Community-wide Perspective Research Articles

Summer Dynamics of Microbial Diversity on a Mountain Glacier.

Glaciers are rapidly receding under climate change. A melting cryosphere will dramatically alter global sea levels, carbon cycling, and water resource availability. Glaciers host rich biotic communities that are dominated by microbial diversity, and this biodiversity can impact surface albedo, thereby driving a feedback loop between biodiversity and cryosphere melt. However, the microbial diversity of glacier ecosystems remains largely unknown outside of major ice sheets, particularly from a temporal perspective. Here, we characterized temporal dynamics of bacteria, eukaryotes, and algae on the Paradise Glacier, Mount Rainier, USA, over nine time points spanning the summer melt season. During our study, the glacier surface steadily darkened as seasonal snow melted and darkening agents accumulated until new snow fell in late September. From a community-wide perspective, the bacterial community remained generally constant while eukaryotes and algae exhibited temporal progression and community turnover. Patterns of individual taxonomic groups, however, were highly stochastic. We found little support for our a priori prediction that autotroph abundance would peak before heterotrophs. Notably, two different trends in snow algae emerged-an abundant early- and late-season operational taxonomic unit (OTU) with a different midsummer OTU that peaked in August. Overall, our results highlight the need for temporal sampling to clarify microbial diversity on glaciers and that caution should be exercised when interpreting results from single or few time points. IMPORTANCE Microbial diversity on mountain glaciers is an underexplored component of global biodiversity. Microbial presence and activity can also reduce the surface albedo or reflectiveness of glaciers, causing them to absorb more solar radiation and melt faster, which in turn drives more microbial activity. To date, most explorations of microbial diversity in the mountain cryosphere have only included single time points or focused on one microbial community (e.g., bacteria). Here, we performed temporal sampling over a summer melt season for the full microbial community, including bacteria, eukaryotes, and fungi, on the Paradise Glacier, Washington, USA. Over the summer, the bacterial community remained generally constant, whereas eukaryote and algal communities temporally changed through the melt season. Individual taxonomic groups, however, exhibited considerable stochasticity. Overall, our results highlight the need for temporal sampling on glaciers and that caution should be exercised when interpreting results from single or few time points.

Niche complementarity among pollinators increases community-level plant reproductive success

Declines in pollinator diversity and abundance have been reported across different regions, with implications for the reproductive success of plant species. However, research has focused primarily on pairwise plant-pollinator interactions, largely overlooking community-level dynamics. Here, we present one of the first efforts linking pollinator visitation to plant reproduction from a community-wide perspective using a well-replicated dataset encompassing 16 well-resolved plant-pollinator networks and data on reproductive success for 19 plant species from Mediterranean shrub ecosystems. We find that models including simple visitation metrics are sufficient to explain the variability in reproductive success observed. However, insights into the mechanisms through which differences in pollinator diversity translate into changes in reproductive success require additional information on network structure. Specifically, we find a positive effect of increasing niche complementarity between pollinators on plant reproductive success. This shows that maintaining communities with a diversity of species but also of functions is paramount to preserving natural ecosystems.

The ‘cost’ of collaborating and other challenges in inter-organizational child welfare practice: a community-wide perspective

ABSTRACT Research consistently identifies challenges in inter-organizational relationships in child welfare practice, yet studies typically examine partnerships among two or three organizations in siloed domains (e.g., child protective services and education) rather than the more encompassing inter-organizational landscape. Using a mixed-methods design, including a quantitative survey (n = 80 organizations) and 67 qualitative interviews with directors/administrators, this study sought to clarify and broaden a systemic understanding of challenges experienced among a comprehensive network of organizations community-wide. The sample included child protective services, schools, courts, law enforcement, domestic violence shelters, advocacy programs, hospitals, health clinics, mental and behavioral health providers, civic groups, religious groups, housing and homelessness services, youth mentorship and recreation programs, food banks, and more. In all, 15 challenges were evidenced and were organized into three clusters: (1) six process and procedural challenges (e.g., the ‘cost’ of collaborating), (2) six engagement challenges (e.g., negotiating roles and resources), and (3) three environmental challenges (e.g., political and policy shifts). Implications are discussed, including recommendations for dedicated staff and funding for collaboration, the use of interdependent response strategies, and enhancing inter-organizational empathy and respect.

