Indirect Causes Research Articles

A Study on Serum Hepatic Enzymes in Smokers and Nonsmoker’s Adult Male

Background: Cigarette smoking is one of the greatest indirect causes of global death and disease. Cigarette smoke consists of many chemicals, including cytotoxic, carcinogenic and free radicals, therefore it affects many organs including liver either directly or indirectly. Objective: The aim of this study was to find out level of serum hepatic enzymes in smokers and non-smokers adult male. Method: This cross-sectional study was conducted in the Department of Biochemistry, Dhaka Medical College, Dhaka, Bangladesh, from January 2019 to December 2019. Total study subjects were one hundred and twenty with age ranging from 20 to 50 years of male gender, selected from attendance of admitted patients and third & forth class employees of Dhaka Medical College Hospital, Dhaka. Study subjects were grouped smokers as Group A and age and gender matched, nonsmokers as Group B. Group A smokers again divided into three groups. Group A1- heavy smokers (who consume 20 cigarette sticks or more per day) consist of thirty study subjects, Group A2- moderate smokers (who consume 11-19 cigarette sticks per day) consist of thirty study subjects and Group A3- light smokers (who consume 1-10 cigarette sticks per day) consist of thirty study subjects. Serum Alanine Transaminase (ALT), Aspartate transaminase (AST) and Alkaline phosphatase (ALP) level of all study subjects were estimated and recorded. Results: Mean age of the study subjects in group A1, A2, A3 & B were 33.88 years, 34.60 years, 34.60 years and 29.80 years. There was a significant increase in serum ALT, AST and ALP level in heavy, moderate and light smokers when compared to nonsmokers, but the increase was more significant in heavy smokers when compared to moderate smokers, also moderate smokers when compared to light smokers. Conclusion: This study revealed that significantly higher level of serum hepatic enzymes with smokers when compared to that of non smokers. This significantly higher level was also seen in heavy smokers in comparison to moderate smokers, moderate smokers in comparison to light smokers.

Perfil epidemiológico, sobrevida e prognóstico materno em unidade de terapia intensiva no nordeste do Brasil

Objective. To study the epidemiologic profile and determine maternal survival and prognosis in an Intensive Care Unit (ICU) in the Northeast of the country. Methods. Analytical cross-sectional design study that evaluated pregnant women, puerperae, and women in postabortion or ectopic pregnancy admitted to an obstetric ICU in Teresina between May/2016 and May/2017. Results. Of the 11,466 occurrences in the period, 456 women were admitted to the ICU. Among the causes of hospitalization, 80.3% patients were direct obstetric causes, 16.2% indirect and 3.5% non-obstetric. A total of 159 patients met the Near Miss criteria, with statistical significance between presentation of the criteria and mortality (p<0.001; x²=30.974). The mortality rate was 3.5%, all of them being Near Miss cases. There was a statistically significant and direct correlation between survival and number of clinical (p<0.001; rp=0.270), laboratory (p<0.001; rp=0.358) and management (p<0.001; rp=0.465) criteria. It was identified that the higher the number of criteria, the longer the length of hospitalization and worse the prognosis (p<0.001). Conclusion. Women admitted to the ICU for indirect obstetric causes who met maternal Near Miss criteria had longer hospitalization and worse prognosis.

Land degradation: Addressing the vulnerability of local people through the lens of transformative change

Land degradation (LD) is driven by many factors resulting from the intricate interplay between natural and socio-economic systems, which adds dynamism and complexity to this phenomenon. The study highlights LD as a source of social vulnerability in the Baragan Plain (Romania), often called the “granary of Europe” due to its century-long history of industrial crop production. We explore the community's perceptions of vulnerability due to LD and the community-based solutions to sustainable transformations through governance using a community-based causal-effect analysis (CBCEA). CBCEA is a participatory approach that uses systems thinking, engages key informants, and generates qualitative causal-effect diagrams to illustrate the system structure. Two workshops with local key informants revealed their views on the direct and indirect causes and effects of LD, strategies they proposed to reduce the community's vulnerability, and the conditions for making the agricultural land decision-making integrative, inclusive, adaptive, and participatory (IIAP). IIAP decision-making was considered a key to transformative governance. Key informants identified “Windbreaks construction” and “(Resilient) Irrigation system” as two effective, context-specific measures to address the causes and effects of LD. We advise caution when implementing the “Irrigation system” measure, as it may risk constraining the system to an undesirable state, commonly referred to as a “trap”.

