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We conducted a retrospective study using the NIS database from 2008 to 2018 to examine the most contemporary national hospitalization trends of transcatheter (TAVR) and surgical (SAVR) aortic valve replacement regarding volume, patient and hospital demographics and economics, resource utilization, total cost of stay, and in-hospital mortality. We demonstrate that TAVR procedures have been performed on a slow by steadily diversifying patient population while volume has grown significantly, while in-hospital mortality, length of stay, discharge home, and costs have improved, whereas these metrics have generally remained stable for SAVR. These trends will likely drive continued TAVR adoption, greatly expanding the overall aortic stenosis patient population eligible for AVR.

BACKGROUND Neoadjuvant chemotherapy before mastectomy helps reduce tumor burden and pathologic response in breast cancer. Limited evidence exists regarding how neoadjuvant chemotherapy impacts outcomes following microvascular breast reconstruction. This study examines the effects of neoadjuvant chemotherapy regimens and schedules on microvascular breast reconstruction complication rates and also assesses the effects of neoadjuvant chemotherapy on circulating immune cells related to wound healing. METHODS Patients who underwent neoadjuvant chemotherapy and microvascular breast reconstruction at Yale New Haven Hospital between 2013 and 2018 were identified. Demographic variables, oncologic history, chemotherapy regimens, and complication profiles were collected. Chemotherapy regimens were stratified by inclusion of anthracycline and order of taxane administration. Chi-square, Fisher's exact, and t tests were used for univariate analysis. Multivariate binary logistic regression was used to control for covariates. RESULTS One hundred patients met inclusion criteria. On multivariate analysis, the administration of taxane first in an anthracycline-containing chemotherapy sequence was associated with increased complications (OR, 3.521; p = 0.012), particularly fat necrosis (OR, 2.481; p = 0.040). In the logistic regression model evaluating the effect of the taxane-first regimen on complication rates, the area under the curve was estimated to be 0.760 (p < 0.0001), particularly fat necrosis 0.635 (p < 0.05). The dosage of chemotherapy, number of days between neoadjuvant chemotherapy completion and surgery, and number of circulating immune cells did not significantly differ among patients who experienced complications. CONCLUSIONS Taxane-first, anthracycline-containing neoadjuvant chemotherapy regimens were associated with increased complications, particularly fat necrosis. The increased postreconstruction complication risk must be weighed against the benefits of taxane-first regimens in improving tumor outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

BACKGROUND Despite changes inthe legality of cannabis use and the increasing prevalence of cannabis use disorder (CUD), there is little data investigating the association between CUD and inpatient atrial fibrillation (AF) hospitalizations. METHODS Using the National Inpatient Sample, we identified Atrial Fibrillation (AF) hospitalizations with and without a codiagnosis of CUD using International Classification of Diseases diagnosis codes and compared demographics, socioeconomics, comorbidities, outcomes, and trends between cohorts. RESULTS Between 2008 and 2018, we identified 5,155,789 admissions for AF of which 31,768 (0.6%) had a codiagnosis of CUD. The proportion of admissions with a history of CUD increased from 0.3% in 2008 to 1.0% in 2018 (p

In this observational study, we compared the prognostic ability of an electronic health record (EHR)-derived risk score, the Rothman Index (RI), automatically derived on admission, to the first 24-hour Sequential Organ Failure Assessment (SOFA) score for outcome prediction in the modern cardiac intensive care unit (CICU). We found that while the 24-hour SOFA score provided modestly superior discrimination for both in-hospital and CICU mortality, the RI upon CICU admission had better calibration for both outcomes. Given the ubiquitous nature of EHR utilization in the United States, the RI may become an important tool to rapidly risk stratify CICU patients within the ICU and improve resource allocation.

