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Current views on obesity.

Although the disorders associated with obesity have been extensively studied, little attention has been paid to the fact that obesity is itself a chronic disease. This misunderstanding of the nature of obesity has contributed to the stigmatization of obese persons and to the use of inappropriate or inadequate treatment regimens. Although the etiology of obesity is still unclear, genetic, metabolic, and social factors are all believed to play a role in its development and progression. Behavioral therapy, exercise, very-low-calorie diets, drug therapy, and surgery affect the treatment of obesity of differing levels of severity. The regaining of weight following treatments other than surgery is very frequent, in part because periods of weight loss are rarely followed by maintenance programs. An increasing awareness of the chronic, multifactorial nature of obesity will ideally lead to the development of new long-term treatment programs that are safe and effective. Such programs are urgently needed in light of new data that show that the prevalence of obesity is increasing in the United States, as much as 30% in the last decade.

Appetite Depressants↗

Temporally and spectrally resolved imaging microscopy of lanthanide chelates.

The combination of temporal and spectral resolution in fluorescence microscopy based on long-lived luminescent labels offers a dramatic increase in contrast and probe selectivity due to the suppression of scattered light and short-lived autofluorescence. We describe various configurations of a fluorescence microscope integrating spectral and microsecond temporal resolution with conventional digital imaging based on CCD cameras. The high-power, broad spectral distribution and microsecond time resolution provided by microsecond xenon flashlamps offers increased luminosity with recently developed fluorophores with lifetimes in the submicrosecond to microsecond range. On the detection side, a gated microchannel plate intensifier provides the required time resolution and amplification of the signal. Spectral resolution is achieved with a dual grating stigmatic spectrograph and has been applied to the analysis of luminescent markers of cytochemical specimens in situ and of very small volume elements in microchambers. The additional introduction of polarization optics enables the determination of emission polarization; this parameter reflects molecular orientation and rotational mobility and, consequently, the nature of the microenvironment. The dual spectral and temporal resolution modes of acquisition complemented by a posteriori image analysis gated on the spatial, spectral, and temporal dimensions lead to a very flexible and versatile tool. We have used a newly developed lanthanide chelate, Eu-DTPA-cs124, to demonstrate these capabilities. Such compounds are good labels for time-resolved imaging microscopy and for the estimation of molecular proximity in the microscope by fluorescence (luminescence) resonance energy transfer and of molecular rotation via fluorescence depolarization. We describe the spectral distribution, polarization states, and excited-state lifetimes of the lanthanide chelate crystals imaged in the microscope.

Chelating Agents↗

Problems in the study of rodent aggression.

Laboratory research has produced detailed descriptions of aggression and defense patterns in the rat, mouse, and hamster, showing strong similarities, but also some differences, across these species. Research on target sites for attack, in conjunction with analyses of the situational antecedents of attack behaviors and of responsivity of these to conditions that elicit fear, has also provided a strong basis for analysis of offensive and defensive aggression strategies and for identification of combinations of these modalities such as may occur in maternal aggression. These patterns have been empirically differentiated from phenomena such as play fighting or predation and compared for laboratory rodents and their wild ancestors. An array of tasks, suitable for use with pharmacological and experimental manipulations, is available for analysis of both aggression and defense. These developments should produce a firm basis for research using animal models to analyze a broad array of aggression-related phenomena, including systematic approaches to understanding the normal antecedents and consequences of each of several differentiable types of aggressive behavior. Despite this strong empirical and analytic background, laboratory animal aggression research has been in a period of decline, spanning several decades, relative to comparable research focusing on areas such as sexual behavior or stress. Problems that may have contributed to the relative neglect of aggression research include confusion about the interpretation of different tasks for eliciting aggression; difficulties and labor intensiveness of observational measures needed for an adequate differentiation of offensive and defensive behaviors; analytic difficulties stemming from the sensitivity of offensive aggression to the inhibitory effects of fear or defensiveness; lack of a clear relationship between categories of aggressive behavior as defined in animal studies and those used in human aggression research; and the social and political difficulties undermining support for research on a topic that, when applied to humans, provides a stigmatizing label. While all of these provide some rationale for eschewing aggression research, aggression remains a serious social, economic, health, and political problem. The neglect of research in this area contributes to an ongoing failure to understand the degree of similarity across mammalian species in the antecedents, neural systems, behavioral expression, and outcomes of aggression. This failure, in turn, hinders analyses of normal and abnormal forms of aggression and of the appropriate roles of the former in society, reducing the possibility of sensitive and effective approaches to control inappropriate human aggressive behaviors.

Aggression↗

Emotional complications of adolescent grand mal epilepsy.

