Search

Background  Tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) increases morbidity and mortality, especially in case of a poor right ventricle. Does repair of mild-to-moderate insufficiency of the tricuspid valve (TV) in patients undergoing MV surgery lead to a benefit in early postoperative outcome? Methods  A total of 22 patients with mild-to-moderate TR underwent MV repair and concomitant TV repair with Tri-Ad (Medtronic ATS Medical Inc., Minneapolis, Minnesota, United States) and Edwards Cosgrove (Edwards Lifesciences Irvine, California, United States) rings. The severity of TR was assessed echocardiographically by using color-Doppler flow images. The tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm. Additional procedures included coronary artery bypass ( n  = 9) and maze procedure ( n  = 15). The following parameters were compared: postoperative and peak dose of noradrenaline (NA), pre/postoperative systolic pulmonary pressure (sPAP), extubation time, operation time, cross-clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), intensive care unit (ICU)-stay, hospital stay, cell saver blood transfusion, intra/postoperative blood transfusion, and postoperative TR. Results  The mean age was 67 ± 14.8 years, 45% were male. Mean EF was 47 ± 16.2%, postoperative 52 ± 12.4%. sPAP was 46 ± 20.1 mm Hg preoperatively, sPAP was 40.6 ± 9.4 mm Hg postoperatively, NA postoperatively was 12 ± 10 μg/min, NA peak was 18 ± 11 μg/min, operation time was 275 ± 92 minutes, CPB was 145 ± 49 minutes, ICU stay was 2.4 ± 2.4 days, hospital stay was 10.8 ± 3.5 days, cell saver blood transfusion was 736 ± 346 mL, intraoperative transfusions were 2.5 ± 1.6. Two patients needed postoperative transfusions. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 at the 4th postoperative day. Two patients required a pacemaker. No reintubation, no in-hospital mortality, and one reoperation because of bleeding complications. Conclusion  Correction of mild-to-moderate TR at the time of MV repair does maintain TV function and avoid right ventricular dysfunction in the early postoperative period improving the clinical outcome., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Telephone delivery of genetic counseling is an alternative to in-person genetic counseling because it may extend the reach of genetic counseling. Previous reports have established the noninferiority of telephone counseling on short-term psychosocial and decision-making outcomes. Here we examine the long-term impact of telephone counseling (TC) vs in-person counseling (usual care [UC])., Methods: We recruited high-risk women for a noninferiority trial comparing TC with UC. Of 1057 potentially eligible women, 669 were randomly assigned to TC (n = 335) or UC (n = 334), and 512 completed the 12-month follow-up. Primary outcomes were patient-reported satisfaction with genetic testing decision, distress, and quality of life. Secondary outcomes were uptake of cancer risk management strategies., Results: TC was noninferior to UC on all primary outcomes. Satisfaction with decision ( d =  0.13, lower bound of 97.5% confidence interval [CI] = -0.34) did not cross its one-point noninferiority limit, cancer-specific distress ( d =  -2.10, upper bound of 97.5% CI = -0.07) did not cross its four-point noninferiority limit, and genetic testing distress ( d =  -0.27, upper bound of 97.5% CI = 1.46), physical function ( d =  0.44, lower bound of 97.5% CI = -0.91) and mental function ( d =  -0.04, lower bound of 97.5% CI = -1.44) did not cross their 2.5-point noninferiority limit. Bivariate analyses showed no differences in risk-reducing mastectomy or oophorectomy across groups; however, when combined, TC had significantly more risk-reducing surgeries than UC (17.8% vs 10.5%; χ 2 = 4.43, P =  .04)., Conclusions: Findings support telephone delivery of genetic counseling to extend the accessibility of this service without long-term adverse outcomes.

Background: Sonoclot is used to measure kaolin-based activated clotting time (kACT) for heparin management. Apart from measuring kACT, the device assesses the patient's coagulation status by glass bead-activated tests (gbACTs; measuring also clot rate [CR] and platelet function [PF]). Recently, a new version of the Sonoclot has been released, and the redesign may result in performance changes. The aim of this study was to evaluate and compare the performance of the new (S2) and the previous (S1) Sonoclot., Methods: The S1 was used in the routine management of 30 patients undergoing elective cardiac surgery. Blood samples were taken at baseline (T1), after heparin administration (200 U/kg, 100 U/kg; T2 and T3), during cardiopulmonary bypass (T4), after protamine infusion (T5), and before intensive care unit transfer (T6). Kaolin-based activated clotting time and gbACTs were measured in duplicate by both the old and the new device and performance compared by Bland-Altman analysis and percentage error calculation., Results: A total of 300 kACT and 180 gbACTs were available. Bland-Altman analysis for kACT revealed that S2 consistently reported results in shorter time compared to S1 (overall = -14.7%). Comparing S2 and S1, the glass bead-activated tests showed mean percentage differences of -18.9% (gbACTs), +37.4% (CR), and -3.7% (PF)., Conclusion: Since clotting is faster in the new S2 compared to S1, shorter clotting times have to be considered in clinical practice. The use of S2 kACT in heparin management will result in higher heparin and protamine dosing unless heparin kACT target values are adjusted to correct for the differences in results between S1 and S2., (© The Author(s) 2016.)

We describe the first case of a pregnant woman presenting with an acute inverted takotsubo-like cardiomyopathy caused by a postpartum diagnosed hemorrhagic pheochromocytoma, successfully treated with percutaneous venoarterial extracorporeal membrane oxygenation (va-ECMO). During admission, an emergency cesarean delivery had to be performed. The fetus needed resuscitation for 5 minutes. The mother was successfully resuscitated and treated with percutaneous va-ECMO for 7 days. Despite advances in diagnostic techniques during the past decade, in many cases, pheochromocytoma in pregnancy is still missed. This results in a maternal and fetal mortality rate of up to 30% in both.

Objective: We know that human vision has limitations, medication administration is a high-risk activity, and some nurses work in environments that do not meet recommended lighting standards. The goal of this study was to inform safe medication administration practices and add evidence for establishing guidelines for lighting decisions by understanding registered nurses' (RNs') decision making about lighting during medication administration., Methods: Grounded theory methodology was followed (n = 16). Theoretical sampling was used to ensure that participants represented a variety of backgrounds and hospital settings. Results were validated by three expert researchers. Two of the researchers had significant expertise in medication administration errors., Results: Data analysis culminated in the substantive theory It Depends. This theory describes a process of frequently automatic decision making about lighting, whose aspects include assessing variation, balancing safety and healing, and RN bias. All RNs expressed concerns about perceived risks in relation to lighting, but had difficulty describing how they confirmed when the correct decision about lighting was made., Conclusions: Nurses are often unaware of their reasons for lighting decisions, and there is a need for education and other measures to increase the likelihood that lighting decisions that enhance patient safety are made by nurses., (© 2014 Wiley Periodicals, Inc.)