Objectives The aim of this study was to examine patterns of care and clinical outcomes among patients with heart failure with reduced ejection fraction (HFrEF) in the United States and Canada. Background In the GUIDE-IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment) trial, the use of N-terminal pro–B-type natriuretic peptide–guided titration of guideline-directed medical therapy (GDMT) was compared with usual care alone for patients with HFrEF in the United States and Canada. It remains unknown whether the country of enrollment had an impact on outcomes or GDMT use. Methods A total of 894 patients at 45 sites across the United States and Canada with HFrEF (ejection fraction ≤40%) were enrolled in the trial. Kaplan-Meier survival estimates stratified by country of enrollment were developed for the trial outcomes, and log-rank testing was compared between the groups. GDMT use and titration were also compared. Results U.S. patients were more likely to be younger, to be Black, to have higher body mass index, and to have histories of defibrillator placement or sleep apnea. Use of β-blockers was significantly higher in Canada at baseline (99.3% vs. 94.0%; p = 0.01) and 6 months (99.0% vs. 94.1%; p = 0.04), and use of mineralocorticoid receptor antagonists was higher in Canada at 6 months (68.3% vs. 55.1%; p = 0.01). Canadian patients were less likely to experience the primary study endpoint (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.45 to 0.93; p = 0.01) due to decreased rates of HF hospitalization (HR: 0.57; 95% CI: 0.38 to 0.86; p = 0.003). The differences in outcomes were driven by increased heart failure hospitalization among U.S. Black patients. Conclusions In GUIDE-IT, patients with HFrEF in Canada were significantly less likely to be hospitalized for heart failure. Differences in GDMT use, along with differences in sociodemographics and care delivery structures, may contribute to these differences, highlighting the importance of increasing diversity in clinical trials. (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment [GUIDE-IT]; NCT01685840 )

Objectives The goal of this study was to describe outcomes of patients with bridge to heart transplantation (BTT) after changes were made to the donor heart allocation system. Background Left ventricular assist devices (LVADs) have been used as a BTT. On October 18, 2018, the donor heart allocation system in the United States was updated. Methods This study identified adults in the United Network for Organ Sharing database with durable, continuous-flow LVAD at listing or implanted while listed between April 2017 and April 2020. Baseline recipient and donor characteristics, waitlist survival, and post-transplantation outcomes were compared pre- and post-allocation system change. Results A total of 1,794 patients met inclusion criteria: 983 in the pre-change period and 814 afterward. The number of patients listed with LVAD decreased nationally over time from 102 in April 2017 to 12 in April 2020 (p Conclusions The number of patients with BTT on the transplant list decreased steadily and dramatically after the allocation system change. Although time to transplant decreased, there was an increase in post-transplant mortality. These data suggest that the risks and benefits of LVAD implantation as a BTT have changed under the new allocation system and that the appropriate indication for this treatment strategy warrants a re-evaluation.

Background Financial toxicity (FT) is a well-established side-effect of the high costs associated with cancer care. In recent years, studies have suggested that a significant proportion of those with atherosclerotic cardiovascular disease (ASCVD) experience FT and its consequences. Objectives This study aimed to compare FT for individuals with neither ASCVD nor cancer, ASCVD only, cancer only, and both ASCVD and cancer. Methods From the National Health Interview Survey, we identified adults with self-reported ASCVD and/or cancer between 2013 and 2018, stratifying results by nonelderly (age, Central Illustration

Introduction The effects of preoperative anemia have been shown to be an independent risk factor associated with poor outcomes in both cardiac and noncardiac surgery. Socioeconomic status and race have also been linked to poor outcomes in a variety of conditions. This study was designed to study iron deficiency anemia as a marker of health disparities, length of stay and hospital cost in digital replantation. Materials and Methods Digit replantations performed between 2008 and 2014 were reviewed from the National Inpatient Sample (NIS) database using the ICD-9-CM procedure codes 84.21 and 84.22. Patients with more than one code or with an upper arm (83.24) or hand replantation (84.23) code were excluded. Extracted variables included age, race, comorbidities, hospital type, hospital region, insurance payer type, and median household income quartile. Digit replantations were separated into patients with and without deficiency anemia. Demographics, comorbidities, and access to care were compared between cohorts by chi-squared and t-tests. Multivariate regressions were utilized to assess the effects of anemia on total cost and length of stay. The regression controlled for demographics, region, income, insurance, hospital type, and comorbidities. Beta coefficient was calculated for length of stay and hospital cost. The regression controlled for significant age, race, region, and comorbidities in addition to the above variables. Results In the studied patient population of those without anemia, 59.5% were Caucasian, and in patients with anemia, 46.7% were Caucasian (p < 0.001). Whereas in the in the studied patient population of those without anemia, 6.7% were Black, and in patients with anemia, 15.7% were Black (p < 0.001). Median household income, payer information, length of stay and total cost of hospitalization had statistically significant differences. Using regression and β-coefficient, the effect of anemia on length of stay and cost was also significant (p < 0.001). Regression controlled for age, race, region and comorbidities, with the β-coefficient for effect on cost 37327.18 and on length of stay 3.96. Conclusion These data show that deficiency anemias are associated with a significant increase in length and total cost of stay in patients undergoing digital replantation. Additionally, a larger percentage of patients undergoing digital replantations and who have deficiency anemia belong to the lowest income quartile. Our findings present an important finding for public health prevention and resource allocation. Future studies could focus on clinical intervention with iron supplementation at the time of digital replantation.

