Blood glucose level on postoperative day 1 is predictive of adverse outcomes after cardiovascular surgery

AIM: Hyperglycaemia is now a recognized predictive factor of morbidity and mortality after coronary artery bypass grafting (CABG). For this reason, we aimed to evaluate the postoperative management of glucose control in patients undergoing cardiovascular surgery, and to assess the impact of glucose levels on in-hospital mortality and morbidity. METHODS: This was a retrospective study investigating the association between postoperative blood glucose and outcomes, including death, post-surgical complications, and length of stay in the intensive care unit (ICU) and in hospital. RESULTS: A total of 642 consecutive patients were enrolled into the study after cardiovascular surgery (CABG, carotid endarterectomy and bypass in the lower limbs). Patients' mean age was 68+/-10 years, and 74% were male. In-hospital mortality was 5% in diabetic patients vs 2% in non-diabetic patients (OR: 1.66, P=0.076). Having blood glucose levels in the upper quartile range (> or =8.8 mmol/L) on postoperative day 1 was independently associated with death (OR: 10.16, P=0.0002), infectious complications (OR: 1.76, P=0.04) and prolonged ICU stay (OR: 3.10, P<0.0001). Patients presenting with three or more hypoglycaemic episodes (<4.1 mmol/L) had increased rates of mortality (OR: 9.08, P<0.0001) and complications (OR: 8.57, P<0.0001). CONCLUSION: Glucose levels greater than 8.8 mmol/L on postoperative day 1 and having three or more hypoglycaemic episodes in the postoperative period were predictive of mortality and morbidity among patients undergoing cardiovascular surgery. This suggests that a multidisciplinary approach may be able to achieve better postoperative blood glucose control. Conclusion: Objectif: L'hyperglycémie a été reconnue comme facteur prédictif de morbidité et mortalité après un pontage aortocoronaire. Notre étude avait pour objectif d'évaluer la prise en charge postopératoire des glycémies chez les patients qui avaient subi une intervention chirurgicale cardiovasculaire et d'évaluer l'impact de ces glycémies sur la mortalité et la morbidité intrahospitalières. Méthodes: Étude rétrospective recherchant une association entre la glycémie postopératoire et les complications postchirurgicales, la mortalité et la durée du séjour aux soins intensifs et à l'hôpital. Résultats: L'étude a été réalisée sur 642 patients qui avaient subi une intervention chirurgicale cardiovasculaire (ex. pontage aortocoronaire, endartérectomie de la carotide, pontage artériel des membres inférieurs). L'âge moyen est de 68 ± 10 ans et 74 % des patients étaient de sexe masculin. La mortalité intrahospitalière a été de 5 % parmi les patients diabétiques et 2 % chez les non-diabétiques (OR 1,66, p = 0,076). Les taux de glycémies situés dans le quartile supérieur (≥ 8,8 mmol/l) à j1 postopératoire sont associés de manière indépendante avec la mortalité (OR 10,16, 95 % CI 3,20-39,00, p = 0,0002), les complications infectieuses (OR 1,76, 95 % CI 1,02-3,00, p = 0,04) et la durée du séjour aux soins intensifs (OR 3,10, 95 % CI 1,83-5,38, p < 0,0001). Les patients qui avaient présenté trois hypoglycémies ou plus (< 4,1 mmol/l) ont présenté un taux augmenté de mortalité (OR 9,08, p ≤ 0,0001) et de complications (OR 8,57, p < 0,0001). Conclusion : Des glycémies supérieures à 8,8 mmol/l à j1 postopératoire et la présence de trois hypoglycémies ou plus en période postopératoire sont des facteurs prédictifs de mauvais pronostic chez les patients qui avaient subi une intervention chirurgicale cardiovasculaire. Ainsi, une approche multidisciplinaire devrait être proposée afin d'obtenir un meilleur contrôle postopératoire des glycémies.

Street-Level Bureaucracy and E-Government

With the intensive use of information and communication technologies, governments are transforming into e-governments. While public management research has given increased attention to this subject lately, this article reviews the limited literature that deals with the impacts of e-government technologies on street-level bureaucracies. A twofold argument is being developed. First, what can be called the 'curtailment thesis', stressing the reduction or disappearance of frontline policy discretion, is addressed. Second, the 'enablement thesis' gets attention, highlighting how technologies provide frontline workers and citizens with additional action resources. The article concludes with propositions for a future research agenda on the topic.