Causal Relationship Model of Health Literacy, Self-Efficacy Perception, Self-Care Behaviors on Blood Sugar Levels Among Elderly People with Type-2 Diabetes

Objective: To develop a causal relationship model of health literacy, self-efficacy perception, and Self-Care Behaviors on Blood Sugar Levels of Type 2 Diabetes on Elderly and check for the developed model's consistency with empirical data. Method: The sample consisted of 455 elderly people with type-2 diabetes who could not control their glycemic control using stratified sampling. The tool used to collect data was a questionnaire. The confidence value was 0.804-0.964. The LISREL program analyzed structural equation model data. Results: The developed causal relationship model consisted of self-care behaviors as direct negative causes of blood sugar levels. Health literacy and self-efficacy were negative indirect causes of blood sugar levels with self-care behavior as a carrier. The developed model was consistent with the empirical data with Chi-Square = 62.20, df= 54, relative Chi-Square = 1.15, p = 0.20733, RMSEA = 0.0183, RMR= 0.00895, SRMR = 0.0186, GFI = 0.983, AGFI = 0.962, CFI = 0.999, NFI = 0.989 and all variables contributed to the percentage variance in blood glucose level. at 97.8 %. Conclusion: The findings revealed that in caring for the elderly with type 2 diabetes, health literacy development must be considered, self-efficacy perception and better self-care behavior in order to help reduce blood sugar levels in this group of elderly people in the end.

Nutrition Education and Nutritional Status of Chronic Lack of Energy Pregnant Women in PUSKESMAS Work Areas Throughout Kupang City

One of the indirect causes of preventable maternal and child mortality is the health status of pregnant women. Pregnant women with SEZ conditions are at risk of experiencing decreased muscle strength, which is needed in the process of labor so that it can result in fetal death, premature birth, birth defects, low birth weight babies, short birth babies and even infant death. The design used is quantitative with a cross sectional approach with univariate and bivariate analysis using the Chi-Square test. The population of this study were all pregnant women who did pregnancy checks at the Puskesmas in Kupang City in 2022. Sample technique using purposive sampling technique. This study was conducted from January to December 2022. The results showed that of all pregnant women who were given nutrition education in the form of counseling and provision of additional food, most experienced weight gain. In contrast to the increase in LiLA, although there is a change in the size of LiLA after being given education, there are still pregnant women who do not experience changes in LiLA. The statistical test results obtained a p-value <0.005, which means that there is a relationship between the provision of nutrition education and the improvement of the nutritional status of pregnant women with SEZ. It is expected for health workers to carry out special monitoring of pregnant women at risk of SEZ in conducting health checks and consuming additional nutritionally balanced foods.

A Study of the Prevalence of Anemia in Children With Severe Acute Malnutrition at a Pediatric Tertiary Care Hospital in South India.

Introduction In developing countries such as India, severe acute malnutrition (SAM) has been a cause for great concern in the pediatric population. SAM is associated with significant morbidity and mortality in children less than 60 months of age and leaves them vulnerable to diseases due to a decrease in immunological response. Children with SAM are prone to infections, and due to nutritional deficiency, many have anemia whichmay be a direct or indirect cause of morbidity and mortality. They are affected by frequent respiratory and gastrointestinal infections. Methodology A cross-sectional study was conducted for a period of two months, from December 1,2023, to January 31, 2024, in children with SAM aged less than 60 months. A detailed history and demographic profile were taken and recorded in a predesigned proforma. Anthropometric measurements of the study subjects were recorded, and lab investigations included complete blood picture, serum iron, serum ferritin, serum folate, and serum vitamin B12 levels. The prevalence and severity of anemia were determined by assessing the hemoglobin levels. The data collected was analyzed in Excel sheets (Microsoft Corporation, Redmond, Washington, United States) and the results were depicted in the form of graphs. Results A total of 300 children were included in the study of which 22 children were aged less than six months and 278 children were in the age group of 6-60 months. The overall gender distribution was 124 (41.4%) males and 176 (58.6%) females. In the age group of <6 months, of the 22 children, six (27.27%) were females while 16 (72.72%) were male. In the age group of 6-60 months, of the 278 children, 170 (61%) were females while 108 (39%) were males. Of the total 300 children, 232 (77.3%) were found to be anemic, of which 54 (23.2%) had mild anemia, 162 (69.8%) had moderate anemia, and 16 (6.89%) had severe anemia. Low serum iron levels were detected in 134 (44.6%) with iron deficiency being more common in females; below-normal ferritin levels were seen in 153 (51%) cases. Folate levels were found to be deficient in 97 (32.3%) children while vitamin B12 levels were deficient in 186 (62%). Conclusion Anemia is a common occurrence in children with SAM. Prevention of anemia starts from the womb by improvement of maternal nutrition and iron, and folic acid supplementation during pregnancy. Exclusive breastfeeding up to six months of age and further continuation of breastfeeding coupled with initiation of home-available complementary feeding from the age of six months onwards go a long way in maintaining healthy nutrition status inchildren in the vulnerable age group of less than 60 months. Healthcare professionals should utilize thewell-baby and well-child visits to educate the parents and primary caretakers regarding the feeding practicesto prevent, detect, and treatanemia, which will help reduce the morbidity and mortality in children with SAM.

