Smoking cessation is associated with lower rates of mood/anxiety and alcohol use disorders.

BACKGROUND: The psychological outcomes that accompany smoking cessation are not yet conclusive but positive outcomes could help to persuade quitting. METHOD: We used data from the longitudinal National Epidemiological Study of Alcohol and Related Conditions. Logistic regression was used to examine associations between cigarette smoking reduction and Wave 2 status of addiction/mental health disorder among daily smokers at Wave 1, stratified by status of the diagnosis of interest at Wave 1. We adjusted for differences in baseline covariates between smokers with different levels of smoking reduction between Wave 1 and Wave 2 using propensity score regression adjustment. RESULTS: After adjusting for propensity scores and other mental health/addiction co-morbidities at Wave 2, among daily smokers who had current or lifetime history diagnosis of the outcome of interest at Wave 1, quitting by Wave 2 predicted a decreased risk of mood/anxiety disorder [adjusted odds ratio (aOR) 0.6, 95% confidence interval (CI) 0.4-0.9] and alcohol disorder (aOR 0.7, 95% CI 0.5-0.99) at Wave 2. Among daily smokers with no lifetime history diagnosis of the outcome of interest at Wave 1, quitting smoking by Wave 2 predicted a decreased risk of drug use disorder at Wave 2 (aOR 0.3, 95% CI 0.1-0.9). CONCLUSIONS: There is no support in our data for the concern that smoking cessation would result in smokers' increased risk of some mental disorders. To the contrary, our data suggest that smoking cessation is associated with risk reduction for mood/anxiety or alcohol use disorder, even among smokers who have had a pre-existing disorder.

Morphological and biochemical studies on the development of cholinergic properties in cultured sympathetic neurons. I. Correlative changes in choline acetyltransferase and synaptic vesicle cytochemistry.

Under certain culture conditions, neonatal rat superior cervical ganglion neurons display not only a number of expected adrenergic characteristics but, paradoxically, also certain cholinergic functions such as the development of hexamethonium-sensitive synaptic contacts and accumulation of choline acetyltransferase (ChAc). The purpose of this study was to determine whether the entire population of cultured neurons was aquiring cholinergic capabilities, or whether this phenomenon was restricted to a subpopulation. After 1--6 and 8 wk in culture, neurons were fixed in KMnO4 after incubation in norepinephrine and prepared for electron microscopy analysis of synaptic vesicle content to determine whether vesicles were dense cored or clear. ChAc, acetylcholinesterase (AChE), and DOPA-decarboxylase (DDC) activities were assayed in sister cultures. In the period from 1 to 8 wk in culture, the average ChAc activity per neuron increased 1,100-fold, and the DDC and AChE activities increased 20- and 30-fold, respectively. After 1 wk in culture, 48 of 50 synaptic boutons contained predominantly dense-cored vesicles, but by 8 wk the synaptic vesicle population was predominantly of the clear type. At intermediate times, the vesicle population in many boutons was mixed. The morphology of the synaptic contacts on neuronal surfaces was that characteristic of autonomic systems, with no definite clustering of the vesicles adjacent to the area of contact. Increased vesicle size correlated with increasing age in culture and the presence of a dense core. Considering these data along with available physiological studies, we conclude that these cultures contain one population of neurons that is initially adrenergic. Over time, under conditions of this culture system, this population develops cholinergic mechanisms. That a neuron may, at a given time, express both cholinergic and adrenergic mechanisms is suggested by the approximately equal numbers of clear and dense-cored vesicles in the boutons found at the intermediate times.

Radiogenic breast cancer effects of mammographic screening.

The radiocarcinogenic implications of published breast-screening policies were compared. With the use of radioepidemiologic data published recently by the National Institutes of Health, expected excess breast cancers were projected. With a base-line mammogram at age 35 and annual mammography after age 40, as few as 150 or as many as 1,000 radiogenic breast cancers were projected for a screening population of 1 million women, depending on the mammographic system employed and the screening schedule.

A proposed solution to the base rate problem in the kappa statistic.

