Intraoperative red blood cell transfusion during coronary artery bypass graft surgery increases the risk of postoperative low-output heart failure.
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BACKGROUND: Hemodilutional anemia during cardiopulmonary bypass (CPB) is associated with increased mortality during coronary artery bypass graft (CABG) surgery. The impact of intraoperative red blood cell (RBC) transfusion to treat anemia during surgery is less understood. We examined the relationship between anemia during CPB, RBC transfusion, and risk of low-output heart failure (LOF). METHODS AND RESULTS: Data were collected on 8004 isolated CABG patients in northern New England between 1996 and 2004. Patients were excluded if they experienced postoperative bleeding or received > or = 3 units of transfused RBCs. LOF was defined as need for intraoperative or postoperative intra-aortic balloon pump, return to CPB, or > or = 2 inotropes at 48 hours. Having a lower nadir HCT was also associated with an increased risk of developing LOF (adjusted odds ratio, 0.90; 95% CI, 0.82 to 0.92; P=0.016), and that risk was further increased when patients received RBC transfusion. When adjusted for nadir hematocrit, exposure to RBC transfusion was a significant, independent predictor of LOF (adjusted odds ratio, 1.27; 95% CI, 1.00 to 1.61; P=0.047). CONCLUSIONS: In this study, we observed that exposure to both hemodilutional anemia and RBC transfusion during surgery are associated with increased risk of LOF, defined as placement of an intraoperative or postoperative intra-aortic balloon pump, return to CPB after initial separation, or treatment with > or = 2 inotropes at 48 hours postoperatively, after CABG. The risk of LOF is greater among patients exposed to intraoperative RBCs versus anemia alone. (+info)
Cancer incidence among semiconductor and electronic storage device workers.
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AIMS: To evaluate cancer incidence among workers at two facilities in the USA that made semiconductors and electronic storage devices. METHODS: 89 054 men and women employed by International Business Machines (IBM) were included in the study. We compared employees' incidence rates with general population rates and examined incidence patterns by facility, duration of employment, time since first employment, manufacturing era, potential for exposure to workplace environments other than offices and work activity. RESULTS: For employees at the semiconductor manufacturing facility, the standardised incidence ratio (SIR) for all cancers combined was 81 (1541 observed cases, 95% confidence interval (CI) 77 to 85) and for those at the storage device manufacturing facility the SIR was 87 (1319 observed cases, 95% CI 82 to 92). The subgroups of employees with > or =15 years since hiring and > or =5 years worked had 6-16% fewer total incidents than expected. SIRs were increased for several cancers in certain employee subgroups, but analyses of incidence patterns by potential exposure and by years spent and time since starting in specific work activities did not clearly indicate that the excesses were due to occupational exposure. CONCLUSIONS: This study did not provide strong or consistent evidence of causal associations with employment factors. Data on employees with long potential induction time and many years worked were limited. Further follow-up will allow a more informative analysis of cancer incidence that might be plausibly related to workplace exposures in the cohort. (+info)
The use of insulin declines as patients live farther from their source of care: results of a survey of adults with type 2 diabetes.
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BACKGROUND: Although most diabetic patients do not achieve good physiologic control, patients who live closer to their source of primary care tend to have better glycemic control than those who live farther away. We sought to assess the role of travel burden as a barrier to the use of insulin in adults with diabetes. METHODS: 781 adults receiving primary care for type 2 diabetes were recruited from the Vermont Diabetes Information System. They completed postal surveys and were interviewed at home. Travel burden was estimated as the shortest possible driving distance from the patient's home to the site of primary care. Medication use, age, sex, race, marital status, education, health insurance, duration of diabetes, and frequency of care were self-reported. Body mass index was measured by a trained field interviewer. Glycemic control was measured by the glycosolated hemoglobin A1C assay. RESULTS: Driving distance was significantly associated with insulin use, controlling for the covariates and potential confounders. The odds ratio for using insulin associated with each kilometer of driving distance was 0.97 (95% confidence interval 0.95, 0.99; P = 0.01). The odds ratio for using insulin for those living within 10 km (compared to those with greater driving distances) was 2.29 (1.35, 3.88; P = 0.02). DISCUSSION: Adults with type 2 diabetes who live farther from their source of primary care are significantly less likely to use insulin. This association is not due to confounding by age, sex, race, education, income, health insurance, body mass index, duration of diabetes, use of oral agents, glycemic control, or frequency of care, and may be responsible for the poorer physiologic control noted among patients with greater travel burdens. (+info)
Literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes.
