Lower Tercile Research Articles

COVID-19 and Health-care Business Continuity in Africa: Perceptions of Risks and Vulnerabilities by Mid-level Management Staff in a Tertiary Care Hospital.

The novel SARS-CoV-2 outbreak disrupted businesses globally and created fears in the general public and among health-care professionals. Almost universally, considerations about the coronavirus pandemic and its effects became priority in the daily operations of businesses, leaving hitherto pressing concerns in the back stage. Early in the pandemic, the management of University of Benin Teaching Hospital set up a Business Continuity Team which undertook an evaluation of the perceptions of mid-level hospital managers about their departments' and units' risks and vulnerabilities in the face of the ongoing pandemic. A modified International Labour Organization (ILO) risk profile self-assessment tool which focused on "people," "processes," "profits," and "partnerships" was used to assess mid-level managers' perceptions of their respective departments' and units' risks and vulnerabilities, consequent on the COVID-19 pandemic. Responses were obtained from heads of departments and units using an online survey. Final scores were divided into terciles (three equal groups) in respect of perceived risks and adverse outcomes of the COVID-19 pandemic. Scores in the lower tercile were grouped as low risk/vulnerability, the middle group of scores as medium risk/vulnerability, and scores in the upper tercile as high risk/vulnerability. Responses were obtained from 35 (49.3%) of the 71 clinical and nonclinical departments and units in the hospital. Fifteen of these (42.9%) were clinical. Nineteen (54.2%) departments were assessed to be at high risk/vulnerability, 9 (47.4%) of which were clinical. Twelve (34.3%) departments were assessed to be at medium risk/vulnerability - 4 (33.3%) of them, clinical. No department was assessed to be at low risk. The highest risk ratings were in the domains of "profits" and "partnerships:" 54 (84.4%) mid-level managers assessed their departments and units to be at high risk of the negative impacts of the coronavirus pandemic with respect to "profits" and 51 (79.7%) with respect to "partnerships." Mid-level managers in clinical and nonclinical departments and units assessed their departments and units to be at medium and high risk of the negative impacts of the COVID-19 pandemic, using the ILO's modified tool. Our findings enabled the management of the hospital and the Business Continuity Team to address the specific areas of concerns that were highlighted, develop contingency plans, and frame risk communication during the pandemic, with a view to fostering increased sense of safety in the workforce. This approach to risk assessment is repeatable, and we recommended it to other hospitals in Africa.

P02.07.B FIBROBLAST ACTIVATION PROTEIN EXPRESSING MESENCHYMAL CELLS INFLUENCE T CELL ABUNDANCE AND FUNCTION IN GLIOBLASTOMA

Abstract BACKGROUND Glioblastomas (GBMs) are aggressive brain tumors with strong immunosuppressive properties. In epithelial cancers, mesenchymal cells expressing fibroblast activation protein (FAP) play an important role in modulating the T cell response. We have recently shown that FAP+ mesenchymal cells are present in human GBMs. The aim of this study was to determine their effect on T cell abundance and function. MATERIAL AND METHODS GBM tumors (16 samples) were mechanically and enzymatically dissociated and analyzed for immune cell subpopulations by flow cytometry. Expression of T cell related genes was analyzed by qRT-PCR in GBMs selected based on FAP protein concentration determined by ELISA (14 FAP high [upper tercile], 16 FAP low [lower tercile]). Immunohistochemistry (IHC) was used to compare the number of CD3+, CD4+, and CD8+ T cells in GBMs with high (upper tercile, n=21) and low abundance of FAP+ stroma (lower tercile, n=20). Co-localization of FAP+ mesenchymal cells and CD3, PD-L1 and PD-L2 was evaluated by immunofluorescence in frozen sections. 8 FAP+ mesenchymal and 3 glioblastoma stem-like cell cultures were derived from human GBMs and PD-L1 and PD-L2 expression was determined using ELISA. Peripheral blood mononuclear cells were isolated from healthy donors´ buffy coats. Proliferation of stimulated T cells in conditioned media from FAP+ mesenchymal cells was analyzed by flow cytometry. RESULTS The percentage of T cells in CD45+ cells from GBMs positively correlated with FAP expression. Expression of the T cell inhibitory molecule PD-L2 was higher in FAP high GBMs. Immunohistochemisty revealed that the numbers of CD3+ and CD8+ T cells were higher in GMBs with a high abundance of FAP+ stroma and T cells were frequently in close proximity to FAP+ mesenchymal cells, which were often PD-L2 positive. In vitro, FAP+ mesenchymal cells expressed more PD-L2 than glioblastoma stem-like cells. T cell proliferation was decreased after exposure to conditioned media from FAP+ mesenchymal cells. CONCLUSION FAP+ mesenchymal cells influence T cell abundance in GBMs and may affect T cell functions by limiting their proliferation via soluble factors or cell-cell contact. Acknowledgment: This work was supported by the National Institute for Cancer Research (LX22NPO5102), the Center for Tumor Ecology (CZ.02.1.01/0.0/0.0/16_019/0000785), Charles University project GAUK 365022 and Cooperatio Program Oncology and Haematology“.