Perceptions of aging across 26 cultures and their culture-level associates

College students (N = 3,435) in 26 cultures reported their perceptions of age-related changes in physical cognitive, and socioemotional areas of functioning and rated societal views of aging within their culture. There was widespread cross-cultural consensus regarding the expected direction of aging trajectories with (a) perceived declines in societal views of aging, physical attractiveness, the ability to perform everyday tasks, and new learning; (b) perceived increases in wisdom, knowledge, and received respect; and (c) perceived stability in family authority and life satisfaction. Cross-cultural variations in aging perceptions were associated with culture-level indicators of population aging, education levels, values, and national character stereotypes. These associations were stronger for societal views on aging and perceptions of socioemotional changes than for perceptions of physical and cognitive changes. A consideration of culture-level variables also suggested that previously reported differences in aging perceptions between Asian and Western countries may be related to differences in population structure.

The Social Inclusion of Older People at Local Level: The Role and Contribution of CDBs

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Reduction of the hand representation in the ipsilateral primary motor cortex following unilateral section of the corticospinal tract at cervical level in monkeys.

BACKGROUND: After sub-total hemi-section of cervical cord at level C7/C8 in monkeys, the ipsilesional hand exhibited a paralysis for a couple of weeks, followed by incomplete recovery of manual dexterity, reaching a plateau after 40-50 days. Recently, we demonstrated that the level of the plateau was related to the size of the lesion and that progressive plastic changes of the motor map in the contralesional motor cortex, particularly the hand representation, took place following a comparable time course. The goal of the present study was to assess, in three macaque monkeys, whether the hand representation in the ipsilesional primary motor cortex (M1) was also affected by the cervical hemi-section.¦RESULTS: Unexpectedly, based on the minor contribution of the ipsilesional hemisphere to the transected corticospinal (CS) tract, a considerable reduction of the hand representation was also observed in the ipsilesional M1. Mapping control experiments ruled out the possibility that changes of motor maps are due to variability of the intracortical microstimulation mapping technique. The extent of the size reduction of the hand area was nearly as large as in the contralesional hemisphere in two of the three monkeys. In the third monkey, it represented a reduction by a factor of half the change observed in the contralesional hemisphere. Although the hand representation was modified in the ipsilesional hemisphere, such changes were not correlated with a contribution of this hemisphere to the incomplete recovery of the manual dexterity for the hand affected by the lesion, as demonstrated by reversible inactivation experiments (in contrast to the contralesional hemisphere). Moreover, despite the size reduction of M1 hand area in the ipsilesional hemisphere, no deficit of manual dexterity for the hand opposite to the cervical hemi-section was detected.¦CONCLUSION: After cervical hemi-section, the ipsilesional motor cortex exhibited substantial reduction of the hand representation, whose extent did not match the small number of axotomized CS neurons. We hypothesized that the paradoxical reduction of hand representation in the ipsilesional hemisphere is secondary to the changes taking place in the contralesional hemisphere, possibly corresponding to postural adjustments and/or re-establishing a balance between the two hemispheres.

Social Inclusion of Older People at Local Level:The Role and Contribution of the CDBs - Conference Proceedings

This is a publication of The National Council on Ageing and Older People The Conference took place on October 3, 2005 . It attracted almost 250 delegates from across the statutory, voluntary and private sectors, and from every county. The Conference provided the opportunity for delegates to focus on the issue of social inclusion of older people at local level and the challenges it presents. It also gave us the opportunity to examine the issue in the context of work done at the international and national levels as well as work done at local level. Read the Report (PDF, 317kb)

Reduced physical activity level and cardiorespiratory fitness in children with chronic diseases.

