Introduction: The Covid-19 pandemic has been associated with a reduction in STEMI volume in cardiac catheterization centers around the United States; yet a paradoxical increase in cardiovascular death within the same time period. Hypothesis: We hypothesized that reduction in STEMI volume during the COVID-19 pandemic may have been secondary to patient reluctance to present to the hospital. Methods: We performed a retrospective review of patients who presented to the emergency department from March 1st-April 19th, 2020 and March 1st-April 19th, 2019 across Northwell Health. Data on clinical comorbidities, time from symptoms onset, and patient outcomes was abstracted through manual chart review. The primary outcome of our study was time from onset of chest pain to presentation to the emergency room. Patients with COVID-19 were excluded from analysis. Variables were compared using the Chi-square test for categorical variables and the student-t for continuous variables. Results: In total 197 patients met our inclusion criteria, with 135 (69%) admitted in 2019 as compared to 62 (31%) presenting during the same time period in during the COVID-19 pandemic. There were no significant differences in the age of our patients and in comorbidities such as hypertension, hyperlipidemia, coronary artery disease, diabetes, chronic kidney disease, or chronic obstructive pulmonary disease. Patients who presented for STEMI during the COVID-19 waited significantly longer from time of onset of symptoms as compared to patients in 2019, (13.5 hours vs. 6.5 hours, p = .05). Patients who presented for STEMI in 2020 were more likely to die during hospitalization, but this did not reach statistical significance (9.7% vs 6.7%, p = .45). Conclusions: Reduction in STEMI volume during the COVID-19 pandemic may be related to patient reluctance to present to the hospital. Efforts to reduce the stigma of hospitalizations during the pandemic is important.
INTRODUCTION: The most widely held theory of facial beauty is that faces which more closely represent the average are the most beautiful. Our study sought to determine whether the theory of averageness could be demonstrated in women seeking rhinoplasty using state of the art machine learning algorithms. METHODS: Photographic analysis consisted of 1192 pre- and post- rhinoplasty photos of women as well as 139 photos of actresses, all of whom are listed as the most beautiful women of all time per IMDB. All photos are frontal shots with the face in a neutral pose. Using a pre-trained deep convolutional network algorithm, the photos were embedded with 128 vectors for clustering analysis. Phenotyping analysis of the pre-rhinoplasty photos was conducted via parameterized Gaussian mixture models optimized via Bayesian Information Criteria (BIC) for expectation-maximization. Furthermore, facial averages were generated via a Delaunay triangulation using the 68 landmarks and facial similarity scores were computed via similarity score of two faces by computing the squared L2 distance between their representations. RESULTS: The optimal number of pheno-groups determined by BIC, bounded by 1–5. The model assigned 410 photos to “pheno-group 1” and 782 photos to “pheno-group 2.” Beautiful actresses were more likely to be in phenotype 2 as compared to pre-rhinoplasty women (82% vs. 65%, p = .0001). Further, post-rhinoplasty women switched from phenotype 1 to phenotype 2 considerably more than they switch from 2 to 1 (21% vs. 7%, p = <.000001). Post-rhinoplasty composite faces were more similar to the “beautiful actresses” composite than the pre-rhinoplasty photos (L2 norm = 0.518 vs. 0.621). CONCLUSION: We demonstrate that women do not become more “average” after rhinoplasty, but rather trend towards the phenotype occupied by above average beautiful women.
Purpose: The majority of patients undergoing EVAR do not require blood transfusion, yet blood type and screen (T&S) is routinely performed. Identifying patients in whom T&S can be avoided presents a substantial cost saving opportunity. Hypothesis: We hypothesized that intraoperative blood transfusions can be predicted preoperatively. Methods: Using the Vascular Study Group of New England database from 2003-2014, we performed a retrospective review of 4700 patients who underwent EVAR. The cohort was split randomly into a training (60%) and validation (40%) set. A backwards logistic regression analysis was performed to identify predictors of intraoperative blood transfusion in the training set. The model was then tested in the validation set to estimate the receiver operating curves (ROC) and goodness of fit. Results: Preoperative hemoglobin, urgency (elective, symptomatic, or ruptured), age, maximal anterior-posterior AAA diameter, female gender, and history of CHF (asymptomatic, mild, moderate, or severe) were all significant predictors of intraoperative blood transfusions. The c-statistic for our model was .82 in the training set and .84 in the validation set, and the Hosmer-Lemenshow goodness-of-fit statistic was 0.99. Conclusions: Intraoperative blood transfusions can be routinely predicted preoperatively. Avoidance of T&S in low risk populations provides a substantial cost-saving opportunity.
