Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices

Neurologic complications after cardiac surgery are of growing importance for an aging surgical population. In this review, we provide a critical appraisal of the impact of current cardiopulmonary bypass (CPB) management strategies on neurologic complications. Other than the use of 20-40 microm arterial line filters and membrane oxygenators, newer modifications of the basic CPB apparatus or the use of specialized equipment or procedures (including hypothermia and "tight" glucose control) have unproven benefit on neurologic outcomes. Epiaortic ultrasound can be considered for ascending aorta manipulations to avoid atheroma, although available clinical trials assessing this maneuver are limited. Current approaches for managing flow, arterial blood pressure, and pH during CPB are supported by data from clinical investigations, but these studies included few elderly or high-risk patients and predated many other contemporary practices. Although there are promising data on the benefits of some drugs blocking excitatory amino acid signaling pathways and inflammation, there are currently no drugs that can be recommended for neuroprotection during CPB. Together, the reviewed data highlight the deficiencies of the current knowledge base that physicians are dependent on to guide patient care during CPB. Multicenter clinical trials assessing measures to reduce the frequency of neurologic complications are needed to develop evidence-based strategies to avoid increasing patient morbidity and mortality.     

Low birth weight subsequent to induced abortion. A historical prospective study of 948 women in Skopje, Yugoslavia.

In the fall of 1972, interviews were conducted with 948 Yugoslavian women whose first pregnancies had been terminated by induced abortion (222) or delivery (726) during 1968-1969. Subjects were indentified from records of the Obstetrics and Gynecology Clinic of Skopje University, Macedonia. Subsequent pregnancies were studied to determine the relative effects of first-pregnancy abortion or delivery on incidences of adverse outcomes. No significant difference were found between first-pregnancy aborters and deliverers for subsequent conception rates, spontaneous abortions, or low-birth-weight rates. The data suggest that while induced abortion of the first pregnancy did not protect against the greater risk of low birth weight for a primiparous birth, neither did it increase that risk. The high proportion of women who denied their abortion raises questions about results of retrospective abortion studies which depend on patient recall.     

Maternal expectations of postpartum social support: validation of the Postpartum Social Support Questionnaire during pregnancy

Thirteen percent of women experience postpartum depression. Prenatal screening for anticipated postpartum social support, a postpartum depression risk factor, may allow for early intervention. We sought to validate use of a modified version of the Postpartum Social Support Questionnaire (PSSQ) in pregnant women at increased risk for postpartum depression. Factor analysis using orthogonal varimax rotation was used. The modified PSSQ, administered during pregnancy, yields similar loading patterns as observed in postpartum administration of the original PSSQ.     

Do Vaccination Strategies Implemented by Nursing Homes Narrow the Racial Gap in Receipt of Influenza Vaccination in the United States?

OBJECTIVES: To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility‐wide vaccination strategies than in residents of facilities without vaccination strategies. DESIGN: Secondary data analysis using the National Nursing Home Survey 2004, a nationally representative survey. SETTING: One thousand one hundred seventy‐four participating nursing homes sampled systematically with probability proportional to bed size. PARTICIPANTS: Thirteen thousand five hundred seven randomly sampled residents of nursing homes between August and December 2004. MEASUREMENTS: Receipt of influenza vaccine within the last year. Logistic regression was used to examine the relationship between facility‐level influenza immunization strategy and racial inequity in receipt of vaccination, adjusted for characteristics at the resident, facility, state, and regional levels. RESULTS: Overall in the Untied States, vaccination coverage was higher for Caucasian and African‐American residents; the racial vaccination gaps were smaller (<6 percentage points) and nonsignificant in residents of homes with standing orders for influenza vaccinations (P=.14), verbal consent allowed for vaccinations(P=.39), and routine review of facility‐wide vaccination rates (P=.61) than for residents of homes without these strategies. The racial vaccination gap in residents of homes without these strategies were two to three times as high (P=.009, P=.002, and P=.002, respectively). CONCLUSION: The presence of several immunization strategies in nursing homes is associated with higher vaccination coverage for Caucasian and African‐American residents, narrowing the national vaccination racial gap.