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C Maynard

Publications and source records attributed to C Maynard.

At least 19 recordsLinked to original sources
PubMed2006

Influences of electrocardiographic ischaemia grades and symptom duration on outcomes in patients with acute myocardial infarction treated with thrombolysis versus primary percutaneous coronary intervention: results from the DANAMI-2 trial.

OBJECTIVE: To determine whether ischaemia grade (GI) on the presenting ECG and duration of symptoms can identify subgroups of patients who would derive more benefit than the general population of patients with ST segment elevation acute myocardium infarction (STEMI) from primary percutaneous coronary intervention (pPCI) over thrombolytic treatment (TT) in reducing mortality or reinfarction. METHODS: 1319 DANAMI-2 (Danish trial in Acute Myocardial Infarction-2) patients were classified as having grade 2 ischaemia (GI2; ST segment elevation without terminal QRS distortion) or grade 3 ischaemia (GI3; ST segment elevation with terminal QRS distortion in > or = 2 adjacent leads), and were divided into early and late groups split by the median time (3 h) from symptom onset to treatment. Outcomes were 30-day mortality and reinfarction. RESULTS: Mortality was significantly higher for GI3 than for GI2 (9.7% v 4.8%, p < 0.001) and doubled for patients presenting late (GI2: 6.0% v 3.3%, p = 0.01; GI3: 12.5% v 4.7%, p = 0.05). Overall mortality did not differ significantly between pPCI and TT; however, a 5.5% absolute mortality reduction was seen in GI3 treated early with pPCI (1.4% v 6.9%, p = 0.10). Reinfarction rate was particularly high among GI3 patients presenting late and treated with TT (12.2%). pPCI in such patients significantly reduced the rate of reinfarction (0%, p < 0.001). Logistic regression analysis showed that age (odds ratio (OR) 1.09, 95% confidence interval (CI) 1.06 to 1.12, p < 0.001), prior angina (OR 2.56, 95% CI 1.44 to 4.54, p = 0.001), heart rate (OR 1.03, 95% CI 1.01 to 1.04, p = 0.001) and GI3 (OR 1.91, 95% CI 1.06 to 3.44, p = 0.031) were independently associated with mortality, whereas the sum of ST segment elevation was not. CONCLUSIONS: GI3 is an independent predictor of mortality among patients with STEMI. Mortality increased significantly with symptom duration in both GI2 and GI3. pPCI may be especially beneficial for patients with GI3 presenting early, whereas patients with GI3 presenting late and treated with TT are at particular risk of reinfarction.

Angioplasty, Balloon, Coronary↗
PubMed2005

Optimization of microbial DNA extraction and purification from raw wastewater samples for downstream pathogen detection by microarrays.

Numerous waterborne pathogens are difficult to detect and enumerate with accuracy due to methodological limitations and high costs of direct culturing. The purity of DNA extracted from wastewater samples is an important issue in the sensitivity and the usefulness of molecular methods such as polymerase chain reaction (PCR) and hybridizations on DNA microarrays. Ten different DNA extraction procedures, including physical and chemical extraction and purification steps, were examined to ascertain their relative effectiveness for extracting bacterial DNA from wastewater samples. The quality of the differentially extracted DNAs was subsequently assessed by PCR amplification and microarray hybridization. Our results showed that great differences existed among the ten procedures and only a few of the methods gave satisfactory results when applied to bacterial pathogens. This observation suggested that the extraction method needed to be carefully selected to produce significant and confident results in the detection of pathogens from environmental samples.

Bacteria↗
PubMed2001

Comparison of short-term outcomes following coronary artery stenting in men versus women.

