Acute Clopidogrel Use and Outcomes in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes Undergoing Coronary Artery Bypass Surgery

OBJECTIVES We sought to characterize patterns of clopidogrel use before coronary artery bypass grafting (CABG) and examine the drug's impact on risks for postoperative transfusions among patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). BACKGROUND Adherence in community practice to American College of Cardiology/American Heart Association guidelines for clopidogrel use among NSTE ACS patients has not been previously characterized. METHODS We evaluated 2,858 NSTE ACS patients undergoing CABG at 264 hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Initiative. We examined the patterns of acute clopidogrel therapy and its association with bleeding risks among those having early CABG ≤5 days and again among those having late surgery >5 days after catheterization. RESULTS Within 24 h of admission, 852 patients (30%) received clopidogrel. In contrast to national guidelines, 87% of clopidogrel-treated patients underwent CABG ≤5 days after treatment. Among those receiving CABG within ≤5 days of last treatment, the use of clopidogrel was associated with a significant increase in blood transfusions (65.0% vs. 56.9%, adjusted odds ratio [OR] 1.36, 95% confidence interval [CI] 1.10 to 1.68) as well as the need for transfusion of ≥4 U of blood (27.7% vs. 18.4%, OR 1.70, 95% CI 1.32 to 2.19). In contrast, acute clopidogrel therapy was not associated with higher bleeding risks if CABG was delayed >5 days (adjusted OR 1.18, 95% CI 0.54 to 2.58). CONCLUSIONS Despite guideline recommendations, the overwhelming majority of NSTE ACS patients treated with acute clopidogrel needing CABG have their surgery within ≤5 days of treatment. A failure to delay surgery is associated with increased blood transfusion requirements that must be weighed against the potential clinical and economic impacts of such delays

Evolution in Cardiovascular Care for Elderly Patients With Non–ST-Segment Elevation Acute Coronary Syndromes: Results From the CRUSADE National Quality Improvement Initiative

OBJECTIVES This study evaluated the impact of age on care and outcomes for non-ST-segment elevation acute coronary syndromes (NSTE ACS). BACKGROUND Recent clinical trials have expanded treatment options for NSTE ACS, now reflected in guidelines. Elderly patients are at highest risk, yet have previously been shown to receive less care than younger patients. METHODS In 56,963 patients with NSTE ACS at 443 U.S. hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) National Quality Improvement Initiative from January 2001 to June 2003, we compared use of guidelines-recommended care across four age groups: <65, 65 to 74, 75 to 84, and ≥85 years. A multivariate model tested for age-related differences in treatments and outcomes after adjusting for patient, provider, and hospital factors. RESULTS Of the study population, 35% were ≥75 years old, and 11% were ≥85 years old. Use of acute anti-platelet and anti-thrombin therapy within the first 24 h decreased with age. Elderly patients were also less likely to undergo early catheterization or revascularization. Whereas use of many discharge medications was similar in young and old patients, clopidogrel and lipid-lowering therapy remained less commonly prescribed in elderly patients. In-hospital mortality and complication rates increased with advancing age, but those receiving more recommended therapies had lower mortality even after adjustment than those who did not. CONCLUSIONS Age impacts use of guidelines-recommended care for newer agents and early in-hospital care. Further improvements in outcomes for elderly patients by optimizing the safe and early use of therapies are likely

The Impact of For-Profit Hospital Status on the Care and Outcomes of Patients With Non–ST-Segment Elevation Myocardial Infarction Results From the CRUSADE Initiative

ObjectivesWe sought to determine whether for-profit status influenced hospitals’ care or outcomes among non–ST-segment elevation myocardial infarction (NSTEMI) patients.BackgroundWhile for-profit hospitals potentially have financial incentives to selectively care for younger, healthier patients, perform highly reimbursed procedures, reduce costs by limiting access to expensive medications, and encourage shorter in-patient length of stay, there are limited data available to investigate these issues objectively.MethodsUsing data from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines) Initiative, we investigated whether for-profit status influenced hospitals’ patient case mix, care, or outcomes among 145,357 patients with NSTEMI treated between January 1, 2001, and December 31, 2005, at 532 U.S. hospitals. Impact of for-profit status on care and outcomes was analyzed overall and after adjustment for clinical and facility factors using regression modeling.ResultsPatients (n = 11,658) treated at 58 for-profit hospitals were of similar age and gender, but were more likely to be nonwhite (black, Asian, Hispanic, and other) and have health maintenance organization/private insurance, diabetes mellitus, congestive heart failure, hypertension, and renal insufficiency compared with 133,699 patients treated at 474 nonprofit hospitals. For-profit hospitals were less likely to use discharge beta-blockers, but all other treatments were similar including the use of interventional procedures (cardiac catheterization and revascularization procedures) compared with nonprofit centers. In-hospital length of stay and mortality were also similar by hospital type.ConclusionsWe found no evidence that for-profit hospitals selectively treat less sick patients, provide less evidence-based care, limit in-hospital stays, or have patients with worse acute outcomes than nonprofit centers

