Community-based nutrition intervention to promote oral health and restore healthy body weight in refugee children: a scoping review

OBJECTIVE

To determine the scope and quality of evidence on the effectiveness of community-based nutrition interventions to promote oral health and restore healthy body weight in school-aged refugee children.

BASIC RESEARCH DESIGN

Scoping review using a systematic approach.

MAIN OUTCOME MEASURES

Oral health and body weight.

RESULTS

Four primary studies, two evaluation studies and one systematic review met the inclusion criteria. No nutrition interventions or reviews to promote oral health in school-aged refugee children were found. There is limited weak evidence for the effectiveness of community-based nutrition interventions to restore healthy body weight in refugee settings. A systematic review also reported weak evidence of correction of child body weight as a result of community-based nutrition interventions in refugee camps.

CONCLUSION

This scoping review found no community-based nutrition interventions for school-aged refugee children to promote oral health and restore healthy body weight. There is limited and weak evidence for the effectiveness of community-based nutrition interventions to restore healthy body weight in refugee settings. There is a need to conduct an early phase study to develop and co-produce community-based nutrition interventions to promote oral health and healthy body weight for children residing in long-term refugee situations and to investigate the feasibility for their implementation.

The BMI values of the lower classes likely declined during the Great Depression

The BMI values of inmates in the McNeil Island Penitentiary in Washington State declined between the 1860s and the 1910s birth cohorts by 1.44. Furthermore, those who were imprisoned in the 1930s had significantly lower BMI values (by between 0.72 and 1.01) than those who were incarcerated at the end of the 19th century. This corresponds to a decrease in weight of some 2.25kg (4.95lbs) for a man of average height of 173.86cm (68.5inches). The diminution in nutritional status among this lower-class sample is hardly surprising, given the high level of unemployment at the time but has not been verified until now. In marked contrast, the BMI values of Citadel cadets increased by 1.5 units in the 1930s. This divergence in BMI values is most likely due to the different social status, to the different regional origins of the two samples or to both.

Direct cerebral perfusion and cooling in experimental cardiac arrest

BACKGROUND

Cerebral protection is a key priority during cardiac arrest (CA). However, current approaches are suboptimal.

OBJECTIVE

To test whether direct perfusion and cooling of the anterior cerebral circulation by means of cerebral vessel cannulation and extracorporeal membrane oxygenation (ECMO) increases cerebral oxygenation and induces cerebral hypothermia during CA.

METHODS

We performed proof-of-concept animal experiments in sheep. We cannulated the carotid artery (for antegrade perfusion) or the jugular vein (for retrograde perfusion) for direct perfusion and cooling, and the jugular vein on the opposite side for drainage. We connected these cannulae to an ECMO circuit. We induced CA and, after 10 minutes, and during open-chest cardiac massage, we provided ECMO-based perfusion and cooling. We measured cerebral tissue oxygen saturation (SctO₂) by near infrared spectroscopy (NIRS) and cerebral temperature by means of invasively inserted tissue temperature probes.

RESULTS

In the antegrade perfusion experiments (n = 2), CA markedly decreased the SctO₂ to below 40% over 10 minutes, despite open-chest cardiac massage. ECMO-based cerebral perfusion and cooling increased SctO₂ levels to 60% and lowered cerebral temperature to 25°C within about 3 minutes. With retrograde perfusion (n = 2), ECMObased cerebral perfusion and cooling was less effective; ECMO increased SctO₂ levels slowly and to a much lesser extent and similarly decreased cerebral temperature slowly and to a lesser extent.

CONCLUSIONS

During experimental CA, cerebral perfusion and cooling are possible by means of an ECMO circuit connected to the anterior cerebral circulation. Antegrade perfusion appears to be superior. Further investigations of the antegrade perfusion technique appear justified.

Haemostatic management for aortic valve replacement in a patient with advanced liver disease

Redo-sternotomy and aortic valve replacement in patients with advanced liver disease is rare and associated with a prohibitive morbidity and mortality. Refractory coagulopathy is common and a consequence of intense activation of the coagulation system that can be triggered by contact of blood with the cardiopulmonary bypass circuitry, bypass-induced fibrinolysis, platelet activation and dysfunction, haemodilution, surgical trauma, hepatic decompensation and hypothermia. Management can be further complicated by right heart dysfunction, porto-pulmonary hypertension, poor myocardial protection, and hepato-renal syndrome. Complex interactions between coagulation/fibrinolysis and systemic inflammatory response syndrome reactions like “post-perfusion-syndrome” also compound haemostatic failure. Given the limited information available for the specific management and prevention of cardiopulmonary bypass-induced haemostatic failure, this report serves to guide the anaesthesia and medical management of future cases of a similar kind. We discuss our multimodal management of haemostatic failure using pharmacological strategies, thromboelastography, continuous cerebral and liver oximetry, and continuous cardiac output monitoring.

