The role of out-of-hospital cardiac arrest in predicting hospital mortality for percutaneous coronary interventions in the Clinical Outcomes Assessment Program.

Published mortality models for percutaneous coronary intervention (PCI), including the Clinical Outcomes Assessment Program (COAP) model, have not considered the effect of out-ofhospital cardiac arrest. The primary objective of this study was to determine if the inclusion of out-of-hospital cardiac arrest altered the COAP mortality model for PCI. The COAP PCI database contains extensive demographic, clinical, procedural and outcome information, including out-of-hospital cardiac arrest, which was added to the data collection form in 2006. This study included 15,586 consecutive PCIs performed in 31 Washington State hospitals in 2006. Using development and test sets, the existing COAP PCI logistic regression mortality model was examined to assess the effect of out-of-hospital arrest on in-hospital mortality. Overall, 2% of individuals undergoing PCI had cardiac arrest prior to hospital arrival. Among 8 hospitals with PCI volumes < 120 cases per year, 4 had cardiac arrest volumes that exceeded 10% of total volume, whereas none of the centers with > 120 cases per year did. In-hospital mortality was 19% in the arrest group and was 1.0% in remaining procedures (p < 0.0001). In the new multivariate model, out-of-hospital cardiac arrest was highly associated with mortality (odds ratio = 5.50; 95% confidence interval [CI] = 3.28-9.25). When evaluated in the test set, the new model had excellent discrimination (c-statistic = 0.89; 95% CI = 0.85-0.93). Out-of-hospital cardiac arrest is an important determinant of risk-adjusted in-hospital mortality for PCI, particularly for hospitals with low volumes and relatively high volumes of cardiac arrest cases.

Geographic and occupational risk factors for ventricular septal defects: Washington State, 1987-2003.

OBJECTIVE: Ventricular septal defect (VSD) is currently the most common congenital cardiac malformation in the United States, but little is known about its etiology. The objective of this study was to address the hypothesis that parents' residence in eastern Washington, a region heavily dominated by the agricultural industry, and employment in agriculturally related occupations can influence the presence of a VSD in their offspring. DESIGN: Population-based case-control study. SETTING: Washington State from January 1, 1987, through December 31, 2003. PATIENTS: Children aged 0 to 2 years diagnosed as having a VSD (n = 3489), and other infants selected at random as control subjects (n = 13 290). MAIN EXPOSURES: Parental occupation and county of maternal residence were obtained from the birth certificate. The latter was categorized according to region (east vs west), rural-urban classification, and the proportion of farm and crop land. MAIN OUTCOME MEASURES: Diagnosis of VSD within the first 2 years of life. RESULTS: The risk of VSD was greater for infants whose mothers resided in eastern Washington (odds ratio, 1.30; 95% confidence interval, 1.03-1.65). The risk of VSD with other cardiac malformations (n = 1205) exhibited a stronger geographic association than did isolated VSD (n = 2284). Analyses restricted to eastern Washington did not reveal a clear relationship between the risk of VSD and an increasing proportion of agricultural land in the mother's county of residence. Parental occupation in agriculture was not associated with the presence of VSD. CONCLUSION: Although these findings suggest regional variation in Washington State in the occurrence of VSD, the basis for this variation remains to be determined.

Effects of a statewide physician-led quality-improvement program on the quality of cardiac care.

BACKGROUND: Several states have implemented mandatory public reporting of outcomes of cardiac revascularization procedures. Washington is the first to develop a nonmandatory, physician-led reporting program with public accountability and universal hospital participation. The purpose of this study was to determine whether quality improvement interventions resulted in the correction of data deficiencies and performance outliers for cardiac revascularization procedures. METHODS: From 1999 through 2003, there were 18 hospitals with coronary bypass surgery and interventional cardiology programs and 12 with only the latter. All patients > or =18 years undergoing 24372 isolated coronary bypass surgeries and 59,656 percutaneous coronary interventions were included. After 1999 to 2001 data were analyzed in early 2002, the Clinical Outcomes Assessment Program implemented a 6-step quality-improvement intervention to measure and remeasure data quality, process compliance, and performance. RESULTS: In 2003, 4 of the 18 surgery programs had 1 statistical outlier with respect to 4 performance measures, whereas 2 of 30 coronary intervention programs were mortality outliers. For bypass surgery, all programs maintained full compliance with program standards by adhering to timely and reliable submission of data, developing plans to address performance outliers, and demonstrating that outlier status did not persist from baseline to remeasurement. For coronary interventions, 1 program was a persistent outlier for mortality in 2002 and 2003. CONCLUSIONS: The Clinical Outcomes Assessment Program has successfully monitored cardiac care patterns in Washington State over a 5-year period. Most hospitals that perform coronary revascularization procedures meet acceptable performance standards.

Structure and Properties of a New Electride, Rb+(cryptand[2.2.2])e.

This is the sixth electride whose crystal structure has been determined and the fourth to show polymorphism. Crystals of the title electride prepared from mixed solvents have a structure similar to that of Li+(cryptand[2.1.1])e-. Electrons occupy cavities that are connected by "ladder-like" channels. The static and spin magnetic susceptibilities of polycrystalline samples that contain this polymorph (called phase α) show Heisenberg 1D antiferromagnetic behavior with -J/kB = 30 K. Similar to other electrides with "localized" electrons, this electride is a poor conductor (σ < 10- 4 ohm-1cm-1). Thin films prepared by high vacuum co-deposition of Rb metal and cryptand[2.2.2] have optical spectra and near-metallic electrical conductivity nearly identical with those of K+(cryptand[2.2.2])e-. These properties would not be expected if the film structure were the same as that obtained for crystals. Rather, they suggest that the films consist of microcrystals whose structure is similar to that of K+(cryptand[2.2.2])e-. Polycrystalline samples prepared by slow evaporation of methylamine from stoichiometric solutions at -78 °C (called phase ß) have properties similar to those of K+(cryptand[2.2.2])e-. The conductivity of samples that contain phase ß is more than an order of magnitude larger than those with phase α. Magnetic and spin susceptibilities show that phase ß samples have much larger electron-electron interactions. As with K+(cryptand[2.2.2])e-, the magnetic susceptibility of phase ß is compatible with alternating linear chain Heisenberg antiferromagnetism, with -J/kB ≈ 300 K and -J'/kB ≈ 240 K. Thin vapor co-deposited films show abrupt changes in the conductivity and optical spectrum at -12 °C that suggest a transition that may be conversion of phase ß to phase α.