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New to the eighth edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual for epithelial cancers of the esophagus and esophagogastric junction are separate, temporally related cancer classifications: 1) before treatment decision (clinical); 2) after esophagectomy alone (pathologic); and 3) after preresection therapy followed by esophagectomy (postneoadjuvant pathologic). The addition of clinical and postneoadjuvant pathologic stage groupings was driven by a lack of correspondence of survival, and thus prognosis, between both clinical and postneoadjuvant pathologic cancer categories (facts about the cancer) and pathologic categories. This was revealed by a machine-learning analysis of 6-continent data from the Worldwide Esophageal Cancer Collaboration, with consensus of the AJCC Upper GI Expert Panel. Survival is markedly affected by histopathologic cell type (squamous cell carcinoma and adenocarcinoma) in clinically and pathologically staged patients, requiring separate stage grouping for each cell type. However, postneoadjuvant pathologic stage groups are identical. For the future, more refined and granular data are needed. This requires: 1) more accurate clinical staging; 2) innovative solutions to pathologic staging challenges in endoscopically resected cancers; 3) integration of genomics into staging; and 4) precision cancer care with targeted therapy. It is the responsibility of the oncology team to accurately determine and record registry data, which requires eliminating both common errors and those related to incompleteness and inconsistency. Despite the new complexity of eighth edition staging of cancers of the esophagus and esophagogastric junction, these key concepts and new directions will facilitate precision cancer care.

The HeartMate II left ventricular assist device is widely used to support failing myocardium. In early 2011, one large center noticed an increasing frequency of thrombosis with this LVAD. It was confirmed at three other centers, but the cause has not been identified. The HeartMate II (Thoratec), a small, axial-flow left ventricular assist device (LVAD), rapidly became integral to the treatment of patients with advanced heart failure. 1 Pivotal trials and postmarketing approval studies of the HeartMate II provide a reference occurrence of thrombosis of 2 to 4% 2 – 4 ; however, an unexpected abrupt increase in the incidence of pump thrombosis was observed in a single-center quality review. To confirm that this finding was not an isolated phenomenon, two additional experienced centers pooled data to investigate the incidence of pump thrombosis and of elevated lactate dehydrogenase (LDH) levels as its clinical biomarker (indicating hemolysis), . . .

Stored red cells undergo progressive structural and functional changes over time. In a study of 6002 patients undergoing cardiac surgery at a single institution, those who received blood stored for 14 days or less had lower rates of complications and death than those who received blood stored for more than 14 days. In a study of patients undergoing cardiac surgery, those who received blood stored for 14 days or less had lower rates of complications and death than those who received blood stored for more than 14 days. More than 14 million units of blood are transfused annually in the United States. 1 Considerable evidence suggests that transfusion increases the risk of serious complications and death in critically ill patients, 2 – 4 especially in patients who are undergoing cardiac surgery. 5 – 12 Some studies have suggested that the risk of complications after transfusion also increases when transfused blood has been stored for long periods. 13 – 18 Blood collection and storage systems licensed by the Food and Drug Administration allow red cells to be stored for up to 42 days. (The median duration of storage of transfused red-cell units in the United States . . .

In a single-group trial, 48 children with severe heart failure received a ventricular assist device designed for children. Survival rates were significantly higher in this group than among propensity-score–matched children receiving support with extracorporeal membrane oxygenation. Systolic heart failure causes 280,000 deaths in adults annually in the United States. 1 Heart failure is much less common among children than among adults, but it is highly lethal, with 46% of children with heart failure dying or undergoing transplantation within 5 years after diagnosis, according to one estimate. 2 The survival rate among children after heart transplantation is estimated at 83% at 3 years, 3 , 4 but the limited availability of donor hearts for children prolongs the waiting period, 5 resulting in a high rate of death among children on waiting lists. 6 – 8 Options for mechanical circulatory support as a bridge to . . .

