A pathway to earlier discharge following TAVI: Assessment of safety and resource utilization.

INTRODUCTION: There is considerable variability within the population of patients treated with transcatheter aortic valve implantation (TAVI), the procedural approach and time to discharge. In Belfast, from the commencement of our program, our approach has been to perform TAVI by the least invasive approach, where feasible, utilizing a percutaneous transfemoral route and local anesthetic. By analyzing our Belfast TAVI database we identified factors that predicted shorter admission times without impacting adversely on patient safety. Following this, we developed an early discharge pathway. The aim of this current study was to perform a prospective analysis of outcomes in our unit since implementation of this pathway assessing discharge time, mortality, serious adverse events, readmission, and resource implications for patients according to time to discharge. METHODS: Consecutive patients who underwent TAVI and were successfully discharged from 2013 to 2014 over a 14 month period were included, and analyzed according to time to discharge. Baseline and procedural characteristics, mortality, serious adverse events, readmission, and cost were assessed. RESULTS: In total 120 patients were included, 26 (21.7%) were discharged the same/next day, 39 (32.5%) early (>1-4 days), and 55 (45.8%) discharged in the late group. There was no significant difference in baseline or preprocedural characteristics. The incidence of complications was low, and there was no difference in 30-day mortality (P = 0.167) or readmission rates between groups (P = 0.952). Resource analysis revealed the late discharge group cost £3,091.6 more per patient per TAVI than same/next day discharge group. CONCLUSION: Same/next day discharge can be performed safely in appropriately selected patients. Although this will be achieved in a minority of patients (21.7% in this study using an early discharge pathway) it has potential for resource and cost savings. © 2015 Wiley Periodicals, Inc.

Sensitivity of [Ru(phen)2dppz]2+ light switch emission to ionic strength, temperature, and DNA sequence and conformation.

The luminescence of DNA-bound [Ru(phen)(2)dppz](2+) is shown to be highly sensitive to environmental conditions such as ionic strength, temperature, and the sequence and secondary structure of the nucleic acid, although not to bulky DNA substituents in the major groove. Each enantiomer has two characteristic lifetimes with any polynucleotide and their relative amplitudes vary as a function of binding ratio. For [poly(dA-dT)](2) as a model sequence, the longer lifetime for Δ-[Ru(phen)(2)dppz](2+) has been assigned to canted intercalation of the complex and the shorter lifetime is ascribed to symmetric intercalation. At a fixed binding ratio, the longer lifetime amplitude increases with increasing ionic strength, without significant change in lifetimes. Increasing temperature has a similar effect, but also affects lifetimes. In general, emission is strongest with AT-rich polynucleotides and with higher-order secondary structures, with intensity increasing as single-stranded < duplex < triplex. However, sequence-context and secondary duplex structure also influence the photophysics since emission with [poly(dA)]·[poly(dT)] is significantly higher than with [poly(dA-dT)](2) or [poly(rA)]·[poly(rU)]. The strong influence of different environmental conditions on the emission of nucleic acid-bound [Ru(phen)(2)dppz](2+) reflects subtle heterogeneities that are inherent elements of DNA recognition by small molecules, amplified by large changes in photophysics caused by differential exposure of the dppz nitrogens to groove hydration.

Short-time windows of correlation between large-scale functional brain networks predict vigilance intraindividually and interindividually.

A better understanding of how behavioral performance emerges from interacting brain systems may come from analysis of functional networks using functional magnetic resonance imaging. Recent studies comparing such networks with human behavior have begun to identify these relationships, but few have used a time scale small enough to relate their findings to variation within a single individual's behavior. In the present experiment we examined the relationship between a psychomotor vigilance task and the interacting default mode and task positive networks. Two time-localized comparative metrics were calculated: difference between the two networks' signals at various time points around each instance of the stimulus (peristimulus times) and correlation within a 12.3-s window centered at each peristimulus time. Correlation between networks was also calculated within entire resting-state functional imaging runs from the same individuals. These metrics were compared with response speed on both an intraindividual and an interindividual basis. In most cases, a greater difference or more anticorrelation between networks was significantly related to faster performance. While interindividual analysis showed this result generally, using intraindividual analysis it was isolated to peristimulus times 4 to 8 s before the detected target. Within that peristimulus time span, the effect was stronger for individuals who tended to have faster response times. These results suggest that the relationship between functional networks and behavior can be better understood by using shorter time windows and also by considering both intraindividual and interindividual variability.

DNA sequence and ancillary ligand modulate the biexponential emission decay of intercalated [Ru(L)2dppz]2+ enantiomers.

