Study of length of stay in the cardiovascular intensive care unit

Coronary artery bypass graft (CABG) surgery is among the most common operations performed in the United States and accounts for more resources expended in cardiovascular medicine than any other single procedure. CABG surgery patients initially recover in the Cardiovascular Intensive Care Unit (CVICU). The post-procedure CVICU length of stay (LOS) goal is two days or less. A longer ICU LOS is associated with a prolonged hospital LOS, poor health outcomes, greater use of limited resources, and increased medical costs. ^ Research has shown that experienced clinicians can predict LOS no better than chance. Current CABG surgery LOS risk models differ greatly in generalizability and ease of use in the clinical setting. A predictive model that identified modifiable pre- and intra-operative risk factors for CVICU LOS greater than two days could have major public health implications as modification of these identified factors could decrease CVICU LOS and potentially minimize morbidity and mortality, optimize use of limited health care resources, and decrease medical costs. ^ The primary aim of this study was to identify modifiable pre-and intra-operative predictors of CVICU LOS greater than two days for CABG surgery patients with cardiopulmonary bypass (CPB). A secondary aim was to build a probability equation for CVICU LOS greater than two days. Data were extracted from 416 medical records of CABG surgery patients with CPB, 50 to 80 years of age, recovered in the CVICU of a large teaching, referral hospital in southeastern Texas, during the calendar year 2004 and the first quarter of 2005. Exclusion criteria included Diagnosis Related Group (DRG) 106, CABG surgery without CPB, CABG surgery with other procedures, and operative deaths. The data were analyzed using multivariate logistic regression for an alpha=0.05, power=0.80, and correlation=0.26. ^ This study found age, history of peripheral arterial disease, and total operative time equal to and greater than four hours to be independent predictors of CVICU LOS greater than two days. The probability of CVICU LOS greater than two days can be calculated by the following equation: -2.872941 +.0323081 (age in years) + .8177223 (history of peripheral arterial disease) + .70379 (operative time). ^

Genetic epidemiology of childhood brain tumors

A rare familial cancer syndrome involving childhood brain tumors (CBT), breast cancer, sarcomas and an array of other tumors has been described (Li and Fraumeni 1969, 1975, 1982, 1987). A survey of CBT identified through the Connnecticut Tumor Registry in 1984 revealed a high frequency of CBT, leukemia and other childhood cancer in siblings of CBT patients (Farwell and Flannery, 1984). Other syndromes such as neurofibromatosis and nevoid basal cell carcinoma syndrome have also been associated with CBT; however, no systematic family studies have been conducted to determine the extent to which cancer aggregates in family members of CBT patients. This family study was designed to determine the frequency of cancer aggregation overall or at specific sites, to determine the frequency of known or potentially hereditary syndromes in families of CBT patients, and to determine a genetic model to characterize familial cancer syndromes and to identify specific kindreds to which such a model(s) might apply. This study includes 244 confirmed CBT patients referred to the University of Texas M. D. Anderson Cancer Center between the years 1944 and 1983, diagnosed under the age of 15 years and resident in the U.S. or Canada. Family histories were obtained on the proband's first (parents, siblings and offspring) and second degree (proband's aunts, uncles and grandparents) relatives following sequential sampling scheme rules. To determine if cancer aggregates in families, we compared the cancer experience in the population to that expected in the general population using Connecticut Tumor Registry calendar year, age, race and sex-specific rates. The standardized incidence ratio (SIR) for cancer overall was 0.91 (41 observed (O) and 44.94 expected (E); 95% Confidence Interval (CI) = 0.65-1.24). We observed a significant excess of colon cancer among the proband's first degree relatives (O/E = 5/1.64; 95% CI = 1.01-7.65), in particular those under age 45 year. Segregation analysis showed evidence for multifactorial inheritance in the small percentage (N = 5) of the families. ^

