Discriminative power of EuroSCORE in predicting morbidity and prolonged hospital stay in an Iranian sample population

EuroSCORE is a simple and rigorous risk stratification model and is, thus, commonly used in predicting the early and late outcomes of cardiac surgery across the world. We aimed to assess the discriminative power of the EuroSCORE model to predict postoperative morbidity and total prolonged length of stay in hospital [LOS] and Intensive Care Unit [ICU] stay in an Iranian group of cardiac surgical population. In a prospective study, the additive EuroSCORE model was applied to 570 patients undergoing isolated coronary artery bypass grafting [CABG] at Tehran Heart Center. The discrimination power of the EuroSCORE model was tested by the area under the receiver operating characteristic [ROC] curve and the calibration by comparing the observed and predicted outcomes across the risk spectrum assessed using the Hosmer-Lemeshow goodness-of-fit test. Mean age was 59.03 +/- 0.73 years and 429 out of 570 [75.3%] patients were men. The overall morbidity rate was 47.5%. The observed morbidity in the high-risk patients [EuroSCORE > 6] was significantly greater than that in the low-risk patients [EuroSCORE 14 days] and prolonged ICU stay [> 72 hours] were more prevalent in the high-risk group than in the low-risk group. The discriminative power of EuroSCORE in predicting morbidity, prolonged LOS, and ICU stay was poor with an area under the ROC curve of 0.617, 0.598, and 0.581, respectively. However, this risk score showed good calibrations for morbidity [p value = 0.119], prolonged LOS [p value = 0.958], and prolonged ICU stay [p value = 0.620]. EuroSCORE provided inappropriate discrimination in predicting early morbidity and prolonged LOS and ICU stay in our study population. Creating a revised model may enable us to accurately predict outcomes in Iranian CABG patients

Adherence and attrition in a web-based lifestyle intervention for people with metabolic syndrome

The aim of this study was to determine adherence and attrition rates in a lifestyle intervention for people with metabolic syndrome. Adherence and attrition data from a randomized controlled trial were collected. Participants were classified as adherence group if they completed assessments at 3 and 6 months follow-up and as attrition group if they did not. Physical activity and quality of life was measured using the International Physical Activity Questionnaire [IPAQ] and the Short Form Health Survey [SF-36]. Generalized Estimating Equations [GEE] was used to explore predictors of attrition. The mean age of participants [n=160] was 44.1 years. Attrition rate in the intervention and control groups at first follow-up were the same [20%]. However, the control group had significantly higher attrition rate [%33.7] compared to the intervention group [%20] at 6 months follow up. Results showed that low educated participants were more likely to not stay in the study than better educated participants [OR=2.95,CI:1.39-6.33,P=0.05]. According with length of the study, attrition was decreased at six month [OR=0.66,CI:0.52-0.83,P<0.001]. Also, some aspects of health-related quality of life contributed to the attrition rate. Those who had higher scores on general health [OR=0.66,CI:0.54-0.97,P=0.023], social functioning [OR=0.44,CI:0.40-0.76,P=0.032], role emotional [OR=0.74,CI:0.54-0.98,P=0.18], vitality [OR=0.55,CI:0.38-0.90,P=0.015] and mental health [OR=0.63,CI:0.45-0.85,P=0.033] were more likely to stay in the study. It remains a concern that Web-based lifestyle programs may fail to reach those who need it most. Participant in the study generally had better quality of life than those who were lost to follow up

Modifiable lifestyle risk factors and metabolic syndrome: opportunities for a web-based preventive program