Because it corrects for chance agreement, kappa (kappa) is a useful statistic for calculating interrater concordance. However, kappa has been criticized because its computed value is a function not only of sensitivity and specificity, but also the prevalence, or base rate, of the illness of interest in the particular population under study. For example, it has been shown for a hypothetical case in which sensitivity and specificity remain constant at .95 each, that kappa falls from .81 to .14 when the prevalence drops from 50% to 1%. Thus, differing values of kappa may be entirely due to differences in prevalence. Calculation of agreement presents different problems depending on whether one is studying reliability or validity. We discuss quantification of agreement in the pure validity case, the pure reliability case, and those studies that fall somewhere between. As a way of minimizing the base rate problem, we propose a statistic for the quantification of agreement (the Y statistic), which can be related to kappa but which is completely independent of prevalence in the case of validity studies and relatively so in the case of reliability.

The predictive validity of lay Diagnostic Interview Schedule diagnoses in the general population. A comparison with physician examiners.

A clinical reexamination by psychiatrists is a useful comparison for exploring lay Diagnostic Interview Schedule-derived psychiatric diagnoses in general population surveys, but as a validity standard psychiatric reexamination is less than ideal. There are many potential sources of disagreement that have nothing to do with the validity of either the lay or the psychiatrist examination. Another approach to comparing lay and psychiatrist diagnoses is to examine their relative predictive power. We describe such a comparison using outcome variables derived from the one-year follow-up examination of Epidemiologic Catchment Area respondents done at the St. Louis site. We examine several outcome variables across nine diagnostic categories. Within the limits of the available data, lay and psychiatrist diagnoses appear to be essentially equal in terms of the number of outcomes better predicted and few of the differences in predictive power approach statistical significance. We discuss the implications of these findings for the analysis of lay interviewer Diagnostic Interview Schedule-derived diagnoses.

A comparison of clinical and diagnostic interview schedule diagnoses. Physician reexamination of lay-interviewed cases in the general population.

We examined the level of agreement between diagnoses derived from data gathered by lay interviewers using the Diagnostic Interview Schedule (DIS) in a general population survey (the Epidemiologic Catchment Area project) and both DIS and clinical diagnoses made by psychiatrists. Overall percent agreement between the lay DIS and the psychiatrists clinical impression ranged from 79% to 96%. The chance-corrected concordance was .60 or better for eight of the 11 diagnoses. Specificities were all 90% or better. Sensitivities were lower, but lay results showed a bias for only two diagnoses: major depression was significantly underdiagnosed and obsessive illness was overdiagnosed. We compared the present results with those of previous studies from clinical settings. We explored possible reasons for disagreement and discussed the implications of the findings for psychiatric epidemiologic research.

The effect of prescribed daily dose frequency on patient medication compliance.

The objective of this study was to determine the relationship between prescribed daily dose frequency and patient medication compliance. The medication compliance of 105 patients receiving antihypertensive medications was monitored by analyzing data obtained from special pill containers that electronically record the date and time of medication removal. Inaccurate compliance estimates derived using the simple pill count method were thereby avoided. Compliance was defined as the percent of days during which the prescribed number of doses were removed. Compliance improved from 59.0% on a three-time daily regimen to 83.6% on a once-daily regimen. Thus, compliance improves dramatically as prescribed dose frequency decreases. Probably the single most important action that health care providers can take to improve compliance is to select medications that permit the lowest daily prescribed dose frequency.

Increasing brain tumor rates: is there a link to aspartame?

In the past two decades brain tumor rates have risen in several industrialized countries, including the United States. During this time, brain tumor data have been gathered by the National Cancer Institute from catchment areas representing 10% of the United States population. In the present study, we analyzed these data from 1975 to 1992 and found that the brain tumor increases in the United States occurred in two distinct phases, an early modest increase that may primarily reflect improved diagnostic technology, and a more recent sustained increase in the incidence and shift toward greater malignancy that must be explained by some other factor(s). Compared to other environmental factors putatively linked to brain tumors, the artificial sweetener aspartame is a promising candidate to explain the recent increase in incidence and degree of malignancy of brain tumors. Evidence potentially implicating aspartame includes an early animal study revealing an exceedingly high incidence of brain tumors in aspartame-fed rats compared to no brain tumors in concurrent controls, the recent finding that the aspartame molecule has mutagenic potential, and the close temporal association (aspartame was introduced into US food and beverage markets several years prior to the sharp increase in brain tumor incidence and malignancy). We conclude that there is need for reassessing the carcinogenic potential of aspartame.

Posttraumatic stress disorder in survivors of a mass shooting.

