Search

The article discusses the overuse of cardiovascular services that are based on definitions, influences, and efforts aimed at addressing such overuse. Topics include the use of the RAND appropriateness method in identifying overuse of cardiovascular services, estimating the impact of overuse on economy and health, and the categories of the factors that contribute to the use of low-value services such as clinical and cultural overuse.

Background. Recent reductions in average door-to-balloon (D2B) times have not been associated with decreases in mortality at the population level. We investigated this seemingly paradoxical finding by assessing components of this association at the individual and population levels simultaneously. We postulated that the changing population of patients undergoing primary percutaneous coronary intervention (pPCI) contributed to secular trends toward an increasing mortality risk, despite consistently decreased mortality in individual patients with shorter D2B times. Methods. This was a retrospective study of ST-elevation myocardial infarction (STEMI) patients who underwent pPCI between Jan 1, 2005, and Dec 31, 2011, in the National Cardiovascular Data Registry (NCDR) CathPCI Registry. We looked for catheterisation laboratory visits associated with STEMI. We excluded patients not undergoing pPCI, transfer patients for pPCI, patients with D2B times less than 15 min or more than 3 h, and patients at hospitals that did not consistently report data across the study period. We assessed in-hospital mortality in the entire cohort and 6-month mortality in elderly patients aged 65 years or older matched to data from the Centers for Medicare and Medicaid Services. We built multilevel models to assess the relation between D2B time and in-hospital and 6-month mortality, including both individual and population-level components o f this association after adjusting for patient and procedural factors. Findings. 423 hospitals reported data on 150116 procedures with a 55% increase in the number of patients undergoing pPCI at these facilities over time, as well as many changes in patient and procedural factors. Annual D2B times decreased significantly from a median of 86 m in (IQR 65-109) in 2005 to 63 min (IQR 47-80) in 2011 (p<0 ⋅ 0001) with a concurrent rise in risk-adjusted in-hospital mortality (from 4-7% to 5 -3%; p=0-06) and risk-adjusted 6-month mortality (from 12 ⋅ 9% to 14 ⋅ 4%; p=0 ⋅001). In multilevel models, shorter patient-specific D2B times were consistently associated at the individual level with lower in-hospital mortality (adjusted OR for each 10 min decrease 0 ⋅ 92; 95% Cl 0⋅91-0⋅93; p<0⋅0001) and 6-month mortality (adjusted OR for each 10 min decrease, 0⋅94; 95% Cl 0⋅93-0⋅95; p<0⋅0001). By contrast, risk-adjusted in-hospital and 6-month mortality at the population level, independent of patient-specific D2B times, rose in the growing and changing population o f patients undergoing pPCI during the study period. Interpretation. Shorter patient-specific D2B times were consistently associated with lower mortality over time, whereas secular trends suggest increased mortality risk in the growing and changing pPCI population. The absence of association of annual D2B time and changes in mortality at the population level should not be interpreted as an indication of its individual-level relation in patients with STEMI undergoing primary PCI. [ABSTRACT FROM AUTHOR]

Objectives: This pilot trial evaluated the feasibility and safety of an early discharge strategy (EDS: ≤72 h, followed by outpatient lifestyle interventions), in comparison with a conventional discharge strategy (CDS) for low-risk (Zwolle risk score ≤3) ST-elevation myocardial infarction (STEMI) patients treated with primary angioplasty. Methods: One hundred patients were randomized to an EDS (n = 54) or a CDS (n = 46). The primary end point was the feasibility of the EDS: (1) ≥70% of EDS patients discharged ≤72 h, (2) ≥70% visited by a nurse ≤7 days after discharge, (3) ≥70% with ≥3 visits by the nurse and (4) ≥70% visited by a cardiologist ≤3 months. Results: The mean age was 59.2 ± 12.2 years and ejection fraction 54.0 ± 7.1%. Eighty-six percent were male (12% diabetics). Vascular access was radial in 91%. Ischemic time was ≤4 h in 75%. Length of stay was shorter in EDS as compared with CDS (70.1 ± 8.1 vs. 111.8 ± 28.3 h, p < 0.001). EDS feasibility was: (1) 72.2%; (2) 81.5%; (3) 76.9%; (4) 72.2%. There were no adverse events or differences in intervention goals and quality of life between groups. Conclusions: An EDS in low-risk STEMI patients is feasible and seems to be safe. A shorter hospital stay could benefit patients and health care systems. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background Posttraumatic Stress Disorder (PTSD) may occur in patients after exposure to a life-threatening illness. About one out of six patients develop clinically relevant levels of PTSD symptoms after acute myocardial infarction (MI). Symptoms of PTSD are associated with impaired quality of life and increase the risk of recurrent cardiovascular events. The main hypothesis of the MI-SPRINT study is that trauma-focused psychological counseling is more effective than non-trauma focused counseling in preventing posttraumatic stress after acute MI. Methods/design The study is a single-center, randomized controlled psychological trial with two active intervention arms. The sample consists of 426 patients aged 18 years or older who are at 'high risk' to develop clinically relevant posttraumatic stress symptoms. 'High risk' patients are identified with three single-item questions with a numeric rating scale (0 to 10) asking about 'pain during MI', 'fear of dying until admission' and/or 'worrying and feeling helpless when being told about having MI'. Exclusion criteria are emergency heart surgery, severe comorbidities, current severe depression, disorientation, cognitive impairment and suicidal ideation. Patients will be randomly allocated to a single 45-minute counseling session targeting either specific MI-triggered traumatic reactions (that is, the verum intervention) or the general role of psychosocial stress in coronary heart disease (that is, the control intervention). The session will take place in the coronary care unit within 48 hours, by the bedside, after patients have reached stable circulatory conditions. Each patient will additionally receive an illustrated information booklet as study material. Socio-demographic factors, psychosocial and medical data, and cardiometabolic risk factors will be assessed during hospitalization. The primary outcome is the interviewer-rated posttraumatic stress level at three-month follow-up, which is hypothesized to be at least 20% lower in the verum group than in the control group using the t-test. Secondary outcomes are posttraumatic stress levels at 12-month follow-up, and psychosocial functioning and cardiometabolic risk factors at both follow-up assessments. Discussion If the verum intervention proves to be effective, the study will be the first to show that a brief trauma-focused psychological intervention delivered within a somatic health care setting can reduce the incidence of posttraumatic stress in acute MI patients. [ABSTRACT FROM AUTHOR]

Background: Out of hospital cardiac arrest is a devastating event and is associated with poor outcomes; however, therapeutic hypothermia (TH) is a novel treatment which may improve neurological outcome and decrease mortality. Despite this, TH is not uniformly implemented across Coronary Care and Intensive Care Units in Canada. Objective: The purpose of this study was to compare cerebral recovery and mortality rates between patients in our Coronary Care Unit who received TH with a historical control group. Materials and Methods: A retrospective chart review was performed of patients admitted to a tertiary care center with out-of-hospital cardiac arrest. Twenty patients who were admitted and cooled after December 2006 were compared with 29 noncooled patients admitted in the 5 years prior as a historical control group. The primary outcomes of interest were in-hospital mortality and neurological outcome. Results: Eleven of 20 (11/20, 55%) patients who were cooled as per protocol survived to hospital discharge, all having a good neurological outcome. Eleven of 29 (11/29, 38%) noncooled patients survived to hospital discharge (Odds Ratio: 0.50, 95% CI: 0.16- 1.60, P=0.26). Eleven of 20 patients who were cooled had a good neurological outcome (CPS I-II, 11/20, 55%), versus 7 of 29 (7/29, 24%) of noncooled patients (Odds ratio: 3.84, 95% CI: 1.13- 13.1, P=0.03). One hundred percent (11/11) of survivors in the cooled group had a good neurological outcome. Conclusion: In our center, the use of TH in out-of-hospital cardiac arrest survivors was associated with improved neurological outcome. [ABSTRACT FROM AUTHOR]

