World mental health: needs and resources.
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Developing Countries↗
Biomedical subjects
A Cohen
Publications and source records attributed to A Cohen.
Persistent pulmonary hypertension of the newborn and smoking and aspirin and nonsteroidal antiinflammatory drug consumption during pregnancy.
OBJECTIVE: Prenatal causation of persistent pulmonary hypertension of the newborn (PPHB) is suggested by a specific pattern of pulmonary vascular remodeling observed immediately after birth in some infants with fatal PPHN. The goal of this study was to determine whether PPHN is associated with fetal exposure to: (1) tobacco and marijuana smoking (ie, contributors to fetal hypoxemia), (2) consumption of aspirin and other nonsteroidal antiinflammatory drugs (ie, inhibitors of prostaglandin synthesis), and (3) cocaine use (ie, a contributor to vasospasm). DESIGN: Case-control interview study. SETTING: Two Harvard-affiliated newborn intensive care units. PARTICIPANTS: Mothers of case infants who had PPHN or who met criteria for the referent group. INTERVENTIONS: During July 1985 through April 1989, we interviewed mothers of 103 infants with PPHN and 298 control infants. Because of potential selection bias that might result from recruiting only inborn control infants even though two-thirds of cases were outborn, separate analyses compared the 103 total and 35 inborn infants with PPHN with the 298 inborn control infants. Multivariate analyses were used to adjust for potential confounding factors, including maternal education and Medicaid health insurance (ie, two markers of socioeconomic status), other antenatal factors found to be associated with PPHN (ie, maternal urinary tract infection and diabetes mellitus), and the infant's sex. MAIN OUTCOME MEASURES: Self-reported use or consumption of tobacco, marijuana, cocaine, aspirin, and other nonsteroidal antiinflammatory drugs during pregnancy. RESULTS: The adjusted odds ratios (and 95% confidence intervals) for maternal pregnancy exposures to the factors of principal interest among the total study population were: aspirin, 4.9 (1.6-15.3); and nonsteroidal antiinflammatory drugs, 6.2 (1.8-21.8); for the inborn group they were aspirin, 9.6 (2.4-39.0); and nonsteroidal antiinflammatory drugs, 17.5 (4.3-71.6). Although the association between tobacco smoking during pregnancy and PPHN was elevated in univariate analyses, with odds ratios (and 95% confidence intervals) of 2.0 (1.2-3.4) and 1.3 (0.6-3.3) for total and inborn populations, respectively, the relationship was not significant after adjustment for all other factors in the final logistic regression model. Acknowledged illicit drug use was too infrequent (3.2%) to evaluate. CONCLUSION: Maternal consumption of nonsteroidal antiinflammatory drugs and aspirin during pregnancy or the reasons these drugs were ingested seem to contribute to an increased risk of PPHN.
Adult↗
Late-onset keratoconjunctivitis sicca syndrome after bone marrow transplantation: incidence and risk factors. European Group or Blood and Marrow Transplantation (EBMT) Working Party on Late Effects.
The incidence, time course and risk factors associated with late-onset keratoconjunctivitis sicca syndrome after bone marrow transplantation (BMT) was evaluated in a multicenter retrospective cohort study conducted by the European Group for Blood and Marrow Transplantation (EBMT) Working Party on Late Effects. Data were requested from participating European centers on all patients transplanted up to December 1980 and on all patients treated during the year of 1984. Twenty-eight centers reported data on 258 patients and 248 could be evaluated for keratoconjunctivitis. Forty-eight of the 248 (19%) patients developed a keratoconjunctivitis sicca syndrome between 3 and 127 months (13.8 months) after BMT. The actuarial probability of developing dry eyes was 21 +/- 3% at 15 years. Thirty-three of the 48 (69%) patients with sicca syndrome had graft-versus-host disease (GVHD) compared to 60 of 200 (30%) patients without keratoconjunctivitis (P < 0.0001). The probability of developing keratoconjunctivitis sicca syndrome at 15 years was 38 +/- 6% for patients with and 10 +/- 3% (P < 0.0001) for those without chronic GVHD. Factors associated with an increased risk for late-onset of keratoconjunctivitis are chronic GVHD (relative risk 3.5; CI, 1.9-6.9), female patients (5.6; CI, 1.6-18.8), age older than 20 years (3.1; CI, 1.6-5.6), single dose irradiation for preparation to BMT (3.8; CI, 1.3-11.3) and methotrexate for prevention of GVHD (3.6, CI, 1.05-12.8). Late-onset kerato- conjunctivitis is a frequent ocular complication of BMT. With adequate treatment, severe corneal defects can be avoided. It occurs more frequently in patients with chronic GVHD, but, independent of chronic GVHD, more frequently in older patients and in females as it is observed in de novo Sjögren's syndrome. These data support the current concept that chronic GVHD is a reaction of both, allo- and autoimmunity.