Validating participants' ability to correctly perform cardiopulmonary resuscitation (CPR) skills during basic life support courses can be a challenge for nursing professional development specialists. This study compares two methods of basic life support training, instructor-led and computer-based learning with voice-activated manikins, to identify if one method is more effective for performance of CPR skills. The findings suggest that a computer-based learning course with voice-activated manikins is a more effective method of training for improved CPR performance.

Purpose: As genetic counseling and testing become more fully integrated into clinical care, alternative delivery models are increasingly prominent. This study examines predictors of genetic testing for hereditary breast/ovarian cancer among high-risk women in a randomized trial of in-person versus telephone-based genetic counseling., Methods: Methods include multivariable logistic regression and interaction analyses., Results: Of the 669 participants, 600 completed counseling and 523 received test results. As previously reported, participants randomized to telephone counseling were significantly less likely to be tested. In intention-to-treat analyses, completion of counseling and testing was associated with: race/ethnicity (odds ratio (OR) = 1.96, 95% confidence interval (CI): 1.20-3.20), perceived stress (OR = 0.89, 95% CI: 0.81-0.98), knowledge (OR = 1.12, 95% CI: 1.02-1.23), and randomization group (OR = 1.48, 95% CI: 1.01-2.16). Further, race/ethnicity moderated the association between randomization group and testing; minority women receiving telephone counseling were least likely to complete testing., Conclusion: Evidence for logistical and communication-based explanations for this interaction is presented. The overall increased access made possible with telephone genetic counseling should be considered in light of the possibility that this may also lead to lower rates of testing among high-risk minority women. Additional care should be taken to assess and address potential barriers when services are delivered by telephone.Genet Med 17 6, 467-475.

Background: Research exists on strategies for successful conduct of community-based participatory research (CBPR). Unfortunately, few published resources are available to advise community-based organizations (CBOs) on preparation for and engagement in CBPR., Objectives: We aimed to create a resource for CBOs that describes how an organization can prepare for and participate in CBPR., Methods: We used a case study approach of one CBO with a decade-long history of collaboration with academic researchers. We identified lessons learned through a retrospective review of organizational records and the documentation of experiences by CBO leadership and research partners. The findings were then labeled according to CBPR Partnership Readiness Model dimensions., Lessons Learned: The review of CBO documents and key informant interviews yielded ten practical tips to increase organizational readiness for and engagement in CBPR., Conclusions: By understanding the best practices for organizational readiness for and participation in CPBR, CBOs will be better equipped to actively participate in community-academic partnerships.

Problem: Georgetown University School of Medicine (GUSOM) offers medical students a course in mind-body medicine (MBM) that introduces them to tools that reduce stress and foster self-awareness. Previous studies reported decreases in students' perceived stress and increases in mindfulness-changes that were associated with increased empathic concern and other elements of professional identity formation. However, no reports have described the impact of an MBM course on the facilitators themselves., Approach: To explore whether MBM facilitation is associated with changes in professional identity, self-awareness, and/or perceived stress, 62 facilitators, trained by the GUSOM MBM program, were invited to complete two validated surveys: the Freiburg Mindfulness Inventory (FMI) and the Perceived Stress Scale (PSS). Forty-two participants also completed a six-item open-ended questionnaire addressing their experience in the context of their professional identity., Outcomes: Facilitators' scores were significantly lower on PSS and higher on FMI compared with normative controls (P < .05), and the two parameters were inversely correlated (-0.46, P < .01). Qualitative analysis revealed three main themes: (1) aspects of professional identity (with subthemes of communication; connections and community; empathy and active listening; and self-confidence); (2) self-care; and (3) mindful awareness., Next Steps: Preliminary findings will be extended with larger studies that examine longitudinal quantitative assessment of communication, connection, and self-confidence outcomes in MBM facilitators, and the impact of MBM facilitation on burnout and resilience.

Objectives: The aim of the study was to determine if Sonoclot with its sensitive glass bead-activated, viscoelastic test can predict postoperative bleeding in patients undergoing cardiac surgery at predefined time points., Design: A prospective, observational clinical study., Setting: A teaching hospital, single center., Participants: Consecutive patients undergoing cardiac surgery (N = 300)., Interventions: Besides routine laboratory coagulation studies and heparin management with standard (kaolin) activated clotting time, additional native blood samples were analyzed on a Sonoclot using glass bead-activated tests. Glass bead-activated clotting time, clot rate, and platelet function were recorded immediately before anesthesia induction and at the end of surgery after heparin reversal but before chest closure., Measurements and Main Results: Primary outcome was postoperative blood loss (chest tube drainage at 4, 8, and 12 hours postoperatively). Secondary outcome parameters were transfusion requirements, need for surgical re-exploration, time of mechanical ventilation, length of intensive care unit and hospital stay, and hospital morbidity and mortality. Patients were categorized into "bleeders" and "nonbleeders." Patient characteristics, operations, preoperative standard laboratory parameters, and procedural times were comparable between bleeders and nonbleeders except for sex and age. Bleeders had higher rates of transfusions, surgical re-explorations, and complications. Only glass bead measurements by Sonoclot after heparin reversal before chest closure but not preoperatively were predictive for increased postoperative bleeding., Conclusions: Sonoclot with its glass bead-activated tests may predict the risk for postoperative bleeding in patients undergoing cardiac surgery at the end of surgery after heparin reversal but before chest closure., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Genetic testing for breast and ovarian cancer susceptibility is now part of routine clinical practice. Although rates of risk-reducing surgery following genetic testing have been increasing, little is known about attitudes toward risk-reducing surgery in women prior to genetic counseling and testing. This study examines correlates of patient intentions to undergo risk-reducing mastectomy (RRM) and risk-reducing oophorectomy (RRO)., Methods: Participants were 696 women, ages 21-85, who sought breast cancer gene 1 and 2 (BRCA1/2) genetic counseling and had at least a 10% risk of carrying a mutation. The sample included women who were affected with breast or ovarian cancer and unaffected women with a known familial BRCA1/2 mutation. Participants completed a precounseling telephone questionnaire., Results: Prior to receiving genetic counseling, 23.3% of participants were considering RRM and 42.5% were considering RRO. Variables that were independently associated with RRM intentions were cancer-specific distress (OR = 1.14, 95% CI = 1.03-1.26), perceived risk of breast cancer (OR = 1.16, 95% CI = 1.05-1.28), education (OR = 1.76, 95% CI = 1.03-2.99), and age (OR = 0.96, 95% CI = 0.95-0.98). Predictors of RRO intentions were perceived risk for ovarian cancer (OR = 1.25, 95% CI = 1.14-1.37), perceived risk of carrying a BRCA1/2 mutation (OR = 1.74, 95% CI = 1.15-2.62), marital status (OR = 1.92, 95% CI = 1.34-2.76), and age (OR = 1.02, 95% CI = 1.00-1.03)., Conclusions: Because precounseling intentions predict subsequent risk-reducing surgery decisions, this study identified patient factors associated with surgical intentions. These factors reinforce the critical role for pretest genetic counseling in communicating accurate risk estimates and management options, and addressing psychosocial concerns, to facilitate informed decision making regarding RRM and RRO., (Copyright © 2014 John Wiley & Sons, Ltd.)