Background and purpose: Poorer stroke care processes and outcomes have been reported for acute stroke patients arriving at centres during off hours and weekends. Objective: To compare each step of the continuous specialized care that Stroke Centres (SC) provide according to time of admission and final outcome. Methods: Observational study of consecutive stroke patients admitted to SC during 2008 and 2009. Patients were classified into two groups according to their arrival time: Work Hours (WH) and Off Hour (OH) (weekends and any time other than 8:00 am to 3:00 pm on weekdays). Differences in time to diagnostic procedures, tPA administration, stroke outcome [modified Rankin Scale, (mRS)] and in-hospital fatality rates were analysed. Results: A total of 912 patients were admitted. Data from 674 patients fulfilling study criteria were analysed. A total of 434 (64.4%) patients arrived during OH. No differences in stroke severity were found when comparing OH and WH. Time to blood test results was higher for WH (median 67 min vs. 47 min; P < 0.01), but time to cranial CT scan was similar. Intravenous tPA was administered to 58 (16.4%) OH vs. 26 (13.1%) WH patients ( P = 0.33). OH arrival was not associated with poorer outcome (mRS ≥ 3) at discharge (32.8% vs. 37%; P = 0.27), or at the 3-month follow-up (30.6% vs. 27.6%, P = 0.52). No differences were found for in-hospital fatality rates (5.8% vs. 5.4%, P = 1.00). Conclusions: The care provided by SC with neurologists on call 24/7 prevents differences in outcomes associated with time of admission and guarantees equal attention to stroke patients. [ABSTRACT FROM AUTHOR]

im of study To analyze the quality of prescriptions in a hospital in Brazil. Methods A cross-sectional pilot study of the quality of prescriptions of adult patients admitted at the cardiovascular ward. Data were collected with the help of a structured form developed by the researchers based on related literature, with items about medications and completeness of prescriptions. The form was divided into four categories of prescription quality indicators: prescription type, legibility and readability of handwriting, and completeness. Main outcome measures 100 patients participated in the study, with ages between 20 and 94 years (mean of 67.12 ± 16.6 years), We analyzed 5,030 on 496 prescriptions for 100 patients. Of 11% the handwriting was considered to be less legible and 17% considered illegible. In terms of readability, a high incidence of medications were prescribed by their brand names (89%), and 13,707 abbreviations (mean of 27.6 per prescription) were used mainly to refer to the route of administration (31%), concentration (27%), and indications for use (20%). In relation to completeness, 471 (95%) prescriptions were considered incomplete, mainly medication data. Conclusion The quality indicators used in this study revealed a high rate of prescription problems and errors. [ABSTRACT FROM AUTHOR]

Background: Reciprocal changes may accompany ST segment elevation in the ischemic territory during acute myocardial infarction (AMI). We examined the hypothesis that isolated inferior ST segment depression on admission is an early sign of anterior wall infarction. Methods: 49 patients admitted to the coronary care unit between January 1996 and June 2008 who presented with inferior ST segment depression in the absence of ST segment elevation. Electrocardiograms (ECGs) obtained on admission and at 24-48 h were reviewed. Culprit artery was determined based on angiographic and echocardiographic data. Results: All patients had ST segment depression in the inferior leads on admission. A subgroup (55%) presented with concomitant ST segment depression in V5-V6. Follow-up ECG showed that 35% developed ST segment elevations and/or T wave inversions in anterior wall leads over 24-48 h. The left anterior descending (LAD) artery or one of its branches was the culprit in 60% of the patients. Sum of ST segment depression, V5-V6 involvement or presence of 'hyperacute' T waves did not predict LAD involvement. Conclusion: Isolated ST segment depression in the inferior wall leads during ACS is usually an early sign of anterior wall AMI, in which the LAD or one of its branches is the culprit artery. [ABSTRACT FROM AUTHOR]

Aim To analyze pre-hospital delay in patients with myocardial infarction from mainland and islands of Split-Dalmatian County, southern Croatia. Methods The study included all patients with myocardial infarction transported by ambulance to the University Hospital Split in 1999, 2003, and 2005. Pre-hospital delay was analyzed in the following intervals: pain-to-call, call-to-ambulance, ambulance-to-door, and door-to-coronary care unit interval. Patients were categorized according to the location from which they were transported: Split, mainland >15 km from Split, and islands. Results There were 1314 patients (62.9% men) transported and hospitalized for myocardial infarction. Total prehospital delay (pain-to-hospital) was significantly reduced from 1999 to 2005 (5.2 hours vs 4.3 hours, P = 0.011). Seventy-five patients (5.7%) were admitted to the coronary care unit within the recommended time-frame of less than 90 minutes, none of which was from the islands, while 248 patients (18.9%) were admitted more than 12 hours from the onset of pain. Conclusion Pre-hospital delay in patients with myocardial infarction in southern Croatia is still too long, especially in patients coming from outside of Split. Prognosis and survival of such patients may be improved by introducing changes to the health care system in remote areas, such as out-of-hospital thrombolysis, greater use of telemedicine, training of lay persons and paramedics in defibrillation, introduction of quality assessment mechanisms, and improved patient transport. [ABSTRACT FROM AUTHOR]

Nursing care in a coronary unit requires a team of specialized health-care professionals, high-tech equipment and leadership that is alert to the daily possibilities and difficulties of nursing care. Objective: To discuss the aspects that can facilitate and hinder nursing administration in a coronary care unit. Methods: This is a bibliographic study based on SciELO and data collection, using semi-structured interviews with six head nurses from the Coronary Care Unit at the Universidade Federal do Rio de Janeiro University Hospital. Results: As to the aspects that facilitate nursing administration, the selected studies and the nurses interviewed point to objective and subjective factors, respectively, such as the use of instruments, distribution of the team and good communication and interpersonal relations. Concerning the aspects that hinder nursing administration, they were in agreement with respect to the mechanization of nursing, the complexity of a critical care unit and the shortage of material resources. Conclusions: It is, therefore, the duty of nursing administration to identify these factors in order to help nursing professionals perform better. This will result in safer and more effective care for patients and their families. [ABSTRACT FROM AUTHOR]

