Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted.

METHODS

An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE).

RESULTS

Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE.

CONCLUSION

This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.

Efficacy of mesh coverage in surgical bullectomy for primary spontaneous pneumothorax: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Thoracic surgeons are now adopting a new method of using a mesh covering to reduce recurrence in surgical pleurodesis for pneumothorax. We aimed to review the literature and compare the outcomes of using mesh covering as an additional procedure during surgical pleurodesis.

METHODS

A comprehensive search was performed from inception to October 2022 on PubMed, Embase, Cochrane and Scopus. Randomised controlled trials (RCTs) and observational cohort studies (OCSs) comparing the use of mesh coverage, and different materials were included. Data were extracted to compare recurrence and other outcomes using a random effect model.

RESULTS

23 studies consisting of 2 RCTs and 21 OCSs totalling 5092 patients were included. Patients with a mesh had a significantly lower recurrence (OR = 0.22, 95% CI 0.12-0.42, p < 0.0001) and a shorter duration of chest tube drainage (SMD = -0.74 days, 95% CI -0.28 to -1.20, p < 0.0001) but no significant difference in the length of operation. The use of polyglycolic acid (PGA) and vicryl mesh was associated with a significantly shorter duration of chest tube drainage [(PGA, SMD = 0.83 days, 95% CI 0.14-1.52, p < 0.0001), (vicryl, SMD = 1.06 days, 95% CI 0.71-2.82, p = 0.0005)]. They also had a shorter post-operative length of stay than oxidized regenerative cellulose (ORC) but this was not statistically significant.

CONCLUSION

The use of a mesh material reduced the incidence of post-operative air leaks in the short term and the recurrence rate in the long term. Some mesh materials such as PGA and vicryl performed better than other materials.

Association of left atrial ejection fraction and cardiovascular outcomes in Asian patients with hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National University of Singapore Yong Loo Lin School of Medicine's Junior Academic Fellowship Scheme

Background

The optimal method of risk stratification of hyp­ertrophic cardiomyopathy (HCM) patients, especially in the Asian population, is unknown. Left atrial ejection fraction (LAEF) is an emerging risk marker for cardiovascular outcomes. This study aimed to investigate whether LAEF was associated with cardiovascular outcomes in Asian patients with HCM.

Methods

This was a retrospective cohort study performed in a tertiary academic centre involving 291 consecutive patients diagnosed with HCM between 2010 and 2017. We collected the relevant clinical characteristics of these patients and retrospectively analysed the index transthoracic echocardiograms for novel left atrial indices including LAEF. We obtained the maximum (LAVmax) and minimum left atrial volumes (LAVmin) using the biplane method of disks in apical 4- and 2-chamber views. LAEF was derived by dividing the difference between LAVmax and LAVmin by LAVmax. We assessed the patients for outcomes of (1) heart failure requiring admission, and (2) a composite of adverse outcomes including all-cause mortality, ventricular tachycardia / ventricular fibrillation (VT/VF) events, appropriate device therapy if an implantable cardioverter defibrillator (ICD) was implanted, stroke and heart failure hospitalization.

Results

The patients had a mean age of 59.0 ± 16.7 years-old at diagnosis and had a male preponderance (71.2%). The most common comorbidities were hypertension, diabetes mellitus and ischemic heart disease. On univariable logistic regression analysis, maximum and minimum left atrial volume index (LAVI) as well as LAEF showed a significant association with heart failure and the predefined composite outcome. On Cox regression analysis adjusting for variables of age, sex, left ventricular ejection fraction (LVEF), left ventricular maximal wall thickness &gt;30mm, significant left ventricular outflow tract (LVOT) gradient of &gt; 30mmHg and more than moderate mitral regurgitation, maximum and minimum LAVI as well as LAEF retained an association with heart failure admission but only minimum LAVI and LAEF were associated with the composite outcome [(OR 0.019, 95% CI 0.02-0.230, p=0.002), (OR 0.226, 95% CI 0.053-0.960, p=0.044), (OR 1.030, 95% CI 1.016-1.045, p&lt;0.001), and (OR 1.016, 95% CI 1.005-1.026, p=0.004) respectively].

Conclusion

LAEF was an independently associated with congestive heart failure as well as a composite of adverse outcomes in Asian patients with HCM.

