Examining the acceptability and feasibility of the Compassionate Mindful Resilience (CMR) programme in adults living with chronic kidney disease: the COSMIC study findings.

BACKGROUND: Individuals with chronic kidney disease experience difficult physical and psychological symptoms, that impact quality of life, and are at increased risk of anxiety and depression. Access to specialist psychological support is limited. This study aimed to support a new service development project, in collaboration with Kidney Care UK, to implement the Compassionate Mindful Resilience (CMR) programme, developed by MindfulnessUK, which provides accessible mindfulness techniques and practices to enhance compassion and resilience, and explore its feasibility for people living with stage 4 or 5 kidney disease and transplant. METHODS: A multi-method feasibility design was utilised. Participants over 18 years, from the UK, with stage 4 or 5 kidney disease or post-transplant, and who were not currently undergoing psychotherapy, were recruited to the four-week CMR programme. Data was collected at baseline, post-intervention and three-months post to measure anxiety, depression, self-compassion, mental wellbeing, resilience, and mindfulness. The acceptability of the intervention for a kidney disease population was explored through qualitative interviews with participants, and the Mindfulness Teacher. RESULTS: In total, 75 participants were recruited to the study, with 65 completing the CMR programme. The majority were female (66.2%) and post-transplant (63.1%). Analysis of completed outcome measures at baseline and post-intervention timepoints (n = 61), and three-months post intervention (n = 45) revealed significant improvements in participant's levels of anxiety (p < .001) and depression (p < .001), self-compassion (p = .005), mental wellbeing (p < .001), resilience (p.001), and mindfulness (p < .001). Thematic analysis of interviews with participants (n = 19) and Mindfulness Teacher (n = 1) generated three themes (and nine-subthemes); experiences of the CMR programme that facilitated subjective benefit, participants lived and shared experiences, and practicalities of programme participation. All participants interviewed reported that they found programme participation to be beneficial. CONCLUSION: The findings suggest that the CMR programme has the potential to improve psychological outcomes among people with chronic kidney disease. Future randomized controlled trials are required to further test its effectiveness.

Experiences of People with Kidney Disease Following the Implementation of the Compassionate Mindful Resilience Programme: Qualitative Findings from the COSMIC Study.

BACKGROUND: Kidney disease is a progressive, debilitating condition. Patients experience challenging physical and psychological symptoms and are at increased risk of anxiety, depression, and poor mental wellbeing. Access to specialist psychological or social support is limited, with inadequate provision of psychosocial support available across UK renal units. The COSMIC study (examining the acceptability and feasibility of the Compassionate Mindful Resilience programme for adult patients with chronic kidney disease) aimed to support a new service development project, in partnership with Kidney Care UK, by implementing the Compassionate Mindful Resilience (CMR) programme, developed by MindfulnessUK, and explore its feasibility for patients with stage 4 or 5 kidney disease and kidney transplant recipients. This paper reports on the qualitative exploratory work which examined the experiences of study participants, their adherence to practice, and the acceptability of the intervention. METHOD: Participants (n = 19) took part in semi-structured interviews, which were transcribed, coded, and thematically analysed. RESULTS: Three themes (and nine subthemes) were reported: experiences of the CMR programme that facilitated subjective benefit, participants' lived and shared experiences, and the practicalities of CMR programme participation. All participants reported that they found taking part in the CMR programme to be a beneficial experience. CONCLUSION: The CMR programme was found to be an acceptable intervention for people living with kidney disease and provided tools and techniques that support the mental health and wellbeing of this patient group. Further qualitative exploration into participant experience should be integrated within future trials of this intervention.

Lateral annular systolic excursion ratio: A novel measurement of right ventricular systolic function by two-dimensional echocardiography.

