed was standardized using the mean and standard deviation for HVAD and HM3. The estimated slope or odds ratio showed the effect on the parameters when standardized speed increased one standard deviation from its mean. Results Forty-two patients (13 HVAD and 29 HM3) were included. With increasing the speed, both devices similarly decreased pulmonary capillary wedge pressure, pulmonary artery systolic pressure, pulmonary artery diastolic pressure, mean pulmonary artery pressure, and improved cardiac index calculated by Fick method. Increasing the speed also had a similar decrement on left ventricular end-diastolic diameter and right ventricular systolic pressure. Worsening right ventricular (RV) function with the increasing speed only occurred in HVAD. At any given standardized speed, HVAD had a higher chance of having worse aortic valve regurgitation (AVR), worse tricuspid regurgitation (TR), and less frequent aortic valve opening compared to HM3 (Table 1). Conclusion HVAD and HM3 overall have a similar instantaneous hemodynamic effect with speed change; however, increasing speed had a higher chance of worsening AVR, TR, and RV function in HVAD compared to HM3.

Purpose It is well established that “high volume” centers have better outcomes for complex surgical care including transplantation. However, few studies have used data-driven methodology to establish clinically meaningful volume thresholds predictive of improved outcomes for centers performing orthotopic heart transplantation (OHT). Methods All OHT cases performed between 2005 and 2015 (with follow-up through 2016) within the United Network for Organ Sharing (UNOS) database were reviewed for potential eligibility. All patients ≥18 years of age undergoing isolated OHT were included. Stratum-specific likelihood ratio analysis (SSLR) was used to establish volume thresholds predictive of the primary outcome of mortality at 1-year. Preoperative characteristics and postoperative outcomes were compared between volume strata using χ2 tests (categorical) or ANOVA (continuous). Results A total of 21,800 recipients (mean age 52.6 ± 12.8 years; 25.2% female) were included in the final cohort. Three distinct center volume strata were identified from the analysis: low ( Conclusion The results of our study demonstrate that higher volume centers perform better than their lower volume counterparts in terms of early mortality after OHT. Our study adds to the existing literature by providing specific, data-driven volume thresholds predictive of improved early outcomes in the contemporary transplant and circulatory support landscape.

Purpose Advances in immunosuppression, bridging therapies, and ex vivo perfusion and ventilation have led to substantial advances in lung transplantation (LTx). Nevertheless, LTx is associated with substantial morbidity and mortality. Better outcomes have been demonstrated in “high volume” lung transplant centers, but the field lacks a definition of high volume. The present study aims to identify meaningful, data-driven volume thresholds predicting improved outcomes for LTx centers. Methods All single and double LTx cases performed on patients over the age of 18 between 2005 and 2015 in the United Network for Organ Sharing (UNOS) database were reviewed. Patients listed for other organs or transplants performed in centers that were active for less than three of the ten years of the study period were excluded. Under 1% of patients were excluded due to lack of follow-up data. Stratum-specific likelihood ratios (SSLR) were calculated to establish volume thresholds predictive of the primary outcome of 1 year mortality. Demographic and outcomes data were compared between volume strata. Results A total of 20,153 recipients were included in the final cohort. We identified two thresholds based on SSLR analysis at 12 and 28 LTx/year, which yielded three distinct volume strata: low (under 12), intermediate (12-27), and high volume (over 27). The majority of transplants are performed at high volume centers, which have shorter lengths of stay (24 days vs 29 for low-volume) and better 30-day and 1-year patient survival (96.7% and 86%, vs 94.2% and 80.3% for low-volume), despite older recipients, greater ischemic time, and increased use of extended-criteria donors. Conclusion The results of our study support that high volume centers outperform their low and intermediate volume counterparts and distinguish between the three volume levels. Our study adds to the existing literature by estimating targets for annual lung transplants at which centers may attain improvements in recipient outcomes.