Pegylated interferons for chronic hepatitis C virus infection: an indirect analysis of randomized trials

Dual therapy with pegylated interferon and ribavirin is recommended for patients with chronic hepatitis C virus infection who meet criteria for treatment, but it is unclear whether pegylated interferon alfa-2a or pegylated interferon alfa-2b is more effective or associated with fewer adverse events. Because data from head-to-head trials of pegylated interferon regimens are sparse, we performed adjusted indirect analysis using trials comparing dual therapy with pegylated interferon alfa-2a or pegylated interferon alfa-2b vs dual therapy with non-pegylated interferon. We searched for potentially relevant randomized controlled trials using electronic databases and reference lists. A total of 16 trials met inclusion criteria. Adjusted indirect comparisons found no statistically significant differences between dual therapy with pegylated interferon alfa-2a and dual therapy with pegylated interferon alfa-2b on the outcomes sustained virologic response [relative risk (RR) = 1.59, 95% CI: 0.56-4.46], withdrawal due to adverse events (RR = 0.86, 95% CI: 0.29-2.55), anaemia (RR = 1.67, 95% CI: 0.32-8.84), depression (RR = 1.09, 95% CI: 0.41-2.90) or flu-like symptoms (RR = 1.10, 95% CI: 0.53-2.29). Adjusting for potential publication bias and stratifying analyses by indicators of methodological quality, human immunodeficiency virus infection status, hepatitis C virus genotype, dose of ribavirin or dose of pegylated interferon did not change conclusions. There is insufficient evidence to support conclusions that dual therapy with one pegylated interferon is superior to the other. However, because estimates are imprecise, our results also do not rule out a clinically significant difference. Head-to-head trials are needed to verify the results of indirect analyses and provide additional guidance on optimal treatment choices.

Rapid painless diagnosis of viral respiratory infection

The concordance of nasal compared with nasopharyngeal swabs was assessed for the diagnosis of respiratory viral infections, and the degree of discomfort associated with each procedure was compared. The use of nasal swabs was shown to be as accurate but significantly less painful than nasopharyngeal swabs for virus diagnosis.

Repair of dyskinetic or akinetic left ventricular aneurysm: results obtained with a modified linear closure

OBJECTIVE

In patients with a dyskinetic or akinetic area of the left ventricle, controversy exists over who will benefit from resection. This study evaluates results achieved with a modified linear closure in 193 of 196 consecutive cases. Preoperative cases (n = 160 [83%]) were in functional class III or IV with congestive heart failure (n = 115 [60%]), angina (n = 108 [56%]), and syncope (n = 67 [35%]). The ejection fraction was 25% +/- 8%, and echocardiography showed significant mitral regurgitation in 86 (45%) patients. In patients with detailed wall motion analysis, 50 (57%) were akinetic, and 37 (43%) were dyskinetic.

METHODS

Repair was completed on the beating heart to minimize ischemia and allow assessment of wall function and viability to guide resection and repair. Additional procedures included coronary artery bypass grafting (n = 175 [91%]), septoplasty (n = 24 [12%]), and arrhythmia ablation (n = 77 [40%]). Ventricular and mitral valve function were assessed by means of preoperative and/or postoperative gated acquisition scans in 171 (90%) patients and Doppler echocardiograms in 170 (88%) patients.

RESULTS

Hospital mortality was low (5/193 [2.6%]), although 34 (18%) patients needed perioperative intra-aortic balloon pump support. Actuarial survival at 1 and 5 years was 91% and 84%. Most late deaths were due to congestive heart failure. Seven patients required transplantation (interval, 36 +/- 32 months). As determined by multivariable analysis, factors predicting poor outcome at 5 years were preoperative mitral regurgitation of 2+ or greater, congestive heart failure, and ventricular tachycardia. Among survivors, 126 (80%) of 157 were in functional class I or II, and the average increase in ejection fraction postoperatively was 9.1% +/- 10.0%. Postoperative echocardiograms in 70 patients with significant mitral regurgitation preoperatively showed improved valve function in 40 (57%) of 70 patients.

CONCLUSIONS

We conclude that repair of dyskinetic or akinetic aneurysms by means of a modified linear closure plus septoplasty in selected patients can be accomplished in the beating heart with low operative mortality, provides good symptomatic relief and long-term survival, and is associated with objective evidence of improved left ventricular and mitral valve function.

Integrating primary and secondary care: the case of Christchurch South Health Centre

AIMS

To study health services utilisation linkages and methodological issues in integrating primary and secondary care services for a defined general practice population (Christchurch South Health Centre, CSHC).

METHODS

The Centre supplied national health index (NHI) linked data on date of birth, gender and community services card (CSC) status for 10,174 patients, and data on primary care. Secondary care providers supplied NHI linked data on specialist outpatients, emergency department usage for 1996 to 1998, and waiting lists. The Health Funding Authority (HFA) supplied NHI linked data on inpatient/daypatients for 1996 and 1997. Data were also obtained relating to community support services and long-term care. Rates of hospital utilisation for the Centre's population were standardised for comparison with national and Christchurch figures using age, gender and CSCs. Overall per capita expenditure was calculated for this population.

RESULTS

Patients with CSCs constituted 31.2% of the practice population, but generated 60.8% of bed-days. Patients with high use health cards (HUHCs) constituted 8.6% of the population, but generated 42.4% of bed-days. This group was at high risk of hospitalisation over a wide range of disease categories. Standardised rates of hospital utilisation were significantly lower for the Centre's older patients, especially for bed-days, than both national and Christchurch figures. Only a small proportion of referrals to specialist outpatients, 28.2% in 1998, was from the Centre's general practitioners (GPs), the remainder being generated internally within the specialist services. The overall expenditure per capita on the Centre's population was $1012, which was substantially less than expected in comparison with national figures.

