Jason N. Katz

Evolution of the coronary care unit: clinical characteristics and temporal trends in healthcare delivery and outcomes.

Objective: To describe long-term temporal trends in patient characteristics, processes of care, and in-hospital outcomes among unselected admissions within the contemporary coronary care unit. Design: Hospital administrative database that records both payment and operation data. Setting: Coronary care unit of a large, academic, tertiary-care medical institution. Patients: A total of 29,275 patients admitted from January 1, 1989 through December 31, 2006. Interventions: Unadjusted time-trend plots were created for all variables of interest, and multivariable modeling of coronary care unit death was performed. Measurements and Main Results: Temporal trends in Coronary Care Unit and in-hospital mortality, length-of-stay, demographic characteristics, discharge diagnoses, Coronary Care Unit procedures, and Charlson comorbidity scores were evaluated. Admission severity increased significantly over time (p < .001), but hospital length-of-stay decreased (p < .001). The proportion of coronary care unit admissions with non-ST-segment elevation myocardial infarction increased (p < .001), whereas ST-segment elevation myocardial infarction decreased (p < .001). The prevalence of non-cardiovascular diagnoses increased, with the rate greatest for comorbid critical illnesses, including sepsis, acute kidney injury, and respiratory failure (all p < .001). The use of non-cardiac procedures, such as mechanical ventilation and central venous catheterization, also increased over time (p < .001). Unadjusted coronary care unit and in-hospital mortality did not change during the study period, although death did decrease in the adjusted setting. Conclusions: Substantial changes have occurred over time in patient characteristics, diagnoses, and procedures within the coronary care unit of a large, academic medical center. In particular, there have been significant increases in noncardiovascular critical illness, the results of which may be influencing patient outcomes. These findings underscore an existing need to clarify the role of the coronary care unit in contemporary cardiovascular care and to develop strategies for optimal training, staffing, and clinical investigation.

Practice patterns, outcomes, and end-organ dysfunction for patients with acute severe hypertension: The Studying the Treatment of Acute hyperTension (STAT) Registry

BACKGROUNDnLimited data are available on the care of patients with acute severe hypertension requiring hospitalization. We characterized contemporary practice patterns and outcomes for this population.nnnMETHODSnSTAT is a 25-institution, US registry of consecutive patients with acute severe hypertension (>180 mm Hg systolic and/or >110 mm Hg diastolic; >140 and/or >90 for subarachnoid hemorrhage) treated with intravenous therapy in a critical care setting.nnnRESULTSnOne thousand five hundred eighty-eight patients were enrolled (January 2007 to April 2008). Median age was 58 years (interquartile range 49-70 years), 779 (49%) were women, and 892 (56%) were African American; 27% (n = 425) had a prior admission for acute hypertension and 486 (31%) had chronic kidney disease. Median qualifying blood pressure (BP) was 200 (186, 220) systolic and 110 (93, 123) mm Hg diastolic. Initial intravenous antihypertensive therapies used to control BP varied, with 1,009 (64%) patients requiring multiple drugs. Median time to achieve a systolic BP <160 mm Hg (<140 mm Hg for subarachnoid hemorrhage) was 4.0 (0.8, 12) hours; 893 (60%) had reelevation to >180 (>140 for subarachnoid hemorrhage) after initial control; and 63 (4.0%) developed iatrogenic hypotension. Hospital mortality was 6.9% (n = 109) with an aggregate 90-day mortality rate of 11% (174/1,588); 59% (n = 943) had acute/worsening end-organ dysfunction during hospitalization. The 90-day readmission rate was 37% (523/1,415), of which one quarter (132/523) was due to recurrent acute severe hypertension.nnnCONCLUSIONnThis study highlights heterogeneity in care, BP control, and outcomes of patients hospitalized with acute severe hypertension.

Alarm/investigation responses of hermit crabs as related to shell fit and crab size

Hermit crabs may acquire shells by trading with other crabs or at predation events that make new shells available. Predation events are located chemically through odors associated with the death of gastropods and the death of conspecifics. Crabs respond identically to either source of cues. Here we report that hermit crabs, Clibanarius vittatus from the field respond in one of three distinct ways to chemicals from gastropod flesh and from conspecific hemolymph: (1) crabs do not respond (23%), (2) crabs flee (40%), and (3) crabs investigate neighboring shells (37%). Changing the size of the shell can cause crabs to change behavior. Altering shell size by clipping down shells resulted in high (approx. 80%) response by investigation. Crabs given a free choice of unoccupied shells fled (86%) in response to chemical stimulation. In a series of experiments small crabs were tested for chemically‐stimulated behavior and then given access to excess empty shells. Chemically‐stimulated behavior was assessed after 24...

Response to Letter Regarding Article, “Acute Kidney Injury and Cardiovascular Outcomes in Acute Severe Hypertension”

We thank Dr Lin and colleagues for their questions regarding the analysis from the Studying the Treatment of Acute Hypertension Registry (STAT) registry exploring the relationship between both acute and chronic kidney disease in patients with acute hypertension.1 There are two different aspects of their questions that can be addressed. First, on the mathematical or statistical level, Lin et al suggest different ways in which the data can be analyzed. The inclusion of various parameters of blood pressure (including mean arterial pressure) as well as the analysis of change in kidney function using different methods were conducted within STAT. The results and conclusions were not significantly different from those presented in the published article, so they were not included owing to space constraints.nnMore importantly, though, Lin et al emphasize that these data are counterintuitive to what would be expected based on studies that have been conducted in …

Eosinophilic lung disease associated with non-Hodgkin lymphoma: A case report and review of the literature

Eosinophilic lung diseases have many causes but are not often the result of neoplastic disease. We describe a patient with subacute dyspnea due to eosinophilic lung disease who also had a peripheral T-cell lymphoma. The diagnosis was made by imaging and transbronchial biopsies of the lungs along with an excisional biopsy of a palpable epitrochlear lymph node. There is a rare association between eosinophilic pneumonias and non-Hodgkin lymphomas. This is the third known case of a peripheral T-cell lymphoma associated with eosinophilic lung disease. This report highlights the association, discusses theorized mechanisms involved, and emphasizes the importance of searching for underlying etiologies for eosinophilic lung disease.