The bi-exponential emission decay of [Ru(L)(2)dppz](2+) (L = N,N'-diimine ligand) bound to DNA has been studied as a function of polynucleotide sequence, enantiomer, and nature of L (phenanthroline vs. bipyridine). The lifetimes (τ(i)) and pre-exponential factors (α(i)) depend on all three parameters. With [poly(dA-dT)](2), the variation of α(i) with [Nu]/[Ru] has little dependence on L for Λ-[Ru(L)(2)dppz](2+) but a substantial dependence for Δ-[Ru(L)(2)dppz](2+). With [poly(dG-dC)](2), by contrast, the Λ-enantiomer α(i) values depend strongly on the nature of L, whereas those of the Δ-enantiomer are relatively unaffected. DNA-bound linked dimers show similar photophysical behaviour. The lifetimes are identified with two geometries of minor-groove intercalated [Ru(L)(2) dppz](2+), resulting in differential water access to the phenazine nitrogen atoms. Interplay of cooperative and anti-cooperative binding resulting from complex-complex and complex-DNA interactions is responsible for the observed variations of α(i) with binding ratio. [Ru(phen)(2)dppz](2+) emission is quenched by guanosine in DMF, which may further rationalise the shorter lifetimes observed with guanine-rich DNA.

Relationships between body burdens of trace metals (As, Cu, Fe, Hg, Mn, Se, and Zn) and the relative body size of small tooth flounder (Pseudorhombus jenynsii).

Several studies have described strong relationships between body size and the accumulation of trace metals in animal tissues. However, few of these studies have utilized aging techniques to control for age related effects. We utilized relative body size (gy(-1)) of a model flounder species, Pseudorhombus jenynsii, in order to control for age related effects on growth and size measurements. We investigated links between relative body size, concentrations of trace metals in flounder muscle tissue, physico-chemical variables (temperature, salinity, pH, and turbidity), and levels of trace metals in the sediment. Flounder were sampled using an otter trawl net in the inner areas of eight estuaries that were either heavily modified or relatively unmodified by urbanization and industrial activity. Our results indicate that this commonly eaten fish is accumulating significant levels of some trace metals in their muscle tissue, both in relatively unmodified and heavily modified estuaries. Concentrations of Cu, Zn and Fe in muscle tissue, as well as temperature, showed a negative relationship to the relative body size of flounder. In contrast, Se and Hg in muscle showed a positive relationship to relative body size. Observed growth patterns indicate that these effects are not driven by age related differences in metabolic activity. Instead, our results suggest that differences in food supply or toxicological effects may be responsible for the observed relationships between relative body size and concentrations of Cu, Zn, and Se in muscle tissues. The use of otolith aging and growth measurement techniques represents a novel method for assessing the relationships between trace metal accumulation and the relative body size of fish in a field environment.

High levels of sediment contamination have little influence on estuarine beach fish communities.

While contaminants are predicted to have measurable impacts on fish assemblages, studies have rarely assessed this potential in the context of natural variability in physico-chemical conditions within and between estuaries. We investigated links between the distribution of sediment contamination (metals and PAHs), physico-chemical variables (pH, salinity, temperature, turbidity) and beach fish assemblages in estuarine environments. Fish communities were sampled using a beach seine within the inner and outer zones of six estuaries that were either heavily modified or relatively unmodified by urbanization and industrial activity. All sampling was replicated over two years with two periods sampled each year. Shannon diversity, biomass and abundance were all significantly higher in the inner zone of estuaries while fish were larger on average in the outer zone. Strong differences in community composition were also detected between the inner and outer zones. Few differences were detected between fish assemblages in heavily modified versus relatively unmodified estuaries despite high concentrations of sediment contaminants in the inner zones of modified estuaries that exceeded recognized sediment quality guidelines. Trends in species distributions, community composition, abundance, Shannon diversity, and average fish weight were strongly correlated to physico-chemical variables and showed a weaker relationship to sediment metal contamination. Sediment PAH concentrations were not significantly related to the fish assemblage. These findings suggest that variation in some physico-chemical factors (salinity, temperature, pH) or variables that co-vary with these factors (e.g., wave activity or grain size) have a much greater influence on this fish assemblage than anthropogenic stressors such as contamination.

Picoliter rheology of gaseous media using a rotating optically trapped birefringent microparticle.

An optically trapped birefringent microparticle is rotated by a circularly polarized beam in a confined gaseous medium. By recording the terminal rotation velocity and the change in polarization of the incident trapping beam, we determine the viscosity by probing a picoliter volume of air, carbon dioxide, and argon in the vicinity of the microparticle. We also characterize the optical force acting on a trapped particle in air using the generalized Lorenz-Mie theory taking into account the aberrations present. This opens up a new potential application of optical tweezers for the accurate measurement of gas viscosity in confined geometries.