The Multi-level Hierarchical Structure Analysis of Influencing Factors of Coal Mine Managers' Blame Avoidance Behavior

BackgroundIn the Chinese coal industry, widespread blame avoidance behavior (BAB) greatly impacts coal mine accidents. Therefore, it is necessary to stop the BAB of coal mine managers and raise the management level of coal mine enterprises for the safe development of Chinese coal industry. MethodsBased on the semi-structured interviews and questionnaire surveys (20 middle-level managers in coal mines), this paper used the Grounded Theory and Nvivo Software qualitative research methodology to open, spindle, and selectively encode the interview data. Then, an index system of factors influencing BAB of coal mine managers was constructed. The influence degree, affected degree, centrality degree, cause degree of each influencing factor were calculated and the hierarchical model of influencing factors of BAB of coal mine managers was established by the DEMATEL-ISM method which is a decision support tool used to evaluate and analyze the interdependencies between influencing factors. ResultsIndex system of factors influencing BAB of coal mine managers included four levels and 12 influencing factors: individual, organizational, institutional environmental, and situational factors. The hierarchical model identified eight causal factors and four consequential factors, of which safety management (15.355), work attitude (14.380), and work group performance (14.281) in the top three of the centrality rankings are the key factors affecting the avoidance behavior of coal mine managers; A 3-level multilevel structure was constructed to reflect the interactions among the factors influencing the BAB of coal mine managers in terms of direct, indirect, and root causes, and corresponding improvement measures were proposed. ConclusionThis study offers a theoretical complement and practical guidance for stopping BAB of coal mine managers.

Pengaruh Tidak Langsung Penggunaan Alat Kontrasepsi terhadap Kejadian Stunting di Desa Oetutulu, Kabupaten Rote Ndao

Stunting is a disorder of child growth and development due to chronic malnutrition and recurrent infections, characterized by a child's length or height below the standard. Indirect causes of stunting include ineffective parenting, health services, food availability, economy, parental education, clean water sources and environmental sanitation. The use of contraceptives is also one of the indirect causes of stunting. In 2023, Northwest Rote Subdistrict experienced 338 incidents of stunting and Oetutulu Village experienced 51 prevalence of stunting caused by a lack of good pregnancy planning, so that the birth distance became too close. This research is an analytic survey research using cross-sectional method. The purpose of this study was to determine the effect of contraceptive use on the incidence of stunting in Oetutulu Village, Rote Ndao Regency. The results showed that there was a significant influence between knowledge (p=0,034) and attitude (p=0,025) of couples of childbearing age on the use of contraceptives. The use of contraceptives also affects the incidence of stunting in Oetutulu Village, Rote Ndao Regency. It is expected that the community of Oetutulu Village can better plan pregnancy programs and use contraceptives as an effort to reduce the incidence of stunting.

The Effectiveness of Bupropion in Cigarette Smoking Cessation - A Narrative Review

Smoking is still a large indirect cause of premature death worldwide. The first line of treatment for smoking cessation is nicotine replacement therapy (NRT). Bupropion, a drug primarily developed as an antidepressant, in some countries is the first drug licensed for smoking cessation that is not associated with nicotine. The drug acts mostly through its inhibition of dopamine reuptake in the neuronal synapses, but other effects of bupropion may also have a role in smoking cessation. There have been many clinical studies of bupropion that have shown impressive results in helping patients with smoking cessation. Because of its antidepressant role, it is useful in smoking cessation in patients with depression. Through the years bupropion has proven to be a potential cost-effective alternative to NRT.

