Can timing of tracheal extubation predict improved outcomes after cardiac surgery?

INTRODUCTION: Early tracheal extubation is a common goal after cardiac surgery. Our study aims to examine whether timing of tracheal extubation predicts improved postoperative outcomes and late survival after cardiac surgery. We also evaluated the optimal timing of extubation and its association with better postoperative outcomes. METHODS: Between 2002 and 2006, 1164 patients underwent early tracheal extubation (<6 hours after surgery) and 1571 had conventional extubation (>6 hours after surgery). Propensity score adjustment and multivariable logistic regression analysis were used to adjust for imbalances in the patients' preoperative characteristics. Receiver operating characteristic curves (ROC) were used to identify the best timing of extubation and improved postoperative outcomes. Cox regression analysis was used to identify whether early extubation is a risk factor for decreased late mortality. RESULTS: Results - Early extubation was associated with lower propensity score-adjusted rate of operative mortality (Odds Ratio =0.55, 95% Confidence Intervals =0.31-0.98, p=0.043). Extubation within 9 hours emerged as the best predictor of improved postoperative morbidity and mortality (sensitivity =85.5%, specificity =52.7%, accuracy =64.5%). Early extubation also predicted decreased late mortality (Hazard Ratio =0.45, 95% Confidence Intervals 0.31-0.67, p<0.001). CONCLUSIONS: Early extubation may predict improved outcomes after cardiac surgery. Extubation within 9 hours after surgery was the best predictor of uncomplicated recovery after cardiac surgery. Those patients intubated longer than 16 hours have a poorer postoperative prognosis. Early extubation predicts prolonged survival up to 16 months after surgery.

The benefits and risks of over-the-counter availability of levonorgestrel emergency contraception.

Removing the prescription requirement for Plan B will help ensure that the product plays a larger role nationally in the reduction of unintended pregnancy and abortion-important public health goals. Over-the-counter (OTC) sale of Plan B should present no serious safety issues. OTC consumers are able to understand and follow the instructions for proper use of Plan B. Efficacy of the OTC product is likely to be the same as, or better than, the prescription product, given more timely access to treatment. Based on the results of a growing body of literature and foreign marketing experience, the risk of unintended health consequences also appears to be minimal. There is no evidence to suggest that American women will abuse Plan B as an OTC product.

Population pressure, poverty and the environment.

PIP: Using the agricultural revolution as a starting point, human population has grown 50 times since then. The amount of environmental and ecological damage inflicted by humans before the agricultural revolution pales in comparison to the damage done afterwards. It took until 1800, or approximately 9800 years from the beginning of the agricultural revolution, for world population to reach 1 billion. It took only 187 years to reach 5 billion and current projections estimate that it will take only 11 years to add the 6th billion. If the governments of the world do not work together during this decade and bring a family planning message to every couple of reproductive age, the results will be catastrophic. Every year 40-50 million acres of forest are cut down. On average, the people living in developing countries are cutting down forests twice as fast as they can grow back. Deforestation, combined with intensive agriculture, is turning the world's farm land into desert. Soil erosion and desertification threaten 1/3 of the total land surface which is home to 1/5 of the population. While high consumption levels in developed countries and industrial pollution worldwide do have a huge impact, the fact remains that increases in population place increased burdens on the ecology's carrying capacity. While the former problems urgently need to be addressed, reducing population growth rates eases pressure on all the aspects of the environment. China suffers from every kind of ecological problem and its reliance on high sulfur coal as a primary energy source threatens to undo all the efficiency improvements made in developed countries. Water shortages are common in China as they are in many other countries, again a problem that would be less severe if population growth were reduced. Urban areas are the fastest growing and least prepared to handle the increased demand for drinking water and sanitation control. The cost of universal family planning is only US$9 billion.^ieng

Limited access. Contraceptive costs may impede use.

PIP: An estimated 290 million more couples will require modern contraception in the 1990s--a 60% increase. Many developing countries and donors strive to switch more of the burden for the rising cost of health and family planning services to the private and commercial sectors. Most family planning specialists promote the shift. Indeed research shows that in some places an equal number of people would use nominal priced contraception as would use free contraception and services. Many people often do prefer private sector services since they tend to be more accessible, dependable, and congenial than public sector services. The vigorous drive towards global privatization of and self sufficient family planning services may instead render modern methods too costly for many poor couples in developing countries. Research indicates that no one should have to pay 1% of income for contraception. Other research demonstrates that individuals tend not to pay for preventive health services, but do willingly pay for curative health services. They consider family planning services to be preventive health services, except for abortion for which they pay dearly. In many developing countries, the private sector cost for oral contraceptives ranges from 5-37% of average per gross national product capita, IUDs from 5-70%, and sterilization from 10-250%. These costs are indeed too expensive for poor couples. Yet these respective costs in developed nations vary from .1-.7%, .1-1%, and 1.7-4.7%. Moreover 50% of the population in developing countries have access to affordable contraceptives. This is especially true in Sub-Saharan Africa where the condom need is crucial to stem the AIDS pandemic. Therefore governments must be committed to universal availability of contraceptives by subsidizing private practitioners and commercial stores and providing free contraception to all in need.^ieng

Developmental and structural studies of an intracellular lipid binding protein expressed in the ileal epithelium.

