Social deprivation and prognostic benefits of cardiac surgery: observational study of 44 902 patients from five hospitals over 10 years

OBJECTIVE

To assess the effects of social deprivation on survival after cardiac surgery and to examine the influence of potentially modifiable risk factors.

DESIGN

Analysis of prospectively collected data. Prognostic models used to examine the additional effect of social deprivation on the end points.

SETTING

Birmingham and north west England.

PARTICIPANTS

44 902 adults undergoing cardiac surgery, 1997-2007.

MAIN OUTCOME MEASURES

Social deprivation with census based 2001 Carstairs scores. All cause mortality in hospital and at mid-term follow-up.

RESULTS

In hospital mortality for all cardiac procedures was 3.25% and mid-term follow-up (median 1887 days; range 1180-2725 days) mortality was 12.4%. Multivariable analysis identified social deprivation as an independent predictor of mid-term mortality (hazard ratio 1.024, 95% confidence interval 1.015 to 1.033; P<0.001). Smoking (P<0.001), body mass index (BMI, P<0.001), and diabetes (P<0.001) were associated with social deprivation. Smoking at time of surgery (1.294, 1.191 to 1.407, P<0.001) and diabetes (1.305, 1.217 to 1.399, P<0.001) were independent predictors of mid-term mortality. The relation between BMI and mid-term mortality was non-linear and risks were higher in the extremes of BMI (P<0.001). Adjustment for smoking, BMI, and diabetes reduced but did not eliminate the effects of social deprivation on mid-term mortality (1.017, 1.007 to 1.026, P<0.001).

CONCLUSIONS

Smoking, extremes of BMI, and diabetes, which are potentially modifiable risk factors associated with social deprivation, are responsible for a significant reduction in survival after surgery, but even after adjustment for these variables social deprivation remains a significant independent predictor of increased risk of mortality.

The predicted probability of having positive non-sentinel lymph nodes in patients who received neoadjuvant chemotherapy for large operable breast cancer

The accuracy of the nomogram in women with positive sentinel nodes following neoadjuvant chemotherapy (NCT) is unknown. The aim of this study was to evaluate the accuracy of the nomogram in patients receiving NCT. Between December 1999 and December 2005, we identified 233 patients who had a positive sentinel lymph node biopsy (SLNB) and complete axillary lymph node dissection at Magee-Womens Hospital of University of Pittsburgh Medical Center. Thirty-two patients (14%) had presented with clinically N0 breast cancer (BC) for which NCT was administered. The computerised BC nomogram was used to calculate the probability of non-sentinel node metastases utilising tumour size before NCT and after NCT for the same patient. The discrimination of the nomogram was assessed by calculating the area under (AUC) the receiver operating characteristic curve (ROC). The median patient age was 51.5 (range: 39-66) years in the NCT group of patients. Twelve patients (37%) had positive axillary non-sentinel lymph nodes (NSLNs). The nomogram was first validated in our institution for 201 patients without NCT and the predicted accuracy of the nomogram by the AUC was 0.73. The area under the ROC was identical regardless of whether pre- or posttreatment tumour size was used to determine predicted probability of NSLN metastases (0.66). The predictive accuracy of the nomogram was found to have less power for patients receiving NCT (0.66) than the non-NCT group of patients.

Differential diagnosis of intractable lateral knee pain with progressive symptoms: a case problem

This case study of an active 22 year old female who sustained a traumatic incident to the right knee focuses on the differential diagnostic process. Although early subjective complaints, clinical presentation, and diagnostic testing results were commensurate with internal derangement of the knee, appropriate medical and surgical management failed to halt the progression of pain and subsequent onset of neurological symptoms. Electrodiagnostic testing conducted 10 months post initial injury produced a definitive diagnosis of an irritative lesion of the right peroneal nerve in the region of the fibular neck. A fibular tunnel release and peroneal nerve decompression was subsequently performed after which complete symptom resolution was achieved, allowing return to full functional activities.

