Multivariate Correlates Research Articles

The relationship between second-year medical students' OSCE scores and USMLE Step 1 scores

The relationship between objective structured clinical examinations (OSCEs) and standardized tests is not well known. We linked second-year medical students' physical diagnosis OSCE scores from 1998, 1999 and 2000 (n = 355) with demographic information, Medical College Admission Test (MCAT) scores, and United States Medical Licensing Examination (USMLE) Step 1 scores. The correlation coefficient for the total OSCE score with USMLE Step 1 score was 0.41 (p < 0.001). Two of 7 skills areas--diagnosis and identification of abnormality--were significant multivariate correlates of USMLE Step 1 score. OSCE station scores accounted for approximately 22% of the variability in USMLE Step 1 scores. A second-year OSCE in physical diagnosis is correlated with scores on the USMLE Step 1 exam, with skills that foreshadow the clinical clerkships most predictive of USMLE scores. This correlation suggests predictive validity of this OSCE and supports the use of OSCEs early in medical school.

Percutaneous coronary intervention outcomes in octogenarians during the stent era (National Cardiovascular Network)

been reviewed in detail. 1 With recent changes in performing PCI, especially with the introduction of intracoronary stents, older data may not adequately reflect contemporary levels of risk. The present study examines the risk of in-hospital mortality following PCI in octogenarians in the stent era using a multiinstitutional database. ••• From January 1998 to June 1999, 2,968 patients 80 years of age underwent PCI in 17 of the National Cardiovascular Network of hospitals; all of these patients were included in this study. The National Cardiovascular Network is an alliance of hospitals that performs a minimum of 500 PCI procedures and 500 coronary artery bypass procedures annually. National Cardiovascular Network physicians meet or exceed American College of Cardiology volume requirements. All PCI procedures were performed using the standard techniques employed during the period of time in which the procedure took place. PCI procedures included balloon dilations, stent implantation, and the use of other new devices. Patients were considered to have diabetes based on a physician’ s diagnosis (nonstressed blood sugar 140 mg/dl on 2 occasions, although this could not reasonably be verified), or if they had received oral hypoglycemic agents or insulin, or were on diet therapy. Patients were considered to have narrowing of the coronary arteries if they had 70% diameter luminal narrowing in the left anterior descending, left circumflex, or right coronary arteries, or of a major branch. Patients had left main disease if there was 70% diameter luminal narrowing in the left main coronary artery. Patients experienced angiographic success if there was a decrease in postprocedure diameter stenosis to 50% and a decrease in percent stenosis by 20%. They were diagnosed with myocardial infarction if new Q waves were seen after the procedure. The variables defined by patient history were hypertension, severity of angina, and prior myocardial infarction. Angina was defined by the Canadian Cardiovascular Society Classification. Heart failure was defined by the New York Heart Association criteria. Demographic, clinical, angiographic, and procedural data, including complications, were recorded at the clinical sites and entered into a local computerized database. Data were sent to the data coordinating center at Emory semi-annually. All fields were defined in a data dictionary. Data are expressed as proportions or as mean SD. Categorical data were compared by chi-square and continuous by analysis of variance. Missing covariate data were imputed using an S-Plus (Mathsoft, Seattle, Washington) procedure that performs multiple imputation using relations among all variables to predict the missing observations. Multivariate correlates of discrete end points were analyzed with logistic regression. Potential nonlinear effects of each of the continuous predictor variables were checked using restricted cubic splines. Statistical modeling and testing were performed using S-Plus. The ability of the models to discriminate among patients with respect to their outcomes was measured using the c-index, which is equivalent to the area under the receiver-operating characteristic curve. Bootstrap validation and calibration of a singly imputed dataset were carried out using the “ validate”and “ calibrate”functions in the “ Design”library of S-Plus statistical functions. There were 2,968 patients with 105 deaths (3.54%). Demographic and clinical characteristics of the 2,485 patients with (13%) and without (87%) an acute myocardial infarction are listed in Table 1. Mean age was 84 years, most of the patients were women, and diabetes was common. Most of the patients had systemic hypertension, a minority had heart failure, and approximately half had unstable angina. Previous coronary artery bypass graft surgeries and PCIs were more common in patients without acute myocardial infarction. Comorbidities of cerebrovascular disease, peripheral vascular disease, renal insuf ficiency, and chronic obstructive pulmonary disease were each noted in a minority of patients. Angiographic characteristics and outcomes according to presentation with and without an acute myocardial infarction are listed in Table 2. Multivessel disease was noted in most of the patients. The mean ejection fraction was 50% and left ventricular end-diastolic pressure was 19 7 mm Hg. Most of the cases underwent elective procedures and stent usage was common. The need for coronary artery bypass grafts, and the occurrence of Q-wave myocardial infarction, and stroke occurred in a small minority of patients. The unadjusted relative risk of death for patients with an

