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Use of normothermic regional perfusion (NRP) to enable organ reconditioning and assessment in donation after circulatory determination of death is controversial. We conducted a scoping review of peer-reviewed articles, news media, legal literature, and professional society position statements addressing ethical and/or legal issues in use of NRP in controlled donation after circulatory determination of death from January 1, 2005, to January 5, 2024. Thematic analysis, assessing the 4 principles of bioethics (autonomy, beneficence, nonmaleficence, and justice) and subthemes identified within each, was conducted for the 112 publications meeting inclusion criteria. More than 30 publications addressed the topic in each of 2022 and 2023, vs ≤6 per year previously. Nonmaleficence was the most frequently addressed bioethical principle (111/112 publications), and the most varied, with 14 subthemes. Attitudes toward NRP differed by type of NRP: of 72 publications discussing thoracoabdominal NRP, 22 (30.6%) were "In Favor," 39 (54.2%) were "Neutral," and 11 (15.3%) were "Against"; of 44 discussing abdominal NRP, 23 (52.3%) were "In Favor," 20 (45.5%) were "Neutral," and 1 (2.3%) was "Against." Attitudes differed by authors' country, degree, and affiliation, and by the clinical focus of the publishing journal. Overall, our review shows that the ethical and legal issues raised by NRP remain unresolved, and the debate centered on nonmaleficence., Competing Interests: Declaration of competing interest The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation., (Copyright © 2024 American Society of Transplantation & American Society of Transplant Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Perioperative blood transfusion is associated with adverse outcomes and higher costs after coronary artery bypass graft (CABG) surgery. We developed risk assessments for patients' probability of perioperative transfusion and the expected transfusion volume to improve clinical management and resource use., Methods: Among 1,266,545 consecutive (2008-2016) isolated CABG operations in The Society of Thoracic Surgeons Adult Cardiac Surgery Database, 657,821 (51.9%) received perioperative transfusions of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate, and/or platelets. We developed "full" models to predict perioperative transfusion of any blood product, and of RBC, FFP, or platelets. Using least absolute shrinkage and selection operator model selection, we built a rapid risk score based on 5 variables (age, body surface area, sex, preoperative hematocrit, and use of intra-aortic balloon pump)., Results: C statistics for the full model were 0.785, 0.815, 0.707, and 0.699 for any blood product, RBC, FFP, and platelets, respectively. C statistics for rapid risk assessments were 0.752, 0.785, 0.670, and 0.661 for any blood product, RBC, FFP, and platelets, respectively. The observed vs expected risk plots showed strong calibration for full models and risk assessment tools; absolute differences between observed and expected risks of transfusion were <10.8% in each percentile of expected risk. Risk assessment-predicted probabilities of transfusion were strongly and nonlinearly associated (P < .0001) with total units transfused., Conclusions: These robust and well-calibrated risk assessment tools for perioperative transfusion in CABG can inform surgeons regarding patients' risks and the number of RBC, FFP, and platelets units they can expect to need. This can aid in optimizing outcomes and increasing efficient use of blood products., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Donation after circulatory death (DCD) donors now represent over 30% of the deceased donor pool in the United States. Compared to donation after brain death, DCD is less likely to result in transplantation. For each potential donor whose organs cannot be utilized for transplantation (ie, dry run), fees are associated with the attempted donation, which add to the overall costs of organ acquisition. To better characterize the true costs of DCD liver acquisition, we performed a cost comparison of the fees associated with organ acquisition for DCD versus donation after brain death at a single transplant institute that comprises 2 liver transplant centers. Cost, recipient, and transportation data for all cases, including fees associated with liver acquisition from July 1, 2019, to October 31, 2021, were collected. We found that the total cost of DCD liver acquisition per liver transplant was $15,029 more than that for donation after brain death donation, with 18% of the costs of the DCD transplant attributed to dry runs. Overall, the costs associated with DCD transplantation accounted for 34.5% of the total organ acquisition costs; however, DCD transplantation accounted for 30.3% of the transplantation volume. Because the expansion of DCD is essential to increasing the availability of liver grafts for transplantation, strategies need to be implemented to decrease the costs associated with dry runs, including using local recovery, transferring donors to hospitals close to transplant centers, and performing more prerecovery organ analysis. Moreover, these strategies are needed to ensure that financial disincentives to DCD procurement and utilization do not reverse the gains made by expanding the organ donor pool using machine perfusion technologies., (Copyright © 2024 American Association for the Study of Liver Diseases.)

Uterus transplantation (UTx) has evolved from a purely experimental procedure to a clinical treatment option available outside the clinical trial context, offering women with absolute uterine-factor infertility an opportunity to experience pregnancy. As UTx becomes better established and more widely known and performed, it is likely to be sought out by geographically and culturally diverse patients, particularly those whose religious beliefs impose barriers to other paths to achieve parenthood, such as gestational surrogacy and adoption. Many religions do not currently have official positions on UTx, meaning that clinicians involved in screening candidates can expect questions about how the UTx process aligns with various religious beliefs. This article provides a broad background on the current positions major world religions have taken on UTx (or its components) and the alternative paths to parenthood of gestational surrogacy and adoption. It is intended to help clinicians communicate the information necessary for individuals interested in uterus donation or transplantation to determine-in consultation with their spiritual advisors or religious authorities when needed-how these options align with religious beliefs or teachings., Competing Interests: The authors report no funding or conflicts of interest other than affiliation with Baylor University Medical Center at Dallas, which is an active uterus transplant center., (Copyright © 2024 Baylor University Medical Center.)

Background: As uterus transplantation transitions to a clinical procedure for women with absolute uterine-factor infertility, transplant centers performing uterus transplantation need information about the experience of living donors. This study examined the psychosocial impact on 17 nondirected uterus donors in the Dallas UtErus Transplant Study 1 y following donation., Methods: A prospective longitudinal study was conducted to measure psychosocial outcomes of depression, anxiety, posttraumatic stress, quality of life, and resilience [measured using the Hospital Anxiety and Depression Scale or Patient Health Questionnaire 9-Item, Generalized Anxiety Disorder 7-Item, Posttraumatic Stress Disorder Checklist for the DSM-5, health-related quality of life Short Form-36, and Connor-Davidson Resilience Scale 10-Item, respectively) assessed at baseline, at 6-mo and 1-y follow-up. Differences among baseline, 6-mo, and 1-y postdonation were analyzed., Results: The median age was 38.0 y, 16 were married, 15 were of non-Hispanic/Latino ethnicity. Most donors did not report psychosocial distress; however, 1 donor reported decline on the role limitations because of Emotional Problems Scale and also showed an increase in depression symptoms at the 6 mo, but at 1 y was below the clinical cutoff for depression. A second donor showed modest decline in emotional well-being. Improvements were seen in other donors on the Physical Functioning Scale and posttraumatic stress symptoms., Conclusions: Although most nondirected donors appeared to remain stable, both positive and negative changes were observed over the first year. Larger studies are needed to determine psychosocial risks and benefit and what additional resources might be needed to ensure optimal psychosocial outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Early in the COVID-19 pandemic, primary care adopted telehealth rapidly to preserve access. Although policy flexibilities persist, but with in-person access restored, insight regarding long-term policy reform is needed for equitable access, especially for underserved, low income, and rural populations., Methods: We used electronic health record data to compare primary care telehealth use in practices serving primarily commercially insured patients versus clinics serving low-income uninsured patients, in March-June 2020 ("early COVID") and March-June 2022 ("late COVID")., Results: Primary care visit mode differed significantly ( P < .0001 ) between settings in both periods. In early COVID, video visits were most used in the commercially insured practices (54.50%), followed by office visits (32.76%); in the low-income, uninsured clinics, phone visits were most used (56.67%), followed by office visits (23.55%). In late COVID, 81.05% of visits to commercially insured practices and 92.04% to uninsured clinics were in-office; continuing telehealth use was primarily video. Smaller but significant ( P ≤ .0001 ) differences in telehealth use by race/ethnicity were also observed, with Black and/or Hispanic patients less likely than White patients to use telehealth during both periods, after adjustment for other characteristics., Conclusions: Findings demonstrate the importance of both phone and video visits in preserving primary care access early in the pandemic. Telehealth use declined in late COVID, but still accounted for ∼20% of primary care visits in the commercially insured setting and less than 10% of visits in the community care clinics. Differences in telehealth use were largely by setting, reflecting income/insurance status, indicating disparities needing to be addressed., Competing Interests: Conflict of interest: The authors have no conflicts of interest to declare., (© Copyright by the American Board of Family Medicine.)