Clinical Course and Treatment of Patients With Apical Aneurysms Due to Hypertrophic Cardiomyopathy

BackgroundThere is controversy about risk of malignant arrhythmias and stroke in patients with apical aneurysms in hypertrophic cardiomyopathy (HCM). ObjectivesThe aim of this study was to estimate the associations of aneurysm size and major HCM risk factors with the incidence of lethal and potentially lethal arrhythmias and to estimate incidence of unexplained stroke. MethodsIn 108 patients (age 57.4 ± 13.5 years, 37% female) from 3 HCM centers, we assessed American Heart Association/American College of Cardiology guidelines risk factors and initial aneurysm size by echocardiography and cardiac magnetic resonance imaging and assessed outcomes after median 5.9 (IQR: 3.7-10.0) years. ResultsImplantable cardioverter defibrillator discharges or sudden cardiac death (SCD) occurred in 21 (19.4%) patients. Of patients with a risk factor, 55% subsequently had ventricular tachycardia (VT), ventricular fibrillation (VF), or SCD at follow-up, compared with 10% in those who did not (P < 0.001). The upper tercile of size had a 5-year cumulative risk of 35%, while the lower tercile had 5-year risk of 6% (P = 0.0046). In those with the smallest aneurysms <2 cm2 and also without risk factors VT, VF, or SCD occurred in only 2.5%. Clinical atrial fibrillation (AF) was prevalent, occurring in 49 (45%). Stroke was commonly associated with AF. Stroke without conventional cause had an incidence of 0.5%/year. Surgery in 19% was effective in reducing symptoms. VT ablation and surgery were moderately effective in preventing recurrent VT. ConclusionsRisk factors and aneurysm size were associated with subsequent VT, VF, or SCD. Patients with aneurysms in the lowest tercile of size have a low cumulative 5-year risk. Clinical AF occurred frequently. Stroke prevalence in absence of known stroke etiologies is uncommon and comparable to risk of severe bleeding.

Surgeon Preference for Maximizing Medical Care Is Associated with Recommending More Extensive Surgery for Low-Risk Thyroid Cancer.

Background: While patient-level determinants of total thyroidectomy use have been well described, surgeon-level drivers of more extensive surgery are present and less well described. This survey sought to examine the associations between surgeons' operative recommendations, their beliefs about cancer, and their attitudes about medical maximizing-minimizing. Methods: A mixed-mode, cross-sectional survey was administered in September 2020 via mail and email to 222 thyroid surgeons identified in the Centers for Medicare & Medicaid Services Provider Utilization and Payment Physician and Other Practitioners dataset. Participants were asked their treatment recommendation for a healthy 45-year-old woman with a solitary 2.0-cm papillary thyroid cancer. Surgeons were assessed with the Brief Worry Scale and a validated, single-item measure of cancer-related worry. The Clinician Maximizer-Minimizer scale was used to assess the extent of medical care that physicians tend to favor with their patients. Participants were categorized into terciles based on their responses to the Maximizer-Minimizer scale. The highest scoring tercile ("Maximizers") was compared with the two lower terciles by Student's t-tests, chi-square, ANOVA, and logistic regression. Results: Of the 149 surgeons (response rate 67.1%), 34.9% recommended total thyroidectomy with or without central neck dissection (CND), and 65.1% recommended lobectomy. Overall, the medical Maximizer-Minimizer scale had an average score of 24.6 (SD 6.8). There were no differences between surgeons' age, race, annual thyroidectomy volume, or practice setting by their Maximizer-Minimizer classification. Participants who recommended total thyroidectomy with or without CND had significantly higher Maximizer-Minimizer scores than those recommending lobectomy (25.9 ± 7.2 vs. 23.8 ± 6.4, p = 0.03). Those classified as maximizers also had more cancer-related worry on both the single-item and Brief Worry Scales (p = 0.02). On logistic regression controlling for age, sex, race, specialty training, practice setting, and annual thyroidectomy volume, maximizers were still more likely to recommend total thyroidectomy with or without a CND (OR 2.4, [CI 1.01-5.55], p = 0.047). Conclusions: Medical maximizing-minimizing tendencies represent one of potentially many unmeasured surgeon characteristics that may explain persistent patterns of over-diagnosis, over-treatment, and over-screening. Surgeons may benefit from awareness of how their own tendencies influence their surgical recommendations in patients with low-risk thyroid cancer.

The Impact of Social Deprivation on Health Care Utilization Patterns Following Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humerus Fractures