This study sought to determine whether women have more adverse in-hospital outcomes after percutaneous transluminal coronary angioplasty (PTCA) and stenting compared with men. There is still controversy regarding whether female gender is an independent predictor of mortality after PTCA. No study has examined gender differences in outcomes following the dissemination of stenting. Data were obtained from the Nationwide Inpatient Sample. In 1997, there were 118,548 angioplasties (36% occurred in women and 59% involved placement of stents). Outcomes included same-admission mortality and coronary artery bypass grafting (CABG). Analyses were performed separately for patients with and without acute myocardial infarction (AMI). In 1997, women had a roughly twofold higher mortality than men in every comparison group, including conventional PTCA alone and stents. Mortality rates after stenting were 4.0% for women and 2.0% for men with AMI (p <0.0001), and 1.1% and 0.5%, respectively, for patients without AMI (p <0.0001). The adjusted odds ratios were 1.47 (95% confidence interval 1.23 to 1.75), and 1.65 (95% confidence interval 1.33 to 2.04), respectively. Similarly, following stenting, women had significantly higher CABG rates than men in both the AMI (1.6% vs 1.2%, p = 0.025) and no AMI groups (1.5% vs 1.0%, p <0.0001). After multivariate adjustment, the results retained significance in the no AMI setting, whereas there was a trend toward significance in the AMI group. This study demonstrates that, despite improved overall outcomes in patients who received stents, women who underwent stenting had higher rates of same-admission mortality and CABG compared with men. Furthermore, it confirms that female gender is an independent predictor of mortality after conventional PTCA.

Aged↗
PubMed2001

The use of trimodality therapy for the treatment of operable esophageal carcinoma in the veteran population: patient survival and outcome analysis.

BACKGROUND: In an effort to improve the cure rates associated with surgical therapy, neoadjuvant chemoradiotherapy is being used with increasing frequency before resection (trimodality therapy). A variety of clinical trials have reviewed this approach, but only one study to the authors' knowledge has shown a survival benefit for trimodality therapy. The extent to which trimodality therapy has gained acceptance in general practice is not clear. The objective of the current study was to determine the extent to which both surgery and trimodality therapy are used for the management of esophageal carcinoma within a large, national health care system and to determine the outcome of patients treated with these treatment approaches. METHODS: The current study was a retrospective cohort study. The study population was comprised of all veterans who underwent either surgery alone or trimodality therapy for operable esophageal carcinoma between the fiscal years of 1993 and 1997. Data were obtained from the Veterans Administration Patient Treatment File, Outpatient Clinic File, and the Beneficiary Identification Record Locator System. The main outcome measures were perioperative mortality and patient survival. RESULTS: During the study period, 695 patients underwent either surgery alone or trimodality therapy for esophageal carcinoma. Five hundred thirty-four (77%) patients were treated with surgery only. One hundred sixty-one (23%) patients underwent surgery after induction chemoradiotherapy (trimodality therapy). Patients selected for trimodality therapy were younger (mean age, 60.8 years vs. 65.6 years), had fewer comorbidities, and were more likely to have a midesophageal tumor. The median survival for all patients was 15.2 months. The type of treatment had no apparent effect on survival. Favorable prognostic factors included younger age, a distal esophageal tumor, and the absence of metastases. The overall perioperative mortality was 13.7 %. The use of trimodality therapy did not increase perioperative mortality. CONCLUSIONS: Trimodality therapy is commonly used within the VA system. The nonrandomized nature of this study does not allow comparison of trimodality therapy to surgery alone, but the overall survival was limited for all patients. The predictors of survival are related to the biology of the disease, and they include patient age, tumor location, and stage at diagnosis.

Aged↗
PubMed2001

Comparison of outcomes of coronary stenting versus conventional coronary angioplasty in the department of veterans affairs medical centers.

