Factors related to rehospitalization within thirty days of discharge after coronary artery bypass grafting

BACKGROUND: Early rehospitalization after coronary artery bypass grafting (CABG) is an expensive and frequently adverse outcome. Rehospitalization rates after various surgical procedures have been used as an indicator of quality of care. Determining the extent to which rehospitalization rates reflect patient case mix and severity of illness rather than quality of care requires detailed information regarding the patients, the care they received, and the reasons for their rehospitalization. METHODS: We conducted a nested case control study comparing 110 CABG patients who were rehospitalized within 30 days after discharge with 224 control patients. Control patients were randomly selected from patients undergoing CABG during the same time frame as the cases and were matched on age, gender, and priority of surgery. A detailed chart review provided information regarding treatment in the postsurgical period, in addition to the preoperative information collected on all CABG patients as part of an ongoing regional prospective study. RESULTS: The overall rehospitalization rate was 13.8%. The most common reasons for rehospitalization included: wound infection (19%), atrial fibrillation (13%), pleural effusion (11%), and thromboembolic event (10%). Preoperative severity of illness and comorbidity accounted for 24% of the total variance. After adjustment for these factors, discharge hematocrit less than 30% (OR = 2.01, p = 0.018) and several discharge medications including: antiarrhythmics (OR = 3.26, p = 0.047), diuretics (OR = 2.18, p = 0.055), beta blockers (OR = 0.44, p = 0.036), and long length of stay (more than 7 days; OR = 2.09, p = 0.029) were the most important predictors of rehospitalization risk. CONCLUSIONS: Although the reasons for rehospitalization after CABG are heterogeneous and related to patient severity of illness as well as comorbid status, several of the most common are potentially preventable and related to quality of care. Rehospitalization was not related to early discharge.     

Exochelin genes in Mycobacterium smegmatis: identification of an ABC transporter and two non-ribosomal peptide synthetase genes

Many strains of mycobacteria produce two ferric chelating substances that are termed exochelin (an excreted product) and mycobactin (a cell-associated product). These agents may function as iron acquisition siderophores. To examine the genetics of the iron acquisition system in mycobacteria, ultraviolet (UV) and transposon (Tn611) mutagenesis techniques were used to generate exochelin-deficient mutants of Mycobacterium smegmatis strains ATCC 607 and LR222 respectively. Mutants were identified on CAS siderophore detection agar plates. Comparisons of the amounts of CAS-reactive material excreted by the possible mutant strains with that of the wild-type strains verified that seven UV mutant strains and two confirmed transposition mutant strains were deficient in exochelin production. Cell-associated mycobactin production in the mutants appeared to be normal. From the two transposon mutants, the mutated gene regions were cloned and identified by colony hybridization with an IS6100 probe, and the DNA regions flanking the transposon insertion sites were then used as probes to clone the wild-type loci from M. smegmatis LR222 genomic DNA. Complementation assays showed that an 8 kb PstI fragment and a 4.8 kb PstI/SacI subclone of this fragment complemented one transposon mutant (LUN2) and one UV mutant (R92). A 10.1 kb SacI fragment restored exochelin production to the other transposon mutant (LUN1). The nucleotide sequence of the 15.3 kb DNA region that spanned the two transposon insertion sites overlapped the 5' region of the previously reported exochelin biosynthetic gene fxbA and contained three open reading frames that were transcribed in the opposite orientation to fxbA. The corresponding genes were designated exiT, fxbB and fxbC. The deduced amino acid sequence of ExiT suggested that it was a member of the ABC transporter superfamily, while FxbB and FxbC displayed significant homology with many enzymes (including pristinamycin I synthetase) that catalyse non-ribosomal peptide synthesis. We propose that the peptide backbone of the siderophore exochelin is synthesized in part by enzymes resembling non-ribosomal peptide synthetases and that the ABC transporter ExiT is responsible for exochelin excretion.     

Patient education for discharge after coronary bypass surgery in the 1990s: are patients adequately prepared?