A literature review was conducted to determine the state of the science related to medication errors and light. The limited literature is discussed in relationship to human vision and light needs. Little systematic action has been taken to increase nurses' awareness of the connection between lighting and potential medication errors. Implications for nursing practice and research about light conditions are provided. Interventions from other industries may aid nursing in making decisions about light conditions.

Background: As BRCA1/2 testing becomes more routine, questions remain about long-term satisfaction and quality of life following testing. Previously, we described long term distress and risk management outcomes among women with BRCA1/2 mutations. This study addresses positive psychological outcomes in BRCA1/2 carriers, describing decision satisfaction and quality of life in the years following testing., Methods: We evaluated satisfaction with testing and management decisions among 144 BRCA1/2 carriers. Prior to genetic testing, we assessed family history, sociodemographics and distress. At a mean of 5.3 years post-testing, we assessed management decisions, satisfaction with decisions and, among women with cancer, quality of life., Results: Overall, satisfaction with decision making was high. Women who had risk reducing mastectomy or oophorectomy were more satisfied with management decisions. Participants who obtained a risk reducing oophorectomy were more satisfied with their genetic testing decision. Among affected carriers, high pretest anxiety was associated with poorer quality of life and having had risk reducing mastectomy prior to testing was associated with better quality of life. The negative impact of pre-test anxiety was diminished among women who had mastectomies before testing., Conclusions: BRCA1/2 carriers are satisfied with their testing and risk management decisions and report good quality of life years after testing. Having risk reducing surgery predicts increased satisfaction and improved quality of life.

Background: Latinas with breast cancer suffer symptom and psychosocial health disparities. Effective interventions have not been developed for or tested in this population., Purpose: We describe community-based participatory research methods used to develop and implement the Nuevo Amanecer program, a culturally tailored, peer-delivered cognitive-behavioral stress management intervention for low-income Spanish-speaking Latinas with breast cancer, and unique considerations in implementing a randomized controlled trial to test the program in community settings., Methods: We applied an implementation science framework to delineate the methodological phases used to develop and implement the Nuevo Amanecer program and trial, emphasizing community engagement processes., Results: In phase 1, we established project infrastructure: academic and community co-principal investigators, community partners, community advisory board, steering committee, and funding. In phase 2, we identified three program inputs: formative research, a community best-practices model, and an evidence-based intervention tested in non-Latinas. In phase 3, we created the new program by integrating and adapting intervention components from the three sources, making adaptations to accommodate low literacy, Spanish language, cultural factors, community context, and population needs. In phase 4, we built community capacity for the program and trial by training field staff (recruiters and interventionists embedded in community sites), compensating field staff, and creating a system for identifying potential participants. In phase 5, we implemented and monitored the program and trial. Engaging community partners in all phases has resulted in a new, culturally tailored program that is suitable for newly diagnosed Latinas with breast cancer and a trial that is acceptable and supported by community and clinical partners. Lessons learned Engagement of community-based organizations and cancer survivors as research partners and hiring recruiters and interventionists from the community were critical to successful implementation in community settings. Having culturally and linguistically competent research staff with excellent interpersonal skills facilitated implementation. Facilitating and maintaining excellent communication among community partners was imperative to troubleshoot implementation issues. Randomization was challenging due to community concerns about assigning women to a control group. Patient privacy regulations and the need for extensive outreach to establish relationships between community partners and clinical sites hampered initial recruitment., Limitations: These were resource-intensive processes to develop and implement the program that need to be compared to less-intensive alternatives., Conclusion: Engaging community members in design and implementation of community-based programs and trials enhances cultural appropriateness and congruence with the community context. If the randomized trial demonstrates that the intervention is effective, it will fill a gap in evidence-based programs to address ethnic disparities in quality of life among Spanish-speaking Latinas with breast cancer.

Purpose: Although guidelines recommend in-person counseling before BRCA1/BRCA2 gene testing, genetic counseling is increasingly offered by telephone. As genomic testing becomes more common, evaluating alternative delivery approaches becomes increasingly salient. We tested whether telephone delivery of BRCA1/2 genetic counseling was noninferior to in-person delivery., Patients and Methods: Participants (women age 21 to 85 years who did not have newly diagnosed or metastatic cancer and lived within a study site catchment area) were randomly assigned to usual care (UC; n = 334) or telephone counseling (TC; n = 335). UC participants received in-person pre- and post-test counseling; TC participants completed all counseling by telephone. Primary outcomes were knowledge, satisfaction, decision conflict, distress, and quality of life; secondary outcomes were equivalence of BRCA1/2 test uptake and costs of delivering TC versus UC., Results: TC was noninferior to UC on all primary outcomes. At 2 weeks after pretest counseling, knowledge (d = 0.03; lower bound of 97.5% CI, -0.61), perceived stress (d = -0.12; upper bound of 97.5% CI, 0.21), and satisfaction (d = -0.16; lower bound of 97.5% CI, -0.70) had group differences and confidence intervals that did not cross their 1-point noninferiority limits. Decision conflict (d = 1.1; upper bound of 97.5% CI, 3.3) and cancer distress (d = -1.6; upper bound of 97.5% CI, 0.27) did not cross their 4-point noninferiority limit. Results were comparable at 3 months. TC was not equivalent to UC on BRCA1/2 test uptake (UC, 90.1%; TC, 84.2%). TC yielded cost savings of $114 per patient., Conclusion: Genetic counseling can be effectively and efficiently delivered via telephone to increase access and decrease costs.

This study examined ethnic differences in adolescent nonfatal suicidal behaviors as well as age and gender variation both across and within ethnic groups. Using a large (n = 14, 346) sample of adolescents in Grades 7 through 12, African Americans reported relatively high rates of suicidal thoughts and attempts and Southeast Asians reported high rates of suicidal thoughts. Hispanic Americans, European Americans, and Asian Americans were similar in their reports of nonfatal suicidal behaviors. Gender differences also varied across ethnicity as Southeast Asian boys (particularly older boys) reported more suicidal thoughts and attempts than Southeast Asian girls.

Hypnobirthing is often regarded as a method of pain relief without drugs. This is to miss the point, as it presupposes that pain is there in the first place. When a woman learns to release the preconceptions, fears and worries about birth that are endemic in our society, her experience of giving birth to her baby can be the most wonderful and empowering experience of her life. Mind and body working together can be a powerful and efficient combination. This is how birth is designed to be, as midwives and hospitals are beginning to discover. Thus hypnobirthing can provide a service that women want as well as save scarce NHS funds.

