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Research study coordinators from 17 sites participating in a cardiac surgery study were trained to administer and score a brief neuropsychological test battery. Results were sent to the study's centralized laboratory for review and feedback. The average examiner errors on the first six protocols were compared with the average errors on the last six protocols over 12 months for each site. Overall, errors for the first six protocols were 4.42, and errors for the last six protocols were 1.83, representing a significant overall decline. Errors for instruction, administration, and recording showed a significant decrease over time. Despite ongoing feedback to examiners, scoring errors did not decline significantly overall; this suggests that a review of all protocols is necessary to achieve reliable scoring. However, when examiners' number of protocols completed was compared with number of scoring errors per protocol, there was a trend for examiners who had completed more protocols to show more improvement in scoring.

Background There is a substantial literature on short-term mortality risk factors for coronary artery bypass graft (CABG) surgery. However, very few studies have examined risk factors for long-term mortality. Methods We analyzed 56,543 veterans who underwent CABG surgery at one of 43 VA cardiac surgery centers between October 1, 1991, and March 30, 2001. Each patient was followed for a minimum of 3.5 months and a maximum of 9.5 years for mortality assessment. The time-varying effects of 22 mortality preoperative risk factors were evaluated using both standard Cox regression models and Cox B-spline regression models. Results Six variables showed significant varying effects over time on mortality after surgery. The effects of previous heart surgery or preoperative intra-aortic balloon pump carried about 5 times and 3 times the risk, respectively, of dying on the first day after surgery, but were not significant during long-term follow-up. Conversely, diabetes had little additional risk immediately after surgery, but the risk increased steadily and doubled at 9.5 years after surgery. Three other risk variables—age, chronic obstructive pulmonary disease, and urgent or emergent status—also had risk changing by 50% to 60% over the next decade. Most of the other 16 risk variables were significantly associated with mortality, but the risk did not vary substantially over time. Conclusions Risk associated with some preoperative variables can change significantly during the decade after surgery, and risk assessments that assume constant risk during the postoperative period may substantially overestimate or underestimate risk at some times. These findings may help clinicians identify appropriate management strategies for patients during the years after CABG surgery, and support an emphasis on noncardiac comorbidities during later postoperative periods.

Background The relationship between the surgical case volume and risk-adjusted clinical outcomes has been examined for different surgical specialties. The purpose of this study was to explore the relationship between the off-pump coronary artery bypass graft procedure volumes (OPCABG) with risk-adjusted outcomes within the Department of Veterans Affairs (VA) 44 cardiac surgery programs. Methods Based on VA Continuous Improvement in Cardiac Surgery Program data, the results of 5,076 OPCABG surgical procedures performed between October 1998 and September 2003 were analyzed. Hierarchical logistic regression models evaluated the relationship between OPCABG procedure volume with risk-adjusted 30-day operative mortality, perioperative morbidity, and 180-day mortality. Both a hospital's average OPCABG volume per 6-month period and the hospital's most recent 6-month OPCABG volume were examined. Results Hospital OPCABG average volume in a 6-month period ranged from 0.2 to 47.4 procedures; whereas the most recent 6-month OPCABG hospital volume ranged from 0 to 76 OPCABG per site. No relationship between the volume measures and the outcome variables was found. Conclusions We did not find an association between OPCABG volume with short-term mortality, perioperative morbidity, or intermediate-term (180-day) mortality.