CONCLUSION

The study demonstrates the importance of primary care factors in the utilisation of secondary care, especially acute hospitalisation in older patients. This needs further study as it could provide important insights into ways of reducing acute admissions. If there is to be more effective management of the primary/secondary care interface, more research and development effort is needed into the characteristics of patients at high risk of referral and admission, and how inappropriate secondary care can be averted.

Maintaining mammography adherence through telephone counseling in a church-based trial

OBJECTIVES

This study assessed the effectiveness of telephone counseling in a church-based mammography promotion intervention trial.

METHODS

Thirty churches were randomized to telephone counseling and control conditions; telephone interview data were used in assessing intervention effects on mammography adherence. Separate analyses were conducted for baseline-adherent participants (maintaining adherence) and baseline-nonadherent participants (conversion to adherence).

RESULTS

Year 1 follow-up data indicated that the telephone counseling intervention maintained mammography adherence among baseline-adherent participants and reduced the nonadherence rate from 23% to 16%.

CONCLUSIONS

Partnerships between the public health and faith communities are potentially effective conduits to promote maintenance of widely endorsed health behaviors such as regular cancer screening.

MindMatters, a whole-school approach promoting mental health and wellbeing

OBJECTIVE

MindMatters is an innovative, national mental health promotion program which provides a framework for mental health promotion in Australian schools. Its objectives are to facilitate exemplary practice in the promotion of whole-school approaches to mental health promotion; develop mental health education resources, curriculum and professional development programs which are appropriate to a wide range of schools, students and learning areas; trial guidelines on mental health and suicide prevention and to encourage the development of partnerships between schools, parents, and community support agencies to promote the mental wellbeing of young people.

METHOD

A team of academics and health education professionals, supported by a reference group of mental health experts, developed MindMatters. The program was piloted in 24 secondary schools, drawn from all educational systems and each State and Territory in Australia. The pilot program was amended and prepared for dissemination nationally.

RESULTS

The program provides a framework for mental health promotion in widely differing school settings. The teacher professional development dimension of the program is central to enhancing the role of schools in broad population mental health promotion.

CONCLUSIONS

Promoting the mental health and wellbeing of all young people is a vital part of the core business of teachers by creating a supportive school environment that is conducive to learning. Teachers need to be comfortable and confident in promoting and teaching for mental health. Specific, targeted interventions, provided within a whole-school framework, address the needs of the minority of students who require additional support.

Results of revascularization in patients with severe left ventricular dysfunction

OBJECTIVE

In patients with coronary disease and poor left ventricular function, bypass grafting remains a surgical challenge. This study evaluates experience in 125 consecutive patients with ejection fraction less than 20% (study group).

METHODS

Preoperative viability studies were not used for patient selection. Clinical data were prospectively collected. The average age of the study subjects was 59 +/- 9 years, and 112 (90%) were male. Most patients (108 [86%]) were in symptom class III or IV. Main indications for surgery included angina in 62 (50%), heart failure and angina in 36 (29%), heart failure in 9 (7%), ventricular arrhythmia in 2 (2%), and critical anatomy in 16 (13%). Significant mitral regurgitation was present in 48 (38%), and distal vessels were poorly visualized in 67 (54%). At surgery, temperature mapping guided an integrated approach to cold cardioplegia. Results in this group were compared with those obtained in case-matched control subjects receiving cardioplegia without temperature mapping (matched for age, sex, functional class, and urgency of operation).

RESULTS

Hospital morbidity (intra-aortic balloon pump support) and mortality rates were significantly lower in the study group versus those of control subjects (15% vs 30%, P =. 004; and 4% vs 11%, P =.03, respectively). In study patients the 5-year actuarial survival was 72%. Among survivors, both anginal class and heart failure class improved significantly. By means of multivariate analysis, survival was adversely affected by older age, class IV symptoms, and poorly visualized distal vessels.

CONCLUSIONS

These results support the use of coronary artery bypass grafting in patients with severe left ventricular dysfunction without case selection on the basis of viability studies or visibility of distal vessels. Low hospital morbidity and mortality rates have been achieved when temperature mapping guides cardioplegia. Symptoms are improved in most patients, and long-term survival is encouraging.

Breast cancer screening adherence: does church attendance matter?

Little is known about the health behaviors of church attendees. This article reviewed telephone interview data of 1,517 women who were church members from 45 churches located in Los Angeles County to determine their breast cancer screening status and to identify the key predictors of screening. Almost all of this sample (96%) reported attending church at least once a month. Key predictors of screening included physician-patient communication, ethnic background, and having medical insurance. Although church-related predictors were not significantly related to screening adherence, the authors compared community-based screening rates from another sample to their sample rates and found that, when controlling for income and education, church members fared better on mammography screening than women who were community residents. This finding suggests that frequent church attendance contributes to better mammography screening status and that the relationship between religious involvement and health behaviors needs further explanation.