Inflammatory bowel diseases (IBDs) are chronic inflammatory disorders of the gastrointestinal tract that affect more than 3 million people worldwide, but the pathological etiology is still unknown. The overall purpose of our investigations was to elucidate the possibility of pathological causes of IBD, and therefore, we determined the difference of inflammatory cytokine profiles in adipose tissue macrophages (ATMs) and T lymphocytes (ATTs) obtained near active lesions of IBD; investigated whether the alteration in ATM activation induces genes involved in collagen formation; and evaluated the effects of fatty acid oxidation inhibitors on factors involved in inflammation and collagen production by ATMs in IBD. Adipose tissues (ATs) were collected near active lesions and also at the margin of resected segments of the bowel from IBD patients with ulcerative colitis (UC) and CD (n=14/group). Normal appearing ATs from control subjects (n=14) who had colon resection for adenocarcinoma were collected as far away from the cancer lesion as possible to rule out possible changes. Compared with inactive disease lesions, ATMs and ATTs from active lesions released more IL-6, IL-4 and IL-13. Treatments of cytokine IL-4 and/or IL-13 to ATMs reduced iNOS expression but increased Arg-I expression which were exacerbated when treated with T cell- and adipocyte-conditioned medium. However, fatty acid oxidation inhibitors prevented the effects of cytokines IL-4 and/or IL-13 on iNOS and Arg-I expressions. This study was the first to show the effect of IL-4 and IL-13 on collagen formation, through iNOS and Arg-I expressions, that was exacerbated in a condition that mimics in vivo condition of active lesions. Moreover, our study was the first to provide potential benefits of fatty acid oxidation inhibitors to ATMs on preventing collagen formation; thus, providing therapeutic implications for individuals with intestinal fibrosis and stricture lesions, although future study should be guaranteed to elucidate the underlying mechanisms., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives: The purpose of this review is to describe the empirical literature on the health-related quality of life (HRQOL) in Latina breast cancer survivors by exploring the social determinants of health. In framing the key domains of survivors' quality of life within a ecological-contextual model that evaluates individual and societal contributions to health outcomes, we provide a comprehensive landscape of the diverse factors constituting Latina survivors' lived experiences and their resultant quality of life outcomes., Methods: We retrieved 244 studies via search engines and reference lists, of which 37 studies met the inclusion criteria., Results: Findings document the importance of the social determinants of HRQOL, with studies documenting ecological and contextual factors accounting for significant variance in HRQOL outcomes. Our review identifies a dearth of research examining community-, institutional-, and policy-level factors, such as health care access, legal and immigration factors, physical and built environments, and health care affordability and policies affecting Latina breast cancer survivors' HRQOL., Conclusions: Overall research on Latina breast cancer survivorship is sparse, with even greater underrepresentation within longitudinal and intervention studies. Results highlight a need for clear documentation of the comprehensive care needs of underserved cancer survivors and interventions considering integrated systems of care to address the medical and ecological factors known to impact the HRQOL of breast cancer survivors., (Copyright © 2011 John Wiley & Sons, Ltd.)

Objectives: The benefit of off-pump coronary artery bypass (OPCAB) surgery may be reduced by strokes caused by microemboli produced after aortic side-clamping for proximal bypass anastomoses. The Heartstring device allows constructing proximal bypass anastomoses without side-clamping of the aorta., Methods: This retrospective study describes 260 consecutive patients who underwent OPCAB surgery; 442 proximal anastomoses were performed with the Heartstring device in this series. Ten percent of the patients were randomly sampled before discharge to undergo a coronary angiogram for assessment of graft patency., Results: Intraoperative Doppler measurements confirmed regular bypass function. Early mortality occurred in 4 patients (1.5%), and stroke occurred in 2 patients (0.8%). Device-related bleeding was negligible, and there were no cases of aortic dissection. Perioperative ischemia occurred in 8 patients (3.1%). Predischarge coronary angiography evaluations in 25 of the patients (of 260) showed that all 42 Heartstring-assisted anastomoses (of 442) were patent., Conclusions: Clampless performance of proximal bypass anastomoses combined with OPCAB is associated with a very low incidence of stroke complications. Short-term follow-up has shown excellent results regarding bypass patency and other adverse events. Prospective randomized trials are required to confirm the advantage of this technique.

Objective: To compare lipid profiles between Mexican American and non-Hispanic white women with polycystic ovary syndrome (PCOS)., Design: Cross-sectional analysis using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines., Setting: University gynecology service., Patient(s): Self-identified Mexican Americans (n = 71) and non-Hispanic whites (n = 120) with PCOS defined by the 2003 European Society of Human Reproduction and Embryology and American Society of Reproductive Medicine consensus., Intervention(s): Serum drawn from fasting state followed by oral glucose tolerance test., Main Outcome Measure(s): Age, body mass index (BMI), androgens, cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, fasting, and minimal model analyses of insulin sensitivity., Result(s): Mexican American women were more insulin resistant than non-Hispanic whites, but cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, and calculated non-HDL cholesterol levels were similar. BMI inversely correlated with HDL cholesterol and positively with triglycerides. Approximately half of both ethnic groups had at least one lipid level in the low (HDL) or high (cholesterol, triglycerides, and LDL cholesterol) range according to National Cholesterol Education Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults guidelines., Conclusion(s): Despite greater insulin resistance among Mexican Americans with PCOS, lipid levels were similar to those of age- and weight-matched non-Hispanic whites. Obesity adversely affected lipid levels-primarily HDL cholesterol and triglycerides-in both groups. The prevalence of dyslipidemia was approximately 50% in each ethnic group., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Aims: Collagen degradation in atherosclerotic plaques with thin fibrous caps renders them more prone to rupture. Fibroblast activation protein (FAP) plays a role in arthritis and tumour formation through its collagenase activity. However, the significance of FAP in thin-cap human fibroatheromata remains unknown., Methods and Results: We detected enhanced FAP expression in type IV-V human aortic atheromata (n = 12), compared with type II-III lesions (n = 9; P < 0.01) and healthy aortae (n = 8; P < 0.01) by immunostaining and western blot analyses. Fibroblast activation protein was also increased in thin-cap (<65 µm) vs. thick-cap (≥ 65 µm) human coronary fibroatheromata (n = 12; P < 0.01). Fibroblast activation protein was expressed by human aortic smooth muscle cells (HASMC) as shown by colocalization on immunofluorescent aortic plaque stainings (n = 10; P < 0.01) and by flow cytometry in cell culture. Although macrophages did not express FAP, macrophage burden in human aortic plaques correlated with FAP expression (n = 12; R(2)= 0.763; P < 0.05). Enzyme-linked immunosorbent assays showed a time- and dose-dependent up-regulation of FAP in response to human tumour necrosis factor α (TNFα) in HASMC (n = 6; P < 0.01). Moreover, supernatants from peripheral blood-derived macrophages induced FAP expression in cultured HASMC (n = 6; P < 0.01), an effect abolished by blocking TNFα (n = 6; P < 0.01). Fibroblast activation protein associated with collagen-poor regions in human coronary fibrous caps and digested type I collagen and gelatin in vitro (n = 6; P < 0.01). Zymography revealed that FAP-mediated collagenase activity was neutralized by an antibody directed against the FAP catalytic domain both in HASMC (n = 6; P < 0.01) and in fibrous caps of atherosclerotic plaques (n = 10; P < 0.01)., Conclusion: Fibroblast activation protein expression in HASMC is induced by macrophage-derived TNFα. Fibroblast activation protein associates with thin-cap human coronary fibroatheromata and contributes to type I collagen breakdown in fibrous caps.

