Simple bedside additive tool for prediction of in-hospital mortality after percutaneous coronary interventions.

BACKGROUND: Risk-adjustment models for percutaneous coronary intervention (PCI) mortality have been recently reported, but application in bedside prediction of prognosis for individual patients remains untested. METHODS AND RESULTS: Between July 1, 1997 and September 30, 1999, 10 796 consecutive procedures were performed in a consortium of 8 hospitals. Predictors of in-hospital mortality were identified by use of multivariate logistic regression analysis. The final model was validated by use of the bootstrap technique. Additional validation was performed on an independent data set of 5863 consecutive procedures performed between October 1, 1999, and August 30, 2000. An additive risk-prediction score was developed by rounding coefficients of the logistic regression model to the closest half-integer, and a visual bedside tool for the prediction of individual patient prognosis was developed. In this patient population, the in-hospital mortality rate was 1.6%. Multivariate regression analysis identified acute myocardial infarction, cardiogenic shock, history of cardiac arrest, renal insufficiency, low ejection fraction, peripheral vascular disease, lesion characteristics, female sex, and advanced age as independent predictors of death. The model had excellent discrimination (area under the receiver operating characteristic curve, 0.90) and was accurate for prediction of mortality among different subgroups. Near-perfect correlation existed between calculated scores and observed mortality, with higher scores associated with higher mortality. CONCLUSIONS: Accurate predictions of individual patient risk of mortality associated with PCI can be achieved with a simple bedside tool. These predictions could be used during discussions of prognosis before and after PCI.

Phonological recoding and self-teaching: sine qua non of reading acquisition.

The self-teaching hypothesis proposes that phonological recoding functions as a self-teaching mechanism enabling the learner to independently acquire an autonomous orthographic lexicon. Successful decoding encounters with novel letter strings provide opportunities to learn word-specific print-to-meaning connections. Although it may not play a central role in skilled word recognition, phonological recoding, by virtue of its self-teaching function, is regarded as critical to successful reading acquisition. This paper elaborates the self-teaching hypothesis proposed by Jorm and Share (1983), and reviews relevant evidence. Key features of phonological recoding include an item-based rather than stage-based role in development, the progressive "lexicalization" of the process of recoding, and the importance of phonological awareness and contextual information in resolving decoding ambiguity. Although phonological skills have been shown to be primary in reading acquisition, orthographic processing appears to be an important but secondary source of individual differences. This implies an asymmetrical pattern of dissociations in both developmental and acquired reading disorders. Strong relationships between word recognition, basic phonological processing abilities and phonemic awareness are also consistent with the self-teaching notion. Finally, it is noted that current models of word recognition (both PDP and dual-route) fail to address the quintessential problem of reading acquisition-independent generation of target pronunciations for novel orthographic strings.

IQ and reading progress: a test of the capacity notion of IQ.

Concepts such as developmental reading disorder and dyslexia have been used to refer to children whose actual reading achievement is substantially below that predicted by performance on IQ tests. Such diagnostic concepts assume that IQ sets a limit on either the level of achievement or the rate of progress of which a child is capable. This assumption was investigated in a longitudinal study of an unselected cohort of 741 children whose reading achievement was assessed at ages 7, 9, 11, and 13 years. Findings on rates of progress and levels of achievement clearly indicate that IQ does not set a limit on reading progress, even in extreme low IQ children. Thus, the use of IQ tests to determine achievement potential in reading appears unwarranted.

Focal segmental glomerulosclerosis in adult African Americans.

We have previously shown that idiopathic focal segmental glomerulosclerosis (FSGS) is the most common non-proliferative primary glomerulopathy in adult African Americans. In this report we present our experience with treated FSGS in 15 such patients followed over five years. They were all treated with prednisone 60 mg daily for three months, followed by a slow tapering. In addition, two patients later had cyclophosphamide, and five had enalapril. At entry hypertension was present in 73% of the patients, nephrotic syndrome in 87%, and elevated serum creatinine (> or = 1.4 mg/dl) in 40%. Five of the 15 patients (33%) developed end-stage renal failure (ESRF), one of them having a "malignant" course after the advent of pregnancy. Two patients (13%) have chronic renal insufficiency (CRI; serum creatinine > 2.5 mg/dl); three (20%) have mild renal insufficiency (serum creatinine 1.4-2.5 mg/dl), and five patients (33%) have normal renal function. The cumulative renal survival was 93% at five years, but only 26% at eight years. At last follow-up all the ten patients who did not develop ESRF were in partial remission (urinary protein of 1.3 g/day +/- 1.21), but 4 of the 5 patients who did not develop ESRF had no prolonged partial remission of nephrotic syndrome. Neither the initial clinical parameters not the use of enalapril correlated with the renal outcome (univariate analysis). However, 4 of the 5 patients who developed ESRF had elevated serum creatinine at entry, versus only 2 of the 10 not developing ESRF (p = 0.09 by two-sided, and 0.045 by one-sided Fisher's exact test). We conclude that the short-term renal outcome in nephrotic adult African Americans with treated FSGS is comparable to that of the non-African Americans, but their long-term prognosis may be poorer. Patients developing ESRF were more likely to present with elevated serum creatinine. Enalapril did not seem to modify the course of renal disease, but its utility and that of other ACE inhibitors in the treatment of FSGS must await prospective randomized studies.