Lifestyle is recognized as a key factor as the cause and management of the metabolic syndrome. The aim of this study was to identify individuals at increased cardiovascular diseases risk and determine main features of lifestyle of participants with metabolic syndrome via internet. The study was conducted from Jun 22 to August 22, 2012 in Tehran, Iran. Recruitment was carried out through the study website. Participants with metabolic syndrome who were interested and met the study criteria were invited for free clinic visits and clinical assessments. Baseline measurements were metabolic syndrome risk factors. Physical activity and dietary intake were measured by international physical activity questionnaire [IPAQ- short form] and the frequency food questionnaire [FFQ] respectively. Metabolic syndrome was defined according to Adult Treatment Panel III diagnostic criteria. Mean [SD] age for men and women were 41.9 [10.4] and 48.1 [7.8] yr respectively. Men were well educated and more likely to participate in the study than women. Men with metabolic syndrome had larger waist circumference [105.5] and lower BMI [29.1] than women with metabolic syndrome [P<0.001]. Approximately 73% of the sample was inactive and 3% of participants had health enhancing physical activity. There were significant differences in the intakes of total fat and cholesterol between men and women [P<0.001]. Because of the high prevalence of metabolic syndrome, national lifestyle modification policies must be developed for population. Web-based healthy lifestyle programs may contribute to the reduction of the metabolic syndrome components

Factor structure of the world health organization's quality of life questionnaire-BREF in patients with coronary artery disease

The World Health Organization Quality of Life Questionnaire [WHOQOL]-BREF is one of the most known general questionnaires for assessment of quality of life [QOL] in both healthy populations and in various diseases subgroups. The aim of the present study was to examine the construct validity of this questionnaire in patients with coronary artery disease [CAD] using factor analysis. Two hundred and seventy-five patients aged 35-80 years old with the diagnosis of CAD admitted to the Tehran Heart Center operating room for coronary artery bypass were consecutively entered into the study. QOL was assessed using the WHOQOL-BREF. To estimate the reliability of the QOL questionnaire, Cronbach's alpha coefficient was measured. To assess the structure of the questionnaire, we firstly performed confirmatory factor analysis to test the hypothesized factor models. Exploratory factor analysis was then performed using the principal component method with varimax rotation. Reliability of the questionnaire was low [Cronbach's alpha for different domains ranged from 0.24 to 0.74]. In confirmatory factor analysis, only the 1-factor model indicated a good fit to the data. The exploratory factor analysis indicated a five-factor solution that jointly accounted for 55.7% of the variance observed. Also, the pattern of item loading was very different from the original structure of the questionnaire. The findings suggest that the WHOQOL-BREF might only be a measure of the overall QOL in patients with CAD, and is not a suitable instrument for measuring the different QOL dimensions as expected in this population

Can a new antiseptic agent reduce the bacterial colonization rate of central venous lines in post-cardiac surgery patients?

Central venous [CV] catheters play an essential role in the management of critically ill patients in the Intensive Care Unit [ICU].CV lines are, however, allied to catheter-associated blood stream infections. Bacterial colonization of CV lines is deemed the main cause of catheter-associated infection. The purpose of our study was to compare bacterial colony counts in the catheter site before CV line insertion in two groups of post-cardiac surgery patients: a group receiving Sanosil [an antiseptic agent composed of H[2]O[2] and silver] and a control group. This interventional prospective double-blinded clinical trial recruited the patients in three post-cardiac surgery ICUs of a heart center. The participants were divided into interventional [113 patients] and control [136 patients] groups. Sanosil was added to the routine preparation procedure [Chlorhexidine bath one day before and scrub with Povidone-Iodine just before the CV line insertion]. After the removal of the CV lines, the catheters tips were sent for culture and evaluation of colony counts. Catheter colonization occurred in 55 [22.1%] patients: 26 [23%] patients in the Sanosil group and 29 [21.3%] in the control group; there was no significant statistical difference between the two groups [p value = 0.75, RR = 1.05, 95%CI: 0.76-1.45]. The most common organism having colonized in the cultures of the catheter tips was staphylococcus epidermis: 20 cases in the control group and 16 cases in the intervention group. Catheter colonization frequently occurs in post-cardiac surgery patients. However, our results did not indicate the effectiveness of adding Sanosil to the routine preparation procedure with respect to reducing catheter bacterial colonization