Mitral valve prolapse and its relationship with stroke

The purpose of this study was to elucidate the relationship between mitral valve prolapse and stroke. A population-based historical cohort investigation was conducted among residents of Olmsted County, Minnesota who had an initial echocardiographic diagnosis of mitral valve prolapse from 1975 through 1989. This cohort (N = 1085) was followed for stroke outcomes using the resources of an operational medical record linkage system. There was an overall two-fold increase in the incidence of stroke among individuals with mitral valve prolapse relative to a standard population (standardized morbidity ratio = 2.12, 95% confidence limits = 1.33-3.21). When the data were partitioned by duration of follow-up from the diagnosis of mitral valve prolapse, or by the calendar years at echocardiographic diagnosis, respectively, the association between mitral valve prolapse and stroke was not modified. Mitral valve prolapse subjects 85 years and older were at highest increased risk of developing strokes relative to the general population (standardized morbidity ratio = 5.47, 95% confidence limits = 2.20-11.24). Coronary heart disease, atrial fibrillation, diabetes mellitus and hypertension, were unlikely to have confounded the association between mitral valve prolapse and stroke.^ The cumulative risk of first stroke among individuals initially diagnosed with mitral valve prolapse age 15 to 64 years, given survival to 15.2 years of follow-up, was 4.0%. The cumulative risk of first stroke among individuals initially diagnosed with mitral valve prolapse age 65 to 74 years, given survival to 11.2 years of follow-up, was 13.2%. The cumulative risk of first stroke among individuals initially diagnosed with mitral valve prolapse age 75 years and older, given survival to 6.7 years of follow-up, was 30.6%.^ Among individuals with mitral valve prolapse, age, diabetes, and atrial fibrillation were associated with an increased risk of stroke. Atrial fibrillation was associated with a four-fold rate of stroke and diabetes associated with a seven-fold rate of stroke.^ Findings from this research support the hypothesis that mitral valvular heart prolapse is linked with a stroke sequela. ^

MEASURING THE EFFECT OF ILLNESS ON THE EXPECTED REMAINING SERVICE TIME FOR THE ACTIVE DUTY ARMY: A LIFE TABLE APPROACH

A life table methodology was developed which estimates the expected remaining Army service time and the expected remaining Army sick time by years of service for the United States Army population. A measure of illness impact was defined as the ratio of expected remaining Army sick time to the expected remaining Army service time. The variances of the resulting estimators were developed on the basis of current data. The theory of partial and complete competing risks was considered for each type of decrement (death, administrative separation, and medical separation) and for the causes of sick time.^ The methodology was applied to world-wide U.S. Army data for calendar year 1978. A total of 669,493 enlisted personnel and 97,704 officers were reported on active duty as of 30 September 1978. During calendar year 1978, the Army Medical Department reported 114,647 inpatient discharges and 1,767,146 sick days. Although the methodology is completely general with respect to the definition of sick time, only sick time associated with an inpatient episode was considered in this study.^ Since the temporal measure was years of Army service, an age-adjusting process was applied to the life tables for comparative purposes. Analyses were conducted by rank (enlisted and officer), race and sex, and were based on the ratio of expected remaining Army sick time to expected remaining Army service time. Seventeen major diagnostic groups, classified by the Eighth Revision, International Classification of Diseases, Adapted for Use In The United States, were ranked according to their cumulative (across years of service) contribution to expected remaining sick time.^ The study results indicated that enlisted personnel tend to have more expected hospital-associated sick time relative to their expected Army service time than officers. Non-white officers generally have more expected sick time relative to their expected Army service time than white officers. This racial differential was not supported within the enlisted population. Females tend to have more expected sick time relative to their expected Army service time than males. This tendency remained after diagnostic groups 580-629 (Genitourinary System) and 630-678 (Pregnancy and Childbirth) were removed. Problems associated with the circulatory system, digestive system and musculoskeletal system were among the three leading causes of cumulative sick time across years of service. ^

A comparison of worker risk of injury while working on fully automated side loaders and other residential collection trucks at a large solid waste collection company

The study aim was to determine whether using automated side loader (ASL) trucks in higher proportions compared to other types of trucks for residential waste collection results in lower injury rates (from all causes). The primary hypothesis was that the risk of injury to workers was lower for those who work with ASL trucks than for workers who work with other types of trucks used in residential waste collection. To test this hypothesis, data were collected from one of the nation’s largest companies in the solid waste management industry. Different local operating units (i.e. facilities) in the company used different types of trucks to varying degrees, which created a special opportunity to examine refuse collection injuries and illnesses and the risk reduction potential of ASL trucks.^ The study design was ecological and analyzed end-of-year data provided by the company for calendar year 2007. During 2007, there were a total of 345 facilities which provided residential services. Each facility represented one observation.^ The dependent variable – injury and illness rate, was defined as a facility’s total case incidence rate (TCIR) recorded in accordance with federal OSHA requirements for the year 2007. The TCIR is the rate of total recordable injury and illness cases per 100 full-time workers. The independent variable, percent of ASL trucks, was calculated by dividing the number of ASL trucks by the total number of residential trucks at each facility.^ Multiple linear regression models were estimated for the impact of the percent of ASL trucks on TCIR per facility. Adjusted analyses included three covariates: median number of hours worked per week for residential workers; median number of months of work experience for residential workers; and median age of residential workers. All analyses were performed with the statistical software, Stata IC (version 11.0).^ The analyses included three approaches to classifying exposure, percent of ASL trucks. The first approach included two levels of exposure: (1) 0% and (2) >0 - <100%. The second approach included three levels of exposure: (1) 0%, (2) ≥ 1 - < 100%, and (3) 100%. The third approach included six levels of exposure to improve detection of a dose-response relationship: (1) 0%, (2) 1 to <25%, (3) 25 to <50%, (4) 50 to <75%, (5) 75 to <100%, and (6) 100%. None of the relationships between injury and illness rate and percent ASL trucks exposure levels was statistically significant (i.e., p<0.05), even after adjustment for all three covariates.^ In summary, the present study shows that there is some risk reduction impact of ASL trucks but not statistically significant. The covariates demonstrated a varied yet more modest impact on the injury and illness rate but again, none of the relationships between injury and illness rate and the covariates were statistically significant (i.e., p<0.05). However, as an ecological study, the present study also has the limitations inherent in such designs and warrants replication in an individual level cohort design. Any stronger conclusions are not suggested.^