Electrophore mass tag dideoxy DNA sequencing

Toward a goal of dideoxy sequencing DNA utilizing electrophore labels, we prepared four electrophore-labeled DNA oligonucleotide primers. Each primer has a different electrophore and DNA sequence but a common glycol keto (alpha,beta-dihydroxyketo) release group. Cleavage of this latter group by either periodate oxidation or a thermal retroaldol reaction releases the electrophores for detection by mass spectrometry. Successful sequencing data with these primers was obtained by capillary electrophoresis on an ABI Model 310 after fluorescence dideoxy terminator cycle sequencing reactions were conducted. In a separate experiment, it was demonstrated that a cocktail of the four electrophore DNA primers could be detected as a dried sample spot by CO2 laser desorption/capillary collection/gas chromatography electron capture mass spectrometry. These results establish some feasibility for our long-term goal of high-speed multiplex electrophore mass tag dideoxy DNA sequencing. Ultimately we plan to use a higher number of electrophore mass tags and to rely on direct detection of the desorbed electrophores by electron capture time-of-flight mass spectrometry.

Southcentral Foundation--Dena A Coy: a model program for the treatment of pregnant substance-abusing women

This article discusses the societal implications of substance abuse by pregnant women and women of child-bearing age and reviews their treatment needs as documented in the literature. It then provides a treatment model for pregnant women, using the Southcentral Foundation-Dena A Coy Residential Treatment Program as a model program. It outlines a number of components that are critical to successful substance abuse treatment of these women; specifically, medical interventions, social service provision, educational/vocational services, psychoeducational programs, psychotherapy, substance abuse interventions, and family preservation and involvement. These components are superimposed on a therapeutic community model that stresses gender and cultural relevance, as well as supportive structure and direction.

Human papillomatous virus infection update: impact on women's health

Human papilloma virus (HPV) is one of the sexually transmitted diseases (STDs) seen throughout the population. More than 60 types of HPV have been identified, and 20 are known to cause genital warts; other types of HPV have an oncogenic potential. During pregnancy, genital warts may grow (possibly due to a suppressed immune system) and the neonate may become exposed. Several cofactors that have been identified in the development of HPV include oral contraceptive use, pregnancy and parity, nutrition, smoking, unsafe sex practices, and immunosuppression. Treatment options are aimed at destroying the visible lesions and include topical therapy, laser vaporization, cryocautery, liquid nitrogen, or simple excision. Health care providers have an important role in counseling about HPV infections. This includes educating clients about risk factors, prevention, signs and symptoms of STDs including HPV, safe sex practices, and the importance of regular examinations. Empowerment and a positive approach must be taken to help the client understand that she has a right to protect herself from STDs including HPV.

Antegrade and retrograde cardioplegia: alternate or simultaneous?

Neither antegrade nor retrograde cardioplegic protection provides homogeneous distribution, and a combination may be required to avoid anaerobic metabolism and depressed postoperative ventricular function. Tepid cardioplegia (29 degrees C) avoids the delayed recovery of cardiac function and metabolism associated with cold cardioplegia (15 degrees C) and reduces the anaerobic metabolism seen with warm (37 degrees C) cardioplegia. We compared two techniques that combine antegrade and retrograde tepid cardioplegia: alternate and simultaneous.

METHODS

Sixty patients undergoing elective isolated coronary artery bypass grafting were randomized to receive near continuous tepid retrograde and either intermittent antegrade cardioplegia (the alternate technique) or antegrade cardioplegia with the solution delivered concurrently through each completed vein graft (the simultaneous technique).

RESULTS

Myocardial lactate extraction was greater after crossclamp release following simultaneous than alternate cardioplegia. Postoperative ventricular function was better after alternate than simultaneous cardioplegia.

CONCLUSION

Both techniques permitted rapid postoperative recovery of myocardial metabolism and ventricular function. However, simultaneous cardioplegia was simpler and did not require deairing the aortic root between antegrade infusions.

Human pediatric and adult ventricular cardiomyocytes in culture: assessment of phenotypic changes with passaging

OBJECTIVES

The purpose of this study was to assess morphologically and biochemically the phenotypic changes which occur in vitro with passaging of human pediatric and adult ventricular cardiomyocytes.

METHODS

Human ventricular cardiomyocytes from 3 children (1 to 2 years of age) and an adult patient (65 years of age) undergoing open heart surgery and an adult heart transplant patient (55 years of age) were isolated, cultured, purified, and passaged. Growth curves and 3H-thymidine uptake studies were performed. Characterization of the cells was done by light microscopy, transmission electron microscopy, immunofluorescent staining for myoglobin, CK-MB, and cardiac-specific troponin I isoform, human ventricular myosin heavy chain (HVMHC) and light chain 1 (HVMLC1), Northern blot analysis of HVMHC, and CK-MB activity and mass measurements. Passage 3 cardiomyocyte and pediatric myocardial phospholipids were analysed by gas chromatography.