Cardiovascular medication use after coronary bypass surgery in patients with renal dysfunction: A national Veterans Administration study. Background Chronic kidney disease is now recognized as an independent risk factor for cardiovascular events. We sought to determine if cardiovascular medications were utilized less in patients with renal dysfunction following coronary artery bypass grafting (CABG) and if the association of decreased medication use was independent of comorbid conditions. We also examined associations between cardiovascular medication use and mortality at 6 months. Methods Data from the National Veterans Adminstration (VA) Continuous Improvement in Cardiac Surgery Program were merged with the national VA pharmacy database. Prescription rates within 6 months of discharge for CABG were obtained for four classes of medicines: beta blockers, lipid-lowering agents, antiplatelet agents, and angiotensin antagonists. Utilization of medications in patients with estimated glomerular filtration rate (GFR) 60 to 90, 30 to 60, and 90. Results In a retrospective analysis of 19,411 patients, the frequency of nonprescription increased with declining GFR. Decreased utilization for patients with GFR 30 to 60 and Conclusion In a large VA population undergoing CABG, renal disease is associated with highly significant decreases in utilization of cardiovascular medications. Nonprescription of medications was associated with adverse outcomes in those with renal dysfunction.

Dead bird surveillance is an effective way to monitor the presence and spread of West Nile virus (WNV) in North America (1), and assays to detect infectious WNV virions, antigen, and RNA in tissues from infected birds are reliable techniques (2–4). More than 28,000 bird carcasses were tested for WNV in the United States from 1999 to 2002 (5). Processing and testing these carcasses require a substantial commitment of resources from federal, state, and local health departments. Simplifying diagnostic procedures by implementing rapid antigen-capture assays would permit increased specimen processing and, ultimately, improved surveillance. Cloacal and oral (nasopharyngeal) swabs from dead corvids (crows and jays) are reliable sources of WNV RNA and infectious virions (6). Three field evaluations of an antigen detection assay applied to corvid carcasses collected shortly after death found that oral swabs were more sensitive than cloacal swabs for detecting WNV antigen, and that sensitivity of the VecTest WNV antigen assay (Medical Analysis Systems, Camarillo, CA, USA) applied to oral swabs was >80% for American Crows, lower for other corvids, and variable for a variety of other species (7–9). Several questions remain unanswered regarding the usefulness of swab specimens for WNV surveillance. How long after death of a bird can WNV be detected in swab specimens? Can swabs from noncorvid birds be used to detect WNV? Can reverse transcription–polymerase chain reaction (RT-PCR) or VecTest detect WNV in oral swab samples that have remained dry and at room temperature? To address these questions, we compared the VecTest WNV antigen assay with standard methods of virus detection from oral and cloacal swabs taken 1–4 days postmortem from experimentally infected American Crows (Corvus brachyrhynchos) and House Sparrows (Passer domesticus). The VecTest, which was originally developed for mosquito pools as a simple, 1-step wicking assay available in a kit, requires no specialized equipment, storage conditions, or highly trained personnel and provides results in 15 minutes (10,11).

Background Risk factors for 30-day operative (short-term) mortality following coronary artery bypass graft (CABG only) procedures are well established. However, little is known about how the risk factors for short-term mortality following valve replacement procedures (with or without a CABG procedure performed) compare with CABG only risk factors. Methods Department of Veterans Affairs (VA) records (65,585 records) were collected from October 1991 through March 2001 and analyzed. Risk factors for short-term mortality were compared across three subgroups of patients: CABG only surgery (n = 56,318), aortic valve replacement (AVR) with or without CABG (n = 7450), and mitral valve replacement (MVR) with or without CABG (n = 1817). Multivariable logistic regression analyses were used to compare the relative magnitude of risk for 19 candidate predictor variables across subgroups. Results Only three patient baseline characteristics differed significantly in magnitude of risk between the procedure groups. Partially or totally dependent functional status significantly increased the risk of short-term mortality for AVR patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.29–2.09) and MVR patients (OR 2.21, 95% CI 1.48–3.30), but not for CABG only patients (OR 1.04, 95% CI 0.93–1.16). Conversely, previous heart surgery and New York Heart Association functional class III or IV symptoms conferred greater magnitude of risk for CABG only patients compared with the valve subgroups. Conclusions Overall, the risk factors for short-term mortality following valve replacement and CABG surgery appear to be relatively consistent. However, clinicians should be aware of the importance of preoperative functional status as a unique predictor of mortality following valve surgery.