Adolescents who have grand mal epilepsy and their parents were interviewed, and the adolescents were evaluated neurologically. Better seizure control and less neurologic disability were unexpectedly associated with less open communication between the adolescents and their families and friends, and with a poorer self-image and poorer expectations for the future. These findings were unrelated to IQ or school performance. This outcome is consistent with other studies of invisible defects and stigmatization, and suggests that youngsters who have relatively mild defects involving social disability may be more troubled than those with more apparent defects, for which denial may be operative. An incidental finding in the study was that a question more predictive of overall family, social, and academic function than the neurologic findings was simply whether or not the youngster was attending the appropriate grade in school for his or her age.

Adolescent↗

A psychiatric 12-year follow-up of adult patients with neurofibromatosis type 1.

The impact of neurofibromatosis type 1 (NF1) on psychiatric symptoms and diagnoses, personality variables and self evaluation was studied in a 12 year-follow-up of patients with NF 1 in the city of Göteborg, Sweden. 48 living adult patients with NF1 were re-evaluated in 1990 in a 12 year long time follow up study. The patients were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders. The following scales were used; the Comprehensive Psychopathological Rating Scale (CPRS), the Karolinska Scales of Personality inventory (KSP) and the Self-Evaluation Scale (SES). A significant psychopathology was found in the NFI patients, p <0.001. One third of the patients were affected by a psychiatric disease, 21% by dysthymia. There was no significant progress in psychiatric symptoms in the follow up period. The personality profile disclosed a heightened self-esteem. The chronic stigmatizing character of NF1 may be the reason for the increased psychopathology found.

Adult↗

What's in a name: mortality and the power of symbols.

One's attitude about oneself, and the treatment one receives from others, might be affected, in some small but measurable way, by stigmatic or salutary labeling due to one's name. If names affect attitudes and attitudes affect longevity, then individuals with "positive" initials (e.g., A.C.E., V.I.P.) might live longer than those with "negative" initials (e.g., P.I.G., D.I.E.). Using California death certificates, 1969-1995, we isolated 2287 male decedents with "negative" initials and 1200 with "positive" initials. Males with positive initials live 4.48 years longer (p<0.0001), whereas males with negative initials die 2.80 years younger (p<0.0001) than matched controls. The longevity effects are smaller for females, with an increase of 3.36 years for the positive group (p<0.0001) and no decrease for the negative. Positive initials are associated with shifts away from causes of death with obvious psychological components (such as suicides and accidents), whereas negative initials are associated with shifts toward these causes. However, nearly all disease categories display an increase in longevity for the positive group and a decrease for the negative group. These findings cannot be explained by the effects of death cohort artifacts, gender, race, year of death, socioeconomic status, or parental neglect.

Aged↗

The functional status of people with epilepsy in rural sub-Saharan Africa.

PURPOSE: Little data is available regarding the impact of epilepsy on the functional status of people with epilepsy (PWE) in developing countries. In sub-Saharan Africa, limited medical services and social stigmatization subject PWE to substantial physical, psychological and social deprivation. To better delineate the overall burden and distribution of epilepsy-associated disability in sub-Saharan Africa, we assessed the functional status of PWE in a rural, population-based sample and made comparisons to published reports from urban Zimbabwe. METHODS: A population-based survey of PWE with epilepsy in rural Zambia utilizing WHO questionnaires. RESULTS: Among 86 PWE in 3 rural Zambian communities, 67% participated in the interviews. Only 62% of PWE were receiving treatment. Five to seven percent of rural PWE reported problems with basic hygiene and 9-14% were unable to fulfill work demands, attend social events or enjoy leisure activities. In contrast, 95% of urban PWE denied any problems with social functioning, work performance or relationships. Compared to the urban population, rural PWE had a greater seizure burden (2.3/month vs. 1/month, p=0.007) and reported more difficulties with activities of daily living, including problem solving (70% vs. 54%, p=0.02), speed of thinking (70% vs. 59%, p=0.02) and relationships with co-workers (68% vs. 26%, p< or =0.005). CONCLUSIONS: A significant proportion of PWE in rural sub-Saharan Africa report problems fulfilling both social and professional functions. These results also suggest that rural PWE may have poorer functional status than their urban counterparts.

Activities of Daily Living↗

Pharmacogenomics of congestive heart failure.

Information on the probable efficacy and safety of drugs for individualized patients should change both the economics and the management of congestive heart failure. Rapidly profiling patients should enhance the ability to develop "designer" drugs for those with similar disease phenotypes. Pharmacogenomics also may resurrect promising drugs that did not show benefit when previously added to standard therapy. The promise of pharmacogenomics has to be tempered, however, by a sensitivity to concerns regarding the potential misuse of genomic information, including loss of confidentiality for the patient, as well as possible stigmatization of groups. Such difficult genoethical issues must be addressed in order to reap the full benefits of this evolving and exciting field.