EXPERT SYSTEM FOR DIAGNOSING DISEASES IN PREGNANT WOMEN USING FORWARD CHAINING AND NAÏVE BAYES METHODS

Disease in pregnant women is a disease suffered during pregnancy, lack of knowledge about the symptoms that are felt during pregnancy makes pregnant women ignore certain symptoms that can indicate dangerous diseases and become an indirect cause of death for the mother and baby in the womb. In addition, the risk of maternal death is also higher due to delays in making a decision to be referred. Based on this, an expert system was created where this system acts as an expert in diagnosing diseases in pregnant women. This system has 22 symptoms including nausea, vomiting, dizziness and so on and there are 5 diseases namely anemia, hemorrhoids, preeclampsia, placenta previa and Gestational Diabetes. By using the methodForward Chaining and Naïve Bayes which can help identify diseases during pregnancy based on the symptoms experienced by pregnant women. This application is web-based so that patients can access the application directly even though they are not at the Puskesmas. Based on testing by entering symptoms, namely blood pressure over 140/90 mm/Hg, easy thirst, blurred vision, pain in the pit of the stomach, and nausea, the results of system diagnosis and manual calculations have the same results, namely Preeclampsia 6.61%, Diabetes Gestional 66 .73% and Anemia 26.65%.

GAMBARAN TIPE ANEMIA PADA IBU HAMIL BERDASARKAN NILAI INDEKS ERITROSIT DI RSIA RESTU IBU TAHUN 2022

Anemia in pregnant women is a global problem that impacts both mother and fetus. Anemia in pregnancy is associated with maternal morbidity and is an indirect cause of maternal death in the entire population of pregnant women. Classification of anemia based on the erythrocyte index value is divided into normochromic normocytic, normochromic macrocytic, hypochromic microcytic and hypochromic macrocytic anemia. The erythrocyte index values ​​are divided into Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin (MCH) and Mean Corpuscular Hemoglobin Concentration (MCHC). The aim of the research is to describe the types of anemia in pregnant women based on the erythrocyte index value at RSIA Restu Ibu Sragen in 2022. This research uses a quantitative descriptive research type with a retrospective approach. The research sample was 51 medical records of pregnant women who experienced anemia at RSIA Restu Ibu Sragen in January-December 2022 using purposive sampling. The materials and tools used were secondary data from laboratory examination results of pregnant women diagnosed with anemia which included hematocrit, hemoglobin, index erythrocytes (MCV, MCH, and MCHC), Microsoft Excel and SPSS Version 21 software. Data analysis used analysis univariate. The results of the study concluded that pregnant women who experienced anemia at RSIA Restu Ibu Sragen were aged 21-34 years with a third trimester pregnancy and were primigravida. Based on the erythrocyte index, normocytic anemia was normochromic in 18 people (35.3%), microcytic hypochromic anemia in 20 people (39.2%), and macrocytic hypochromic anemia in 13 people (25.5%). So it can be said that most pregnant women experience microcytic hypochromic anemia.

Intervensi Sosial Sebagai Strategi Komunikasi Dalam Menurunkan Stunting di Sidoarjo Jawa Timur

The stunting rate decreased by 2.8%, which was 21.6% in 2022 compared to 24.4% in 2021. The decline is a positive development, but it is still above the threshold set by the World Health Organization (WHO) which should not exceed 20%. This shows that the problem of stunting in Indonesia still requires serious attention. The purpose of the study was to understand social intervention as one of the communication strategies in reducing stunting rates in Sidoarjo Regency. Interventions in communication for social and behavioral change include various methods such as interpersonal communication, the utilization of mass media, and community mobilization and its social aspects. Qualitative research approach with constructivism paradigm. The data collection method was an in-depth interview with 4 resource persons, namely a public relations officer of the Sidoarjo Regency Health Office and three mothers who were the target audience for reducing stunting rates. The results showed that efforts to reduce stunting were carried out through two social interventions, namely specific nutrition interventions to address direct causes and nutrition-sensitive interventions to address indirect causes. Social interventions are carried out in a convergent manner with an emphasis on handling the causes of nutritional problems. Social and behavioral change communication approaches are used to raise awareness about stunting so as to encourage pregnant women and stunted children to improve nutrition and behave healthily.