Age-specific Differences in the Use of Endovascular Treatment and Hospital Outcomes in Patients with Acute Ischemic Stroke: A Community-wide Perspective (5256)

Age-specific Differences in the Use of Endovascular Treatment and Hospital Outcomes in Patients with Acute Ischemic Stroke: A Community-wide Perspective (5256)

Abstract WP41: Age-Specific Differences in the Use of Endovascular Treatment and Hospital Outcomes in Patients With Acute Ischemic Stroke: A Community-Wide Perspective

Background: Relatively limited information is available about trends over time in the use of endovascular treatment in patients of different ages hospitalized with acute ischemic stroke and the association between use of thrombectomy treatment and hospital outcomes in age strata. We performed this analysis to evaluate trends in the utilization of endovascular treatment in acute ischemic stroke by age strata in real-world practice. Methods: We conducted this study by identifying patients admitted with a primary diagnosis of ischemic stroke in the United States from 2007 to 2016 using the Nationwide Inpatient Sample. International Classification of Diseases, ninth revision, and tenth, Clinical Modification (ICD-9-CM, ICD-10-CM) codes were used to identify patients admitted for ischemic stroke and undergoing endovascular treatment. Results: Of the 4,590,533 patients admitted with ischemic stroke, 269,922 (5.88%) received intravenous thrombolytic treatment, and 51,375 (1.12%) underwent endovascular treatment. There is almost 12-fold significant increase in the use of endovascular treatment patients admitted with acute ischemic stroke between 2007 to 2016. Patients who were 75 years and older experienced a marked increase in the receipt of endovascular treatment over time (0.12% 2007; 1.91% 2016; trend p<0.0001). We observed statistically significant improvement in outcomes including minimal disability (6.3% to 18.8%; trend p<0.0001) and in hospital mortality (25.0% to 16.5%; trend p<0.0001) in patients 75 years and older treated with endovascular treatment in study period. We observed similar trend of outcomes in each of the other age-specific groups under study (<55, 55-64 and 65-74 years). Conclusions: Our findings indicate a recent increase in the use of endovascular in middle-aged and elderly patients with acute ischemic strokes. The impact of endovascular treatment on hospital outcomes was observed in each of our age strata understudy though the magnitude of absolute and relative benefit varied according to age.

Signatures of the collapse and incipient recovery of an overexploited marine ecosystem.

The Northwest Atlantic cod stocks collapsed in the early 1990s and have yet to recover, despite the subsequent establishment of a continuing fishing moratorium. Efforts to understand the collapse and lack of recovery have so far focused mainly on the dynamics of commercially harvested species. Here, we use data from a 33-year scientific trawl survey to determine to which degree the signatures of the collapse and recovery of the cod are apparent in the spatial and temporal dynamics of the broader groundfish community. Over this 33-year period, the groundfish community experienced four phases of change: (i) a period of rapid, synchronous biomass collapse in most species, (ii) followed by a regime shift in community composition with a concomitant loss of functional diversity, (iii) followed in turn by periods of slow compositional recovery, and (iv) slow biomass growth. Our results demonstrate how a community-wide perspective can reveal new aspects of the dynamics of collapse and recovery unavailable from the analysis of individual species or a combination of a small number of species. Overall, we found evidence that such community-level signals should be useful for designing more effective management strategies to ensure the persistence of exploited marine ecosystems.

