Trend, predictors, and outcomes of combined mitral valve replacement and coronary artery bypass graft in patients with concomitant mitral valve and coronary artery disease: a National Inpatient Sample database analysis.

Aims: Combined mitral valve replacement (MVR) and coronary artery bypass graft (CABG) procedures have been the norm for patients with concomitant mitral valve disease (MVD) and coronary artery disease (CAD) with no large-scale data on their safety and efficacy. Methods and results: The National Inpatient Sample database (2002-18) was queried to identify patients undergoing MVR and CABG. The major adverse cardiovascular events (MACE) and its components were compared using a propensity score-matched (PSM) analysis to calculate adjusted odds ratios (OR). A total of 6 145 694 patients (CABG only 3 971 045, MVR only 1 933 459, MVR + CABG 241 190) were included in crude analysis, while a matched cohort of 724 237 (CABG only 241 436, MVR only 241 611 vs. MVR + CABG 241 190) was selected in PSM analysis. The combined MVR + CABG procedure had significantly higher adjusted odds of MACE [OR 1.13, 95% confidence interval (CI) 1.11-1.14 and OR 1.96, 95% CI 1.93-1.99] and in-hospital mortality (OR 1.29, 95% CI 1.27-1.31 and OR 2.1, 95% CI 2.05-2.14) compared with CABG alone and MVR alone, respectively. Similarly, the risk of post-procedure bleeding, major bleeding, acute kidney injury, cardiogenic shock, sepsis, need for intra-aortic balloon pump, mean length of stay, and total charges per hospitalization were significantly higher for patients undergoing the combined procedure. These findings remained consistent on yearly trend analysis favouring the isolated CABG and MVR groups. Conclusion: Combined procedure (MVR + CABG) in patients with MVD and CAD appears to be associated with worse in-hospital outcomes, increased mortality, and higher resource utilization compared with isolated CABG and MVR procedures. Randomized controlled trials are needed to determine the relative safety of these procedures in the full spectrum of baseline valvular and angiographic characteristics

The Evolutionary Pathway to Obligate Scavenging in Gyps Vultures

The evolutionary pathway to obligate scavenging in Gyps vultures remains unclear. We propose that communal roosting plays a central role in setting up the information transfer network critical for obligate scavengers in ephemeral environments and that the formation of a flotilla-like foraging group is a likely strategy for foraging Gyps vultures. Using a spatial, individual-based, optimisation model we find that the communal roost is critical for establishing the information network that enables information transfer owing to the spatial-concentration of foragers close to the roost. There is also strong selection pressure for grouping behaviour owing to the importance of maintaining network integrity and hence information transfer during foraging. We present a simple mechanism for grouping, common in many animal species, which has the added implication that it negates the requirement for roost-centric information transfer. The formation of a flotilla-like foraging group also improves foraging efficiency through the reduction of overlapping search paths. Finally, we highlight the importance of consideration of information transfer mechanisms in order to maximise the success of vulture reintroduction programmes

Both habitat change and local lek structure influence patterns of spatial loss and recovery in a black grouse population

The final publication is available at Springer via http://dx.doi.org/10.1007/s10144-015-0484-3Land use change is a major driver of declines in wildlife populations. Where human economic or recreational interests and wildlife share landscapes this problem is exacerbated. Changes in UK black grouse Tetrao tetrix populations are thought to have been strongly influenced by upland land use change. In a long-studied population within Perthshire, lek persistence is positively correlated with lek size, and remaining leks clustered most strongly within the landscape when the population is lowest, suggesting that there may be a demographic and/or spatial context to the reaction of the population to habitat changes. Hierarchical cluster analysis of lek locations revealed that patterns of lek occupancy when the population was declining were different to those during the later recovery period. Response curves from lek-habitat models developed using MaxEnt for periods with a declining population, low population, and recovering population were consistent across years for most habitat measures. We found evidence linking lek persistence with habitat quality changes and more leks which appeared between 1994 and 2008 were in improving habitat than those which disappeared during the same period. Generalised additive models (GAMs) identified changes in woodland and starting lek size as being important indicators of lek survival between declining and low/recovery periods. There may also have been a role for local densities in explaining recovery since the population low point. Persistence of black grouse leks was influenced by habitat, but changes in this alone did not fully account for black grouse declines. Even when surrounded by good quality habitat, leks can be susceptible to extirpation due to isolation