We aimed to compare physical activity level and cardiorespiratory fitness in children with different chronic diseases, such as type 1 diabetes mellitus (T1DM), obesity (OB) and juvenile idiopathic arthritis (JIA), with healthy controls (HC). We performed a cross-sectional study including 209 children: OB: n = 45, T1DM: n = 48, JIA: n = 31, and HC: n = 85. Physical activity level was assessed by accelerometer and cardiorespiratory fitness by a treadmill test. ANOVA, linear regressions and Pearson correlations were used. Children with chronic diseases had reduced total daily physical activity counts (T1DM 497 +/- 54 cpm, p = 0.003; JIA 518 +/- 28, p < 0.001, OB 590 +/- 25, p = 0.003) and cardiorespiratory fitness (JIA 39.3 +/- 1.7, p = 0.001, OB 41.7 +/- 1.2, p = 0.020) compared to HC (668 +/- 35 cpm; 45.3 +/- 0.9 ml kg(-1) min(-1), respectively). Only 60.4% of HC, 51.6% of OB, 38.1% of JIA and 38.5% of T1DM children met the recommended daily 60 min of moderate-to-vigorous physical activity. Low cardiorespiratory fitness was associated with female gender and low daily PA. Children with chronic diseases had reduced physical activity and cardiorespiratory fitness. As the benefits of PA on health have been well demonstrated during growth, it should be encouraged in those children to prevent a reduction of cardiorespiratory fitness and the development of comorbidities.

Ampakine CX546 bolsters energetic response of astrocytes: a novel target for cognitive-enhancing drugs acting as alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor modulators.

Glutamate was previously shown to enhance aerobic glycolysis i.e. increase glucose utilization and lactate production with no change in oxygen levels, in mouse cortical astrocytes by a mechanism involving glutamate uptake. It is reported here that a similar response is produced in both hippocampal and cerebellar astrocytes. Application of the cognitive-enhancing drug CX546 promoted further enhancement of glucose utilization by astrocytes from each brain area following glutamate exposure. alpha-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors represent the purported molecular target of cognitive-enhancing drugs such as CX546, and the presence of AMPA receptor subunits GluR1-4 was evidenced in astrocytes from all three regions by immunocytochemistry. AMPA itself did not stimulate aerobic glycolysis, but in the presence of CX546, a strong enhancement of glucose utilization and lactate production was obtained in cortical, hippocampal and cerebellar astrocytes. The effect of CX546 was concentration-dependent, with an EC(50) of 93.2 microm in cortical astrocytes. AMPA-induced glucose utilization in the presence of CX546 was prevented by the AMPA receptor antagonist 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) and the negative modulator GYKI 52466. In addition, the metabolic effect of CX546 in the presence of AMPA was mimicked by the AMPA receptor modulator cyclothiazide. Our data suggest that astrocyte energetics represents a novel target for cognitive-enhancing drugs acting as AMPA receptor modulators.

An experimental study on the shallow-level migmatization of ferrogabbros from the Fuerteventura Basal Complex, Canary Islands

Spectacular shallow-level migmatization of ferrogabbroic rocks occurs in a metamorphic contact aureole of a gabbroic pluton of the Tierra Mala massif (TM) on Fuerteventura (Canary Islands). In order to improve our knowledge of the low pressure melting behavior of gabbroic rocks and to constrain the conditions of migmatization of the TM gabbros, we performed partial melting experiments on a natural ferrogabbro, which is assumed as protolith of the migmatites. The experiments were performed in an internally heated pressure vessel (IHPV) at 200 MPa, 930-1150 degreesC at relatively oxidizing conditions. Distinct amounts of water were added to the charge. From 930 to 1000 degreesC, the observed experimental phases are plagioclase (An(60-70)), clinopyroxene, amphibole (titanian magnesiohastingsites), two Fe-Ti oxides, and a basaltic, K-poor melt. Above 1000 degreesC, amphibole is no longer stable. The first melts are very rich in non-native plagioclase (>70 wt.%). This indicates that at the beginning of partial melting plagioclase is the major phase which is consumed to produce melt. In the experiments, plagioclase is stable up to high temperatures (1060 degreesC) showing increasing An content with temperature. This is not compatible with the natural migmatites, in which An-rich plagioclase is absent in the melanosomes, while amphibole is stable. Our results show that the partial melting of the natural rocks cannot be regarded as an ``in-situ'' process that occurred in a closed system. Considerable amounts of alkalis probably transported by water-rich fluids, derived from the mafic pluton underplating the TM gabbro, were necessary to drive the melting reaction out of the stability range of plagioclase. A partial melting experiment with a migmatite gabbro showing typical ``in-situ'' textures as starting material supports this assumption. Crystallization experiments performed at 1000 degreesC on a glass of the fitised ferrogabbro with different water contents added to the charge show that generally high water activities could be achieved (crystallization of amphibole), independently of the bulk water content, even in a system with very low initial bulk water content (0.3 wt.%). Increasing water contents produce plagioclase richer in An, reduces the modal proportion of plagioclase in the crystallizing assemblage and extends the melt fraction. High melt fractions of >30 wt.% could only be observed in systems with high bulk water contents (> - 2 wt.%). This indicates that the migmatites were generated under water-rich conditions (probably water-saturated), since those migmatites, which are characterized as ``in-situ'' formations, show generally high amounts of leucosomes (>30 wt.%). (C) 2003 Elsevier B.V. All rights reserved.