A multi-level examination of how the organizational context relates to readiness to implement prevention and evidence-based programming in community settings

Prior theoretical and empirical research suggests that multiple aspects of an organization's context are likely related to a number of factors, from their interest and ability to adopt new programming, to client outcomes. A limited amount of the prior research has taken a more community-wide perspective by examining factors that associate with community readiness for change, leaving how these findings generalize to community organizations that conduct prevention or positive youth development programs unknown.Thus for the current study, we examined how the organizational context of the Cooperative Extension System (CES) associates with current attitudes and practices regarding prevention and evidence-based programming. Attitudes and practices have been found in the empirical literature to be key indicators of an organization's readiness to adopt prevention and evidence-based programming. Based on multi-level mixed models, results indicate that organizational management practices distinct from program delivery may affect an organization's readiness to adopt and implement new prevention and evidence-based youth programs, thereby limiting the potential public health impact of evidence-based programs. Openness to change, openness of leadership, and communication were the strongest predictors identified within this study. An organization's morale was also found to be a strong predictor of an organization's readiness. The findings of the current study are discussed in terms of implications for prevention and intervention.

Hyperparasitoids Use Herbivore-Induced Plant Volatiles to Locate Their Parasitoid Host

Author SummaryIn nature, plants often release volatiles in response to damage by herbivores (e.g., by caterpillars), and these can indirectly help defend the plants. Indeed, it is well documented that volatiles can recruit the natural enemies of herbivores, such as predators and parasitoid wasps, whose offspring feed on and develop within their caterpillar hosts. However, such induced plant odours can also be detected by other organisms. One important group of organisms, hyperparasitoids, the enemies of the parasitoids that indirectly benefit the plants, have not been included in this trophic web because so little is known about their foraging behaviour. Here, using a combination of laboratory and field experiments, we demonstrate that hyperparasitoid wasps also take advantage of the odours that plants produce in response to the feeding by caterpillars. The larvae of parasitic wasps developing inside the caterpillar alter the composition of the oral secretions of their herbivorous host and thereby affect the cocktail of volatiles the plant produces. The hyperparasitoids on the lookout for their parasitoid prey can preferentially detect infected caterpillars, although not all parasitoid wasps gave away their presence through this host–plant interaction. We conclude that herbivore-induced plant volatiles can affect the interaction among parasitoids and their enemies and thereby may reduce the indirect defence accrued for the plant.

A piece of the puzzle: a method for comparing pollination quality and quantity across multiple species and reproductive events

• Understanding how pollination affects plant reproductive success and how changes in pollination service affect plant populations, communities and ecosystems is of increasing concern. Yet supplemental hand-pollination traditionally used to assess pollen limitation is prohibitive for large-scale comparative work. Moreover, it does not differentiate between quality and quantity aspects of pollen limitation, and it may suffer from confounds of post-pollination processes such as resource availability to fill seeds. • Here, we highlight pollen tubes as the functional link between pollen arrival and seed production and suggest that consideration of pollen tubes leads to a better depiction of limitation at the pre-zygotic (pollination) phase of sexual reproduction. • We assessed the rigor of piecewise regression to analyze the relationship between the numbers of pollen grains and pollen tubes observed in nonmanipulated wilted flowers. We illustrate how parameters obtained from this analysis provide quantitative insight into the relative relevance of the quantity and quality of pollen receipt in limiting natural pollination success, and can facilitate comparisons among data sets. • This nonmanipulative method opens up new opportunities for rigorous assessment of the relative importance of the quantity and quality of pollination in limiting plant reproduction, especially from a community-wide perspective.

269 Previously known and newly diagnosed atrial fibrillation complicating initial acute myocardial infarction: a community-wide perspective