Phonological confusability in short-term memory for sentences as a predictor of reading ability.

Upon entry to kindergarten, a group of 477 children was given sentence memory tasks involving rhyming and non-rhyming sentences. These tasks were readministered to the children at the end of Grade 1 when the children were also tested for reading ability. Short-term memory for sentences was found to correlate with Grade 1 reading ability on both occasions when it was tested. Furthermore, at both ages the children found rhyming sentences harder to recall than non-rhyming sentences. However, contrary to some previous research, the study failed to find that poor readers were less severely penalized when the short-term memory sentence stimuli rhymed. The possible role of scaling artifacts in producing inconsistent results between studies is discussed.

A six month randomized controlled trial of long acting injectable risperidone 50 and 100mg in treatment resistant schizophrenia.

It has been suggested that atypical antipsychotic drugs (A-APDs) other than clozapine may be effective to improve positive symptoms in some patients with treatment resistant schizophrenia (TRS), if both the dose is higher, and the duration of the trial longer, than those which have been ineffective in non-TRS (NTRS) patients. This hypothesis was tested with long acting injectable risperidone (Risperdal Consta®, RLAI). One hundred sixty TRS patients selected for persistent moderate-severe delusions or hallucinations, or both, were randomized to RLAI, 50 or 100mg biweekly, in a six month, outpatient, double-blind, multicenter trial. We hypothesized that RLAI, 100mg, would be more effective than RLAI, 50mg. However, both doses produced clinically significant and equivalent improvement in PANSS Total, Positive, and Negative subscale scores, as well as key cognitive, global and functional measures, with increasing response during the course of the study, confirming the value of longer clinical trial duration for patients with TRS, but not superiority of the higher dose. The overall response rate was comparable to that previously reported for clozapine and high dose olanzapine, another A-APD, in TRS. Both doses of RLAI were equally well tolerated, producing minimal extrapyramidal side effects and few drop outs. Plasma levels of the active moiety, risperidone+9-hydroxyrisperidone, during treatment with RLAI 100mg, were comparable to those for 6-8 mg/day oral risperidone, which have not been effective in TRS. Further study of RLAI, ≥ 50-100mg biweekly, should compare it with clozapine and oral risperidone in TRS, with duration of treatment ≥ six months.

Impact of health care initiatives on outcomes of acute coronary syndromes.

Assessing efforts to apply clinical guidelines in community practice, with the goal of improving the quality and outcomes of care, presents many challenges.

Phonological recoding and orthographic learning: A direct test of the self-teaching hypothesis.

According to the self-teaching hypothesis (Share, 1995), word-specific orthographic representations are acquired primarily as a result of the self-teaching opportunities provided by the phonological recoding of novel letter strings. This hypothesis was tested by asking normal second graders to read aloud short texts containing embedded pseudoword targets. Three days later, target spellings were correctly identified more often, named more quickly, and spelled more accurately than alternate homophonic spellings. Experiment 2 examined whether this rapid orthographic learning can be attributed to mere visual exposure to target strings. It was found that viewing the target letter strings under conditions designed to minimize phonological processing significantly attenuated orthographic learning. Experiment 3 went on to show that this reduced orthographic learning was not attributable to alternative nonphonological factors (brief exposure durations or decontextualized presentation). The results of a fourth experiment suggested that the contribution of pure visual exposure to orthographic learning is marginal. It was concluded that phonological recoding is critical to the acquisition of word-specific orthographic representations as proposed by the self-teaching hypothesis.

Prevalence of the Fuld profile in temporal lobe epilepsy.

A pattern of performance on the WAIS-R presumably related to temporal lobe abnormalities associated with Alzheimer's Disease was examined in patients with focal temporal lobe EEG abnormalities to determine if the profile was related to other forms of temporal lobe disease. Among 120 patients with unilateral or bilateral temporal lobe EEG abnormalities, only 4(3%) demonstrated the profile. The presence of the profile was unrelated to laterality of EEG abnormality. These findings were discussed in regard to previous studies and the utility of the so-called Fuld profile.

Factors associated with reading-plus-spelling retardation and specific spelling retardation.

Factors associated with reading-plus-spelling retardation and specific spelling retardation were investigated in a large sample of Dunedin children who were studied longitudinally between the ages of three and 11 years. Those with reading-plus-spelling retardation showed poor performance on WISC-R Verbal subtests relative to non-retarded children, but superior performance on Picture Completion and Object Assembly subtests. The group with reading-plus-spelling retardation also had poor speech articulation but no significant language, motor or neurological dysfunction. Their educational attainment in reading, writing and mathematics was consistently poor. Specific spelling retardation was associated with deficits on WISC-R Arithmetic and Coding subtests, teacher ratings of low attentiveness and poor achievement in writing and mathematics. No language, motor or neurological deficits were apparent in this group.