Reasons for higher in-hospital mortality >24 hours after percutaneous transluminal coronary angioplasty in women compared with men

Women have a higher in-hospital mortality rate than men after percutaneous transluminal coronary angioplasty (PTCA). To determine reasons for this, we analyzed the outcome of PTCA at our institution from 1989 to 1995 for 5,989 patients (2,101 women). Women were older than men (66.8 ± 10.9 vs 61.0 ± 11.2 years, respectively; p <0.0001) and more likely to have diabetes mellitus, hypertension, or a history of congestive heart failure than men. In-laboratory complications at the time of PTCA were similar for women and men. During the first 24 hours after PTCA, women were more likely than men to become hypotensive (0.33% vs 0.08%, p = 0.04) and had a higher rate of vascular injury than men (1.6% vs 0.6%, p <0.001). More than 24 hours after the procedure, women had a significantly higher mortality rate (1.2% vs 0.52%, p = 0.017), which was no longer significantly different after adjustment for age (odds ratio 0.72, 95% confidence interval 0.39 to 1.32). Multivariate correlates of death >24 hours after PTCA were age, a prior history of congestive heart failure, vascular injury, and use of thrombolytic agents. Of those dying >24 hours after the procedure, 67% of women suffered a noncardiac-related death compared with only 10% of men (p <0.001). The noncardiac death rate was 0.8% for women and 0.05% for men. These deaths were related to renal failure, vascular complications, bleeding, hypotension, and stroke, especially hemorrhagic stroke. In conclusion, immediate procedural complications at PTCA were similar for women and men; however, mortality was higher for women >24 hours after PTCA and before discharge due to a higher rate of noncardiac death.

Electrocardiographic exercise stress testing for cardiac risk assessment in patients undergoing noncardiac surgery.

The value of exercise electrocardiography in the prediction of perioperative cardiac risk has yet to be defined. This study was performed to determine the predictive value of exercise electrocardiography as compared with clinical parameters and resting electrocardiography. A total of 204 patients at intermediate risk for cardiac complications prospectively underwent exercise electrocardiography before noncardiac surgery. Of these, 185 were included in the final evaluation. All patients underwent follow-up evaluation postoperatively by Holter monitoring for 2 days, daily 12-lead electrocardiogram, and creatine kinase, creatine kinase MB, and troponin-T measurements for 5 days. Cardiac events were defined as cardiac death, myocardial infarction, minor myocardial cell injury, unstable angina pectoris, congestive heart failure, and ventricular tachyarrhythmia. Potential risk factors for an adverse event were identified by univariate and multivariate logistic regression analysis. Perioperative cardiac events were observed in 16 patients. There were 6 cases of myocardial infarction and 10 cases of myocardial cell injury. The multivariate correlates of adverse cardiac events were definite coronary artery disease (odds ratio, 8.8; 95% confidence interval [CI], 1.1--73.1; P = 0.04), major surgery (odds ratio, 4.7; 95% CI, 1.3--16.3; P = 0.02), reduced left ventricular performance (odds ratio, 2.0; 95% CI, 1.1--3.8; P = 0.03), and ST-segment depression of 0.1 mV or more in the exercise electrocardiogram (odds ratio, 5.2; 95% CI, 1.5--18.5; P = 0.01). A combination of clinical variables and exercise electrocardiography improved preoperative risk stratification. This prospective study shows that a ST-segment depression of 0.1 mV or more in the exercise electrocardiogram is an independent predictor of perioperative cardiac complications.

Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States

STUDY OBJECTIVEDeterminants of leisure time physical activity (LTPA) in rural middle aged and older women of diverse racial and ethnic groups are not well understood. This study examined: (1) urban-rural...