Atrial fibrillation (AF) is an understudied entity within myocardial infarction (MI) comorbidity. AF carries an increased risk of death but whether this risk is independent of other characteristics remains controversial. Our community-based data allow us, for the first time, to study the occurrence of AF over a long period of observation after MI and determine its impact on mortality post-MI. From an existing MI incident cohort (1983–2007), AF was identified by diagnostic codes for prior AF and from an ECG database for new-onset AF. Heart failure (HF) was defined by the Framingham criteria. Patients were followed from MI until death or last follow-up. Proportional hazards regression examined the association of AF with post-MI mortality. Among 3215 MI patients (mean age 68 y, 42% women), 303 patients (9%) had prior AF. During a mean follow-up of 7 y, 215 patients (30%) developed AF 2 days and 511 (70%) > 2 days of MI. 1639 deaths were observed and AF was associated with an increased risk of death (table). After adjusting for MI characteristics, AF is an independent predictor of long-term mortality, irrespective of its timing. This underscores the importance of its evaluation and management after MI. Impact of Atrial Fibrillation on long-term Mortality in Myocardial Infarction Patients Prior AF AF 2 days post-MI AF > 2 days post-MI HR (95% CI) p-value HR (95% CI) p-value HR (95% CI) p-value Unadjusted 3.54 (3.06,4.10) <0.0001 2.98 (2.51,3.53) <0.0001 4.29 (3.77,4.89) <0.0001 Adjusted for age, sex and comorbidity 1.68 (1.44,1.95) <0.0001 1.80 (1.51,2.14) <0.0001 2.86 (2.51,3.26) <0.0001 Adjusted for age, sex, comorbidity and HF 1.46 (1.26,1.70) <0.0001 1.60 (1.34,1.90) <0.0001 2.30 (2.01,2.63) <0.0001

Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns

Upon delivery, the neonate is exposed for the first time to a wide array of microbes from a variety of sources, including maternal bacteria. Although prior studies have suggested that delivery mode shapes the microbiota's establishment and, subsequently, its role in child health, most researchers have focused on specific bacterial taxa or on a single body habitat, the gut. Thus, the initiation stage of human microbiome development remains obscure. The goal of the present study was to obtain a community-wide perspective on the influence of delivery mode and body habitat on the neonate's first microbiota. We used multiplexed 16S rRNA gene pyrosequencing to characterize bacterial communities from mothers and their newborn babies, four born vaginally and six born via Cesarean section. Mothers' skin, oral mucosa, and vagina were sampled 1 h before delivery, and neonates' skin, oral mucosa, and nasopharyngeal aspirate were sampled <5 min, and meconium <24 h, after delivery. We found that in direct contrast to the highly differentiated communities of their mothers, neonates harbored bacterial communities that were undifferentiated across multiple body habitats, regardless of delivery mode. Our results also show that vaginally delivered infants acquired bacterial communities resembling their own mother's vaginal microbiota, dominated by Lactobacillus, Prevotella, or Sneathia spp., and C-section infants harbored bacterial communities similar to those found on the skin surface, dominated by Staphylococcus, Corynebacterium, and Propionibacterium spp. These findings establish an important baseline for studies tracking the human microbiome's successional development in different body habitats following different delivery modes, and their associated effects on infant health.

Cardiovascular Disease Surveillance in the Comparative Effectiveness Landscape

As the leading cause of death in the Western world, cardiovascular disease (CVD) constitutes an enormous public health problem.1 The last 4 decades have been characterized chiefly by the postponement of CVD events and CVD related deaths until older age. Thus, the burden of CVD is increasing in parallel with the increase in life expectancy.2 Within this context, identifying persons with CVD, measuring its incidence and outcome and how these vary over time and across populations is essential. A central goal of this monitoring (otherwise termed surveillance) has been to understand the determinants of the trends in CVD and in particular the respective responsibility of primary prevention versus that of the care of established disease in the genesis of the CVD trends. A direct extension of surveillance is its application to assess the effectiveness of care and the response to interventions designed to improve the quality of care. Articles see pp 414, 475, and 508 Over the first year of its existence, the journal Circulation: Cardiovascular Quality and Outcomes published 3 important articles that illustrate the clinical relevance of surveillance and the applicability of trend studies to care improvement. The article by Lewsey et al constitutes a classic example of CVD surveillance.3 The authors present much needed data on recent (1986 to 2005) trends in the epidemiology of stroke indicating that age- and sex-specific incidence rates of fatal and nonfatal hospitalized strokes in Scotland declined in men from 235 (95% CI, 229 to 242) to 149 (144 to 154) and in women from 299 (292 to 306) to 182 (177 to 188). The decline in incidence of hospitalized stroke varied by age, but overall this equated to a relative reduction in the risk of stroke of 31% in men and 42% in women. Declines in the …