Objective To evaluate effects of atrial fibrillation (AF) on cardiac biomarkers and outcomes in a trial population of patients with heart failure (HF) with reduced ejection fraction treated with optimal guideline-directed medical therapy. Methods We performed a secondary analysis of 894 patients in the Guiding Evidence-Based Therapy Using Biomarker-Intensified Treatment in Heart Failure (GUIDE-IT) trial (January 2013–July 2016). Patients were stratified by AF status and compared with regard to guideline-directed medical therapy use, longitudinal levels of N-terminal pro–B type natriuretic peptide (NT-proBNP), and outcomes including HF hospitalization and mortality. Results After adjustment, AF was associated with a significant increase in the risk of HF hospitalization or cardiovascular death (hazard ratio, 1.28; 95% CI, 1.02 to 1.61; P=0.04) and HF hospitalization (hazard ratio, 1.31; 95% CI, 1.02 to 1.68; P=.03) but with no difference in mortality during a median 15 months of follow-up. There were no significant differences in medication treatment between those with and those without AF. At 90 days, a higher proportion of patients with AF (89.4% vs 81.5%; P=.002) had an NT-proBNP level above 1000 pg/mL (to convert NT-proBNP values to pmol/L, multiply by 0.1182), and AF patients had higher NT-proBNP levels at all time points through 2 years of follow-up. Conclusion Among patients with HF with reduced ejection fraction, prevalent AF was associated with higher NT-proBNP concentrations through 2 years of follow-up and higher risk for HF hospitalization despite no substantial differences in medical therapy.

BACKGROUND Although cannabis may worsen nausea and vomiting for patients with gastroparesis, it may also be an effective treatment for gastroparesis-related abdominal pain. Given conflicting data and a lack of current epidemiological evidence, we aimed to investigate the association of cannabis use on relevant clinical outcomes among hospitalized patients with gastroparesis. MATERIALS AND METHODS Patients with a diagnosis of gastroparesis were reviewed from the National Inpatient Sample (NIS) database between 2008 and 2014. Gastroparesis was identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes with patients classified based on a diagnosis of cannabis use disorder. Demographics, comorbidities, socioeconomic status, and outcomes were compared between cohorts using χ and analysis of variance. Logistic regression was then performed and annual trends also evaluated. RESULTS A total of 1,473,363 patients with gastroparesis were analyzed [n=33,085 (2.25%) of patients with concomitant cannabis use disorder]. Patients with gastroparesis and cannabis use disorder were more likely to be younger and male gender compared with nonusers (36.7±18.8 vs. 51.9±16.8; P

While percutaneous cholecystostomy (PC) is a recommended treatment strategy in lieu of cholecystectomy (CCY) for acute cholecystitis among patients who may not be considered good surgical candidates, reports on disparities in treatment utilization remain limited. The aim of this study was to investigate the role of demographic, clinical, and socioeconomic factors in treatment of acute cholecystitis. Patients with a diagnosis of acute cholecystitis who underwent CCY versus PC were reviewed from the U.S. Nationwide Inpatient Sample (NIS) database between 2008-2014. Measured variables including age, race/ethnicity, Charlson comorbidity index (CCI), hospital type/region, insurance payer, household income, length of stay (LOS), hospital cost, and mortality were compared using chi-square and ANOVA. Multivariable logistic regression was performed to identify specific predictors of cholecystitis treatment. A total of 1,492,877 patients (CCY:n=1,435,255 versus PC:n=57,622) were analyzed. The majority of patients that received PC were at urban teaching hospitals (65.2%). LOS was significantly longer with higher associated costs for PC [(11.1±11.0 versus 4.5±5.3 days; P

Despite literature and guidelines recommending same admission cholecystectomy (CCY) after endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute gallstone pancreatitis, clinical practice remains variable. The aim of this study was to investigate the role of clinical and socio-demographic factors in the management of acute gallstone pancreatitis. Patients with acute gallstone pancreatitis who underwent ERCP during hospitalization were reviewed from the U.S. Nationwide Inpatient Sample database between 2008 and 2014. Patients were classified by treatment strategy: ERCP + same admission CCY (ERCP + CCY) versus ERCP alone. Measured variables including age, race/ethnicity, Charlson Comorbidity Index (CCI), hospital type/region, insurance payer, household income, length of hospital stay (LOS), hospitalization cost, and in-hospital mortality were compared between cohorts using χ2 and ANOVA. Multivariable logistic regression was performed to identify specific predictors of same admission CCY. A total of 205,012 patients (ERCP + CCY: n = 118,318 versus ERCP alone: n = 86,694) were analyzed. A majority (53.4%) of patients that did not receive same admission CCY were at urban-teaching hospitals. LOS was longer with higher associated costs for patients with same admission CCY [(6.8 ± 5.6 versus 6.4 ± 6.5 days; P

