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). ^

A systematic review of economic evaluations for interventions of cardiovascular diseases

Background. Cardiovascular disease (CVD) exhibits the most striking public health significance due to its high prevalence and mortality as well as huge economic burdens all over the world, especially in industrialized countries. Major risk factors of CVDs have been the targets of population-wide prevention in the United States. Economic evaluations provide structured information in regard to the efficiency of resource utilization which can inform decisions of resource allocation. The main purpose of this review is to investigate the pattern of study design of economic evaluations for interventions of CVDs. ^ Methods. Primary journal articles published during 2003-2008 were systematically retrieved via relevant keywords from Medline, NHS Economic Evaluation Database (NHS EED) and EBSCO Academic Search Complete. Only full economic evaluations for narrowly defined CVD interventions were included for this review. The methodological data of interest were extracted from the eligible articles and reorganized in Microsoft Access database. Chi-square tests in SPSS were used to analyze the associations between pairs of categorical data. ^ Results. One hundred and twenty eligible articles were reviewed after two steps of literature selection with explicit inclusion and exclusion criteria. Descriptive statistics were reported regarding the evaluated interventions, outcome measures, unit costing and cost reports. The chi-square test of the association between prevention level of intervention and category of time horizon showed no statistical significance. The chi-square test showed that sponsor type was significantly associated with whether new or standard intervention being concluded as more cost effective. ^ Conclusions. Tertiary prevention and medication interventions are the major interests for economic evaluators. The majority of the evaluations were claimed from either a provider’s or a payer’s perspective. Almost all evaluations adopted gross costing strategy for unit cost data rather than micro costing. EQ-5D is the most commonly used instrument for subjective outcome measurement. More than half of the evaluations used decision analytic modeling techniques. The lack of consistency in study design standards in published evaluations appears in several aspects. Prevention level of intervention is not likely to be a factor for evaluators to decide whether to design an evaluation in a lifetime horizon or not. Published evaluations sponsored by industry are more likely to conclude that new intervention is more cost effective than standard intervention.^

Percutaneous transluminal coronary angioplasty and coronary events in a biethnic Texas community, 1985--1990

The relationship between change in myocardial infarction (MI) mortality rate (ICD codes 410, 411) and change in use of percutaneous transluminal coronary angioplasty (PTCA), adjusted for change in hospitalization rates for MI, and for change in use of aortocoronary bypass surgery (ACBS) from 1985 through 1990 at private hospitals was examined in the biethnic community of Nueces County, Texas, site of the Corpus Christi Heart Project, a major coronary heart disease (CHD) surveillance program. Age-adjusted rates (per 100,000 persons) were calculated for each of these CHD events for the population aged 25 through 74 years and for each of the four major sex-ethnic groups: Mexican-American and Non-Hispanic White women and men. Over this six year period, there were 541 MI deaths, 2358 MI hospitalizations, 816 PTCA hospitalizations, and 920 ACBS hospitalizations among Mexican-American and Non-Hispanic White Nueces County residents. Acute MI mortality decreased from 24.7 in the first quarter of 1985 to 12.1 in the fourth quarter of 1990, a 51.2% decrease. All three hospitalization rates increased: The MI hospitalization rates increased from 44.1 to 61.3, a 38.9% increase, PTCA use increased from 7.1 to 23.2, a 228.0% increase, and ACBS use increased from 18.8 to 29.5, a 56.6% increase. In linear regression analyses, the change in MI mortality rate was negatively associated with the change in PTCA use (beta = $-$.266 $\pm$.103, p = 0.017) but was not associated with the changes in MI hospitalization rate and in ACBS use. The results of this ecologic research support the idea that the increasing use of PTCA, but not ACBS, has been associated with decreases in MI mortality. The contrast in associations between these two revascularization procedures and MI mortality highlights the need for research aimed at clarifying the proper roles of these procedures in the treatment of patients with CHD. The association between change in PTCA use and change in MI mortality supports the idea that some changes in medical treatment may be partially responsible for trends in CHD mortality. Differences in the use of therapies such as PTCA may be related to differences between geographical sites in CHD rates and trends. ^