Severity of Myocardial Infarction

Cardiovascular disease constitutes a burden of epidemic proportion,1 and understanding its determinants is essential to designing effective interventions. Doing so requires the ability to track disease burden at the population level. In the United States, without national registries, community surveillance is the method of choice.2 Community surveillance studies are mostly retrospective by design, rely on diagnostic codes for case finding, and require a defined population in which events can be consistently and reliably captured and validated with standardized approaches. Applied to cardiovascular disease, community surveillance measures its burden in communities by tracking the incidence of events, their severity, and their mortality, thereby enabling the appraisal of the components of cardiovascular diseases in a given population.2 Because of the aforementioned methodological requirements, few surveillance studies exist in the United States. They include the Atherosclerosis Risk in Communities (ARIC) Study,3 the Minnesota Heart Survey,4 the Olmsted County Study,5 and the Worcester Heart Attack Study.6 The data from these studies indicate that, although deaths from coronary disease have declined, the incidence of myocardial infarction in the United States has remained mostly stable. Thus, the decline in mortality can be envisioned as reflecting an improvement in survival, which may be mediated by a declining severity of myocardial infarction. Article p 503 The article by Myerson et al7 in this issue of Circulation specifically addresses this important and understudied issue in ARIC between 1987 and 2002. They examined a large, multiracial population and relied on several indicators, including the composite Predicting Risk of Death in Cardiac Disease Tool (PREDICT) score to conclude that the severity of infarction declined over time. Indeed, the proportion of infarctions with major ECG abnormalities, ST-segment elevation, and Q waves decreased, as did biomarker values and the proportion of persons presenting with shock. …

Multidecade-long trends (1986–2005) in the utilization of coronary reperfusion and revascularization treatment strategies in patients hospitalized with acute myocardial infarction: a community-wide perspective

The objectives of our community-wide investigation were to describe multidecade-long trends (1986-2005) in the utilization of thrombolytic therapy, percutaneous coronary interventions, and coronary artery bypass graft surgery in patients hospitalized with acute myocardial infarction (AMI). The study sample consisted of 9422 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 11 annual periods between 1986 and 2005. Increases in the utilization of percutaneous coronary interventions were observed between 1986 (2.0%) and 2005 (50.7%) with the most rapid increases beginning in the late 1990s. Utilization of coronary artery bypass graft surgery during hospitalization for AMI increased moderately in the 1990s, remained stable thereafter, and declined to being performed in 3.8% of hospitalized patients in 2005. The use of thrombolytic therapy increased between 1986 and 1995 (9.3-25.2%) and decreased markedly thereafter through 2005 (<1%). Demographic and clinical characteristics of several patients were associated with the receipt of these treatment regimens. The results of this study in residents of a large Central New England community suggest an increasingly invasive approach to the management of patients hospitalized with AMI.

Prehospital transport of patients with acute myocardial infarction: A community-wide perspective

The objectives of this population-based study were to examine the use of emergency medical services (EMS) in greater Worcester, Massachusetts, residents (2000 census = 478,000) hospitalized with acute myocardial infarction (AMI) at all metropolitan Worcester medical centers in four biennial periods between 1997 and 2003. A secondary study aim was to describe the demographic and clinical characteristics of patients with AMI transported to metropolitan Worcester hospitals by EMS, compared with those transported by other means, and their hospital outcomes. We reviewed the medical records of 3805 patients hospitalized for confirmed AMI at 11 greater Worcester medical centers during 1997, 1999, 2001, and 2003. Information about the use of EMS, patient characteristics, and hospital outcomes was obtained through the review of hospital charts. A total of 2693 greater Worcester residents with AMI (70.8%) were transported to area hospitals by ambulance. Patients transported by ambulance were older, were more likely to be women, had a greater prevalence of comorbidities, and had a different symptom profile than patients transported by other means. Patients arriving at greater Worcester hospitals by ambulance were more likely to develop serious clinical complications, including heart failure and cardiogenic shock, and die during hospitalization compared with patients not transported by EMS. Our results suggest that the majority of greater Worcester residents seeking care for AMI are transported by EMS. Patients transported by ambulance differ from patients transported by other means and are more likely to experience adverse hospital outcomes. The reasons why patients use EMS in the setting of AMI need to be further explored and patients' care-seeking behavior enhanced.