The added value of the multi-system spread information for ocean heat content and steric sea level investigations in the CMEMS GREP ensemble reanalysis product

Since 2016, the Copernicus Marine Environment Monitoring Service (CMEMS) has produced and disseminated an ensemble of four global ocean reanalyses produced at eddy-permitting resolution for the period from 1993 to present, called GREP (Global ocean Reanalysis Ensemble Product). This dataset offers the possibility to investigate the potential benefits of a multi-system approach for ocean reanalyses, since the four reanalyses span by construction the same spatial and temporal scales. In particular, our investigations focus on the added value of the information on the ensemble spread, implicitly contained in the GREP ensemble, for temperature, salinity, and steric sea level studies. It is shown that in spite of the small ensemble size, the spread is capable of estimating the flow-dependent uncertainty in the ensemble mean, although proper re-scaling is needed to achieve reliability. The GREP members also exhibit larger consistency (smaller spread) than their predecessors, suggesting advancement with time of the reanalysis vintage. The uncertainty information is crucial for monitoring the climate of the ocean, even at regional level, as GREP shows consistency with CMEMS high-resolution regional products and complement the regional estimates with uncertainty estimates. Further applications of the spread include the monitoring of the impact of changes in ocean observing networks; the use of multi-model ensemble anomalies in hybrid ensemble-variational retrospective analysis systems, which outperform static covariances and represent a promising application of GREP. Overall, the spread information of the GREP product is found to significantly contribute to the crucial requirement of uncertainty estimates for climatic datasets.Data from the reanalyses presented in this work are available from the Copernicus Marine Environment Monitoring Service (CMEMS, http://marine.copernicus.eu/). Part of this work was supported by the EOS COST Action (“Evaluation of Ocean Synthesis”, http://eos-cost.eu/) through its Short Term Scientific Missions program. The full C-GLORS dataset is available at http://c-glors.cmcc.it. This work has received funding from the Copernicus Marine Environment Monitoring Service (CMEMS).Published287-3124A. Oceanografia e climaJCR Journa

Development of an Ion Thruster and Power Processor for New Millennium's Deep Space 1 Mission

The NASA Solar Electric Propulsion Technology Applications Readiness Program (NSTAR) will provide a single-string primary propulsion system to NASA's New Millennium Deep Space 1 Mission which will perform comet and asteroid flybys in the years 1999 and 2000. The propulsion system includes a 30-cm diameter ion thruster, a xenon feed system, a power processing unit, and a digital control and interface unit. A total of four engineering model ion thrusters, three breadboard power processors, and a controller have been built, integrated, and tested. An extensive set of development tests has been completed along with thruster design verification tests of 2000 h and 1000 h. An 8000 h Life Demonstration Test is ongoing and has successfully demonstrated more than 6000 h of operation. In situ measurements of accelerator grid wear are consistent with grid lifetimes well in excess of the 12,000 h qualification test requirement. Flight hardware is now being assembled in preparation for integration, functional, and acceptance tests

Frequency and Clinical Implications of Discordant Creatine Kinase-MB and Troponin Measurements in Acute Coronary Syndromes

OBJECTIVES We sought to evaluate the association between discordant cardiac marker results and in-hospital mortality and treatment patterns in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). BACKGROUND Creatine kinase-MB (CK-MB) and cardiac troponins (cTn) are often measured concurrently in patients with NSTE ACS. The significance of discordant CK-MB and cTn results is unknown. METHODS Among 29,357 ACS patients in the CRUSADE initiative who had both CK-MB and cTn measured during the first 36 hours, we examined relationships of four marker combinations (CK-MB-/cTn-, CK-MB+ /cTn-, CK-MB-/cTn+ , and CK-MB+ /cTn+) with mortality and American College of Cardiology/American Heart Association guidelines-recommended acute care. RESULTS The CK-MB and cTn results were discordant in 28% of patients (CK-MB+ /cTn-, 10%; CK-MB-/cTn+ , 18%). In-hospital mortality was 2.7% among CK-MB-/cTn- patients; 3.0%, CK-MB+ /cTn-; 4.5%, CK-MB-/cTn+ ; and 5.9%, CK-MB+ /cTn+ . After adjustment for other presenting risk factors, patients with CK-MB+ /cTn- had a mortality odds ratio (OR) of 1.02 (95% confidence interval [CI] 0.75 to 1.38), those with CK-MB-/ cTn+ had an OR of 1.15 (95% CI 0.86 to 1.54), and those with CK-MB+ /cTn+ had an OR of 1.53 (95% CI 1.18 to 1.98). Despite variable risk, patients with CK-MB+ /cTn- and CK-MB-/cTn+ were treated similarly with early antithrombotic agents and catheter-based interventions. CONCLUSIONS Among patients with NSTE ACS, an elevated troponin level identifies patients at increased acute risk regardless of CK-MB status, but an isolated CK-MB+ status has limited prognostic value. Recognition of these risk differences may contribute to more appropriate early use of antithrombotic therapy and invasive management for all cTn+ patients