Introduction: Accurate assessment of right ventricular (RV) systolic function has prognostic and therapeutic implications in many disease states. Echocardiography remains the most frequently deployed imaging modality for this purpose, but estimation of RV systolic function remains challenging. The purpose of this study was to evaluate the diagnostic performance of a novel measurement of RV systolic function called lateral annular systolic excursion ratio (LASER), which is the fractional shortening of the lateral tricuspid annulus to apex distance, compared to right ventricular ejection fraction (RVEF) derived by cardiac magnetic resonance imaging (CMR). Methods: A retrospective cohort of 78 consecutive patients who underwent clinically indicated CMR and transthoracic echocardiography within 30 days were identified from a database. Parameters of RV function measured included: tricuspid annular plane systolic excursion (TAPSE) by M-mode, tissue Doppler S', fractional area change (FAC) and LASER. These measurements were compared to RVEF derived by CMR using Pearson's correlation coefficients and receiver operating characteristic curves. Results: LASER was measurable in 75 (96%) of patients within the cohort. Right ventricular systolic dysfunction, by CMR measurement, was present in 37% (n = 29) of the population. LASER has moderate positive correlation with RVEF (r = 0.54) which was similar to FAC (r = 0.56), S' (r = 0.49) and TAPSE (r = 0.37). Receiver operating characteristic curves demonstrated that LASER (AUC = 0.865) outperformed fractional area change (AUC = 0.767), tissue Doppler S' (AUC = 0.744) and TAPSE (AUC = 0.645). A cohort derived dichotomous cutoff of 0.2 for LASER was shown to provide optimal diagnostic characteristics (sensitivity of 75%, specificity of 87% and accuracy of 83%) for identifying abnormal RV function. LASER had the highest sensitivity, accuracy, positive and negative predictive values among the parameters studied in the cohort. Conclusions: Within the study cohort, LASER was shown to have moderate positive correlation with RVEF derived by CMR and more favorable diagnostic performance for detecting RV systolic dysfunction compared to conventional echocardiographic parameters while being simple to obtain and less dependent on image quality than FAC and emerging techniques.

Examining the Acceptability and Feasibility of the Compassionate Mindful Resilience (CMR) Programme in Adult Patients with Chronic Kidney Disease: The COSMIC Study Protocol.

Kidney disease is often progressive, and patients experience diminished health-related quality of life. In addition, the impact of the coronavirus (COVID-19) pandemic, and its associated restrictions, has brought many additional burdens. It is therefore essential that effective and affordable systems are explored to improve the psychological health of this group that can be delivered safely during the COVID-19 pandemic. The aim of this study is to support a new service development project in partnership with the UK's leading patient support charity Kidney Care UK by implementing the four-session Compassionate Mindful Resilience (CMR) programme, developed by MindfulnessUK, and explore its effectiveness for patients with stage 4 or 5 chronic kidney disease or have received a kidney transplant. The study will utilise a quasi-experimental, pretest/posttest design to measure the effect of the CMR programme on anxiety, depression, self-compassion, the ability to be mindful, wellbeing, and resilience, using pre- and posttests, alongside a qualitative exploration to explore factors influencing the feasibility, acceptability, and suitability of the intervention, with patients (and the Mindfulness Teacher) and their commitment to practice. Outcomes from this study will include an evidence-based mindfulness and compassion programme for use with people with kidney disease, which is likely to have applicability across other chronic diseases.

Evaluation of echocardiographic derived parameters for right ventricular size and function using cardiac magnetic resonance imaging.

