Effects and moderators of coping skills training on symptoms of depression and anxiety in patients with cancer: Aggregate data and individual patient data meta-analyses.

PURPOSE: This study evaluated the effects of coping skills training (CST) on symptoms of depression and anxiety in cancer patients, and investigated moderators of the effects. METHODS: Overall effects and intervention-related moderators were studied in meta-analyses of pooled aggregate data from 38 randomized controlled trials (RCTs). Patient-related moderators were examined using linear mixed-effect models with interaction tests on pooled individual patient data (n = 1953) from 15 of the RCTs. RESULTS: CST had a statistically significant but small effect on depression (g = -0.31,95% confidence interval (CI) = -0.40;-0.22) and anxiety (g = -0.32,95%CI = -0.41;-0.24) symptoms. Effects on depression symptoms were significantly larger for interventions delivered face-to-face (p = .003), led by a psychologist (p = .02) and targeted to patients with psychological distress (p = .002). Significantly larger reductions in anxiety symptoms were found in younger patients (pinteraction < 0.025), with the largest reductions in patients <50 years (ß = -0.31,95%CI = -0.44;-0.18) and no significant effects in patients ≥70 years. Effects of CST on depression (ß = -0.16,95%CI = -0.25;-0.07) and anxiety (ß = -0.24,95%CI = -0.33;-0.14) symptoms were significant in patients who received chemotherapy but not in patients who did not (pinteraction < 0.05). CONCLUSIONS: CST significantly reduced symptoms of depression and anxiety in cancer patients, and particularly when delivered face-to-face, provided by a psychologist, targeted to patients with psychological distress, and given to patients who were younger and received chemotherapy.

Heterozygotes for ACAN dwarfism alleles in horses have reduced stature.

Homozygous and compound heterozygous Miniature horses for ACAN alleles D1, D2, D3* and D4 exhibit chondrodysplastic dwarfism (OMIA 001271-9796). In a previous study, the carrier rate for these four alleles, combined, was 26.2%. The purpose of this study was to investigate whether carriers of these dwarfism-causing alleles had a shorter withers height than non-carriers. A total of 245 Miniature horses were tested for these four ACAN alleles and also were measured for withers height. Of these horses, 98 were carriers and 147 were non-carriers. A statistically significant difference of 1.43 inches was observed with the carriers being shorter (P = 1.72E - 11). The range of heights for the two groups overlapped, indicating that other factors, including genes, have an impact on withers height. However, the high carrier rate of these dwarfism-causing variants may be due to selection for decreased height.

Trichomonas vaginalis virus: a review of the literature.

Trichomonas vaginalis (TV) is a parasitic protozoan responsible for the sexually transmitted infection trichomoniasis. Trichomonas vaginalis virus (TVV) is a nonsegmented, 4.5-5 kbp, double-stranded RNA virus, from the Totiviridae family, which inhabits TV. A capsid protein consisting of 120 subunits is covered in channels aiding in RNA release. TVV is closely associated with the Golgi complex and is transmitted vertically. TVV has four subspecies, TVV1, TVV2, TVV3, and TVV4. The clinical significance of TVV and its effect on the pathogenicity of TV is not well known. We performed a systematic review of the literature on TVV to better understand its clinical significance and its role in the pathogenesis of TV.

Multiple alleles of ACAN associated with chondrodysplastic dwarfism in Miniature horses.

Chondrodysplastic dwarfism in Miniature horses appeared to be a recessive genetic trait based on the occurrence of affected offspring by normal parents. Dwarf phenotypes vary and range from abnormal abortuses to viable offspring with evidence of skeletal dysplasia. A genome-wide association study implicated a region of ECA1 with dwarfism in Miniature horses. Aggrecan (ACAN) was a candidate gene in that region, and exons were sequenced to compare DNA sequences for dwarf and non-dwarf horses. Sequencing led to the discovery of variants in exons 2, 6, 7 and 15 associated with dwarfism. The four variants are identified with reference to Ecab 3.0 (GCF_002863925.1) as g.95291270del (rs1095048841), g.95284530C>T (ERP107353), g.95282140C>G (rs1095048823) and g.95257480_95257500del (rs1095048839) and designated here as D1, D2, D3* and D4 respectively. A previous study at another laboratory reported dwarfism associated with homozygosity for D3*. Homozygotes for those variants and compound heterozygotes for any combination of those variants always expressed a dwarfism phenotype. However, eight additional horses with dwarfism were found, seven of which were heterozygotes for D2, D3* or D4, suggesting the existence of additional ACAN alleles causing dwarfism. Among Miniature horses, the combined frequency of D1, D2, D3* and D4 was 0.163, suggesting a carrier rate of 26.2% for alleles causing chondrodysplastic dwarfism.