RESULTS

Pediatric cells were smaller (P < 0.01) and divided faster (P < 0.001, ANOCOVA) than adult cells. The cardiomyocytes showed phenotypic changes in primary culture with essentially complete loss of sarcomeres by 10 days and a gradual loss of myofilaments with passaging. The cells were identified as cardiomyocytes by immunohistochemistry for myoglobin, CK-MB, cardiac-specific troponin I isoform, HVMHC and HVMLC1, and by Northern blot analysis for the 3'-end of HVMHC mRNA. The composition of phospholipid fatty acids in the cultured pediatric cells was similar to that found in the pediatric myocardium. CK-MB activity and mass could be measured in the cardiomyocytes. The adult cardiomyocytes were more difficult to maintain than the pediatric cells which could be cultured for as long as 6 months.

CONCLUSIONS

Primary cultures of human pediatric and adult partially differentiated ventricular cardiomyocytes can be passaged. Although rapid disorganization of the myofibrils occurs, the non-contractile cells can be identified as cardiomyocytes by morphological appearance, immunofluorescent staining, Northern blot analysis for HVMHC, and CK-MB activity.

Use of acute psychiatric beds: a point prevalence survey in North and South Thames regions

BACKGROUND

Concerns have been expressed, particularly in inner cities, about the growing pressure on acute psychiatric beds, evidenced by increased occupancy rates, difficulties in accessing beds, and increasing use of private beds by health authorities. This study investigated these concerns by conducting a census of psychiatric patients occupying acute beds. The proportion of patients who no longer required acute care and their needs for alternative provision were determined, together with bed occupancy rates.

METHODS

A point prevalence survey of acute psychiatric patients in all National Health Service acute psychiatric units and seven private psychiatric units in North and South Thames regions was conducted on 15 June 1994. Sociodemographic, diagnosis and admission characteristics data were collected. Patients who no longer required acute care were identified and the alternative service provision required for these patients was determined. Bed occupancy rates were calculated.

RESULTS

A total of 3710 psychiatric patients (including those on leave) were ennumerated. More than one in five (23.2 per cent) were defined as inappropriately located. The main alternative services required for inappropriately located patients who could be discharged to the community were professional support in patient's home (71.5 per cent), and housing or more appropriate housing (61 per cent). For inappropriately located patients who could not be discharged into the community, the main alternative services required were group home (29.3 per cent) and in-patient rehabilitation (20.8 per cent). Bed occupancy rates were high on the day of the survey (95 per cent).

CONCLUSION

Best use is not being made of acute psychiatric beds in the Thames regions. A high proportion of patients occupying beds are those who no longer require acute care, but for whom alternative services are unavailable.

DNA sequencing by capillary electrophoresis using short oligonucleotide primer libraries

Two strategies for DNA sequencing by primer walking using short oligonucleotide primer libraries have been successfully employed along with capillary electrophoresis using replaceable polymer solutions of linear polyacrylamide and fluorescence detection. A 3.5-kb stretch of the single-stranded M13mp18 template was sequenced with T7 PRISM dye-terminator/Sequenase chemistry. An in-house base-calling program offered read lengths of roughly 450 bases with an average of 97.8% accuracy.

The neuropeptide Y antagonist PYX2 decreases lordosis behavior

Neuropeptide Y (NPY) has been localized to noradrenergic neurons and both the noradrenergic system and NPY play a facilitatory role in the control of luteinizing hormone-releasing hormone (LHRH) and luteinizing hormone (LH) release. The present experiments examined whether NPY also plays a role in the control of lordosis. Adult female guinea pigs were ovariectomized (ovx) and implanted with a cannula into the lateral ventricle. In Experiment 1, intracerebroventricular (ICV) administration of the NPY antagonist PYX2 (0, 0.5, 2.0 or 10.0 μg) caused a dose-dependent decrease in lordosis behavior in ovx, estrogen and progesterone-primed guinea pigs. In addition to an effect on the mean lordosis response, PYX2 also decreased the percent of animals showing lordosis and the maximum lordosis response. In Experiment 2, NPY administration (25 μg, ICV) 30 min after PYX2 (2 μg, ICV) to ovx estrogen and progesterone-primed females significantly reversed the effect of the PYX2. Because the NPY antagonist PYX2 reversibly decreased lordosis behavior this suggests that NPY plays a facilitatory role in the control of lordosis behavior.

Adequate distribution of warm cardioplegic solution

Seventy-five patients undergoing coronary artery bypass grafting were randomized to receive warm antegrade (N = 25), warm retrograde (N = 25), or a combination of warm antegrade and retrograde (N = 25) delivery of blood cardioplegic solution. Myocardial oxygen utilization, lactate and acid metabolism, and adenine nucleotides and their degradation products were measured during the operation and cardiac function was assessed postoperatively. Warm retrograde delivery of cardioplegic solution increased lactate and acid release during cardioplegia and reperfusion, decreased left ventricular adenosine triphosphate concentrations, and reduced the washout of adenine nucleotide degradation products from both left and right ventricles. Warm antegrade delivery of cardioplegic solution resulted in less lactate and acid release during cardioplegia but more lactate accumulated in the territory of the left anterior descending artery during the crossclamp period. Intermittent antegrade delivery of the cardioplegic solution during combination cardioplegia washed out lactate and acid, which suggested inhomogeneous delivery of the cardioplegic solution during continuous retrograde cardioplegia. Combination cardioplegia best preserved adenosine triphosphate in the left ventricle and resulted in the best postoperative left and right ventricular function. A combination of intermittent antegrade and continuous retrograde delivery of cardioplegic solution provided better myocardial protection than either antegrade or retrograde delivery of cardioplegic solution alone.