BackgroundDisparities in social determinants of health have been linked to worse patient reported outcomes, higher postoperative pain, and increased risk of revision surgery following orthopaedic procedures. Identification of perioperative predictors of healthcare utilization is of particular interest to mitigate cost and improve patient outcomes. The aim of this study is to elucidate the effect of social deprivation levels, using the Area Deprivation Index (ADI), on healthcare utilization following pinning of supracondylar humerus (SCH) fractures. Identifying risk factors for discrepancies in healthcare utilization following SCH fracture fixation can help mitigate unnecessary healthcare spending and improve care of vulnerable patient populations. MethodsThis is a retrospective review of a single institution’s experience with SCH fracture pinning between 2010 and 2023. Demographic variables and healthcare utilization data were recorded within 90 days of surgery. The ADI was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared. Results1186 patients from a single level one trauma center were included in this study. The upper, middle, and lower terciles of ADI consisted of 226, 458, and 502 patients, respectively. The most deprived tercile had greater emergency department visitation within 90 days of surgery relative to the least and intermediate deprived terciles (IRR 1.85, 95% CI 1.10-3.08). Identifying as White was an independent risk factor for increased outpatient clinic utilization (IRR 1.17, 95% CI 1.03-1.34). Higher levels of social deprivation were independent risk factors for increased ED visitation. There was no difference in 90-day inpatient readmission rates or telephone/telehealth calls made to the clinic between the least, intermediate, and most deprived patients. ConclusionsThis study begins to shed light on how social determinants of health impact the postoperative care of the pediatric orthopedic patient and which patient populations are the most at-risk for disproportionate resource utilization after pinning of SCH fractures. Understanding these differences may lead to improved patient outcomes while decreasing potentially unnecessary burden on the healthcare system. Level of EvidenceIII; retrospective comparative study Key Concepts1.Social determinants of health impact the postoperative care of the pediatric patient in the setting of supracondylar humerus fractures, more socially deprived patients are at higher risk of postoperative emergency department visits, patient race is shown to be a factor in postoperative clinic utilization.

ENSO-based outlook of droughts and agricultural outcomes in Afghanistan

Drought is one of the key drivers of food insecurity in Afghanistan, which is among the most food insecure countries in the world. In this study, we build on previous research and seek to answer the central question: “What is the influence of El Niño-Southern Oscillation (ENSO) on drought outlooks and agricultural yield outcome in Afghanistan, and how do these influences vary spatially?” We do so by utilizing multiple indicators of droughts and available wheat yield reports. We find a clear distinction in the probability of drought (defined as being in the lower tercile) in Afghanistan during La Niña compared to El Niño events since 1981. The probability of drought in Afghanistan increased during La Niña, particularly in the North, Northeast, and West regions. La Niña events are related to an increase in the probability of snow drought, particularly in parts of the Amu Darya basin. It is found that relative to El Niño events, snow water equivalent [total runoff] during La Niña events January–March (March–July total runoff) decreases between 9% and 30% (28%–42%) for the five major basins in the country. The probability of agricultural drought during La Niña events is found to be higher than 70% in the rainfed and irrigated areas of the Northeast, North, and West regions. This result is at least partly supported by reported wheat yield composites related to La Niña events that tend to be lower than for El Niño events across all regions in the case of rainfed wheat (statistically significant in Northeast, West, and South regions) and in some cases for irrigated wheat. The results of this study have direct implications for improving early warning of worsening food insecurity in Afghanistan during La Niña events, given that we now have long-lead and skillful forecasts of ENSO up to 18–24 months in advance, which could potentially be used to provide earlier warning of worsening food insecurity in Afghanistan

Telehealth Expansion and Medicare Beneficiaries’ Care Quality and Access

Understanding the association of telehealth use with health care outcomes is fundamental to determining whether telehealth waivers implemented during the COVID-19 public health emergency should be made permanent. The current literature has yielded inconclusive findings owing to its focus on select states, practices, or health care systems. To estimate the association of telehealth use with outcomes for all Medicare fee-for-service (FFS) beneficiaries by comparing hospital service areas (HSAs) with different levels of telehealth use. This US population-based, retrospective cohort study was conducted from July 2022 to April 2023. Participants included Medicare claims of beneficiaries attributed to HSAs with FFS enrollment in Parts A and B. Low, medium, or high tercile of telehealth use created by ranking HSAs according to the number of telehealth visits per 1000 beneficiaries. The primary outcomes were quality (ambulatory care-sensitive [ACS] hospitalizations and emergency department [ED] visits per 1000 FFS beneficiaries), access to care (clinician encounters per FFS beneficiary), and cost (total cost of care for Part A and/or B services per FFS Medicare beneficiary) determined with a difference-in-difference analysis. In this cohort study of claims from approximately 30 million Medicare beneficiaries (mean [SD] age in 2019, 71.04 [1.67] years; mean [SD] percentage female in 2019, 53.83% [2.14%]) within 3436 HSAs, between the second half of 2019 and the second half of 2021, mean ACS hospitalizations and ED visits declined sharply, mean clinician encounters per beneficiary declined slightly, and mean total cost of care per beneficiary per semester increased slightly. Compared with the low group, the high group had more ACS hospitalizations (1.63 additional hospitalizations per 1000 beneficiaries; 95% CI, 1.03-2.22 hospitalizations), more clinician encounters (0.30 additional encounters per beneficiary per semester; 95% CI, 0.23-0.38 encounters), and higher total cost of care ($164.99 higher cost per beneficiary per semester; 95% CI, $101.03-$228.96). There was no statistically significant difference in ACS ED visits between the low and high groups. In this cohort study of Medicare beneficiaries across all 3436 HSAs, high levels of telehealth use were associated with more clinician encounters, more ACS hospitalizations, and higher total health care costs. COVID-19 cases were still high during the period of study, which suggests that these findings partially reflect a higher capacity for providing health services in HSAs with higher telehealth intensity than other HSAs.