Characterizing the acute heat stress response in gilts: I. Thermoregulatory and production variables.

Identifying traits associated with susceptibility or tolerance to heat stress (HS) is a prerequisite for developing strategies to improve efficient pork production during the summer months. Study objectives were to determine the relationship between the thermoregulatory and production responses to acute HS in pigs. Prepubertal gilts (n = 235; 77.9 ± 1.2 kg BW) were exposed to a thermoneutral (TN) period (P1, 24 h; 21.9 ± 0.5 °C, 62 ± 13% RH; fed ad libitum) followed immediately by a subsequent acute HS period (P2, 24 h; 29.7 ± 1.3 °C, 49 ± 8% RH; fed ad libitum). Rectal temperature (TR), skin temperature (TS), and respiration rate (RR) were monitored and BW and feed intake (FI) were determined. All pigs had increased TR, TS, and RR (0.80 °C, 5.65 °C, and 61.2 bpm, respectively; P < 0.01) and decreased FI and BW (29% and 1.10 kg, respectively; P < 0.01) during P2 compared to P1. Interestingly, body temperature indices did not explain variation in FI during P2 (R2 ≤ 0.02). Further, the percent change in BW during P2 was only marginally explained by each body temperature index (R2 ≤ 0.06) or percent change in FI (R2 = 0.14). During HS, TR was strongly correlated with P1 TR (r = 0.72, P < 0.01), indicating a pig's body temperature during TN conditions predicts the severity of hyperthermia during HS. Additionally, the change in TR (ΔTR, HS TR - TN TR) was larger in pigs retrospectively classified as susceptible (SUS) as compared to tolerant (TOL) pigs (1.05 vs. 0.51 °C, respectively; P < 0.01). In summary, thermoregulatory responses and production variables during acute HS are only marginally related. Further, changes in BW and FI were unexpectedly poorly correlated during acute HS (r = 0.34; P < 0.01). Collectively, suboptimal growth is largely independent on the thermoregulatory response and hypophagia during acute HS. Consequently, incorporating solely body temperature indices into a genetic index is likely insufficient for substantial progress in selecting HS tolerant pigs.

Effects and moderators of psychosocial interventions on quality of life, and emotional and social function in patients with cancer: An individual patient data meta-analysis of 22 RCTs.

OBJECTIVE: This individual patient data (IPD) meta-analysis aimed to evaluate the effects of psychosocial interventions (PSI) on quality of life (QoL), emotional function (EF), and social function (SF) in patients with cancer, and to study moderator effects of demographic, clinical, personal, and intervention-related characteristics. METHODS: Relevant studies were identified via literature searches in 4 databases. We pooled IPD from 22 (n = 4217) of 61 eligible randomized controlled trials. Linear mixed-effect model analyses were used to study intervention effects on the post-intervention values of QoL, EF, and SF (z-scores), adjusting for baseline values, age, and cancer type. We studied moderator effects by testing interactions with the intervention for demographic, clinical, personal, and intervention-related characteristics, and conducted subsequent stratified analyses for significant moderator variables. RESULTS: PSI significantly improved QoL (ß = 0.14,95%CI = 0.06;0.21), EF (ß = 0.13,95%CI = 0.05;0.20), and SF (ß = 0.10,95%CI = 0.03;0.18). Significant differences in effects of different types of PSI were found, with largest effects of psychotherapy. The effects of coping skills training were moderated by age, treatment type, and targeted interventions. Effects of psychotherapy on EF may be moderated by cancer type, but these analyses were based on 2 randomized controlled trials with small sample sizes of some cancer types. CONCLUSIONS: PSI significantly improved QoL, EF, and SF, with small overall effects. However, the effects differed by several demographic, clinical, personal, and intervention-related characteristics. Our study highlights the beneficial effects of coping skills training in patients treated with chemotherapy, the importance of targeted interventions, and the need of developing interventions tailored to the specific needs of elderly patients.