Refractive error, IQ and reading ability: a longitudinal study from age seven to 11.

Children from a population sample whose cycloplegic refractive errors included myopia, pre-myopia and hypermetropia were compared on measures of IQ and reading with a group of children without significance refractive errors. At age 11 both those with myopia and with pre-myopia had increased verbal and performance IQ, while those with hypermetropia had slightly reduced verbal and performance IQ, in comparison with the children without refractive errors. The differences in verbal IQ were not attributable simply to earlier differences, but the differences in performance IQ were attributable to earlier differences. No significant differences in reading scores were found at either age. It is concluded that differing abilities of myopic and other children at age 11 are not fully explained by differences in family background or in pre-existing ability.

Focused utilization review strategies.

Researchers from the Michigan Health Care Education and Research Foundation, a research affiliate of Blue Cross and Blue Shield of Michigan, compared three focused utilization review (UR) strategies to determine which method most effectively and efficiently identifies nonacute inpatient hospital admissions. Intensity, Severity, Discharge-Appropriateness (ISD-A) criteria were used to identify nonacute admissions in 8,973 cases in 73 Michigan hospitals. Significant proportions of nonacute admissions were found in medical, psychiatric, and substance abuse cases; surgical admissions had the lowest rates. Strategies involving the concentration ratio were most effective at indicating potential efficiency gains. Focused UR on Diagnosis-Related Groups (DRGs) with nonacute rates greater than 15% captured 41% of admissions and accounted for 85% of nonacute admissions, 85% of nonacute days, and 80% of potential dollar savings. This suggests that UR efforts focused primarily on DRGs with high nonacute rates would significantly improve the efficiency and effectiveness of the overall UR process.

Are patients receiving maximal medical therapy following carotid endarterectomy?

BACKGROUND: Most patients in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) did not receive lipid-lowering treatment. As vascular event rates can be lowered with statins, antihypertensive agents, and newer antiplatelet agents, the authors conducted a study to determine the usage of these medications in patients following carotid endarterectomy (CE). METHODS: Claims data from Blue Cross and Blue Shield Michigan were used to study non-Medicare members who underwent CE in the years 1999 to 2001 (n = 1,049). Prescription of pharmacotherapy and sustained use (>80% use of the follow-up period) were examined in the 365-day period following index CE. RESULTS: Overall, 1,049 individuals underwent CE during the years 1999 to 2001. For the 1-year period following CE, the statin prescription rate was 70, 66, and 73% for the 3 study years. Sustained statin use was noted, on average, in 38%. The 3-year average was lower for sustained use of angiotensin-converting enzyme inhibitor (19%) and even lower for prescription antiplatelet agents (5%). CONCLUSIONS: Use of statins has increased following carotid endarterectomy (CE) compared with the North American Symptomatic Carotid Endarterectomy Trial era, but sustained treatment with statins remains at <40%. Recent studies have shown a decrease in vascular event rates with statins regardless of low-density lipoprotein level, suggesting that statin use should be routine following CE. Increased statin use as part of a multimodality intensive medical regimen following CE has the potential to improve long-term vascular event rates in this population.

Reliability and validity of utilization review criteria. Appropriateness Evaluation Protocol, Standardized Medreview Instrument, and Intensity-Severity-Discharge criteria.

A study was conducted to assess the reliability and validity of the Appropriateness Evaluation Protocol (AEP), the Standardized Medreview Instrument (SMI) and the Intensity-Severity-Discharge criteria set (ISD), three utilization review instruments used to determine whether inpatient care is required. Reliability and validity were assessed for retrospective application of these instruments to charts of a sample of 119 medical cases from 21 hospitals in the state of Michigan. The reliability of each instrument was determined by having the instrument applied by two different nurse reviewers to each hospital record. Results indicated that the AEP and ISD were moderately reliable, while the SMI had low reliability. The validity of each instrument was tested by comparing the judgments of nurse reviewers using the instruments with the judgment of a panel of physicians. The AEP and ISD were found to be moderately valid and the SMI was found to have low validity. Results suggested that the SMI should not be used. The modest level of validity of the other two instruments suggests that payment should never be denied on the basis of the instrument alone. Payment should be denied only if a physician confirms the judgment based on the instrument that inpatient care was not required.

Reading disability and middle ear disease.

The association between specific reading disability and middle ear disease was investigated in a longitudinal study of 962 children followed from age 5 to 11. No significant differences were found in the prevalence of middle ear abnormalities between the reading disabled group (n = 49) and the remainder.

Behaviour problems in specific reading retarded and general reading backward children: a longitudinal study.

A sample of 453 Australian children was followed over the first three years of schooling. Behaviour problems were assessed at the beginning of the first year at school and at the end of the second and third years. At the end of the third year the children were classified as specific reading retarded, general reading backward or normal. At school entry backward readers were found to have behaviour problems, principally relating to attentional deficit. It was concluded that this factor may play a causative role in their reading difficulty. Retarded readers, on the other hand, showed no evidence of behaviour problems.