Adolescent↗
Laboratory reference values for the 70 year olds.
Reference values for common laboratory tests were determined as part of a cross-sectional survey of 70 year olds in Jerusalem in 1991. Subjects were systematically chosen from electoral lists. They were extensively interviewed regarding demographic, socioeconomic and health characteristics. Subsequently, 456 underwent a thorough medical examination including hematologic, biochemical and endocrinologic testing. Analysis of disease-specific mortality and hospital morbidity at 3 year follow-up proved these subjects to be representative of the overall Jerusalem Jewish population of 70 year olds. Test-specific reference subgroups were determined to exclude effects of known diseases and drug consumption. Reference values in these subgroups differ significantly from reference values currently used for adults without regard to age. The determination of disease for subjects provided the opportunity to identify changes that might reflect normal aging and those that might be affected by subclinical pathology. Interpretation of laboratory testing of older adults must consider the age-related differences in reference values.
Aged↗
The nutritional status of 70 year olds in Jerusalem.
Inadequate nutrition is a major problem of elderly people today, a rapidly growing segment of western societies. Yet information on the nutritional state of the elderly in the community is much needed. We surveyed the nutritional status of a cohort of 70 year olds living in western Jerusalem. A total of 605 persons were interviewed in their home regarding socioeconomic variables, education, self-assessed global health status, use of medicines, and activities of daily living (ADL). In the second stage, a subsample of 463 of the above attended an outpatient geriatric clinic where a medical history was taken and a physical examination, a cognitive test, a psychological profile, blood and urine tests, electrocardiogram, pulmonary function tests, and grip strength measurement performed. Most of the sample population lived at home. Twelve percent reported having severe financial problems. Approximately 14% exhibited some cognitive problems, 83% were totally independent in ADL, and only 15% were housebound with 2.5% being bedbound. Body mass index (BMI) of < 19 kg/m2 was found in 1.1% of the population, while obesity, defined as a BMI > 30 kg/m2, was found in 13.5% of males and 28.6% of females. Polypharmacy was prevalent. A quarter of the study population were taking three or more prescription drugs. Serum triglycerides were below the normal limit in 7.3% of males and 4.7% of females, while total serum cholesterol concentrations were low in 13.9% and 4.7% of males and females respectively. Serum albumin was found below the lower limit of normal (35 g/l) in 16.9% of females and 11.4% of males. The significance of these results, their relation to other nutritional surveys, and their implications for the future are discussed.
Activities of Daily Living↗
Characteristics of falls in 70 year olds in Jerusalem.
Falling is a serious and common problem among the elderly and may result in injury and functional deterioration. The characteristics and risk factors for falling were studied in a cross-sectional study of a cohort of 70-year-old community-dwelling Jewish elderly in Jerusalem. The cohort was found to be representative of the total 70-year-old population of Jerusalem by virtue of having similar hospitalization and mortality rates. Around 28.2% of the cohort reported falling during the past year. Women were more likely than men to have fallen during the past year (39 vs. 19%; P < 0.001). Falls occurred mainly outside of the home, resulting in fractures in 8.4% of persons who fell, all of them women. A female gender, low visual efficiency, poor self-reported general health status, low serum hemoglobin levels, and low lymphocyte counts were associated with a higher incidence of falls. There was no relationship between the pattern of pharmaceutic drug use or utilization of health care services and the risk of falling. We conclude that among the younger elderly, characteristics of falls and risk factors may be different from those in the older elderly.