BACKGROUND: Cardiac Magnetic Resonance Imaging (cMRI) is the gold standard for right ventricular (RV) assessment due to its high spatial resolution. The American Society of Echocardiography (ASE) recommends eight structural and six functional quantitative parameters for evaluation of the RV. This study sought to simplify echocardiographic RV assessment by examining the relative diagnostic value of the echo recommended parameters by applying them to cMRI imaging of the RV. METHODS: We applied ASE recommended measures of RV size and function to 56 cMRI's and compared them to RV volumetric analysis obtained from cMRI. Pearsons' correlation coefficient was used to compare ASE prescribed parameters to corresponding cMRI calculated RV end diastolic volume (RVEDV) and RV ejection fraction (RVEF). The diagnostic performance of each parameter in predicting abnormal RV size or function was analyzed using receiver operator characteristic curves. Youden-J index was used to determine optimal sensitivity/specificity cut-points. Stepwise regression modeling was performed to identify measurements independently associated with RV size or RVEF. RESULTS: RV end diastolic area (RVEDA) correlated best with RVEDV (r = .76, p < 0.001) and RV fractional area change (RVFAC) correlated best with RVEF (r = .7, p < 0.001). The best ASE parameter for identifying RV dilatation was RVEDA (Youden-J index = .84), the optimal cutoff was 32.3 cm2 which yielded sensitivity/specificity of 84% and 100%, respectively. The best parameter for diagnosing RV dysfunction was RVFAC (Youden-J index = .52), with an optimal cutoff of 42% leading to sensitivity/specificity of 64% and 88%, respectively. CONCLUSION: The area based echocardiographic parameters for RV size and function, RVEDA and RV fractional area change outperform linear measurements in predicting RV dilation and RV systolic dysfunction. These parameters should be examined in further echocardiographic based studies as the primary parameters to guide quantitative RV assessment.

Relation of Venous Thromboembolism Risk to Ischemic Stroke Risk in Hospitalized Patients with Cancer.

Patients with cancer are at increased risk for venous thromboembolism (VTE). However, the relationship of cancer type to the risk of arterial thrombosis in patients with high VTE risk has not been described. The goal of this study is to determine the rate of arterial thrombosis in patients with different types of solid tumors stratified by VTE risk. Using the 2012 National Inpatient Sample, we identified 373,789 hospitalizations involving patients ≥18 years associated with solid tumors, stratified by type. Data were collected on clinical characteristics, VTE (deep vein thrombosis [DVT] and pulmonary embolism [PE]), and arterial thrombosis (primary diagnosis of myocardial infarction [MI] and ischemic stroke). Subjects with solid tumors (stages I to IV) were stratified by VTE risk - high versus low. Certain solid tumor types (esophageal, lung, melanoma, ovarian, pancreatic, stomach, and uterine) were found to be associated with a higher rate of VTE compared with other cancer types (6.8% vs 3.9%, p < 0.001). Multivariate analysis applied to the high VTE risk group showed no increased risk for MI (odds ratio [OR] 0.93, p = 0.74), however, the rate of ischemic stroke was increased (OR 1.22, p < 0.001). Those in the high VTE risk group who had metastatic disease were at higher risk for arterial thrombosis (MI OR 1.35, p < 0.001, ischemic stroke OR 2.43, p < 0.001). In conclusion, different cancer types are associated with increased risk of both venous and arterial thrombosis and the risk is further increased by the presence of metastatic disease.

Effect of preoperative pulmonary hypertension on outcomes in patients with severe aortic stenosis following surgical aortic valve replacement.

Pulmonary hypertension (PH) is prevalent in patients with aortic stenosis (AS); however, previous studies have demonstrated inconsistent results regarding the association of PH with adverse outcomes after aortic valve replacement (AVR). The goal of this study was to evaluate the effects of preoperative PH on outcomes after AVR. We performed a regional prospective cohort study using the Northern New England Cardiovascular Disease Study Group database to identify 1,116 consecutive patients from 2005 to 2010 who underwent AVR ± coronary artery bypass grafting for severe AS with a preoperative assessment of pulmonary pressures by right-sided cardiac catheterization. PH was defined as a mean pulmonary artery pressure of ≥25 mm Hg, with severity based on the pulmonary artery systolic pressure-mild, 35 to 44 mm Hg; moderate, 45 to 59 mm Hg; and severe, ≥60 mm Hg. We found that PH was present in 536 patients (48%). Postoperative acute kidney injury, low-output heart failure, and in-hospital mortality increased with worsening severity of PH. In multivariate logistic regression, severe PH was independently associated with postoperative acute kidney injury (adjusted odds ratio 4.1, 95% confidence interval [CI] 1.7 to 10, p = 0.002) and in-hospital mortality (adjusted odds ratio 6.9, 95% CI 2.5 to 19.1, p <0.001). There was a significant association between PH and decreased 5-year survival (adjusted log-rank p value = 0.006), with severe PH being associated with the poorest survival (adjusted hazard ratio 2.4, 95% CI 1.3 to 4.2, p = 0.003). In conclusion, severe PH in patients with severe AS is associated with increased rates of in-hospital adverse events and decreased 5-year survival after AVR.