Objective: Cardiovascular disease contributes more than three quarters of all cardiovascular deaths worldwide. Adherence to myocardial infarction (MI) guidelines might not be possible in many rural hospitals. We aim to share our three-year experience in rural settings regarding to ST-elevation MI (STEMI) patients particularly by focusing on determinants of in-hospital mortality. Methods: We retrospectively analysed our data for 559 acute STEMI patients admitted to our coronary care unit in Kastamonu city, Turkey between August 2004 and August 2007. Key demographic and clinical characteristics and data regarding symptom duration, prehospital transfer settings and insurance status were collected. Killip classes and in-hospital therapy of all patients were recorded. Results: A total of 54 patients (9.66%) died within the hospitalisation period. Multivariate analysis revealed that advanced age > 65 years, late admission, hypotension at presentation, killip class > 2, anterior location, posterior location, lack of fibrinolysis and cardiogenic shock were independent predictors of in-hospital mortality. Conclusions: In rural hospital settings, clinical resources and transfer facilities are limited. Therefore, improvement of early transfer and prehospital fibrinolysis capabilities should decrease mortality. [ABSTRACT FROM AUTHOR]

Aim: This study was undertaken to assess the demographics, clinical parameters and outcomes of patients undergoing cardiopulmonary resuscitation (CPR), by the code blue team at our center to compare with other centers. Materials and Methods: Data were collected retrospectively from all adult patients who underwent CPR at our hospital from 2007 to 2008. CPR was performed on 290 patients and it was given 313 times. Clinical outcomes of interest were survival at the end of CPR and survival at discharge from the hospital. Factors associated with survival were evaluated via binomial and chi square-tests. Results: Of the 290 patients included, 95 patients (30.4%) had successful CPR. However, only 35 patients (12%) were alive at discharge. The majority requiring CPR were above 60 years of age (61.7%). Males required CPR more than females. There were 125 women (43.1%) and 165 males (56.9%) aged 3 to 78 (average 59.6) years. Majority (179) of the cases (61.7%) were above 60 years of age. Regarding the various wards, 54 cases (17.3%) were in the internal medicine ward, 63 cases (20.1%) in the surgery ward, 1 case (0.3%) in the clinic, 11 cases (3.5%) in the paraclinic, 116 cases (37.1%) in the emergency (ER), 55 cases (17.5%) in the Intensive Care Unit (ICU) and Coronary Care Unit (CCU), and 13 cases (4.2%) were in other wards. Cardiac massage was done in 133 cases (42.5%), defibrillation only via electroshock3 cases (1%), and both were used in177 cases (56.5%). The ER had the most cases of CPR. Both cardiac massage and electroshock defibrillation were needed in most cases. Conclusion: In-hospital CPR for cardiopulmonary arrest was associated with 30.4% success at our center at the end of CPR but only 12% were alive at discharge. Duration of CPR >10 minutes was predictive of significantly decreased survival to discharge. [ABSTRACT FROM AUTHOR]

Abstract: Background: The major objective of this study was to determine whether individual hospital performance would be assessed differently if clinical data were added to an administrative dataset. Methods: Patients in the 2004 New York State AMI Registry (AMI registry) who could be matched to patients in the New York State Hospital Discharge Database (SPARCS model) comprised the study sample (n =3153). Stepwise logistic regression models were developed (SPARCS model, SPARCS/AMI registry model). Risk-adjusted mortality rates (RAMR) for each hospital in the matched dataset were determined and compared for the SPARCS and the SPARCS/AMI registry model. The RAMR for each hospital was determined by dividing its observed mortality rate by its expected mortality rate and multiplying by the overall mortality rate for the state of New York. Hospitals were considered outliers if they had a RAMR significantly higher or lower than the overall statewide mortality rate. Hierarchical Models were also used to identify hospital outliers. Results: The SPARCS logistic model identified two high hospital outliers; the SPARCS/AMI registry model identified one of those outliers and no others. When Hierarchical Models were used, the SPARCS model also identified two high outliers (one in common with the logistic model) and the SPARCS/AMI registry model identified one high outlier (the same as identified in the logistic model). Conclusion: It is worth exploring the impact of the addition of a small number of clinical data elements to administrative datasets on hospital outlier status. [Copyright &y& Elsevier]

The article presents a study which investigates the survival impact of regionalization of acute myocardial infarction (AMI) care on percutaneous coronary intervention (PCI) hospitals in the U.S. Risk-standardized mortality rates (RSMRs) between PCI hospitals and non-PCI hospitals within the same health care regions were analyzed. The study suggests that regionalizing AMI care to PCI hospitals can reduce mortality rates, however, survival outcomes varies across the regions.

Summary: Optimum management of Duchenne muscular dystrophy (DMD) requires a multidisciplinary approach that focuses on anticipatory and preventive measures as well as active interventions to address the primary and secondary aspects of the disorder. Implementing comprehensive management strategies can favourably alter the natural history of the disease and improve function, quality of life, and longevity. Standardised care can also facilitate planning for multicentre trials and help with the identification of areas in which care can be improved. Here, we present a comprehensive set of DMD care recommendations for management of rehabilitation, orthopaedic, respiratory, cardiovascular, gastroenterology/nutrition, and pain issues, as well as general surgical and emergency-room precautions. Together with part 1 of this Review, which focuses on diagnosis, pharmacological treatment, and psychosocial care, these recommendations allow diagnosis and management to occur in a coordinated multidisciplinary fashion. [Copyright &y& Elsevier]

The article discusses the need to establish a network of coronary care units all over Pakistan for the treatment of people who suffered heart attacks. Topics include the concentration of cardiac institutes in Pakistan's urban cities, the need for small towns and non-urban areas to have facilities for emergency treatment, and the value of primary and secondary prevention as the foundation of the overall health care problems.

The article discusses a study which evaluated the effectiveness of public release of data on cardiac quality indicators in improving the quality of care at hospitals. The study randomized the participating hospital corporations to early or delayed feedback of a public report card on their baseline performance between April 1999 and March 2001 on a set of indicators for acute myocardial infarction (AMI) and congestive heart failure (CHF). It was found that the publication of hospital report card did not result in an improvement in hospital performance.

Background and objective: There are limited data regarding the need for intensive care or the appropriate length of hospital stay for patients with ST elevation acute myocardial infarction (STEMI). In order to optimize resources, we tried to determine the need of coronary care unit (CCU) admission for patients with STEMI who remained in Killip class I after a successful primary percutaneous coronary intervention (PPCI). Methods: From August of 2006 till June of 2008, we analyzed data from all patients admitted in our CCU who met these criteria, a total of 278. We prospectively recorded all in-hospital adverse events and event-free survival at 30 and 90 days (all cause death, stroke, new acute coronary syndrome or re-hospitalization due to heart failure). Medical treatment was optimized according to the current guidelines. Results: A coronary stent was implanted in 96% of the patients. None of the patients had any adverse event that could not be resolved in a step-down unit. Survival at 30 and at 90 days was 99.6% and 98.3% respectively. Event-free survival was 97.3% at 30 days and 94.3% at 90 days. The median length of stay was three days in the CCU and five days in the hospital. Conclusion: Patients with STEMI treated with PPCI who remained in Killip class I after the procedure and receive optimal pharmacological treatment have an excellent prognosis. All of them can probably be admitted safely to a step-down unit. Wide application of this management strategy may result in substantial cost savings. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To compare the risk of cardiovascular-related hospitalization, statin adherence, and direct (medical and drug) and indirect (disability and medically related absenteeism) costs in US employees In whom atorvastatin or simvastatin was newly prescribed. PATIENTS AND METHODS: Active employees aged 18 to 64 years with a new atorvastatin or simvastatin prescription were identified from a deidentified claims database for 23 privately insured US companies from January 1,1999, through December 31,2006. Employees given atorvastatin were matched to those given simvastatin according to propensity scores based on patient characteristics, index statin dose, preindex cardiovascular events, and wage. Outcomes were compared between matched cohorts during the 2-year postindex period, including the risk of cardiovascular-related hospitalization, adherence to the index statin, use of other lipid-lowering drugs, direct medical costs for third-party payers, and indirect costs to employers. Indirect costs were computed as follows: Disability Payments + Daily Wage x Days of Medically Related Absenteeism. Atorvastatin and simvastatin drug costs were imputed using recent pricing to account for the availability of lower-cost generic simvastatin after the study period. RESULTS: Among 13,584 matched pairs, treatment with atorvastatin vs simvastatin was associated with a reduced risk of cardiovascular-related hospitalization, higher adherence, and less use of other lipid-lowering drugs. The increase In statin costs associated with atorvastatin vs simvastatin therapy was almost completely offset by reductions In medical service and indirect costs. CONCLUSION: In this study, treatment with atorvastatin compared with simvastatin was associated with a reduced risk of cardiovascular events, reduced Indirect costs, and a minimal difference in total costs to employers. [ABSTRACT FROM AUTHOR]