Influence of concomitant CABG and urgent/emergent status on mitral valve replacement surgery

Background. Outcomes and resource utilization of patients undergoing mitral valve replacement (MVR) with or without concomitant coronary artery bypass grafting (CABG) were reviewed. Methods. Data for 1,844 patients undergoing isolated primary MVR at Emory University Hospitals between 1980 and 1997 were recorded prospectively in a computerized database. Results. The four groups included patients undergoing elective MVR with (n = 360) or without CABG (n = 1332) and urgent/emergent MVR with (n = 66) or without CABG (n = 86). Length of stay was significantly higher in patients undergoing elective MVR with CABG (15 days) than in those without CABG (11 days) but was not significantly different in patients undergoing urgent/emergent MVR with CABG (17 days) than in those without CABG (19 days). In-hospital mortality was significantly higher for patients undergoing elective (14%) or urgent/emergent (41%) MVR with CABG than in those undergoing MVR without CABG (elective:6%; urgent/emergent:20%). The 19-year survival rate was 32% for patients undergoing elective MVR with CABG compared with 51% for those without CABG and 28% for patients undergoing urgent/emergent MVR with CABG compared with 46% for those without CABG. Multivariate correlates of long-term mortality included older age, concomitant CABG, and urgent/emergent status. Hospital costs were significantly higher for patients undergoing elective MVR with ($33,216) than for those without ($23,890) CABG. No significant difference in cost were noted between patients undergoing urgent/emergent MVR with ($40,535) and without ($31,981) CABG. Conclusions. The addition of CABG or urgent/emergent status to patients undergoing MVR significantly increases morbidity, mortality, and costs. Careful scrutiny of the benefits versus resource utilization is required for patients undergoing high risk MVR.

Stroke after coronary artery operation: incidence, correlates, outcome, and cost

Background. Stroke is a major complication of coronary operation, with reported rates of postoperative cerebral dysfunction ranging from 0.4% to 13.8%. In this report, the incidence, correlates, outcomes, and costs of stroke in coronary operation were evaluated at Emory University between 1988 and 1996.Methods. Data were entered prospectively into a dedicated computerized database at Emory University and analyzed retrospectively. Univariate and multivariate analyses were utilized where appropriate.Results. Data from 10,860 patients undergoing primary coronary operation between 1988 and 1996 were analyzed. There were 250 patients not entered into the database. Stroke occurred in 244 (2.2%). Univariate predictors of stroke (p < 0.05) included age, female gender, hypertension, diabetes, prior stroke, prior transient ischemic attack (TIA), and carotid bruits. Multivariate correlates included age (odds ratio 1.07) previous TIA (odds ratio 2.2), and carotid bruits (odds ratio 1.9), although the area under the Receiver Operating Characteristics (ROC) curve was only 0.69, suggesting limited ability to predict stroke. One and 5 year survival rates were 64% and 44% with stroke, and 94% and 81% without stroke, respectively. Among the stroke group, 23% of the patient population died before hospital discharge. The stroke group had a significantly longer length of hospital stay, as well as higher costs.Conclusions. Stroke is a devastating complication of coronary operation, significantly increasing morbidity, mortality, and cost. Three independent variables were identified for predicting stroke, including age, previous TIA, and carotid bruits. Patients should be carefully screened for cerebrovascular disease to help prevent stroke and its associated morbidity.

Determinants of coronary blood flow after thrombolytic administration

OBJECTIVESThis study evaluated the determinants of coronary blood flow following thrombolytic administration in a large cohort of patients.BACKGROUNDTighter residual stenoses following thrombolysis have been associated with slower coronary blood flow, but the independent contribution of other variables to delayed flow has not been fully explored.METHODSThe univariate and multivariate correlates of coronary blood flow at 90 min after thrombolytic administration were examined in a total of 2,195 patients from the Thrombolysis in Myocardial Infarction (TIMI) 4, 10A, 10B and 14 trials. The cineframes needed for dye to first reach distal landmarks (corrected TIMI frame count, CTFC) were counted as an index of coronary blood flow.RESULTSThe following were validated as univariate predictors of delayed 90-min flow in two cohorts of patients: a greater percent diameter stenosis (p < 0.0001 for both cohorts), a decreased minimum lumen diameter (p = 0.0003, p = 0.0008), a greater percent of the culprit artery distal to the stenosis (p = 0.03, p = 0.02) and the presence of any of the following: delayed achievement of patency (i.e., between 60 and 90 min) (p < 0.0001 for both cohorts), a culprit location in the left coronary circulation (left anterior descending or circumflex) (p = 0.02, p < 0.0001), pulsatile flow (i.e., reversal of flow in systole, a marker of heightened microvascular resistance, p = 0.0003, p < 0.0001) and thrombus (p = 0.002, p = 0.03). Despite a minimal 16.4% residual stenosis following stent placement, the mean post-stent CTFC (25.8 ± 17.2, n = 181) remained significantly slower than normal (21.0 ± 3.1, n = 78, p = 0.02), and likewise 34% of patients did not achieve a CTFC within normal limits (i.e., <28 frames, the upper limit of the 95th percent confidence interval previously reported for normal flow). Those patients who failed to achieve normal CTFCs following stent placement had a higher mortality than did those patients who achieved normal flow (6/62 or 9.7% vs. 1/118 or 0.8%, p = 0.003).CONCLUSIONSLumen geometry is not the sole determinant of coronary blood flow at 90 min following thrombolytic administration. Other variables such as the location of the culprit artery, the duration of patency, a pulsatile flow pattern and thrombus are also related to slower flow. Despite a minimal 16% residual stenosis, one-third of the patients treated with adjunctive stenting still have a persistent flow delay following thrombolysis, which carries a poor prognosis.

Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting

Background. Diabetes mellitus is an established independent risk factor for significant morbidity and mortality after coronary artery bypass grafting.Methods. The impact of diabetes on short- and long-term follow-up after coronary artery bypass grafting was studied by comparing the outcomes between 9,920 patients without diabetes mellitus and 2,278 patients with diabetes from 1978 to 1993.Results. Compared with nondiabetic patients, the group with diabetes was older (62 ± 10 years versus 60 ± 10 years), comprised more women (31% versus 19%), had a greater incidence of hypertension (61% versus 44%) and previous myocardial infarction (51% versus 48%), had class III-IV angina more commonly (69% versus 63%), showed a higher incidence of congestive heart failure (11% versus 5%) or triple-vessel or left main disease (60% versus 50%), and had lower ejection fractions (0.54 versus 0.57) (all, p ≤ 0.05). Diabetic patients had a higher incidence of postoperative death (3.9% versus 1.6%) and stroke (2.9% versus 1.4%) (both, p ≤ 0.05), but not Q wave myocardial infarction (1.8% versus 2.9%). Diabetics had lower survival (5 years, 78% versus 88%; 10 years, 50% versus 71%; both, p ≤ 0.05) and lower freedom from percutaneous transluminal coronary angioplasty (5 years, 95% versus 96%; 10 years, 83% versus 86%; latter, p ≤ 0.05), but diabetics did not have lower freedom from either myocardial infarction (5-years, 92% versus 92%; 10-years, 80% versus 84%) or additional coronary artery bypass grafting (5-years, 98% versus 99%; 10-years, 90% versus 91%). Multivariate correlates of long-term mortality were diabetes, older age, reduced ejection fraction, hypertension, congestive heart failure, number of vessels diseased, and urgent or emergent operation.Conclusions. Diabetics have a worse hospital and long-term outcome after coronary artery bypass grafting. The increased risk in such patients can only partially be explained by other demographic characteristics.

Coronary artery bypass grafting in patients with advanced left ventricular dysfunction