Short hospitalizations for patients undergoing coronary artery bypass grafting (CABG) require continuous nursing evaluation of patients' discharge education. Six institutions collaborated in surveying 300 postoperative patients with CABG to identify learning priorities and patients' perceptions of the effectiveness of discharge education. Data analysis from the self-administered questionnaire demonstrated consistent patient priorities across institutions. Differences in teaching methods and content did not affect perceived preparedness or importance scores. Regional experience demonstrates that variable teaching efforts meet patients' priorities and provide high overall patient preparedness for discharge. Patients with the shortest hospitalizations had higher preparedness scores.     

Congenital fibrosis of the extraocular muscles type 2, an inherited exotropic strabismus fixus, maps to distal 11q13

The extraocular fibrosis syndromes are congenital ocular-motility disorders that arise from dysfunction of the oculomotor, trochlear, and abducens nerves and/or the muscles that they innervate. Each is marked by a specific form of restrictive paralytic ophthalmoplegia with or without ptosis. Individuals with the classic form of congenital fibrosis of the extraocular muscles (CFEOM1) are born with bilateral ptosis and a restrictive infraductive external ophthalmoplegia. We previously demonstrated that CFEOM1 is caused by an autosomal dominant locus on chromosome 12 and results from a developmental absence of the superior division of the oculomotor nerve. We now have mapped a variant of CFEOM, exotropic strabismus fixus ("CFEOM2"). Affected individuals are born with bilateral ptosis and restrictive ophthalmoplegia with the globes "frozen" in extreme abduction. This autosomal recessive disorder is present in members of three consanguineous Saudi Arabian families. Genetic analysis of 70 individuals (20 affected individuals) reveals linkage to markers on chromosome 11q13, with a combined LOD score of 12.3 at the single nonrecombinant marker, D11S1314. The 2.5-cM CFEOM2 critical region is flanked by D11S4196/D11S4162 and D11S4184/1369. Two of the three families share a common disease-associated haplotype, suggesting a founder effect for CFEOM2. We hypothesize that CFEOM2 results from an analogous developmental defect to CFEOM1, one that affects both the superior and inferior divisions of the oculomotor nerve and their corresponding alpha motoneurons and extraocular muscles.     

Character and chlorine reactivity of dissolved organic matter from a mountain pine beetle impacted watershed

Lodgepole pine needle leachates from trees killed by the mountain pine beetle epidemic in Colorado were evaluated for dissolved organic matter (DOM) character, biodegradation, treatability by coagulation and disinfection byproduct (DBP) formation. An average of 8.0 (±0.62) mg-DOC/g-dry weight of litter was leached from three sets of needle samples representing different levels of forest floor degradation. Fluorescence analysis included collection of excitation and emission matrices, examination of peak intensities and development of a 4-component parallel factor (PARAFAC) analysis model. Peak intensity and PARAFAC analyses provided complementary results showing that fresh leachates were initially dominated by polyphenolic/protein-like components (60-70%) and humic-like fluorescence increased (40-70%) after biodegradation. Humic-like components were removed by coagulation (20-64%), while polyphenolic/protein-like components were not, which may create challenges for utilities required to meet OM removal regulations. DBP formation yields after 24 h chlorination were 20.5-26.4 μg/mg-DOC for trihalomethanes and 9.0-14.5 μg/mg-DOC for haloacetic acids for fresh leachates; increased after biodegradation to 19.2-64.2 and 7.1-30.9 μg/mg-DOC, respectively; and decreased after coagulation (fresh: 11.3-17.7;5.7-7.6 μg/mg-DOC, respectively; biodegraded: 12.0-27.3 and 2.9-7.2 μg/mg-DOC, respectively), reflective of changes in concentration of humic material. Humic-like PARAFAC components and peak intensities were positively correlated (R(2) ≥ 0.45) to DBP concentrations, while polyphenolic/protein-like components were not (R(2) ≤ 0.17).     