Steroid use predisposes adult patients to increased perioperative complications including wound dehiscence and delayed wound healing. A similar large study investigating the perioperative impact of steroid use in pediatric patients has not been performed. The National Surgical Quality Improvement Project Pediatric Database was queried from 2012–2017 to identify patients who received steroid preoperatively. Patient demographics, comorbidities, surgical variables, and outcomes were compared between cohorts. Patients were propensity score matched and thirty-day adverse events were compared. Of 425,251 pediatric surgery patients, 9716 (2.3%) received preoperative steroids. Pediatric patients treated with steroids were older and had more comorbidities. After propensity score matching, the steroid population had a significantly higher rate of adverse events, including prolonged hospital stay (15.3% vs. 9.1%, p

Introduction: Due to discrepancies between donor supply and recipient demand, the cardiac transplantation process aims to prioritize the most medically urgent patients. It remains unknown how recipients with the lowest medical urgency compare to others in the allocation process. Methods: We performed a retrospective analysis of the United Network for Organ Sharing database. Patients listed for cardiac transplantation between January 2011 to May 2020 were stratified according to status at time of transplantation. Baseline recipient and donor characteristics, waitlist survival, and post-transplantation outcomes were compared between lower urgency listing and higher urgency listing in the years before and after the 2018 allocation system change. Results: Lower urgency patients in the old system were older (58.5 vs. 56 years) and more likely female (54.4% vs. 23.8%) compared to the highest urgency patients, and these trends persisted in the new system for the lowest urgency patients (59 vs. 55 years; 47.0% vs. 23.9% female; p Conclusions: Cardiac transplantation for lower urgency patients has not been well characterized. Our analysis demonstrates that, over the last decade, these patients receive hearts from donors with additional comorbidities compared to higher urgency patients but that outcomes are similar at one year. Our results may support the utility of early listing and less stringent thresholds for organ acceptance to increase access to cardiac transplantation.

Background Because of discrepancies between donor supply and recipient demand, the cardiac transplantation process aims to prioritize the most medically urgent patients. It remains unknown how recipients with the lowest medical urgency compare to others in the allocation process. We aimed to examine differences in clinical characteristics, organ allocation patterns, and outcomes between cardiac transplantation candidates with the lowest and highest medical urgency. Methods and Results We performed a retrospective analysis of the United Network for Organ Sharing database. Patients listed for cardiac transplantation between January 2011 and May 2020 were stratified according to status at time of transplantation. Baseline recipient and donor characteristics, waitlist survival, and posttransplantation outcomes were compared in the years before and after the 2018 allocation system change. Lower urgency patients in the old system were older (58.5 versus 56 years) and more likely female (54.4% versus 23.8%) compared with the highest urgency patients, and these trends persisted in the new system ( P P P P Conclusions Patients transplanted as lower urgency receive hearts from donors with additional comorbidities compared with higher urgency patients, but outcomes are similar at 1 year.

Background Racial and ethnic disparities contribute to differences in access and outcomes for patients undergoing heart transplantation. We evaluated contemporary outcomes for heart transplantation stratified by race and ethnicity as well as the new 2018 allocation system. Methods and Results Adult heart recipients from 2011 to 2020 were identified in the United Network for Organ Sharing database and stratified into 3 groups: Black, Hispanic, and White. We analyzed recipient and donor characteristics, and outcomes. Among 32 353 patients (25% Black, 9% Hispanic, 66% White), Black and Hispanic patients were younger, more likely to be women and have diabetes mellitus or renal disease (all, P P =0.003) and 7.7% to 9.0% ( P =0.002), respectively. Compared with White patients, Black patients were less likely to undergo transplantation (adjusted hazard ratio [aHR], 0.87; CI, 0.84–0.90; P P =0.004). There were no differences in transplantation likelihood or post‐transplant mortality between Hispanic and White patients. Following the allocation system change, transplantation rates increased for all groups ( P P =0.024). Conclusions Although the proportion of Black and Hispanic patients listed for cardiac transplantation have increased, significant disparities remain. Compared with White patients, Black patients were less likely to be transplanted, even with the new allocation system, and had a higher risk of post‐transplantation death.