Factors influencing subseasonal predictability of northern Eurasian cold spells

AbstractCold‐air outbreaks have significant impacts on human health, energy consumption, agriculture, and overall well‐being. This study aims to evaluate the effectiveness of Subseasonal‐to‐Seasonal (S2S) models in predicting cold conditions over northern Eurasia, defined here as the lower tercile of weekly mean 2‐metre temperature anomalies. To assess the predictability of these events we use ensemble hindcasts from five prediction systems from the S2S database. Our analysis focuses on identifying the conditions under which the models confidently predict cold temperatures with a high (&gt;0.5) probability 3–4 weeks ahead, which potentially can represent windows of forecast opportunity. We compare the group of forecasts that correctly predicted the events to the group that forecasted events that did not occur in practice (false alarms). Most of the confident forecasts of cold spells, both correct and false alarms, have cold anomalies already in the initial conditions, often in conjunction with either a negative phase of the North Atlantic Oscillation, or Scandinavian Blocking. We find that S2S models tend to overpredict cold temperatures, with false alarms occurring more likely when the forecasts are initialized during a weak polar vortex. Furthermore, most of the confident false alarms receive the signal from the stratosphere rather than following internal tropospheric dynamics. False alarms initialized during the weak polar vortex conditions are more common when the vortex is in a recovery stage and, subsequently, the downward ‐propagating signal is short‐lived in the troposphere. The analysis of forecasts during different Madden–Julian Oscillation (MJO) phases shows that nearly half of all confident correct cold‐temperature forecasts are initialized during an active MJO in phases 6–8. On the other hand, most false alarms occur during phase 3, which we suggest is due to the presence of the Scandinavian Blocking regime in the initial conditions for this phase.

The impact of social deprivation on healthcare utilization patterns following rotator cuff repair

BackgroundDisparities in social determinants of health have been linked to worse patient reported outcomes, higher pain, and increased risk of revision surgery following rotator cuff repair. Identification of perioperative predictors of increased healthcare utilization is of particular interest to surgeons to improve outcomes and mitigate the total cost of care. The effect of social deprivation on healthcare utilization has not been fully characterized. MethodsThis is a retrospective review of a single institution's experience with primary rotator cuff repair between 2012-2020. Demographic variables (age, race, gender, ASA score) and healthcare utilization (hospital readmission, emergency department visits, follow-up visits, telephone calls) were recorded within 90 days of surgery. The Area Deprivation Index (ADI) was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared. ResultsA total of 1695 patients were included. The upper, middle, and lower terciles of ADI consisted of 410, 767, and 518 patients, respectively. The most deprived tercile had greater emergency department visitation and office visitation within 90 days of surgery relative to the least and intermediate deprived terciles. Higher levels of social deprivation were independent risk factors for increased ED visitation and follow-up visitation. There was no difference in 90-day readmission rates or telephone calls made between the least, intermediate, and most deprived patients. ConclusionsPatients with higher levels of deprivation demonstrated greater postoperative hospital utilization. We hope to use these results to identify risk factors for increased hospital use, guide clinical decision making, increase transparency, and manage patient outcomes following rotator cuff repair surgery.

Factors associated with dietary patterns (DPS) and nutritional status among pregnant women in AM-HDSS, South Ethiopia.

Malnutrition during pregnancy increases the risk of chronic illness later in life and adverse birth outcomes in subsequent generations. In this regard, consumption of diets rich in adequate energy, protein, vitamins, and minerals from a variety of foods is essential. Evidence on the status of maternal dietary pattern is very crucial. Hence, the aim of this study was to assess factors associated with dietary patterns and nutritional status of pregnant women in South Ethiopia. A community-based cross-sectional study was conducted among 638 randomly selected pregnant women using a validated, a pre-tested, contextualized food frequency questionnaire using interviewer-administered structured questionnaire by digital open-source toolkit. Principal component factor analysis was employed to determine dietary patterns. Bivariable and multivariable ordinal logistic regression analyses were used to identify factors associated with dietary patterns and nutritional status, using STATA version 16. The dietary habits of pregnant women were best explained by three distinct dietary patterns. Urban dwellers (AOR = 2.18; 95% CI: 1.33, 3.59), from high socio-economic status (AOR = 2.43; 95% CI: 1.68, 3.51), from middle socio-economic status (AOR = 1.72; 95% CI: 1.19, 2.48), primigravida mothers (AOR = 1.72; 95% CI: 1.07, 2.78), and multigravida mothers (AOR = 2.08; 95% CI: 1.39, 3.10) were high likelihood to consume the highest tercile of "Cereals-Pulses and Dairy" compared to rural dwellers, from low socio-economic status and grand multigravida, respectively. Attending formal education (AOR = 1.60; 95% CI: 1.02, 2.51), from higher socioeconomic status (AOR = 1.56; 95% CI: 1.02, 2.38), not having food aversion (AOR = 1.98; 95% CI: 1.16, 3.39), and had good dietary knowledge (AOR = 2.16; 95% CI: 1.08, 4.32) were associated with a higher tercile consumption of "Nutrient-Dense" food compared to those without formal education, having food aversion and had poor dietary knowledge, respectively. Not attending formal education (AOR = 2.22; 95% CI: 1.48, 3.36), had decision-making autonomy (AOR = 1.91; 95% CI: 1.26, 2.90), and had good dietary knowledge (AOR = 1.86; 95% CI: 1.13, 3.08) were found to consume the highest tercile of "Leafy local food" compared to their counterpart. Consumption of lower terciles "Nutrient-Dense" food (AOR = 1.63; 95% CI: 1.07, 2.47) and "Leafy local food" (AOR = 2.32; 95% CI: 1.54, 3.51) were found to be factors associated with under nutrition during pregnancy. Three distinct dietary patterns were identified. Factors associated with these major dietary patterns included place of residence, socio-economic status, educational level, dietary knowledge, food aversion, number of pregnancies, and maternal decision-making autonomy. Under nutrition among pregnant women was found to be high and associated with the consumption of 'Nutrient-Dense' and 'Leafy local' foods. Therefore, concerned health authorities should strengthen dietary counseling during pregnancy, provide family planning services, and promote women's education.