COVID-19 vaccine uptake in the United States has proved challenging. A deeper characterization extending beyond demographics and political ideologies of those hesitating or resisting is needed to guide ongoing conversations. This study examined associations between US adults' vaccination intentions and mental health history, experience of the COVID-19 pandemic, and mental health outcomes. An online population-based cross-sectional survey was administered nationwide during January 4-7, 2021. Participants were questioned about past and current mental health, and completed the Patient Health Questionnaire 8 (PHQ-8), Generalized Anxiety Disorder 7-item (GAD-7), and Posttraumatic Diagnostic Scale (PDS)-5 (to capture symptoms of depression, anxiety, and traumatic stress, respectively). Experience of the pandemic included cumulative county-level COVID case and death rates, self-reported COVID-19 testing/exposure/diagnosis, and self-reported impact on routines, resources, and relationships. Of 936 respondents, 66% intended to be vaccinated, 14.7% responded "maybe," and 19.6% "no." Past diagnosis of obsessive compulsive disorder, less impact on routines or social supports, not having been screened or tested for COVID-19, not knowing someone who tested positive, and not self-isolating were associated with less intention to vaccinate. After controlling for demographic and pandemic experience factors, symptoms of traumatic stress, but not other mental health outcomes, were associated with less intention to vaccinate. The apparent contradiction between less negative impact of the pandemic and symptoms of traumatic stress being associated with less intention to be vaccinated indicates the complex nature of barriers to vaccine uptake. Results from this study contribute to the evidence base needed to improve ongoing and future communications about, and strategies to increase uptake of, vaccination.

Objectives: Information regarding vaccination and the association with individuals' characteristics, experiences, and information sources is important for crafting public health campaigns to maximize uptake. Our objective was to investigate factors associated with intentions for COVID-19 vaccination among a sample of U.S. adults using a population-based cross-sectional survey., Method: Data were collected via an online questionnaire administered nationwide from January 4, to January 7, 2021 following the emergency use authorization for two SARS-CoV-2 mRNA-based vaccines., Results: Of 936 U.S. adult respondents, 66% stated an intention to be vaccinated once a COVID-19 vaccine was available to them; 14.7% responded "maybe" and 19.6% "no." Unadjusted and multivariate associations revealed "no/maybe" vaccination intentions were associated with younger age, female, Black race, lower income, history of not receiving the influenza vaccine, lower fear of COVID-19, suffering moderate to severe reduction in access to food/nutrition, and lower trust in health care authorities, personal health care providers, and/or traditional news media as sources of COVID-19 information. Of respondents "maybe" intending to be vaccinated, 65% reported "a lot" of trust in personal health care providers as sources of COVID-19 information. Respondents stating "no" intention to be vaccinated were skeptical of all COVID-19 information sources considered., Conclusions: Our findings confirm observations predating COVID-19 vaccine availability regarding sociodemographic characteristics associated with vaccine hesitancy in the United States. We further identify personal health care providers as the most trusted information source among people who "maybe" intend to get vaccinated and demonstrate the challenge in reaching people not intending to be vaccinated. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

This study describes the characteristics of women who contacted an active program performing uterus transplantation (UTx) in the US, expressing interest in becoming a uterus transplant recipient or a living donor. Basic demographic and self-reported clinical information was collected from women who contacted any of the three US UTx programs from 2015 to July 2022. The three centers received 5194 inquiries about becoming a UTx recipient during the study timeframe. Among those reporting a cause of infertility, almost all of the reports (4066/4331, 94%) were absence of a uterus, either congenitally (794/4066, 20%) or secondary to hysterectomy (3272/4066, 80%). The mean age was 34 years, and 49% (2545/5194) had at least one child at the time of application. The two centers using living donors received 2217 inquiries about becoming living donors. The mean age was 34 years, and 60% (1330/2217) had given birth to ≥1 child. While most of the UTx clinical trial evidence has focused on young women with congenital absence of the uterus, these results show interest from a much broader patient population in terms of age, cause of infertility, and parity. These results raise questions about whether and to what extent the indications and eligibility criteria for UTx should be expanded as the procedure transitions from the experimental phase to being offered as a clinical treatment.

Background: The prevalence of depression symptoms among U.S. adults increased dramatically during the early months of the COVID-19 pandemic. We sought to understand the impact of the pandemic on people with a history of depression., Methods: In June 2020, a national sample of 5023 U.S. adults, including 760 reporting past/current diagnoses of depression, completed survey measures related to the COVID experience, coping, anxiety, depression, and PTSD., Results: After adjusting for sociodemographic characteristics, a history of depression increased the odds of negative effects of pandemic on multiple aspects of life: routines, access to mental health treatment, alcohol use, prescription painkiller use, and other drug use. Those with a history of depression also scored significantly higher on the PHQ-8, GAD-7, and PDS-5 (all ps < 0.0001). Greater use of adaptive coping strategies was significantly associated with lower scores, and greater use of maladaptive strategies with higher scores. Individuals reporting a history of depression reported greater use of both adaptive and maladaptive strategies., Conclusions: Adaptive coping strategies appear to be protective and help regulate symptomatology, suggesting that particular focus during the clinical encounter on developing tools to promote well-being, alleviate stress, and decrease perceptions of helplessness could mitigate the effects., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Uterus transplantation (UTx) has come of age in the 21st century, building on the 20th century developments in vascular anastomosis and effective immunosuppressive protocols that have enabled solid organ transplantation to become the life-extending and life-improving treatment option we know today. However, UTx has the goal of enabling reproduction, meaning that research has focused on establishment of pregnancy and healthy live birth in addition to surgical technique and immunosuppression., Summary: The Dallas Uterus Transplant Study (DUETS), established at Baylor University Medical Center in 2015, is one of four UTx programs in the USA, and it holds the distinction of being home not only to the first US live birth but also the highest volume UTx program worldwide, with 23 uterus transplants performed to date, resulting in 15 live births. Innovations pioneered at our center span all aspects of the UTx process, all seeking to improve success for recipients in terms of achieving pregnancy and live birth, while also minimizing the burden on donors and recipients. They have included the following: (1) a deceased donor hysterectomy approach that allows the uterus to be procured prior to cross clamp; (2) proof of concept with use of only superior uterine veins after procuring both the superior and inferior uterine veins during the donor surgery, enabling the choice of the best option in terms of size and location for outflow, while also preserving ovary viability in living donors; (3) contribution to robot-assisted technique/minimally invasive technique with vaginal extraction of the uterus graft for living donor surgeries, shortening donor recovery times; (4) developing a robot-assisted technique for graft hysterectomies, improving recovery times for recipients at the end of their UTx journey; (5) refining immunosuppression protocols to enable embryo transfer as early as 3 months after induction therapy, increasing recipients' chances for achieving up to two live births during the 5 years posttransplant the UTx protocol specifies; and (6) building on our clinical trial experience to now offer UTx in the U.S. outside the setting of a clinical study., Key Messages: Our center along with others throughout the world has demonstrated that UTx can be reproducible, result in live births from both living and deceased donors, and be safely introduced as a clinical option. Due to the complexity of UTx as well as the need for long-term multidisciplinary care, centers implementing UTx should have an established abdominal transplant program, a gynecologic surgery program, high-risk obstetric and neonatal care, and institutional support and oversight, and should partner with established UTx programs for protocol development and operative proctoring., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Background: Ethical frameworks for organ donation following circulatory death (DCD) were established >20 years ago. However, considerable variation exists among these, indicating consensus has not been reached on all issues. Additionally, advances such as cardiac DCD transplants and normothermic regional perfusion (NRP) may have reignited old debates. Methods: We reviewed the English-language literature addressing ethical issues in DCD from 1993 to 2022, examining changes in frequency with which ethical principles and their sub-themes identified within each, were addressed. Results: Non-maleficence was the most frequently addressed principle (192 of 199 articles), as well as the most varied, with 9 subthemes (versus 2-4 within each of the other bioethical principles). Conclusions: There were several changes in the terminology used to refer to DCD over time, and substantial interest in cardiac DCD and NRP in recent publications, arising in 11 and 19 of the 30 publications from 2018 to 2022.

As the COVID-19 pandemic continues, interest in mental health impacts is shifting from short-term to long-term outcomes. As part of a longitudinal online survey study examining mental health impacts of the pandemic, we assessed the risk of attrition bias related to a history of depression-a condition research shows can increase challenges of recruitment and retention. Among 5023 participants who completed the baseline survey, significantly more reporting a history of depression were lost to follow-up: baseline to 3 months: 497/760 (65.4%) vs 2228/4263 (52.3%), P  < 0.001; 3 to 6 months: 179/263 (68.1%) vs 1183/2035 (58.1%), P  = 0.002. Participants reporting a history of depression also had greater adjusted odds of a Patient Health Questionnaire-8 score ≥10 (odds ratio [OR] = 3.97, 95% confidence interval [CI] 3.27, 4.84), Generalized Anxiety Disorder-7 score ≥10 (OR = 3.77, 95% CI 3.07, 4.62), and Posttraumatic Diagnostic Scale for DSM V score ≥ 28 (OR = 7.17, 95% CI 4.67, 11.00) at baseline, indicating a need to account for attrition bias when examining these outcomes. Similar considerations likely apply to other longitudinal survey studies and are important to address to ensure accurate evidence is available to support policy decisions regarding resource allocation and funding., Competing Interests: This work was supported by the Baylor Scott & White Dallas Foundation and the W. W. Caruth, Jr. Fund at Communities Foundation of Texas. The authors report no conflicts of interest. Deidentified data are available upon reasonable request to the corresponding author., (Copyright © 2022 Baylor University Medical Center.)