The article discusses the results of a study on the assessment of clinical outcomes and utilization of therapies recommended by guidelines for individuals with ST-segment-elevation myocardial infarction (STEMI), brought to on-site heart surgery (OHS) hospitals and non-OHS facilities. The study noted that in-hospital mortality rates in patients presented to non-OHS are much greater. It is said that the guideline-recommended drugs are less likely to be given to patients within 24 hours and at their discharge.

Background: The aim of this study was to assess gender differences in admission level of care, management and outcome in patients with non ST-elevation acute coronary syndromes (NSTE-ACS), initially admitted to either coronary care units (CCU) or general wards. Method: Patients admitted to CCUs were routinely registered in the RIKS-HIA registry. In addition, patients admitted to general wards with suspected ACS were also identified and registered. Multivariable regression analysis was used to adjust for baseline differences between the genders. Results: We included 570 consecutive patients with a discharge diagnosis of NSTE-ACS. Women were less likely to be admitted to coronary care units (56% versus 69%, P=0.002), even after adjustment (odds ratio (OR), 0.65; 95% confidence interval (CI): 0.43-0.98). After adjustment for differences in baseline characteristics, women were treated similarly to men. We found no significant differences in crude short-, or long-term mortality between the genders. However, adjustment for background characteristics revealed lower one-year mortality in women (OR: 0.58; 95% CI: 0.34-0.99). Conclusion: In this study on patients with NSTE-ACS, women were less likely to be admitted to coronary care units. However, the overall treatment was as intensive for women as for men. Moreover, after adjustment, one-year mortality was lower in women. [ABSTRACT FROM AUTHOR]

Objective To assess prescriber adherence to standard anti-hypertensive treatment guidelines in South Africa, determine if supply data are useful indicators of drug use, and assess the cost implications of not complying with the guidelines. Methods We undertook two studies: an analysis of records of the anti-hypertensive drugs supplied to all 54 public-sector hospitals with a hypertension clinic in KwaZulu-Natal, and a direct-observation survey of anti-hypertensive drug prescriptions presented to pharmacies in a subset of 16 of the 54 hospitals. We calculated the relative use of each anti-hypertensive drug group as a proportion of all anti-hypertensive drugs supplied or prescribed. We ranked drug groups in order of use for comparison with recommended South African standard treatment guidelines, and we compared the proportions derived from supply data with those derived from the prescription survey. Findings Supply data showed that, in line with treatment guidelines, diuretics and angiotensin-converting enzyme inhibitors were the most frequently supplied medicines (42% and 27%, respectively). However, methyldopa -- not included in the treatment guidelines -- represented 10% of all anti-hypertensives supplied, but the proportion varied widely between hospitals (0--37%). Reserpine, second choice in the treatment guidelines, was used in high amounts by only two hospitals. Calcium channel blockers and beta blockers represented a small proportion of the anti-hypertensive drugs supplied: 6% each. Results from the prescription survey were in concordance with supply data for the most frequently prescribed drugs but gave slightly different estimates of the use of others. Conclusion Supply data, the most available source of information about drug use in developing countries, are (with some provisos) a reliable data source for the evaluation of adherence to treatment guidelines. Our results showed substantial non-adherence to standard treatment guidelines. [ABSTRACT FROM AUTHOR]

The article presents a study which aims to evaluate the perception of health care staff about the efficiency, working environment and the clinical safety of a cardiovascular intervention short stay unit (SSU). The study participants include cardiologists, cardiology fellows, cardiology advanced trainees and nurses at a tertiary referral hospital in New South Wales. Results revealed that there are substantial concerns from both nurses and doctors regarding patient's safety.

This article explains the clinical signs and symptoms of acute coronary syndrome for the benefit of all nurses, especially those who don't specialize in working with patients with cardiovascular disease. The term coronary syndrome is an umbrella term that includes myocardial ischemia, unstable angina, non-ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction. The article also describes the risk factors for coronary artery disease.

The nursing care work load and the optimum nurse to patient ratio have not been explored specifically in Coronary Care Units (CCU). Aim. To assess the reliability and validity of the Greek version of the Nursing Activity Score (NAS) and of the Comprehensive Nursing Intervention Score (CNIS) in a Greek CCU patient population in order to estimate the optimal patient/nurse ratio. Method. A pilot study employing a descriptive and correlational design was conducted in two CCUs, one in a Metropolitan area and one in a country town. Translation of the scales from English to Greek, reverse translation and validity assessment were performed by an expert group. The TISS-28 scale was employed as the gold standard. During the course of 3 weeks, 116 daily NAS and CNIS reports were obtained, from a sample of 47 patients. Internal consistency reliability analyses (Cronbach's α), non-parametric correlation analyses (SPSS 10.0) and descriptive statistics were carried out. Results. Patients' demographic data were: age 68.64±11.35 years; gender 72.3% men, length of CCU stay 3.48±2.13 days, mortality 2.1%. Cronbach's α was 0.76 for CNIS, and 65 for NAS. NAS and CNIS measurements and NAS-TISS28 and CNIS-TISS28 showed significant correlation (tau=0.51, tau=0.4 and tau=0.41, respectively; p<0.001). Patient/nurse ratios per shift per day were estimated as 2.93±0.75 by NAS and as 2.01±0.52 by CNIS. Conclusions. These pilot results support the validity of the NAS and CNIS scales for use in Greek CCUs. Further ivestigation of the optimum CCU patient/nurse ratio, is required. [ABSTRACT FROM AUTHOR]