Protein-RNA interactions in the U5 snRNP of Saccharomyces cerevisiae

We present here the first insights into the organization of proteins on the RNA in the U5 snRNP of Saccharomyces cerevisiae. Photo-crosslinking with uniformly labeled U5 RNA in snRNPs reconstituted in vitro revealed five contacting proteins, Prp8p, Snu114p, p30, p16, and p10, contact by the three smaller proteins requiring an intact Sm site. Site-specific crosslinking showed that Snu114p contacts the 5' side of internal loop 1, whereas Prp8p interacts with five different regions of the 5' stem-loop, but not with the Sm site or 3' stem-loop. Both internal loops in the 5' domain are essential for Prp8p to associate with the snRNP, but the conserved loop 1 is not, although this is the region to which Prp8p crosslinks most strongly. The extensive contacts between Prp8p and the 5' stem-loop of U5 RNA support the hypothesis that, in spliceosomes, Prp8p stabilizes loop 1-exon interactions. Moreover, data showing that Prp8p contacts the exons even in the absence of loop 1 indicate that Prp8p may be the principal anchoring factor for exons in the spliceosome. This and the close proximity of the spliceosomal translocase, Snu114p, to U5 loop 1 and Prp8p support and extend the proposal that Snu114p mimics U5 loop 1 during a translocation event in the spliceosome.     

Direct evidence for the deoxyribonuclease activity of the plant ribosome inactivating protein gelonin

Several plant ribotoxins, including gelonin, were reported to have additional weak nuclease activities on supercoiled DNA. The potential contribution of this activity to their cytotoxicity has not been given serious consideration due to concerns about contaminating nucleases in the protein preparations. We now report the degradation of single-stranded DNA by preparations of native plant gelonin and recombinant gelonin produced in E. coli. The DNase activity of both preparations is similarly modulated by zinc. An SDS-PAGE DNase assay identifies gelonin as the polypeptide responsible for deoxyribonuclease activity.     

Computer Support for a Neighborhood Health Clinic: Design and Implementation

Neighborhood comprehensive health care centers have become an important model of health care delivery in large metropolitan areas. Constraints in manpower resources dictate the need to explore ways and means by which computer technology can support the activity of health professionals in these centers. The Department of Community Medicine at Baylor has designed and is in the process of implementing a computer support system for a neighborhood health clinic, Casa de Amigos, of the Harris County Hospital District.     

New theories of the A-axis growth of ice crystals

New theories are presented for the $\text{A-}\text{axis}$ growth rate of ice crystals in flowing water or saline solutions with a high degree of subcooling. An existing theory, based on laminar boundary-layer flow over the front stagnation point of the growing crystal is believed to be unsatisfactory because the assumptions of first-order boundary-layer theory are inadmissible at the low crystal tip Reynolds number ($\text{≈3 × 10}{}^{\mathrm{?3}}$) encountered.Two models have been developed, one based on an analysis for creeping flow over the crystal tip, the other on conduction of heat along the growing crystal, this heat then being removed by forced convection from the relatively large flat faces of the crystal. These models give much closer agreement with the experimental results for $\text{A-}\text{axis}$ growth in pure water.When modified to allow for salt diffusion from the ice tip in creeping flow, both models also give improved estimates of growth rates in saline solutions although the improvement is not so pronounced as for growth in pure water.     

Short communication: Milking order consistency of dairy cows in large Australian herds

We used on-farm records from dairy infrastructure to examine the consistency of the milking order over 150 d in 5 Australian dairy herds that were milking more than 500 cows as a single group. Within a single day the difference in milking order rank position was less than 20 percentage points for 72% of cows. The correlation coefficient comparing milking rank position in the morning and afternoon was 0.72, with the position of cows at the beginning and end of the milking order being more consistent than cows toward the middle of the milking order. Over a period of 150 d, cows with a mean position in the first and last 20% of the milking order maintained their position more consistently than cows in the middle of the milking order. Milking position of cows between one month and the next was highly correlated (r = 0.88). In large herds, subpopulations of cows are regularly milked toward the beginning and the end of the milking order. It is common for cows to be collected from the paddock as a group, to wait as a group in the dairy yard to be milked, and to return individually to the paddock or feed pad immediately after they have been milked. Thus, cows milked later in the milking order are likely to be away from the paddock for several hours longer than cows milked earlier in the milking order. This may affect their welfare though differences in time available for lying down, equality of pasture eaten, and time spent standing in the dairy yard.