How severity and classification of pulmonary hypertension affect pregnancy outcomes: a systematic review and timeline.

Women with pulmonary hypertension (PH) have increased mortality during pregnancy and the peripartum period. An increasing number of publications suggest improvements in maternal outcomes, so we conducted a systematic review focusing on disease severity and maternal survival. After screening 9097 potential studies from 1967 to 2021, we identified 66 relevant publications. Outcomes improved continuously over time and mortality fell from 11.6% in studies published before 2015 to 8.2% in studies published after 2015. Mortality was lower in patients with mild disease (0.8%) than in those with Eisenmenger syndrome (26.2%) or idiopathic pulmonary arterial hypertension (7.4-24.0%). One major drawback of the published studies is that they define severity using echocardiographic-estimated pulmonary artery pressures, without considering more contemporary parameters. This systematic review provides new insights for preconception counseling on pregnancy risks related to PH and suggests that PH classification and severity should be carefully considered in determining an individual's pregnancy-associated risk.

The Year in Cardiothoracic Critical Care: Selected Highlights from 2019.

In 2019, cardiothoracic and vascular critical care remained an important focus and subspecialty. This article continues the annual series to review relevant contributions in postoperative critical care that may affect the cardiac anesthesiologist. Herein, the pertinent literature published in 2019 is explored and organized by organ system.

Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have been associated with improved perioperative outcomes following several surgical procedures. Less is known, however, regarding their use following hepatic surgery. METHODS: An evidence-based, standardized perioperative care pathway was developed and implemented prospectively among patients undergoing open liver surgery between 1 January 2014 and 31 July 2015. Perioperative outcomes, including length of hospital stay, postoperative complications and healthcare costs, were compared between groups of patients who had surgery before and after introduction of the ERAS pathway. Provider perceptions regarding the perioperative pathway were assessed using an online questionnaire. RESULTS: There were no differences in patient or disease characteristics between pre-ERAS (42 patients) and post-ERAS (75) groups. Although mean pain scores were comparable between the two groups, patients treated within the ERAS pathway had a marked reduction in opioid use on the first 3 days after surgery compared with those treated before introduction of the pathway (all P < 0·001). Duration of hospital stay was shorter in the post-ERAS group (median 5 (i.q.r. 4-7) days versus 6 (5-7) days in the pre-ERAS group; P = 0·037) and there was a lower incidence of postoperative complications (1 versus 10 per cent; P = 0·036). Implementation of the ERAS pathway was associated with a 40·7 per cent decrease in laboratory costs (-US $333; -€306, exchange rate 4 January 2016) and a 21·5 per cent reduction in medical supply costs (-US $394; -€362) per patient. Although 91·0 per cent of providers endorsed the ERAS pathway, 33·8 per cent identified provider aversion to a standardized protocol as the greatest hurdle to implementation. CONCLUSION: The introduction of a multimodal ERAS programme following open liver surgery was associated with a reduction in opioid use, shorter hospital stay and decreased hospital costs. ERAS was endorsed by an overwhelming majority of providers.

Population and subspecific genetic differentiation in the foxtail pine (Pinus balfouriana).

We performed an allozyme survey of genetic differentiation in Pinus balfouriana, a subalpine conifer endemic to California that is comprised of two allopatric subspecies, one in the Klamath Mountains and the other in the southern Sierra Nevada. Although the two subspecies are morphologically distinct and gene flow between them is virtually nonexistent, we observed much higher levels of differentiation among populations within a subspecies than between the two subspecies. Differentiation is particularly strong in the Klamath populations (multilocus FST = 0.242), which are small, isolated, and ecologically marginal. We attribute this strong differentiation to the mountain island effect, in which populations restricted to high elevations become isolated from each other on different mountains separated by unsuitable intervening habitat, with consequent reduced gene flow allowing populations to evolve independently. Populations of P. balfouriana in the Klamath region only exist scattered on the few highest ridges and peaks that rise above 2,000 m, which defines the lower limit of the species elevational distribution. This pattern of distribution has allowed genetic drift and allelic sorting through historical events to produce strong population-level differentiation, which was likely in place before the two subspecies were geographically separated. Because P. balfouriana occurs on both serpentine soils and nonserpentine soils in the Klamath Mountains, we tested for genetic differentiation between populations growing on serpentine versus nonserpentine soils and our results were equivocal. Our data, combined with several other studies of conifers, show that the mountain island effect can produce significant genetic differentiation in conifers whose life-history traits of widely dispersed pollen, long generation times, and high outcrossing rates would lead us to predict a more homogenous population genetic structure.