Micrografting in extensive quantities. The ideal hair restoration procedure

BACKGROUND

Smaller hair transplant grafts in greater quantities are becoming an unmistakable trend. As hair grow in groups of one to four, the process is mathematically and aesthetically logical.

OBJECTIVE

To produce a natural appearing distribution of hair in the balding individual in an acceptable time frame.

METHODS

Grafts reflecting natural patterns are used. Four hundred one-hair grafts are densely packed into a frontal hairline 4-5 mm wide to create a transition zone between the forehead and a new hairline. Two- to four-hair grafts are densely packed behind the frontal zone in a graded fashion. Grafts containing no more than four hairs are used.

RESULTS

The results produce a slightly less dense but better balance that looks like the natural veneer of a normal mature male. In women or men with thinning hair, surgically increasing density satisfies many patient objectives.

CONCLUSION

Transplantation with one- to four-hair grafts in extensive quantities produces a natural "hairy" appearance without the artificial look typical of the large traditional grafts. By using this technique, many patients can be completed in just one session.

Vitamin E for coronary bypass operations. A prospective, double-blind, randomized trial

BACKGROUND

Free radical lipid peroxidation contributes to the abnormal metabolism and ventricular function frequently seen after cardiac operations. Antioxidants may improve metabolic and functional recovery.

METHODS

A prospective, randomized, double-blind clinical trial was conducted to determine the effects of vitamin E (alpha-tocopherol) (n = 14) or a corn oil placebo (n = 14) in patients undergoing elective coronary bypass operations. The RRR-alpha-tocopheryl acetate doubled the alpha-tocopherol levels in the heart. Myocardial metabolism and ventricular function were assessed after the operation.

RESULTS

Atrial pacing induced myocardial lactate production in the control patients but lactate consumption in the alpha-tocopherol-treated patients on bypass 25 minutes after crossclamp release. Left ventricular stroke work indices were higher, at similar ventricular volumes, in the alpha-tocopherol-treated group, which indicates improved preload recruitable stroke work, and diastolic compliance was greater 4 hours after the operation. The postoperative creatine kinase cardiac isoenzyme levels were lower in the patients who received alpha-tocopherol.

CONCLUSIONS

Pretreatment with alpha-tocopherol sufficient to double the myocardial concentrations had a small but significant metabolic and functional effect after elective coronary bypass operations when compared with placebo. These results do not justify pretreatment of low-risk patients, but they do justify an evaluation in high-risk patients.

Optimal flow rates for retrograde warm cardioplegia

Retrograde delivery of warm blood cardioplegia may improve nutrient cardioplegic flow beyond coronary obstructions, but may not adequately perfuse the right ventricle and the posterior left ventricle. To determine the optimal flow rate for warm retrograde cardioplegia, we assessed 62 patients undergoing elective coronary artery bypass in two studies. In the low flow study, administration of 50 ml/min (n = 9), 75 ml/min (n = 11), or 100 ml/min (n = 7) was associated with high lactate production and oxygen extraction during cardioplegic administration. At 50 minutes of cardioplegic arrest, the coronary venous effluent pH was low in all groups. In the high flow study, 30 patients all received flow rates of 100, 200, and 300 ml/min in randomized order during the crossclamp period. In addition, five patients received cardioplegia at a rate of 500 ml/min for the duration of the crossclamp period. Administration of 200 ml/min or higher minimized lactate production and maintained coronary venous pH within the physiologic range, but flows of 300 ml/min or higher did not increase oxygen use or reduce lactate or acid production. Patients in the low flow groups had significantly greater myocardial lactate release during cardioplegic infusion and after removal of the crossclamp than the high flow group. Warm retrograde cardioplegia should be delivered at flow rates of at least 200 ml/min during elective coronary artery bypass operations.

DNA sequencing by capillary electrophoresis: use of a two-laser-two-window intensified diode array detection system

This paper presents the principles of an instrument designed for DNA sequencing using the standard four-dye-labeled primer approach. The method is based on capillary electrophoresis with laser-induced fluorescence and an intensified diode array detector. An important goal of the instrument design has been a detection system that possesses high sensitivity and high spectral resolution. Based on an analysis of the spectral characteristics of the four standard dye-labeled primers, FAM, JOE, ROX, and TAMRA, the strategy has been to use a two-laser-two-window approach, in which a 488-nm argon ion laser illuminates one window, followed by a 543-nm helium-neon laser illuminating the second window. The two-window approach has no moving parts and permits continuous illumination. Spectral resolution is provided by a grating spectrograph and a cooled intensified diode array. The estimated limit of detection for the standard four dye-labeled primers was found to be in the sample concentration range of 1 x 10(-12) M. To achieve these low levels, complete free-radical polymerization of polyacrylamide has been found to be necessary in order to reduce background noise. In addition, reduction in background noise was accomplished by continual purging of the anodic reservoir in order to prevent electrolysis products from entering the capillary. Separation of DNA sequencing reaction products is demonstrated on a 9% T linear polyacrylamide column.