Ethnicity influences cardiovascular outcomes and complications in patients with type 2 diabetes

AIM

To determine whether cardiovascular outcomes in type 2 diabetes (T2D) differ according to ethnicity, and whether ethnicity influences the effect of gender on these outcomes in Caucasians, East-Southeast-Asians, Middle-Easterners, South-Asians and Pacific-Islanders.

METHODS

We compared demographics, HbA1c, lipid profile, renal function markers, and prevalence of macrovascular and microvascular complications between ethnic groups. Cross-sectional data was prospectively collected from 204 consecutive patients at Westmead Hospital's T2D clinic from April-October 2015. Univariate analysis was performed using chi-squared test for categorical data, and Mann-Whitney-U or Kruskal-Wallis test for continuous data.

RESULTS

Compared to Caucasians, South-Asians were diagnosed younger, were currently younger, had lower body-mass-index (BMI) and better renal function but higher rates of non-ST-elevation myocardial infarction (STEMI, 21.7% versus 3.5%, p<0.05). East-Southeast-Asians had lower BMI but more nephropathy than Caucasians (59% versus 39%, p<0.05). East-Southeast-Asian males had fewer CVD than Caucasians, but this protection was absent in East-Southeast-Asian females. Middle-Easterners had more non-STEMI than Caucasians (5.3% vs 3.5%, p<0.05). Middle-Eastern females were not at lower CVD risk than males. Caucasians had most PVD (20% versus 6%, p<0.05).

CONCLUSIONS

Ethnicity influences rates of diabetes-related complications. Female CVD protection is altered in some groups. Ethnicity should be considered in assessing CVD and complications risk.

[Microsurgery in children]

While we celebrated the fortieth anniversary of the first free flap in children, new techniques emerged in reconstructive surgery (NPT, artificial dermis…) and reduced microsurgery procedures. However, microsurgery in children as in adults still have clinical applications in reconstructive surgery. Free flaps remain essential in clinical situations where they are the only ones to provide capacity for growth and stability scarring, two elements essential to the future quality of life of the children.

The influence of FKBP5 genotype on expression of FKBP5 and other glucocorticoid-regulated genes, dependent on trauma exposure

The FK506 binding protein 51 (FKBP5), an intrinsic regulator of the glucocorticoid receptor, has been associated with pathological behaviors particularly in the context of childhood trauma (CT), via a putatively regulatory polymorphism, rs1360780. However, trans- and cis-acting effects of this locus and its interaction with CT are incompletely understood. To study its effects on the expression of glucocorticoid-regulated genes including FKBP5, we used lymphoblastoid cell lines (LCLs) derived from 16 CT-exposed patients with greater than two substance dependence/suicidal behavior diagnoses (casesCT+) and 13 non-CT-exposed controls (controlsCT-). This study in LCLs measures long-term trait-like differences attributable to genotype or lasting epigenetic modification. Through analysis of differential allelic expression (DAE) using an FKBP5 3'-UTR reporter single nucleotide polymorphism (SNP), rs3800373, that is in strong linkage disequilibrium with rs1360780, we confirmed that the rs1360780 risk allele (A) (or conceivably that of a linked SNP) leads to higher FKBP5 expression in controlsCT-. Intriguingly, casesCT+ did not show DAE, perhaps because of a genotype-predicted difference in FKBP5 DNA methylation restricted to casesCT+. Furthermore, through correlation analyses on FKBP5 expression at baseline and after induction by dexamethasone, we observed that casesCT+ had lower induction of FKBP5 expression, indicating that overall they may have strong ultra-short negative-feedback. Only casesCT+ showed an effect of rs1360780 genotype on expression of FKBP5 and other glucocorticoid-regulated genes. Together, these results confirm that the rs1360780 locus alters FKBP5 expression and further that in trans-fashion this locus affects the expression of other glucocorticoid-regulated genes after a glucocorticoid challenge. The CT exposure appears to be essential for trans-effects of rs1360780 on glucocorticoid-regulated genes.