Aims The impact of mechanical ventilation (MV) at the time of heart transplantation is not well understood. In addition, MV was recently removed as a criterion from the new US heart transplantation allocation system. We sought to assess for the association between MV at transplantation and 1-year mortality. Methods and results We utilized the United Network for Organ Sharing database and included all adult, single organ heart transplantations from 1990 to 2019. We utilized multivariable logistic regression adjusting for demographics, comorbidities, and markers of clinical acuity. We identified 60 980 patients who underwent heart transplantation, 2.4% (n = 1431) of which required MV at transplantation. Ventilated patients were more likely to require temporary mechanical support, previous dialysis, and had a shorter median waitlist time (21 vs. 95 days, P Conclusion We found a strong association between the presence of MV at heart transplantation and 90-day and 1-year mortality. Future studies are needed to identify which patients requiring MV have reasonable outcomes, and which are associated with substantially poorer outcomes.

Objective: To assess the timing, type, and associated adjunct procedures for secondary cleft rhinoplasty nationally. Design: Data were extracted from a national database of all secondary cleft rhinoplasty procedures (Current Procedural Terminology [CPT] codes 30460 and 30462). Frequency statistics were utilized to analyze demographics, comorbidities, surgical procedures, and timing. Chi-squared analysis and Fisher exact test were used for analysis. Setting: National Surgical Quality Improvement Program-Pediatric Database. Participants: A total of 1720 patients met inclusion criteria for secondary cleft rhinoplasty repair. Interventions: No relevant intervention. Main Outcomes and Measures: Age, demographics, comorbidities, and associated procedures. Results: Over 5 consecutive years, 1720 patients underwent secondary cleft lip rhinoplasty nationally. Mean patient age was 9.3 ± 5.3 years. Unilateral cleft rhinoplasty patients were older (9.0 years) than bilateral patients (7.8 years; P = .001). Rib grafting was performed in 6.3% of patients at a mean age of 10.6 years with a higher proportion of Asian and female patients. Auricular grafts were more commonly performed by otolaryngology than plastic surgery. The most common adjunct procedures included secondary cleft lip revision (33.1%) and tympanostomy tube placement (10.2%). When subdividing by type of cleft rhinoplasty, tip rhinoplasty was performed at a mean age of 7.3 years compared to rhinoplasty with osteotomies and a major septal component at 12.1 years ( P < .001). Conclusions: This study reveals that a large proportion of cleft rhinoplasties are performed in skeletally immature patients. Although patients undergoing rib grafting, nasal osteotomies, and a major septal component were older, these procedures are still performed in a large proportion of patients who are younger than expected.

OBJECTIVEHealth policy changes have led to increased emphasis on value-based care to improve resource utilization and reduce inpatient hospital length of stay (LOS). Recently, LOS has become a major determinant of quality of care and resource utilization. For adolescent idiopathic scoliosis (AIS), the determinants of extended LOS after elective posterior spinal fusion (PSF) remain relatively unknown. In the present study, the authors investigated the impact of patient and hospital-level risk factors on extended LOS following elective PSF surgery (≥ 4 levels) for AIS.METHODSThe Kids’ Inpatient Database (KID) was queried for the year 2012. Adolescent patients (age range 10–17 years) with AIS undergoing elective PSF (≥ 4 levels) were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended hospital LOS was defined as greater than the 75th percentile for the entire cohort (> 6 days), and patients were dichotomized as having normal LOS or extended LOS. Patient demographics, comorbidities, complications, LOS, discharge disposition, and total cost were recorded. A multivariate logistic regression model was used to determine the odds ratio for risk-adjusted LOS. The primary outcome was the degree to which patient comorbidities or postoperative complications correlated with extended LOS.RESULTSComorbidities were overall significantly higher in the extended-LOS cohort than the normal-LOS cohort. Patients with extended LOS had a significantly greater proportion of blood transfusion (p < 0.001) and ≥ 9 vertebral levels fused (p < 0.001). The overall complication rates were greater in the extended-LOS cohort (20.3% [normal-LOS group] vs 43.5% [extended-LOS group]; p < 0.001). On average, the extended-LOS cohort incurred $18,916 more in total cost than the normal-LOS group ($54,697 ± $24,217 vs $73,613 ± $38,689, respectively; p < 0.001) and had more patients discharged to locations other than home (p < 0.001) than did patients in the normal-LOS cohort. On multivariate logistic regression, several risk factors were associated with extended LOS, including female sex, obesity, hypertension, fluid electrolyte disorder, paralysis, blood transfusion, ≥ 9 vertebrae fused, dural injury, and nerve cord injury. The odds ratio for extended LOS was 1.95 (95% CI 1.50–2.52) for patients with 1 complication and 5.43 (95% CI 3.35–8.71) for patients with > 1 complication.CONCLUSIONSThe authors’ study using the KID demonstrates that patient comorbidities and intra- and postoperative complications all contribute to extended LOS after spinal fusion for AIS. Identifying multimodality interventions focused on reducing LOS, bettering patient outcomes, and lowering healthcare costs are necessary to improve the overall value of care for patients undergoing spinal fusion for AIS.