Background: Accidental connection of an enteral system to an intravenous (IV) system frequently results in the death of the patient. Misconnections are commonly attributed to the presence of universal connectors found in the majority of patient care tubing systems. Universal connectors allow for tubing misconnections between physiologically incompatible systems., Methods: The purpose of this review of case studies of tubing misconnections and of current expert recommendations for safe tubing connections was to answer the following questions: In tubing connections that have the potential for misconnections between enteral and IV tubing, what are the threats to safety? What are patient outcomes following misconnections between enteral and IV tubing? What are the current recommendations for preventing misconnections between enteral and IV tubing? Following an extensive literature search and guided by 2 models of threats and errors, the authors analyzed case studies and expert opinions to identify technical, organizational, and human errors; patient-related threats; patient outcomes; and recommendations., Results: A total of 116 case studies were found in 34 publications. Each involved misconnections of tubes carrying feedings, intended for enteral routes, to IV lines. Overwhelmingly, the recommendations were for redesign to eliminate universal connectors and prevent misconnections. Other recommendations were made, but the analysis indicates they would not prevent all misconnections., Conclusions: This review of the published case studies and current expert recommendations supports a redesign of connectors to ensure incompatibility between enteral and IV systems. Despite the cumulative evidence, little progress has been made to safeguard patients from tubing misconnections.

Oxidized regenerated cellulose is widely used as a bioabsorbable topical hemostatic agent. Postoperative visualization of this material through routine chest imaging, such as conventional radiography, computer tomography (CT), magnetic resonance imaging as well as sonography, may prove difficult and, to our knowledge, is not described in the literature. We describe a case where the mediastinal packing with Surgicel™ Nu-Knit™ after a mitral valve repair procedure led to a delayed obstruction of the superior vena cava, necessitating a re-thoracotomy and curettage of the hemostatic material. The hemostatic agent was not prospectively interpreted as the cause of a severe upper inflow restriction, despite repeated imaging. Retrospectively, the hemostatic material as a cause of the upper inflow obstruction could have been identified earlier if its presence would have been known to the radiologist. We strongly recommend that the surgeon inform the radiologist that such materials were used to improve the diagnostic yield of CT interpretation.

Health care errors are routinely reported in the scientific and public press and have become a major concern for most Americans. In learning to identify and analyze errors health care can develop some of the skills of a learning organization, including the concept of systems thinking. Modern experts in improving quality have been working in other high-risk industries since the 1920s making structured organizational changes through various frameworks for quality methods including continuous quality improvement and total quality management. When using these tools, it is important to understand systems thinking and the concept of processes within organization. Within these frameworks of improvement, several tools can be used in the analysis of errors. This article introduces a robust tool with a broad analytical view consistent with systems thinking, called CauseMapping (ThinkReliability, Houston, TX, USA), which can be used to systematically analyze the process and the problem at the same time., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background and Aim of the Study: Bicuspid aortic valve is the most common congenital heart malformation, and a high percentage of patients with this condition will develop complications over time. It is rare that pilots undergo aortic valve surgery, and the confirmation of flight-licensing requirements after aortic valve replacement (AVR) is a challenge for the patient's cardiac surgeon and, particularly, for the Aeromedical Examiner (AME). Only AMEs are able to determine the flight status of pilots. Furthermore, in military and in civil aviation (e.g., Red Bull Air Race), the high G-load environment experienced by pilots is an exceptional physiological parameter, which must be considered postoperatively., Methods: A review was conducted of the aeronautical, surgical and medical literature, and of European pilot-licensing regulations. Case studies are also reported for two Swiss Air Force pilots., Results: According to European legislation, pilots can return to flight duty from the sixth postoperative month, with the following limitations: that an aortic bioprosthesis presents no restrictions in cardiac function, requires no cardioactive medications, yet requires a flight operation with co-pilot, the avoidance of accelerations over +3 Gz and, in military aviation, restricts the pilot to non-ejection-seat aircraft. The patient follow up must include both echocardiographic and rhythm assessments every six months. Mechanical prostheses cannot be certified because the required anticoagulation therapy is a disqualifying condition for pilot licensing., Conclusion: Pilot licensing after aortic valve surgery is possible, but with restrictions. The +Gz exposition is of concern in both military and civilian aviation (aerobatics). The choice of bioprosthesis type and size is determinant. Pericardial and stentless valves seem to show better flow characteristics under high-output conditions. Repetitive cardiological controls are mandatory for the early assessment of structural valve disease and rhythm disturbances. A pre-emptive timing is recommended when reoperation is indicated, without waiting for clinical manifestations of structural valve disease.

An 86-year-old man underwent pacemaker implantation for symptomatic atrio-ventricular block grade 2 Mobitz II. The patient suffered repeated admissions for iterative sterile wound necrosis, leading to two generator re-implantations. No bacterial infection was detected in the microbiological screening tests. The skin patch testing to titanium was negative. Nevertheless, we decided to remove the pacemaker system and to implant a gold-plated generator with polyurethane leads. Since then, there has been no recurrence of wound complications. Gold-plated generator and polyurethane leads are effective in treating allergic reactions to pacemaker system components in selected cases. Negative skin patch testing to titanium does not exclude allergic reaction to this pacemaker component.

Aortic complications are very rare during off-pump coronary artery bypass grafting (OPCAB). When they occur, the mortality is high. We report a case of perforation of the posterior aortic wall after punching out the hole in the ascending aorta with an automatic aortic cutter to avoid clamping for the proximal anastomosis during a routine OPCAB procedure. The consequence was a massive hemorrhage, emergency conversion to cardiopulmonary bypass and replacement of the aortic valve and of the ascending aorta.

Although the BBAP E3 ligase and its binding partner BAL are overexpressed in chemotherapy-resistant lymphomas, the role of these proteins in DNA damage responses remains undefined. Because BAL proteins modulate promoter-coupled transcription and contain structural motifs associated with chromatin remodeling and DNA repair, we reasoned that the BBAP E3 ligase might target nucleosomal proteins. Herein, we demonstrate that BBAP selectively monoubiquitylates histone H4 lysine 91 and protects cells exposed to DNA-damaging agents. Disruption of BBAP-mediated monoubiquitylation of histone H4K91 is associated with the loss of chromatin-associated H4K20 methylase, mono- and dimethyl H4K20, and a delay in the kinetics of 53BP1 foci formation at sites of DNA damage. Because 53BP1 localizes to DNA damage sites, in part, via an interaction with dimethyl H4K20, these data directly implicate BBAP in the monoubiquitylation and additional posttranslational modification of histone H4 and an associated DNA damage response.