Accidental Falls↗
Hypertension in the Jerusalem 70 year olds study population: prevalence, awareness, treatment and control.
As part of the Jerusalem 70 year olds study, we evaluated the prevalence, awareness, treatment and control of hypertension (blood pressure > or = 160 mm Hg systolic and/or > or = 95 mm Hg diastolic, or current treatment with prescribed antihypertensive medications). The study cohort consisted of 448 participants, 224 of whom had hypertension. Relative to other populations, awareness was high (87%). Although the treatment rate was also relatively high (86%), the control rate was only 43%. Untreated isolated systolic hypertension was uncommon (5%), as was orthostatic hypotension (6.9%). Thus, despite a remarkable degree of awareness and treatment rate of hypertension, control levels were disappointingly low. This finding, if confirmed, requires further elucidation.
Aged↗
The Jerusalem 70 year olds longitudinal study: gastrointestinal findings.
The objective of this part of the first cross-section of the longitudinal study of a cohort of 70 year olds in Jerusalem was to survey the gastrointestinal symptoms and signs of this heterogeneous population and thus contribute to the knowledge of the development of gastrointestinal diseases in this age group. A total of 605 persons replied to a home-visit questionnaire gathering data on socioeconomic and migration variables. Later on, 463 of these attended an examination at the Geriatric Research Institute where an in-depth anamnesis and physical examination were conducted. A battery of biochemical and hematologic blood tests were performed as well as urine analysis, ECG, and pulmonary function tests. At 3 year follow-up, the interviewed subjects, subjects examined in the hospital, and the control group consisting of 70 year olds who were not examined, were compared. By the measures of disease-specific mortality and hospital morbidity, the three groups were found to be similar, demonstrating that the sample population does represent the total Jerusalem 70-year-old population. This paper describes the symptoms, signs and laboratory results of the gastrointestinal part of this study. Up to a third of the subjects complained of upper gastrointestinal symptoms, most prominent of which was heartburn. Almost 10% of subjects complained of abdominal pain occurring at least once a week, but less than 1% noted left lower quadrant pain. There was a direct association between upper abdominal pain and symptoms of ischemic heart disease. The second part of this study, which began in 1996, will provide additional information regarding the natural history of these complaints.
Aged↗
Determinants of loneliness in Jerusalem's 70-year-old population.
This study aims to find the determinants of feelings of loneliness in 70 year olds living in Jerusalem. Results based on home interviews (n = 605) of a 40% systematic sample of 70 year olds in the electoral register showed that around 46.3% of females and 21.3% of males reported being lonely. Persons of European/North American origin felt less lonely than those of Asian or African origin, probably due to the former's wider social support network, perceiving friends, neighbors or other relatives as being available to back up children in an emergency. The major factors associated with loneliness were: being depressed, having a poor self-assessed health status, not attending synagogue, and being widowed but not remarried. Factors that did not reduce loneliness included having paid employment, watching TV or listening to the radio. No association was found between cognitive status and loneliness. Our systems model suggests a strong reciprocal relationship between loneliness and depression.
Aged↗
Factors predicting emergency room utilization in a 70-year-old population.
Emergency room (ER) utilization in a representative sample (n = 605) of 70-year-old Jerusalem residents was investigated using multiple and logistic regression techniques. Around 23% of the study population visited an ER during the pre-interview year. Problems associated with ER use were heart diseases (mainly ischemic), asthma, renal disorders, psychiatric problems, headaches, and nocturia. Also associated with increased ER use were prior hospital admissions, taking sleeping pills, driving a car, distance from one's general practitioner, and low self-assessed health status. The availability of help from children increased ER use, possibly by sharing in the decision-making process or by helping with post-visit financial bureaucracy. Persons with cognitive problems had decreased ER use, possibly due to their inability to cope with the related complex decision-making process. The inclusion of interaction terms improved the models fit, in keeping with the general philosophy of geriatric care which often deals with cases presenting multiple diagnoses in addition to various social problems. Information on key variables identified as predictors of ER use in order to predict ER use as a basis for budget allocation to specific sick funds, was collected by means of a postal questionnaire or by phone.