The effect of life events on blood pressure and body mass index in children

In Conroe, Texas, 492 students ages 5 to 15 participated in a screening examination for cardiovascular risk factor study. Among 492 students, 141 elementary and junior high students participated in the present sub-study to investigate the effect of the number of recent life events on blood pressure and on body mass index. Using the elementary and junior high school Coddington scales, life events occurring in the past 12 months were measured for students ages 9 to 14 years, no significant differences in life events were observed by age and sex. The number of life events was not related to blood pressure but was positively correlated to body mass index in children and adolescents. ^

The relationship of obesity and cardiovascular disease

Aim. To review published literature on the relationship of obesity and cardiovascular disease.^ Methods. To look at all the studies published on the topic from 2005.^ Results. In the studies done prior to 2011, body mass index and in particular waist to hip ratio (51.57) was found to be associated with coronary heart disease. But, this relationship was challenged by the latest Lancet 2011meta-analysis 1 which concluded that singly or in combination, body-mass index, waist circumference, and waist-to-hip ratio did not importantly improve prediction of first-onset cardiovascular disease when additional information exists on blood pressure, history of diabetes, and cholesterol measures were available. Furthermore, they also found long-term reproducibility of BMI to be superior to that of waist-to-hip ratio (or waist circumference). Interestingly, body mass index in later childhood and early adult life showed positive association with coronary heart disease later in life 2. In US female health professionals 3 increasing body mass index was found to be associated with increased coronary heart disease risk. Overall 4, physical activity was found to be independently associated with fewer risk factors, less coronary artery disease, and fewer adverse events in women. Finally, obesity was found to be associated with increased overall cardiovascular mortality and coronary heart disease mortality 5.^ Conclusions. There is insufficient data to draw guidelines regarding parameters of obesity affecting cardiovascular disease. But there is data to support that lower body mass index would lead to decreased cardiovascular disease mortality. And physical activity has a direct association with less coronary artery disease in women.^

Systematic review of current trends of cardiovascular disease (CVD) and association between health insurance coverage and CVD mortality among women aged 60--65 in Texas in 2000--2011

Cardiovascular disease (CVD) is highly preventable, yet it is a leading cause of death among women in Texas. The primary goals of this research were to examine past and current trends of CVD, as well as identify whether there is an association between the insurance coverage and mortality from CVD among women aged 60–65 in Texas between 2000 and 2011. ^ The systematic review of the research is based on the guidelines and recommendations set by the Centre for Reviews and Dissemination for conducting reviews in health care. Over 47 citations of peer-reviewed articles from Ovid MEDLINE and PubMed databases and five websites were identified, of which 7 studies met inclusion criteria for the first systematic review to examine the trends of CVD in Texas. Ten citations of peer-reviewed articles from Ovid MEDLINE and PubMed databases and five web sites were reviewed for the second systematic review (to study the association between insurance coverage and cardiovascular health among Texas women 60–64 years of age), of which 3 studies met inclusion criteria and were included in the research. The results of the study highlighted key gaps in the existing literature and important areas for the further research, as well as determined directions for future public health CVD prevention programs in Texas. ^ Based on the conducted research, the major determinants of premature mortality among women attributed to cardiovascular disease are based on individual level characteristics, more specifically sex, age, race/ethnicity, and education. The results indicate that African American and non-Hispanic white women are more likely to have higher CVD mortality rates than Hispanic women due to higher prevalence of cardiac risk factors. The data also shows higher levels of mortality from CVD in the southeastern United States, with Texas ranking as the third state with the highest prevalence of CVD among women. According to the Texas Department of State Health Services, there are approximately 56,000 deaths caused by CVD annually in Texas, which represents about one death every ten minutes. Coronary artery disease and stroke were the causes of 31.2 percent of all female deaths in Texas in 2009, meaning that approximately 68 women die from any form of cardiac disease in Texas each day. ^ The data of the reviewed studies indicate that women' lack of health insurance was significantly associated with a higher prevalence of cardiovascular disease. The uninsured women were more likely to be unaware of their risk factors and more likely to have undiagnosed diabetes—a co-morbidity factor of CVD. One of the studies also reports strong correlation between state rates of uninsured and lower rates of preventive care. Given these strong correlations, those who were chronically uninsured were at a higher risk of mortality than the insured, due to prolonged periods of time without basic access to preventive and medical care. ^ Suggested recommendations to decrease CVD mortality rates in Texas are consistent with the existing literature and include state policy development that addresses elimination of health disparities, consideration of potential benefits of universal health coverage by the legislative policymakers, and maintenance of solid partnerships between public health agencies and hospitals to educate on, diagnose, and treat CVD among the female population in Texas. ^