Objective. The aim of this study was to determine the long-term survival and control of angina in patients with coronary artery disease and sequentially decreased ejection fractions (EF) after first-time coronary artery bypass grafting. Methods. Between 1981 and 1995, 156 (1.3%) patients with an EF less than 0.25 (group 1), 588 (5%) patients with an EF of 0.25 to 0.34 (group 2), 2,438 (20.6%) patients with an EF of 0.35 to 0.49 (group 3), and 8,648 (73.1%) patients with an EF equal to or greater than 0.50 (group 4) underwent coronary artery bypass grafting. The EFs were determined by uniplanar or biplanar left ventriculography. For each group, the clinical and angiographic characteristics and the operative and outcome data were compared. Survival curves were derived and compared for each group. Correlates of angina, and of early (30-day) and long-term mortality, for all groups were analyzed. Results. For all groups the mean age was approximately 60 ± 10 years. Group 1 had the highest percentage of patients who were men (88%), had congestive heart failure (34%), had hypertension (53%), and had left main coronary artery disease (24%). Groups 1 through 3, compared with group 4, had a lower percentage of complete revascularization ( p < 0.0001), a lower percentage of internal mammary artery grafts ( p < 0.0001), and a greater use of intraaortic balloon pump ( p < 0.0001), but had similar cross-clamp and cardiopulmonary bypass times, number of grafts, incidences of myocardial infarction, and stroke. Hospital mortality for groups 1, 2, 3, and 4 was 3.8% (n = 6), 3.4% (n = 20), 3% (n = 72), and 1.6% (n = 134), respectively. Groups 1 through 3, compared with group 4, had similar incidences of angina during follow-up (31% to 40% versus 33%, respectively; p < 0.06). Survival was greatest for group 4 compared with groups 1 through 3 at 1, 5, and 10 years ( p < 0.0001). Patients in group 1 had 1-, 5-, and 7-year survivals of 90%, 64%, and 49%. Multivariate correlates of early mortality were advanced age, female sex, decreased EF, hypertension, diabetes, and emergency operation. Multivariate correlates of long-term mortality included severity of preoperative angina class, congestive heart failure, number of diseased vessels, and incomplete revascularization. The strongest correlates of angina at follow-up were younger age, female sex, previous myocardial infarction, lower ejection fraction, and incomplete revascularization. The absence of an internal mammary artery graft did not predict the occurrence of angina or influence long-term survival. Conclusions. In the long term there is a higher mortality in patients with sequentially decreased left ventricular function undergoing coronary artery bypass grafting, although more than 60% of patients with an EF less than 0.25 were alive and had good control of angina at 5 years despite having a higher percentage of risk factors, poorer functional status, and more complex coronary disease. Failure of symptom control and survival beyond 5 years appeared to be influenced by preexisting medical conditions and factors that affect the ability to completely revascularize the myocardium. These results suggest that in selected patients with ischemia and poor left ventricular function, coronary artery bypass grafting may preserve remaining viable myocardium, provide relief of symptoms, and offer survival greater than 60% at more than 5 years.

Prevalence and predictors of long-term work disability due to carpal tunnel syndrome.

The objective of this study was to describe patterns and predictors of work absence in the prospective, community-based Maine Carpal Tunnel Study. Three hundred fifteen patients with carpal tunnel syndrome (CTS) were recruited from physicians' offices throughout Maine. The patients completed questionnaires at entry and after 6, 18, and 30 months. The questionnaires included scales measuring symptom severity, functional status, general and mental health status, exposure to physical stressors, work status, and other indicators. The analyses examined univariate and multivariate correlates of work absence. The mean age was 43, 72% of subjects were female, 71% underwent carpal tunnel release, and 45% were receiving Workers' Compensation. Fifty-two percent worked in managerial or technical occupations, 15% in service occupations, and 13% in heavy labor or machine operation. Forty-five percent of patients changed jobs or were absent from work (aside from postoperative recovery) during the 30-month follow-up. In multivariate logistic regression models, correlates of work absence at 18 months included worse functional status of the hand at study entry and at 6-month follow-up, involvement of an attorney at the time of enrollment (P < 0.002 for each), and work absence at 6 months (P = 0.03). Worse upper extremity functional status and having a contested Workers' Compensation claim are critical predictors of work absence and should be principal targets of interventions to reduce work disability in CTS.

Correlates of HIV Seropositivity and HIV Testing Among Out-of-Treatment Drug Users

This study: 1) examined the rate and correlates of human immunodeficiency virus (HIV) seropositivity; and 2) assessed whether self-selection in HIV testing influenced the rate and correlates of HIV seropositivity in a group of out-of-treatment drug users. Data were collected from 856 out-of-treatment drug users in Philadelphia between January 1993 and August 1994. Seventy-four percent of the sample elected to take an HIV test that was included in the project in which the drug users were enrolled, and of these, 11% were HIV positive. Multivariate analyses indicated that those who were younger, those who had an injection-drug-using sex partner, and those who reported no recent sexual activity were more likely to be HIV positive. An examination of the multivariate correlates of HIV testing indicated that subjects who took an HIV test had higher rates of participation in some risk behaviors than did subjects who did not take an HIV test, but lower rates for other risk behaviors. None of the correlates of HIV seropositivity were correlates of HIV testing. Although the generalizability of the HIV seroprevalence rate is unclear, it is probable that the correlates of HIV seropositivity are generalizable to the total sample. The results of this study indicate the importance of interventions that target sexual risk behavior among out-of-treatment drug users, and of assessing the impact of self-selection bias whenever the rate and correlates of HIV seropositivity are examined.