Long‐term Outcome after Isolated Endarterectomy of the Femoral Bifurcation

Long-term outcome after endarterectomy of the femoral bifurcation has not been widely investigated, and the aim of this study was to assess its late results from a community-wide perspective. Between 1983 and 2006 111 isolated endarterectomies of the common femoral artery and/or the proximal part of the superficial femoral artery or profunda femoris were performed in 90 patients at the Oulu University Hospital, Oulu, Finland. A total of 77 limbs were treated surgically for claudication and 34 others for critical limb ischemia. Angiographic findings of 100 extremities were evaluated. The in-hospital mortality rate was 1.8%. The mean follow-up period was 5.9 years. At 5-, 10-, and 15-year follow-up the overall survival was 60.5%, 32.7%, and 17.6%, respectively (S.E < 0.05). A C-reactive protein value > or = 10 mg/l was predictive of poor late survival (p = 0.008). Limb salvage rates after isolated femoral endarterectomy at 5-, 10-, and 15-year follow-up were 93.7%, 93.7%, and 85.2%, respectively (S.E. < 0.08). Critical limb ischemia (p = 0.006) and current smoking (p = 0.027) were independent predictors of major lower limb amputation. A total of 41 limbs were subjected to ipsilateral vascular procedures after femoral endarterectomy, only one of which was re-endarterectomy. Freedom from any ipsilateral revascularization procedure at 5-, 10-, and 15-year follow-up was calculated at 68.0%, 50.6%, and 42.5%, respectively (S.E. < 0.08). The overall linearized rate of reintervention on the ipsilateral limb was 0.16 +/- 0.44/year. The linearized rate among patients who had any ipsilateral vascular reintervention was 0.43 +/- 0.66/year. Isolated femoral endarterectomy is a rather low-risk and durable procedure. However, a significant number of reinterventions distal or proximal to the endarterectomized site can be expected in one third of patients.

Decompensated Heart Failure in the Setting of Kidney Dysfunction: A Community-Wide Perspective

Background: Patients with heart failure (HF) and kidney disease have a poor long-term outlook which has provided impetus for the identification of factors of prognostic importance and more fully understanding the impact of kidney dysfunction in patients with HF. Objectives: Our objectiveswere to describe the characteristics, hospital treatment practices, as well as hospital and long-term outcomes in patients with varying degrees of kidney dysfunction who were hospitalized with acute HF at all medical centers in a large New England metropolitan area. Methods: Residents of the Worcester metropolitan area hospitalized with clinical findings of decompensated HF at 11 greater Worcester medical centers during 1995 and 2000 comprised the study sample. Kidney function was classified into 4 categories of estimated glomerular filtration rate (eGFR) for purposes of analysis: <30 (n = 569), 30–44 (n = 725), 45–59 (n = 763), and ≧60 (n = 2,293) ml/min per 1.73 m². Results: The average age of the study sample was 76 years and 57% were women. Patients with severe kidney dysfunction were less likely to receive angiotensin-converting enzyme inhibitors, diuretics and digoxin during hospitalization for acute HF compared to patients with more normal kidney function. Patients with lower eGFR levels had higher in-hospital and post-discharge death rates in comparison to those with higher levels of eGFR. Conclusion: Our results demonstrate the impact of renal impairment on the prognosis of patients with decompensated HF. Our findings highlight the less than optimal management of these high-risk patients. Increased surveillance and enhanced treatment of patients with HF and kidney dysfunction remains warranted to improve the survival outlook of these patients.