One Dimensional(1D)-to-2D Crossover of Spin Correlations in the 3D Magnet ZnMn2O4

We report on the intriguing evolution of the dynamical spin correlations of the frustrated spinel ZnMn₂O₄. Inelastic neutron scattering and magnetization studies reveal that the dynamical correlations at high temperatures are 1D. At lower temperature, these dynamical correlations become 2D. Surprisingly, the dynamical correlations condense into a quasi 2D Ising-like ordered state, making this a rare observation of two dimensional order on the spinel lattice. Remarkably, 3D ordering is not observed down to temperatures as low as 300 mK. This unprecedented dimensional crossover stems from frustrated exchange couplings due to the huge Jahn-Teller distortions around Mn³⁺ ions on the spinel lattice.

[Free tissue transfers with lengthening of vascular pedicle using interpositional vein grafts. About 10 cases]

The realization of free flaps with lack of reliable vessels nearby the loss of substance is a difficult problem for plastic surgeons. We report 10 cases of free tissue transfers with a one-stage technique lengthening the vascular pedicle of the free flap with interpositional vein grafts. Taking into consideration the good results and the low rate of morbidity, the authors emphasize the use of this technique rather than a two-stage procedure.

Generic properties of Mn spinels with an immiscibility induced by a Jahn-Teller distortion

The generic properties are scrutinized in Mn spinels with an immiscibility induced by a Jahn-Teller distortion through the CoFe(2-x)Mn(x)O(4) system. The x-ray diffraction experiment reveals that the immiscibility occurs at 1.1<x<2.0 and the relevant kinetics becomes faster with x. The temperature of the Jahn-Teller transition, which accompanies a sharp resistivity anomaly and matches the immiscibility gap boundary, increases with increasing x. The evolution of the magnetic and structural properties with various thermal treatments is studied carefully in this paper. Based on our comprehensive results, we have constructed a phase diagram of CoFe(2-x)Mn(x)O(4).

[Dupuytren's contracture. A report of three cases in Black Africans]

Having reported the first case of Dupuytren's disease in West Africa in 1990, the authors report two further cases, which brings the number of Dupuytren's disease reported in West Africa to three. The authors demonstrate by a literature review, that numerous cases had in fact been described in black people since 1974. The factors which are incriminated are always alcoholism, microtrauma and other factors like diabetes. Dupuytren's disease appears to be a condition, which is actually not so rare in black people after all.

Extending low-dose epidural analgesia for emergency Caesarean section using ropivacaine 0.75%

We compared ropivacaine 0.75% and bupivacaine 0.5% for extending low-dose epidural analgesia for emergency Caesarean section, using a prospective double-blind randomised controlled trial design. The trial was halted after 45 patients were studied (23 ropivacaine; 22 bupivacaine) because bupivacaine was replaced by levobupivacaine in our unit. Time to reach T4 for loss of cold sensation was similar in both groups, although analgesic supplementation was required less often in the ropivacaine group than in the bupivacaine group (2/23 vs. 9/21; p = 0.01).

134INCOMPLETE HISTONE ACETYLATION OF SOMATIC CHROMATIN IN BOVINE OOCYTES

Histone acetylation as an important regulatory mechanism of chromatin structure preceeding zygotic gene expression in early embryo development. After fertilization, transcriptional activation of the embryo begins during the S/G2 phase of the first cell cycle. However, the precise mechanism underlying activation of zygotic transcription remains to be understood, especially in bovine nuclear transfer (NT) embryos. It is known that acetylation of histone H4 lysine 5 (H4K5) represents hyperacetylation state, which is correlated with gene expression. In this study, the acetylation of H4K5 was observed during pronuclear formation by using immunofluorescence analysis with anti-AcH4K5. Our data were analyzed by the general linear models (GLM) procedure of the SAS. In IVF embryos, acetylation of H4K5 occurred on the paternal chromatin at 8h after fertilization but did not occur on the maternal chromatin until 10h after fertilization. Reconstructed oocytes with deactylated somatic cell nuclei began to show signs of acetylation on chromatin at 3h after fusion. When acetylation intensity was calculated using an image analyzer, IVF embryos presented a higher acetylation signal than NT embryos (P&lt;0.05). To induce hyperacetylation in NT embryos, somatic cells were exposed to trichostatin A (TSA, 1μM for 60h), a specific inhibitor of histone deacetylase (HDAC), prior to NT. Acetylated signals of H4K5 increased significantly in TSA-treated cells as compared with non-treated cells (P&lt;0.05). The reconstructed embryos with TSA-treated cells showed a higher fluorescence intensity than the oocytes with non-treated cells (P&lt;0.05), but weak signals compared to IVF embryos. Thus, the results demonstrated low histone acetylation level of somatic cell nuclei after NT during the zygotic progress. Our findings suggest that developmental failures of NT embryos may be due to incomplete chromatin remodeling of somatic cell nuclei during early embryonic development.