Declines in an augur buzzard Buteo augur population in a region of increasing human development

As with many areas in Africa, Kenya has witnessed rapid human development in recent decades, including an increase in urbanization and an intensification of agriculture. The impact of these land use changes on wildlife populations have, however, rarely been examined. The Augur Buzzard is a widespread raptor species, thought to adapt relatively well to human alterations of habitat. In this study, we explore trends in Augur Buzzard (Buteo augur) territory occupancy over nearly two decades around Lake Naivasha, Kenya, in relation to land-use changes, particularly expansion in human housing and flower farms. We hypothesized that these changes would cause population declines in this species within our study area. Using remote-sensed satellite imagery, we found that human development (agriculture and human settlement) increased from 9 to 24% of the study area from 1995 to 2014. We found a 47% decline in active territories over this same time period, representing an annualized decline of 3.1%. Based on the length of three generations this would qualify this species to be uplisted to at least Vulnerable in our study area, raising our concerns that the same pattern may be occurring across the species’ range. We then explored whether abandonment of individual territories was associated with either (i) the current amount or (ii) the change in human development within a range of buffer circles of varying radii (0.1–5.0 km). Contrary to our expectations, no associations were found between human development and territorial abandonment, and thus we could not attribute specific territorial abandonment to these broad scale anthropogenic land cover changes. We encourage further research to investigate whether territorial abandonment may be associated with either finer resolution (habitat specific) changes, or sources of direct mortality, for example human persecution or electrocutions. These factors might explain the decline in this population better than broader scale increases in anthropogenic land cover

Calculations of Financial Incentives for Providers in a Pay-for-Performance Program: Manual Review Versus Data From Structured Fields in Electronic Health Records

© 2015 Wolters Kluwer Health, Inc. All rights reserved. BACKGROUND:: Hospital report cards and financial incentives linked to performance require clinical data that are reliable, appropriate, timely, and cost-effective to process. Pay-for-performance plans are transitioning to automated electronic health record (EHR) data as an efficient method to generate data needed for these programs. OBJECTIVE:: To determine how well data from automated processing of structured fields in the electronic health record (AP-EHR) reflect data from manual chart review and the impact of these data on performance rewards. RESEARCH DESIGN:: Cross-sectional analysis of performance measures used in a cluster randomized trial assessing the impact of financial incentives on guideline-recommended care for hypertension. SUBJECTS:: A total of 2840 patients with hypertension assigned to participating physicians at 12 Veterans Affairs hospital-based outpatient clinics. Fifty-two physicians and 33 primary care personnel received incentive payments. MEASURES:: Overall, positive and negative agreement indices and Cohen’s kappa were calculated for assessments of guideline-recommended antihypertensive medication use, blood pressure (BP) control, and appropriate response to uncontrolled BP. Pearson’s correlation coefficient was used to assess how similar participants’ calculated earnings were between the data sources. RESULTS:: By manual chart review data, 72.3% of patients were considered to have received guideline-recommended antihypertensive medications compared with 65.0% by AP-EHR review (κ=0.51). Manual review indicated 69.5% of patients had controlled BP compared with 66.8% by AP-EHR review (κ=0.87). Compared with 52.2% of patients per the manual review, 39.8% received an appropriate response by AP-EHR review (κ=0.28). Participants’ incentive payments calculated using the 2 methods were highly correlated (r≥0.98). Using the AP-EHR data to calculate earnings, participants’ payment changes ranged from a decrease of $91.00 (−30.3$18.20 (+7.4%) for medication use (interquartile range, −14.4% to 0%) and a decrease of $100.10 (−31.4$36.40 (+15.4%) for BP control or appropriate response to uncontrolled BP (interquartile range, −11.9% to −6.1%). CONCLUSIONS:: Pay-for-performance plans that use only EHR data should carefully consider the measures and the structure of the EHR before data collection and financial incentive disbursement. For this study, we feel that a 10% difference in the total amount of incentive earnings disbursed based on AP-EHR data compared with manual review is acceptable given the time and resources required to abstract data from medical records