Increased imidazoline and alpha 2 adrenergic binding in platelets of women with dysphoric premenstrual syndromes

An association between dysphoric premenstrual syndromes (PMS) and a lifetime history of major depressive disorders has previously been documented. Other studies have demonstrated an increase in the binding of radiolabeled imidazoline compounds to platelets of depressed patients. Clonidine and related imidazoline compounds interact with alpha 2 adrenoceptors to inhibit neuronal noradrenergic activity and in higher concentrations, they stimulate noradrenergic activity through their interaction with imidazoline receptors. Here we report increased 3H para-aminoclonidine binding to high affinity alpha 2 adrenoceptor sites as well as to nonadrenergic imidazoline binding sites in platelets of women with dysphoric PMS. This higher binding was most pronounced during the late-luteal-symptomatic phase of the menstrual cycle and, to a lesser degree, during the non-symptomatic mid-follicular phase. Binding to the imidazoline site distinguished women with dysphoric PMS from women with no such symptoms, was highly positively correlated with the severity of symptoms, and was negatively correlated with plasma levels of progesterone. These findings suggest that platelet imidazoline binding sites might be a biological marker for dysphoric states in PMS or for the vulnerability to develop them. These findings also point to a possible biological link between dysphoric PMS and major depressive disorders.

Which techniques of cardioplegia prevent ischemia?

One hundred seven patients undergoing coronary artery bypass grafting were randomized to receive warm antegrade (n = 21), warm retrograde (n = 22), cold antegrade (n = 20), cold retrograde (n = 22), or intermittent cold antegrade (n = 22) blood cardioplegia. Myocardial oxygen consumption and lactate production, adenine nucleotides, and adenine nucleotide degradation products were measured during the operation, and creatine kinase-MB release was assessed postoperatively. Warm cardioplegia resulted in greater myocardial lactate production than cold cardioplegia (p = 0.048). Retrograde cardioplegia was associated with greater lactate production than antegrade cardioplegia (p = 0.015). Adenosine triphosphate depletion was similar among groups. However, poorly diffusible metabolites of adenosine triphosphate accumulated to the greatest extent in the intermittent cold group. Levels of hypoxanthine were highest after warm retrograde cardioplegia. Operative mortality and morbidity were low and were not different among groups. In summary, none of the five techniques of cardioplegia evaluated in this study was able to completely prevent myocardial ischemia. Anaerobic lactate production was minimized with cold cardioplegia and with antegrade cardioplegic delivery. Hypothermia may have impaired regeneration of adenosine triphosphate, however, particularly in association with inadequate or intermittent cardioplegic flow.

Far upstream regions of class II MHC Ea are necessary for position-independent, copy-dependent expression of Ea transgene

The chromatin upstream of the class II MHC Ea gene contains specific, DNase I hypersensitive (DH) sites (groups I-V), overlapping and extending the promoter proximal and distal control regions. To determine whether the Ea DH groups I-V define a functionally important chromatin domain or locus control region (LCR), we have used wild type Ead gene constructs to generate transgenic mouse lines from strains that do not express an endogenous Ea gene product. Constructs contained either DH groups I-V 'Longs' or DH groups I-II 'Shorts', of the hypersensitive sites defined within 20 kb 5' of Ea. We show that position-independent, copy number-dependent expression of the Ead gene occurs only with the Long construct (8/8 transgenic mouse lines, over a range of copy numbers, 1-30 copies); in contrast, the Short constructs are subject to position-dependent effects. This suggests that the region delineated by Ea DH groups I-II is necessary but not sufficient as an LCR, which requires the presence of the upstream regions containing DH III-V for complete position-independent, copy number-dependent expression. These results introduce an immunologically-important, putative LCR which can be used to target genes to cells of the B cell lineage, as well as to other class II MHC expressing cells, and highlight the importance of chromatin structure analysis as a means to locate DNA regions of regulatory interest which are dispersed over a large distance.

Ventricular function after normothermic versus hypothermic cardioplegia

Warm cardioplegia produced by essentially continuous infusion has been used as an alternative to traditional cold intermittent infusion techniques during cardiac surgery, but its effects on postoperative left ventricular function have not been defined. We performed a randomized clinical trial to assess the effects of warm and cold blood cardioplegia on load-independent indices of ventricular function. Fifty-three patients were randomized to warm (n = 27) or cold (n = 26) cardioplegia. Myocardial oxygen consumption, lactate production, adenine nucleotides, and adenine nucleotide degradation products were measured during cardioplegia and reperfusion. In 13 patients per group, pressure-volume loops were constructed and ventricular function was assessed 3 hours after the operation. Warm cardioplegia resulted in greater myocardial lactate production but improved recovery of oxygen consumption during reperfusion. Depletion of adenosine triphosphate was similar between groups, but total adenine nucleotides (adenosine triphosphate + adenosine diphosphate + adenosine monophosphate) fell further during warm cardioplegia. Cold cardioplegia was associated with an accumulation of adenosine diphosphate and adenosine monophosphate. Creatine kinase MB isoenzyme release was reduced in the warm group. Three hours after the operation, end-systolic elastance and preload-recruitable stroke work index were increased after warm cardioplegia, and early diastolic relaxation was also increased. Increased systolic function after warm cardioplegia may have been related to improved myocardial protection, elevated arterial lactate concentrations, or increased circulating catecholamine levels. Altered diastolic compliance in the warm group may reflect greater active relaxation during early diastolic filling.