135DNA METHYLATION PROFILES IN THE PREIMPLANTATION PORCINE EMBRYOS

DNA methylation at CpG dinucleotides is an important epigenetic regulation process, which is associated with gene expression without any change in DNA sequence. During early development of the mouse embryo, dynamic changes in DNA methylation of the genome occur. After fertilization, active demethylation occurs on the paternal genome followed by passive demethylation until morula stage and then de novo methylation at the blastocyst stage. This study was designed to investigate changes in DNA methylation of in vivo- and in vitro-fertilized (IVF) porcine embryos. DNA methylation states were observed in preimplantation porcine embryos by using an immunofluorescence method after staining with an antibody against 5-methylcytosine. In contrast to the data from mouse embryos, active demethylation of the genome from the paternal pronucleus was not observed in the porcine embryos. Also, no passive demethylation was detected in in vivo- and IVF-derived embryos until the morula stage. Moreover, differential de novo methylation was not shown on the genome of the inner cell mass. Whole genomes of inner cell mass and trophectoderm cells were fully methylated. Our results demonstrate that DNA methylation of porcine embryos is different from that of mouse embryos during preimplantation development, suggesting that the machinery to regulate DNA methylation may be species-specific in mammals.

First-order transition from a Kondo insulator to a ferromagnetic metal in single crystalline FeSi(1-x)Ge(x)

The phase diagram of FeSi(1-x)Ge(x), obtained from magnetic, thermal, and transport measurements on single crystals, shows a discontinuous transition from Kondo insulator to ferromagnetic metal with x at a critical concentration, x(c) approximately 0.25. The gap of the insulating phase strongly decreases with x. The specific heat gamma coefficient appears to track the density of states of a Kondo insulator. The phase diagram is consistent with an insulator-metal transition induced by a reduction of the hybridization with x in conjunction with disorder on the Si/Ge ligand site.

Effect of intensive dietetic interventions on weight and glycaemic control in overweight men with Type II diabetes: a randomised trial

OBJECTIVE

To investigate the effectiveness of intensive innovative methods for implementing dietary prescriptions on weight management and glycaemic control in overweight men with Type II diabetes.

DESIGN

A randomised clinical trial with a 12-week intervention period - three isocaloric dietary intervention groups (intermittent energy restriction, pre-portioned meals and self-selected meals) each with weekly dietitian contact - and a follow-up visit after 18 months.

SUBJECTS

A total of 51 men with Type II diabetes (mean age 54 y, mean body mass index (BMI) 31.7 kg/m(2)).

MEASUREMENTS

Weight, body composition, waist circumference, glycaemic control (HbA(1c)) and blood lipids.

RESULTS

For all subjects, intensive diet therapy over the 12-week intervention period resulted in a mean reduction in energy intake of 2360+/-2780 kJ/day (564+/-665 kcal/day) and significant reductions in weight (6.4+/-4.6 kg), waist circumference (8.1+/-4.6 cm), percent body fat (1.9+/-1.5%), HbA(1c) (1.0+/-1.4%) and triglyceride levels (0.3+/-0.6 mmol/l) compared to baseline levels. Intervention group did not affect clinical outcomes, with the exception of percent body fat. A total of 27 (52.9%) subjects attended the 18-month follow-up visit. At this visit, none of the improvements in clinical parameters was maintained, with all parameters returning to preintervention levels.

CONCLUSIONS

: A dietary prescription of 6000-7000 kJ/day (1400-1700 kcal/day) was effective in achieving a 6% weight loss and improving glycaemic control. The method of implementation made no difference to the outcomes between groups at 12 weeks or 18 months. Thus, we propose that it was the intensive weekly contact with a health professional in combination with moderate energy restriction that facilitated the successful short-term results seen.