Validation of four different risk stratification systems in patients undergoing off-pump coronary artery bypass surgery: a UK multicentre analysis of 2223 patients

BACKGROUND

Various risk stratification systems have been developed in coronary artery bypass graft surgery (CABG), based mainly on patients undergoing procedures with cardiopulmonary bypass.

OBJECTIVE

To assess the validity and applicability of the Parsonnet score, the EuroSCORE, the American College of Cardiology/American Heart Association (ACC/AHA) system, and the UK CABG Bayes model in patients undergoing off-pump coronary artery bypass surgery (OPCAB) in the UK.

METHODS

Data on 2223 patients who underwent OPCAB in eight cardiac surgical centres were collected. Predicted mortality risk scores were calculated using the four systems and compared with observed mortality. Calibration was assessed by the Hosmer-Lemeshow (HL) test. Discrimination was assessed using the receiver operating characteristic (ROC) curve area.

RESULTS

30 of 2223 patients (1.3%) died in hospital. For the Parsonnet score the HL test was significant (p < 0.001) and the receiver operating characteristic curve (ROC) area was 0.74. For the EuroSCORE the HL test was also significant (p = 0.008) and the ROC area was 0.75. For the ACC/AHA system the HL test was non-significant (p = 0.7) and the ROC area was 0.75. For the UK CABG Bayes model the HL test was also non-significant (p = 0.3) and the ROC area was 0.81.

CONCLUSIONS

The UK CABG Bayes model is reasonably well calibrated and provides good discrimination when applied to OPCAB patients in the UK. Among the other three systems, the ACC/AHA system is well calibrated but its discrimination power was less than for the UK CABG Bayes model. These data suggest that the UK CABG Bayes model could be an appropriate risk stratification system to use for patients undergoing OPCAB in the UK.

Complete rescue of the nude mutant phenotype by a wild-type Foxn1 transgene

In this paper we describe the production and analysis of mice carrying a 110-kb transgene that encompasses the wild-type Foxn1 genomic locus. Mutations in Foxn1 cause the nude phenotype. We show that in the hair follicles, transgenic mice with increased Foxn1 gene dosage exhibited increased Foxn1 expression that was restricted correctly to the nascent, post-mitotic cells of the differentiating hair cortex and hair cuticle lineages. We also demonstrate for the first time that a Foxn1 transgene rescues completely both the hair follicle and the thymus defects in animals that are also homozygous for the nude mutation at the endogenous Foxn1 locus, causing the development of a full coat of hair and a normal population of peripheral blood T lymphocytes. We conclude that sufficient cis-acting regulatory information resides within this 110-kb transgene to direct reliable and appropriate tissue-specific expression of the Foxn1 gene.

Regulation of Mg2+ homeostasis by insulin in perfused rat livers and isolated hepatocytes

Several recent studies demonstrate that adrenergic receptor stimulation evokes marked changes in Mg2+ homeostasis. As insulin counter-regulates many of the metabolic consequences of adrenergic receptor stimulation, we evaluated the potential influence of insulin on Mg2+ movements in response to adrenergic stimulation. The data demonstrate that insulin is able to block the Mg2+ efflux from perfused rat livers stimulated by isoproterenol or 8-Br-cAMP, but has little or no effect on epinephrine or phenylephrine induced Mg2+ efflux. Thus, evidence is provided demonstrating that there are redundant adrenergic pathways regulating Mg2+ efflux from liver tissue. One of these pathways, the beta-adrenergic component, is selectively blocked by insulin. Furthermore, these findings may provide a cellular explanation for hypomagnesemia associated with diabetes.

Young adults' knowledge, attitudes, and behavior about abortions in young women

OBJECTIVE

To document opinions and decision-making strategies of young adults regarding abortions for young women.

METHODS

Eighty-nine male and 215 female college students completed a questionnaire on abortion during routine visits to their university health center.