Plausible impact of dietary habits on reduced blood sugar in diabetic opium addicts with coronary artery disease

The effect of opium on glycemic control in diabetics is a controversial issue, as some studies have shown glucose lowering effect of opium in diabetes while the results of other studies do not support this idea. The possible role of opioid peptides in the regulation of food intake has been previously investigated. However, there is no data available about relationship between opium using and dietary pattern. The aim of the present study was to determine the daily intake of different nutrients in opium addict with diabetes diagnosed with coronary artery disease [CAD]. This study comprised 232 consecutive diabetic patients with CAD, and candidates for isolated coronary artery bypass surgery in Tehran Heart Center. Of these, 26 patients were opium addicts. Nutritional assessment was obtained by a validated semi-quantitative food frequency questionnaire [FFQ]. In opium addicts compared to non-addicts, consumption of carbohydrates [360.0 +/- 120.9 versus 447.8 +/- 249.8 Gr/day, P=0.016] and vitamin A [1170.4 +/- 570.2 versus 1496.3 +/- 889.6 micro g/d as Retinol Activity Equivalent [RAE], P=0.040] was lower than non-addicts and intake of other nutrients were similar across two group of patients. Opium addiction in diabetic patients may lead to decrease of vitamin A and carbohydrate intake. This study showed that carbohydrate intake in addicted diabetic patients is lower than their non-addict counterpart. Thus, the so called lowering effect of opium on blood sugar may be due to nutritional habit of addicted patients

Determinants of length of stay in surgical ward after coronary bypass surgery: glycosylated hemoglobin as a predictor in all patients, diabetic or non-diabetic

Reports on the determinants of morbidity in coronary artery bypass graft surgery [CABG] have focused on outcome measures such as length of postoperative stay in the Intensive Care Unit [ICU]. We proposed that major comorbidities in the ICU hampered the prognostic effect of other weaker but important preventable risk factors with effect on patients' length of hospitalization. So we aimed at evaluating postoperative length of stay in the ICU and surgical ward separately. We studied isolated CABG candidates who were not dialysis dependent. Preoperative, operative, and postoperative variables as well as all classic risk factors of coronary artery disease were recorded. Using multivariate analysis, we determined the independent predictors of length of stay in the ICU and in the surgical ward. Independent predictors of extended length of stay in the surgical ward [> 3 days] were a history of peripheral vascular disease, total administered insulin during a 24-hour period after surgery, glycosylated hemoglobin [HbA1c], last fasting blood sugar of the patients before surgery, and inotropic usage after cardiopulmonary bypass. The area under the Receiver Operating Characteristic Curve [AUC] was found to be 0.71 and Hosmer-Lemeshow [HL] goodness of fit statistic p value was 0.88. Independent predictors of extended length of stay in the ICU [> 48 hours] were surgeon category, New York Heart Association functional class, intra-aortic balloon pump, postoperative arrhythmias, total administered insulin during a 24-hour period after surgery, and mean base excess of the first 6 postoperative hours [AUC = 0.70, HL p value = 0.94]. This study revealed that the indices of glycemic control were the most important predictors of length of stay in the ward after cardiac surgery in all patients, diabetic or non-diabetic. However, because HbA1c level did not change under the influence of perioperative events, it could be deemed a valuable measure in predicting outcome in CABG candidates