Intersite coupling effects in a kondo lattice

The La dilution of the Kondo lattice CeCoIn5 is studied. The scaling laws found for the magnetic susceptibility and the specific heat reveal two well-separated energy scales, corresponding to the single-impurity Kondo temperature T(K) and an intersite spin-liquid temperature T(*). The Ce-dilute alloy has the expected Fermi liquid ground state, while the specific heat and resistivity in the dense Kondo regime exhibit non-Fermi-liquid behavior, which scales with T(*). These observations indicate that the screening of the magnetic moments in the lattice involves antiferromagnetic intersite correlations with a larger energy scale in comparison with the Kondo impurity case.

Possible beneficial effect of exercise, by reducing oxidative stress, on the incidence of preeclampsia

We hypothesize that regular exercise enhances antioxidative enzymes in pregnant women, which reduce oxidative stress and, thus, the incidence of preeclampsia. Oxidative stress with enhanced lipid peroxide formation could lead to endothelial dysfunction in preeclampsia. Other conditions, such as increased transferrin saturation and decreased iron-binding capacity, directly and indirectly promote the process of oxidative stress and subsequent endothelial dysfunction. Exercise increases oxidative metabolism and produces a prooxidant environment. This acidic environment during exercise (at or beyond anaerobic threshold) promotes oxygen release from hemoglobin and increases in PO(2) in tissues, as well as releases iron from transferrin. When exercise is repeated regularly, the body promptly adjusts so that oxidative stress is eliminated or reduced. The body's adaptations to a regular exercise habit seem to have an antioxidant effect. In humans, training effects have been identified with an enhanced activity of antioxidative enzymes. Another concerted adaptation that regular exercise brings to women's bodies is resistance against production of prooxidants by increasing the number of mitochondria. Equally important is a training effect that decreases susceptibility to lipid peroxidation. Evidence suggests that physically active women are less likely to develop preeclampsia. In theory, intracellular and extracellular conditions resulting from regular exercise should counteract the enhancement of oxidative stress, thus interfering with the process leading to endothelial dysfunction. This position paper describes a hypothesis and includes a brief review of exercise physiology and biochemical research in preeclampsia. Unlike other preventive treatments, such as aspirin or calcium supplements, a regular exercise habit leads to a positive and healthy lifestyle without concern of side effects.

Polymelia with two extra forelimbs at the right scapular region in a male Korean native calf

In a male Korean native calf 14 days of age, polymelia (notomelia) was observed macroscopically and radiographically. External features included two normal forelimbs, two normal hindlimbs and two undeveloped extra forelimbs. The extra forelimbs were attached to the caudal regions of the right scapula and devoid of muscular tissues. In the extra forelimbs, a scapula-like bone formed a joint with the incompletely duplicated humerus. The humerus fused with the incompletely duplicated radius. The ulna, carpal bones, metacarpal bones and phalanges were completely duplicated. But one set of the duplicated carpal bones consisted of five bones: radial, accessory, fourth carpal, fused second and third carpal, and fused ulnar and intermediate carpal bones. The hoof and the rudimentary hoof of accessory digit were duplicated.

Rhinocerebral zygomycosis in childhood acute lymphoblastic leukaemia

The hazards associated with invasive candidiasis and aspergillosis in oncology patients are well recognised. These conditions typically present late in treatment, often after prolonged or recurrent episodes of neutropenia. We report the occurrence of Absidia corymbifera infection causing rhinocerebral zygomycosis in two children with acute lymphoblastic leukaemia, early in the induction phase of treatment and within a 3-month interval, in the same oncology unit. The initial presentation of facial pain was rapidly followed by the development of cranial nerve palsies, cavernous sinus thrombosis, diabetes insipidus, seizures and death within 9 days of symptom onset, despite aggressive management with high-dose liposomal amphotericin (Ambisome), surgical debridement and local instillation of amphotericin solution. These cases highlight the need for awareness of zygomycosis as a potentially lethal fungal infection that can present even with short duration exposure to the usual risk factors. Their occurrence within a limited time period raises questions as to the relative importance of environmental exposure. The failure of medical and surgical intervention to impact on the course illustrates the need to develop appropriate preventative strategies which may have to incorporate measures to reduce the environmental exposure of susceptible patients.