Alternative techniques of cardioplegia

BACKGROUND

Although normothermic cardioplegia has been used with acceptable clinical results, no studies have previously been performed to determine the metabolic consequences of these various techniques of myocardial protection. Therefore, we have performed a randomized clinical trial to assess the effects of three cardioplegic techniques on myocardial metabolic recovery.

METHODS AND RESULTS

Seventy-four patients undergoing coronary artery bypass graft surgery were randomized to receive normothermic antegrade blood cardioplegia (n = 25), normothermic retrograde blood cardioplegia (n = 23), or intermittent cold antegrade blood cardioplegia (n = 26). Myocardial oxygen consumption and lactate production, adenine nucleotides, and adenine nucleotide degradation products were measured during the operation, and cardiac creatine kinase isoenzyme (CK-MB) release was assessed after surgery. Warm antegrade cardioplegia maximized myocardial oxygen consumption during cardioplegic delivery. Postoperative CK-MB release was less after warm antegrade cardioplegia, but the difference was not statistically significant. Warm retrograde cardioplegia resulted in the greatest degree of anaerobic lactate production but did not increase morbidity and mortality. Perioperative myocardial infarctions and postoperative low-output syndrome were most common after cold cardioplegia, but this trend was not statistically significant. During warm antegrade cardioplegia, adenosine triphosphate (ATP) was metabolized to diffusible precursors, which were washed out during cardioplegic infusion. Warm retrograde cardioplegia produced a breakdown of ATP to inosine and hypoxanthine, small molecules that accumulated during the cross-clamp period and were not washed out, perhaps because of inadequate perfusion with retrograde delivery. During cold cardioplegia, ATP was dephosphorylated, and adenosine diphosphate, adenosine monophosphate, and adenosine accumulated. These compounds were not regenerated to ATP but were not washed out of myocytes because they are large anionic molecules.

CONCLUSIONS

Intermittent cold cardioplegia inhibited mitochondrial function but prevented the degradation of adenine nucleotides. Warm antegrade cardioplegia had the greatest myocardial oxygen consumption, and warm retrograde cardioplegia had the greatest anaerobic lactate production. There were no differences in clinical outcomes between cardioplegic groups.

The effect of warm heart surgery on postoperative bleeding

The effects of normothermic systemic perfusion (35 degrees to 37 degrees C; n = 73) were compared with those of moderately hypothermic systemic perfusion (25 degrees to 29 degrees C; n = 73) with respect to blood loss, transfusion requirements, and platelet levels in 146 patients undergoing isolated, primary coronary artery bypass grafting. In addition, most patients were given an antifibrinolytic medication during operation as follows: tranexamic acid (10 gm intravenously; n = 63), epsilon-aminocaproic acid (15 gm intravenously; n = 63), or no drug as a control. (n = 20). Normothermic patients tended to bleed less at 24 hours (warm, 864 +/- 42 ml and cold, 918 +/- 68 ml), but these differences were not statistically significant. Patients receiving either tranexamic acid or epsilon-aminocaproic acid, regardless of perfusion temperature, bled less after 6, 12, and 24 hours than did cold control patients (p less than 0.05). Warm control patients also bled less than did cold control patients after 6 or 12 hours (p less than 0.05), and neither drug further reduced blood loss in these patients. Circulating platelet levels were better preserved in patients receiving either tranexamic acid or epsilon-aminocaproic acid and in patients with warm perfusion and no drug than in cold control patients. Normothermic systemic perfusion, tranexamic acid, and epsilon-aminocaproic acid each reduced postoperative blood loss and preserved platelets.

Optimal delivery of blood cardioplegia

A prospective randomized controlled trial was performed to determine optimal flow rates and hemoglobin concentrations for continuous normothermic blood cardioplegia and to compare warm heart surgery with standard intermittent cold blood cardioplegia. Thirty-five patients received intermittent cold blood cardioplegia, low hemoglobin low flow, low hemoglobin high flow, high hemoglobin low flow, or high hemoglobin high flow warm blood cardioplegia (seven patients per group: low hemoglobin, 50 g/l; high hemoglobin, 80 g/l; low flow, less than 80 ml/min; high flow, greater than 80 ml/min). Hypothermia resulted in a significantly greater accumulation of ADP and AMP during cross clamp, consistent with impaired mitochondrial function. Low hemoglobin low flow warm blood cardioplegia increased myocardial oxygen consumption and coronary sinus blood flow after cross clamp release, and also decreased lactate consumption. Postoperative myocardial performance and diastolic compliance were reduced in low hemoglobin low flow warm patients, and diastolic compliance was increased with high hemoglobin high flow warm blood cardioplegia when compared with cold patients. In this study, continuous normothermic cardioplegia was safe when delivered at 80 ml/min or greater, with a hemoglobin concentration of at least 80 g/l, affording myocardial metabolic and functional recovery comparable to that found after intermittent cold blood cardioplegia.