Purpose Mechanical circulatory support (MCS) has been considered a “bridge to decision/therapy” alternative to ameliorate compromised hemodynamic condition in patients whom conventional medical therapy is insufficient to maintain the adequate organ perfusion and function. Outcomes of patients after temporary mechanical support depend on various factors and can range from mortality to recovery to a bridge to cardiac replacement like heart transplant or long term ventricular assist devices. We aim to retrospectively analyze medical record information and clinical outcomes from patients with axillary Impella 5.0 seen at our institution. Methods This retrospective analysis study was designed to gather information about patients that were implanted with an axillary Impella 5.0 at The Methodist Hospital between 2010 and 2019. Subjects were identified and selected through chart review and physician referrals. Results Through the span of about a decade, we have placed about 48 axillary Impella 5.0 devices in a wide range of patients divided into 42 men and 6 women. 24 patients were over the age of 60, 15 patients between 41 and 60 years old, and 9 patients between 29-40 years of age. Of those patients, about 26 patients were upgraded from an Intra-aortic balloon pump, 10 patients had no previous MCS, and the rest either had ECMO or other impella devices. About 44 patients met their hemodynamic needs via the axillary impella device. The 4 remaining patient had either concurrent ECMO and/or RVAD. In regards to outcomes, 22 patients were able to be bridged to OHT or LVAD, 18 patients expired and were not candidates for advanced HF therapy, and 8 patients were able to have the impella weaned off. Conclusion Our single center retrospective study shows that axillary impella 5.0 devices are a viable device for bridge to recovery and/or bridge to cardiac replacement. Over 62% of our patients were able to be bridged to heart transplant/LVAD or have the impella weaned off due to cardiac recovery. Our rate of success is largely due to the increased support provided by the Impella 5.0 devices, but also with the added benefit allowing these patients to be ambulatory to help reduced critical illness morbidity and mortality.

BACKGROUND CONTEXT MHD prevalence in patients with substance abuse history has been well-described. However, the impact of current or historical substance abuse/dependence in adolescent idiopathic scoliosis (AIS) patients on risk of subsequent development of new-onset mental health disorders (MHDs) is unknown. PURPOSE This study evaluated the: (1) demographics and (2) new-onset diagnosis of MHD among AIS patients with baseline substance abuse/dependence. The goal of this study was to determine whether substance abuse among AIS patients increases the odds of subsequent new-onset development of a MHD. STUDY DESIGN/SETTING Retrospective review of prospectively collected data. PATIENT SAMPLE Using the NYS Statewide Planning and Research Cooperative System (SPARCS), we identified age, gender, race, and Charlson/Deyo-index propensity-score matched cohorts of AIS patients with or without prior/current substance abuse. AIS patients with comorbid substance abuse were included from 2009-11, with minimum 2-year follow-up. A total of 386 AIS patients (n=193 in each group) were included. OUTCOME MEASURES Demographic information, length of stay, hospital charges, new-onset MHD diagnosis at 2-year follow-up METHODS The NYS Statewide Planning and Research Cooperative System was reviewed to identify all 10-25 year-old AIS patients with prior or concurrent substance abuse (AIS-Sub: alcohol, tobacco, cannabis, amphetamine, opioid or polysubstance) from 2009-11 to ensure two-year follow-up. Patients with prior or concurrent MHD(s) were excluded. AIS-Sub were 1:1 propensity score-matched by age, sex, race and Charlson/Deyo index to AIS patients without substance abuse (AIS-NoSub). Cohorts were compared for subsequent incidence/development of individual and overall MHDs (depressive, anxiety, stress, sleep and/or eating disorder). Binary stepwise logistic regressions were utilized to calculate odds ratios (OR) of developing individual or any MHDs based on baseline substance abuse. RESULTS A total of 386 AIS patients were included (n=193 each in AIS-Sub and AIS-NoSub). AIS-Sub and AIS-NoSub patients had comparable age (both 20.8 years), sex (62.2 vs 62.7% male), race (54.9 vs 52.8% white), insurance (55.4 v 45.6% Medicaid), and Charlson-Deyo (0.29 vs 0.37) respectively. AIS-Sub patients had higher rates of new-onset subsequent overall MHDs (16.1% vs 3.6%), with only depressive disorder higher among individual MHDs (10.9% vs 0.5%), both p CONCLUSIONS AIS patients with prior or current substance abuse/dependence were at increased two-year risk of developing any new-onset MHD, specifically depressive disorders. This data may guide preoperative screening and optimization efforts for scoliosis surgeons, as MHDs have been associated with poor outcomes following spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