Effect of genetic variants, especially CYP2C9 and VKORC1, on the pharmacology of warfarin.

The genes encoding the cytochrome P450 2C9 enzyme (CYP2C9) and vitamin K-epoxide reductase complex unit 1 (VKORC1) are major determinants of anticoagulant response to warfarin. Together with patient demographics and clinical information, they account for approximately one-half of the warfarin dose variance in individuals of European descent. Recent prospective and randomized controlled trial data support pharmacogenetic guidance with their use in warfarin dose initiation and titration. Benefits from pharmacogenetics-guided warfarin dosing have been reported to extend beyond the period of initial dosing, with supportive data indicating benefits to at least 3 months. The genetic effects of VKORC1 and CYP2C9 in African and Asian populations are concordant with those in individuals of European ancestry; however, frequency distribution of allelic variants can vary considerably between major populations. Future randomized controlled trials in multiethnic settings using population-specific dosing algorithms will allow us to further ascertain the generalizability and cost-effectiveness of pharmacogenetics-guided warfarin therapy. Additional genome-wide association studies may help us to improve and refine dosing algorithms and potentially identify novel biological pathways.

Predictors of rapid aortic dilatation in adults with a bicuspid aortic valve.

BACKGROUND AND AIM OF THE STUDY: The role of atherosclerosis and atherosclerotic risk factors in predicting progressive aortic dilatation in patients with bicuspid aortic valve (BAV) is not well defined. The study aim was to assess the role of these risk factors in progressive aortic dilatation in patients with this condition. METHODS: Adult patients were identified with BAV who displayed rapid aortic dilatation, and the association of the condition with hemodynamic and atherosclerotic risk factors was assessed. By using the Dartmouth-Hitchcock and Hartford Hospital echocardiographic databases between 1997 and 2009, a total of 135 patients with BAV and serial echocardiograms recorded at least one year apart were allocated to groups of rapid progressors (RP; n = 53) or slow progressors (SP; n = 82). Rapid aortic progression was defined as an annual rate of progression > or = 75th percentile at the sinus of Valsalva or ascending aorta level. Univariate atherosclerotic and hemodynamic variables that correlated with rapid aortic dilatation were analyzed, and independent predictors of rapid aortic dilatation identified. RESULTS: The RP group had higher mean random blood glucose levels, greater coronary artery disease, more tobacco use, and a higher National Heart, Lung and Blood Institute 10-year risk of developing coronary heart disease (10-year risk). An elevated 10-year risk of > 7% (OR 4.5; 95% CI 1.92-10.73), tobacco use (OR 5.05; 95% CI 1.51-16.86) and higher random blood glucose level (OR 1.01; 95% CI 1.002-1.03) were independent predictors of rapid aortic dilatation. CONCLUSION: In adults with BAV and non-dilated aortas at baseline, an elevated 10-year risk, tobacco use and hyperglycemia may serve as predictors of rapid aortic dilatation.

Defining patient-prosthesis mismatch and its effect on survival in patients with impaired ejection fraction.