RESULTS

Among the salient findings, most respondents took a pro-abortion stance for girls under 18 in cases of rape (92% of students), incest (90%), or danger to the girl's health (90%). A much lower priority was given for abortion in cases of fetal abnormalities (55% of students), economic hardship (51%), or for girls who were married (55%). Abortion was considered acceptable regardless of circumstances by 46% of students and never a good idea by 18%. The outcome of unplanned pregnancies for minors should be decided by the girl (90% of students), partner (55%), parents (29%), and state or federal law (8%). Abortions for minors should require parental notification (45%) or consent (33%). Although only one student felt illegal abortions were safe, 19% would seek this kind of abortion and 4% of females would try to cause their own miscarriage if abortions were outlawed in the United States.

CONCLUSIONS

The vast majority of young adults believed that girls under 18 should retain the right to decide the outcome of their pregnancy and should not be subjected to governmental restrictions. The highest priority for abortion was given to girls who had been victimized or whose health was at risk. Although nearly all respondents are aware of the hazards of criminal abortions, many would resort to such unsafe practices if legal alternatives were no longer available.

Differential regulation of circulating Mg2+ in the rat by beta 1- and beta 2-adrenergic receptor stimulation

Extracellular Mg2+ homeostasis was studied in vivo in the anesthetized rat. Animals were infused with isoproterenol (ISO) for 10 minutes, and serum Mg2+ was measured after the infusion and then 10 and 20 minutes later. A dose-dependent increase in circulating Mg2+ was observed in animals infused with ISO at a rate of 0.1 microgram.kg-1.min-1 or higher. The time course of the effect demonstrated that circulating Mg2+ continued to increase 20 minutes after the end of the ISO infusion. A predicted maximal increase in serum Mg2+ concentration of 19.3% was derived with a predicted EC50 of 0.08 microgram.kg-1.min-1. The maximal percent increase corresponded to a net increase of 6.7 mumol/300 g body wt. Because infusion of ISO resulted in changes in hemodynamic parameters, most notably a drop in blood pressure, a group of animals was infused with nitroprusside to mimic the hypotensive response via a nonadrenergic mechanism. Under these conditions, there was a transient increase in circulating Mg2+ that was largely inhibited by propranolol, indicating that hypotension per se was not responsible for the mobilization of Mg2+. Infusion of salbutamol, but not prenalterol, also induced an increase in circulating Mg2+. Pretreatment with butoxamine, ICI-118551, or propranolol prevented the ISO-induced increase in serum Mg2+. Pretreatment with atenolol minimally affected the ISO-induced changes in circulating Mg2+. Pretreatment with CGP-20271A actually enhanced the ISO-induced increase in circulating Mg2+. This evidence demonstrates the existence of a pool of Mg2+ that is mobilized into the circulation in response to selective beta 2-adrenergic stimulation.

A comparison of early mortality and morbidity after single and bilateral internal mammary artery grafting with the free right internal mammary artery

OBJECTIVE

To compare differences in early mortality and morbidity in patients receiving a single internal mammary artery graft (SIMA) with those receiving bilateral internal mammary artery grafts (BIMA) with a free right internal mammary artery (RIMA).

DESIGN

Retrospective analysis of 150 patients undergoing BIMA grafting between 1989-1992 who were carefully matched with 150 patients undergoing SIMA grafting between 1987-1992 for known cardiovascular risk factors, extent of coronary disease, left ventricular function, and number of coronary grafts. Operative variables noted included aortic cross clamp time and bypass time. Postoperative cardiac, respiratory, and wound complications were also noted.

RESULTS

Operative mortality was 2% in the SIMA group and 1.3% in the BIMA group (NS). Other than the prevalence of ventricular arrhythmias (P = 0.025), which were more common in the BIMA group, there were no significant differences between the two groups in terms of postoperative morbidity. At median (interquartile range) follow up of 27.94(0.86) and 23.94(0.74) months for the SIMA and BIMA groups respectively there were no deaths. 87% of the SIMA group and 91% of the BIMA group were free of symptoms at follow up.