OBJECTIVE: Posttraumatic stress disorder (PTSD) has been best studied among combat veterans. Less is known about PTSD among civilian populations exposed to traumatic events. A recent mass murder spree by a gunman in a cafeteria in Killeen, Tex., has provided a unique opportunity to study acute-phase civilian responses to a combat type of experience. METHOD: Approximately 1 month after the disaster, 136 survivors were interviewed with the Diagnostic Interview Schedule/Disaster Supplement. RESULTS: In the acute postdisaster period, 20% of the men and 36% of the women met criteria for PTSD, which was the most prevalent psychiatric disorder. Most subjects who developed PTSD had no history of psychiatric illness. Rates of preexisting PTSD were relatively high and did not predict the presence of PTSD after the disaster. A history of other predisaster psychiatric disorders predicted postdisaster PTSD in women but not in men. One-half of the women and one-fourth of the men with postdisaster PTSD also met criteria for another postdisaster psychiatric diagnosis, especially major depression. Psychopathology was infrequent in subjects without PTSD. CONCLUSIONS: Disaster intervention workers may be able to most effectively use limited mental health provider resources in the acute postdisaster period by focusing on screening for acute PTSD, which will identify the majority of cases with psychiatric disorders following this kind of disaster. Survivors who have no history of psychiatric disorder should be screened along with those who do because in the present study, they represented the majority of the PTSD cases. Subjects with a history of major depression and women with preexisting psychopathology may be especially vulnerable to posttraumatic syndromes. Individuals with PTSD should be further examined for additional psychiatric diagnoses that may complicate recovery, especially major depression. PTSD among survivors of civilian combat-like experiences does not appear to present in the same way that it has been described in Vietnam veterans.

One-year follow-up of survivors of a mass shooting.

OBJECTIVE: This report describes a 1-year follow-up study of survivors of a mass shooting incident. Acute-phase data from this incident were previously reported in this journal. METHOD: The Diagnostic Interview Schedule/Disaster Supplement was used to assess 136 survivors at 1-2 months and again a year later, with a 91% reinterview rate. RESULTS: In the acute postdisaster period, 28% of subjects met criteria for posttraumatic stress disorder (PTSD), and 18% of subjects qualified for another active psychiatric diagnosis. At follow-up, 24% of subjects reported a history of postdisaster PTSD (17% were currently symptomatic), and 12% another current psychiatric disorder. Half (54%) of all 46 individuals identified as having had PTSD at either interview were recovered at follow-up, and no index predictors of recovery were identified. There were no cases of delayed-onset PTSD (beyond 6 months). Considerable discrepancy in identified PTSD cases was apparent between index and follow-up. Inconsistency in reporting, rather than report of true delayed-onset, was responsible for all PTSD cases newly identified at 1 year. The majority of subjects with PTSD at index who were recovered at follow-up reported no history of postdisaster PTSD at follow-up, suggesting considerable influence of fading memory. CONCLUSIONS: This study's findings suggest that disaster research that conducts single interviews at index or a year later may overlook a significant portion of PTSD. The considerable diagnostic comorbidity found in this study was the one robust predictor of PTSD at any time after the disaster. Disaster survivors with a psychiatric history, especially depression, may be most vulnerable to developing PTSD and therefore may deserve special attention from disaster mental health workers.

Is antisocial personality a valid diagnosis among the homeless?

OBJECTIVE: It has been argued that among the homeless many of the features of antisocial personality may be artifacts of homelessness and that strict application of the diagnostic criteria may be insensitive to social and cultural factors in this group. The authors studied a large group of homeless men and women to investigate the appropriateness of the diagnosis of antisocial personality disorder among the homeless. METHOD: Six hundred homeless men and 300 homeless women were randomly selected from shelters and street locations in St. Louis and interviewed with the National Institute of Mental Health Diagnostic Interview Schedule. RESULTS: In this sample of homeless men and women, most, but not all, adult symptoms of antisocial personality disorder were significantly associated with number of childhood conduct disorder symptoms. The onset of symptoms of antisocial personality disorder usually preceded the onset of homelessness. The rates of antisocial personality disorder were not significantly affected by discounting the antisocial disorder symptoms thought to be confounded with homelessness. CONCLUSIONS: Overall, the data support the appropriateness of the diagnosis of antisocial personality disorder among homeless populations. It cannot be said from these data that homelessness often leads to antisocial behaviors.

The relation of ulcerative colitis to psychiatric factors: a review of findings and methods.