Healthcare-associated infections (HAI) are generally preventable causes of increased cost, morbidity, and mortality. Further, HAI carry penalties in the era of hospital value-based care. However, very little is known about the incidence and outcomes of HAI among patients hospitalized with common cardiovascular conditions. Using a national database, we identified adults aged ≥18 years hospitalized with 5 common cardiovascular conditions, including heart failure, acute myocardial infarction, coronary artery bypass grafting, cardiogenic shock, and atrial fibrillation or flutter. We assessed for temporal trends in incidence, cost, length of stay (LOS), and mortality associated with ventilator-associated pneumonia, catheter-associated urinary tract infections, central line-associated bloodstream infection, and Clostridium difficile infections. Between 2008 and 2015, we identified 159,021 hospitalizations ≥1 HAI (49.6% heart failure, 20.4% acute myocardial infarction, 10.5% coronary artery bypass grafting, 18.6% cardiogenic shock, and 11.9% atrial fibrillation or flutter). Clostridium difficile infections (75.4%) were the most common followed by catheter-associated urinary tract infections (15.1%), ventilator-associated pneumonia (7.9%), and central line-associated bloodstream infection (3.1%). Nearly half of the patients (46.3%) with HAI required discharge to a skilled care facility compared with 15.7% of patients who did not. After propensity matching, HAI remained associated with an increased LOS (4.9 vs 9.6 days, p

Objective Previous studies have identified the impact of affective disorders on preoperative and postoperative perception of pain. However, there is a scarcity of data identifying the impact of affective disorders on postdischarge narcotic refills. The aim of this study was to determine whether patients with affective disorders have more narcotic refills after complex spinal fusion for deformity correction. Methods The medical records of 121 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (≥5 level) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative complication rates, baseline and postoperative patient-reported pain scores, ambulatory status, and narcotic refills were collected for each patient. The primary outcome was the rate of 6-week and 3-month narcotic refills. Results Of the 121 patients, 43 (35.5%) had a clinical diagnosis of anxiety or depression (affective disorder) (AD n = 43; No-AD n = 78). Preoperative narcotic use was significantly higher in the AD cohort (AD 65.9% vs. No-AD 37.7%, P = 0.0035). The AD cohort had significantly higher pain scores at baseline (AD 6.5 ± 2.9 vs. No-AD 4.7 ± 3.1, P = 0.004) and at the first postoperative pain score reported (AD 6.7 ± 2.6 vs. No-AD 5.6 ± 2.9, P = 0.049). However, there were no significant differences in narcotic refills at 6 weeks (AD 34.9% vs. No-AD 25.6%, P = 0.283) and 3 months (AD 23.8% vs. No-AD 17.4%, P = 0.411) after discharge between the cohorts. Conclusions Our study suggests that whereas spinal deformity patients with affective disorders may have a higher baseline perception of pain and narcotic use, the impact of affective disorders on narcotic refills at 6 weeks and 3 months may be minimal after complex spinal fusion.

Background Corticosteroid use continues to rise nationally. Studies have evaluated the impact of chronic steroid use on surgical outcomes in smaller populations. This study investigated the impact of chronic steroid use on perioperative surgical outcomes in a surgical cohort of more than 5 million surgical patients, using a statistically rigorous methodology. Methods The National Surgical Quality Improvement Program Database was queried 2008–2016 to evaluate chronic steroid use. Patient demographics, comorbidities, and outcomes were compared, using χ2 and t test analysis, and then repeated after propensity score matching. Finally, a double-adjustment logistic regression was utilized, yielding odds ratios to assess the effect of chronic steroids on perioperative outcomes within the matched population. Results Between 2008 and 2016, a total of 5,244,588 patients met inclusion criteria, of whom 181,901 (3.5%) were taking steroids for a minimum of 30 days before surgery. Patients on chronic steroids had significantly more comorbidities compared with the remaining population. After propensity score matching and double-adjusted logistic regression, chronic steroid use was found to be associated with increased surgical complications and poorer surgical outcomes. Chronic steroid use significantly increased a patient’s risk of having a hospital stay longer than 30 days by 19%, risk of readmission within 30 days by 58%, risk of reoperation by 21%, and risk of death by 32%. Conclusion After controlling for differences in comorbidities and demographics, patients on chronic steroids have significantly poorer perioperative outcomes. Chronic steroid use should be evaluated and, if possible, addressed before surgery, given their significant impact on surgical outcomes.