A 2 R_⊕ Planet Orbiting the Bright Nearby K Dwarf Wolf 503

Since its launch in 2009, the Kepler telescope has found thousands of planets with radii between that of Earth and Neptune. Recent studies of the distribution of these planets have revealed a gap in the population near 1.5–2.0 R⊕, informally dividing these planets into "super-Earths" and "sub-Neptunes." The origin of this division is difficult to investigate directly because the majority of planets found by Kepler orbit distant, dim stars and are not amenable to radial velocity follow-up or transit spectroscopy, making bulk density and atmospheric measurements difficult. Here, we present the discovery and validation of a newly found 2.03^(+0.08)_(-0.07) R⊕ planet in direct proximity to the radius gap, orbiting the bright (J = 8.32 mag), nearby (D = 44.5 pc) high proper motion K3.5V star Wolf 503 (EPIC 212779563). We determine the possibility of a companion star and false positive detection to be extremely low using both archival images and high-contrast adaptive optics images from the Palomar observatory. The brightness of the host star makes Wolf 503b a prime target for prompt radial velocity follow-up, and with the small stellar radius (0.690 ± 0.025R⊙), it is also an excellent target for HST transit spectroscopy and detailed atmospheric characterization with JWST. With its measured radius near the gap in the planet radius and occurrence rate distribution, Wolf 503b offers a key opportunity to better understand the origin of this radius gap as well as the nature of the intriguing populations of "super-Earths" and "sub-Neptunes" as a whole

A 2 Earth Radius Planet Orbiting the Bright Nearby K-Dwarf Wolf 503

Since its launch in 2009, the Kepler telescope has found thousands of planets with radii between that of Earth and Neptune. Recent studies of the distribution of these planets have revealed a rift in the population near 1.5-2.0$R_{\bigoplus}$, informally dividing these planets into "super-Earths" and "sub-Neptunes". The origin of this division is not well understood, largely because the majority of planets found by Kepler orbit distant, dim stars and are not amenable to radial velocity follow-up or transit spectroscopy, making bulk density and atmospheric measurements difficult. Here, we present the discovery and validation of a newly found $2.03^{+0.08}_{-0.07}~R_{\bigoplus}$ planet in direct proximity to the radius gap, orbiting the bright ($J=8.32$~mag), nearby ($D=44.5$~pc) high proper motion star Wolf 503 (EPIC 212779563). We classify Wolf 503 as a K3.5V star and member of the thick disc population. We determine the possibility of a companion star and false positive detection to be extremely low using both archival images and high-contrast adaptive optics images from the Palomar observatory. The brightness of the host star makes Wolf 503b a prime target for prompt radial velocity follow-up, HST transit spectroscopy, as well as detailed atmospheric characterization with JWST. With its measured radius near the gap in the planet radius and occurrence rate distribution, Wolf 503b offers a key opportunity to better understand the origin of this radius gap as well as the nature of the intriguing populations of "super-Earths" and "sub-Neptunes" as a whole

LSST Science Book, Version 2.0

A survey that can cover the sky in optical bands over wide fields to faint magnitudes with a fast cadence will enable many of the exciting science opportunities of the next decade. The Large Synoptic Survey Telescope (LSST) will have an effective aperture of 6.7 meters and an imaging camera with field of view of 9.6 deg^2, and will be devoted to a ten-year imaging survey over 20,000 deg^2 south of +15 deg. Each pointing will be imaged 2000 times with fifteen second exposures in six broad bands from 0.35 to 1.1 microns, to a total point-source depth of r~27.5. The LSST Science Book describes the basic parameters of the LSST hardware, software, and observing plans. The book discusses educational and outreach opportunities, then goes on to describe a broad range of science that LSST will revolutionize: mapping the inner and outer Solar System, stellar populations in the Milky Way and nearby galaxies, the structure of the Milky Way disk and halo and other objects in the Local Volume, transient and variable objects both at low and high redshift, and the properties of normal and active galaxies at low and high redshift. It then turns to far-field cosmological topics, exploring properties of supernovae to z~1, strong and weak lensing, the large-scale distribution of galaxies and baryon oscillations, and how these different probes may be combined to constrain cosmological models and the physics of dark energy.Comment: 596 pages. Also available at full resolution at http://www.lsst.org/lsst/sciboo