Cardiovascular Agents↗

Management of depression in the outpatient office.

Current practice suggests that primary care physicians are in the best position to identify initially and treat depression in the ambulatory setting. Educating primary care physicians about depression is essential for identifying and adequately caring for depressed patients. Depression is commonly seen and easily treated in primary care settings. A structured, consistent approach to the depressed patient is essential and should include patient education; eliciting information about symptoms; clinical observation about the examination; a history of previous psychiatric episodes; family history of affective disorders; history from relatives, other providers, or other clinics if necessary; aggressive use of medication alone or in combination with psychotherapeutic techniques; and appropriate referral. Depression is associated with significant suffering and disability and increased utilization of health care services. Depressed patients can present with a variety of somatic and cognitive symptoms. Primary care physicians should be alert for denial and minimization of symptoms as well as for the presence of stigmatization. The biologic, psychological, and social aspects of depression should be expanded on as needed according to the patient's illness beliefs. A medical model such as that used for explaining diabetes or coronary artery disease may be useful. Primary care physicians miss the diagnosis of depression in as any as two out of three cases, and when the diagnosis is made, patients are often undertreated and given antidepressants at subtherapeutic dosages and for only short periods of time. Treatment of depression can be extremely satisfying and gratifying for patients and physicians, who need to have a high index of suspicion for depression. All antidepressants have the same efficacy, and the selection is based primarily on their side-effect profile. The new generation of antidepressants are better tolerated, relieve symptoms of depression, improve the quality of life, and probably improve morbidity and mortality. In many cases, depression is chronic and recurrent, and treatment should be long-term to prevent relapses. As with other chronic diseases, if a patient requires treatment that the primary care provider cannot render alone, it needs to be coordinated. In particular, consultants may need to be called in for psychotherapy. Primary care physicians should feel confident that, given enough time and cooperation, they can almost always find a treatment regimen that succeeds in alleviating and perhaps preventing the great suffering and risk occasioned by depression in medically ill ambulatory patients.

Ambulatory Care↗

Social and behavioral aspects of male homosexuality.

This article describes some of the social and behavioral aspects of homosexual life styles, with particular reference to their implications for diagnosis, treatment, and continuing medical management. The cultural, psychologic, and sexual variables that may necessitate varying the management of homosexual or bisexual men compared with heterosexual men are emphasized. Areas of psychosomatic involvement, and the influence of social support and stigmatization on presentation and response, are also discussed.

Attitude↗

Variation in DNA repair is a factor in cancer susceptibility: a paradigm for the promises and perils of individual and population risk estimation?

The repair of DNA damage protects the genome of the cell from the insults of cancer causing agents. This was originally demonstrated in individuals with the rare genetic disease, xeroderma pigmentosum, the prototype of cancer genes, and subsequently in the relationship of mismatch repair to colon cancer. Recent studies suggest that individuals with less dramatic reductions in the capacity to repair DNA damage are observed at polymorphic frequency and these individuals have an increased susceptibility to several types of cancer. Screening of individuals for DNA sequence variation in the exons of 9 DNA repair genes has resulted in identification of 15 different polymorphic amino acid substitution variants. Although the studies to relate these variants to reduced DNA repair capacity and cancer status have not been completed, the available information is sufficient to suggest that DNA repair genes should be incorporated into molecular epidemiology and cancer susceptibility studies. The availability of molecular epidemiology data presents exciting opportunities for refinement of risk estimation models and identification of individuals at increased risk of disease, with resultant opportunities for effective surveillance and early intervention and treatment. The opportunities to acquire susceptibility data are associated with possible perils for establishment of regulations for permissible exposures to carcinogenic agents and also stigmatization of 'at risk' individuals that may result in decreased access to employment opportunities and health care.

Animals↗

Bundling a pregnancy test with the Yuzpe regimen of emergency contraception.

The recent United States Food and Drug Administration approval of a commercial kit containing the Yuzpe regimen for emergency contraception is a welcome event. Unlike emergency contraceptive pills sold in other countries, however, the United States product has a pregnancy test bundled with the pills. The test could identify existing pregnancies and avoid unnecessary use of the pills, although any protection against lawsuits alleging injury to an embryo is speculative. Conversely, no major medical organization recommends routine pregnancy testing before using emergency contraceptive pills. The test might stigmatize the Yuzpe regimen as being dangerous to an embryo. Difficulty in understanding the pregnancy test instructions could, paradoxically, deter some women from using the pills after having bought them. The bulky size of the pregnancy test reagent stick makes the package indiscreet, and the test adds unnecessary cost to emergency contraception. The greatest usefulness of the test could be to confirm or exclude a pregnancy several weeks after taking the pills, rather than before. If bundling an unnecessary test with emergency contraception is the only way to bring this useful product to the United States market, then the public health benefits could outweigh the disadvantages. However, this approach sets a worrisome precedent and further isolates the United States from the international medical community.