The authors reviewed all known English-language literature on the association between psychiatric factors and ulcerative colitis to ascertain the evidence for such an association and evaluate the methods used in these studies. Most of the 138 studies contained serious flaws in research design, such as lack of control subjects, unspecified manner of data collection, and absence of diagnostic criteria. Analysis revealed that methodological flaws were significantly related to the finding of a positive association between psychiatric factors and ulcerative colitis. Seven studies represented solid systematic investigation, and all seven failed to find such an association.

Posttraumatic stress disorder among substance users from the general population.

OBJECTIVE: The purpose of the study was to evaluate the prevalence of posttraumatic stress disorder (PTSD) among substance users in the general population. METHOD: The St. Louis Epidemiologic Catchment Area study, a survey of psychiatric illness in the general population, collected data on PTSD and substance use with the Diagnostic Interview Schedule. Among the 2,663 respondents, 430 reported a traumatic event that could qualify for PTSD; however, the rate of PTSD was low, 1.35% overall. To evaluate the relationship between PTSD and substance use, respondents were hierarchically classified into one of four substance use categories ranging from polydrug use to alcohol use only. Substance users from each category as well as substance users in general were compared with persons who did not meet the substance use threshold (comparison subjects). RESULTS: Findings indicate that cocaine/opiate users are over three times as likely as comparison subjects to report a traumatic event, report more symptoms and events, and are more likely to meet diagnostic criteria for PTSD. Physical attack, but not combat-related events, was the most prevalent event reported among cocaine/opiate users. Onset of substance use preceded onset of posttraumatic symptoms, suggesting that substance use predisposes the individual to exposure to traumatic events. When other variables--including antisocial behavior--were controlled, female gender and use of cocaine/opiates predicted PTSD. CONCLUSIONS: These analyses of the co-occurrence of substance abuse and PTSD warrant further study and suggest that PTSD is much more common among substance abusers than was previously known.

New methods in cross-cultural psychiatry: psychiatric illness in Taiwan and the United States.

OBJECTIVE: Cross-cultural psychiatric research has suffered from many methodological shortcomings. To answer some of these shortcomings, the present study compared rates of psychiatric disorders in Taiwan and the United States by combining data from both countries into a single data set. METHOD: Results from large, community-based surveys in the United States and Taiwan, the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area survey and the Taiwan Psychiatric Epidemiological Project, were combined into a single data set. This integration of the data sets was possible because both surveys used the NIMH Diagnostic Interview Schedule to ascertain cases. The integrated data sets were then analyzed with identical algorithms to generate lifetime prevalence rates of psychiatric disorders according to DSM-III criteria for both the United States and Taiwan. RESULTS: Lifetime prevalence rates of psychiatric illness in Taiwan were generally lower than U.S. rates. The rates of any disorder were 21.56% in Taiwan and 35.55% in the United States (Z = 22.34, p less than 10(-109]. The rates of most specific disorders were lower in Taiwan, and none of the rates was higher in Taiwan. CONCLUSIONS: While a culturally determined response bias may have lowered the rates in Taiwan somewhat, the results appear to be valid. Implications for the future use of structured diagnostic interviews in cross-cultural research are discussed.

A randomized trial of povidone-iodine compared with iodine tincture for venipuncture site disinfection: effects on rates of blood culture contamination.

BACKGROUND: Contamination of blood cultures creates problems in their interpretation and unneeded resource utilization. Because skin flora comprise the major group of contaminant species, more effective skin disinfection at the venipuncture site could reduce contamination. SUBJECTS AND METHODS: We performed a randomized trial in adult inpatients at a tertiary care teaching hospital. Antecubital venipuncture sites were randomly disinfected with povidone-iodine or iodine tincture, and blood cultures (two bottles, 10 mL of blood) were drawn by professional phlebotomists. Scoring of contaminant species was restricted to skin flora. Hospital resource utilization was compared among patients with contaminated blood cultures and those with sterile blood cultures. RESULTS: Of the 3,851 blood cultures collected during the study, 120 (3.1%) were contaminated with skin flora. The contamination rate for blood cultures collected after povidone-iodine was 3.8% (74 of 1,947), compared with a rate of 2.4% (46 of 1,904, P = 0.01) after iodine tincture. The difference in mean total hospital costs for patients with contaminated blood cultures and those with sterile blood cultures was $4,100 (95% confidence interval: $740 to $7,400, P = 0.02). CONCLUSIONS: Iodine tincture is superior to povidone-iodine for venipuncture site antisepsis before blood culture sampling. Because of the high costs associated with contaminated blood cultures, hospitals should consider switching from povidone-iodine to iodine tincture. Reduction of the contamination rate may improve the quality of patient care and reduce hospital costs.