Although the short-term benefits of stent deployment have been established, less is known about long-term outcomes. This study compares short- and long-term outcomes in veterans undergoing stenting and conventional coronary angioplasty. We used Department of Veterans Affairs databases to identify 27,224 veterans who had undergone percutaneous coronary intervention (PCI) in Veterans Affairs medical centers between October 1994 and September 1999. Patients were classified according to whether they had acute myocardial infarction (AMI) as the principal diagnosis. Baseline characteristics were similar in the stent and conventional groups. In AMI, hospital mortality was 2.9% for those with stents and 4.8% for those who underwent conventional coronary angioplasty (p <0.0001), whereas for patients without AMI, hospital mortality was similar (1.2% vs 1.4%, p = 0.12). For AMI, same-admission bypass surgery rates were lower in the stent group (0.7% vs 3.2%, p <0.0001) and in the group without AMI (1.2% vs 3.3%, p <0.0001). Two-year survival was better for stenting in veterans with (90% vs 88%, p = 0.006) and without (92% vs 91%, p = 0.008) AMI. For AMI, 2-year rehospitalization rates for PCI (10% vs 13%, p <0.0001), coronary artery bypass surgery (4% vs 6%, p <0.0001), and unstable angina (17% vs 23%) were lower for those who had stenting. In the no-AMI group, 2-year rehospitalization rates for PCI (14% vs 17%, p <0.0001), coronary artery bypass surgery (5% vs 8%, p <0.0001), and unstable angina (22% vs 29%, p <0.0001) were lower in the stent group. Veterans who underwent stenting had lower hospital mortality, reduced rates of same-admission bypass surgery, marginally better survival, and lower rates of rehospitalization than their counterparts who had conventional coronary angioplasty.

Adult↗
PubMed2001

Early clinical outcomes and routine management of patients with non-ST-segment elevation myocardial infarction: a nationwide perspective.

BACKGROUND: Myocardial infarction (MI) in the absence of electrocardiographic ST-segment elevation or new bundle branch block is the cause of hospitalization for a large and steadily increasing proportion of patients with acute ischemic chest pain. Despite its prevalence, the common demographic features, current hospital-based management, and short-term clinical outcome among patients with non-ST-segment elevation MI remain poorly defined. METHODS: A total of 183 113 patients with non-ST-segment elevation MI were identified in the National Registry of Myocardial Infarction database. Using a validated model, 43 928 patients (24.0%) were retrospectively placed in major, 34 917 (19.1%) in intermediate, and 104 268 (56.9%) in minor severity clinical event categories that included hospital death, recurrent myocardial ischemia, and nonfatal recurrent MI. RESULTS: The administration of widely available and universally recommended pharmacologic therapies, including aspirin and beta-adrenergic blocking agents, was suboptimal, particularly among patients with major severity clinical events. In contrast, coronary angiography and mechanical revascularization procedures were commonplace (>60% of all patients) and most frequently performed in patients within the minor (compared with the major) severity clinical event category (58.2% and 42.7%, respectively). CONCLUSIONS: Patients with non-ST-segment elevation MI are a heterogeneous population, with readily identifiable demographic characteristics and clinical features associated with important early outcomes, including death. Nationwide efforts directed toward maximizing pharmacologic therapy utilization and the performance of invasive procedures according to established guidelines must continue.

Aged↗
PubMed2001

Assessment of vital status in Department of Veterans Affairs national databases. comparison with state death certificates.

PURPOSE: To determine the extent to which Department of Veterans Affairs (VA) database vital status information agrees with Washington state death certificates. METHODS: Using each data source, vital status was determined for 19,481 Washington state resident veterans hospitalized in Washington VA hospitals from 1994 to 1997, and for 33,602 Washington state resident veterans who were seen as outpatients during 1997. RESULTS: The agreement between VA and Washington state records was excellent for hospitalized veterans (kappa = 0.91, p < 0.0001). Three thousand one hundred-eight individuals (86.2% of all deaths) appeared in both files. Of those deaths missing in the VA files, 71% had no service-connected disability, VA pension, or other compensation. Among outpatients, agreement between the death files was very good (kappa = 0.82, p < 0.001). Three hundred seventy-two individuals (69.8% of all deaths) appeared in both files. Of those deaths missing in the VA files, 63% had no service-connected disability or VA pension or other compensation. CONCLUSIONS: The VA death files are a valid source of vital status information for veterans hospitalized in recent years. For veterans having exclusively outpatient visits, however, the VA files miss a substantial proportion of deaths. For these patients, alternative means of vital status ascertainment are warranted.

Aged↗
PubMed2001

The evaluation of a precordial ECG BELT: technologist satisfaction and accuracy of recording.