The volume of abdominal organ offers received by the Baylor Simmons Transplant Institute has increased over time, resulting in a higher workload for our donor call team. To quantify the increase in organ offers, determine the characteristics of these offers, and estimate the impact on our transplant center workload, we collected center-specific organ offer data from May 2019 to July 2021 using the UNOS Center Acceptance and Refusal Evaluation Report and performed a time study that collected the number of communications and time spent on communications for organ offers made during a typical week. The total offers per month increased by 140% (270/month to 648/month), while the number of transplanted organs remained stable. In addition, the percentage of offers for organs that were never transplanted increased from 54% to 75%. In a representative week-long time study, surgeons made 505, center coordinators 590, and answering service coordinators 318 distinct communications, averaging 3, 4, and 2 communications/hour. Between November 2019 and July 2021, offer-related workload increased by an estimated 97%. These results demonstrate a sizeable inefficiency in abdominal organ allocation associated with a nonrecoverable cost to our transplant center., (© 2022 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background: Little research is available regarding vaccination attitudes among those recently diagnosed with COVID-19. This is important to investigate, particularly among those experiencing mild-to-moderate illness, given the ongoing need to improve uptake of both initial vaccine series and booster doses, and the divergent ways such an experience could impact attitudes., Methods: From September 3 - November 12, 2021, all patients enrolled in Baylor Scott & White's "COVID-19 Digital Care Journey for Home Monitoring" were invited to participate in an online survey that included questions about vaccination status and attitudes/opinions regarding COVID-19 and the COVID-19 vaccines. Following an item asking about accordance of COVID-19 vaccination with religious/personal beliefs, participants were asked to describe those beliefs and how they relate to taking/not taking the vaccine., Results: Of 8,075 patients age ≥ 18 years diagnosed with COVID-19 and invited to join the survey during the study period, 3242 (40.2%) were fully vaccinated. In contrast, among the 149 who completed the questionnaire, 95(63.8%) reported full vaccination. Responses differed significantly between vaccination groups. The vaccinated group strongly agreed that COVID-19 is a major public health problem, the vaccines are safe and effective, and their decision to vaccinate included considering community benefit. The unvaccinated group responded neutrally to most questions addressing safety and public health aspects of the vaccine, while strongly disagreeing with statements regarding vaccine effectiveness and other preventative public health measures. The vaccinated group strongly agreed that taking the vaccine accorded with their religious/personal beliefs, while the unvaccinated group was neutral. In qualitative analysis of the free text responses "risk perception/calculation" and "no impact" of religious/personal beliefs on vaccination decisions were frequent themes/subthemes in both groups, but beliefs related to the "greater good" were a strong driver among the vaccinated, while statements emphasizing "individual choice" were a third frequent theme for the unvaccinated., Conclusion: Our results show that two of the three factors that drive vaccine hesitancy (complacency, and lack of confidence in the vaccines) are present among unvaccinated adults recently diagnosed with COVID-19. They also show that beliefs emphasizing the importance of the greater good promote public health participation., (© 2022. The Author(s).)

Background: Mental health impacts of the COVID-19 pandemic are well recognized, but little is known about the pandemic experience among people experiencing mental health symptoms., Methods: In June 2020, a national sample of 5023 U.S. adults, including 785 scoring ⩾10 on the PHQ-8 for symptoms of depression, completed survey measures related to their pandemic experience., Results: After adjusting for sociodemographic characteristics, aspects of the COVID-19 pandemic experience for which participants scoring PHQ-8 ⩾ 10 had the greatest increase in odds of reporting moderate/severe negative impacts included: mental health treatment access (odds ratio [OR], 95% confidence interval [CI] = 8.81, 6.70-11.57), family stress/discord (OR, 95% CI = 5.21, 4.24-6.42), food access (OR, 95% CI = 3.76, 2.97-4.77), and income/employment (OR, 95% CI = 3.19, 2.66-3.83). They were also significantly more likely to report increased use of prescription painkillers (OR, 95% CI = 8.46, 4.50-15.92) and other drugs (OR, 95% CI = 4.43, 2.85-6.89), and less trust in healthcare authorities/providers, family/friends, and employers, and more trust in websites/blogs/social media, for COVID-19 information ( P -values < .05)., Conclusions: The interplay among depressive symptoms, substance use, lack of trust in healthcare authorities, and negative impact of the pandemic on family, finances, and access to mental health treatment and food indicate the need for robust social and behavioral health safety nets to buffer communities from the shadow epidemics of depression, family violence, and overdose deaths during public health disasters., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Background: Substantial evidence is emerging regarding the broad societal and psychological impacts of the COVID-19 pandemic, but little is known about whether infected individuals are differently affected., Aim: We evaluated psychological differences between individuals who do vs. do not report testing positive for COVID-19., Methods: An online survey was offered to adults (≥18 years) who were diagnosed with COVID-19 by a provider within a large integrated-delivery healthcare system, enrolled in COVID-19-related clinical trials at the healthcare system, or responded to targeted local distribution. Measures assessed included the 8-item Patient Health Questionnaire depression scale, Generalized Anxiety Disorder 7-item Scale, and Posttraumatic Diagnostic Scale for DSM-5., Results: Of 487 respondents, 43% reported testing positive for COVID-19, including 11% requiring hospitalization. Overall rates of general anxiety disorder and posttraumatic stress were 34% and 16%, respectively, with no significant differences between groups. Prevalence of depression was higher among respondents reporting a positive COVID-19 test (52% vs. 31%). This difference persisted after controlling for respondent characteristics (odds ratio = 3.7, p  < 0.01)., Conclusions: People who report testing positive for COVID-19, even those not requiring hospitalization, have increased risk for depression. Mental health care screening and services should be offered to individuals testing positive, facilitating early intervention.

The COVID-19 pandemic has caused disproportionate suffering among vulnerable and socioeconomically disadvantaged portions of the population. Low-income and minority populations are likely to experience disparate disease and mental health burdens. Currently, there is little evidence regarding how the experience of the early months of the US COVID-19 outbreak differed by income level, and how that related to mental health symptoms. The present study used data from a national sample of US adults (n = 5023) who completed measures related to the COVID experience, the COVID-19 Fear Scale, the Generalized Anxiety Disorder-7 (GAD-7), and the Patient Health Questionnaire-8 (PHQ-8). Multivariable regression was performed to determine whether income level (low: <$45,000 vs high: ≥$75,000) was significantly associated with COVID experience measures, PHQ-8, GAD-7, and COVID fear scores. Among the low-income group, COVID-19 had a significantly greater negative impact on: family income/employment, access to food, access to mental health treatment, and stress and discord in the family. Participants in the low-income group also had greater odds of a PHQ-8 score ≥10 (odds ratio [OR] = 1.38, 95% confidence interval [CI] 1.08, 1.77) and a GAD-7 score ≥10 (OR = 1.65, 95% CI 1.27, 2.14) compared to those in the high-income group. Study findings suggest substantial differences in how COVID-19 impacted daily life and mental health between adults living in low-income households compared to high-earning households during the early months of the pandemic.

Objectives: Studies investigating the association between vitamin D and severity of COVID-19 have mixed results perhaps due to immunoassay assessment of total 25-hydroxyvitamin D (tD) (the sum of 25-hydroxyvitamin-D2 [25-OH-D2] and 25-hydroxyvitamin-D3 [25-OH-D3]). Liquid chromatography tandem mass spectrometry (LC-MS/MS) has high analytical specificity and sensitivity for 25-OH-D2 and 25-OH-D3, and thus enables a more accurate assessment of impact on COVID-19 outcomes., Methods: We established reference intervals for 25-OH-D3 and tD using LC-MS/MS. 25-OH-D2, 25-OH-D3 and tD were quantitated for 88 COVID-19 positive and 122 COVID-19 negative specimens. Chi-square or Fisher's exact tests were used to test associations in binary variables. T-Tests or Wilcoxon rank sum tests were used for continuous variables. Cox proportional hazards were used to test associations between 25-OH-D3 or tD levels and length of stay (LOS). For mortality and ventilation, logistic regression models were used., Results: COVID-19 patients with deficient (<20 ng/mL) levels of 25-OH-D3 had significantly longer LOS by 15.3 days. COVID-19 P patients with deficient (<20 ng/mL) and insufficient (<30 ng/mL) of tD had significantly longer LOS by 12.1 and 8.2 days, respectively. Patients with insufficient levels of tD had significantly longer LOS by 13.7 days. COVID-19 patients with deficient serum 25-OH-D3 levels had significantly increased risk-adjusted odds of in-hospital mortality (OR [95% CI]: 5.29 [1.53-18.24]); those with insufficient 25-OH-D3 had significantly increased risk for requiring ventilation during hospitalization was found at LCMS insufficient cutoff (OR [95% CI]: 2.75 [1.10-6.90])., Conclusions: There is an inverse relationship of 25-hydroxyvitamin D levels and hospital LOS for COVID-19 patients. Vitamin D status is a predictor for severity of outcomes. LCMS results are useful for assessing the odds of mortality and the need for ventilation during hospitalization., Competing Interests: The authors have declared that no competing interests exist.