Carcass composition of market weight pigs subjected to heat stress in utero and during finishing.

Objectives were to investigate the effects of prolonged gestational and/or postnatal heat stress on performance and carcass composition of market weight pigs. Pregnant gilts were exposed to gestational heat stress (GHS, 28°C to 34°C, diurnal) or thermal neutral (18°C to 22°C, diurnal) conditions during the entire gestation or during the first or second half of gestation. At 14 wk of age (58 ± 5 kg), barrows were housed in heat stress (32°C, HS) or thermal neutral (21°C, TN) conditions. Feed intake and BW were recorded weekly, and body temperature parameters were monitored twice weekly until slaughter (109 ± 5 kg). Organs were removed and weighed, and loin eye area (LEA) and back fat thickness (BF) were measured after carcass chilling. Carcass sides were separated into lean, separable fat, bone, and skin components and were weighed. Moisture, lipid, and protein content were determined in the LM at the 10th rib. Data were analyzed using a split plot with random effect of dam nested within gestational treatment. Carcass measurements included HCW as a covariate to control for weight. Planned orthogonal contrast statements were used to evaluate the overall effect of GHS in the first half, second half, or any part of gestation. Gestational heat stress did not alter postnatal performance or most body temperature parameters (P > 0.10). However, ADFI in the finishing period was increased (P < 0.05) in response to GHS, particularly in pigs receiving GHS in the first half of gestation. Gestational heat stress during the first half of gestation decreased head weight as a percent of BW (P = 0.02), whereas GHS in the second half of gestation decreased bone weight as a percent of BW (P = 0.02). Heat stress reduced ADG, BW, and HCW (P < 0.0001). Lean tissue was increased in HS pigs on both a weight and percentage basis (P < 0.0001), but LEA was similar to TN carcasses (P = 0.38). Carcasses from HS barrows also had less carcass separable fat (P < 0.01) and tended to have less BF (P = 0.06) compared with those from TN barrows, even after controlling for HCW. However, percent intramuscular fat did not differ between treatments (P = 0.48). The LM from HS carcasses had a greater moisture to protein ratio (P = 0.04). HS barrows also had decreased heart (P < 0.001) and kidney (P < 0.0001) as a percent of BW compared with TN pigs. In summary, GHS may affect head and bone development, subsequently affecting carcass composition. Chronic HS during finishing results in longer times to reach market weight and a leaner carcass once market weight is achieved.

Interest in genetic testing for modest changes in breast cancer risk: implications for SNP testing.

BACKGROUND: Advances in genomics may eventually lead to 'personalized genetic medicine,' yet the clinical utility of predictive testing for modest changes in risk is unclear. We explored interest in genetic testing for genes related to modest changes in breast cancer risk in women at moderate to high risk for breast cancer. METHODS: Women (n = 105) with a negative breast biopsy and ≥1 relative with breast or ovarian cancer completed telephone surveys. We measured demographic and psychosocial variables and, following presentation of hypothetical scenarios of genetic tests for lower-penetrance breast cancer gene mutations, assessed interest in willingness to pay for and comprehension of test results. We used logistic regression models with generalized estimating equations to evaluate combinations of risk level, cost and behavioral modifiers. RESULTS: Many women (77%) reported 'definite' interest in genetic testing, with greater interest in tests that conveyed more risk and cost less. Behavioral modifiers of risk (taking a vitamin; diet/exercise), having a regular physician, greater perceived benefits of genetic testing, and greater cancer worry also influenced interest. Most participants (63%) did not understand relative vs. absolute risk. Women with less understanding reported more cancer worry and greater willingness to pay for testing. CONCLUSION: Interest in genetic testing for mutations related to modest changes in risk was high, modified by both test and psychosocial factors. Findings highlight the need for education about benefits and risks of testing for mutations that convey modest changes in risk, particularly given the current lack of clinical validity/utility and availability of direct-to-consumer genetic testing.