Objectives: We sought to examine the combined effect of hospital and physician volume of primary percutaneous coronary intervention (PCI) on in-hospital mortality. Background: An inverse relationship between volume and outcome has been observed for both hospitals and physicians after primary PCI for acute myocardial infarction. Methods: Using the New York State PCI registry, we examined yearly hospital volume, physician volume, and risk-adjusted mortality in 7,321 patients undergoing primary PCI for acute myocardial infarction. Risk-adjusted mortality rates for high-volume hospitals (>50 cases/year) and high-volume physicians (>10 cases/year) were compared with their respective low-volume counterparts. Results: Primary PCI by high-volume hospitals (odds ratio [OR]: 0.58; 95% confidence interval [CI]: 0.38 to 0.88) and high-volume physicians (OR: 0.66; 95% CI: 0.48 to 0.92) was associated with lower odds of mortality. Furthermore, there was a significant interaction between hospital and physician volume on adjusted mortality (p = 0.02). Although unadjusted mortality was lower when primary PCI was performed by high-volume physicians in high-volume hospitals compared with low-volume physicians in low-volume hospitals (3.2% vs. 6.7%, p = 0.03), the risk-adjusted mortality rate was not statistically significant (3.8% vs. 8.4%, p = 0.09). In low-volume hospitals, the average risk-adjusted mortality rate for low-volume physicians was 8.4% versus 4.8% for high-volume physicians (OR: 1.44; 95% CI: 0.68 to 3.03). However, in high-volume hospitals, the risk-adjusted mortality rate for high-volume physicians was 3.8% versus 6.5% for low-volume physicians (OR: 0.58; 95% CI: 0.39 to 0.86). Conclusions: During primary PCI, physician experience significantly modifies the hospital volume-outcome relationship. Therefore, policymakers need to consider physician experience when developing strategies to improve access to primary PCI. [Copyright &y& Elsevier]

Background: Although the incidence of hip replacement surgery is rapidly increasing, there are few data describing the hospital resource utilization associated with these procedures. We aimed to examine the in-hospital outcomes and resource utilization of primary and revision hip replacement. Methods: We analysed data from the 2005/2006 Victorian Admitted Episodes Database that included one or more of the International Classification of Diseases procedure codes for hip replacement. Demographic parameters and in-hospital outcomes, including length of stay, duration of intensive/coronary care and discharge destination, were examined. Results: A total of, 7724 separations had a hip replacement. Primary procedures accounted for 86.8% of all separations. Of these, 79.3% were total hip replacements and the remainder were partial hip replacements. Most partial hips were managed (81.6%) and funded (60.0%) within the public system, whereas revisions were largely managed privately (59.0%). Revisions had less satisfactory outcomes than primary total hips, with 22.9% more revisions remaining in hospital for more than a week ( P < 0.0001), 14.6% more requiring intensive care ( P < 0.0001) and 10.9% less being discharged to a private residence ( P < 0.001) (adjusting for confounders). Although primary partial and revision replacements accounted for only 16.8 and 13.2% of all hip replacements, they utilised up to 27.5 and 34.6% of hospital resources, respectively. Conclusion: Partial and revision hip replacements are resource intensive for the public and private health-care systems, respectively. It is imperative that strategies to reduce the incidence of these procedures are implemented, as failure to do so will have important implications for the allocation of health-care funding. [ABSTRACT FROM AUTHOR]

Abstract: Background: Early risk stratification of patients with chest pain may be improved by combining cardiac Troponin I (cTnI) results and ECG findings with markers of left-ventricular dysfunction, inflammation or renal function. Methods: Serial measurements of cTnI were prospectively performed in 452 chest pain patients with a non-diagnostic ECG for AMI and admitted to the coronary care unit. NT-pro BNP, CRP, cystatin C and creatinine-clearance were retrospectively analyzed in admission samples. The prognostic value of these markers alone and in different combinations together with ECG findings was evaluated by multivariate logistic regression models. Results: During follow-up, 14 deaths and 21 myocardial (re)-infarctions occurred. Independent predictors for the combined endpoint of death or (re)-infarction were peak cTnI ≥0.1 μg/L within 24 h (OR 3.9; 95% confidence interval [CI]1.5–10.4), cystatin C ≥1.28 mg/L (OR 5.6; 95% CI 1.9–16.3) and NT-pro BNP ≥550 ng/L (OR 2.7; 95% CI 1.0–7.3). At 2 h from admission, a combination of cTnI ≥0.1 μg/L, an abnormal ECG and NT-pro BNP or cystatin C as a third variable resulted in a similar stratification of patients to different risk groups. Conclusion: cTnI, NT-pro BNP and cystatin C are strong risk predictors in patients with chest pain. For pragmatic reasons, a combination of cTnI ≥0.1 μg/L, ECG findings and a marker of renal function, preferably cystatin C, appears to be most appropriate for early risk stratification of these patients. [Copyright &y& Elsevier]

To evaluate the use of antidotal therapy in patients with an elevated digitalis concentration following chronic or acute exposure. Retrospective review of patient records over 2 years in 20 city hospitals in France. Overall 838 patients with an elevated serum digitalis concentration (digoxin > 1.95 ng/ml or digitoxin > 23 ng/ml) were included in the study. Of these, 67 (8%) had received antidotal therapy with Fab fragments. The relationships between previously reported prognostic criteria and use of antidotal therapy were investigated. We identified five independent factors that were associated with the use of antidotal therapy: acute overdose (OR 15.74), Fab fragment availability in the hospital (11.06), serum potassium (1.81), and heart rate (0.96). Mortality was significantly lower in Fab-treated (6%, 4/67) than untreated patients (15%, 117/770). Antidotal therapy is underused in patients with an elevated digitalis concentration especially in patients with chronic digitalis exposure. These patients in our series presented a higher mortality rate than patients with acute poisoning. Although they were older and tended to have a history of cardiac disease, they did not differ from patients with acute poisoning with regard to the main severity criteria and prognostic factors. The use of identical criteria for antidotal treatment after acute and chronic poisoning should help optimize outcomes. Fab fragment availability is insufficient in France but ranks only second after type of poisoning (acute or chronic) in the multivariate association with Fab treatment. [ABSTRACT FROM AUTHOR]

The article discusses the outcome of the implementation of the continuous quality improvement (CQI) program to reduce post-percutaneous coronary intervention (PCI) length of hospital stay (LOHS) at a tertiary facility university hospital in Newark, New Jersey. It cites the procedures and routines established under the program and notes how the program affected PCI volume. In conclusion, it notes that the program's goal of increasing early post-PCI discharge is attainable in 95%.

