Novel patient-centered approach to facilitate same-day discharge in patients undergoing elective percutaneous coronary intervention

Background Same‐day discharge ( SDD ) after elective percutaneous coronary intervention is safe, less costly, and preferred by patients, but it is usually performed in low‐risk patients, if at all. To increase the appropriate use of SDD in more complex patients, we implemented a “patient‐centered” protocol based on risk of complications at Barnes‐Jewish Hospital. Methods and Results Our objectives were as follows: (1) to evaluate time trends in SDD ; (2) to compare (a) mortality, bleeding, and acute kidney injury, (b) patient satisfaction, and (c) hospital costs by SDD versus no SDD ( NSDD ); and (3) to compare SDD eligibility by our patient‐centered approach versus Society for Cardiovascular Angiography and Interventions guidelines. Our patient‐centered approach was based on prospectively identifying personalized bleeding, mortality, and acute kidney injury risks, with a personalized safe contrast limit and mitigating those risks. We analyzed Barnes‐Jewish Hospital's National Cardiovascular Data Registry Cath PCI Registry data from July 1, 2009 to September 30, 2015 (N=1752). SDD increased rapidly from 0% to 77% ( P &lt;0.001), independent of radial access. Although SDD patients were comparable to NSDD patients, SDD was not associated with adverse outcomes (0% mortality, 0% bleeds, and 0.4% acute kidney injury). Patient satisfaction was high with SDD . Propensity score–adjusted costs were 7331 lower/ SDD patient ( P <0.001), saving an estimated 1.8 million annually. Only 16 patients (6.95%) met the eligibility for SDD by Society for Cardiovascular Angiography and Interventions guidelines, implying our patient‐centered approach markedly increased SDD eligibility. Conclusions With a patient‐centered approach, SDD rapidly increased and was safe in 75% of patients undergoing elective percutaneous coronary intervention, despite patient complexity. Patient satisfaction was high, and hospital costs were lower. Patient‐centered decision making to facilitate SDD is an important opportunity to improve the value of percutaneous coronary intervention. </jats:sec

Thermal history of the central Gotthard and Aar massifs, European Alps: Evidence for steady state, long-term exhumation

International audienceQuantifying long-term exhumation rates is a prerequisite for understanding the geodynamic evolution of orogens and their exogenic and endogenic driving forces. Here we reconstruct the exhumation history of the central Aar and Gotthard external crystalline massifs in the European Alps using apatite and zircon fission track and apatite (U-Th)/He data. Age-elevation relationships and time-temperature paths derived from thermal history modeling are interpreted to reflect nearly constant exhumation of ∼0.5 km/Ma since ∼14 Ma. A slightly accelerated rate (∼0.7 km/Ma) occurred from 16 to 14 Ma and again from 10 to 7 Ma. Faster exhumation between 16 and 14 Ma is most likely linked to indentation of the Adriatic wedge and related thrusting along the Alpine sole thrust, which, in turn, caused uplift and exhumation in the external crystalline massifs. The data suggest nearly steady, moderate exhumation rates since ∼14 Ma, regardless of major exogenic and endogenic forces such as a change to wetter climate conditions around 5 Ma or orogen-perpendicular extension initiated in Pliocene times. Recent uplift and denudation rates, interpreted to be the result of climate fluctuations and associated increase in erosional efficiency, are nearly twice this ∼0.5 km/Ma paleoexhumation rate

Exhumation history along the eastern Amundsen Sea coast, West Antarctica, revealed by low-temperature thermochronology

West Antarctica experienced a complex tectonic history, which is still poorly documented, in part due to extensive ice cover. Here we reconstruct the Cretaceous to present thermotectonic history of Pine Island Bay area and its adjacent coasts, based on a combination of apatite and zircon fission track and apatite (U-Th-Sm)/He thermochronology. In addition, we report petrographic information for the catchments of Pine Island, Thurston Island, and Thwaites glaciers. Our data suggest that the underlying bedrock of the Pine Island and Thwaites Glacier catchments are very different and vary from granitoids to (Cenozoic?) volcanogenic sequences and low-grade metamorphics. Our thermochronology data show that the upper crustal rocks of Pine Island Bay experienced very rapid cooling during the late Cretaceous. We attribute this rapid cooling of basement rocks and associated reduction in mean elevation to tectonic denudation driven by gravitational collapse of the Cretaceous orogen along the proto-Pacific Gondwana margin. Rapid Cretaceous crustal cooling was followed by very slow cooling during the Cenozoic, with no erosional response—within the limits of thermochronological methods—to the onset of glaciation and subsequent climatic changes. Cenozoic rifting within the West Antarctic Rift appears to have had little effect on erosion processes around Pine Island Bay; instead, our data suggest Cenozoic crustal tilting toward Pine Island Trough, a major geomorphic feature previously suggested to be a branch of the rift system

Effects of Anacetrapib in Patients with Atherosclerotic Vascular Disease

BACKGROUND: Patients with atherosclerotic vascular disease remain at high risk for cardiovascular events despite effective statin-based treatment of low-density lipoprotein (LDL) cholesterol levels. The inhibition of cholesteryl ester transfer protein (CETP) by anacetrapib reduces LDL cholesterol levels and increases high-density lipoprotein (HDL) cholesterol levels. However, trials of other CETP inhibitors have shown neutral or adverse effects on cardiovascular outcomes. METHODS: We conducted a randomized, double-blind, placebo-controlled trial involving 30,449 adults with atherosclerotic vascular disease who were receiving intensive atorvastatin therapy and who had a mean LDL cholesterol level of 61 mg per deciliter (1.58 mmol per liter), a mean non-HDL cholesterol level of 92 mg per deciliter (2.38 mmol per liter), and a mean HDL cholesterol level of 40 mg per deciliter (1.03 mmol per liter). The patients were assigned to receive either 100 mg of anacetrapib once daily (15,225 patients) or matching placebo (15,224 patients). The primary outcome was the first major coronary event, a composite of coronary death, myocardial infarction, or coronary revascularization. RESULTS: During the median follow-up period of 4.1 years, the primary outcome occurred in significantly fewer patients in the anacetrapib group than in the placebo group (1640 of 15,225 patients [10.8%] vs. 1803 of 15,224 patients [11.8%]; rate ratio, 0.91; 95% confidence interval, 0.85 to 0.97; P=0.004). The relative difference in risk was similar across multiple prespecified subgroups. At the trial midpoint, the mean level of HDL cholesterol was higher by 43 mg per deciliter (1.12 mmol per liter) in the anacetrapib group than in the placebo group (a relative difference of 104%), and the mean level of non-HDL cholesterol was lower by 17 mg per deciliter (0.44 mmol per liter), a relative difference of -18%. There were no significant between-group differences in the risk of death, cancer, or other serious adverse events. CONCLUSIONS: Among patients with atherosclerotic vascular disease who were receiving intensive statin therapy, the use of anacetrapib resulted in a lower incidence of major coronary events than the use of placebo. (Funded by Merck and others; Current Controlled Trials number, ISRCTN48678192 ; ClinicalTrials.gov number, NCT01252953 ; and EudraCT number, 2010-023467-18 .)

The Case of Charles Dexter Ward

Presentation from English 1102-H3: The Double: Duplicitous Discourse in Literary Fiction and Popular Film, discussion forum led by Professor L. Andrew Cooper, March 10, 2011.Runtime: 11:13 minutes