Outcome of Coronary Bypass Surgery Versus Coronary Angioplasty in Diabetic Patients With Multivessel Coronary Artery Disease

Objectives. This study sought to compare the outcome of percutaneous transluminal coronary angioplasty (PTCA) (n = 834) and coronary artery bypass graft surgery (CABG) (n = 1805) in diabetic patients with multivessel coronary disease from an observational database.Background. There is concern about selection of revascularization in diabetic patients with multivessel coronary artery disease.Methods. Data were collected prospectively and entered into a computerized database. Follow-up was by letter or telephone or additional events resulting in readmission.Results. After CABG there were more in-hospital deaths (0.36% vs. 4.99%, p < 0.0001) and a trend toward more Q wave myocardial infarctions than after PTCA. Five- and 10-year survival rates were 78% and 45% after PTCA and 76% and 48% after CABG, respectively (p = 0.47). At 5 and 10 years, insulin-requiring patients had lower survival rates of 72% and 31% after PTCA and 70% and 48% after CABG, respectively (p = 0.54). Multivariate correlates of long-term mortality were older age, low left ventricular ejection fraction, heart failure and hypertension. In the total group, insulin requirement was a correlate of long-term mortality. For the total group, choice of therapy had a multivariate hazard ratio close to 1. In the insulin-requiring subgroup, the multivariate hazard ratio was 1.35 (95% confidence interval 1.01 to 1.79) for PTCA versus CABG. Corrected for baseline differences, 5- and 10-year survival rates were 68% and 36% after PTCA and 75% and 47% after CABG, respectively, in the insulin-requiring subgroup. Nonfatal events were more common after PTCA, especially additional revascularization.Conclusions. This study reveals a high incidence of events in diabetic patients and raises further questions about angioplasty in insulin-requiring diabetic patients with multivessel disease.

Dating Violence in Two High School Samples: Discriminating Variables

Given that dating violence is a serious problem for adolescents, research is needed to inform dating violence prevention programs which often target correlates of violence. The current two studies examined the multivariate correlates of dating violence in two high schools. The Riggs and O'Leary (1989) model of courtship aggression was used to select a number of variables that are most amenable to change through prevention and intervention strategies. Multivariate analyses, although showing similar discriminating variables for males and females, yielded slightly different patterns of predictors of male and female dating violence. The results have implications for the development of high school-based dating violence prevention programs and for the further examination of sex differences in dating violence.

Prediction and assessment of the severity of post-operative pain and of satisfaction with management

A prospective observational study of cohorts of patients undergoing hip replacement (30), knee replacement (31), and spinal nerve root decompressive surgery (30) were interviewed pre-operatively to identify factors which might correlate with and potentially predict severe post-operative pain and dissatisfaction with analgesic management. The hip patients comprised 33% females and averaged 64 years, while the knee patients were 45% female and older (mean 71 years) and the spinal patients were 43% female and averaged 50 years. The three groups were similar with respect to all other pre-operative variables. Pain intensity was assessed mainly by self-report using the Present Pain Intensity (PPI) and Visual Analogue Scales (VAS) of the McGill Pain Questionnaire. The PPI was preferred by patients and nurses and, as there were no analytical advantages for the VAS, the PPI data are presented. The average post-operative pain during routine management mainly with patient controlled intravenous opiate, was mild to moderate and declined over days 1–5, declined further at discharge but rose slightly 1 month after discharge. The hip replacement patients experienced significantly ( P<0.01) less pain overall than the patients in the other two groups. Nurses' assessments of pain severity from observed behaviour were low and agreed poorly with the patients' self reports. Assessed on Likert Scales (0–6), the patients generally indicated good or excellent pain control, better than expected pain experience, and high levels of satisfaction with analgesic management. Significant ( P≤0.01) multivariate correlates of severe post-operative pain assessed by logistic regression analysis of 11 variables were female gender, high pre-operative pain severity, and younger age. Significant ( P≤0.01) multivariate correlates of both worse than expected pain experience and low satisfaction were female gender, high pre-operative pain severity, high anxiety about risks and problems, low expected pain severity, age (younger) and high willingness to report pain. These variables may reasonably be tested in further studies as potential predictors of adverse post-operative pain experience.