Abstract 19065: Resource Utilization After Cardiac Surgery in Adults With Congenital Heart Diseases: A Nationwide Analysis

Objective: This study examined resource utilization following cardiac surgery among ACHD patients.Methods: We used the NIS (2012-2018) to identify &gt;18yo admissions with TOF, Pulmonary valve anomalies/Congenital Pulmonary Stenosis, cTGA, DORV, TGA, HLHS, and Ebstein's anomaly and Open-heart valve or Great Vessels\Conduit replacement procedures. Hospitalization costs were adjusted for inflation to 2022 US dollars using the medical care component of the US Consumer Price Index. A mixed-effect linear regression model was used to identify factors associated with increased costs.Results: Out of 91,565 admissions, 4,578 involved one of the procedures of interest. The median age was 32 (IQR 34 - 46), and 46.6% were females. The median hospitalization cost was $54,400 (IQR 40,990 - 74,520). Valve procedures were the most common (79%). Overall, 19% of admissions had multiple HRU codes, with Blood transfusions (12.5% ) and ICD/pacemakers (7.2% being the most common. The high and low tercile group had a median hospitalization cost of $92,370 (IQR 74,850 - 120,900) and $36,300, IQR 31,180 - 40,930). Hospital-level factors, complications, and the need for HRU services significantly increased hospitalization costs. Notably, in-hospital mortality was associated with a 58% cost increase. Conclusion: Although the proportion of ACHD admissions requiring cardiac surgery is relatively low, the economic burden is significantly high, particularly those with in-hospital mortality. On average, higher hospitalization costs are associated with complications, the utilization of HRU procedures, the type of hospital providing care, and the US region.

Dietary Sources, Sex, and rs5888 (SCARB1) as Modulators of Vitamin A's Effect on Cardiometabolic Health.

Although preclinical studies have attributed vitamin A (VA) cardiometabolic benefits, these effects are still controversial and not always supported in large human studies. Here, the outcomes associated with VA and its relationship with habitual dietary sources, sex, and genetic background have been studied. To do so, the data from an observational study (n = 455) (64% females, mean age of 36 years) showing that suboptimal VA intake (mainly from retinol rather than carotene) is associated with cardiometabolic risk (CMR) were considered. A higher odds ratio (OR) of suffering ≥ 2 simultaneous CMR factors was observed in men in the low consumption tercile of retinol (OR = 2.04; p = 0.019). In women, however, this relationship was not evident. Then, incubation of peripheral blood mononuclear cells (PBMCs) with VA-related compounds (ex vivo functional assay from 81 men and women) induced specific changes in the activity of genes involved in lipid homeostasis and inflammatory status, which were dependent on the type of compound tested and the sex of the person. In addition, the presence of the genetic variant rs5888 in SCARB1 was identified as having a high influence on VA-related metabolic response. The new evidence derived from this study could be relevant for personalized nutritional advice concerning VA and CMR.

Interhospital variability in failure to rescue rates following aortic valve surgery

ObjectiveThis study evaluated interhospital variability and determinants of failure-to-rescue for patients undergoing surgical aortic valve replacement. MethodsAn observational study was conducted among 28,842 patients undergoing aortic valve replacement with or without coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals participating in the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Postoperative complications were defined as major (stroke, renal failure, reoperation, prolonged ventilation, sternal infection) and overall (major plus 14 other morbidities). Hospital terciles of observed to expected (O/E) mortality were compared on crude rates of major and overall complications, operative mortality, and failure to rescue (among major and overall complications). The correlation between hospital observed and expected failure-to-rescue rates was assessed. ResultsMedian Society of Thoracic Surgeons Adult Cardiac Surgery Database predicted mortality risk was similar across hospital O:E mortality terciles (P = .10). As expected, mortality rates significantly increased across terciles (low O/E tercile: 1.6%, high O/E tercile: 4.7%; P < .001). Failure-to-rescue rates increased substantially across hospital mortality terciles among patients with major (low tercile, 8.8% and high tercile, 20.8%) and overall (low tercile, 3.0% and high tercile, 8.9%) complications. Hospital-level expected failure to rescue had a higher correlation with observed complications for overall complications (R2 = 0.71) compared with Society of Thoracic Surgeons major complications (R2 = 0.24). ConclusionsConsiderable interhospital variation exists in failure-to-rescue rates following aortic valve replacement. Hospitals in the low O/E mortality tercile experience failure to rescue nearly one-third less than those in the high O/E mortality tercile. Efforts to advance quality will benefit from identifying and disseminating optimal rescue strategies in this patient population.