Partial deletion of the LAMA3 gene is responsible for hereditary junctional epidermolysis bullosa in the American Saddlebred Horse.

Laminin 5 is a heterotrimeric basement membrane protein integral to the structure and function of the dermal-epidermal junction. It consists of three glycoprotein subunits: the alpha3, beta3 and gamma2 chains, which are encoded by the LAMA3, LAMB3 and LAMC2 genes respectively. A mutation in any of these genes results in the condition known as hereditary junctional epidermolysis bullosa (JEB). A 6589-bp deletion spanning exons 24-27 was found in the LAMA3 gene in American Saddlebred foals born with the skin-blistering condition epitheliogenesis imperfecta. The deletion confirms that this autosomal recessive condition in the American Saddlebred Horse can indeed be classified as JEB and corresponds to Herlitz JEB in humans. A diagnostic test was developed and nine of 175 randomly selected American Saddlebred foals from the 2007 foal crop were found to be carriers of the mutation (frequency of 0.026).

Gestational, periparturient and preweaning growth traits of Holstein versus Gir x Holstein F1 crossbred dairy calves born to Holstein dams.

The objectives of this study were to assess the gestational, periparturient and preweaning growth traits of Holstein vs Gir x Holstein (G x H F1) cross-bred dairy calves. Holstein cows (n=64) pregnant with Holstein (H x H) calves (bulls, n=16; heifers, n=18) or G x H (bulls, n=8; heifers, n=22) calves were sampled from 60 days of gestation through calving for serum progesterone (P4) and in utero placentome sizes, and at parturition for calving ease scores (CES), calf vigour scores (CVS), and placental characteristics. Post-calving calf measures included birth weight (day 0) and body weight (kg), hip width (HW), body length (BL), wither height (WH), hip height (HH) and heart girth (HG) through 42 days of age. Serum IgG and calf vital function tests (respiration rate (RR), heart rate (HR), rectal temperature (RT) and fecal scores) were recorded on days 1, 3, 7 and 14 of age (a.m. and p.m.). Serum gestational P4 was higher (p < 0.05) for cows with H x H than G x H calves. Placentome measurements in utero were greater (p < 0.01) for H x H calves than for G x H calves, while at parturition placental characteristics did not differ (p > 0.10). Gestation length, CES and CVS also did not differ (p > 0.10) between H x H and G x H calves. Calf RR and HR were higher (p < 0.05) for H x H than G x H calves at both a.m. and p.m., while RT, fecal scores and serum IgG did not differ (p > 0.10) between H x H and G x H calves. Birth weight did not differ (p > 0.10) between H x H and G x H calves within sex. Moreover, bulls did not differ (p > 0.10) in any of the growth measures between H x H and G x H calves, whereas H x H heifers at days 28 and 42 of age were greater (p < 0.05) in all growth traits than G x H heifers. Nevertheless, the relative change in growth measures over time (days 0 to 42) did not differ (p > 0.10) between H x H and G x H calves. While subtle differences in gestational, early growth and vital function characteristics were observed, these data suggest very similar developmental profiles between H x H and G x H calves.

Perfusion safety in Europe: managing risks, learning from mistakes.

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?

Pathology of Whitewater Arroyo viral infection in the white-throated woodrat (Neotoma albigula).

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.

Natural bovine lentivirus type 1 infection in Holstein dairy cattle. II. Lymphoid tissue lesions.