The standard method for performing electrocardiogram (ECG) recordings presents a challenge to technicians because of the need to correctly position the individual precordial electrodes according to 6 bony thoracic landmarks. A proposed new method using a 6-lead ECG BELT for precordial application was compared to the standard method to determine the level of agreement among automated interpretations. A comparison of automated interpretations from repeat standard recordings served as the control. Results indicate that BELT and standard automated interpretations disagreed significantly more frequently than repeat standard recording automated interpretations of the cardiac rhythm. The BELT's most obvious weakness was the inability to obtain a recording with a stable ECG baseline, triggering automated detection of "baseline artifact or wander," and requiring a repeat recording. These findings suggest that the ECG BELT is not adequate for clinical application in its current form.

Electrocardiography↗
PubMed2001

Validation of advanced ECG diagnostic software for the detection of prior myocardial infarction by using nuclear cardiac imaging.

The investigators report the diagnostic performance of the latest version (Version 2.5) of the recently developed Cardiovise algorithm for detecting prior myocardial infarction (MI). The Cardiovise 2.5 prior MI algorithm, a component of Cardiovise Cardiac Diagnostic System (Inovise Medical, Inc, Newberg, OR), uses scalar QRS, scalar T wave, and vectorcardiographic QRS criteria for detecting, sizing, and localizing prior MI. In this study only the detection part of the algorithm's performance was evaluated, using 105 patients with and 98 patients without prior MI as indicated by the results of cardiac imaging with Sestamibi. The specificity, and sensitivity of Cardiovise 2.5 for detecting prior MI in this population of patients are 97% and 79%, respectively. The sensitivity and overall diagnostic performance of Cardiovise 2.5 was significantly better than those of a total of 6 human readers (3 cardiologists and 3 primary care physicians) and to 2 commercially available ECG diagnostic algorithms.

Algorithms↗
PubMed2001

Unstable angina in the myocardial infarction triage and intervention registry (MITI): short- and long-term outcomes in men and women.

BACKGROUND: Studies of unstable angina have focused on hospital mortality; long-term mortality studies have been limited by small numbers of patients or health care providers. The objectives of this study were to determine whether men and women with unstable angina had different presentations, mortality rates, and procedure utilization. METHODS: We analyzed a prospective observational registry of 4305 men (60%) and 2847 women (40%) with unstable angina who were admitted to coronary care units in King County, Washington, between 1988 and 1994. We compared the rates of symptoms, survival, and procedure utilization between sexes after adjustment for age, race, insurance status, and medical history. RESULTS: Women were older and had higher rates of hypertension and congestive heart failure than men but had lower rates of cigarette smoking, previous myocardial infarction, and previous procedure use (P <.0001). Women had significantly higher rates of dyspnea, nausea, and epigastric pain and less diaphoresis than men did (P <.0001). Women underwent fewer procedures, but after adjustment for age and medical history this difference was no longer significant except for coronary bypass grafting (odds ratio 0.50, 95% confidence interval [CI] 0.37-0.69); after index hospitalization, men and women underwent procedures at similar rates. Although women had higher rehospitalization rates than men, early mortality (odds ratio 0.89, 95% CI 0.55-1.4) and late mortality (hazard ratio 0.98, 95% CI 0.95-1.0) were similar between men and women after adjustment for age. CONCLUSIONS: Women and men with unstable angina have different risk factors and symptoms upon presentation but have similar procedure use and mortality rates.

Aged↗
PubMed2001

Racial differences in outcomes of veterans undergoing percutaneous coronary interventions.