BACKGROUND Microvascular reconstruction is the standard of care in head and neck reconstruction, though its perioperative safety in an older population has been controversial due to safety concerns, warranting further investigation. MATERIALS AND METHODS An "older" (≥71 years) cohort undergoing reconstruction after mandibulectomy/glossectomy was compared to the remaining population in a National Surgical Quality Improvement Program (2008-2016) analysis. Cases required both a mandibulectomy/glossectomy and microvascular or local flap reconstruction (exclusion criteria: missing ages and simultaneous microvascular and local flap reconstruction). Demographics, comorbidities, and procedure types were analyzed on 985 patients (236 [24.4%] were ≥71). Outcomes were compared by reconstruction type. Regressions were performed calculating the impact of age on length of hospital stay (LOHS) and operative time. RESULTS Ablative procedures were comparable, but older patients received local flaps at higher rates (22.5% vs. 9.6%; p

Background Two-stage implant breast reconstruction is the most commonly performed breast reconstruction procedure. Limited data exist regarding reconstruction complication rates examined by mastectomy indication. Methods Patients who underwent two-stage implant breast reconstruction at Yale New Haven Hospital from 2011 to 2017 were included in the study. Perioperative complications were compared. Chi-square analysis, t tests, and Fisher's exact tests were used to determine significant associations. A binary logistic regression was used to determine variables with a significant impact on the likelihood of mastectomy flap necrosis. Results Between 2011 and 2017, complete perioperative records were available for 141 patients who underwent 226 mastectomies followed by two-stage tissue expander/permanent implant reconstruction. Of the 226 mastectomies, 134 were therapeutic and 92 were prophylactic. On regression analysis, there were no significant differences in demographics, comorbidities, or mastectomy and reconstructive details between the two breast groups except for there being more modified radical mastectomies in therapeutic breasts (p = 0.003). When comparing complications, there was a significantly higher risk of mastectomy flap necrosis in the therapeutic group (p = 0.017). Therapeutic mastectomies had a 9.5 times higher risk of mastectomy flap necrosis than prophylactic mastectomies when adjusted for confounding variables. There were no significant differences in other reconstructive complications between the two groups. Conclusions Patients undergoing therapeutic mastectomies have a significantly higher risk of mastectomy flap necrosis than those undergoing prophylactic mastectomies. Although the underlying cause still needs to be determined, differences in technique may be related to mastectomy flap necrosis. Clinical question/level of evidence Risk, II.

Introduction Cleft palate repair has rare, but potentially life-threatening risks. Understanding the risk factors for adverse events following cleft palate repair can guide surgeons in risk stratification and parental counseling. Methods Patients under 2 years of age in National Surgical Quality Improvement Project Pediatric Database (NSQIP-P) from 2012 to 2016 who underwent primary cleft palate repair were identified. Risk factors for adverse events after cleft palate repair were identified. Results Outcomes for 4989 patients were reviewed. Mean age was 1.0 ± 0.3 years and 53.5% were males. Adverse events occurred in 6.4% (320) of patients. The wound dehiscence rate was 3.1%, and the reoperation rate was 0.9%.On multivariate analysis, perioperative blood transfusion (adjusted odds ratio [aOR] 30.2), bronchopulmonary dysplasia/chronic lung disease (aOR 2.2), and prolonged length of stay (LOS) (aOR 1.1) were significantly associated with an adverse event.When subdivided by type of adverse event, reoperation was associated with perioperative blood transfusion (aOR 286.5), cerebral palsy (aOR 11.3), and prolonged LOS (aOR 1.1). Thirty-day readmission was associated with American Society of Anesthesiologists Physical Status Classification class III (aOR 2.0) and IV (aOR 4.8), bronchopulmonary dysplasia/chronic lung disease (aOR 2.5), cerebral palsy (aOR 5.7), and prolonged LOS (aOR 1.1). Finally, wound dehiscence was significantly associated with perioperative blood transfusion only (aOR 8.2). Conclusions Although adverse events following cleft palate surgery are rare, systemic disease remains the greatest predictor for readmission and reoperation. Neurologic and pulmonary diseases are the greatest systemic risk factors. Intraoperative adverse events requiring blood transfusion are the greatest surgical risk factor for post-surgical complications.