Major and trace element analyses of ODP Leg 120 volcanic rocks (Table 1)

Widespread Lower Cretaceous magmatism occurred along the Indian-Australian/Antarctic margins, and in the juvenile Indian Ocean, during the rifting of eastern Gondwana. The formation of this magmatic province probably began around 120-130 Ma with the eruption of basalts on the Naturaliste Plateau and at Bunbury, western Australia. On the northeast margin of India, activity began around 117 Ma with the Rajmahal continental basalts and associated lamprophyre intrusions. The formation of the Kerguelen Plateau in the Indian Ocean began no later than 114 Ma. Ultramafic lamprophyres (alnoites) were emplaced in the Prince Charles Mountains near the Antarctic continental margin at ~ 110 Ma. These events are considered to be related to a major mantle plume, the remnant of which is situated beneath the region of Kerguelen and Heard islands at the present day. Geochemical data are presented for each of these volcanic suites and are indicative of complex interactions between asthenosphere-derived magmas and the continental lithosphere. Kerguelen Plateau basalts have Sr and Nd isotopic compositions lying outside the field for Indian Ocean mid-ocean ridge basalts (MORB) but, with the exception of Site 738 at the southern end of the plateau, within the range of more recent hotspot basalts from Kerguelen and Heard Islands. However, a number of the plateau tholeiites are characterized by lower 206Pb/204Pb ratios than are basalts from Kerguelen Island, and many also have anomalously high La/Nb ratios. These features suggest that the source of the Kerguelen Plateau basalts suffered contamination by components derived from the Gondwana continental lithosphere. An extreme expression of this lithospheric signature is shown by a tholeiite from Site 738, suggesting that the southernmost part of the Kerguelen Plateau may be underlain by continental crust. The Rajmahal tholeiites mostly fall into two distinct geochemical groups. Some Group I tholeiites have Sr and Nd isotopic compositions and incompatible element abundances, similar to Kerguelen Plateau tholeiites from Sites 749 and 750, indicating that the Kerguelen-Heard mantle plume may have directly furnished Rajmahal volcanism. However, their elevated 207Pb/204Pb ratios indicate that these magmas did not totally escape contamination by continental lithosphere. In contrast to the Group I tholeiites, significant contamination is suggested for Group II Rajmahal tholeiites, on the basis of incompatible element abundances and isotopic compositions. The Naturaliste Plateau and the Bunbury Basalt samples show varying degrees of enrichment in incompatible elements over normal MORB. The Naturaliste Plateau samples (and Bunbury Basalt) have high La/Nb ratios, a feature not inconsistent with the notion that the plateau may consist of stretched continental lithosphere, near the ocean-continent divide.

Major element oxides of minerals from a lava pond at ODP Site 206-1256

At Ocean Drilling Program Site 1256 (6°44.2'N, 91°56.1'W), during Leg 206, a thick massive unit was cored in two neighboring penetrations of the uppermost basement, Holes 1256C and 1256D. This thick massive lava flow, commonly referred to as the "Lava Pond," is identified as Unit 18 (>30 m thick) in Hole 1256C and Unit 1 (>74.2 m thick) in Hole 1256D (Wilson et al., 2003, doi:10.2973/odp.proc.ir.206.2003). In the coarse-grained basalt that comprises this lithological unit, low-temperature "background" alteration events are present. This report provides microprobe analyses of both primary and secondary minerals present in this massive lava pond. The analyses of typically magmatic minerals (titanomagnetite, plagioclase, and clinopyroxene) are given for comparison with secondary minerals.