BACKGROUND: In the era of stenting relatively little is known about racial differences in the outcomes of percutaneous interventions (PCI). The purpose of this study was to determine whether there were racial differences with respect to short- and long-term outcomes in veterans undergoing PCI. METHODS: We used the national Department of Veterans Affairs (VA) patient treatment file to identify 24,625 African American and white veterans who had PCI in VA medical centers between October 1, 1994, and September 30, 1999. Baseline demographic characteristics were obtained, as was a measure of comorbidity. Short-term outcomes included hospital mortality and same-admission coronary artery bypass surgery, and long-term outcomes were vital status and rehospitalization. Multivariate statistical methods were used to adjust for patient differences when comparing both short- and long-term outcomes for African American and white veterans. RESULTS: African Americans were 11% of veterans, and in comparison with their white counterparts had more hypertension, diabetes, and acute myocardial infarction. African Americans less often underwent stenting (44% vs 49%), although hospital mortality (2.0% vs 1.9%) and same-admission bypass surgery (1.9% vs 2.2%) rates were similar. Two-year survival was 89% in African Americans and 91% in white veterans (P =.0014), and after adjustment for covariates African Americans had slightly higher mortality rates (hazard ratio 1.11, 95% confidence interval 1.05-1.17). At 2 years almost 61% of both African American and white veterans were rehospitalized for any reason. CONCLUSION: Short- and long-term outcomes for African American and white veterans undergoing PCI in VA medical centers were similar, although African Americans underwent stenting less often.

Black or African American↗
PubMed2001

Improved outcomes associated with stenting in the healthcare cost and utilization project.

Recent results from Medicare indicated that both hospital mortality and the use of same admission coronary artery bypass graft (CABG) surgery were lower in patients receiving stents, and that stenting did not alter the finding of improved outcomes at high volume centers. The purpose of this report is to compare outcomes in a national sample of patients of all ages receiving stents with those undergoing conventional balloon angioplasty. A second purpose is to evaluate the volume outcome hypothesis. This study included 100,318 angioplasties from 191 hospitals in 19 states; 43,966 (44%) involved stent placement. The major outcomes of interest were same admission hospital death and same admission CABG surgery. In comparison to patients with conventional angioplasty, patients receiving stents were younger, less often female and nonwhite, and had less diabetes and hypertension. In the group without infarction, hospital mortality was lower in the stent group (0.7% vs 0.9%, P = 0.01), as was the use of same admission bypass surgery (1.4% vs 2.7%, P < 0.0001). The same pattern was true for myocardial infarction; hospital mortality (2.7% vs 4.2%, P < 0.0001) and bypass surgery rates (1.6% vs 5.3%, P < 0.0001) were lower in the stent group. These results persisted after adjustment for important predictors of outcome. In general, outcomes were better in high volume centers, although in the stent group, there was no clear relationship between volume and outcome. These results support earlier findings that hospital mortality and particularly same admission surgery rates are lower with stenting. Although the volume outcome association for stenting was less clear in this study than in Medicare, these results do not mean that the fundamental volume outcome relationship has been changed by stenting.

Aged↗
PubMed2001

The relationship between alcohol screening questionnaires and mortality among male veteran outpatients.

OBJECTIVE: This study evaluated whether responses to alcohol screening questionnaires predicted mortality in a Department of Veterans Affairs (VA) primary care population. METHOD: This study involved 5,703 male outpatients (mean age = 64) who were enrolled in General Internal Medicine clinics at three Veterans Affairs (VA) medical centers and returned mailed questionnaires in 1993-94. The two questionnaires included the CAGE and Alcohol Use Disorders Identification Test (AUDIT) alcohol screening tests. Mortality was ascertained using the VA Beneficiary Identification and Record Locator System. Five-year crude and adjusted mortality rates were calculated for patients who screened positive and patients who screened negative on each alcohol screening test. RESULTS: The risk of mortality was increased among drinkers who scored > or = 8 on the full AUDIT (hazard ratio: 1.47; 95% confidence interval [CI]: 1.08-2.00) or the three AUDIT consumption questions (1.58; 1.11-2.27), after adjusting for age, smoking, sociodemographic characteristics and chronic illnesses. The risk of mortality was also increased among drinkers who reported drinking > or = 3 drinks daily (1.69; 1.28-2.22) or prior alcohol treatment (1.66; 1.27-2.17), in "fully adjusted" models. A positive CAGE score (> or = 2) was associated with significantly increased risk of mortality among drinkers in a model adjusted only for age and smoking (1.27; 1.02-1.58). Among nondrinkers, neither a positive CAGE score (> or = 2) nor report of prior alcohol treatment was associated with increased risk of mortality. CONCLUSIONS: VA outpatients who reported drinking during the previous year and who had a positive result on an alcohol screening test experienced higher mortality over the subsequent 5 years than did patients who screened negative.