BACKGROUND: How best to define patient-prosthesis mismatch (PPM) continues to be debated. Over time, the indexed effective orifice area has become the most widely used method. However, the clinical relevance of PPM remains controversial. METHODS: The indexed geometric orifice area and indexed effective orifice area were calculated for 143 patients having undergone aortic valve replacement with a normal left ventricular function 0.45 or less. Using the indexed geometric orifice area method, PPM was defined as nonsignificant if 1.2 cm(2)/m(2) or greater and as significant if less than 1.2 cm(2)/m(2). Using the indexed effective orifice area method, PPM was considered as nonsignificant if greater than 0.85 cm(2)/m(2), as moderate if greater than 0.65 cm(2)/m(2) and less than or equal to 0.85 cm(2)/m(2), and as severe PPM if 0.65 cm(2)/m(2) or less. RESULTS: The number of patients classified as having PPM differed according to the method used to predict its presence (PPM: Effective orifice area method = 72.7%; geometric method = 19.6%). Regardless of the method used to classify PPM there was no significant effect on mortality (adjusted hazard ratio: 2.65 at 1 year, 0.99 at 5 years, 0.92 at 9 years; p = not significant). The postoperative mean transvalvular gradient (17.1 ± 6.5 mm Hg) and left ventricular function (0.50 ± 0.145) improved significantly compared with the preoperative findings. CONCLUSIONS: The method used to calculate PPM resulted in significant classification discordance. However, regardless of classification, the presence of PPM did not adversely affect long-term outcome.

An economic analysis of aspirin desensitization in aspirin-exacerbated respiratory disease.

BACKGROUND: Aspirin desensitization is an effective therapy for moderate-to-severe aspirin-exacerbated respiratory disease (AERD). Desensitization also allows the use of aspirin for secondary cardiovascular prevention. OBJECTIVE: We sought to investigate the cost-effectiveness of aspirin desensitization with subsequent aspirin therapy in patients with AERD. METHODS: The Healthcare Cost and Utilization Project was used, together with average reimbursements from a large Midwestern health care plan, to model the costs of aspirin desensitization for therapeutic and prophylactic use in patients with AERD. Event probabilities were based on the published literature. RESULTS: Ambulatory desensitization for AERD cost $6768 per quality-adjusted life year (QALY) saved ($18.54 per additional symptom-free day). Aspirin desensitization for AERD remained cost-effective (<$50,000 per QALY saved) across a wide range of assumptions. When secondary cardiovascular prophylaxis was considered, ambulatory aspirin desensitization was less expensive than an alternative antiplatelet agent, clopidogrel. Clopidogrel cost $106,453 per incremental QALY saved when compared with desensitization. CONCLUSIONS: Aspirin desensitization is a cost-effective therapeutic intervention in patients with moderate-to-severe AERD. Although the incremental cost-effectiveness of clopidogrel in individuals with aspirin allergy is marginal, if available, ambulatory desensitization remains a less-expensive option for secondary cardiovascular prophylaxis.

Percutaneous and surgical treatment of aortic stenosis.

Aortic stenosis due to calcific degeneration is the most common valvular disorder among the elderly. With the growing elderly population, the prevalence of this disease will continue to increase. Based on converging lines of evidence linking calcific aortic stenosis with atherosclerosis, there has been interest in drug therapy to slow the progression of aortic stenosis. Unfortunately, recently completed prospective trials have been disappointing. Mechanical measures remain the principal form of therapy. Among percutaneous techniques, aortic valvuloplasty provides only transient and modest benefit at a significant risk of stroke and vascular injury. However, aortic valvuloplasty can play a useful role in stabilizing patients who require additional attention prior to definitive surgery. Building on this foundation, a bold new technique of percutaneously implanting a balloon-mounted valve has been developed. Although promising, there have been relatively few patients treated in this fashion (at a single center) and with only limited follow-up. Surgical treatment, specifically valve replacement, is still the definitive treatment of choice for patients with symptomatic aortic stenosis. Surgeons and patients must choose between a variety of models of both tissue and mechanical valves and a variety of surgical approaches. Recent trends include the use of tissue valves in increasingly younger patients and continued interest in alternatives to full median sternotomy in approaching the valve.