Frequently, the most critical calculations, considerations, and preparations for patient care and medication administration are made in noisy, dimly lit, and chaotic areas of the nursing unit. Healthcare has begun to recognize the impact of the physical work environment plays in the ability of humans to perform reliably and safely. This article reviews the draft guidelines recently released by the United States Pharmacopeia for public comment for the physical environment to promote safe medication administration.

A growing body of scientific evidence demonstrates negative effects of fatigue on human performance. Nursing practice encompasses many tasks that require optimal performance. Fatigue can be the result of a multitude of contributing causes. Nurses and nursing leaders must be aware of the causes and effects of fatigue and ensure that its impact is considered where staffing and patient safety intersect.

In a neonatal unit, an experienced nurse inadvertently connected a feeding tube to an intravenous catheter. An analysis of this error, including the historical perspective, reveals that this threat to safety has been documented since 1972. Implications for nursing practice include the redesign of systems to accommodate human factors science and a change in health care's view of vigilance.

Transition of primiparous heifers to the milking herd is a period with multiple stressors. The objective of these studies was to determine effects of parlour experience and prepartum milking (pre-milking) on behavioural and physiological indicators of stress after calving. Two experiments were conducted, one was in a free-stall housing confinement system and the second was in a modified grazing system. Forty-eight first-calf heifers were assigned to three treatments: control; experienced heifers taken through the parlour without milking; or pre-milk heifers milked for 3 weeks prior to estimated parturition. Blood was collected within 24 h of parturition and on days 3, 5, 7, 10 and 14 following parturition for cortisol and acute phase protein determination. In the grazing system, 20 heifers were assigned to a prepartum milked or control group as in the confinement system and behaviour observations included days -21, -14, -7, -5, -3 and -1 relative to calving and days 1, 3, 7, 9, 14, and 16 post-calving. Milk production was greatest for prepartum milked heifers in both housing systems. However, somatic cell score was reduced by prepartum milking only in the confinement system. Balking occurred least in parlour-experienced heifers. In confinement housing, shifting while in the parlour was the only behaviour that was greater at first milking in control heifers. Kicking was most frequent for parlour experienced heifers on day 2. Grazing system pre-milked heifers shifted more at their first milking (day -21) than did the controls at their first milking (day 1). Shifting within cow was greatest on day -21 compared with day -5 (P<0.05). Pre-milked heifers shifted more on day 1 post-calving than did the control heifers (P<0.05). These results showed that shifting was the most indicative behaviour of restlessness, was transient, and decreased by day 5 prior to calving. Cortisol and alpha1-acid glycoprotein concentrations were not different; however, haptoglobin increased for all treatments up to and including day 3 and haptoglobin concentrations of pre-milked heifers began to decrease by day 5 post-calving. Pre-milked heifers had lower haptoglobin concentrations than the control heifers and tended to have lower concentrations than experienced heifers on day 10 post partum. By day 14 post partum, all haptoglobin concentrations were <200 microg/ml, but the haptoglobin concentration of control heifers was greater than that of pre-milked and experienced heifers. These results showed that prepartum milking and parlour experience shorten some acute phase protein responses, but minimally affect early parlour behaviours.

Objective: The effectiveness of intentional weight loss in reducing cardiovascular disease (CVD) events in type 2 diabetes is unknown. This report describes 1-year changes in CVD risk factors in a trial designed to examine the long-term effects of an intensive lifestyle intervention on the incidence of major CVD events., Research Design and Methods: This study consisted of a multicentered, randomized, controlled trial of 5,145 individuals with type 2 diabetes, aged 45-74 years, with BMI >25 kg/m2 (>27 kg/m2 if taking insulin). An intensive lifestyle intervention (ILI) involving group and individual meetings to achieve and maintain weight loss through decreased caloric intake and increased physical activity was compared with a diabetes support and education (DSE) condition., Results: Participants assigned to ILI lost an average 8.6% of their initial weight vs. 0.7% in DSE group (P < 0.001). Mean fitness increased in ILI by 20.9 vs. 5.8% in DSE (P < 0.001). A greater proportion of ILI participants had reductions in diabetes, hypertension, and lipid-lowering medicines. Mean A1C dropped from 7.3 to 6.6% in ILI (P < 0.001) vs. from 7.3 to 7.2% in DSE. Systolic and diastolic pressure, triglycerides, HDL cholesterol, and urine albumin-to-creatinine ratio improved significantly more in ILI than DSE participants (all P < 0.01)., Conclusions: At 1 year, ILI resulted in clinically significant weight loss in people with type 2 diabetes. This was associated with improved diabetes control and CVD risk factors and reduced medicine use in ILI versus DSE. Continued intervention and follow-up will determine whether these changes are maintained and will reduce CVD risk.

Background: The diagnosis of cancer sets off a cascade of complex decisions at a time when patients feel vulnerable and distressed. Although clinical decisions used to follow one standard, many guidelines now outline several options and include explicit recognition of the need to incorporate patients' preferences to determine the most appropriate treatment., Purpose: The purpose of this article is to provide a brief overview of empirical studies about cancer patients' treatment-related decision making, to highlight the areas of congruence and divergence in that empirical literature, and then to generate a framework that points to future interventions and research., Methods: Through a group discussion with a range of experts in the field, we generated a framework for the critical treatment decisions and key issues within those decisions. Then, we reviewed the literature describing the experiences of cancer patients and evaluating interventions designed to improve the quality of treatment decisions., Results: We identified four major differences that influence decision making across cancers and across individuals with the same diagnosis. We also identified four common themes across situations and people. There is considerable evidence that decision aids can improve the quality of decisions across a range of diseases, although the data for cancer treatment decision making are limited. Other interventions such as navigation-skill training are promising but have little evidence of benefit for cancer decisions., Conclusions: There are many opportunities for behavioral research to extend and contribute to the understanding and improvement of cancer treatment decision making. Some key areas in need of research include developing taxonomies of disease and patient characteristics and increasing understanding of the lived experiences of cancer survivors, of the influence of time and timing, of the relationship of information and preferences, and of participation in randomized clinical trials.