Bovine immunodeficiency virus (BIV) in Holstein cows was associated with morphologic evidence of lymphoid organ deficiency. Cows were subjected to normal management practices including parturition and lactation without adverse environmental stresses. During the clinical disease process there was marked weight loss and wasting with frequent and severe concurrent infections. Lymphoid follicular hyperplasia and dysplasia in lymph nodes, and hypertrophy and hyperplasia in hemal lymph nodes were characteristics of the lymphoid tissues. Atrophy of lymphoid cell compartments with depletion of lymphocytes and a lymphocytic lymphoid folliculitis were components of the lymphoid system pathology. The nodal tissue lesions resembled those observed in feline, simian, and human lentiviral disease. A functional correlation with immune system deficiency was the development of multiple bacterial infections which failed to resolve after appropriate therapy. The BIV-associated disease syndrome in dairy cows may be useful as a model system for investigation of the pathogenesis of the lymphoid organ changes that occur in humans and animals with lentiviral infection.

The effects of GnRH administration postinsemination on serum concentrations of progesterone and pregnancy rates in dairy cattle exposed to mild summer heat stress.

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.

Novadaq Spy Intraoperative Imaging System--current status.

The Novadaq Spy Intraoperative Imaging System is able to depict a fluorescent contrast agent emitting light at 830 nm when passing through the vascular tree or through myocardial chambers. The passage of the contrast agent can be observed in real time, allowing quality control in adult and congenital cardiovascular surgery.

Natural bovine lentiviral type 1 infection in Holstein dairy cattle. I. Clinical, serological, and pathological observations.

Clinical, serological, and pathological abnormalities observed in Holstein cows naturally infected with bovine lentivirus 1 bovine immunodeficiency virus (BIV) and other infections were progressive and most commonly associated with weight loss, lymphoid system deficiency, and behavioral changes. Clinical evidence of meningoencephalitis was dullness, stupor, and occasional head or nose pressing postures. The polymerase chain reactions associated the BIV provirus with the lesions in the central nervous system and lymphoid tissues. Multiple concurrent infections developed in retrovirally infected cows undergoing normal stresses associated with parturition and lactation. A major functional correlate of the lymphoreticular alterations was the development of multiple secondary infections which failed to resolve after appropriate antibacterial therapy. The chronic disease syndrome in dairy cows associated with BIV may be useful as a model system for investigation of the pathogenesis of the nervous system lesions and lymphoid organ changes that occur in humans with lentiviral infection.

Predictors of complications in acute type B aortic dissection.

OBJECTIVES: Medical treatment is generally advocated for patients with acute type B aortic dissection without complications. The objective of this retrospective analysis was to determine whether there are any initial findings that can help predict the long-term course of the disease. METHODS: Case records of the 130 patients treated for type B aortic dissection between 1988 and 1997 were reviewed; 41 (31%) were operated on in the acute phase (<14 days), 31 (24%) were operated on in the chronic phase and 58 (45%) were treated medically. RESULTS: Overall acute mortality was 10.8%; 22% for patients operated on in the early phase and 5.6% for medically treated patients. Age (P=0.002), persistent pain (P=0.01) and malperfusion (P=0.001) were significant independent predictors of the need for surgery. Paraplegia/para paresis (P=0.0001), leg ischaemia (P=0.003), pleural effusion (P=0.003), rupture (P=0.0001), shock (P=0.0001), age (P=0.003), cardiac failure (P=0.002) and aortic diameter >4.5 cm (P=0.002) were significant predictors of poor survival. Age and shock also emerged as independent risk factors. Patients without malperfusion (P=0.0001), pleural effusion (P=0.003), rupture (P=0.0001) and shock (P=0.0001) had a significantly better event-free survival (freedom from repeat surgery and death). The actuarial survival rate for high-risk patients (malperfusion, rupture, shock) was 62% at 1 year and 40% at 5 years; the corresponding values for low-risk patients were 94 and 84%, respectively. CONCLUSIONS: Rupture, shock and malperfusion are significant predictors of poor survival in patients with acute type B aortic dissection.

Contemporary perspectives in tobacco cessation: what oncologists need to know.