This study examines the patterns of gene integration of gfp-bsd upon stable transfection into the T3Bo strain of Babesia bovis using a plasmid designed to integrate homologous sequences of the parasite's two identical ef-1α A and B genes. While the transfected BboTf-149-6 cell line displayed two distinct patterns of gene integration, clonal lines derived from this strain by cell sorting contained only single gfp-bsd insertions. Whole genome sequencing of two selected clonal lines, E9 and C6, indicated two distinct patterns of gfp-bsd insertion occurring by legitimate homologous recombination mechanisms: one into the expected ef-1α orf B, and another into the ef-1α B promoter. The data suggest that expression of the ef-1α orf B is not required for development of B. bovis in cultured erythrocyte stages. Use of legitimate homologous recombination mechanisms in transfected B. bovis supports the future use of transfection methods for developing efficient gene function assignment experiments using gene knockout techniques.

Malfunction of a continuous-flow left ventricular assist device (CF-LVAD) due to device thrombosis is a potentially life-threatening event that currently presents a diagnostic challenge. We aimed to propose a practical echocardiographic assessment to diagnose LVAD malfunction secondary to pump thrombosis.Among 52 patients implanted with a CF-LVAD from a single center who underwent echocardiographic pump speed-change testing, 12 had suspected pump thrombosis as determined by clinical, laboratory, and/or device parameters. Comprehensive echocardiographic evaluation was performed at baseline pump speed and at each 1,000-rpm interval from the low setting of 8,000 rpm to the high setting of 11,000 rpm in 11 of these patients.Receiver operating characteristic curves and stepwise logistic regression analyses showed that the best diagnostic parameters included changes in the LV end-diastolic diameter (0.6 cm), aortic valve opening time (80 msec), and deceleration time of mitral inflow (70 msec) from lowest to highest pump speed. One parameter was predictive of pump malfunction, with 100% sensitivity and 89% specificity, whereas 2 of 3 parameters increased the sensitivity to 100% and specificity to 95%.The 3 echocardiographic variables of measured changes in LV end-diastolic diameter, aortic valve opening time, and deceleration time of mitral inflow between the lowest (8,000 rpm) and highest pump speed settings (11,000 rpm) during echo-guided pump speed-change testing appear highly accurate in diagnosing device malfunction in the setting of pump thrombosis among patients supported with CF-LVAD. Further investigation is warranted to create and validate a prediction score.

The use of mechanical circulatory support (MCS) devices has increased sixfold since 2006. Although there is an established legal and ethical consensus that patients have the right to withdraw and withhold life-sustaining interventions when burdens exceed benefits, this consensus arose prior to the widespread use of MCS technology and is not uniformly accepted in these cases. There are unique ethical and clinical considerations regarding MCS deactivation. Our center recently encountered the challenge of an awake and functionally improving patient with a total artificial heart (TAH) who requested its deactivation. We present a narrative description of this case with discussion of the following questions: (1) Is it ethically permissible to deactivate this particular device, the TAH? (2) Are there any particular factors in this case that are ethical contraindications to proceeding with deactivation? (3) What are the specific processes necessary to ensure a compassionate and respectful deactivation? (4) What proactive practices could have been implemented to lessen the intensity of this case's challenges? We close with a list of recommendations for managing similar cases.