Aged↗
Profile of Jerusalem's 70 year olds--medical data.
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Aged↗
Profile of Jerusalem's 70 year olds--social data.
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Activities of Daily Living↗
Paraprofessional delivery of a theory based HIV prevention counseling intervention for women.
This report describes a mid-course process evaluation of an HIV risk-reduction counseling intervention delivered by specially trained peer paraprofessionals. One of the key questions addressed is whether paraprofessionals can successfully implement a theory-based counseling intervention. The project, known as Project CARES, is a 5-year demonstration research project to prevent HIV infection and unplanned pregnancies in women at risk for HIV infection and transmission who were recruited from homeless shelters, drug treatment facilities, and hospital-based service settings for HIV-infected women. Project CARES uses an enhanced counseling intervention based on the Transtheoretical Model, also known as the Stages of Change model, to promote condom and other contraceptive use for women who wish to avoid pregnancy, condom use for disease prevention, and reproductive health service use. Peer paraprofessionals, called advocates, provide stage-tailored counseling using a structured manual which guides them in the selection of specific counseling activities appropriate to a woman's level of readiness to change her behavior. Data from process evaluation forms completed by advocates in Philadelphia and Baltimore document that the delivery of the intervention is consistent with the theoretical model upon which it was based. Paraprofessionals can become skilled in the delivery of a stage-based counseling intervention in health and social service settings. The use of paraprofessionals in HIV prevention service delivery may be a cost-effective way to enhance and extend services for women.
Acquired Immunodeficiency Syndrome↗
NCCN Colorectal Cancer Practice Guidelines. The National Comprehensive Cancer Network.
In summary, the committee believes that a multidisciplinary approach is necessary for the management of the patient with colorectal cancer. The committee endorses the concept that treatment of patients on a clinical trial has priority over standard or accepted therapy. The recommended surgical procedure for managing resectable colon cancer is an en bloc resection; laparoscopic surgery should be done only in the context of a clinical trial. For patients with stage III disease, 5-FU-based adjuvant chemotherapy is recommended. A patient who has metastatic disease in the liver or lung should be considered for surgical resection if he or she is a candidate for surgery and if surgery can extend survival. The committee advocates a conservative post-treatment surveillance program for colon and rectal cancer patients. A determination of CEA should be done only if CEA was elevated at baseline and decreased following primary resection. Abdominal and pelvic CT scans should be utilized only when there are clinical indications of possible recurrence. Patients whose disease progresses during 5-FU-based therapy should be considered for treatment with irinotecan or encouraged to participate in a phase I or II clinical trial.
Colonic Neoplasms↗
Atrial septal aneurysm. Morphological characteristics in a large population: pathological associations. A French multicenter study on 259 patients investigated by transoesophageal echocardiography.
UNLABELLED: A strong association between interatrial septal aneurysm (IASA) and stroke has recently led many authors to consider IASA as a potential cardiac source of embolism. We studied the morphological characteristics and main associations of IASA in a large cooperative study based on transoesophageal echocardiographic examinations; 259 IASA were studied in 134 men and 125 women with a mean age of 59 +/- 15 years. Fifty-five percent of IASA were found to overlap the commonly described fossa ovalis region. IASA protruded into the right atrium in 90% of the cases. They appeared thin in 81% of the patients and highly mobile in 79%. Fifty-eight percent of patients had a history of systemic embolic events, while an atrial septal shunt was detected in 61% of the patients. In patients with an embolic event, only the mobility of IASA was significantly higher than in those with no embolic event. In nine cases a pulmonary embolism was associated with arterial embolism. Furthermore, we reported three cases of paradoxical embolism. However, the true demonstration of a thrombus within the IASA was quite rare. CONCLUSION: IASA is probably an important risk factor for stroke. In patients with IASA and a history of embolic events, IASA may enhance migration of a thrombus constituted in situ or transiting through it. Marked mobility of IASA may also increase the risk of peripheral embolus.