Objective: Our objectives were two-fold: 1) To evaluate the benefits of population health strategies focused on social determinants of health and integrated into the primary care medical home (PCMH) and 2) to determine how these strategies impact diabetes and cardiovascular disease outcomes among a low-income, primarily minority community. We also investigated associations between these outcomes and emergency department (ED) and inpatient (IP) use and costs., Design: Retrospective cohort., Setting: Community-based PCMH: Baylor Scott & White Health and Wellness Center (BSW HWC)., Patients/participants: All patients who attended at least two primary care visits at BSW HWC within a 12-month time span from 2011-2015., Methods: Outcomes for patients participating in PCMH only (PCMH) as compared to PCMH plus population health services (PCMH+PoPH) were compared using electronic health record data., Main Outcomes: Diastolic and systolic blood pressure, hemoglobin A1c, ED visits and costs, and IP hospitalizations and costs were examined., Results: From 2011-2015, 445 patients (age=46±12 years, 63% African American, 61% female, 69.5% uninsured) were included. Adjusted regression analyses indicated PCMH+PoPH had greater improvement in diabetes outcomes (prediabetes HbA1c= -.65[SE=.32], P=.04; diabetes HbA1c= -.74 [SE=.37], P<.05) and 37% lower ED costs than the PCMH group (P=.01). Worsening chronic disease risk factors was associated with 39% higher expected ED visits (P<.01), whereas improved chronic disease risk was associated with 32% fewer ED visits (P=.04)., Conclusions: Integrating population health services into the PCMH can improve chronic disease outcomes, and impact hospital utilization and cost in un- or under-insured populations., Competing Interests: Competing Interests: Wesson: Paid consultant for Tricida, Inc (San Francisco) regarding metabolic acidosis (not related to this study), (Copyright © 2022, Ethnicity & Disease, Inc.)

Objective: Extracorporeal membrane oxygenation (ECMO) use in adult patient populations has grown rapidly with wide variation in practices and outcomes. We evaluated the impact on patient outcomes, resource use, and costs of an initiative to coordinate and standardize best practices across ECMO programs within a large integrated health care system., Methods: The ECMO Collaborative Project brought clinicians and service-line leaders from 4 programs within a single health care system together with operational subject matter experts tasked with developing and implementing standardized guidelines, order sets, and an internal database to support an automated quarterly report card. Patient outcomes, resource use, and financial measures were compared for the 16 months before (January 2017 to April 2018; "precollaborative," n = 185) versus the 14 months after (November 2018 to December 2019, "postcollaborative," n = 243) a 6-month implementation and blanking period. Subset analyses were performed for venoarterial ECMO, venovenous ECMO, and extracorporeal cardiopulmonary resuscitation., Results: Survival to discharge/transfer increased significantly (in-hospital mortality hazard ratio, 0.75; 95% confidence interval [95% CI], 0.58-0.99) for the postcollaborative versus the precollaborative period (107/185, 57.8% vs 113/243, 46.5%, P = .03), predominantly due to improvement among patients receiving venoarterial ECMO (hazard ratio, 0.61; 95% CI, 0.41-0.91). The percentage of patients successfully weaned from ECMO increased from 58.9% (109/185) to 70% (170/243), P = .02. Complication rates decreased by 40% (incidence rate ratio, 0.60; 95% CI, 0.49-0.72). No significant changes were observed in ECMO duration, intensive care unit or hospital length of stay, or cost-per-case; payment-per-case and contribution-margin-per-case both decreased significantly., Conclusions: The ECMO Collaborative Project improved survival to discharge/transfer, weaning rates and complications, without additional costs, through coordination and standardization across ECMO programs within a health care system., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Uterus transplantation (UTx) offers women with absolute uterine factor infertility a path to motherhood that enables them to carry their own pregnancy. Debates about the ethics of UTx have evolved in tandem with its clinical evolution: clinical trials have provided evidence regarding risks and benefits to donors and recipients that were initially uncertain; technical advances have altered the balance between risks and benefits; and the experiences of donors and recipients has revealed questions that were not anticipated. As UTx transitions to a clinical procedure, questions remain about long-term risks and benefits, applications beyond carrying a pregnancy, and cost and access., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Acute kidney injury (AKI) and chronic kidney disease (CKD) are important drivers of morbidity and mortality in patients with cirrhosis before and after liver transplantation (LT). In this review, we examine the role of novel kidney biomarkers for early recognition of kidney injury. Studies are limited by lack of reference standards, heterogeneous definitions of outcomes and biomarker cutoffs, and inconsistent diagnostic performance. Overall, a change in biomarker is more relevant than an absolute cutoff. Cystatin C and urinary neutrophil gelatinase-associated lipocalin (uNGAL) are the most studied candidate biomarkers and identify AKI or progression of AKI earlier than serum creatinine (sCr). Kidney injury molecule 1 and liver-type fatty acid-binding protein (L-FABP) also show potential. NGAL and interleukin 18 may play a role in differentiating acute tubular necrosis from other forms of AKI. Combining novel biomarkers with the Model for End-Stage Liver Disease score may assist prognosis. Persistent elevations in select markers (eg, NGAL) can portend irreversible injury. Several pretransplantation markers (including sCr) predict posttransplantation kidney dysfunction. Pretransplantation assessment of clinical factors (eg, age, diabetes) and novel markers (osteopontin and tissue inhibitor of metalloproteinases 1 [TIMP-1]) may predict renal kidney recovery after LT. Intraoperative changes in biomarkers predict early post-LT AKI. Prediction of CKD remains difficult, although a combination of biomarkers (eg, beta-2 microglobulin, CD40) is promising. Novel biomarkers have yet to replace sCr in guideline-based evaluation and management of kidney dysfunction in patients with cirrhosis. We propose a theoretical framework for practical incorporation of these biomarkers that considers patient characteristics (risk for irreversible injury), markers of functional and structural change, and assessment of the AKI-CKD continuum to identify patients at the highest risk for progressive kidney disease before and after LT., (© 2021 by the American Association for the Study of Liver Diseases.)

Minimally invasive procurement of uterine grafts for transplantation can decrease living donor recovery time. We examined recipient outcomes for grafts procured by robotic-assisted donor hysterectomies with transvaginal extraction in the Dallas UtErus Transplant Study (DUETS). All 5 grafts were successfully transplanted. Recipients had a median 4.5-hour surgical time, 0.25 L estimated blood loss, and 4-day hospital stay. Four recipients had grade III surgical complications and three had acute cellular rejection. At 18 months, graft viability was 100%, with an 80% live birth rate. This report demonstrates the feasibility and reproducible success of using uterus grafts from living donors who underwent robotic-assisted donor hysterectomy., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Restrictive sternal precautions intended to prevent cardiac surgery patients from damaging healing sternotomies lack supporting evidence and may decrease independence and increase postacute care utilization. Data regarding the impact of alternative approaches on safety and outcomes are needed to guide evidence-based best practices., Objective: To examine whether an approach allowing greater freedom during activities of daily living than permitted under commonly used restrictive sternal precautions can safely decrease postacute care utilization., Design: Before-and-after study, using propensity score adjustment to account for differences in patient clinical and demographic characteristics, surgery type, and surgeon., Setting: 600-bed acute care hospital., Intervention: Beginning March 2016, the acute care hospital replaced traditional weight- and time-based precautions given to patients who underwent median sternotomy with the "Keep Your Move in the Tube" (KMIT) approach for mindfully performing movements involved in the activities of daily living, guided by pain., Main Outcome Measures: The study compared sternal wound complications, discharge disposition, 30-day readmission, and functional status between consecutive cardiac surgery patients with "independent" or "modified independent" preoperative functional status who underwent median sternotomy in the 1.5 years before (n = 627, standard precautions group) and after (n = 477, KMIT group) KMIT implementation., Results: The odds of discharge to home, versus to inpatient rehabilitation or skilled nursing facility, were ~3 times higher for KMIT than standard precautions patients (risk-adjusted odds ratio [rOR], 95% confidence interval [CI] = 2.90, 1.95-4.32, and 3.03, 1.57-5.86, respectively). KMIT patients also had significantly higher odds of demonstrating "independent" or "modified independent" functional status on final inpatient physical therapy treatment for bed mobility (rOR, 95% CI = 7.51, 5.48-10.30) and transfers (rOR, 95% CI = 3.40, 2.62-4.42). No significant difference was observed in sternal wound complications (in-hospital or causing readmission) (rOR, 95% CI = 1.27, 0.52-3.09) or all-cause 30-day readmissions (rOR, 95% CI = 0.55, 0.23-1.33)., Conclusions: KMIT increases discharge-to-home for cardiac surgery patients without increasing risk for adverse events and reducing utilization of expensive institutional postacute care., (© 2021 American Academy of Physical Medicine and Rehabilitation.)