Japanese couples' childbirth experiences in Michigan: implications for care

BACKGROUND

Subtle cultural differences in the childbirth experience for expatriate Japanese couples living in southeast Michigan can sometimes cause conflicts between them and American health caregivers. The purpose of this study was to examine Japanese couples' perceptions and experiences of prenatal care and childbirth in a region of the United States, and to explore the implications for providing culturally competent care.

METHODS

In this qualitative study, in-depth interviews of 11 Japanese couples (n = 22) were conducted at an outpatient primary care clinic in southeast Michigan by a team of researchers fluent in the Japanese language and knowledgeable about the culture. Participants also completed a short questionnaire.

RESULTS

The major themes that emerged comprised perceptions related to a language barrier, ultrasonography, prenatal vitamin supplementation, episiotomy, epidural anesthesia, and practitioner-patient relationship. Throughout these six themes it was evident that Japanese health care professionals had difficulty accepting health care that was different from the care provided in their home country.

CONCLUSION

The most striking finding of this study was the difficulty for health caregivers to provide culturally competent care. Although the program has strongly invested in health professionals and support staff who were fluent in Japanese and knowledgeable about Japanese culture, conflicts still occurred.

The circadian rhythm of blood pressure during pregnancy

OBJECTIVE

To review the literature on the circadian rhythm of blood pressure during pregnancy.

DATA SOURCES

Computerized searches on MEDLINE, CINAHL, and MIRLYN.

STUDY SELECTION

Selected studies from 1 969 to 1997 were evaluated.

DATA EXTRACTION

Data were extracted and information was organized under the following areas: definition of and the interconnection between circadian rhythm and blood pressure; the circadian variability of blood pressure throughout the trimesters; the patterns of the circadian rhythm of blood pressure in pregnancies defined as normal and those complicated by chronic hypertension and preeclampsia; and clinical implications.

DATA SYNTHESIS

The circadian rhythm of blood pressure in pregnancy is the same as in the non-pregnant state, with a nocturnal decrease, especially during sleep. In patients with chronic hypertension, the nocturnal fall in blood pressure may be steeper. Patients with mild preeclampsia may experience a less pronounced nocturnal decrease in blood pressure. Patients with severe preeclampsia may display a reversed circadian rhythm, with no decrease and/or an increase in nocturnal blood pressure.

CONCLUSIONS

The patterns of the circadian rhythm of blood pressure during normal pregnancy and pregnancies complicated by chronic hypertension and preeclampsia warrant consideration when monitoring patients and implementing management plans.

Effect of exercise on blood pressure in pregnant women with a high risk of gestational hypertensive disorders

OBJECTIVE

To prospectively determine whether moderate exercise during pregnancy lowers blood pressure.

STUDY DESIGN

A randomized, controlled trial with one test group and one control group. All subjects have a history of mild hypertension, gestational hypertensive disorders or a family history of hypertensive disorders. Subjects were recruited before 14 weeks' gestation. After four weeks of observation, the subjects were randomly assigned to either the exercise or control group. The exercise group visited the laboratory three times a week for 10 weeks (18-28 gestation weeks) to perform 30 minutes of exercise at Rating of Perceived Exertion level 13.

RESULTS

A total of 16 pregnant women (mean age, 30 years) participated. The mean metabolic equivalent during exercise sessions was 4.7 (SD = 0.8). Blood pressure measurements were compared before and after the 10-week exercise period in the two groups. Systolic blood pressures did not change significantly, but diastolic blood pressure (DBP) in the exercise group decreased by 3.5 mm Hg, while that in the control group increased by 1.1 mm Hg. Thus, the pre-post change in DBP differed by 4.6 mm Hg between groups. Exercise treatment reduced the diastolic blood pressure to a near-significant level in the exercise group (t = 2.34, df = 7, P = .052). Percent body fat did not differ between the exercise and control groups either before or after exercise treatment. ANOVA revealed that pregnancy had a significant effect (F(1, 14) = 5.7, P = .03) on increasing the percentage of fat, but exercise treatment did not (F(1, 14) = .18, P = .68). Estimated energy expenditure in overall daily physical activities during the intervention did not differ between the two groups despite the inclusion of exercise.