A community-wide perspective into changing trends in the utilization of diagnostic and interventional procedures in patients hospitalized with acute myocardial infarction

Limited data are available describing contemporary trends in the utilization of diagnostic and interventional procedures in patients hospitalized with acute myocardial infarction (AMI). The objectives of our population-based investigation were to examine long-term trends (1986-2003) in the utilization of cardiac catheterization, percutaneous coronary interventions (PCI), and coronary artery bypass graft surgery (CABG) in a community sample of patients hospitalized with AMI. We examined the demographic and clinical characteristics of patients who received these diagnostic and interventional procedures and determined whether the profile of patients undergoing these procedures had changed over time. The study sample consisted of 9422 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 10 annual periods between 1986 and 2003. Information on patient demographics, clinical course, and treatment practices was obtained through the review of hospital medical records. Marked increases were observed in the utilization of cardiac catheterization (18.4% to 55.8%) and PCI (2.0% to 42.1%) between 1986 and 2003, respectively. Utilization of CABG showed modest increases in the early 1990s, whereas its use was relatively stable thereafter. Several demographic and clinical characteristics were associated with the receipt of these diagnostic and interventional procedures. The results of this study of patients hospitalized with AMI in a large New England community suggest evolving trends in the use of cardiac catheterization, PCI, and CABG. Despite these changing patterns, our findings suggest that there remains room for improvement in the therapeutic management of patients hospitalized with AMI, including certain high-risk groups.

Serum glucose levels and hospital outcomes in patients with acute myocardial infarction without prior diabetes: a community-wide perspective

Elevated serum glucose levels are associated with an increased risk of adverse outcomes in patients with diabetes in the setting of acute myocardial infarction. It is, however, unclear whether a similar association exists in nondiabetic patients and whether this relationship is changing over time. The objectives of this population-based investigation were to examine the magnitude of elevated glucose levels in patients with acute myocardial infarction and the association between admission serum glucose levels and hospital outcomes in patients not known to have prior diabetes. The sample consisted of 3601 patients without a history of prior diabetes who were hospitalized with acute myocardial infarction at all greater Worcester (Massachusetts) medical centers in five biennial periods between 1995 and 2003. The average age of our study population was 70 years, 59% were men, and the average glucose level at the time of hospital admission was 149 mg/dl. Approximately one-third of patients presented with glucose levels<120 mg/dl, whereas one-quarter had serum glucose levels>or=160 mg/dl. Patients in the uppermost quintiles of serum glucose were significantly more likely to develop heart failure and cardiogenic shock, and die during hospitalization than patients with lower serum glucose levels. Patients with the highest glucose levels were less aggressively treated with effective cardiac medications and coronary interventions. The results of this population-based investigation provide insights into the magnitude and impact of hyperglycemia in patients not known to have prior diabetes who are hospitalized with acute myocardial infarction. Increased surveillance and more aggressive treatment strategies are needed to improve the outlook of patients with elevated serum glucose levels.

Long-term trends in the use of coronary reperfusion strategies in acute myocardial infarction: a community-wide perspective

The objectives of our study were to examine long-term (1986-2003) trends in the use of percutaneous coronary interventions (PCI) and thrombolytic therapy in the management of patients hospitalized with acute myocardial infarction (AMI) while our secondary study goal was to examine factors associated with use of these coronary reperfusion strategies. While there have been considerable changes in the management of patients hospitalized with AMI over time, limited contemporary data are available about changing trends in the use of different coronary reperfusion strategies, particularly from the more generalizable perspective of a population-based investigation. The study sample consisted of 9,422 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 10 annual periods between 1986 and 2003. Divergent trends in the use of PCI and thrombolytic therapy during hospitalization for AMI were noted. Use of thrombolytic therapy increased after its introduction to clinical practice in the mid-1980's through the early 1990's with a progressive decline in use thereafter. In 2003, 3.5% of patients hospitalized with AMI were treated with clot lysing therapy. On the other hand, marked increases in the use of PCI during hospitalization for AMI were noted over time. In 2003, 42.1% of patients with AMI received a PCI. Several demographic and clinical factors were associated with the use of these different treatment strategies. The results of our study in a large Northeast community suggest evolving changes in the hospital management of patients with AMI. Current management practices emphasize the utilization of PCI to restore coronary reperfusion to the infarct related artery.