Purpose of Review: Uterus transplantation (Utx) offers women with absolute uterine factor infertility the opportunity to carry their own pregnancies. As Utx transitions from an experimental to standard clinical procedure, we review the status of the ethical issues applicable to the stakeholders involved., Recent Findings: With more than 65 Utx procedures reported to date, evidence is accruing that enables the chance of success - a live birth - for the recipient to be weighed against the risks the recipient incurs through the Utx process, as well as risks to living donors undergoing surgery, to children exposed in utero to immunosuppressants and the uterine graft environment, and to third parties related to uterus procurement from multiorgan deceased donors. Experience has also informed aspects of recipient and donor autonomy that must be safeguarded., Summary: Clinical trial results provides a basis for weighing the interests of the stakeholders implicated in Utx, and so can inform transplant centers' and regulatory bodies' development of policies and protocols that will determine access to Utx and allocation of organs, together with other considerations of justice. Additional evidence, particularly on long-term outcomes, is needed, and new questions can be expected to arise as access to and indications for Utx broaden., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Opioid-induced respiratory depression (OIRD) and oversedation are rare but potentially devastating adverse events in hospitalised patients. We investigated which features predict an individual patient's risk of OIRD or oversedation; and developed a risk stratification tool that can be used to aid point-of-care clinical decision-making., Design: Retrospective observational study., Setting: Twelve acute care hospitals in a large not-for-profit integrated delivery system., Participants: All inpatients ≥18 years admitted between 1 July 2016 and 30 June 2018 who received an opioid during their stay (163 190 unique hospitalisations)., Main Outcome Measures: The primary outcome was occurrence of sedation or respiratory depression severe enough that emergent reversal with naloxone was required, as determined from medical record review; if naloxone reversal was unsuccessful or if there was no evidence of hypoxic encephalopathy or death due to oversedation, it was not considered an oversedation event., Results: Age, sex, body mass index, chronic obstructive pulmonary disease, concurrent sedating medication, renal insufficiency, liver insufficiency, opioid naïvety, sleep apnoea and surgery were significantly associated with risk of oversedation. The strongest predictor was concurrent administration of another sedating medication (adjusted HR, 95% CI=3.88, 2.48 to 6.06); the most common such medications were benzodiazepines (29%), antidepressants (22%) and gamma-aminobutyric acid analogue (14.7%). The c-statistic for the final model was 0.755. The 24-point Oversedation Risk Criteria (ORC) score developed from the model stratifies patients as high (>20%, ≥21 points), moderate (11%-20%, 10-20 points) and low risk (≤10%, <10 points)., Conclusions: The ORC risk score identifies patients at high risk for OIRD or oversedation from routinely collected data, enabling targeted monitoring for early detection and intervention. It can also be applied to preventive strategies-for example, clinical decision support offered when concurrent prescriptions for opioids and other sedating medications are entered that shows how the chosen combination impacts the patient's risk., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Acuity circles (AC) liver allocation policy was implemented to eliminate donor service area geographic boundaries from liver allocation and to decrease variability in median Model of End-stage Liver Disease (MELD) score at transplant and wait list mortality. However, the broader sharing of organs was also associated with more flights for organ procurements and higher costs associated with the increase in flights., Objective: To determine whether the costs associated with liver acquisition changed after the implementation of AC allocation., Design, Setting, and Participants: This single-center cost comparison study analyzed fees associated with organ acquisition before and after AC allocation implementation. The cost data were collected from a single transplant institute with 2 liver transplant centers, located 30 miles apart, in different donation service areas. Cost, recipient, and transportation data for all cases that included fees associated with liver acquisition from July 1, 2019, to October 31, 2020, were collected., Exposures: Primary liver offer acceptance with associated organ procurement organization or charter flight fees., Main Outcomes and Measures: Specific fees (organ acquisition, surgeon, import, and charter flight fees) and total fees per donor were collected for all accepted liver donors with at least 1 associated fee during the study period., Results: Of 213 included donors, 171 were used for transplant; 90 of 171 (52.6%) were male, and the median (interquartile range) age of donors was 41.0 (30.0-52.8) years in the pre-AC period and 36.9 (24.0-48.8) years in the post-AC period. There was no significant difference in the post-AC compared with pre-AC period in median (range) MELD score (24 [8-40] vs 25 [6-40]; P = .27) or median (range) match run sequence (15 [1-3951] vs 10 [1-1138]; P = .31), nor in mean (SD) distance traveled (155.83 [157.00] vs 140.54 [144.33] nautical miles; P = .32) or percentage of donors requiring flights (58.5% [69 of 118] vs 56.8% [54 of 95]; P = .82). However, costs increased significantly in the post-AC period: total cost increased 16% per accepted donor (mean [SD] of $52 966 [13 278] vs $45 725 [9300]; P < .001) and 55% per declined donor (mean [SD] of $15 865 [3942] vs $10 217 [4853]; P < .001). Contributing factors included more than 2-fold increases in the proportions of donors incurring import fees (31.4% [37 of 118] vs 12.6% [12 of 95]; P = .002) and surgeon fees (19.5% [23 of 118] vs 9.5% [9 of 95]; P = .05), increased acquisition fees (10% increase; mean [SD] of $43 860 [3266] vs $39 980 [2236]; P < .001), and increased flight expenses (43% increase; mean [SD] of $12 904 [6066] vs $9049 [5140]; P = .002)., Conclusions and Relevance: The unintended consequences of implementing broader sharing without addressing organ acquisition fees to account for increased importation between organ procurement organizations must be remedied to contain costs and ensure viability of transplant programs.

Objective: To investigate the impact of limiting the definition of post-coronary artery bypass graft (CABG) atrial fibrillation (AF) to AF/flutter requiring treatment-as in the Society of Thoracic Surgeons' (STS) database- on the association with survival., Patients and Methods: We assessed in-hospital incidence of post-CABG AF in 7110 consecutive isolated patients with CABG without preoperative AF at 4 hospitals (January 1, 2004 to December 31, 2010). Patients with ≥1 episode of post-CABG AF detected via continuous in-hospital electrocardiogram (ECG)/telemetry monitoring documented by physicians were assigned to the following: Group 1, identified as having post-CABG AF in STS data and Group 2, not identified as having post-CABG AF in STS data. Patients without documented post-CABG AF constituted Group 3. Survival was compared via a Cox model, adjusted for STS risk of mortality and accounting for site differences., Results: Over 7 years' follow-up, 16.0% (295 of 1841) of Group 1, 18.7% (79 of 422) of Group 2, and 7.9% (382 of 4847) of Group 3 died. Group 2 had a significantly greater adjusted risk of death than both Group 1 (hazard ratio [HR]: 1.16; 95% confidence interval [CI], 1.02 to 1.33) and Group 3 (HR: 1.94; 95% CI, 1.69 to 2.22)., Conclusions: The statistically significant 16% higher risk of death for patients with AF post-CABG missed vs captured in STS data suggests treatment and postdischarge management should be investigated for differences. The historical misclassification of "missed" patients as experiencing no AF in the STS data weakens the ability to observe differences in risk between patients with and without post-CABG AF. Therefore, STS data should not be used for research examining post-CABG AF., (© 2020 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc.)