Pretreatment with clopidogrel before elective primary percutaneous coronary intervention (PCI) has been shown to reduce ischemic complications. There are limited data about the value of clopidogrel pretreatment in the setting of PCI for ST-elevation myocardial infarction (STEMI). We aimed to examine the effect of clopidogrel preloading on angiographic and clinical outcomes in patients with STEMI who were treated with PCI. We conducted a prospective registry of all patients treated with primary PCI for STEMI from March 2003 to June 2006. Excluded were patients with cardiogenic shock. For the current analysis, patients (n = 292) were allocated into 2 groups. One group received clopidogrel loading dose before PCI (in the emergency department or coronary care unit, n = 165); the other,immediately after PCI (n = 127). TIMI myocardial perfusion (TMP) grade at the end of PCI and 30-day and 6-month clinical outcomes were assessed. Clinical characteristics were similar among the groups. However, patients pretreated with clopidogrel were more likely to receive aspirin and β blockers before the current admission. TMP grade 3 occurred in a higher proportion of patients in the clopidogrel pretreatment group than in the no-pretreatment group (85% vs 71%, p = 0.01). Multivariate logistic regression analysis showed that clopidogrel pretreatment was associated with an odds ratio of 2.2 for TMP grade 3 (1.2 to 3.9, p = 0.01). Furthermore, the incidence of reinfarction at 30 days was lower in the pretreatment group (0% vs 3.2%, respectively, p = 0.04). In conclusion, these findings support the early use of clopidogrel in patients with STEMI who are treated with primary PCI. [Copyright &y& Elsevier]

Background The urgency and level of care provided for acute coronary syndromes partially depends on the symptoms manifested. Objectives To detect differences between women and men in the type, severity, location, and quality of symptoms across the 3 clinical diagnostic categories of acute coronary syndromes (unstable angina, myocardial infarction without ST-segment elevation, and myocardial infarction with ST-segment elevation) while controlling for age, diabetes, functional status, anxiety, and depression. Methods A convenience sample of 112 women and 144 men admitted through the emergency department and hospitalized for acute coronary syndromes participated. Recruitment took place at 2 urban teaching hospitals in the Midwest. Data were collected during structured interviews in each patient's hospital room. Forty-eight symptom descriptors were assessed. Demographic characteristics, health history, functional status, anxiety, and depression levels also were measured. Results Regardless of clinical diagnostic category, women reported significantly more indigestion (β = 0.25; confidence interval [CI] = 0.01-0.49), palpitations (β = 0.31; CI = 0.06-0.56), nausea (β = 0.37; CI = 0.10-0.65), numbness in the hands (β = 0.29; CI = 0.02-0.57), and unusual fatigue (β = 0.60; CI = 0.27- 0.93) than men reported. Differences between men and women in dizziness, weakness, and new-onset cough did differ by diagnosis. Reports of chest pain did not differ between men and women. Conclusions Women with acute coronary syndromes reported a higher intensity of 5 symptoms (but not chest pain) than men reported. Whether differences between the sexes in less typical symptoms are clinically significant remains unclear. [ABSTRACT FROM AUTHOR]

Background Signs and symptoms of acute coronary syndromes differ between men and women, but whether men and women respond differently to these indications is not well understood. Such responses influence health outcomes because success of treatment depends on how quickly healthcare is sought. Objective To explore differences between Lebanese men and women in cognitive, emotional, and behavioral responses to signs and symptoms of acute coronary syndromes. Methods A convenience sample of 149 men and 63 women with unstable angina or acute myocardial infarction were interviewed within 72 hours of admission to coronary care in a tertiary center by using the Response to Symptoms Questionnaire. Demographic and clinical data were obtained from medical records. Results Women were older, less educated, and more often widowed than men. More women had hypertension but more men were current smokers. Women had shoulder pain, dyspnea, nausea and vomiting, and palpitations more often than men did. Women's signs and symptoms were rated more severe by the women than men's were by the men. Women were less likely to know signs and symptoms of myocardial infarction than were men and delayed coming to the hospital longer than men did. Delay correlated with the characteristics of the signs and symptoms and not realizing their importance in men and with dyspnea and taking the "wait and see" approach in women. Conclusion Factors related to promptness in seeking care for acute coronary syndromes differ between Lebanese men and women. [ABSTRACT FROM AUTHOR]

Abstract: Background: Glycemia and inflammatory markers were associated with clinical outcomes in patients with acute coronary syndrome (ACS). Objectives: To evaluate the role of glycemia and inflammatory markers as predictors of late cardiovascular outcomes after ACS. Methods: One hundred and ninety-nine ACS patients of a Coronary Care Unit were included, from March to November 2002. They were reassessed clinically after ∼3 years. Clinical variables, glycemia, CRP and fibrinogen were evaluated as event and mortality predictors. Statistical analyses included Cox multivariate analysis and survival curves (Kaplan–Meier). Results: At admission, 16.7% had normal glycemia. After 3 years, this proportion increased to 55.2%; the 40.6% who belonged to the borderline category decreased to 27.1%; the 42.7% with elevated glycemia decreased to 17.7%. Glycemia was not associated with the development of major cardiovascular events (MACE) and mortality at follow-up (∼3 years). Considering MACE, CRP (p <0.001), but not fibrinogen, was predictive in bivariate analysis. Regarding mortality, both fibrinogen (p =0.020) and CRP (p =0.008) were predictive in bivariate analysis. Conclusion: Glycemia was not associated with late mortality after ACS, but inflammatory markers were, suggesting that these are more sensitive markers to predict events in long-term. Moreover, glucose intolerance prevalence is lower in the follow-up after the ACS episode. [Copyright &y& Elsevier]

This article describes the creation and function of a cardiovascular service line in a university healthcare-based system. In 2001, an organizational structure (service line) was created to establish accountability between vascular surgeons, cardiologists and hospital administrators. The purpose of this merger was to provide focused, efficient care of cardiovascular patients at a reduced cost. Performance measures included clinical volume change, market share, length of stay, patient satisfaction and hospital margins. Between 2000 and 2006, annual patient volumes increased from 28,140 to 38,182 patients per year (36% increase). Endovascular case volumes increased from 730 to 1591 per year. Between 2003 and 2006, the average length of stay dropped from 7.7 to 5.5 days. Hospital margins increased from an average of 2.8 to 8%. This service line has improved efficiency and care of heart and vascular patients with decreased length of stay and hospital cost. [ABSTRACT FROM AUTHOR]

The article presents research on the differences in mortality rate, hospital transfer and coronary revascularization for black and white patients suffering myocardial infarction admitted to hospitals with and without revascularization services. The study found that black patients were less likely to be transferred when admitted to hospitals without revascularization services, and were less likely to undergo revascularization in hospitals with the service. The study concludes that the higher long-term mortality rate of blacks may be linked to the lower use of revascularization or other lacking aspects of their care.

Objective: To describe the beliefs and attitudes of intensive care unit (ICU) nurses toward visiting, visiting hours, and open visiting policies in critical care settings.Design: A descriptive, cross-sectional, multicenter survey.Setting: Seventeen hospitals in Flanders (Dutch-speaking Belgium), including 30 ICUs. Sixteen mixed adult medical/surgical ICUs, three medical ICUs, five surgical ICUs, three coronary care units, two post-cardiac surgery ICUs, and one burn unit.Participants: A total of 531 intensive care nurses.Measurements and Results: We devised a questionnaire comprising 20 items assessing beliefs and 14 items assessing attitudes. Nurses indicated their level of agreement for each statement on a five-point rating scale. Nurses believed that open visiting hampers planning of adequate nursing care (75.2%), interferes with direct nursing care (73.8%), and causes nurses to spend more time in providing information to the patients' families (82.3%). The presumed effects of visits on the patients and families were contradictory. Most nurses (75.3%) did not want to liberalize the visiting policy of their unit.Conclusions: ICU nurses have rather skeptical beliefs and attitudes toward visiting and open visiting policy. This suggests that the culture at Flemish ICUs is not ready for a drastic liberalization of the visiting policy. [ABSTRACT FROM AUTHOR]