Background Heart failure (HF) and atrial fibrillation (AF) frequently coexist and may be associated with worse HF outcomes, but there is limited contemporary evidence describing their combined prevalence. We examined current trends in AF among hospitalizations for HF with preserved (HFpEF) ejection fraction or HF with reduced ejection fraction (HFrEF) in the United States, including outcomes and costs. Methods and Results Using the National Inpatient Sample, we identified 10 392 189 hospitalizations for HF between 2008 and 2017, including 4 250 698 with comorbid AF (40.9%). HF hospitalizations with AF involved patients who were older (average age, 76.9 versus 68.8 years) and more likely White individuals (77.8% versus 59.1%; P P P Conclusions AF is increasingly common among hospitalizations for HF and is associated with higher costs and in‐hospital mortality. Over time, patients with HF and AF were younger, less likely to be White individuals, and had more comorbidities; in‐hospital mortality decreased. Future research will need to address unique aspects of changing patient demographics and rising costs.

Heart failure (HF) is a major driver of health care costs in the United States and is increasing in prevalence. There is a paucity of contemporary data examining trends among hospitalizations for HF that specifically compare HF with reduced or preserved ejection fraction (HFrEF or HFpEF, respectively).Using the National Inpatient Sample, we identified 11,692,995 hospitalizations due to HF. Hospitalizations increased from 1,060,540 in 2008 to 1,270,360 in 2018. Over time, the median age of patients hospitalized because of HF decreased from 76.0 to 73.0 years (P0.001). There were increases in the proportions of Black patients (18.4% in 2008 to 21.2% in 2018) and of Hispanic patients (7.1% in 2008 to 9.0% in 2018; P0.001, all). Over the study period, we saw an increase in comorbid diabetes, sleep apnea and obesity (P0.001, all) in the entire cohort with HF as well as in the HFrEF and HFpEF subgroups. Persons admitted because of HFpEF were more likely to be white and older compared to admissions because of HFrEF and also had lower costs. Inpatient mortality decreased from 2008 to 2018 for overall HF (3.3% to 2.6%) and HFpEF (2.4% to 2.1%; P0.001, all) but was stable for HFrEF (2.8%, both years). Hospital costs, adjusted for inflation, decreased in all 3 groups across the study period, whereas length of stay was relatively stable over time for all groups.The volume of patients hospitalized due to HF has increased over time and across subgroups of ejection fraction. The demographics of HF, HFrEF and HFpEF have become more diverse over time, and hospital inpatient costs have decreased, regardless of HF type. Inpatient mortality rates improved for overall HF and HFpEF admissions but remained stable for HFrEF admissions.

Background Several studies have shown improved outcomes in closed compared with open medical and surgical intensive care units. However, very little is known about the ideal organizational structure in the modern cardiac intensive care unit (CICU). Methods and Results We retrospectively reviewed consecutive unique admissions (n=3996) to our tertiary care CICU from September 2013 to October 2017. The aim of our study was to assess for differences in clinical outcomes between an open compared with a closed CICU. We used multivariable logistic regression adjusting for demographics, comorbidities, and severity of illness. The primary outcome was in‐hospital mortality. We identified 2226 patients in the open unit and 1770 in the closed CICU. The unadjusted in‐hospital mortality in the open compared with closed unit was 9.6% and 8.9%, respectively ( P =0.42). After multivariable adjustment, admission to the closed unit was associated with a lower in‐hospital mortality (odds ratio [OR], 0.69; 95% CI: 0.53–0.90, P =0.007) and CICU mortality (OR, 0.70; 95% CI, 0.52–0.94, P =0.02). In subgroup analysis, admissions for cardiac arrest (OR, 0.42; 95% CI, 0.20–0.88, P =0.02) and respiratory insufficiency (OR, 0.43; 95% CI, 0.22–0.82, P =0.01) were also associated with a lower in‐hospital mortality in the closed unit. We did not find a difference in CICU length of stay or total hospital charges ( P >0.05). Conclusions We found an association between lower in‐hospital and CICU mortality after the transition to a closed CICU. These results may help guide the ongoing redesign in other tertiary care CICUs.