Background: New-onset atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG) is associated with poor outcomes, but data on the effects of its characteristics are lacking and conflicting. We examined the effect number of post-CABG AF events has on long-term mortality risk, and whether this is sex dependent., Methods: Routinely collected Society of Thoracic Surgeons (STS) data were supplemented with details on new-onset post-CABG AF (detected in-hospital by continuous electrocardiogram/telemetry monitoring) and long-term survival for 9203 consecutive patients with isolated-CABG (2002-2010). With the use of Cox regression, we determined the propensity-adjusted (STS-recognized risk factors) effect of number of AF events on survival, testing for effect modification by sex and controlling for AF duration., Results: AF occurred in 739 women (29.4%) and 2157 men (32.3%) (P < .001). Adjusted results showed 2 or more AF events significantly (P < .001) increased 5-year mortality risk, independently of total AF duration. However, mortality risk differed between the sexes (P < .001): women with 2 AF episodes had the greatest increase (hazard ratio [HR] = 2.98; 95% confidence interval [CI], 1.43-4.83; versus women without AF), followed by women and men with 4 or more AF events (HR = 2.76 [95% CI, 1.27-4.55] and HR = 2.73 [95% CI, 2.30-3.19], respectively). A single post-CABG AF episode was not associated with increased mortality risk., Conclusions: Both men and women who experienced 2 or more post-CABG AF episodes showed increased risk of 5-year mortality, independent of total AF duration. Although men's risk increased as the number of AF events increased, women's risk peaked at 2 AF events. Future research needs to determine whether this divergence stems from differences in treatment/management or underlying biology., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We sought to fill important gaps in the existing evidence regarding new-onset atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG) by comparing the incidence, characteristics, and effect on long-term survival between men and women., Methods: Nine thousand two hundred three consecutive patients without preoperative AF underwent isolated CABG from 2002 to 2010 at 3 US academic medical centers and 1 high-volume specialty cardiac hospital. Detailed data on CABG AF events detected via continuous in-hospital electrocardiogram/telemetry monitoring were supplemented with Society of Thoracic Surgeons data, and survival data, censored at October 31, 2011, using a copy of the Social Security Death Master File archived before state-owned data were removed (November 1, 2011)., Results: Propensity-adjusted (Society of Thoracic Surgeons-recognized risk factors) incidence of post-CABG AF was 31.5% overall, 32.8% in men, and 27.4% in women. Over the 9-year study period, women had a significantly lower risk of post-CABG AF (absolute difference, -5.3% [95% confidence interval (CI), -10.5% to -0.6%]), and significantly shorter first (-2.9 hours; 95% CI, -5.8 to 0.0), and longest (-4.3 hours; 95% CI, -8.3 to -0.3) AF duration. Post-CABG AF was associated with significantly increased risk of long-term mortality (overall hazard ratio [HR], 1.56; 95% CI, 1.45-1.67; men HR, 1.57; 95% CI, 1.49-1.65; women HR, 1.54; 95% CI, 1.14-2.07)., Conclusions: In our study, women had lower adjusted risk of post-CABG AF and experienced shorter episodes. The adjusted risk of long-term mortality was 56% greater among patients who developed post-CABG AF compared with those who did not. The effect of post-CABG AF on long-term survival did not differ between the sexes., (Copyright © 2019. Published by Elsevier Inc.)

Background: Two quality measures used in public reporting and value-based payment programs require β-blockers be administered less than 24 hours before isolated coronary artery bypass graft surgery to prevent atrial fibrillation and mortality. Questions have arisen about continued use of these measures., Methods: We conducted a systematic search for randomized controlled trials (RCTs) examining the impact of preoperative β-blockers on atrial fibrillation or mortality after isolated coronary artery bypass graft surgery to determine what evidence of efficacy supports the measures., Results: We identified 11 RCTs. All continued β-blockers postoperatively, making it unfeasible to separate the benefits of preoperative vs postoperative administration. Meta-analysis was precluded by methodologic variation in β-blocker utilized, timing and dosage, and supplemental and comparison treatments. Of the eight comparisons of β-blockers/β-blocker plus digoxin versus placebo (n = 826 patients), six showed significant reductions in atrial fibrillation/supraventricular arrhythmias. Of the three comparisons (n = 444) of β-blockers versus amiodarone, two found no significant difference in atrial fibrillation; the third showed significantly lower incidence with amiodarone. One RCT compared β-blocker plus amiodarone versus each of those drugs separately; the combination reduced atrial fibrillation significantly better than the β-blocker alone, but not amiodarone alone. Seven RCTs reported short-term mortality, but this outcome was too rare and the sample sizes too small to provide any meaningful comparisons., Conclusions: Existing RCT evidence does not support the structure of quality measures that require β-blocker administration specifically within 24 hours before coronary artery bypass graft surgery to prevent postoperative atrial fibrillation or short-term mortality. Quality measures should be revised to align with the evidence, and further studies conducted to determine optimal timing and method of prophylaxis., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To compare diagnostic accuracy between primary care E-Visit and face-to-face (F2F) encounters for low-acuity illnesses., Patients and Methods: This cross-sectional retrospective analysis of electronic health records in a large not-for-profit integrated delivery system included patients covered by the health care system's employee health plan with an established affiliated physician-patient relationship and an F2F encounter in the past 12 months who had an E-Visit (n=490) or an F2F (n=2201) primary care encounter for a low-acuity illness from July 1, 2015, through December 22, 2016. Patients with a related follow-up visit within 10 days resulting in a revised diagnosis, as determined by 2 physician reviewers, were compared (1) including only the first encounter for each patient and (2) including all encounters more than 10 days apart for included patients., Results: In both analyses, a follow-up visit occurred within 10 days more than 40% of the time in both groups. However, follow-up visits related to the initial diagnosis occurred only 9% to 12% of the time. Only 2.1% to 2.4% of initial diagnoses were identified by both physician reviewers as revised, whereas 3.8% to 5.5% were so identified by at least 1 reviewer. The only significant difference observed between the E-Visit and F2F groups was in the rate of related follow-up visits when only each patient's first encounter was considered, which was higher for E-Visits (12% vs 9%; P=.04)., Conclusion: Diagnostic accuracy for low-acuity illnesses in this population was equivalent between E-Visit and F2F encounters., (Copyright © 2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: Studies with authors trained in research methods are of higher quality than those without. We examined inclusion of authors with master's or doctoral degrees incorporating advanced research methods training on original research articles in high-impact journals, investigating differences between journals and by first-author sex., Methods: Using all original research articles from 1 issue of The New England Journal of Medicine ( NEJM ), Journal of the American Medical Association ( JAMA ), Annals of Internal Medicine ( Annals ), and JAMA-Internal Medicine/Archives of Internal Medicine ( Archives ) every alternate month, February 1994 to October 2016, we assessed the prevalence of articles listing authors with master's/doctoral research degrees and its adjusted associations with time of publication, journal, and first-author sex via multivariable logistic regression models (accounting for number of authors, study type, specialty/topic, and continent and for interactions between journal and time of publication, study type, and continent)., Results: Of 3009 articles examined, 84.4% (n=2539) had authors listing research degrees. After adjustment, the prevalence of such articles increased from 1994 to 2016 ( P <.001), but patterns differed among journals. Annals and NEJM increased to approximately100% by 2016; JAMA and Archives peaked around 2010 to 2011, then declined. Articles with female first authors were more likely to list authors with research degrees (adjusted odds ratio=1.66; 95% CI, 1.29-2.13; P <.001)., Conclusion: The prevalence of original research articles listing authors trained in research methods in high-impact journals increased significantly but is now declining at some journals, with potential effects on quality. The greater prevalence among female first-authored articles suggests possible sex differences in structuring/crediting research teams or subconscious sex bias during review.

Objectives: Postoperative atrial fibrillation (AF) following coronary artery bypass graft surgery (CABG) is significantly associated with reduced survival, but poor characterisation and inconsistent definitions present barriers to developing effective prophylaxis and management. We sought to address this knowledge gap., Methods: From 2002 to 2010, 11 239 consecutive patients without AF underwent isolated CABG at five sites. Clinical data collected for the Society of Thoracic Surgeons (STS) Database were augmented with details on AF detected via continuous in-hospital ECG/telemetry monitoring to assess new-onset post-CABG AF (adjusted for STS risk of mortality); time to first AF; durations of first and longest AF episodes; total in-hospital time in AF; number of in-hospital AF episodes; operative mortality; stroke; discharge in AF; and length of stay (LOS)., Results: Unadjusted incidence of new-onset post-CABG AF was 29.5%. Risk-adjusted incidence was 33.1% and varied little over time (P=0.139). Among 3312 patients with post-CABG AF, adjusted median time to first AF was 52 (IQR: 48-55) hours; mean (SD) duration of first and longest events were 7.2 (5.3,9.1) and 13.1 (10.4,15.9) hours, respectively, and adjusted median total time in AF was 22 (IQR: 18-26) hours. Adjusted rates of operative mortality, stroke and discharge in AF did not vary significantly over time (P=0.156, P=0.965 and P=0.347, respectively). LOS varied (P=0.035), but in no discernible pattern., Conclusions: Each year, ~800 000 people undergo CABG worldwide; >264 000 will develop post-CABG AF. Onset is typically 2-3 days post-CABG and episodes last, on average, several hours. Effective prophylaxis and management is urgently needed to reduce associated risks of adverse outcomes., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Primary care practices become patient-centered medical homes (PCMHs) to improve care. However, investment costs and opportunities to offset those costs are critical to the decision. We examined potential offsets through commercial payer per-member-per-month (PMPM) payments and the Medicare Merit-based Incentive Payment System (MIPS) for a network that spent $4 818 260 over 4 years obtaining and renewing PCMH recognition for 57 practices. With PMPM payments of $3.37 to $8.98, "breakeven" requires that 2.4% to 6.4% of the network's 1645 commercially insured patients per physician be covered, while applying MIPS incentive payments of half the maximum available each year to the network's average 2016 Medicare reimbursement of $196 812 per physician showed they would exceed PCMH costs by 2022.