Background: The DANish StUdy of impaired glucose metabolism in the settings of cardiac rehabilitation (DANSUK) examined the effect of an intensified multifactorial intervention on risk factor profile in 104 patients with type 2 diabetes mellitus (T2DM) or impaired glucose tolerance (IGT) attending hospital-based outpatient comprehensive cardiac rehabilitation (CCR) compared to usual care (UC). Methods: Patients with ischemic heart disease (67%), congestive heart failure (7%), or at least 3 risk factors for ischemic heart disease (26%) discharged from 1 coronary care unit were referred to CCR. Of 473 eligible individuals, 201 agreed to participate in the study, and 52% had T2DM or IGT. Patients randomized to CCR received a stepwise implementation of behavioral modification and pharmacotherapy. Results: After 1 year, patients with T2DM in the CCR group experienced a mean change in HbA1c of −0.65% ± 0.9% compared with a mean change of −0.08% ± 0.7% in the UC group (P < .05). Mean change in systolic and diastolic blood pressures was −8 ± 15 and −5 ± 9 mm Hg in the CCR group compared with a mean change of −0.8 ± 15 and −0.2 ± 7 mm Hg in the UC group (P < .05). Patients with IGT attending CCR obtained a significantly higher exercise capacity compared with patients in the UC group (P < .05). Conclusions: In a group of patients with impaired glucose metabolism attending CCR, an intensified multifactorial intervention with an integrated diabetes module was more efficient in improving risk factor control than UC. Besides the improvement in the exercise capacity of patients with IGT, in patients with T2DM, both HbA1c and blood pressure were lowered to a level that has been shown to reduce both cardiac and diabetic complications. These findings have important implications for patients with impaired glucose metabolism in the future settings of CCR. [Copyright &y& Elsevier]

BACKGROUND: Over the last three decades, nurse theorists have strongly advocated the use of conceptual models of nursing to guide nursing practice. Within coronary care units, conceptual model-based care has had inconsistent application and is currently challenged by contemporary approaches such as pathways of care. AIMS: This paper aims to critically analyze the use of Orem's self-care deficit nursing theory as a modus operandi to effectively meet the needs of hospitalized patients in coronary care. RESULTS: Although complex both in the language and construction, the self-care model , provides a comprehensive and holistic approach to the care of people in coronary care. CONCLUSIONS: This paper highlights the potential contribution the application of the self-care deficit nursing theory to the coronary care setting from a philosophical and practical perspective. Orem's conceptual model of nursing and current practice in coronary care units share certain similarities that render a useful model for use in practice. However, while it is recommended for consideration for use in both practice and educational settings, further empirical work is required in the area, together with realistic and practical application of the theory to practice in a way that embraces contemporary notions. [ABSTRACT FROM AUTHOR]

The purposes of this study were to test the validity of a recent scale based on the estimation of a time of exhaustion (entitled Estimated Time Limit scale) to predict a time limit (Tlim) and to regulate exercise intensity and to investigate the reliability of the Estimated Time Limit scale and the Ratings of Perceived Exertion (RPE) scale. 14 male runners performed one incremental test, one constant velocity test at 85% of Maximal Aerobic Velocity (MAV), one constant duration test and one retest of 15 min. on an outdoor track. The difference between Estimated Time Limit values obtained during the incremental test at 85% MAV and measured Tlim values during the constant velocity test were examined, the velocities at ETL=13 (i.e., 15 min.) obtained during the incremental test were compared with measured velocities during the constant duration test or the retest (only the best performance was used), and RPE and Estimated Time Limit values during the constant duration test were compared with those measured during retest. The results have shown a nonsignificant correlation between Estimated Time Limit values at 85% MAV and measured Tlim values during constant velocity test. There was a significant correlation (p<.02, r =.64) between velocities at ETL=13 and measured velocities. However, the slope and y intercept value of this regression were significantly different from those of the identity line. There was no significant difference between constant duration test and retest for the values of RPE and Estimated Time Limit with high correlations (between r=.77 and .99 for RPE scale, and r=.74 and .99 for Estimated Time Limit scale). Moreover, the regression lines were close to the identity line. The RPE and Estimated Time Limit scales are reliable, but the lack of validity for the Estimated Time Limit scale suggests that more studies must be performed before using this scale to predict Tlim and regulate exercise intensity in male runners. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The number of elderly patients with acute myocardial infarction (AMI) is growing rapidly, and their early and postdischarge mortality is high. Several studies have reported a decline in mortality after myocardial infarction; however, the magnitude of the decline among the elderly has not been fully investigated. Methods: We assessed trends in management, in-hospital, and long-term outcomes of 1475 elderly patients (aged ≥75 years, 42% women) hospitalized with AMI in all 25 operating coronary care units in Israel between 1992 and 2002, from our prospective nationwide biennial surveys. Results: Between 1992 and 2002, a significant increase was observed in the use of acute reperfusion therapy (27%-48%), coronary angiography (6%-47%), percutaneous coronary intervention (3%-33%), coronary bypass (2%-8%), aspirin (53%-88%), beta-blockers (18%-65%), angiotensin-converting enzyme inhibitors (26%-63%), and lipid-lowering drugs (0%-43%). These changes were associated with a 42% reduction in 30-day mortality (27.6%-16.1%; adjusted odds ratio 0.57; 95% confidence interval [CI], 0.36-0.93). One-year cumulative mortality declined by 20% (37%-29%; adjusted odds ratio 0.74; 95% CI, 0.49-1.13). Conclusions: The management of elderly patients with AMI changed substantially during the last decade. This change was associated with a significant reduction in early mortality, whereas cumulative 1-year mortality improved only slightly. Better adherence to in-hospital management guidelines and better implementation of postdischarge health policy may further decrease mortality and morbidity in the elderly after AMI. [Copyright &y& Elsevier]

Background: The Global Registry of Acute Coronary Events (GRACE) hospital discharge risk score (GRACE score) developed from a multinational registry involving all subsets of acute coronary syndrome (ACS) predicted 6-month survival. There is currently no validated risk model to predict mortality beyond 6 months. Methods and Results: Of the 1143 consecutive patients with ACS admitted to coronary care unit in 2000 to 2002 (mean age, 64.9 ± 12.6 years), 39% had ST-elevation myocardial infarction, 39% had non–ST-elevation infarction, and 22% had unstable angina. The mortality was 7.5% during index admission, 12.1% at 6 months, 14.8% at 1 year, 18.7% at 2 years, 25.0% at 3 years, and 39.2% at 4 years. The GRACE hospital discharge risk score calculated for 1057 hospital survivors discriminated survival from death at 6 months (C index, 0.81), 1 year (C index, 0.82), 2 years (C index, 0.81), 3 years (C index, 0.81), and 4 years (C index, 0.80). The risk score worked for all 3 subsets of ACS at all time points, with C index >0.75 in all analyses. A separate multivariable mortality model for these 1057 patients over the 4-years follow-up period identified 10 independent predictors of mortality. Seven were in the GRACE risk model (age, history of ischemic heart disease, heart failure, increased heart rate on admission, serum creatinine level, evidence of myonecrosis, not receiving in-hospital percutaneous coronary intervention). Conclusions: The GRACE postdischarge risk score contains relevant prognostic factors and accurately discriminate survivors from nonsurvivors over the longer term (up to 4 years) in all subsets of ACS patients. [Copyright &y& Elsevier]