On the Relationship Between Reliability Diagrams and the “Signal‐To‐Noise Paradox”

AbstractThe “signal‐to‐noise paradox” for seasonal forecasts of the winter North Atlantic Oscillation (NAO) is often described as an “underconfident” forecast and measured using the ratio‐of‐predictable components (RPCs) metric. However, comparison of RPC with other measures of forecast confidence, such as spread‐error ratios, can give conflicting impressions, challenging this informal description. We show, using a linear statistical model, that the “paradox” is equivalent to a situation where the reliability diagram of any percentile forecast has a slope exceeding 1. The relationship with spread‐error ratios is shown to be far less direct. We furthermore compute reliability diagrams of winter NAO forecasts using seasonal hindcasts from the European Centre for Medium‐range Weather Forecasts and the UK Meteorological Office. While these broadly exhibit slopes exceeding 1, there is evidence of asymmetry between upper and lower terciles, indicating a potential violation of linearity/Gaussianity. The limitations and benefits of reliability diagrams as a diagnostic tool are discussed.

Sleep Duration in Adolescence and Its Prenatal, Perinatal, and Health Determinants in a Large Population-based Cohort Followed from Birth.

Objective To investigate sleep duration and its associated factors in adolescents aged 11 years from the 2004 Pelotas (Brazil) Birth Cohort Study. Methods Sleep duration was assessed using a self-report sleep habits. Independent variables included perinatal, sociodemographic, behavioral, and health characteristics. The associations were estimated using multiple linear regression. Results The mean sleep duration of 3,179 adolescents was 9.3 hour (SD =1.7 hour). Longer sleep duration was associated with lower socioeconomic status at birth (β: 0.37, 95% CI: 0.12; 0.61), lower mother's education level ( p < 0.001), and being female (β: 0.19, 95% CI: 0.06; 0.33). Shorter sleep duration was associated with cesarean section delivery (β: -0.16, 95% CI: -0.31; -0.02); having classes in the morning shift (β: -1.38, 95% CI: -1.51; -1.26), and lower terciles of physical activity ( p = 0.04). Conclusions The mean sleep duration observed in this study was consistent with the international recommendations for this age range. Adolescents from lower income families, who are more active, study in shifts other than morning, girls, and those born through vaginal delivery presented higher sleep duration than their counterparts.

Association of Days Alive and Out of the Hospital After Ventricular Assist Device Implantation With Adverse Events and Quality of Life

There is a need to better assess the cumulative effect on morbidity and mortality in patients undergoing durable left ventricular assist device (LVAD) implantation. This study evaluates a patient-centered performance metric (days alive and out of hospital [DAOH]) for durable LVAD therapy. To determine the incidence of percent of DAOH before and after LVAD implantation and (2) explore its association with established quality metrics (death, adverse events [AEs], quality of life). This was a retrospective national cohort study of Medicare beneficiaries implanted with a durable continuous-flow LVAD between April 2012 and December 2016. The data were analyzed from December 2021 to May 2022. Follow-up was 100% complete at 1 year. Data from The Society of Thoracic Surgeons Intermacs registry were linked to Medicare claims. The number of DAOH 180 days before and 365 days after LVAD implantation and daily patient location (home, index hospital, nonindex hospital, skilled nursing facility, rehabilitation center, hospice) were calculated. Percent of DAOH was indexed to each beneficiary's pre- (percent DAOH-BF) and postimplantation (percentage of DAOH-AF) follow-up time. The cohort was stratified by terciles of percentage of DAOH-AF. Among the 3387 patients included (median [IQR] age: 66.3 [57.9-70.9] years), 80.9% were male, 33.6% and 37.1% were Interfaces Patient Profile 2 and 3, respectively, and 61.1% received implants as destination therapy. Median (IQR) percent of DAOH-BF was 88.8% (82.7%-93.8%) and 84.6% (62.1-91.5%) for percent of DAOH-AF. While DAOH-BF was not associated with post-LVAD outcomes, patients in the low tercile of percentage of DAOH-AF had a longer index hospitalization stay (mean, 44 days; 95% CI, 16-77), were less likely to be discharged home (mean. -46.4 days; 95% CI, 44.2-49.1), and spent more time in a skilled nursing facility (mean, 27 days; 95% CI, 24-29), rehabilitation center (mean, 10 days; 95% CI, 8-12), or hospice (mean, 6 days; 95% CI, 4-8). Increasing percentage of DAOH-AF was associated with patient risk, AEs, and indices of HRQoL. Patients experiencing non-LVAD-related AEs had the lowest percentage of DAOH-AF. Significant variability existed in the percentage of DAOH within a 1-year time horizon and was associated with the cumulative AEs burden. This patient-centered measure may assist clinicians in informing patients about expectations after durable LVAD implantation. Validation of percentage DAOH as a quality metric for LVAD therapy across centers should be explored.