Within the last 5 years there has been a large outgrowth of smoking cessation research, largely encouraged by the release of the 1996 Clinical Practice Guidelines for Treating Tobacco Use and Dependence. These federal guidelines published by the Agency for Healthcare Policy and Research offered comprehensive empirical evidence that tobacco cessation interventions are effective and encouraged routine implementation within medical settings. Since that time, numerous studies in tobacco cessation have augmented the state of knowledge regarding successful smoking intervention modalities. Unfortunately, approximately one-third of cancer-related deaths continue to be attributed to smoking behaviors. It is imperative that health care providers encourage and participate in the smoking cessation efforts of their patients and family members. This article provides a review of the current literature in smoking cessation and describes first-line therapies with proven effectiveness in tobacco cessation. Clinicians are encouraged to consistently screen for tobacco use and provide brief interventions utilizing behavioral counseling and pharmacotherapies to treat their patients' tobacco dependence.

Does the morphology of mitral paravalvular leaks influence symptoms and hemolysis?

BACKGROUND AND AIM OF THE STUDY: Prosthetic mitral valve replacement (MVR) is associated with paravalvular leak in up to 12.5% of patients. The influence of the morphology and location of paravalvular leaks on clinical symptoms and degree of leak-related hemolysis is unknown. METHODS: Morphology, size, location and number of paravalvular leaks were analyzed in 96 consecutive patients with primary mitral paravalvular leaks. RESULTS: Mitral leak was diagnosed a median of 119 days after primary MVR. A small (1-2 mm) paravalvular leak was found in 41 patients (43%), an intermediate leak (3-5 mm) in 26 (27%), and a large leak (6-15 mm) in 29 (30%). Single leaks were observed in 70 patients (73%), whilst 26 (27%) had multiple leaks. Paravalvular leaks occurred around the entire prosthetic circumference, but were seen predominantly around the mitral commissural areas (76%). The larger the size of the leak, the more symptomatic the patient (p = 0.006); 80% of patients with small leaks were in NYHA classes I and II, whilst 62% with intermediate/large leaks were in NYHA classes III and IV. The number of leaks was not correlated with severity of clinical symptoms. Multiple leaks were more likely to cause significant hemolysis. Patients with preoperative chronic renal insufficiency, postoperative infection or large (>5 cm) left atria were more likely to develop multiple leaks. The size and location of the leaks was surgeon-dependent. CONCLUSION: Intraoperative transesophageal echocardiography is mandatory to detect possible small leaks and technical errors. Strict monitoring of all MVR patients is necessary for prolonged periods, as the appearance of paravalvular leaks is not necessarily correlated with clinical symptoms. Small paravalvular leaks, in particular, may go unnoticed. As the location and size of the leaks were significantly surgeon-dependent, self-monitoring should be mandatory for all surgeons.

Pre-pregnancy drinking: how drink size affects risk assessment.

AIMS: We considered the role of drink size in determining average daily consumption among groups at risk for Fetal Alcohol Syndrome. DESIGN: In-person hour-long interviews gathered cross-sectional retrospective data about drinking before an index pregnancy. SETTING: Subjects were recruited at public clinics in Los Angeles and the San Francisco Bay area. To reach those not necessarily seeking prenatal care, community outreach in the same urban areas was undertaken. PARTICIPANTS: Three hundred and twenty-one pregnant women were interviewed: 102 Native Americans, 185 African Americans, and 34 Caucasians. MEASUREMENTS: Volume of drinking prior to pregnancy was assessed using the graduated frequency series, which asks respondents to specify their drinking in terms of standard drinks. Using vessel models and photographs, respondent-defined drink sizes were then determined, and volume was recalculated accordingly. FINDINGS: For most beverages, the difference in milliliters between self-selected drink size and a standard size drink was significant, with the mean self-selected drink sizes ranging from 49% above the standard size (for beer) to 307% above the standard size (for spirits). For women whose pre-pregnancy average daily volume (ADV) was at the risk level of > or = 1 standard drink per day, ADV increased from four to almost 10 standard drinks per day when self-defined drink sizes were instead considered. Similarly, for women having three or more standard drinks a day, their daily dose of ethanol increased from 57 g to 153 g of ethanol per day. CONCLUSIONS: If risk levels have been based on underestimates that assume women with alcohol-affected infants had standard drink sizes, then true risk levels may be higher than previously thought. Related, risk drinkers presenting at prenatal clinics may be missed if screening protocols do not ask about drink size.