Copeptin, a stable peptide derived from the vasopressin precursor, correlates with the individual stress level.

BACKGROUND: During stress, vasopressin is a potent synergistic factor of CRH as a hypothalamic stimulator of the HPA axis. The measurements of CRH and vasopressin levels are cumbersome because of their instability and short half-life. Copeptin is a more stable peptide stoichiometrically released from the same precursor molecule. The aim of our study was to compare copeptin and cortisol levels in different stress situations. METHODS: Three groups of patients with increasing stress levels were investigated: a) healthy controls without apparent stress (n=20), b) hospitalized medical patients with moderate stress (n=25) and c) surgical patients 30 minutes after extubation, with maximal stress (n=29). In all patients we assessed cortisol and copeptin levels. Copeptin levels were measured with a new sandwich immunoassay. RESULTS: Cortisol levels in controls were (median, IQ range, 486 [397-588] nmol/L), not significantly different as compared to medical patients (438 [371-612] nmol/L, p=0.69). Cortisol levels in surgical patients after extubation were higher (744 [645-1062] nmol/L p<0.01 vs controls and medical patients). Copeptin levels in controls were 4.3 [3.2-5.5] pmol/L, which was lower as compared to medical patients (17.5 [6.4-24.1], p<0.001) and surgical patients after extubation (67.5 [37.8-110.0] pmol/L, p<0.001). The correlation between copeptin levels and cortisol was r=0.46, p<0.001. CONCLUSION: Copeptin is a novel marker of the individual stress level. It more subtly mirrors moderate stress as compared to cortisol values.

Evaluation of cholinesterase level in an endemic population exposed to malathion suspension formulation as a vector control measure

The manuscript describes a study on the blood cholinesterase (ChE) level in an exposed population at different interval of time after spraying with malathion suspension (SRES) use for kala-azar vector control in an endemic area of Bihar, India. The toxicity of a 5% malathion formulation in the form of a slow release emulsified suspension (SRES) was assessed by measuring serum ChE levels in spraymen and in the exposed population.The study showed a significant decrease in ChE levels in the spraymen (p < 0.01) after one week of spraying and in exposed population one week and one month after of spraying (p < 0.01), but was still within the normal range of ChE concentration, one year after spraying, the ChE concentration in the exposed population was the same as prior to spraying (p > 0.01). On no occasion was the decrease in ChE level alarming. A parallel examination of the clinical status also showed the absence of any over toxicity or any behavioural changes in the exposed population. Hence, it may be concluded that 5% malathion slow release formulation, SRES, is a safe insecticide for use as a vector control measure in endemic areas of kala-azar in Bihar, India so long as good personal protection for spraymen is provided to minimize absorption and it can substitute the presently used traditional DDT spray.

Weigh2go: A Peripatetic Level 1 Weight Management Service

The aim of this intervention is to increase the accessibility of appropriate evidence based support to people who are clinically obese to enable them to make lifestyle changes that will lead to weight loss. Objectives1. Identify patients whose lifestyle put them at risk of obesity and poor health outcomes and provide them with advice and support along with signposting to specific services and activities. 2. Identify patients who are overweight or obese and offer them a structured multi-component programme of support for them to loose weight. 3. Through the use of software collect data to monitor outcomes at individual and practice levels.