CONCLUSION

This study detected a strong trend that 10 weeks of moderate exercise lowered the diastolic blood pressure among pregnant women at risk of hypertensive disorders. The reductions were probably due to the effect of exercise itself, not to weight or overall daily physical activity levels.

Physical activity and postpartum well-being

OBJECTIVE

To describe reported patterns of postpartum physical activity and to identify benefits or risks associated with postpartum physical activity at 6 weeks postpartum.

DESIGN

Secondary analysis of longitudinal data collected prenatally and postpartum in a study of obstetric outcomes at a midwestern tertiary-care center and its ambulatory satellite and hospital clinics.

PARTICIPANTS

One thousand three women completed a questionnaire at the 6-week postpartum clinic visit. Mean age was 29.7 years, and mean education level was 15.3 years.

VARIABLES OF INTEREST

Participation in vigorous exercise, change in postpartum activity level, postpartum weight retention, infant feeding method, maternal postpartum adaptation, and participation in activities for fun.

RESULTS

Nearly 35% reported doing vigorous exercise with a modal frequency of three times per week. More active women had retained significantly less weight (8.6 lb [3.9 kg]) than their less active counterparts (11.3 lb [5.1 kg]). Vigorous exercisers demonstrated a consistent pattern of better scores on measures of postpartum adaptation and were more likely than nonexercisers to participate in fun activities, such as socializing, hobbies, and entertainment. Breastfeeding was not adversely affected by vigorous exercise.

CONCLUSIONS

These exploratory results indicate that physical and psychologic benefits may accrue to postpartum women who are able to exercise vigorously and avoid decreasing their usual level of activity. A prospective randomized test of this relationship is warranted. Although positive outcomes of physical activity have been demonstrated in the population at large, exercise has rarely been an element in postpartum care plans. Nurses who care for women after childbirth should assess women's exercise goals and support them in their desired activities.

Pregnancy interruption using mifepristone (RU-486). A new choice for women in the USA

Mifepristone (RU-486) has recently been granted approval from the Food and Drug Administration for the early termination of pregnancy. Availability is anticipated during 1997. This article describes the pharmacologic function of mifepristone and discusses its potential clinical use in the United States, including its safety, efficacy, and possible complications.

Exercise-induced hyperthermia may prevent accurate core temperature measurement by tympanic membrane thermometer

The purpose of this study was to assess the effect of exercise-induced hyperthermia on brain and deep trunk temperature measurement in order to determine the optimal temperature site of the body for varying nursing practices in outpatient clinical settings. Eight women, 18 to 50 years old (30.9 +/- 12.6; mean +/- SD), participated in the study. Subjects were asked to perform their regular aerobic exercise in a natural environment while body temperature (ear and rectal) and heart rate (HR) were measured simultaneously and repeatedly before, during, and after exercise. Glass mercury rectal thermometers were used for measurement of deep trunk temperature, an infrared tympanic membrane thermometer for measurement of brain temperature, and a portable heart rate monitor for monitoring heart rate. Rectal temperature was higher than ear temperature for all but one of the 40 pairs of observation. The time pattern varied for the two modes of temperature (F = 9.67; df 4,28; p < .001). Rectal temperature changed over time (F = 7.86; df 4,28; p < .002), and ear temperature did not (F = 1.5; df 4,28; p = .25), indicating that ear temperature did not respond to exercise. While rectal temperature was strongly correlated with HR (r = .60), ear temperature did not correlate either with rectal temperature (r = .02) or with HR (r = .08). Thus deep trunk temperature responds to exercise at moderate levels. On the other hand, ear temperature does not increase due to exercise. Ear temperature is not a valid indicator of trunk temperature during and immediately after exercise.

Tympanic versus rectal thermometry in pregnant women

OBJECTIVE

To assess the accuracy of the tympanic membrane thermometer for use with pregnant women.

DESIGN

Cross-sectional descriptive study.

SETTING

A major medical center in the midwestern United States.

PARTICIPANTS

Thirty-three hospitalized, afebrile pregnant women.

MAIN OUTCOME MEASURES

Tympanic membrane thermometers and glass mercury thermometers were used to measure body temperature at the ear and rectum, respectively. The results were compared using two statistical methods: the Pearson correlation coefficient and a new technique suggested by Bland and Altman (1986).