Long-Term Survival in Patients With Repair of Tetralogy of Fallot: 36-Year Follow-Up of 490 Survivors of the First Year After Surgical Repair

Objectives. We sought to analyze risk factors for long-term survival (up to 36 years) after surgical repair of tetralogy of Fallot (TOF).Background. Survival after repair is excellent, but data >20 years are rare.Methods. From 1958 to 1977, 658 patients underwent correction of TOF at our institution and were analyzed for survival. Of this patient group (age 12.2 ± 8.6 years [mean ± SD], range 2 to 67), 39.7% had a previous palliation. Operative (n = 139) and 1-year (n = 29) deaths were excluded for long-term calculations, resulting in a study group of 490 patients.Results. Actuarial 10-, 20-, 30- and 36-year survival rates were 97%, 94%, 89% and 85%, respectively. Mortality increased 25 years postoperatively from 0.24%/year to 0.94%/year (p = 0.003). The most common cause of death was sudden death (n = 13), followed by congestive heart failure (n = 6). Multivariate correlates of impaired long-term survival were date of operation (before 1970, p = 0.0104), preoperative polycythemia (p = 0.0487) and use of a right ventricular (RV) outflow patch (p = 0.0079). Postoperative systolic RV/left ventricular pressure ratio and age showed no influence. Patients without preoperative polycythemia and an RV outflow patch (n = 164) had a 36-year actuarial survival rate of 96% and normal life expectancy.Conclusions. Cyanosis, operative experience of the surgeon and an RV outflow tract patch influence long-term outcome after repair of TOF in older children. Early repair by experienced surgeons to avoid polycythemia and excessive RV hypertrophy is supported by this study. However, mortality risk increases 25 years postoperatively, and thus heart monitoring should be intensified.

Surgery for acquired heart disease The importance of completeness of revascularization during long-term follow-up after coronary artery operations

Completeness of revascularization after coronary artery bypass operation has been shown to improve short- and medium-term outcome. The purpose of this study was to assess the independent contribution of completeness of revascularization to long-term outcome. A total of 2057 patients with multivessel disease with complete revascularization and 803 with incomplete revascularization, mean age 57 ± 9 years, was studied. The patient groups were similar except for more prior myocardial infarctions, worse left ventricular function, and more three-vessel disease in the incomplete revascularization group. Complications of perioperative infarction and stroke were not different between those having complete versus incomplete revascularization. The hospital death rate for patients having complete revascularization during the period of study was 0.7% versus 1.5% for those having incomplete revascularization ( p = 0.06). Length of hospital stay for the two groups of patients also was not different. At late follow-up (mean 11.7 years for complete and 10.8 years for incomplete) patients who had incomplete revascularization had a significantly higher prevalence of recurrent angina. Multivariate analysis demonstrated the strongest predictors of incomplete revascularization to be number of vessels diseased and left ventricular function (ejection fraction). The multivariate correlates of survival were older age, left ventricular dysfunction, and completeness of revascularization. Completeness of revascularization correlated with improved overall patient survival, as well as survival in patients with normal left ventricular function. Furthermore, the curves continued to separate over time, such that the difference was greater at 8 years than at 4 years, although by 12 years the curves started to converge. (J T horac C ardiovasc S urg 1996;112:227-37)

In-Hospital and Long-term Outcome After Reoperative Coronary Artery Bypass Graft Surgery

Increasingly over the past several years, patients have returned after coronary surgery for reoperative procedures, and the experience has become substantial. In this report, we describe immediate- and long-term outcomes after reoperative coronary artery bypass graft surgery. The source of data was the clinical database at Emory University. The surgical procedure and statistical methods were standard. Data were collected prospectively and entered into a computerized database. Follow-up was by letter, telephone, or hospital records documenting additional events resulting in readmission. In-hospital correlates of survival were determined by logistic regression, and long-term correlates were determined by Cox model analysis. There were 2030 patients with a mean age of 61 and a mean of 7.8 +/- 4.1 years since the first surgery. The mean ejection fraction was close to 50%, and the majority had three-vessel or left main disease. Urgent or emergency surgery was required in 16.6%. The internal mammary was used in 60.1%. Q-wave myocardial infarctions occurred in just over 5%. Neurological events increased from 1.2% at less than age 50 to 4.1% at more than age 70. The hospital mortality increased from 5.7% at less than age 50 to 10% at more than age 70, with an overall rate of 7.0%. Mortality was 5.7% for elective, 10.9% for urgent, and 16.4% for emergency cases. Angina was noted at follow-up in 41.3%. Urgent or emergency surgery, reduced ejection fraction, hypertension, older age, and female sex were univariate and multivariate correlates of in-hospital death. Diabetes was a univariate correlate only. Five- and 10-year survival rates were 76% and 55%, respectively. Five- and 10-year myocardial infarction-free survival rates were 63% and 40%, respectively. By 12 years, few patients were free of cardiac events. The univariate and multivariate correlates of long-term mortality were older age, reduced ejection fraction, hypertension, diseased vessels, presence of diabetes, congestive failure, and emergency surgery, with a strong trend for female sex. The use of the internal mammary artery was not a correlate for long-term mortality. Patients undergoing reoperative procedures have higher mortality initially and at long term than patients undergoing a first procedure. Expected mortality based on covariates may help in the decision of whether to perform reoperative coronary artery bypass graft surgery.