Antimicrobial misuse in patients with positive blood cultures.

PURPOSE: Inappropriate antimicrobial use was examined among a randomly and prospectively selected cohort of patients with at least one positive result of blood cultures. This misuse was then analyzed with respect to hospital charges and length of stay (LOS). PATIENTS AND METHODS: The study consisted of 70 patients (average age, 58.5 years) who had not undergone bone marrow transplantation. Patient charts were reviewed daily for the following information: clinical signs and symptoms of infection, pertinent laboratory data, culture results, detailed data on each antimicrobial in every antimicrobial regimen and their appropriateness, hospital charges, LOS, diagnostic and procedure codes, and discharge status. Three severity of illness variables were generated. Inappropriate antimicrobial use was described according to one of 12 categories. RESULTS: The percent of antimicrobial misuse, defined as the proportion of days of administration of antimicrobials on which one or more antimicrobials were judged inappropriate, was found to be 22.3%. After adjustment for severity of illness and diagnosis, this average inappropriateness correlated with 4.2 additional hospitalization days and $5,368 additional hospital charges. CONCLUSION: Our results cannot distinguish among several possible reasons for these associations, including direct causality (e.g., toxicity and prolonged hospitalization for antimicrobial use) and indirect links such as inappropriate utilization of other resources and influences of severity of illness on antimicrobial use not accounted for in our equations. Nevertheless, the magnitude of the association gives import to the desirability of further studies.

More effective suppression of hemostatic system activation in patients undergoing cardiac surgery by heparin dosing based on heparin blood concentrations rather than ACT.

This study was designed to determine whether the maintenance of higher than usual patient-specific heparin concentrations during cardiopulmonary bypass (CPB) was associated with more effective suppression of hemostasis system activation. Thirty-one patients scheduled for repeat cardiac surgery or combined procedures (i.e., coronary revascularization + valve repair/replacement) were consented and enrolled in this study. All patients received porcine heparin and protamine and were randomly assigned to monitoring of anticoagulation by either celite ACT alone (Control, n = 16) or by kaolin ACT combined with on-site measurements of whole blood heparin concentration (Intervention, n = 15). Blood specimens collected before administration of heparin, before weaning from CPB and after administration of protamine were analyzed with a battery of coagulation assays. Patients in the intervention cohort received appreciably greater heparin doses than control patients, resulting in higher anti-Xa heparin levels at the end of CPB. Fibrinopeptide A and D-dimer levels were higher in the control group before discontinuation of CPB. Percent decrease during CPB were greater in the control group for factors V and VIII, fibrinogen and antithrombin III. Percent decrease in complement 3 was greater in the control group after protamine and bleeding times measured in the Intensive Care Unit were significantly more prolonged in this group. Maintenance of higher patient-specific heparin concentrations during CPB more effectively suppresses excessive hemostatic system activation than do standard heparin doses chosen based on measurement of ACT. These findings may explain, at least in part, the significant reduction in perioperative blood loss and blood product use when higher heparin concentrations are maintained.

Alcohol, drugs, and psychiatric comorbidity among homeless women: an epidemiologic study.

BACKGROUND: Very little is known about the mental health of homeless women. The present study is one of the first to focus on psychiatric diagnosis and comorbidity in a population of homeless women systematically interviewed with a structured instrument. METHOD: Three hundred homeless women randomly selected from St. Louis shelters were interviewed using the Diagnostic Interview Schedule (DIS). RESULTS: The population of homeless women in St. Louis is predominantly young adult, single, and black; most have young children and average nearly a high school education. Schizophrenia and bipolar affective disorder account for only a small portion of the mental illness in these women. Nearly one in three has a history of substance abuse, with drug abuse being more prevalent than alcoholism. One third of the sample met lifetime criteria for posttraumatic stress disorder. One fourth of the women have received inpatient psychiatric care, and the majority with a nonsubstance Axis I diagnosis have received some mental health treatment. CONCLUSION: Although major mental illness is overrepresented among these homeless women, the majority do not suffer from major mental illness. Despite the severity of the stressors these women face, the large numbers escaping psychiatric disorders speak to their resilience and to the likelihood that important factors other than mental illness contribute to their homelessness. Future studies to examine positive outcomes and investigate protective factors might provide a valuable source of information on coping with the stresses associated with homelessness and point to more effective interventions.