Aged↗
PubMed2001

Effects of compensation method on physician behaviors.

OBJECTIVE: To examine physician and leader perceptions of the relationship between physician compensation and the productivity of physicians practicing in medical groups. STUDY DESIGN: Key informant interviews identified subjects' perceptions of factors influencing physician productivity and the behavioral effects of individual financial incentives. Interview transcripts were analyzed by a team of physicians, economists, and other researchers. STUDY POPULATION: Physicians, medical leaders, and group practice administrators (n = 114) representing 46 medical group practices in California, Oregon, Washington, and Wisconsin were interviewed. RESULTS: Five major themes emerged: (1) Most physicians reported that financial incentives did not substantially affect their own behavior, except for productivity. However, they suggested that specific compensation models do lead to certain seemingly undesirable physician behaviors. (2) By contrast, medical group leaders reported that financial incentives do affect a variety of physician behaviors. (3) Four productivity drivers emerged: financial incentives, demand-side factors, systems and infrastructure, and other individual or group attributes. (4) Physician compensation systems are evolving toward a blend of production-based and production-neutral incentives, plus new metrics aligned with the demands of managed care. (5) Culture, size, and specialty mix are significant determinants of group physician compensation systems. CONCLUSIONS: Compensation method is perceived to be a significant influence on physician productivity, particularly among group practice leaders. The changing context of medical practice represents another powerful "macro" lever on physician behavior.

Attitude of Health Personnel↗
PubMed2001

[The late referral of diabetic patients with kidney insufficiency to nephrologists has a high human and financial cost: interdisciplinary communication is urgently needed].

The "late referral to nephrologist" (LRN) phenomenon has been described recently, first in Europe and subsequently in every country where dialysis and transplantation are offered without restriction. Definition of LRN is based on an arbitrary date of referral which is three months before the first dialysis session. LRN patients suffer much more morbidities and consequently more hospitalizations, particularly in intensive care units. They have less access to home and self dialysis, to peritoneal dialysis and to renal transplantation than their "on time" referred counterparts. Even if mortality is more important in late referred patients, the additional cost of LRN phenomenon is substantial; it has been evaluated from 16 800 to 30 500 euros for the first year of treatment. Every kind of patients are concerned, including diabetics. Explanation of the LRN phenomenon is complex and needs a multidisciplinary approach.

Costs and Cost Analysis↗
PubMed2000

Outcomes of coronary angioplasty procedures performed in rural hospitals.

PURPOSE: To determine how many rural hospitals in the United States performed coronary angioplasty; to compare patient outcomes in rural and urban hospitals; and to assess whether outcomes were better in rural hospitals in which more procedures were performed. SUBJECTS AND METHODS: In 1996, among patients 65 years of age and older, 201,869 coronary angioplasties were performed in 996 hospitals that were included in the Medicare Provider Analysis and Review files. Geographic location was defined as rural or urban, according to U.S. Census Bureau criteria. Outcome variables were in-hospital death and coronary artery bypass surgery performed during the same admission. Hospital volumes were categorized as low (< or = 100 cases or fewer per year), medium (101 to 200 cases per year), or high (> 200 cases per year). RESULTS: Fifty-one rural hospitals accounted for 4% of all angioplasties performed. After angioplasty, in-hospital mortality was greater in rural hospitals (8.1% versus 6.4%, P = 0.001) among patients with acute myocardial infarction, but was not different for patients without infarction (1.4% versus 1.3%, P = 0.41). Coronary artery bypass surgery rates during the same admission were similar in rural and urban hospitals. In general, in-hospital mortality and same-admission surgery rates were lower in high-volume centers in both rural and urban areas. CONCLUSION: Although in-hospital mortality after angioplasty for acute myocardial infarction was worse in low- and medium-volume rural centers, overall outcomes in rural and urban hospitals were similar.

Aged↗