Expanding marine protected areas to include degraded coral reefs.

Marine protected areas (MPAs) are a commonly applied solution to coral reef degradation, yet coral reefs continue to decline worldwide. We argue that expanding the range of MPAs to include degraded reefs (DR-MPA) could help reverse this trend. This approach requires new ecological criteria for MPA design, siting, and management. Rather than focusing solely on preserving healthy reefs, our approach focuses on the potential for biodiversity recovery and renewal of ecosystem services. The new criteria would help identify sites with the highest potential for recovery and the greatest resistance to future threats (e.g., increased temperature and acidification) and sites that contribute to MPA connectivity. The DR-MPA approach is a compliment rather than a substitute for traditional MPA design approaches. We believe that the DR-MPA approach can enhance the natural, or restoration-assisted, recovery of DRs and their ecosystem services; increase total reef area available for protection; promote more resilient and better-connected MPA networks; and improve conditions for human communities dependent on MPA ecosystem services.

Anthem Blue Cross and Blue Shield's coronary services network: a managed care organization's approach to improving the quality of cardiac care for its members.

OBJECTIVE: To describe a managed care organization's efforts to improve value for its members by forming a coronary services network (CSN). DESIGN: To identify high-quality facilities for its CSN, Anthem Blue Cross and Blue Shield reviewed claims data and clinical data from hospitals that met its general quality standards. An external firm measured and risk-adjusted applicant hospitals' mortality rates. Hospitals that demonstrated superior performance were eligible to join the CSN. In 1996, 2 years after the CSN was formed, clinical outcomes of participants and new applicants were analyzed again by the same external firm. PATIENTS AND METHODS: Data on more than 10,000 consecutive (all-payer) inpatients discharged after coronary bypass surgery in 1993 were collected from 16 applicant hospitals using a uniform format and data definitions. This analysis was expanded to 23 participating and applicant hospitals that discharged more than 13,000 patients who underwent either bypass surgery or coronary revascularization in 1995. We compared risk-adjusted routine length of stay (a measure of efficiency), mortality rates, and adverse outcome rates between CSN and non-CSN facilities. RESULTS: From 1993 to 1995, overall length of stay in the network decreased by 20%, from 12.3 to 9.8 days (P < or = 0.01) and severity-adjusted mortality rates decreased by 7.3%, from 2.9% to 2.7%. Initially, facilities outside the network had comparable efficiency but much higher mortality. However, they improved so much in both measures that their severity-adjusted mortality rate for bypass surgery in 1995 was no more than 10% higher than that of CSN hospitals. CONCLUSION: The creation of a statewide CSN that emphasized and improved the level of performance among providers ultimately benefited the carrier's managed care members. The desirability of participation was evidenced by an increase in the number of applicant hospitals over the 2 years. This may have stimulated quality improvement among competing providers in the region and among CSN facilities themselves.

The clinical efficacy and scintigraphic evaluation of post-coronary bypass patients undergoing percutaneous transluminal coronary angioplasty for recurrent angina pectoris.

The efficacy of percutaneous transluminal angioplasty in improving recurrent anginal symptoms and myocardial perfusion after coronary artery bypass graft surgery was assessed prospectively in 55 patients, of whom 50 had an initial angiographic and clinical success. Although 80% of those successfully dilated were initially free of angina at 23 +/- 11 months of follow-up, one half of these patients had recurrent angina. Although only 48% of the patient cohort had complete relief of angina, 94% had less angina than before dilatation and 86% were able to decrease antianginal medications. Fifteen patients with persistent or recurrent angina had from one to five repeat dilatations. After angioplasty, lung thallium uptake, the extent of abnormal scan segments, and the magnitude of redistribution in dilated lesions were significantly reduced (n = 24 patients). Redistribution defects were seen in 38% of patients on postangioplasty scans. All were associated with subsequent angina. Of various clinical, angiographic, exercise, and thallium-201 scan variables, only the presence of delayed redistribution was an independent predictor of recurrent angina. Restenosis was the most common underlying cause for this exercise-induced perfusion defect. Thus percutaneous coronary angioplasty performed as primary therapy for recurrent angina after bypass surgery is moderately successful in long-term follow-up for the amelioration of symptoms and enhancement of regional myocardial perfusion.

The safety of protamine sulfate in diabetics undergoing cardiac catheterization.

The frequency of anaphylactoid reactions to protamine sulfate was examined by reviewing the records of diabetic patients undergoing cardiac catheterization over a 5-year period, and by prospectively monitoring diabetic patients receiving NPH insulin during the infusion of protamine sulfate. No anaphylactoid reactions were noted after protamine administration (48 +/- 5 mg) in the retrospective study in either patients with prior exposure to protamine (74 catheterizations) or in diabetics with no exposure to protamine (132 catheterizations). In the prospective study, no anaphylactoid reactions were seen in the 24 NPH insulin-dependent diabetics during the infusion of protamine sulfate (45 +/- 5 mg). Five of the 42 patients (12%) from the retrospective study who underwent vascular surgery developed severe reactions to much larger doses of protamine (380 +/- 118 mg). Diabetics with prior exposure to protamine sulfate do not appear to be at increased risk of anaphylactoid reaction after the administration of protamine sulfate in the dose range of less than 50 mg at the time of cardiac catheterization.