Comparison of activated coagulation time and whole blood heparin measurements with laboratory plasma anti-Xa heparin concentration in patients having cardiac operations.

Previous reports suggest that activated clotting times do not correlate with heparin concentration during cardiopulmonary bypass. This study was designed to compare whole blood heparin concentration and activated clotting time measurements with laboratory-based plasma heparin concentration. Sixty-two patients having cardiac operations requiring cardiopulmonary bypass were enrolled in this study. The study was conducted in two phases. In phase I of this trial, blood specimens were obtained from 30 patients before heparin administration and after each of three heparin doses (20, 80, and 150 U/kg). In phase II, blood specimens were obtained from 32 patients before heparin administration and 10 minutes after each of the following: heparin administration (250 or 300 U/kg), initiation of cardiopulmonary bypass, achievement of hypothermia, initiation of rewarming, and immediately before discontinuation of bypass. Blood specimens were used to measure activated clotting time (kaolin and celite), whole blood heparin concentration, and anti-factor Xa plasma heparin concentration. In phase I, activated clotting time (celite: r = 0.91; kaolin: r = 0.93) and whole blood heparin concentration (r = 0.98) measurements correlated well with plasma heparin concentration. After initiation of cardiopulmonary bypass (phase II), weak correlations for activated clotting time measurements (celite: r = 0.34; kaolin: r = 0.59) and a strong correlation for whole blood heparin concentration (r = 0.95) were evident when compared with plasma heparin concentration. During bypass, activated clotting time measurements also inversely correlated with temperature (celite: r = -0.21; kaolin: r = -0.19) and hematocrit (celite: r = -0.26; kaolin: r = -0.21). A weak correlation between activated clotting time measurements and plasma heparin concentration is evident during the cardiopulmonary bypass period, probably because of the influence of both reduced hematocrit and temperature on the activated clotting time assay. In contrast, whole blood heparin measurements correlate well with plasma heparin concentration before and during bypass. Further studies are needed to determine whether maintaining heparin levels during cardiopulmonary bypass by monitoring heparin concentration is more effective in preventing consumptive activation of the hemostatic system, reducing bleeding, and minimizing the use of blood products after cardiopulmonary bypass when compared with a protocol based on activated clotting time.

Prospective evaluation and clinical utility of on-site monitoring of coagulation in patients undergoing cardiac operation.

Although laboratory coagulation tests permit a rational approach to both diagnosis and management of coagulation disorders after cardiopulmonary bypass, their clinical utility is limited by delays in obtaining results. This study was designed to evaluate prospectively the impact of on-site coagulation testing on blood product use, operative time, and intraoperative management of microvascular bleeding. Patients who underwent cardiac procedures involving cardiopulmonary bypass and subsequently developed microvascular bleeding were randomly assigned to receive either standard therapy (n = 36) or therapy defined by a treatment algorithm based on results from an on-site coagulation monitoring laboratory (n = 30). No differences were found between treatment groups in hematologic assay data, operative procedures, or duration of cardiopulmonary bypass. Patients treated in accordance with on-site laboratory results (algorithm therapy) received significantly less intraoperative fresh frozen plasma (0.4 +/- 1.1 U versus 2.4 +/- 2.8 U; p = 0.0006) during the treatment interval, had shorter operative times, and had less mediastinal chest tube drainage during the initial perioperative interval (158 +/- 169 ml versus 326 +/- 258 ml; p = 0.003) than did patients in the standard therapy group. Patients who underwent algorithm therapy also received fewer platelet (1.6 +/- 5.9 versus 6.4 +/- 8.2 U; p = 0.02) and red blood cell (1.9 +/- 1.7 U versus 4.1 +/- 4.1 U; p = 0.01) transfusions after the operation. Nine of 36 (25%) standard group patients received initial therapy which differed from that which would have been guided by the on-site algorithm protocol. Our findings indicate that rapid and accurate coagulation test results can guide specific therapy and optimize treatment of microvascular bleeding in patients who undergo cardiac operations.