Variation in allozymes and stomatal size in pinyon (Pinus edulis, Pinaceae), associated with soil moisture.

Microgeographic allozyme variation was examined in pinyon pine, Pinus edulis, among five collection sites in Owl Canyon, Colorado. Relatively dry and moist sites were identified by associated plant communities and the sizes and densities of trees. Three moist sites and two dry sites were compared, and because all sites were within 600 m of one another, isolation by distance was not considered as a viable explanation of genetic differentiation between sites. Allelic frequencies at glycerate dehydrogenase (Gly) differed by 14% between moist and dry areas, and the pattern of microgeographic variation found here-allele 3 higher in frequency on dry sites-was consistent with previous studies of microgeographic variation in contrasting moist and dry sites. Trees within one of the dry sites were examined to test the hypothesis that stomata sizes and densities are heterogeneous among Gly genotypes. Heterozygotes had the longest and widest stomata; the stomatal area of heterozygotes was 28% greater than the stomatal area of homozygotes. Whereas the stomatal areas of the two homozygotes were similar, their shapes did not overlap when projected on a bivariate plot of length and width. These results suggest that stomatal shape may play a role in adapting pinyon to heterogeneity in soil moisture.

Hemispherectomy for intractable seizures in children: a report of 58 cases.

Fifty-eight children who underwent anatomical, functional, or modified anatomical hemispherectomy for intractable seizures from 1986 to 1995 were evaluated for seizure control, motor function, and complications. Age at surgery ranged from 0.3 to 17.3 years (median 2.8 years). Twenty-seven anatomical, 27 functional, and 4 modified anatomical hemispherectomies were performed. Seizure control and motor function in the 50 patients with more than 1 year follow-up revealed a 90% or better reduction in seizure frequency in 44/50 (88%) overall: 19/22 (86%) anatomical, 23/26 (89%) functional, and 2/2 modified anatomical. Motor function of the preoperatively hemiparetic extremities was improved or unchanged postoperatively in 38/50 (76%) of the patients. Complications included one intraoperative death, one late death from shunt obstruction managed elsewhere, late postoperative seizure breakthrough requiring reoperation and further disconnection in 5/27 functional hemispherectomy patients, mild cerebrospinal fluid infections in 3/27 anatomical hemispherectomy patients, and hydrocephalus requiring shunting in 3/27 functional hemispherectomy patients. A review of the literature and comparison of techniques is presented.

Metabolic responses of the neonatal rabbit brain to hydrocephalus and shunting.

The metabolic changes that occur in the neonatal brain as a result of hydrocephalus, and the response to ventriculoperitoneal shunting, vary with the maturational stage of the brain. In this study, local glucose utilization (LCMRglu) and oxidative metabolic capacity were estimated using 2-deoxyglucose autoradiography and cytochrome oxidase histochemistry, respectively. Hydrocephalus was induced in rabbit pups via intracisternal kaolin injections at 4-6 days of age. Shunting occurred at 19-26 days of age and the animals were sacrificed at ages ranging from 33 to 331 days. In normal animals there was a high glucose demand early in life which showed a decrease at about 60 days of age. In rabbits sacrificed prior to 60 days of age the controls showed the highest LCMRglu with significant decreases in both the hydrocephalic and shunted animals. After 60 days of age the shunted animals had higher LCMRglu than both the hydrocephalic and control subjects. Oxidative metabolic capacity peaked before 50 days of age in normal animals. At the youngest age, both the hydrocephalic and shunted animals showed higher cytochrome oxidase density rates than the control rabbits. In the older group, the hydrocephalic animals remained high while the shunted animals approximated the control densities. Neither the changes seen in the LCMRglu nor the oxidative metabolic capacity were correlated with changes in cell packing density or increased intracranial pressure. These data suggest that when the brain is compromised by hydrocephalus, there is an initial compensatory increase in oxidative metabolic capacity. The development of the glycolytic pathway appears to be retarded by hydrocephalus, but with shunting and the passage of time, the LCMRglu rebounds to levels above that of controls.