Ophthalmic Manifestations of Leukemia and Their Management

Patients with leukemia often have ophthalmic manifestations. These occur either from direct infiltrations of neoplastic cells or from indirect or secondary causes. Nearly all ocular structures can be affected by leukemia. Sometimes, ophthalmic involvement can be the first sign of disease relapse. This review article aims to highlight different ocular manifestations of leukemia along with treatment. It involves studying the available material in textbooks, printed and online journals. As there is high prevalence of ocular findings in leukemia, it can be a standard practice that all leukemic patients should have screening by ocular examination. Awareness of the clinical spectrum of leukemic infiltration of ocular region is essential for rapid diagnosis, prompt initiation of treatment and better outcome. If prompt diagnosis and treatment can be done, worsening of vision may be minimized or prevented. Mugda Med Coll J. 2024; 7(1): 36-41

Deforestation drivers in northern Morocco: an exploratory spatial data analysis

Formulating effective policies to address or mitigate deforestation requires a comprehensive understanding of the contributing factors. This study examines the drivers of deforestation from 2001 to 2020 in the Tangier-Tetouan-Al Hoceima (TTA) region, a northern Moroccan area distinguished by the country’s highest deforestation rate. Through an extensive review of existing literature and employing Geist and Lambin’s deforestation framework, we identified five key causes: infrastructure extension, agricultural expansion, logging, wildfires as direct causes, and demographic factors as an indirect cause. Data on deforestation and its contributing factors were sourced from diverse databases, including Global Forest Change (GFC), Global Land Analysis and Discovery (GLAD), Burned Area Product (MODIS Fire_CCI51), World Population, Forest Proximate People (FPP), and National Forest Inventory (NFI) datasets. Pixel-level analysis of GFC data indicated that wildfires are the primary driver of deforestation in the region, accounting for 35.2%, followed by agricultural expansion (30.6%), logging (13.2%), and infrastructure extension (10.1%). The remaining 10.9% of losses were attributed to other disturbances, such as illegal extraction, pests, and dieback. Spatial patterns were further analyzed through Exploratory Spatial Data Analysis (ESDA) methods at a 1 km2 gridded scale, revealing strong clustering for all studied factors. Spatial relationships were explored using the bivariate local Moran’s index, which highlighted the highest spatial dependence between deforestation and fires (I = 0.21). Correlations between deforestation and other factors, including agricultural expansion, logging, infrastructure extension, and demographic pressure, were assessed at 0.18, 0.17, 0.08, and 0.05, respectively. Landscape pressures (LSP), encompassing deforestation, agricultural expansion, fires, infrastructure extension, and demographic pressure, were analyzed using the local Geary index, revealing a positive correlation in approximately 59% of spatial units. Last, a composite map of LSP clusters and an explanatory diagram illustrating dominant patterns in the TTA region were generated based on the results from local Geary’s multivariate and local Moran’s univariate tests.

Vaccination against nodular dermatitis in cattle as an indirect cause of abortions

Lumpy skin disease was first found in the Russian Federation in 2015. Since 2016, vaccination against lumpy skin disease has been mandatory for cattle of all age groups. In this regard, studying the effect of vaccination against lumpy skin disease on the reproductive ability of cows is relevant. One of the reasons for the decrease in the reproductive ability of cows is abortions at different stages of pregnancy. Statistical processing of abortions in Holstein cows for 2019-2022 was carried out. The first experimental group included animals, in which abortions were diagnosed in the period from the first to the sixth month after vaccination against lumpy skin disease; the second group – from the seventh to the twelfth month after vaccination. The total number of abortions during the reference period was 436. In the first experimental group, 232 abortions were diagnosed or 53.2% of all abortions, which was 6.4% more than in the second experimental group. A comparative assessment of the percentage of abortions at different stages of pregnancy indicated that in the first experimental group, abortions with a pregnancy period of less than 70 days accounted for 52.1%, which was 2.8% less than in the second experimental group, and abortions in late stages, correspondingly more by 2.8%. Thus, vaccination against lumpy skin disease may be one of the indirect causes of abortions in cows.

Learning Causes of Functional Dynamic Targets: Screening and Local Methods.

This paper addresses the challenge of identifying causes for functional dynamic targets, which are functions of various variables over time. We develop screening and local learning methods to learn the direct causes of the target, as well as all indirect causes up to a given distance. We first discuss the modeling of the functional dynamic target. Then, we propose a screening method to select the variables that are significantly correlated with the target. On this basis, we introduce an algorithm that combines screening and structural learning techniques to uncover the causal structure among the target and its causes. To tackle the distance effect, where long causal paths weaken correlation, we propose a local method to discover the direct causes of the target in these significant variables and further sequentially find all indirect causes up to a given distance. We show theoretically that our proposed methods can learn the causes correctly under some regular assumptions. Experiments based on synthetic data also show that the proposed methods perform well in learning the causes of the target.