CONCLUSIONS

The earlier fears regarding increased early mortality and morbidity after BIMA surgery were not confirmed by this study. All patients receiving both mammary arteries had a free rather than pedicle right internal mammary graft. The early mortality and morbidity reported here compares favourably with previous reports on the use of a pedicle graft.

Extent of disability following traumatic extremity amputation

Extremity amputation is a devastating injury. Forty-two patients who sustained traumatic limb amputation were contacted 3-57 months (mean, 25 months; median, 24 months) after injury to evaluate residual disability and to determine what factors were associated with a good recovery. There were 35 men and 7 women with ages ranging from 5 to 73 years (mean, 34 years). Amputation was the result of a motor vehicle crash in 18, work-related injury in 11, motorcycle crash in 9, and other causes in 4. There were 46 amputations done: 8 above-knee (AK), 25 below-knee (BK), 5 above-elbow (AE), and 9 below-elbow (BE). Twenty patients reported no problems with their prosthesis, 8 had major (e.g., infections) and 6 had minor (e.g., skin breakdown) problems. Eight patients did not receive or did not use a prosthesis. Fourteen patients were discharged to an inpatient rehabilitation facility, 25 to home with outpatient rehabilitation, and 3 had no rehabilitation. Of those who worked before their injury, only 50% returned to work. The mean and median time to return to work were 14 and 12 months, respectively. Three of five full-time students returned to school. The amputation level in patients returning to work or school was BK in 12, BE in 3, and AE in 1. No patient with a AK amputation and only 1 (9%) patient with a work-related injury returned to work. Associated injuries or inpatient rehabilitation did not correlate with returning to work. Eighty-eight percent of patients were satisfied with their adjustment and could perform all activities of daily living.(ABSTRACT TRUNCATED AT 250 WORDS)

Structural factors governing azide and cyanide binding to mammalian metmyoglobins

The structural factors governing azide and cyanide binding have been examined by measuring the effects of 46 mutations at key topological positions in the distal pocket in sperm whale, pig, and human myoglobin. Replacement of His64 (E7) with smaller amino acids results in dramatic increases in the association rate constant for azide binding primarily due to relief of steric hindrance imposed by the imidazole side chain. Gln64 and His64 (native) metmyoglobins have abnormally low rate constants for azide dissociation (0.1-0.3 s-1) due to direct hydrogen bonding between the N epsilon atoms of these residues and the bound ligand. Mutations at positions 67(E10) and 68(E11) produce large but complex changes in the azide binding parameters as a result of both steric and electrostatic effects, which alter water coordination, influence the rate of anion movement into the distal pocket, and affect the stability of the Fe-N3 bond. Replacement of Phe46 with Leu or Val and substitution of Arg(Lys)45 with Glu and Ser cause disorder in the position of the distal histidine side chain and result in 4-700-fold increases in both k'N3 and kN3 but produce little change in overall azide affinity. All of these results suggest strongly that azide enters the distal pocket of native myoglobin through a polar channel that is regulated by a His64 "gate." In contrast to azide binding, the rate constant for cyanide association decreases 4-300-fold when the distal histidine is replaced with apolar residues. His64, Gln64, and distal pocket water molecules appear to facilitate deprotonation of HCN, which is the major kinetic barrier to cyanide binding at neutral pH.