RESULTS

Auditory canal temperature measured by a tympanic membrane thermometer correlated with rectal temperature as measured by a glass mercury thermometer (r = 0.38, p = 0.01). Thus, the tympanic membrane thermometer is acceptable for monitoring the body temperature of pregnant women. However, the device's estimation of rectal temperature is not clinically reliable.

CONCLUSIONS

Tympanic membrane thermometers, when applied with direct measures, are acceptable for use with pregnant women. It is not recommended that the rectal estimate mode be used with pregnant women.

Exercise guidelines for pregnant women

Despite remarkable improvements in high technologies and an increase in the number of studies related to exercise for pregnant women, the guidelines for maternal exercise remain contradictory. The effects of exercise in pregnant women and cardiovascular modifications due to pregnancy, and effects of maternal exercise on the fetal environment, including uterine and umbilical hemodynamic changes, are reviewed. Suggested future directions in this area of nursing science are discussed.

Cultural views of breastfeeding among high-school female students in Japan and the United States: a survey

This study compares the attitudes toward breastfeeding of high-school students in Japan and the United States. The study was conducted as a cross-sectional survey with a convenience sample (N = 329). Data were collected in 1989 and 1990 at two private, girls-only high schools (Tokyo, Japan and Farmington, Michigan). Retrieval rates were 100 percent (Tokyo) and 78 percent (Michigan) respectively. Responses were compared by the chi-square (chi 2) test with Yate's correction and factor analyses. Tokyo students perceived that their mothers talked positively about breastfeeding (54 percent), while only 17 percent of Michigan students reported that their mothers did so (< .001). Less than five percent of the Tokyo students felt that breastfeeding disturbs family life, whereas nearly 98 percent of the Michigan students felt so (p < .001). Tokyo students scored significantly higher on the 'family' factor, while the Michigan students scored significantly higher on the 'self' factor. Overall, this study indicates that high school students in Japan have more positive attitudes toward breastfeeding than students in the United States; however, teenagers in the United States are more interested than their Japanese age-mates in gaining information about breastfeeding.

The role of a Drosophila POU homeo domain gene in the specification of neural precursor cell identity in the developing embryonic central nervous system

The Drosophila embryonic central nervous system (CNS) is derived from a stereotypic array of progenitor stem cells called neuroblasts (NBs). Each of the approximately 25 NBs per hemisegment undergoes repeated asymmetric divisions to produce, on average, 5-10 smaller ganglion mother cells (GMCs); each GMC, in turn, divides to produce two neurons. We demonstrate that the protein product encoded by a POU homeo domain gene (dPOU28/pdm-2) is expressed in the cell nuclei of a subset of NBs and GMCs. In the wild-type animal, GMC-1 is the only identified cell in the NB4-2 lineage that expresses dPOU28 protein to a high level, and it divides to produce the RP2 neuron and a second cell of unknown fate. Our results suggest that the presence of ectopically induced dPOU28/pdm-2 protein in the progeny of GMC-1 is sufficient to cause both of these cells to adopt their parental GMC-1 cell fate, leading to duplication of the RP2 neuron (and its sister cell) on the basis of both immunological and morphological criteria. These observations clearly implicate a role for dPOU28/pdm-2 in the specification of GMC-1 cell identity in the NB4-2 lineage and possibly in the specification of cell fate in other NB lineages in the developing embryonic CNS.

Prompted voiding therapy for urinary incontinence in aged female nursing home residents

A study of 85 incontinent female nursing home residents explored the effects of two nursing interventions (prompted voiding and socialization) on incontinence. Findings indicate that a controlled prompted voiding programme is useful in decreasing incontinent episodes. Positive effects of prompted voiding were noted over a 5-week experimental period. It is suggested that nursing homes incorporate prompted voiding into their care. Nursing homes adopting this protocol should be encouraged to keep data that will contribute further to knowledge in this area. Recommendations for additional research are made.

Lymphadenopathy in dogs associated with aluminosilicate

Granulomatous lymphadenopathy, associated with the presence of needle-like refractile particles, was recognised in two dogs. The material was detected in macrophages, either free within the cytoplasm or in membrane-bound lysosomes. By mineral analysis under direct vision in an electron microscope microanalyser (EMMA 4) the particles were found to contain aluminosilicate.