Enterocytes located in the pig distal small intestine (ileum) contain a cytosolic protein that is homologous to two proteins that are also synthesized in these cells: intestinal and "liver" fatty acid-binding proteins (I- and L-FABPc, respectively). To begin to investigate the functional interrelationships of these three proteins, we compared their patterns of tissue-specific expression and developmental regulation in the mouse. Blot hybridization analyses of RNA prepared from 12 adult tissues revealed that this mRNA was confined to the small intestine. Unlike I- and L-FABPc mRNA, which are most abundant in the proximal jejunum, this mRNA is most abundant in the ileum. While I- and L-FABPc gene transcription commence in late fetal life coincident with initial cytodifferentiation of the mouse gut epithelium, the ileal gene is activated later, at the suckling/weaning transition (postnatal day 12). The ileal location and developmental pattern of expression suggested that this protein may play a role in the intracellular transport of bile salts in the ileal epithelium. To test this hypothesis, we expressed the porcine ileal peptide (PIP) in Escherichia coli, purified it to apparent homogeneity, and analyzed its binding properties for bile acids and fatty acids using 13C NMR spectroscopy. Like I-FABPc, PIP binds palmitate and oleate with a 1:1 molar stoichiometry. However, unlike I-FABPc PIP binds chenodeoxycholate. In addition, the presence of chenodeoxycholate blocks fatty acid binding to PIP, but not to I-FABPc. E. coli-derived PIP was subsequently crystallized with and without chenodeoxycholic acid. All crystals are orthorhombic in the P2(1)2(1)2(1) space group. The unit cell dimensions are a = 36.15 A, b = 50.13 A, and c = 67.18 A.

The attempt to break down overseas population assistance: Population Crisis Committee.

PIP: The Vice President of the Population Crisis Committee comments on current US population policies and on the potential impact of these policies on family planning programs around the world. The policies of the current administration pose a serious threat to family planning programs in developing countries. In May, 1984, the administration issued a population policy draft which identified economic mismanagement as the cause of most 3rd World problems and claimed that the free enterprise system was capable of solving most population growth problems. It further stated that the US would no longer provide funding support to any government or nongovernment organization (NGO) which promoted abortions regardless of the funding source for the abortion activities. The draft paper engendered considerable negative reaction, and it was revised before it was presented at the Mexico City Population Conference in July, 1984. The revised policy exempted foreign government organizations and agencies from the abortion restrictions. The restrictions were preserved for all NGOs. In December, 1984, the government began to implement the policy in earnest. US$17 million is support was withdrawn from the International Planned Parenthood Federation (IPPF). IPPF operates worldwide and is a major source of contraceptive supplies in many Latin American and African countries. 6 years ago IPPF, at the request of US Agency for International Development (USAID) instituted accounting procedures to track all abortion related expenses. Less than .5% of the federation's funds are spent on abortion related activities. In January, 1985, funds previously appropriated for the UN Fund for Population Activities (UNFPA) were withheld because of UNFPA involvement in family planning in China. No US funds were used in the UNFPA China project, and UNFPA was not involved in abortion activities in China. Indeed, UNFPA policies prohibit involvement in abortion programs and in any coercive program. In March, 1985, all but US$10 million in appropriated funds were released to UNFPA as a result of congressional and foreign pressure. Steps to restrict the activities of national and local level NGOs are also being taken. The administration is planning to impose contract restriction on all USAID grant agreements. The restriction will forbid all foreign NGOs from promoting abortion regardless of the source of the funding for abortion activities. Preliminary wording of the contract clause indicates that the restrictions will apply to all abortions except those undertaken to save the life of the mother and that the NGOs will have to allow US inspection of all their books. These restrictions cannot be applied to USAID contracts awarded to NGOs in the US because these restrictions would be illegal in the US; however, US NGOs will be required to impose these restriction on any overseas subgrantees. These restrictions will force USAID to increase funding for the generally less effective programs which are operated by foreign governments. Worldwide negative consequences of the new US policies will include increases in unwanted pregnancy, infant mortality, maternal mortality, and abortion.^ieng

Delayed marriage and the asexual revolution.

PIP: China has experienced a moral revolution along with its social and economic revolution. The moral revolution was backed by China's communist ideology and propaganda machine, which stresses discipline, devotion, and self-denial. Young people are expected to delay sexual activity and marriage until their late 20's and to focus their energies on building the state. Little in Chinese society is provocative which reinforces the propaganda. Privacy is practically nonexistent, another reinforcement of the code of conduct. A major share of the decline in the birth rate is attributed to later age at marriage. It is not clear whether the pattern of restraint can be maintained as liberalization policies seep into other aspects of Chinese society. New sex programs in the schools indicate a shift away from puritanical morals. The government will be faced with 2 choices if liberalization continues: to allow earlier marriages but not childbirth, or to make contraceptive services available to sexually active, unmarried individuals. Economic reforms loosening the restrictions on individual initiative, interest in modern technology, and other moves away from doctrinaire policies of the early 70's represent tests to the social and economic revolution. One of the most difficult tests will be to the family planning program if there is a major change in sexual mores.^ieng