Percutaneous transluminal coronary angioplasty as a first revascularization procedure in single-, double- and triple-vessel coronary artery disease

We sought to compare in-hospital and long-term outcome after angioplasty in patients with single-, double- and triple-vessel disease. Coronary angioplasty is increasingly used in patients with multivessel disease. The source of data was the clinical data base at Emory University. Patients who had previous coronary revascularization or who underwent angioplasty in the setting of acute myocardial infarction were excluded. Of 10,783 patients, 71% had one-vessel, 24% two-vessel and 5% three-vessel disease. Age, male gender, diabetes, hypertension, history of previous myocardial infarction, Canadian Cardiovascular Society class III or IV angina and congestive failure all increased with severity of disease. Complete revascularization was achieved in most patients with one-vessel disease, in a minority with two-vessel disease and rarely in those with three-vessel disease. Emergency coronary bypass surgery increased from 1.7% with one-vessel disease to 3.2% with three-vessel disease. Q wave myocardial infarctions could not be shown to vary significantly with severity of disease. The mortality rate increased from 0.2% with one-vessel disease to 1.2% with three-vessel disease. The number of vessels diseased was a multivariate correlate of in-hospital and long-term mortality. The 1-, 5- and 10-year survival was 0.99, 0.93 and 0.86 for one-vessel disease and 0.97, 0.89 and 0.76 for two-vessel disease, respectively. The 1-, 5- and 9-year survival was 0.95, 0.85 and 0.70 in three-vessel disease, respectively. Freedom from myocardial infarction, coronary bypass surgery and repeat angioplasty was also lower with more severe disease. Patients have increasing in-hospital and long-term mortality as the severity of disease increases. There is also an increased incidence of myocardial infarction and revascularization procedures with more severe disease.

Neurologic events after coronary bypass grafting: Further observations with warm cardioplegia

Warm heart surgery has documented myocardial protection benefit, but with an added neurologic threat. It is hypothesized that moderately hypothermic aerobic heart surgery will maintain the myocardial protection and reduce neurologic risk. This study compared 493 patients undergoing coronary artery bypass graft operations with normothermic (35 degrees to 37% degrees C) continuous blood cardioplegia and normothermic perfusion to 379 coronary artery bypass grafting patients with hypothermic (33 degrees to 29 degrees C) continuous blood cardioplegia and hypothermic perfusion to test this hypothesis. There was no difference in age, sex, prior myocardial infarction, hypertension, prior neurologic event, congestive failure, or diabetes. The hypothermic group had more reoperations (24% versus 14%; p = 0.0002), class III/IV angina (83% versus 71%; p = 0.002), a trend to more triple-vessel (54% versus 47%; p = 0.10) and left main disease (18% versus 14%; p = 0.10), lower ejection fractions (0.52 +/- 0.15 versus 0.55 +/- 0.13), more grafts placed (3.6 +/- 1.1 versus 3.4 +/- 1.1; p = 0.04), but fewer internal mammary arteries (62% versus 78%; p < 0.0001). Postoperative myocardial infarction rate was 1.2% in the hypothermic group and 1.3% in the normothermic group (p = not significant). Intraaortic balloon pump requirement was 3.4% with hypothermic and 1.4% with normothermic groups (p = 0.05). The incidence of postoperative neurologic events was significantly higher in the normothermic group (4.7% versus 1.8%; p = 0.038). The multivariate correlates of stroke were older age and normothermic cardioplegia, whereas the only multivariate correlate of death was older age.(ABSTRACT TRUNCATED AT 250 WORDS)