Neuroamine related compounds in the CSF of hydrocephalic rabbits.

The effects of neonatal hydrocephalus on the levels of tyrosine, tryptophan, 5-hydroxyindoleacetic acid (5-HIAA), and homovanillic acid (HVA) in CSF were determined by high-performance liquid chromatography (HPLC) with fluorometric detection in normal and chronically hydrocephalic rabbits. The hydrocephalic rabbits showed a highly significant increase in both the serotonin metabolite 5-HIAA and the dopamine metabolite HVA. There were no significant effects of the hydrocephalus on either tyrosine or tryptophan levels. There was a significant positive correlation between the intracranial pressure (ICP) and the increase in 5-HIAA and HVA, but not with the two precursor amino acids. There was a significant decrease in these amino acid precursors with age in both groups. A trend towards higher levels of 5-HIAA and HVA in older rabbits was also evident, however this change was not to the degree found in the hydrocephalics. These data indicate that increased ICP affects the mechanism of removal of 5-HIAA and HVA from the cerebrospinal fluid.

Field experimental evidence for diffuse competition among Southwestern riparian birds.

In a 6-yr study of 70 generally insectivorous bird species in Arizona riparian woodlands, abundances of cavity-nesting species increased on 50 experimental plots compared with 49 control plots, following addition of artificial nest boxes. Open-nesting birds increased in abundance on control plots during the study but avoided experimental plots relative to control plots after box addition. Multivariate analysis revealed that a negative response of open nesters to the experiment was widespread among a large and ecologically diverse group of species. Results of this field experiment suggest that communitywide (diffuse) competition was an important factor influencing the distribution and abundance of birds in these riparian ecosystems.

Attitudes, beliefs, and knowledge about mammography among women over forty years of age.

In this study, the relative impact of health beliefs and physician request in predicting previous mammography experience among women over age 40 was examined. Responses from a sample of 201 women were analyzed using multiple regression techniques. The variable that accounted for the largest proportion (56%) of variance between women who had a mammogram or intended to and those who had not had the test and did not intend to was physician request for mammography. Women's perceptions about the benefits of mammography and perceived barriers were also significant, but the relative strength of these variables was low. Among women who had been asked by a physician to have a mammogram, 89.6% had done so, while only 10.4% of women who had not been asked to have a mammogram had done so. Implications for cancer education are discussed.

Primary lymphoma of the cervix. A case report.

A case of primary lymphoma of the cervix, which illustrates the difficulty in histological diagnosis in such cases, is presented, and one method of treating the condition, namely by chemotherapy, is discussed.

Carcinoma of the cervix -- a tragic disease in South Africa.

Reports from several large gynaecological oncology units in South Africa reveal that most patients with carcinoma of the cervix present in an advanced stage of the disease when it is incurable. Mass Papanicolaou smear campaigns in other areas in the world have resulted in almost complete eradication of the disease, and it is suggested that invasive carcinoma of the cervix is preventable in most cases. It is considered that it is the responsibility of the State Health Department to institute mass Papanicolaou smear campaigns in South Africa for certain sections of the population who are at risk, and these have been defined. This would reduce the enormous cost of management of most of these cases in their advanced stages.

Acid precipitation in the Western United States.

Precipitation chemistry data from a rural area at an elevation of 2900 meters near the Continental Divide in Colorado show unexpectedly low pH values for bulk precipitation. A significant downward trend in pH over the last 3 years is associated with increasing amounts of nitric acid in precipitation.

The Abortion and Sterilization Act in 1975--experience of the Johannesburg Hospital Pregnancy Advisory Clinic.

The experience of a Pregnancy Advisory Service operating in terms of the Abortion and Sterilization Act of 1975 is reviewed. A total of 454 applications for abortion were considered, of which 198 (44%) were accepted and the abortions performed. The urgent need for sex education at schools, colleges and universities is stressed, in view of the large number of scholars and students under the age of 17 who seek an abortion. There are also patients who discontinue contraception for a variety of reasons, on medical advice or otherwise, without an alternative being suggested or sought. Motivation of patient, nurse and doctor needs urgent improvement.