Strong links between metal contamination, habitat modification and estuarine larval fish distributions.

Changes to larval fish assemblages may have far reaching ecological impacts. Correlations between habitat modification, contamination and marine larval fish communities have rarely been assessed in situ. We investigated links between the large-scale distribution of stressors and larval fish assemblages in estuarine environments. Larval fish communities were sampled using a benthic sled within the inner and outer zones of three heavily modified and three relatively unmodified estuaries. Larval abundances were significantly greater in modified estuaries, and there were trends towards greater diversity in these systems. Differences in larval community composition were strongly related to sediment metal levels and reduced seagrass cover. The differences observed were driven by two abundant species, Paedogobius kimurai and Ambassis jacksoniensis, which occurred in large numbers almost exclusively in highly contaminated and pristine locations respectively. These findings suggest that contamination and habitat alteration manifest in substantial differences in the composition of estuarine larval fish assemblages.

Preliminary results of a prospective randomized trial of restrictive versus standard fluid regime in elective open abdominal aortic aneurysm repair.

BACKGROUND: Open abdominal aortic aneurysm (AAA) repair is associated with a significant morbidity (primarily respiratory and cardiac complications) and an overall mortality rate of 4% to 10%. We tested the hypothesis that perioperative fluid restriction would reduce complications and improve outcome after elective open AAA repair. METHODS: In a prospective randomized control trial, patients undergoing elective open infra-renal AAA repair were randomized to a "standard" or "restricted" perioperative fluid administration group. Primary outcome measure was rate of major complications (MC) after AAA repair and secondary outcome measures included: Sequential Organ Failure Assessment Score; FiO2/PO2 ratio; Urinary Albumin/Creatinine Ratio; Length-of-stay in, intensive care unit, high dependency unit, in-hospital. This prospective Randomized Controlled Trial was registered in a publicly accessible database and has the following ID number ISRCTN27753612. RESULTS: Overall 22 patients were randomized, 1 was excluded on a priori criteria, leaving standard group (11) and restricted group (10) for analysis. No significant difference was noted between groups in respect to age, gender, American Society Anesthesiology class, Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity scores, operation time, and operation blood loss. There were no in-hospital deaths and no 30-day mortality. The cumulative fluid balance on day 5 postoperative was for standard group, 8242 +/- 714 mL, compared with restricted group, 2570 +/- 977 mL, P < 0.01. MC were significantly reduced in the restricted group (n = 10), 1 MC, compared with standard group (n = 11), 14 MC, P < 0.024. Total and postoperative length-of-stay in-hospital was significantly reduced in the restricted group, 9 +/- 1 and 8 +/- 1 days, compared with standard group, 18 +/- 5 and 16 +/- 5 days, P < 0.01 and P < 0.025, respectively. CONCLUSIONS: Serious complications are common after elective open AAA repair, and we have shown for the first time that a restricted perioperative fluid regimen can prevent MC and significantly reduce overall hospital stay.

Pilot study of sexual dysfunction following abdominal aortic aneurysm surgery.

INTRODUCTION: The complication of sexual dysfunction as a quality of life (QoL) component after abdominal aortic aneurysm (AAA) surgery in men is poorly studied. AIMS: To investigate the prevalence of sexual dysfunction and to highlight the importance of discussing this issue with patients undergoing AAA repair. MAIN OUTCOME MEASURES: The self-reported sexual dysfunction prevalence pre- and postoperatively, the effects on sexual QoL, and the postoperative Sexual Health Inventory for Men (SHIM) scores. METHODS: Between April 1999 and July 2002, a questionnaire-based study, including the SHIM, was conducted on male patients 1-2 years after their elective open (EO) and rupture open (RO) or endovascular repair (EVAR) AAA repair. Demographics, risk factors for sexual dysfunction, sexual history, and postoperative sexual QoL data were obtained. RESULTS: Out of 142 alive male patients surveyed, 56 (40%) patients responded (26 EO, 21 EVAR, and 9 RO repair). The mean age was 69, 73, and 70 years, respectively, and 65%, 66%, and 66%, respectively, admitted to be sexually active postoperatively. The self-reported sexual dysfunction prevalence preoperatively was 27% (EO), 63% (EVAR), and 45% (RO); and postoperatively was 58%, 76%, and 67%, respectively. Detection using SHIM was higher at 70%, 95%, and 78%, respectively. There was a significantly greater increase in the postoperative prevalence of sexual dysfunction in the EO group than in the EVAR group (P < 0.05, chi(2)). The sexual QoL was worsened postoperatively in all groups: 53% (EO), 75% (EVAR), and 50% (RO); but only one-third of EO and EVAR patients, and none in RO patients, would seek treatment for their sexual dysfunction. CONCLUSION: There was a negative impact on the sexual QoL in all groups after surgery, and a significantly higher proportion of patients experienced deterioration in sexual QoL following EO surgical repair. Our results demonstrate the need for a prospective study.