Postpartum production performance of dairy heifers may be enhanced by prepartum milking by alleviating the stress of the periparturient period. The objective of this study was to determine the impact of prepartum milking of dairy heifers on postpartum reproduction, udder health, milk production and other associated production characteristics. Pregnant heifers (Holstein, n=21; Jersey n=10) were assigned to either a prepartum milked (premilked, n=15) or control (n=16) group. Premilked heifers were milked twice daily starting 3 weeks prior to anticipated calving dates, and milk yield recorded at each milking. All heifers were evaluated on days 21, 14 and 7 before calving, and udder oedema scores and milk conductivity readings were recorded. Following calving, measurements were taken twice weekly to assess udder oedema, milk conductivity (indicative of udder infection), and reproductive health, which included palpation for uterine tone and uterine position, vaginal electrical impedance (VEI) and the quantification of cross-sectional area of the uterine horns (uterine difference) by transrectal ultrasonography. Uterine tone, uterine position, uterine difference, and VEI did not differ (P>0.10) with treatment. Overall, up to week six inclusive, postpartum premilked heifers had lower (P<0.01) udder oedema scores than control heifers and up to week five inclusive, had lower (P<0.01) milk conductivity readings (indicative of fewer incidences of udder infections) than control heifers. The premilked heifers of both breeds produced more milk (P<0.01) at calving and more milk overall from calving to day 60 postpartum than the control heifers. In summary, udder health and milk production were improved post calving in premilked heifers compared with controls. However, no overt differences in reproductive characteristics were observed between the premilked and control heifers.

The effects of broth pH, pressure, temperature, and fermentation medium on specific cake resistance were studied for dead-end microfiltration of Bacillus subtilis. Decreases in pH and transmembrane pressure decreased the specific cake resistance for cells grown in both complex and defined media. With the complex medium, the reduction in resistance with temperature decrease did not offset the flux decrease caused by the increase in viscosity. The greatest decrease in specific cake resistance occurred with adjustment of pH to 7.5 for cells grown in defined medium. For those cells the change in pH resulted in aggregation leading to a large increase in flux., (Copyright 2006 Wiley Periodicals, Inc.)

Objectives: Youth are increasingly at risk for contracting HIV infection, and community-level interventions are needed to reduce behavioral risk., Design: A randomized, controlled, multi-site community-level intervention trial was undertaken with adolescents living in 15 low-income housing developments in five US cities., Methods: Baseline (n = 1172), short-term follow-up (n = 865), and long-term follow-up (n = 763) risk assessments were conducted among adolescents, ages 12-17, in all 15 housing developments. The developments were randomly assigned in equal numbers to each of three conditions: experimental community-level intervention (five developments); "state-of-the-science" skills training workshops (five developments); and, education-only delayed control intervention (five developments)., Results: At long-term follow-up, adolescents living in the housing developments receiving the community-level intervention were more likely to delay onset of first intercourse (85%) than those in the control developments (76%), while those in the workshop developments (78%) did not differ from control condition adolescents. Adolescents in both the community-level intervention (77%) and workshop (76%) developments were more likely to use a condom at last intercourse than those in control (62%) developments., Conclusions: Community-level interventions that include skills training and engage adolescents in neighborhood-based HIV prevention activities can produce and maintain reductions in sexual risk behavior, including delaying sexual debut and increasing condom use.

Objective: To address unanticipated results from randomized trials, researchers often focus on client-level data about services received during treatment. Program-level observations can also be helpful, especially in understanding treatment delivered in groups. Using both approaches, this article strives to better understand inconsistent results from a trial comparing medical and nonmedical group-format day treatment., Method: Dependent treatment seekers were randomized to a hospital-based medical day-treatment program or to one of two community-based nonmedical day treatment programs. Services received during treatment were captured from clients using the Treatment Services Review (N = 230 subjects; 78 women), and group sessions were observed to measure therapeutic style using an Event Form (N = 48 observations)., Results: The trial had found better medical outcomes at the hospital than at either nonmedical program, but most other tests had demonstrated similar outcomes at day hospital and one of the nonmedical sites and worse outcomes (psychiatric, family/social and employment) at the other nonmedical study site. Our analysis of services reported by study participants found a pattern of fewer substance misuse-oriented groups and less serious discussions about medical, psychiatric and family/social problems at the same nonmedical site that had worse outcomes. The way that services were delivered at that site further helped to explain the poorer outcomes there: Groups tended to be more didactic, classroom-like and less discussion-oriented., Conclusions: Although services received are helpful in explaining treatment outcome, treatment observation adds explanatory value. Without increasing the cost of service provision, programs that rely heavily on didactic approaches might improve their outcomes simply by encouraging more interactive discussions that engage the clients.

Unlabelled: The kaolin-based activated clotting time (ACT) is commonly used for monitoring heparin-induced anticoagulation alone and combined with aprotinin during cardiopulmonary bypass. However, aprotinin prolongs ACT measurements. Recently, a new so-called 'aprotinin-insensitive' ACT test (SaiACT) has been developed for the SONOCLOT analyzer. In this study we evaluated and compared this new test for the SONOCLOT analyzer in vitro with an established kaolin-based ACT from HEMOCHRON (HkACT). Twenty-five patients undergoing elective valve surgery donated 80 mL of blood after induction of anesthesia. The blood was withdrawn in citrated tubes and processed to analyze effects of heparin (0, 1, 2, and 3 U x mL(-1)), aprotinin (0, 200 kIU x mL(-1)), and 25% hemodilution with calcium-free lactated Ringer's solution on ACT measurements. A total of 400 blood samples were analyzed and ACT was measured in a wide, clinically relevant range in duplicate with SaiACT and HkACT. Addition of aprotinin to heparinized blood samples induced no significant changes of SaiACT measurements. By contrast, HkACT readings increased significantly: aprotinin prolonged HkACT in heparinized blood samples by 20% +/- 37% (2 U x mL(-1)) and 24% +/- 18% (3 U x mL(-1)), respectively, and in vitro hemodilution increased this effect., Implications: Current standard techniques to measure heparin-induced anticoagulation during cardiopulmonary bypass are affected by aprotinin, a drug widely used in this setting. The aim of this study was to investigate in vitro a new, so-called 'aprotinin-insensitive' test from SONOCLOT to measure heparin-induced anticoagulation more reliably in combination with aprotinin.

There is a renewed effort in Europe to develop strategies for improving patient safety in hospital care. Nevertheless, traditional hierarchical structures, methods of teaching, and the established tendency to focus on human error rather than organisational causes in medical accidents prohibit effective problem analysis and subsequent learning from our mistakes. Changing the work environment in order to enhance safety in cardiovascular perfusion services requires new efforts in individual clinics, in national perfusion societies, and on a European level. What tools do we have at hand in our profession to alter these influences and to improve perfusion safety? How can national perfusion societies in Europe enhance improvements which extend outside national boundaries?

This study is a prospective analysis of the outcome of subpectoral breast augmentation. Forty-seven patients undergoing breast augmentation were studied. They were assessed for pectoralis muscle function, breast sensation, and body image before and after subpectoral breast augmentation with saline implants. The patients were evaluated as follows: Pectoralis function was determined by measuring maximal voluntary isometric force. Sensation was evaluated by two means: vibration and pressure. The patient's body image was assessed using the Multidimensional Body-Self Relations Questionnaire. Results indicated a significant change in breast sensation at 3 months postoperatively but not at 6 months. Pectoralis muscle function did not significantly change during the study period. Body image was significantly improved at both postoperative measuring periods. The authors conclude that breast augmentation results in improved body image with negligible effect on muscle or nerve function.