ObjectiveIn order to predict at hospital admission the prognosis of patients with serious and life-threatening COVID-19 pneumonia, we sought to understand the clinical characteristics of hospitalised patients at admission as the SARS-CoV-2 pandemic progressed, document their changing response to the virus and its variants over time, and identify factors most importantly associated with mortality after hospital admission.DesignObservational study using a prospective hospital systemwide COVID-19 database.Setting15-hospital US health system.Participants26 872 patients admitted with COVID-19 to our Northeast Ohio and Florida hospitals from 1 March 2020 to 1 June 2022.Main outcome measures60-day mortality (highest risk period) after hospital admission analysed by random survival forests machine learning using demographics, medical history, and COVID-19 vaccination status, and viral variant, symptoms, and routine laboratory test results obtained at hospital admission.ResultsHospital mortality fell from 11% in March 2020 to 3.7% in March 2022, a 66% decrease (p<0.0001); 60-day mortality fell from 17% in May 2020 to 4.7% in May 2022, a 72% decrease (p<0.0001). Advanced age was the strongest predictor of 60-day mortality, followed by admission laboratory test results. Risk-adjusted 60-day mortality had all patients been admitted in March 2020 was 15% (CI 3.0% to 28%), and had they all been admitted in May 2022, 12% (CI 2.2% to 23%), a 20% decrease (p<0.0001). Dissociation between observed and predicted decrease in mortality was related to temporal change in admission patient profile, particularly in laboratory test results, but not vaccination status or viral variant.ConclusionsHospital mortality from COVID-19 decreased substantially as the pandemic evolved but persisted after hospital discharge, eclipsing hospital mortality by 50% or more. However, after accounting for the many, even subtle, changes across the pandemic in patients’ demographics, medical history and particularly admission laboratory results, a patient admitted early in the pandemic and predicted to be at high risk would remain at high risk of mortality if admitted tomorrow.

To understand the consequences of functional cardiac stress testing among patients considering noncardiac nonophthalmologic surgery. A retrospective cohort study of 118,552 patients who made 159,795 visits to a dedicated preoperative risk assessment and optimization clinic between 2008 and 2018. A large integrated health system. Patients who visited a dedicated preoperative risk assessment and optimization clinic before noncardiac nonophthalmologic surgery. To assess changes to care delivered, we measured the probability of completing additional cardiac testing, cardiac surgery, or noncardiac surgery. To assess outcomes, we measured time-to-mortality and total one-year mortality. In causal inference models, preoperative stress testing was associated with increased likelihood of coronary angiography (relative risk: 8.6, 95% CI 6.1–12.1), increased likelihood of percutaneous coronary intervention (RR: 4.1, 95% CI: 1.8–9.2), increased likelihood of cardiac surgery (RR: 6.8, 95% CI 4.9–9.4), decreased likelihood of noncardiac surgery (RR: 0.77, 95% CI 0.75–0.79), and delayed noncardiac surgery for patients completing noncardiac surgery (mean 28.3 days, 95% CI: 23.1–33.6). The base rate of downstream cardiac testing was low, and absolute risk increases were small. Stress testing was associated with higher mortality in unadjusted analysis but was not associated with mortality in causal inference analyses. Preoperative cardiac stress testing likely induces coronary angiography and cardiac interventions while decreasing use of noncardiac surgery and delaying surgery for patients who ultimately proceed to noncardiac surgery. Despite changes to processes of care, our results do not support a causal relationship between stress testing and postoperative mortality. Analyses of care cascades should consider care that is avoided or substituted in addition to care that is induced. •Cardiac stress testing probably leads to higher rates of cardiac testing and interventions (a “care cascade”)•However, stress testing also decreases the likelihood that patients will complete surgery•Stress testing probably does not change mortality in the short- or long-term•Health datasets rarely capture care that is considered but not completed; many care cascades might instead be substitutions

Comparative outcomes of patients undergoing pericardiocentesis or pericardial window are limited. Development of pericardial effusion after cardiac surgery is common but no data exist to guide best management. Procedural billing codes and Cleveland Clinic surgical registries were used to identify 1,281 patients who underwent either pericardiocentesis or surgical pericardial window between January 2000 and December 2012. The 656 patients undergoing an intervention for a pericardial effusion secondary to cardiac surgery were also compared. Propensity scoring was used to identify well-matched patients in each group. In the overall cohort, in-hospital mortality was similar between the group undergoing pericardiocentesis and surgical drainage (5.3% vs 4.4%, p = 0.49). Similar outcomes were found in the propensity-matched group (4.9% vs 6.1%, p = 0.55). Re-accumulation was more common after pericardiocentesis (24% vs 10%, p <0.0001) and remained in the matched cohorts (23% vs 9%, p <0.0001). The secondary outcome of hemodynamic instability after the procedure was more common in the pericardial window group in both the unmatched (5.2% vs 2.9%, p = 0.036) and matched cohorts (6.1% vs 2.0%, p = 0.022). In the subgroup of patients with a pericardial effusion secondary to cardiac surgery, there was a lower mortality after pericardiocentesis in the unmatched group (1.5% vs 4.6%, p = 0.024); however, after adjustment, this difference in mortality was no longer present (2.6% vs 4.5%, p = 0.36). In conclusion, both pericardiocentesis and surgical pericardial window are safe and effective treatment strategies for the patient with a pericardial effusion. In our study there were no significant differences in mortality in patients undergoing either procedure. Observed differences in outcomes with regard to recurrence rates, hemodynamic instability, and in those with postcardiac surgery effusions may help to guide the clinician in management of the patient requiring therapeutic or diagnostic drainage of a pericardial effusion.