Aortic valve replacement for aortic stenosis in France – influence of centers' volumes on TAVR adoption rate and outcomes

Abstract Aims Over the last decade, transcatheter aortic valve replacement (TAVR) became extensively used, now being the recommended as first line procedure for aortic valve replacement (AVR) in selected patients' populations. It is unknown whether TAVR adoption rate and variability in outcomes is influenced by centers' volume. Methods From a French administrative hospital-discharge database, we collected all AVR performed in France between 2007 and 2019. Centers were stratified to terciles based on their annual SAVR per year per center during 2007–2009 (“pre TAVR era”). Results There was 218,489 AVRs (153,747 SAVR and 74,732 TAVR) performed in 46 centers between 2007–2019. Number of total AVR and even more so number of number of TAVR significantly and linearly increased from 2007 to 2019 in all terciles but faster in the high volume tercile (+17, +17 and +31 AVR/center/year in the low, middle and high terciles respectively, P [ANCOVA]&amp;lt;0.001; +11, + 19 and +33 TAVR/center/year in the low, medium and high tercile respectively, P [ANCOVA] &amp;lt;0.00, Figure 1). The age of patients underwent TAVR remained grossly unchanged in all three terciles, however, the Charlson index declined from 2010 to 2019 (from 1.35±1.42 to 0.65±1.04, from 1.21±1.40 to 0.65±1.05 and from 1.53±1.58 to 0.81±1.21, in the low, middle and high terciles, P for trend &amp;lt;0.001, 0.021, and &amp;lt;0.001, respectively). Charlson score in the years 2017–2019, was higher in the high than middle and low terciles (0.87±1.22, 0.76±1.11 and 0.65±1.04, respectively, P&amp;lt;0.0001). The in-hospital mortality rate for TAVR significantly declined from 2010 to 2019 for TAVR in all terciles (from 8.3% to 2.1%, from 7.5% to 2.5% and from 8.2% to 2.1% for low, middle and high TAVR terciles, respectively; p for trend = 0.002, 0.001 and &amp;lt;0.001, respectively, Figure 2). Average mortality in 2017–2019 was similar in all terciles (2.3%, 2.5% and 2.2% for low, middle and high terciles, respectively, P=0.47). After adjusting for age, sex and Charlson score, mortality was higher in the low tercile compared with middle and high terciles (OR 1.15, P&amp;lt;0.001, confidence interval [CI] 1.0–1.2, and OR 1.18, P&amp;lt;0.001, CI 1.1–1.2, respectively). Conclusions From 2007 to 2019 total AVR linearly increased, mostly due to increase in TAVR, irrespective of centers' volume, but increase rate was higher in high volume centers. A constant decline in patients risk profile, with a striking decrease in mortality rate, was observed in all volume terciles. High-volume centers patients' have higher risk profile, with adjusted mortality slightly lower than medium and low volume centers. Funding Acknowledgement Type of funding sources: None.

Dietary diversity and impact of Moringa oleifera Lam. leaves supplemented – Diet on the nutritional status and CD4 cell counts of patients receiving antiretroviral therapy in Nigeria: A double - Blind randomized trial

BackgroundTo maintain an optimal nutritional status and immunological function in PLHIV, a diet with adequate nutrients is of utmost importance. This is a major challenge among poor populations in developing worlds like Nigeria, where malnutrition and food insecurity are endemic. This study aimed to assess the type of regular diet consumed and assess the impact of supplementation of the diet with Moringa oleifera Lam. leaves on the nutritional status and CD4 cell counts of PLHIV that are on ART in Nigeria. MethodA double-blind, randomized trial was conducted. Two hundred consented patients were randomly allocated to either the Moringa oleifera Lam. group (MOG) or the control group (COG). The FAO individual dietary diversity questionnaire was used. The regular diets of participants at baseline and six months were monitored. The measurements of weight, BMI, MUAC, and CD4 cell counts were obtained from baseline to six months of Moringa oleifera Lam. leaves supplementation. ResultsOne hundred and seventy-seven patients completed the six-month follow-up (89 MOG versus 88 COG). At both baseline and sixth month, the foods most commonly consumed by the participants in both MOG and COG were cereals, spices and condiments, oils, fats and palm oil, and dark green vegetables. At baseline, significantly higher consumption of legumes, nuts & seeds (p = 0.001) was observed in the MOG and higher consumption of other vegetables (p = 0.024) in COG. Consumption of cereals, roots, and tubers was significantly higher (p = 0.024; 0.045) in the COG in the sixth month. In both groups, participants were in the medium or low dietary diversity tercile. Throughout the study period, all the nutritional status variables observed were not significantly different between the two study groups [(p > 0.0001); weight; p = 0.5556; BMI; p = 0.5145; MUAC; p = 0.6456]. Over the study period, the treatment by time interaction shows a significant difference in CD4 counts by treatment group (p < 0.0001) and an estimate of fixed effects 10.33 folds greater in the MOG than COG. All tests were conducted at 95CI. ConclusionThis study revealed a poor dietary diversity amongst PLHIV. Supplementation of regular diet with Moringa oleifera Lam. leaves did not affect the nutritional status but could improve the immune response of HIV-positive adults attending the antiretroviral treatment centre in the present study area.