Background: Maze-III is a complex surgical procedure designed to treat chronic atrial fibrillation. A reduction in the number of right and left atrial incisions could decrease the operative time. The aim of this study was to assess the results of a mini-maze operation and to define predictors of its failure., Methods: Between 1995 and 2000, 72 patients (mean age 64 +/- 9 years) undergoing cardiac surgery had a concomitant mini-maze operation for symptomatic chronic atrial fibrillation. Three and 12 months post-operatively, heart rhythm and left atrial transport functions were assessed by electrophysiology, echocardiography, and magnetic resonance imaging. Multivariate analysis was performed to identify predictors of failure of the mini-maze operation., Results: Operative mortality was 1.4% (1/72). Death during follow-up occurred in 5.6% of patients (4/71), in one due to chronic heart failure. After 1 year, 80% of patients (48/60) were either in sinus rhythm (n = 43; 72%) or had a pacemaker (n = 5; 8%) implanted due to sick sinus syndrome. Intermittent and chronic atrial fibrillation was found in 20% of patients (12/60). Preoperative duration of atrial fibrillation (p = 0.05), preoperative left atrial diameter (p = 0.001), preoperative right atrial diameter (p = 0.02), a reduced left ventricular ejection fraction (p = 0.03), an increased left ventricular end-diastolic diameter (p = 0.04), and the presence of mitral valve stenosis (p = 0.001) were found to be univariate predictors of failure of the mini-maze operation 1 year postoperatively. Multivariate analysis defined preoperative diagnosis of mitral valve stenosis (p = 0.005; OR 117.5), longer duration of preoperative atrial fibrillation (p = 0.01; OR 1.33), and increased preoperative left ventricular end-systolic diameter (p = 0.02; OR 1.2) as incremental independent risk factors for failure of the mini-maze operation to cure chronic atrial fibrillation., Conclusion: The mini-maze operation is a safe procedure with similar results to that of Cox's Maze-III operation. The less-invasive mini-maze operation could be applicable even to patients with severely reduced left ventricular function, in whom complex cardiac surgery has to be performed concomitantly as well as in those presenting severe comorbidities.

We immunohistochemically compared benign myoepithelial tumors (adenomyoepitheliomas [AMEs]) and metaplastic matrix-producing (MMP-CA) and spindle cell (MSC-CA) carcinomas of the breast to identify helpful diagnostic markers. Normal myoepithelial cells (MECs) consistently expressed cytokeratin, alpha-smooth muscle actin (SMA), myosin, S-100, CD10, and maspin. They were variably positive for vimentin and negative for epithelial membrane antigen (EMA), steroid receptors, p53, and HER-2/neu. MECs in AMEs less frequently expressed CD10 (4/8 [50%]) and myosin (6/8 [75%]) but frequently acquired characteristics of luminal cells, such as expression of EMA (5/8 [63%]) and steroid receptors (5/8 [63%]). No abnormal p53 or HER-2/neu expression was seen in AMEs. MMP-CA and MSC-CA were similar to AMEs in cytokeratin, vimentin, S-100, maspin, and HER-2/neu expression. MMP-CAs expressed less alpha-SMA (2/8 [25%]) and myosin (2/7 [29%]) and lacked estrogen receptor (0/9 [0%]). MSC-CAs were consistently CD10+ (4/4 [100%]) yet failed to express myosin (0/3 [0%]). p53 overexpression was seen frequently in MMP-CAs (4/8 [50%]) and MSC-CAs (1/3 [33%]). Benign myoepithelial mammary tumors differ immunophenotypically from normal MECs; a panel of immunohistochemical markers may be required to establish their myoepithelial origin. A similarly altered myoepithelial phenotype also is characteristic of metaplastic mammary carcinomas. The abnormal expression of oncogenes or antioncogenes, such as p53, may be more useful for distinguishing between those entities than the expression of the classic myoepithelial markers.

The white-throated woodrat is a principal host of Whitewater Arroyo (WWA) virus, an arenavirus, in the western United States. The purpose of the present study was to investigate the pathology of WWA infection in this species. Twenty-one animals (eight newborn, seven juvenile, and six adult) were inoculated with WWA virus and killed at varying intervals after inoculation. The most striking histological findings were lymphocytic meningitis and perivascular lymphocytic cuffing in the brains of the animals killed on day 85, 113 or 121. Arenaviral antigen was detected immunohistochemically in the brain of each affected animal, suggesting that the inflammatory lesions in the brain were caused by WWA virus. Comparisons of the results of tests for infectious virus and antigen in brain and other solid tissues indicated that immunohistochemistry may be a useful method for detection of WWA viral antigen in post-mortem specimens.

The objective of this study was to evaluate whether administration of GnRH postinsemination would improve reproductive performance in heat-stressed dairy cattle. Estrous cycles of Holstein cows were synchronized using the OvSynch protocol and cows were artificially inseminated. Cows were then administered the following treatments: control (no GnRH; n=37), GnRH (100 microg) on Day 5 (GnRH-D5; n=34), or GnRH (100 microg) on Day 11 (GnRH-D11; n=34) postinsemination. Cows were provided access to both fans and sprinklers, and environmental data was collected hourly. Rectal temperatures and blood samples were obtained from cows on Days -9, -2, 0 (AI) and on alternate days from Day 5 to Day 19 postinsemination. Blood serum was collected for the analysis of progesterone (P(4)) by RIA. In a subset of cows (n=6/treatment) ultrasonography was performed on alternate days from Day 5 to Day 19 postinsemination to assess numbers of corpora lutea (CL) and CL cross-sectional areas. Pregnancy status of cows was confirmed at Day 30 postinsemination. Environmental data indicated that cows experienced mild heat stress during the trials (mean daily THI=73-77). Serum P(4) was greater (P<0.05) after Day 9 for GnRH-D5 cows and after Day 15 for GnRH-D11 cows through Day 19 postinsemination. The number of CLs present for GnRH-D5 cows was greater (P<0.05) on Day 17 than in either the control or GnRH-D11 treatment groups. On Day 17 postinsemination, both the GnRH-D5 and GnRH-D11 cows were observed to have greater (P<0.05) total CL tissue area than control cows. The interval from insemination to when serum P(4) returned to <1 ng/ml (i.e. luteolysis and return to estrus) did not differ (P>0.10) among treatment groups. Control cows (19%) tended to exhibit lower pregnancy rates (P<0.08) compared to the GnRH-D5 and GnRH-D11 treatment groups combined (35%). In summary, the treatment of heat-stressed dairy cows with GnRH postinsemination (Day 5 or 11) results in the appearance of more CL tissue, increased serum concentrations of P(4) and a tendency toward greater pregnancy rates.