Midwifery hurdles: Navigating tuberculosis screening challenges in South Africa.

In South Africa, screening for tuberculosis during pregnancy is a serious challenge. Tuberculosis is one of the leading indirect causes of mortality in pregnant women. The objective of the study was to explore the challenges experienced by midwives regarding tuberculosis in pregnant women. A qualitative exploratory research method was used to conduct the study. The study population comprised midwives who worked at primary healthcare clinics in the selected local area, Capricorn District, Limpopo province. Purposive non-probability sampling was used to select 10 participants. Data from participants were acquired using in-depth individual semi-structured interviews. Data analysis was carried out using manual thematic analysis following Tesch's technique. The outcomes of this study included midwives knowing their roles regarding tuberculosis screening among pregnant women. They further highlighted their challenges while screening tuberculosis in pregnant women, such as shortage of screening tools, withholding of tuberculosis information, and language barrier. Midwives should have the necessary equipment and be trained in various languages used in the province to improve tuberculosis screening among all pregnant women.Contribution:Infected pregnant women and their unborn children's health can be improved by tuberculosis screening.

The Effect of Auricular Acupressure on Uterine Contractions, Fetal Heart Rate, and Length of Labor in the Active Phase of Primigravida

The still high maternal mortality rate (MMR) in Indonesia, especially in East Java, is caused by indirect causes or other causes such as prolonged labor, so a method is needed to treat cases of prolonged labor such as auricular acupressure. Auricular acupressure (AKAR) is a non-pharmacological method proven effective for uterine contractions, but its side effects on the fetal heart rate (FHR) are unknown. The research aimed to analyze the AKAR method on uterine contractions, FHR, and labor duration in the first stage's active phase. This type of research is truly experimental, with a pretest-posttest control group design. The research subjects were 41 respondents, primigravida active phase first-stage mothers, selected by consecutive sampling and randomly divided into two groups, namely 21 AKAR groups and 20 deep breathing relaxation control groups. The research results of the Friedman test statistical test ρ-value equal 0.000 in the AKAR group and ρ-value equal 0.000 in the control group, meaning that AKAR influences uterine contractions. The Friedman Test findings show that AKAR does not affect FHR (ρ-value equal 0.618). The Independent Sample Test ρ-value equal 0.29 indicates no statistically significant difference between the two groups' labor lengths throughout the first stage's active phase. The AKAR group's average labor time in the first stage of the active phase was 365.40 minutes, with a minimum of 267 minutes and a high of 395 minutes. Conclusion: The auricular acupressure method affects uterine contractions but does not affect the fetal heart rate. There was no difference in the length of labor in the first active phase of labor between the auricular acupressure and deep breathing relaxation groups, so it is recommended that the auricular acupressure method can be used as an alternative complementary care to prevent prolonged labor.

Diagnostic Implication of Skin Tubercles in Choking Case: An Autopsy Case

Tuberous sclerosis is a genetic disorder that affects every organ system, has a diverse presentation and progression, and can be life threatening. The authors encountered a case of a choking death caused by a fragment of rice cake. The deceased was an inmate of a social welfare institution due to mental retardation. The deceased was a 60-year-old male, 170 cm in height, and weighed 74 kg. Autopsy revealed multiple tubercles on the face, undigested food material, including rice cake, in the stomach, cardiomegaly (460 g) with mild coronary atherosclerosis, fatty infiltration into the myocardium, severe pulmonary congestion and edema with froth in the bronchus, and a yellowishbrown mass in each kidney. The brain showed firmness of the cortex in the parietal lobe and blurring of the white-grey matter interface. Histologically, the kidney masses were consistent with angiomyolipoma, and the brain lesion revealed abnormal neurons and astrocytes with a ballooned appearance and glassy cytoplasm, suggestive of tuberous sclerosis. Fatty infiltration and focal interstitial fibrosis were observed in the heart. Toxicology results were negative. The authors determined that the autopsy findings were consistent with tuberous sclerosis and that it may have been the cause of mental retardation, which served as an indirect cause of choking.

Cardiac physiology and pathophysiology in pregnancy.

Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.