To assess the incremental contribution of preoperative stress test results toward a diagnosis of obstructive coronary artery disease (CAD), prediction of mortality, or prediction of perioperative myocardial infarction in patients considering noncardiac, nonophthalmologic surgery. A retrospective cohort study of visits to a preoperative risk assessment and optimization clinic in a large health system between 2008 and 2018. To assess diagnostic information of preoperative stress testing, we used the Begg and Greenes method to calculate test characteristics adjusted for referral bias, with a gold standard of angiography. To assess prognostic information, we first created multiply-imputed logistic regression models to predict 90-day mortality and perioperative myocardial infarction (MI), starting with two tools commonly used to assess perioperative cardiac risk, Revised Cardiac Risk Index (RCRI) and Myocardial Infarction or Cardiac Arrest (MICA). We then added stress test results and compared the discrimination for models with and without stress test results. Among 136,935 visits by patients without an existing diagnosis of CAD, the decision to obtain preoperative stress testing identified around 4.0% of likely new diagnoses. Stress testing increased the likelihood of CAD (likelihood ratio: 1.31), but for over 99% of patients, stress testing should not change a decision on whether to proceed to angiography. In 117,445 visits with subsequent noncardiac surgery, stress test results failed to improve predictions of either perioperative MI or 90-day mortality. Reweighting the models and adding hemoglobin improved the prediction of both outcomes. Cardiac stress testing before noncardiac, nonophthalmologic surgery does not improve predictions of either perioperative mortality or myocardial infarction. Very few patients considering noncardiac, nonophthalmologic surgery have a pretest probability of CAD in a range where stress testing could usefully select patients for angiography. Better use of existing patient data could improve predictions of perioperative adverse events without additional patient testing. •The pretest probability of obstructive coronary artery disease is very low in patients considering noncardiac surgery.•Even with careful patient selection, stress testing can't efficiently diagnose CAD or select patients for angiography.•Stress test results don't improve predictions of death or myocardial infarction beyond commonly-used risk scores.•Prediction models that make better use of existing data could improve predictions of adverse operative events.

ObjectivesTo describe variation in and drivers of contemporary preoperative cardiac stress testing.SettingA dedicated preoperative risk assessment and optimisation clinic at a large integrated medical centre from 2008 through 2018.ParticipantsA cohort of 118 552 adult patients seen by 104 physicians across 159 795 visits to a preoperative risk assessment and optimisation clinic.Main outcomeReferral for stress testing before major surgery, including nuclear, echocardiographic or electrocardiographic-only stress testing, within 30 days after a clinic visit.ResultsA total of 8303 visits (5.2%) resulted in referral for preoperative stress testing. Key patient factors associated with preoperative stress testing included predicted surgical risk, patient functional status, a previous diagnosis of ischaemic heart disease, tobacco use and body mass index. Patients living in either the most-deprived or least-deprived census block groups were more likely to be tested. Patients were tested more frequently before aortic, peripheral vascular or urologic interventions than before other surgical subcategories. Even after fully adjusting for patient and surgical factors, provider effects remained important: marginal testing rates differed by a factor-of-three in relative terms and around 2.5% in absolute terms between the 5th and 95th percentile physicians. Stress testing frequency decreased over the time period; controlling for patient and physician predictors, a visit in 2008 would have resulted in stress testing approximately 3.5% of the time, while a visit in 2018 would have resulted in stress testing approximately 1.3% of the time.ConclusionsIn this large cohort of patients seen for preoperative risk assessment at a single health system, decisions to refer patients for preoperative stress testing are influenced by various factors other than estimated perioperative risk and functional status, the key considerations in current guidelines. The frequency of preoperative stress testing has decreased over time, but remains highly provider-dependent.