Role of surgeon in length of stay in ICU after cardiac bypass surgery

We presumed that the surgeon himself has an impact on the results after coronary artery bypass grafting [CABG] as there is no unique protocol for the discharge of post-operative cardiac patients at our institution. Therefore, we examined whether the surgeon himself has an impact on the intensive care unit [ICU] stay of isolated CABG patients. We prospectively studied a total of 570 consecutive patients undergoing elective CABG. Length of stay in the ICU was defined as the number of days in the ICU unit post-operatively. Seven operating surgeons were classified in 3 categories on the basis of the mean hospital stay of their patients [1, 2 and 3 if the mean total patients' stay in hospital was <8 days, between 8 to 10 days, and longer than 10 days; respectively]. Using a multivariable regression model, we determined the independent predictors of length of stay in the ICU [> 48 hours] and examined the role of surgeon in this regard. Incidence of post-operative arrhythmia and length of ICU stay were higher in the patients of surgeon category 3 than those of surgeon categories 1 and 2. Surgeon category 3 also operated on patients with higher Euro SCOREs than did surgeon categories 1 and 2. With the aid of a multivariable stepwise analysis, three variables were identified as independent predictors significantly associated with ICU length of stay: age, history of cerebrovascular accident, and surgeon category. Surgeon category may independently predict a prolonged length of stay in the ICU. We suggest that a unique discharge protocol for post-CABG patients be considered to restrict the role of surgeon in the ICU stay of these patients

Quality of life in coronary artery disease: SF-36 compared to WHOQOL-BREF

The Short Form Health Survey [SF-36] and WHO Quality of Life-BREF [WHOQOL-BREF] questionnaires are two common tools to assess changes in quality of life [QOL] over the course of treatment, especially in patients with coronary artery disease [CAD]. However, the value of these two instruments among CAD patients has not been studied and compared. The objective of the present study was; therefore, to compare the SF-36 with the WHOQOL-BREF in these patients. Between May and September 2006, patients with a final diagnosis of CAD who were candidates for isolated coronary artery bypass grafting [CABG] and hospitalized in Tehran Heart Center were randomly divided into two groups of 268 patients [for assessment of QOL with the SF-36] and 275 patients [for assessment of QOL with the WHOQOL-BREF]. The correlations between the WHOQOL-BREF domains and SF-36 subscales, in addition to those between the SF-36 components summary scores and WHOQOL-BREF domains, were examined with Pearson's correlation coefficients. The correlations between the physical, psychological, and social domains of the WHOQOL-BREF and physical functioning, mental health, and social functioning of the SF-36 were weak with Pearson's correlation coefficients of 0.015, -0.036, and 0.042, respectively [r < 0.3]. There were also poor correlations between the physical component summary of the SF-36 and physical domain of the WHOQOL-BREF [r=0.001], and between the mental component summary of the SF-36 and mental domain of the WHOQOL-BREF [r=-0.082]. The correlation between the two questionnaires of the SF-36 and WHOQOL-BREF in the evaluation of QOL in CAD patients is weak

Relationship between serum magnesium level and arrythmias following postcoronary artery bypass grafting

Atrial and ventricular arrhythmias are among the most common complications after coronary artery bypass graft [CABG] surgery. It is known that cardiopulmonary bypass reduces serum magnesium level. In this study, we evaluated the relationship between total blood magnesium level [TMG] and the incidence of perioperative arrhythmias. TMG was measured in patients who were scheduled for CABG on three occasions: just before anesthesia, on intensive care unit [ICU] arrival and on the first morning after operation. Patients were evaluated for primary cardiac rhythm, serum creatinine, urine output in operating room and diuretic therapy. Supplemental magnesium [SMG] was also recorded in operating room and ICU. Patients were then evaluated for the rate and kind of arrhythmia occurring during the next 3 days. Mean TMG level in 170 cases was 2.2 [0.5], 2.6 [0.6] and 2.4 [0.6] mg/dl on three occasions respectively. 53 patients developed post-operative arrhythmia [31%] [Atrial Fibrillation [AF] [7.1%], Non-AF Supraventricular arrhythmia [14.7%] and Ventricular arrhythmia [16.5%]]. Although there was a significant difference between TMG on three occasions [P < 0.001], all values were within normal range. Although TMG was higher in arrhythmic patients compared to nonarrhythmics [2.26 vs. 2.14], both values were in normal range and there was no significant difference between two groups. This study shows that routine magnesium administration has no significant effect on serum magnesium level. We conclude that though routine regimen of magnesium administration has no effect on incidence of perioperative arrhythmia, it is probably necessary for maintaining normal magnesium level