Patient characteristics and outcomes among bariatric surgery patients with high narcotic overdose scores.

Obesity-related chronic pain can increase the risk of narcotic abuse in bariatric surgery patients. However, assessment of overdose risk has not been evaluated to date. A NARxCHECK® overdose score ("Narx score") was obtained preoperatively on all patients undergoing bariatric surgery (n = 306) between 2018 and 2020 at a single-center academic bariatric surgery program. The 3-digit score ranges from 000 to 999 and is based on patient risk factors found within the Prescription Drug Monitoring Program. A Narx score ≥ 200 indicates tenfold increased risk of narcotic overdose. Patient characteristics, comorbidities, and emergency room (ER) visits were compared between patients in the upper (≥ 200) and lower (000) terciles of Narx scores. Morphine milligram equivalent (MME) prescribed at discharge and refills was also evaluated. Patients in the upper tercile represented 32% (n = 99) of the study population, and compared to the lower tercile (n = 101, 33%), were more likely to have depression (63.6% vs 38.6%, p = 0.0004), anxiety (47.5% vs 30.7%, p = 0.0150), and bipolar disorder (6.1% vs 0.0%, p = 0.0120). Median MME prescribed at discharge was the same between both groups (75); however, high-risk patients were more likely to be prescribed more than 10 tablets of a secondary opioid (83.3% vs 0.0%, p = 0.0111), which was prescribed by another provider in 67% of cases. ER visits among patients who did not have a complication or require a readmission was also higher among high-risk patients (7.8% vs 0.0%, p = 0.0043). There were no deaths or incidents of mental health-related ER visits in either group. Patients with a Narx score ≥ 200 were more likely to have mental health disorders and have potentially avoidable ER visits in the setting of standardized opioid prescribing practices. Narx scores can help reduce ER visits by identifying at-risk patients who may benefit from additional clinic or telehealth follow-up.

Exploring the feasibility of the aorta to pulmonary artery ratio as novel risk marker of acute aortic syndromes in dilated aorta without conventional criteria for surgery

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Based on current guidelines, surgery indication of thoracic ascending aortic aneurysm (TAAA) is mainly driven by the aortic diameter. However, most cases of TAAA acute complications occur in patients who did not previously meet the 55 mm criteria for preventive surgical replacement (1). Both aorta indexed to height and to body surface area have been proposed as possible solution but indexed diameters of healthy aortas widely vary (2). Accordingly, new individualized biomarkers to improve the risk stratification of dilated aorta without a conventional criteria for surgery remain an unmet clinical need. Since aorta and pulmonary artery have an established ratio in general population (upper normal ratio of 1.2) (3), the aorta-to-pulmonary-artery ratio (A:PA) may better define the wall stress in a dilated aorta, overcoming the individual limitations of conventional size criteria. Purpose The aim of our study is to find a novel aortic indexed diameter with better prognostic performance. Therefore, we aimed to explore the feasibility of using the A:PA as risk predictor in TAAA with aortic diameter &amp;lt; 55 mm. Methods All consecutive patients with an acute aortic syndrome (AAS), diagnosed by CT scan in our tertiary hospital between January 2010 and June 2021 undergoing surgical repair, were retrospectively analyzed. Patients with pulmonary hypertension were excluded to prevent distortions in the pulmonary artery diameter. Basic clinical characteristics regarding indications of surgery were collected along with measurements of the aortic maximum diameter and pulmonary artery maximum diameter, obtained by multiplane reconstruction (Figure, Panels A, B). Patients were categorized into three groups based on aortic diameter terciles: group A included patients with &amp;lt; 47 mm, group B ≥ 47 mm but &amp;lt; 55 mm and group C ≥ 55 mm. Considering a high risk of concomitant confounding factors the lower tercile was subsequently excluded of the analysis. Results A total 48 patients were included. 69% of the patients had an aortic diameter that would have not fulfilled a preventive surgery indication. Two patients had bicuspid aortic valve, both of them with aortic aneurysms &amp;gt; 55 mm. None had high risk connective tissue disorders. There were no significant differences in baseline characteristics between the groups (Table 1). A PA ratio was similar in group B and C [1.91 (0.41) versus 2.11(0.45); p = 0.251], suggesting a similar aortic wall stress between aortas despite the difference in aortic diameters [49.5 mm (5.0) versus 58 mm (4.7); p &amp;lt; 0.001] (Figure 1, Panels C, D). Conclusions: Our findings suggest that the A PA ratio may be a promising risk stratification biomarker for TAAA without a conventional criteria for preventive surgery. This novel parameter should be prospectively tested in cohorts of TAAA. To the best of our knowledge, this is the first attempt to describe the usefulness of this parameter. Abstract FIGURE 1 Abstract TABLE 1