Background: Despite many studies comparing on- versus off-pump coronary artery bypass graft (CABG), there is no consensus as to whether one of these techniques offers patients better outcomes., Methods: We searched PubMed from inception to June 30, 2015, and identified additional studies from bibliographies of meta-analyses and reviews. We identified 42 randomized controlled trials (RCTs) and 31 rigorously adjusted observational studies (controlling for the Society of Thoracic Surgeons-recognized risk factors for mortality) reporting mortality for off-pump versus on-pump CABG at specified time points. Trial data were extracted independently by 2 researchers using a standardized form. Differences in probability of mortality (DPM) were estimated for the RCTs and observational studies separately and combined, for time points ranging from 30 days to 10 years., Results: RCT-only data showed no significant differences at any time point, whereas observational-only data and the combined analysis showed short-term mortality favored off-pump CABG (n = 1.2 million patients; 36 RCTs, 26 observational studies; DPM [95% confidence interval (CI)], -44.8% [-45.4%, -43.8%]) but that at 5 years it was associated with significantly greater mortality (n = 60,405 patients; 3 RCTs, 5 observational studies; DPM [95% CI], 10.0% [5.0%, 15.0%]). At 10 years, only observational data were available, and off-pump CABG showed significantly greater mortality (DPM [95% CI], 14.0% [11.0%, 17.0%])., Conclusions: Evidence from RCTs showed no differences between the techniques, whereas rigorously adjusted observational studies (with >1.1 million patients) and the combined analysis indicated that off-pump CABG offers lower short-term mortality but poorer long-term survival. These results suggest that, in real-world settings, greater operative safety with off-pump CABG comes at the expense of lasting survival gains., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: New-onset atrial fibrillation (AF) after coronary artery bypass graft (CABG) operation is associated with poorer survival. Blanket prophylaxis efforts have not appreciably decreased incidence, making targeted prevention for high-risk patients desirable. We compared predictive abilities of existing scores developed/used to predict adverse CABG outcomes (Society of Thoracic Surgeons' [STS] risk of mortality) or AF not associated with cardiac operation (the Cohorts for Heart and Aging Research in Genomic Epidemiology [CHARGE]-AF score, the CHA 2 DS 2 -VASc score), and a risk model for predicting postoperative AF following cardiac operations (POAF score), with age (the most consistently identified post-CABG AF risk factor)., Methods: Data submitted to the STS Adult Cardiac Surgery Database were used to assess new-onset AF in 8,976 consecutive patients without preoperative AF undergoing isolated CABG from 2004 to 2010 at five participating centers. Five logistic regression models (for CHA 2 DS 2 -VASc score, CHARGE-AF score, POAF score, STS risk score, and age, respectively, all modeled with restricted cubic splines) with a random effect for site were fitted to predict post-CABG AF. Estimates were used to compute and compare receiver operating characteristic (ROC) areas., Results: New-onset AF occurred in 2,141 patients (23.9%). The ROC area was greatest for CHARGE-AF (0.68, 95% confidence interval [CI]: 0.67-0.69), followed by age (0.66, 95% CI: 0.65-0.68), POAF score (0.65, 95% CI: 0.64-0.66), CHA 2 DS 2 -VASc (0.59, 95% CI: 0.58 to 0.60), and STS risk of mortality (0.58, 95% CI: 0.56-0.59). CHARGE-AF was significantly more predictive than age (p < 0.0001); the other scores were significantly less predictive (p < 0.0001)., Conclusions: Only CHARGE-AF performed better than age alone. Its performance was moderate and comparable with published risk models specifically targeted at new-onset post-isolated CABG AF. Future research should continue to focus on developing better predictive models., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Inconsistent definitions of atrial fibrillation after coronary artery bypass grafting have caused uncertainty about its incidence and risk. We examined the extent to which limiting the definition to post-coronary artery bypass grafting atrial fibrillation events requiring treatment underestimates its incidence and impact on 30-day mortality., Methods: We assessed in-hospital atrial fibrillation and 30-day mortality in 9268 consecutive patients without preoperative atrial fibrillation who underwent isolated coronary artery bypass grafting at 5 US hospitals (2004-2010). Patients who experienced 1 or more episode of post-coronary artery bypass grafting atrial fibrillation detected via continuous in-hospital electrocardiogram/telemetry monitoring were divided into those for whom Society of Thoracic Surgeons data (applying the definition "atrial fibrillation/flutter requiring treatment") also indicated atrial fibrillation versus those for whom it did not. Risk-adjusted 30-day mortality was compared between these 2 groups and with patients without post-coronary artery bypass grafting atrial fibrillation., Results: Risk-adjusted incidence of post-coronary artery bypass grafting atrial fibrillation incidence was 33.4% (27.0% recorded in Society of Thoracic Surgeons data, 6.4% missed). Patients with post-coronary artery bypass grafting atrial fibrillation missed by Society of Thoracic Surgeons data had a significantly greater risk of 30-day mortality (odds ratio, 2.08, 95% confidence interval, 1.17-3.69) than those captured. By applying the significant underestimation of post-coronary artery bypass grafting atrial fibrillation incidence we observed (odds ratio [Society of Thoracic Surgeons vs missed], 0.78; 95% confidence interval, 0.72-0.83) to the approximately 150,000 patients undergoing isolated coronary artery bypass grafting in the United States each year estimates this increased risk of mortality is carried by 9600 patients (95% confidence interval, 9420-9780) annually., Conclusions: Defining post-coronary artery bypass grafting atrial fibrillation as episodes requiring treatment significantly underestimates incidence and misses patients at a significantly increased risk for mortality. Further research is needed to determine whether this increased risk carries over into long-term outcomes and whether it is mediated by differences in treatment and management., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The patient-centered medical home (PCMH) shows promise for improving care and reducing costs. We sought to reduce the uncertainty regarding the time and cost of PCMH transformation by quantifying the direct costs of transforming 57 practices in a medical group to National Committee for Quality Assurance (NCQA)-recognized Level III PCMHs., Methods: We conducted structured interviews with corporate leaders, and with physicians, practice administrators, and office managers from a representative sample of practices regarding time spent on PCMH transformation and NCQA application, and related purchases. We then developed and sent a survey to all primary care practices (practice-level response rate: initial recognition-44.6%, renewal-35.7%). Direct costs were estimated as time spent multiplied by average hourly wage for the relevant job category, plus observed expenditures., Results: We estimated HealthTexas' corporate costs for initial NCQA recognition (2010-2012) at $1,508,503; for renewal (2014-2016), $346,617; the Care Coordination resource costs an additional ongoing $390,790/year. A hypothetical 5-physician HealthTexas practice spent another estimated 239.5 hours ($10,669) obtaining, and 110.5 hours ($4,957) renewing, recognition., Conclusion: Centralized PCMH support reduces the burden on practices; however, overall time and cost remains substantial, and should be weighed against the mixed evidence regarding PCMH's impact on quality and costs of care., Competing Interests: Conflict of interest: none declared., (© Copyright 2017 by the American Board of Family Medicine.)

Background: New-onset atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG) is associated with increased morbidity and poorer long-term survival. Although many studies show differences in outcome in women versus men after CABG, little is known about the sex-specific incidence and characteristics of post-CABG AF., Methods and Results: Overall, 11 236 consecutive patients without preoperative AF underwent isolated CABG from 2002 to 2010 at 4 US academic medical centers and 1 high-volume specialty cardiac hospital. Data routinely collected for the Society of Thoracic Surgeons database were augmented with details on new-onset post-CABG AF events detected via continuous in-hospital ECG/telemetry monitoring. Unadjusted incidence of post-CABG AF was 29.5% (3312/11 236) overall, 30.2% (2485/8214) in men, and 27.4% (827/3022) in women. After adjustment for Society of Thoracic Surgeons-recognized risk factors, women had significantly lower risk for post-CABG AF (odds ratio [95% confidence interval]=0.75 [0.64-0.89]), shorter first, longest, and total duration of AF episodes (mean difference [95% confidence interval]=-2.7 [-4.7 to -0.8] hours; -4.1 [-6.9 to -1.2] hours; -2.4 [-2.5 to -2.3] hours, respectively). At 48 hours, AF-free probabilities were 77% for women and 72% for men ( P <0.001). Number of episodes ( P =0.18), operative mortality ( P =0.048), stroke ( P =0.126), and discharge in AF ( P =0.234) did not differ significantly by sex., Conclusions: These novel data on sex-specific characteristics of new-onset AF after isolated CABG show that women had lower adjusted risk for post-CABG AF and experienced shorter episodes. Investigation of sex-specific impacts on outcomes is needed to identify optimal strategies for prevention and management to ensure all patients achieve the best possible outcomes., (© 2016 American Heart Association, Inc.)