MS 073 Guide to the William C. Moloney MD papers; 1952-1954

William C. Moloney MD kept a personal journal, with photographs, for much of his two years in Japan with the Atomic Bomb Casualty Commission. In January of 1986, Dr.Moloney donated his journal, correspondence and diary pages to the Harris County Medical Archive. He died in 1998 at the age of 91. His first contribution was a set of ten reprints representing his work with the ABCC from 1952 to 1954. Dr.Moloney's journal is a fine document, one which will be of great use to historians. It is an important record of personal impressions, thoughts and details of events. The journal gives new insights into the work of the ABCC and into the people who participated in that work. Dr. Moloney wrote in his journal from April 1952 to February 1954. The Korean War was on and there was a great deal of military activity in southern Japan. The collection is open for research. The collection consists of a handwritten journal, loose calendar or notebook pages and some reprints. The journal is in generally fair condition. The paper is slightly acidic and the binding is loose. There are numerous photos glued onto the pages. The collection encompasses the years 1952-1954 and is 0.25 cubic feet (1 box).

Expanding Learning Time in Schools: Considering the Challenges of Implementation and the Potential Impact

Considering the broader context of school reform that is seeking education strategies that might deliver substantial impact, this article examines four questions related to the policy and practice of expanding learning time: (a) why do educators find the standard American school calendar insufficient to meet students’ educational needs, especially those of disadvantaged students? (b) how do educators implement a longer day and/or year, addressing concerns about both educational quality and costs? (c) what does research report about outcomes of expanding time in schools? and (d) what are the future prospects for increasing the number of expanded-time schools? The paper examines these questions by considering research, policy, and practice at the national level and, throughout, by drawing upon additional evidence from Massachusetts, one of the leading states in the expanded-time movement. In considering the latter two questions, the article explores the knowns and unknowns related to expanded learning time and offers suggestions for further research.

The association of nonfatal occupational injuries with non -work -related morbidity

A case-referent study of occupational injuries sustained by 474 workers employed in the heavy equipment machinery industry over a two year period, 1985-1986, was undertaken to examine the association of occupational injuries with non-work-related morbidity. Its specific aim was to evaluate whether employees who experienced a work-related injury had an increased prevalence of non-work-related morbidity, specifically for injuries, cardiovascular disease, mental disorders, all other disease outcomes and total morbidity, compared to employees who did not experience a work-related injury. In order to determine the direction of the relationship, the use of the previous calendar year was employed to assess non-work-related morbidity. A secondary objective of the study was the evaluation of the utility of two existing data sources, workers' compensation and group health insurance claims, and the feasibility of conducting studies based on these data.^ The association of non-work-related non-back injuries and subsequent occupational injury was statistically significant (OR = 1.31, 95% CI 1.02-1.67) for all WC claims. The strength of the association was supported by the elevated odds ratio for non-work-related injuries when severity of occupational injury was assessed by WC claim costs of $100 and greater (OR = 1.47, 1.09--1.97), and by lost workdays (OR = 1.37). Factors that predispose an individual to a non-back injury, such as personal attributes and lifestyle characteristics, also influence that individual's risk of subsequent occupational injury. These factors may be reflected in an employee's reaction to life stressors which influence susceptibility to injury. The role of employee assistance programs as a component of injury prevention strategies is suggested.^ An increased but nonsignificant prevalence of non-work-related injuries, cardiovascular disease, mental disorders, and other morbidity conditions was noted among cases. These findings do not provide support of a causal factor in the etiology of occupational injuries. In contrast to non-back injuries, these conditions are chronic in nature and their influence on risk of occupational injuries uncertain.^ In general, cases tended to file more group health insurance claims for other morbidity than did referents. The association with increased total morbidity was consistent whether worker compensation claims were analyzed by total number of claims, claims with costs of $100 and greater, or by lost workdays. Whether persons who sustained an occupational injury were in fact in poor general health than referents, warrant further investigation. ^