Adult↗
A clinical trial of active management of labor.
BACKGROUND: Active management of labor is a multifaceted program that, as implemented at the National Maternity Hospital in Dublin, is associated with a lower rate of cesarean delivery than the rate usually found in the United States. We conducted a randomized trial to evaluate the efficacy of this approach in lowering the rate of cesarean section among women delivering their first babies. METHODS: We randomly assigned 1934 nulliparous women at low risk of complications of pregnancy, before 30 weeks' gestation, to active management of labor or to a usual-care group. The components of active management were customized childbirth classes; strict criteria for the diagnosis of labor; standardized management of labor, including early amniotomy and treatment with high-dose oxytocin; and one-to-one nursing. A low-risk subgroup was defined as including women with full-term, uncomplicated pregnancies who spontaneously went into labor (the protocol-eligible subgroup). Women meeting these criteria who had been randomly assigned to the active-management group were admitted to a separate unit where their labor was managed by trained, certified nurse-midwives. RESULTS: There was no difference between groups in the rate of cesarean section either among all women (active management, 19.5 percent; usual care, 19.4 percent) or in the protocol-eligible subgroup (active management, 10.9 percent; usual care, 11.5 percent). In the protocol-eligible subgroup, the median duration of labor was shortened by 2.7 hours by active management (from 8.9 to 6.2 hours), and the rate of maternal fever was lower (7 percent vs. 11 percent, P = 0.007). The percentage of women in whom labor lasted longer than 12 hours was three times higher in the usual-care group than in the active-management group (26 percent vs. 9 percent, P < 0.001). CONCLUSIONS: Active management of labor did not reduce the rate of cesarean section in nulliparous women but was associated with a somewhat shorter duration of labor and less maternal fever.
Adult↗
Assessing goodness-of-fit of parametric regression models for lifetime data-graphical methods.
Graphical methods are often used to check goodness-of-fit of models to data. It is common to plot residuals against a reference distribution so that when the model fits the data, the configuration should be close to a straight line. Since the resemblance to a straight line is often unclear, it has been suggested to add simulated envelopes within which the configuration is expected to lie. The implementation of this method for survival data analysis is not straightforward. In this paper we point out the difficulties which arise in constructing envelopes on residual plots for randomly censored data. Methods are suggested to deal with the problems and evaluated; they are illustrated by simulated data and on a follow-up study of myeloma.
Computer Graphics↗
p53 expression is required for thymocyte apoptosis induced by adenosine deaminase deficiency.
Adenosine deaminase (ADA, EC 3.5.4.4) is a ubiquitous enzyme in the purine catabolic pathway. In contrast to the widespread tissue distribution of this enzyme, inherited ADA deficiency in human results in a tissue-specific severe combined immunodeficiency. To explain the molecular basis for this remarkable tissue specificity, we have used a genetic approach to study ADA deficiency. We demonstrate that ADA deficiency causes depletion of CD8low transitional and CD4+CD8+ double-positive thymocytes by an apoptotic mechanism. This effect is mediated by a p53-dependent pathway, since p53-deficient mice are resistant to the apoptosis induced by ADA deficiency. DNA damage, known to be caused by the abnormal accumulation of dATP in ADA deficiency, is therefore responsible for the ablation of T-cell development and for the immunodeficiency. The two thymocyte subsets most susceptible to apoptosis induced by ADA deficiency are also the two thymocyte subsets with the lowest levels of bcl-2 expression. We show that thymocytes from transgenic mice that overexpress bcl-2 in the thymus are rescued from apoptosis induced by ADA deficiency. Thus, the tissue specificity of the pathological effects of ADA deficiency is due to the low bcl-2 expression in CD8low transitional and CD4+CD8+ double-positive thymocytes.
Adenosine Deaminase↗