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BACKGROUND: Inconsistent findings reported in the literature contribute to the lack of complete understanding of the association of literacy with health outcomes. We evaluated the association between literacy, physiologic control and diabetes complications among adults with diabetes. METHODS: A cross-sectional study of 1,002 English speaking adults with diabetes, randomly selected from the Vermont Diabetes Information System, a cluster-randomized trial of a diabetes decision support system in a region-wide sample of primary care practices was conducted between July 2003 and March 2005. Literacy was assessed by the Short-Test of Functional Health Literacy in Adults. Outcome measures included glycated hemoglobin, low density lipoprotein, blood pressure and self-reported complications. RESULTS: After adjusting for sociodemographic characteristics, duration of diabetes, diabetes education, depression, alcohol use, and medication use we did not find a significant association between literacy and glycemic control (beta coefficent,+ 0.001; 95% confidence interval [CI], -0.01 to +0.01; P = .88), systolic blood pressure (beta coefficent, +0.08; 95% CI, -0.10 to +0.26; P = .39), diastolic blood pressure (beta coefficent, -0.03; 95% CI, -0.12 to +0.07, P = .59), or low density lipoprotein (beta coefficent, +0.04; 95% CI, -0.27 to +0.36, P = .77. We found no association between literacy and report of diabetes complications. CONCLUSION: These findings suggest that literacy, as measured by the S-TOFHLA, is not associated with glycated hemoglobin, blood pressure, lipid levels or self-reported diabetes complications in a cross-sectional study of older adults with diabetes under relatively good glycemic control. Additional studies to examine the optimal measurement of health literacy and its relationship to health outcomes over time are needed. (+info)
Limitations of diabetes pharmacotherapy: results from the Vermont Diabetes Information System study.
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BACKGROUND: There are a wide variety of medications available for the treatment of hyperglycemia in diabetes, including some categories developed in recent years. The goals of this study were to describe the glycemic medication profiles in a cohort of adult patients enrolled in primary care, to compare the regimens with measures of glycemic control, and to describe potential contraindicated regimens. METHODS: One thousand and six subjects with diabetes cared for in community practices in the Northeast were interviewed at home at the time of enrollment in a trial of a diabetes decision support system. Laboratory data were obtained directly from the clinical laboratory. Current medications were obtained by direct observation of medication containers by a research assistant. RESULTS: The median age of subjects was 63 years; 54% were female. The mean A1C was 7.1%, with 60% of subjects in excellent glycemic control (A1C < 7%). Ninety percent of patients were taking 2 or fewer medications for glycemic control, with a range of 0 to 4 medications. Insulin was used by 18%. As the number of diabetes medications increased from 0 to 4, the A1C increased from 6.5% to 9.2% (p < 0.001). The association between glycemic control and number of glycemic medications was confirmed using logistic regression, controlling for potential confounders. Almost 20% of subjects on metformin or thiazolidenediones had potential contraindications to these medications. CONCLUSION: Patients with diabetes cared for in primary care are on a wide variety of medication combinations for glycemic control, though most are on two or fewer medications. A greater number of diabetes medications is associated with poorer glycemic control, reflecting the limitations of current pharmacotherapy. One quarter of patients are on glycemic medications with potential contraindications. (+info)
Statewide quality improvement outreach improves preventive services for young children.