Background: Continuous positive airway pressure (CPAP) treatment for acute cardiogenic pulmonary edema can have important benefits in acute cardiac care. However, coronary care units are usually not equipped and their personnel not adequately trained for applying CPAP with mechanical ventilators. Therefore we investigated in the coronary care unit setting the feasibility and outcome of the simple Boussignac mask-CPAP (BCPAP) system that does not need a mechanical ventilator. Methods: BCPAP was introduced in a coronary care unit where staff had no CPAP experience. All consecutive patients transported to our hospital with acute cardiogenic pulmonary edema, a respiratory rate > 25 breaths/min and a peripheral arterial oxygen saturation of < 95% while receiving oxygen, were included in a prospective BCPAP group that was compared with a historical control group that received conventional treatment with oxygen alone. Results: During the 2-year prospective BCPAP study period 108 patients were admitted with acute cardiogenic pulmonary edema. Eighty-four of these patients (78%) were treated at the coronary care unit of which 66 (61%) were treated with BCPAP. During the control period 66 patients were admitted over a 1-year period of whom 31 (47%) needed respiratory support in the intensive care unit. BCPAP treatment was associated with a reduced hospital length of stay and fewer transfers to the intensive care unit for intubation and mechanical ventilation. Overall estimated savings of approximately € 3,800 per patient were achieved with the BCPAP strategy compared to conventional treatment. Conclusion: At the coronary care unit, BCPAP was feasible, medically effective, and cost-effective in the treatment of acute cardiogenic pulmonary edema. Endpoints included mortality, coronary care unit and hospital length of stay, need of ventilatory support, and cost (savings). [ABSTRACT FROM AUTHOR]

This paper relates the diffusion of the coronary stent to the presence of prominent or ‘star’ physicians within a local peer group. The paper uses panel data on coronary care in Florida covering the period immediately following the 1995 Food and Drug Administration (FDA) approval of the stent, a significant improvement in coronary angioplasty. Adoption timing and utilization varied considerably across doctors between 1995 and 2001. We consider the role of asymmetric social influence among physicians based on professional status. Defining ‘star’ status as having completed residency at a top-ranked hospital, we find that the diffusion of stents by non-stars depends positively on the number of stars practicing contemporaneously at the same hospitals, while we find no social influence in the opposite direction. The findings indicate that lack of local exposure to star physicians may slow adoption, and clustering of stars in a small number of hospitals may entail welfare costs. [ABSTRACT FROM AUTHOR]

Objective: to evaluate the clinical outcome of patients with acute coronary syndrome (ACS) in the Coronary Care Unit (CCU) over three decades in Dunedin, New Zealand. Design: registry study. Setting and patients: all consecutive patients (n = 3,013) with ACS admitted to the CCU from 1979 to 1981 (n = 966) and from 1989 to 1991 (n = 1470) were included prospectively. Data on ACS patients managed in the CCU in 2001 2002 (n - 577) were obtained via medical chart review. Results: there was a rising proportion of older (≥75 years of age) patients with ACS (3.8% in 1979-1981, 15.2% in 1989-1991 and 25.6% in 2001 2002, P<0.0005). However, we observed a progressive reduction of in-hospital mortality for ACS 110.7, 7.3 and 5.0%, P<0.005) and for ST-elevation myocardial infarction (STEMI) 118.4, 16.1 and 6.6%, P<0.005). The progressive fall in mortality rate was also observed amongst older patients, both for ACS (27, 19.2 and 11.5%, P - 0.011) and for STEMI (34.8, 30.9 and 15.4%, P<0.005). Of concern, only 10% of patients presented within 1 h of symptom onset and 50% within 5 h, and this has not changed over three decades. The variables associated with <5 h from symptom onset to presentation were men [odds ratio (OR) 1.25, 95% confidence interval (CI) 1.10-1.42, P = 0.001], a history of ischaemic heart disease (OR 1.25, 95% CI 1.09-1.43, P = 0.002) and STEMI (OR 1.41, 95% CI 1.18-1.67, P<0.0001). Advanced age was not a predictor for late presentation. Conclusions: over the past three decades, more old patients were treated in the CCU. However, there was a decline in hospital mortality,, particularly for STEMI. Further efforts are required to decrease the time to presentation. [ABSTRACT FROM AUTHOR]

In many settings, firms rely on independent contractors, or freelancers, for the provision of certain services. The benefits of such relationships for both firms and workers are often understood in terms of increased flexibility. Less understood is the impact of freelancing on individual performance. While it is often presumed that the performance of freelancers is largely portable across organizations, it is also possible that a given worker's performance may vary across organizations if he or she develops firm-specific skills and knowledge over time. We examine this issue empirically by considering the performance of cardiac surgeons, many of whom perform operations at multiple hospitals within narrow periods of time. Using patient mortality as an outcome measure, we find that the quality of a surgeon's performance at a given hospital improves significantly with increases in his or her recent procedure volume at that hospital but does not significantly improve with increases in his or her volume at other hospitals. Our findings suggest that surgeon performance is not fully portable across hospitals (i.e., some portion of performance is firm specific). Further, we provide preliminary evidence suggesting that this result may be driven by the familiarity that a surgeon develops with the assets of a given organization [ABSTRACT FROM AUTHOR]

Abstract: Background: Coronary flow reserve (CFR) assessment by transthoracic Doppler echocardiography has been found to be useful in subjects with suspected coronary artery disease. An important clinical question is whether such technique can be successfully applied in patients admitted to the coronary care unit with an acute coronary syndrome to detect a significant left anterior descending (LAD) disease. Methods: One hundred fifty-nine patients with acute coronary syndrome (93 patients with unstable angina, 66 with acute inferior or lateral myocardial infarction) were included in the present analysis. Patients underwent a high-dose dipyridamole stress (0.84 mg/kg) with combined assessment of CFR in the LAD and regional wall motion. Blood flow velocities were recorded in the mid-distal portion of the LAD using a digital ultrasonographic system and CFR was calculated as the ratio of hyperemia-induced peak diastolic velocity to resting peak diastolic flow velocity. All patients underwent coronary angiography and a significant LAD stenosis was classified for lumen narrowing ≥70%. Results: Adequate Doppler recordings in the LAD were obtained in 92% of patients. A contrast agent was used in the 39% of examinations. No major adverse reaction occurred in any patient. A receiving operating characteristic curve showed that a CFR value <1.9 had a sensitivity of 85%, a specificity of 87%, a positive predictive value of 71%, a negative predictive value of 94% and a diagnostic accuracy of 86% for identifying a significant LAD stenosis. The area under the receiving operating characteristic curve computed for CFR was significantly higher than for wall motion score index (p <0.001). In a stepwise forward, multiple logistic regression analysis, both CFR (OR=4.8, 95% C.I. 3.7–5.3; p <0.00001) and the wall motion score index for the LAD territory (OR=4.2, 95% C.I. 2.6–6.8; p <0.0001) were independent determinants of LAD stenosis ≥70%. Conclusion: Early assessment of CFR by transthoracic Doppler echocardiography is feasible and safe and provides additional information to identify subjects with acute coronary syndrome and significant LAD stenosis. [Copyright &y& Elsevier]