A Study of the Epidemiology of AIDS in Ireland and an Evaluation of an AIDS Education Programme in Second-level Schools

Second-level school students have been identified by the Minister for health as a priority group for education on AIDS. An education programme was accordingly initiated in 1988 in Community Care Area 1 in South county Dublin. This report evaluates this education intervention by means of pre- and post- intervention questionnaires. The questionnaire examined knowledge and attitudes of students relevant to AIDS. The results showed that the level of knowledge of students living in this area was high prior to intervention. The education programme succeeded in improving some aspects of knowledge and also influenced some attitudes of the students. A study of the epidemiology of Aids in Ireland reveals that the epidemic is at a relatively early stage with a consequent rapid doubling time of 9-10 months. In comparison with most developed countries Ireland has a high proportion of AIDS cases occurring among intravenous drug abusers and directly related to this a high number of HIV infected children. Examination of the literature reveals that behaviour change has occurred most noticeably among the homosexual/bisexual risk group. There is some evidence that the comprehensive programmes can achieve change in the behaviour of intravenous drug abusers. There are very few reports linking behaviour change among adolescents and young adults to education programmes. Much of the available literature relates to changes in knowledge and attitudes. International recommendations on the nature of the ideal health education intervention on AIDS are reviewed. The importance of a comprehensive health education programme which incorporates AIDS education and which commences early in youth is noted. The role of the community physician in relation to education programmes and other aspects of monitoring and management of the AIDS epidemic is discussed.This resource was contributed by The National Documentation Centre on Drug Use.

Correlating the end-Triassic mass extinction and flood basalt volcanism at the 100 ka level

New high-precision U/Pb geochronology from volcanic ashes shows that the Triassic-Jurassic boundary and end-Triassic biological crisis from two independent marine stratigraphic sections correlate with the onset of terrestrial flood volcanism in the Central Atlantic Magmatic Province to <150 ka. This narrows the correlation between volcanism and mass extinction by an order of magnitude for any such catastrophe in Earth history. We also show that a concomitant drop and rise in sea level and negative delta C-13 spike in the very latest Triassic occurred locally in <290 ka. Such rapid sea-level fluctuations on a global scale require that global cooling and glaciation were closely associated with the end-Triassic extinction and potentially driven by Central Atlantic Magmatic Province volcanism.

Blood glucose level on postoperative day 1 is predictive of adverse outcomes after cardiovascular surgery.

AIM: Hyperglycaemia is now a recognized predictive factor of morbidity and mortality after coronary artery bypass grafting (CABG). For this reason, we aimed to evaluate the postoperative management of glucose control in patients undergoing cardiovascular surgery, and to assess the impact of glucose levels on in-hospital mortality and morbidity. METHODS: This was a retrospective study investigating the association between postoperative blood glucose and outcomes, including death, post-surgical complications, and length of stay in the intensive care unit (ICU) and in hospital. RESULTS: A total of 642 consecutive patients were enrolled into the study after cardiovascular surgery (CABG, carotid endarterectomy and bypass in the lower limbs). Patients' mean age was 68+/-10 years, and 74% were male. In-hospital mortality was 5% in diabetic patients vs 2% in non-diabetic patients (OR: 1.66, P=0.076). Having blood glucose levels in the upper quartile range (> or =8.8 mmol/L) on postoperative day 1 was independently associated with death (OR: 10.16, P=0.0002), infectious complications (OR: 1.76, P=0.04) and prolonged ICU stay (OR: 3.10, P<0.0001). Patients presenting with three or more hypoglycaemic episodes (<4.1 mmol/L) had increased rates of mortality (OR: 9.08, P<0.0001) and complications (OR: 8.57, P<0.0001). CONCLUSION: Glucose levels greater than 8.8 mmol/L on postoperative day 1 and having three or more hypoglycaemic episodes in the postoperative period were predictive of mortality and morbidity among patients undergoing cardiovascular surgery. This suggests that a multidisciplinary approach may be able to achieve better postoperative blood glucose control.