Eocene-Oligocene calcareous nannofossil events of ODP Sites from the Southern Ocean

The evolution of the Southern Ocean climate during the late Eocene-late Oligocene interval is examined through highresolution, quantitative calcareous nannofossil analyses on samples from the Southern Ocean sections on Maud Rise and Kerguelen Plateau. We determined the abundance patterns of the counted species to clarify the biostratigraphy, which we correlated with high-resolution magnetostratigraphy [Roberts, A.P., Bicknell, S.J., Byatt, J., Bohaty, S.M., Florindo, F., Harwood, D.M., 2003a. Magnetostratigraphic calibration of Southern Ocean diatom datums from the Eocene-Oligocene of Kerguelen Plateau (Ocean Drilling Program Sites 744 and 748). In: Florindo, F., Cooper, A.K., O'Brien, P.A. (Eds.), Antarctic Cenozoic Palaeoenvironments: Geologic Record and Models. Palaeogeogr., Palaeoclimatol., Palaeoecol. 198 145-168; Florindo, F., Roberts, A.P., in press. Eocene-Oligocene magnetobiochronology of ODP Sites 689 and 690, Maud Rise, Weddell Sea, Antarctica. Geol. Soc. Am. Bull.], and used this data to interpret paleoceanographic changes through the late Eocene to late Oligocene. Percentage plots of the individual species, compared with R-mode principal component and cluster analysis results, allowed us to divide the assemblages into three groups: temperate-water taxa, cool-water taxa, and no temperature-affinity taxa. We attempt correlations between these paleoecological groups and the major sea-surface temperature (SST) variations with tectonic and paleoceanographic changes in the Southern Ocean. During the late Eocene, the nannofossil assemblage data reveal that there were several minor SST decreases (coolings) from 36 to 34 Ma, before the Eocene/Oligocene (E/O) boundary. A sharp cooling event, dated at 33.54 Ma (earliest Oligocene), occurred about 160 kyr after the E/O boundary, which is dated at 33.7 Ma. Relatively stable, cool conditions are interpreted to persist until the latest Oligocene, when an increase in abundance of temperate-water taxa, which corresponds to an antithetical decrease in abundance of cool-water indicators, is recorded. On the basis of our dating, the opening of the Drake Passage, allowing shallow-water circulation, began by 33.54 Ma at the latest, while the establishment of deep-water connections through the Tasmanian Gateway occurred at 33 Ma, as suggested by Exon et al. [Proc. ODP, Init. Rep. 189 (2001) 1].

Abundances and contents of major silicoflagellates from IODP Holes of Exp302

The silicoflagellate taxa obtained in IODP Expedition 302 (ACEX) were identified and counted in order to establish the silicoflagellate biostratigraphy in the central Arctic Ocean. These microfossils in the ACEX samples were preserved in the Lithology Units 1/6 and 2, which are dark silty clay and biosiliceous ooze, respectively. The silicoflagellate skeletons in the ACEX samples are assigned to 56 taxa. Seven taxa were described as new species, which were abundant in Lithology Unit 2. Comparison with several study cases outside the Eocene Arctic Ocean suggested that the silicoflagellate assemblages in ACEX were unique in Lithology Unit 2. The dominance of silicoflagellate taxa varied throughout the lithological section. Based on the cluster analysis by Morishita similarity index C(Lambda), the silicoflagellate assemblageswere divided into nine assemblage groups. The silicoflagellate datum event of the first occurrence of Corbisema hexacantha in the lower part of Lithology Unit 1/6 is regarded. Based on the datum events for silicoflagellate and palynomorphs, the assigned epoch of Lithology Units 1/6 and 2 is the middle Eocene.