Health care providers and facilities: health facilities--2005. End of Year Issue Brief.

The mission of every hospital in America is to serve the health care needs of individuals in their communities, 24 hours a day, seven days a week. Their task, and the task of their medical staff, is to continually care for and to cure their patients. American health facilities are said to provide the best, most sophisticated, and most beneficial health care in the world. However, a hospital's ability to care for each patient who walks through their doors is continuously challenged on numerous fronts--the shortage of key hospital personnel, the increased cost of caring for the uninsured, the continued problem of medical errors, and the growth of niche and specialty hospitals. As of 2002, there were 5,794 registered hospitals in the United States, according to the most recent data available from the American Hospital Association (AHA). The AHA also states that there are 4,927 community hospitals, which includes nongovernmental, non-profit hospitals, investor-owned (for-profit) hospitals, and hospitals owned by state and local governments. The AHA defines community hospitals as all non-federal, short-term general and other specialty hospitals. Specialty hospitals include obstetrics and gynecology, rehabilitation, orthopedic and other individually described specialty services. Statistics provided by the AHA indicate that the number of rural and urban community hospitals is approximately equal--2,178 rural hospitals compared to 2,749 urban hospitals.

Health care providers and facilities: medical malpractice and tort reform--2005. End of Year Issue Brief.

As health care professionals continue to feel the crunch of rising malpractice insurance rates and increased jury awards, medical malpractice remains a priority for acute care professionals. Medical associations claim that rapidly increasing premiums and the declining number of insurers often lead physicians to stop practicing medicine or to relocate. This may lead to a shortage of physicians, particularly physicians who practice high-risk specialties such as neurology. The pressure to retain an adequate supply of health care professionals is particularly acute in rural areas. It is difficult to pinpoint the origins of the escalating cost of medical malpractice coverage. Insurers and physicians claim excessive litigation and overly generous jury awards have hardened the market. Trial lawyers and consumer advocacy groups assert insurance premium rates have not reflected increasing medical inflation or the payouts of jury awards during the last 30 years. The majority of states have some form of basic coverage requirement that medical malpractice insurers must offer. However, because of the complexities and variety of coverage plans, physicians often are unaware that gaps in coverage exist. As of May 2005, the American Medical Association (AMA) has declared a state

Public health: tobacco taxes and Internet sales--2005. End of Year Issue Brief.

Raising tobacco taxes is an action that resonates with lawmakers, public health and anti-tobacco advocates, and the majority of the electorate. The relatively broad base of support for increasing excise taxes and the potential for increased tax revenue mitigate the concerns over targeting tobacco-users--23 percent of the population--to pay for state programs and the unreliability of the tobacco tax as a permanent source of revenue. Tobacco excise taxes generated $10.2 billion, or about 1.5 percent of all states' revenue. Characterized as sin taxes or user fees and viewed as an effective method to deter price-sensitive adolescents from using tobacco, excise taxes on tobacco have increased in an unprecedented number of states since November 2001. Previously, no more than three states, on average, had increased cigarette taxes in a year. The legislative action is viewed as a politically safe and relatively easy way to raise taxes and increase revenue without incurring the wrath of anti-tax voters. During this period the increases in tobacco taxes ranged from a $0.12 per pack increase in Louisiana to a $0.75 increase in Massachusetts and Michigan. Nationwide the state tax rate per pack of cigarettes ranges from a low in South Carolina of $0.07 to $2.46 in Rhode Island. The mean tobacco excise tax for the nation is approximately $0.92. With an excise tax increase, states can channel needed funds to programs favored by voters in economically strapped times. Indeed, many of the 44 states that increased their tobacco tax announced that the revenue would permit the state to restore or at least reduce proposed cuts to Medicaid and other health programs. Excise taxes also place little administrative burden on states, since the wholesaler pays the tax directly to the state and the additional cost then is passed on to the consumer.

Health care providers and facilities issue brief: certificate of need: year end report-2004.

At one time, every state was required by the federal government to have a certificate of need (CON) program. The process was intended to keep down costs associated with the construction of new health facilities in the state, and prevent over development. When the federal requirement was lifted, however, a number of states did away with their programs. Some later restored them in some form, and many have kept their programs alive for years, requiring a governmental seal of approval for building new facilities such as hospitals and long-term care facilities or for acquiring major medical equipment.