Early and late results following combined coronary bypass surgery and mitral valve replacement

To study the effect of various perioperative and operative variables, we analysed the results of 66 consecutive patients undergoing mitral valve replacement (MVR) and coronary artery bypass grafting (CABG). The mean age was 61.2 years (34 males and 32 females), the mean follow-up 54.71 +/- 7.8 months. The hospital mortality rate was 7.6% (5/66). New York Heart Association (NYHA) functional class (P < 0.01), left ventricular global wall motion score (increased scores indicating impaired function, P = 0.005) and cross-clamp time (P < 0.05) were associated with hospital mortality. There was no significant relationship of age (certainly up to the age of 70), cause of mitral valve disease, severity of mitral regurgitation, number of grafts, presence of angina, or previous myocardial infarction with hospital mortality. There were eight late deaths, survival at 1, 3 and 5 years was 92.4%, 83.2% and 80.2%, respectively. Although there was a trend for pulmonary vascular resistance (P = 0.15), NYHA class (P = 0.18) and aortic cross-clamp time (P = 0.09) to be associated with late survival, the only factor significantly related to late survival was global wall motion score (P = 0.001), i.e. those with scores of more than 10. Severity of mitral regurgitation and cause of mitral valve disease have been reported as being related to late survival in patients undergoing combined CABG and MVR, but we have found no such relationship. Our results indicate that both hospital and late mortality after this operation are strongly correlated with left ventricular function.

Anticipatory guidance for the adolescent. Parents' concerns

Parents' opinions regarding anticipatory guidance for adolescents have not been adequately investigated. In this study, 932 parents of adolescents completed a computerized questionnaire listing 30 common psychosocial-medical concerns of adolescence. Respondents were asked how important it is for private pediatricians to discuss these topics with their teenagers during regular checkups. Ten items were rated important by > or = 90% of parents, 22 items by > or = 80%, and 29 items by > or = 66%. Heeding parents' expectations and concerns, pediatricians should incorporate discussions of psychosocial-medical issues as a meaningful component of routine adolescent health care.

Myocardial infarction in a young adult due to Kawasaki disease. A case report and review of the late cardiological sequelae of Kawasaki disease

Although Kawasaki disease is generally self-limiting, 15-25% of children with Kawasaki disease may develop significant cardiovascular sequelae, presentation may occur acutely or late (death has been reported up to 14 years after the acute illness). The most common late complication is the persistence of coronary artery aneurysms, these may produce myocardial ischaemia and even myocardial infarction, valvular dysfunction has also been reported. However the occurrence of late abnormalities of myocardial function is controversial. We describe a 24-year-old man who presented with myocardial infarction as a result of coronary artery aneurysms caused by Kawasaki disease, he gave no recent or childhood history of prodromal illness compatible with Kawasaki disease. The diagnosis was confirmed at post mortem.

Stimulation cycles suppressed with gonadotropin-releasing hormone analog yield accelerated embryos

A retrospective study was performed to assess embryonic development and morphology in 71 patients whose follicular stimulation was regulated after down regulation with a gonadotropin-releasing hormone analog, leuprolide acetate. The embryos were compared with those from 66 patients who did not receive agonists and who were treated during the same period. A separate group of thawed embryos cryopreserved after down regulation in 21 patients was compared with embryos frozen after conventional stimulation during the same period from 21 other patients. Eleven morphological criteria were assessed in the fresh embryos, and analyses did not reveal any differences between the groups studied. However, the rate of development of embryos obtained during down-regulated cycles was significantly higher than that of embryos developing in conventional stimulation cycles. Although no significant morphological differences could be shown between the groups of cryopreserved embryos, there was a decreased incidence of implantation of embryos from patients who were exposed to analogs. It is suggested that embryos from down-regulated cycles should be cryopreserved earlier to correct for their accelerated development.

Acid injury of Escherichia coli

Two strains of Escherichia coli sublethally treated in acidic environments showed an increased sensitivity to violet red bile agar. The death of cells, treated in tryptic soy broth which had been acidified with two inorganic and five organic acids, was followed on both nutrient agar and the selective medium violet red bile agar. The death rates determined on violet red bile agar were much faster than those established on nutrient agar. Therefore, it appeared that unreliable results may occur if selective media are used for the detection and enumeration of Enterobacteriaceae in acid foods.