Survival in patients with peripheral vascular disease after percutaneous coronary intervention and coronary artery bypass graft surgery.

BACKGROUND: Patients with peripheral vascular disease (PVD) undergoing coronary revascularization have high rates of adverse outcomes. Whether there are important differences in outcomes for surgical versus percutaneous coronary revascularization is unknown. The objective of this study was to compare survival in patients with PVD who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) surgery for multivessel coronary artery disease. METHODS: In-hospital data were collected on 1,305 consecutive patients undergoing coronary revascularization (PCI, n = 341; CABG, n = 964) in northern New England from 1994 to 1996. Patient records were linked to the National Death Index to assess survival out to 3 years (mean 1.2 years). Logistic and Cox proportional hazards regression were used to calculate risk-adjusted odds ratios and hazard ratios. RESULTS: Compared with CABG patients, those undergoing PCI were more often women, had more renal failure, more prior coronary revascularizations, were more likely to have two-vessel coronary artery disease and were more likely to undergo the procedure emergently. They were less likely to have a history of heart failure. After adjusting for differences in baseline characteristics, patients undergoing CABG had better intermediate survival than did PCI patients (hazard ratio 0.68; 95% confidence interval, 0.46 to 1.00; p = 0.05). CONCLUSIONS: Patients with multivessel coronary artery disease and PVD undergoing CABG surgery have better intermediate survival out to 3 years than similar patients undergoing PCI. This information may be useful in counseling patients with PVD requiring coronary revascularization.

Stability of ascending aortic dilatation following aortic valve replacement.

BACKGROUND: Replacement of the ascending aorta (Asc Ao) at the time of aortic valve replacement (AVR) is controversial because the risk of progressive dilatation following valve replacement is uncertain. Our aim was to determine the natural history of ascending aortic dilatation following AVR. METHODS AND RESULTS: We studied 185 patients undergoing AVR at our institution between 1992 and 1999. Clinical and echocardiographic data were obtained by merging our institutional echocardiographic database with the DHMC component of the Northern New England Cardiovascular Disease Study Group database. Baseline Asc Ao measurements obtained from intraoperative transesophageal echocardiograms or early (<8 weeks) postoperative transthoracic echocardiograms were compared with late follow-up measurements (mean follow-up 30.0+/-23.4 months). During follow-up, there was no increase in the mean Asc Ao diameter (3.6+/-0.6 cm versus 3.6+/-0.6 cm, p=NS). Progressive aortic dilatation, defined as an increase in diameter >0.3 cm, occurred in 27/185 patients (15%). Baseline Asc Ao dilatation (>or=3.5 cm) was present in 107/185 patients (58%). In this subset of patients, there was no increase in mean Asc Ao diameter (4.0+/-0.4 versus 3.9+/-0.6 cm, p=NS) and progressive aortic dilatation occurred in only 10 patients (9.3%). No patients with baseline aortic dilatation (range, 3.5 to 5.3 cm) dilated beyond 5.5 cm on follow-up (range, 2.4 to 5.5 cm). There were no clinical or valvular characteristics that predicted progressive Asc Ao dilatation. CONCLUSIONS: An increase in Asc Ao dilatation occurs infrequently following AVR and therefore, argues against routine Asc Ao replacement at the time of AVR.

Reversible myocardial dysfunction after traumatic brain injury: mechanisms and implications for heart transplantation.