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OBJECTIVE: Although clinical trials demonstrate the efficacy of quality improvement outreach in improving service delivery, evidence for broad community effectiveness has been lacking. The objective of this study was to test the effectiveness of a statewide pediatric quality improvement outreach program in improving preventive services for children who are younger than 5 years. METHODS: All pediatric practices in Vermont (n = 35) were invited to participate in a preventive services quality improvement initiative. Ninety-one percent agreed. Participating practices serve >80% of all Vermont children who are younger than 5 years. The main outcome measured was change in 9 preventive services areas: (1) immunizations up to date; (2) anemia screening; (3) tuberculosis risk assessment and indicated screening; (4) lead screening; (5) infant sleep position counseling; (6) environmental tobacco smoke-exposure risk assessment; (7) blood pressure screening; (8) vision screening; and (9) dental risk assessment. RESULTS: All practices demonstrated improvement in 1 or more preventive services areas. The mean number of areas chosen was 5 (range: 1-9). Practices that selected a specific preventive service area as a quality improvement goal were more likely to demonstrate improvement in that area than practices that did not choose to focus on that preventive services area. CONCLUSIONS: The work in this project has provided the evidence for an effective statewide pediatric quality improvement outreach program to improve preventive services for children who are younger than 5 years. Practices' decision to focus on a specific preventive service area as a quality improvement goal seems necessary for improvement in that area. This approach may be effective in other states or regions. (+info)
Reducing healthy worker survivor bias by restricting date of hire in a cohort study of Vermont granite workers.
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OBJECTIVE: To explore the healthy worker survivor effect (HWSE) in a study of Vermont granite workers by distinguishing "prevalent" from "incident" hires based on date of hire before or after the start of follow-up. METHODS: Records of workers between 1950 and 1982 were obtained from a medical surveillance programme. Proportional hazards models were used to model the association between silica exposure and lung cancer mortality, with penalised splines used to smooth the exposure-response relationship. A sensitivity analysis compared results between the original cohort and subcohorts defined by restricting date of hire to include varying proportions of prevalent hires. RESULTS: Restricting to incident hires reduced the 213 cases by 74% and decreased the exposure range. The maximum mortality rate ratio (MRR) was close to twofold in all subcohorts. However, the exposure at which the maximum MRR was achieved decreased from 4.0 to 0.6 mg-year/m3 as the proportion of prevalent hires decreased from 50% in the original cohort to 0% in the subcohort of incident hires. CONCLUSION: Despite loss in power and restricted exposure range, decreasing the relative proportion of prevalent to incident hires reduced HWSE bias, resulting in stronger evidence for a dose-response between silica exposure and lung cancer mortality. (+info)
Do state parity laws reduce the financial burden on families of children with mental health care needs?
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OBJECTIVE: To study the financial impact of state parity laws on families of children in need of mental health services. DATA SOURCE: Privately insured families in the 2000 State and Local Area Integrated Telephone Survey National Survey of Children with Special Health Care Needs (CSHCN) (N=38,856). STUDY DESIGN: We examine whether state parity laws reduce the financial burden on families of children with mental health conditions. We use instrumental variable estimation controlling for detailed information on a child's health and functional impairment. We compare those in parity and nonparity states and those needing mental health care with other CSHCN. PRINCIPLE FINDINGS: Multivariate regression results indicate that living in a parity state significantly reduced the financial burden on families of children with mental health care needs. Specifically, the likelihood of a child's annual out-of-pocket (OOP) health care spending exceeding $1,000 was significantly lower among families of children needing mental health care living in parity states compared with those in nonparity states. Families with children needing mental health care in parity states were also more likely to view OOP spending as reasonable compared with those in nonparity states. Likewise, living in a parity state significantly lowered the likelihood of a family reporting that a child's health needs caused financial problems. The likelihood of reports that additional income was needed to finance a child's care was also lower among families with mentally ill children living in parity states. However, we detect no significant difference among residents of parity and nonparity states in receipt of needed mental health care. CONCLUSION: These results indicate that state parity laws are providing important economic benefits to families of mentally ill children undetected in prior research. (+info)