Objective: Female sex is considered a risk factor for adverse outcomes following isolated coronary artery bypass graft (CABG) surgery. We assessed the association between sex and short-term mortality following isolated CABG, and estimated the 'excess' deaths occurring in women., Methods: Short-term mortality was investigated in 13 327 consecutive isolated CABG patients in North Texas between January 2008 and December 2012. The association between sex and CABG short-term mortality, and the excess deaths among women were assessed via a propensity-adjusted (by Society of Thoracic Surgeons-recognised risk factors) generalised estimating equations model approach., Results: Short-term mortality was significantly higher in women than men (adjusted OR=1.39; 95% CI 1.04 to 1.86; p=0.027). This significantly greater risk translates into 35 'excess' deaths among women included in this study (>10% of the total 343 deaths in the study cohort) and into 392 'excess' deaths among the ∼40 000 women undergoing isolated CABG in the USA each year., Conclusions: The higher risk associated with female sex lead to 35 'excess' deaths in women in this study cohort (over 10% of the total deaths) and to 392 'excess' deaths among women undergoing isolated CABG in the USA each year. Further research is needed to assess the causal mechanisms underlying this sex-related difference. Results of such work could inform the development and implementation of sex-specific treatment and management strategies to reduce women's mortality following CABG. Based on our results, if such work brought women's short-term mortality into line with men's, total short-term mortality could be reduced by up to 10%.

Objective: To examine changes in representation of women among first authors of original research published in high impact general medical journals from 1994 to 2014 and investigate differences between journals., Design: Observational study., Study Sample: All original research articles published in Annals of Internal Medicine, Archives of Internal Medicine, The BMJ, JAMA, The Lancet, and the New England Journal of Medicine (NEJM) for one issue every alternate month from February 1994 to June 2014., Main Exposures: Time and journal of publication., Main Outcome Measures: Prevalence of female first authorship and its adjusted association with time of publication and journal, assessed using a multivariable logistic regression model that accounted for number of authors, study type and specialty/topic, continent where the study was conducted, and the interactions between journal and time of publication, study type, and continent. Estimates from this model were used to calculate adjusted odds ratios against the mean across the six journals, with 95% confidence intervals and P values to describe the associations of interest., Results: The gender of the first author was determined for 3758 of the 3860 articles considered; 1273 (34%) were women. After adjustment, female first authorship increased significantly from 27% in 1994 to 37% in 2014 (P<0.001). The NEJM seemed to follow a different pattern, with female first authorship decreasing; it also seemed to decline in recent years in The BMJ but started substantially higher (approximately 40%), and The BMJ had the highest total proportion of female first authors. Compared with the mean across all six journals, first authors were significantly less likely to be female in the NEJM (adjusted odds ratio 0.68, 95% confidence interval 0.53 to 0.89) and significantly more likely to be female in The BMJ (1.30, 1.01 to 1.66) over the study period., Conclusions: The representation of women among first authors of original research in high impact general medical journals was significantly higher in 2014 than 20 years ago, but it has plateaued in recent years and has declined in some journals. These results, along with the significant differences seen between journals, suggest that underrepresentation of research by women in high impact journals is still an important concern. The underlying causes need to be investigated to help to identify practices and strategies to increase women's influence on and contributions to the evidence that will determine future healthcare policies and standards of clinical practice., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Studies examining outcomes after coronary artery bypass grafting (CABG) by gender and/or race have shown conflicting results. It remains to be determined if, or how, gender and race are independent risk factors for CABG operative mortality. Using all consecutive patients who underwent isolated CABG at Baylor University Medical Center in Dallas, Texas, from January 2004 to October 2011, the risk-adjusted associations between gender and race, respectively, and operative mortality were estimated using a generalized propensity approach, accounting for recognized Society of Thoracic Surgeons risk factors for mortality. Women were nearly 2 times more likely to die during or within 30 days of the operation than men (odds ratio 1.96, 95% confidence interval 1.44 to 2.66, p <0.0001), while no significant mortality differences were observed among races. In conclusion, these findings suggest that women face a significantly greater risk for operative death that should be taken into account during the treatment decision-making process but that race is not associated with CABG mortality and so should not be among the factors considered., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Health information technology shows promise for improving chronic disease care. This study assessed the impact of a diabetes management form (DMF), accessible within an electronic health record. From 2007 to 2009, 2108 diabetes patients were seen in 20 primary care practices; 1103 visits involved use of the DMF in 2008. The primary outcome was "optimal care": HbA1c ≤8%, low-density lipoprotein (LDL) cholesterol <100 mg/dL, blood pressure <130/80 mm Hg, not smoking, and aspirin prescription in patients ≥40 years. After adjusting for number of visits, age, sex, and insulin use, DMF-exposed patients showed less improvement in attaining "optimal care" (estimated difference-in-difference [DID] = -2.06 percentage points; P < .001), LDL cholesterol (DID = -2.30; P = .023), blood pressure (DID = -3.05; P < .001), and total cholesterol (DID = -0.47; P = .004) targets. Documented microalbumin tests, aspirin prescription, and eye and foot exams increased more. Thus, DMF use was associated with smaller gains in achieving evidence-based targets, but greater improvement in documented delivery of care., (© 2013 by the American College of Medical Quality.)

Randomized controlled trials have shown no significant difference in survival between immediate open repair and surveillance with selective repair for asymptomatic abdominal aortic aneurysms of 4.0 to 5.5 cm in diameter. This lack of difference has been shown to hold true for all diameters in this range, in men and women, but the question of whether patients of different ages might obtain different benefits has remained unanswered. Using the pooled patient-level data for the 2,226 patients randomized to immediate open repair or surveillance in the United Kingdom Small Aneurysm Trial (UKSAT; September 1, 1991, to July 31, 1998; follow-up 2.6 to 6.9 years) or the Aneurysm Detection and Management (ADAM) trial (August 1, 1992, to July 31, 2000; follow-up 3.5 to 8.0 years), the adjusted effect of age on survival in the 2 treatment groups was estimated using a generalized propensity approach, accounting for a comprehensive array of clinical and nonclinical risk factors. No significant difference in survival between immediate open repair and surveillance was observed for patients of any age, overall (p = 0.606) or in men (p = 0.371) or women separately (p = 0.167). In conclusion, survival did not differ significantly between immediate open repair and surveillance for patients of any age, overall or in men or women. Combined with the previous evidence regarding diameter, and the lack of benefit of immediate endovascular in trials comparing it with surveillance repair for small abdominal aortic aneurysms, these results suggest that surveillance should be the first-line management strategy of choice for asymptomatic abdominal aortic aneurysms of 4.0 to 5.5 cm., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system., Study Setting: Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed., Study Design: We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems., Data Collection: Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs)., Principal Findings: Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs., Conclusions: AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems., (© Health Research and Educational Trust.)

Deep sternal wound infections (DSWIs) are serious complications of sternotomy, leading to increased mortality and costs of care. Topical applications of autologous platelet concentrate and vancomycin have both shown promise in preventing DSWIs. From January 1, 1998, to November 30, 2010, 1,866 patients without previous sternotomy underwent cardiac surgery at the Baylor University Medical Center, Dallas, by a single surgeon who systematically adopted application of a paste containing vancomycin, calcium-thrombin, and platelet-rich plasma (PRP paste) to the edges of sternal wounds before closure in December 2005. A propensity-adjusted logistic regression model employing Firth's penalized maximum likelihood method was used to assess the association between the use of the PRP paste (intervention) and the incidence of severe DSWI. Eleven patients (0.59%) developed severe DSWIs. All were among the 1,318 patients in the control group (0.83%); no severe DSWIs developed in the 548 patients in the intervention group. Both the unadjusted and adjusted associations between the study intervention and DSWI were statistically significant (unadjusted p value=0.021; adjusted p value=0.005; adjusted odds ratio=0.05, 95% confidence interval 0.01, 0.50). In conclusion, the PRP paste appears to prevent severe DSWIs., (Copyright © 2014 Elsevier Inc. All rights reserved.)