Reversible myocardial dysfunction is known to occur in patients with cerebrovascular accidents and brain death. Several mechanisms for transient myocardial dysfunction have been proposed, including increased sympathetic activity, hormone depletion, and a reduction in coronary perfusion pressure. The relative importance of each of these mechanisms remains controversial. We report the case of a 19-year-old man who suffered traumatic brain death associated with reversible myocardial dysfunction despite elevated cardiac enzymes. Myocardial recovery occurred after correcting his hemodynamic instability and hypothermia emphasizing the importance of normalization of coronary perfusion pressure and core body temperature. The mechanisms for reversible myocardial dysfunction and their implications for heart transplantation following traumatic brain death are reviewed. A diagnostic strategy is proposed that would allow early recognition of reversible myocardial dysfunction in brain-dead patients.

Veterans' system-of-care preferences for percutaneous transluminal coronary angioplasty in a rural setting.

CONTEXT: In the Veterans Health Administration (VHA), regionalization of high-technology health care services may influence veterans who live far from referral centers to obtain care locally, through the private sector. PURPOSE: To understand veterans' system-of-care preferences for a high-technology regionalized service. METHODS: The charts of 142 veterans who were referred for percutaneous transluminal coronary angioplasty (PTCA) by their VHA cardiologists were reviewed. FINDINGS: Fifty-two percent of these veterans obtained the procedure outside the VHA system. Insurance coverage and out-of-pocket costs were strongly associated with veterans' obtaining PTCA outside of the VHA system; travel distance was not. CONCLUSIONS: As the VHA begins to understand veterans' use of multiple systems of care, it will be important to understand the relationship between out-of-pocket costs and the system of care used for high-technology health care services.

Gender-related changes in the practice and outcomes of percutaneous coronary interventions in Northern New England from 1994 to 1999.

OBJECTIVES: We sought to determine whether the changing practice of interventional cardiology has been associated with improved outcomes for women, and how these outcomes compare with those for men. BACKGROUND: Previous work from the early 1990s suggested women are at a higher risk than men for adverse outcomes after percutaneous coronary interventions (PCIs). From 1994 to 1999 data were collected on 33,666 consecutive hospital admissions for a PCI in Northern New England. Multivariate models were used to adjust for differences in case-mix across year of procedure when comparing outcomes. Direct standardization was used to calculate adjusted rates. RESULTS: From 1994 to 1999, the case-mix worsened for both women and men, although women had more co-morbidities than did men throughout the period. Stent use increased over time (>75% in 1999). Concomitantly, the need for emergency coronary artery bypass graft surgery (CABG) decreased significantly (p(trend) < or = 0.001; in 1999: 0.06% for women, 0.05% for men). Although the emergency CABG rates were higher for women at the beginning of the study, by the end, they were comparable (adjusted odds ratio 1.34, 95% confidence interval 0.76 to 2.38, p = 0.315). The myocardial infarction (MI) rates decreased over time for both women (by 29.7%, p(trend) = 0.378) and men (by 37.6%, p(trend) = 0.009) and did not differ by gender. The mortality rates did not decrease significantly over time and were not significantly different between the genders (mean 1.21% for women, 1.06% for men; p = 0.096). CONCLUSIONS: Concurrent with the changing practice of PCI, and despite treating sicker patients, there have been important improvements in post-PCI CABG and MI rates for women, as well as for men. Unlike in earlier years, there are no longer significant differences in outcomes by gender.

Veterans' care preference for coronary artery bypass grafting in a rural setting.

We wanted to determine what factors were associated with rural veterans' use of Department of Veterans Affairs (VA) facilities over the private sector for coronary artery bypass grafting (CABG) surgery. We reviewed the charts of 137 veterans who were referred for CABG by their VA cardiologists. Most veterans (69%) obtained CABG through the VA system. Although patients who had to drive fewer additional miles to obtain VA care were somewhat more likely to use the VA system, patients who lacked insurance or faced high out-of-pocket cost estimates for care in the private sector obtained care through the VA at dramatically higher rates. Although patients using the VA system were younger and more likely to have significant coronary artery disease, clinical outcomes did not significantly differ across systems of care. As the VA begins to understand veterans' use of multiple systems of care, it will be important to understand what influences veterans' choice of VA or private sector care.