Background: The objective of this study was to evaluate the impact of left atrial appendage (LAA) exclusion on short-term outcomes in patients with atrial fibrillation undergoing isolated coronary artery bypass graft surgery. Methods: We queried the 2010 to 2014 National Readmissions Database for patients who underwent coronary artery bypass graft repair with and without LAA ligation by using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes ( International Classification of Diseases, Ninth Revision, Clinical Modification : 36.1xx). Only patients with a history of atrial fibrillation were included in our analysis. The primary outcome of our study was 30-day readmissions following discharge. Secondary outcomes were in-hospital mortality and stroke. To assess the postoperative outcomes, we used multivariate logistic regression models to adjust for clinical and demographic covariates. Results: In total, we analyzed 253 287 patients undergoing coronary artery bypass graft surgery, 7.0% of whom received LAA closure. LAA exclusion was associated with a greater risk of postoperative respiratory failure (8.2% versus 6.2%, P <0.0001) and acute kidney injury (21.8% versus 18.5%, P <0.0001), but it did not significantly change the rate of blood transfusions or occurrence of cardiac tamponade. LAA exclusion was associated with a nonsignificant reduction in stroke (7.9% versus 8.6%, P =0.12), no difference in in-hospital mortality (2.2% versus 2.2% P =0.99), and a greater risk of 30-day readmission (16.0% versus 9.6%, P <0.0001). After covariate adjustment, LAA ligation remained a significant predictor of 30-day readmission (odds ratio, 1.640 [95% CI, 1.603–1.677], P <0.0001). Conclusions: LAA exclusion during isolated coronary artery bypass graft surgery in patients with atrial fibrillation is associated with a higher rate of 30-day readmission. Postoperative measures to mitigate the loss of the hormonal and hemodynamic effects of the LAA may increase the therapeutic benefit of this procedure.
Background Cardiogenic shock ( CS ) is associated with significant morbidity, and mortality rates approach 40% to 60%. Treatment for CS requires an aggressive, sophisticated, complex, goal‐oriented, therapeutic regimen focused on early revascularization and adjunctive supportive therapies, suggesting that hospitals with greater CS volume may provide better care. The association between CS hospital volume and inpatient mortality for CS is unclear. Methods and Results We used the Nationwide Inpatient Sample to examine 533 179 weighted patient discharges from 2675 hospitals with CS from 2004 to 2011 and divided them into quartiles of mean annual hospital CS case volume. The primary outcome was in‐hospital mortality. Multivariate adjustments were performed to account for severity of illness, relevant comorbidities, hospital characteristics, and differences in treatment. Compared with the highest volume quartile, the adjusted odds ratio for inpatient mortality for persons admitted to hospitals in the lowest‐volume quartile (≤27 weighted cases per year) was 1.27 (95% CI 1.15 to 1.40), whereas for admission to hospitals in the low‐volume and medium‐volume quartiles, the odds ratios were 1.20 (95% CI 1.08 to 1.32) and 1.12 (95% CI 1.01 to 1.24), respectively. Similarly, improved survival was observed across quartiles, with an adjusted inpatient mortality incidence of 41.97% (95% CI 40.87 to 43.08) for hospitals with the lowest volume of CS cases and a drop to 37.01% (95% CI 35.11 to 38.96) for hospitals with the highest volume of CS cases. Analysis of treatments offered between hospital quartiles revealed that the centers with volumes in the highest quartile demonstrated significantly higher numbers of patients undergoing coronary artery bypass grafting, percutaneous coronary intervention, or intra‐aortic balloon pump counterpulsation. A similar relationship was demonstrated with the use of mechanical circulatory support (ventricular assist devices and extracorporeal membrane oxygenation), for which there was significantly higher use in the higher volume quartiles. Conclusions We demonstrated an association between lower CS case volume and higher mortality. There is more frequent use of both standard supportive and revascularization techniques at the higher volume centers. Future directions may include examining whether early stabilization and transfer improve outcomes of patients with CS who are admitted to lower volume centers.