Contraceptives, Postcoital↗

Adolescent acceptance of different foods by obesity status and by sex.

This work investigated possible differences in food preference between obese and normal-weight adolescents, as well as between female and male seventh-grade pupils (average age = 13.1 years). Survey of affinities for nine food groups was determined with a facial hedonic scale. The children were divided according to their BMI into normal-weight and obese group, respectively. In this sample of adolescents, we could not find any proof for the theory of increased preference for fattening foods by obese compared to normal-weight people. In fact, our normal-weight group showed greater liking of sweets, meat, and cereals than the obese group. Normal-weight boys also preferred meat and sweets more than normal-weight girls. We consider psychological and social factors (e.g., perception of ideal body shape or social stigmatism of obesity) as the most logical explanations for the observed differences. Further research should clarify whether food preference plays a significant role in the etiology of adolescent obesity.

Adolescent↗

Progression of lymphatic vessel dilatation in the presence of living adult Wuchereria bancrofti.

Bancroftian filariasis, a mosquito-transmitted disease commonly known as elephantiasis, is caused by infection with the parasite Wuchereria bancrofti. Infection with this parasite can induce a broad array of chronic debilitating and socially stigmatizing conditions, but the pathogenesis of this morbidity remains obscure. Recent evidence indicates that in filariasis-endemic areas the primary lesion is not lymphatic vessel obstruction but, rather, dilatation. To determine the extent to which lymphatic dilatation occurs in the presence of living adult W. bancrofti, we performed longitudinal ultrasonographic measurements in 80 men (mean age 24 years) in Brazil who had a total of 107 W. bancrofti nests detectable by ultrasound. Initial mean lymphatic vessel diameter at the site of the worms was 3.4 mm (range, 0.7-11.3), and was greater in men with 2 or more nests (3.9 mm) than in those with only one nest (3.0 mm, P = 0.003). During the study period (2-35 months, mean, 13.7), lymphatic vessel diameter increased at the site of 92 (86.0%) adult worm nests. Mean rate of increase of lymphatic vessel diameter was 1.2 mm per person-year (range, 0-0.93 mm per month). In a general linear model, no factors, including treatment with antifilarial drugs, were significantly associated with rate of vessel diameter increase. Thus, lymphatic vessel dilatation progress in the presence of living adult W. bancrofti; the rate of this progression is heterogeneous. These data suggest that lymphatic dilatation will continue to progress in most infected persons even after mass treatment with currently recommended antifilarial drugs. In addition to interrupting transmission, the global programme for elimination of lymphatic filariasis should address the potential for disease progression in persons who remain infected with adult W. bancrofti.

Adolescent↗

The prolonged epidemic of anthroponotic cutaneous leishmaniasis in Kabul, Afghanistan: 'bringing down the neighbourhood'.

In order to investigate the distribution and causes of the spread of anthroponotic cutaneous leishmaniasis (ACL) in Kabul, Afghanistan, a cross-sectional study was conducted during 1997-98 amongst 75,787 residents in the 13 central districts of the city. Using data on active lesions and scars with their times of onset, migration patterns and age of subjects, 2 independent methods were used to estimate, retrospectively, the annual incidence of ACL in recent years. Results indicated a rapid increase in incidence from 1987, peaking in 1996 when an estimated 12% of the population had active disease. Active prevalence was lowest in infants (aged < 2 years), and while risk was gender-independent in children and adolescents, active prevalence in those aged > 20 years was significantly higher amongst females than males (odds ratio [OR] = 1.51, 95% CI 1.34-1.70). About 44% of lesions were located on the head, 38% on upper limbs, 16% on lower limbs and 2% elsewhere. The relative frequency of head lesions dropped with age (P < 0.001), and amongst adults was lowest amongst males (P < 0.001), possibly due to the protective effect of a beard. Within the study population, 32% reported that they had immigrated from outside Kabul, 34% that they had been born in Kabul but had since migrated to another district of the city, and 34% that they had been born in the district of their present residence. Active prevalence amongst those born in their current district of residence was positively associated with the percentage of immigrants in their district (P = 0.027), indicating that a 1% increase in the percentage of immigrants increased the odds of an active lesion by 12% (OR = 1.12, 95% CI 1.01-1.24), but there was no association with the percentage of migrants from other districts in Kabul (P = 0.65) or with war damage (P = 0.33). As active prevalence was not significantly greater in immigrants than local Kabulis, these results support the hypothesis that the epidemic in Kabul has been maintained by a steady influx of susceptible immigrants. It is important that the new opportunities for social development that now exist in Kabul are not hampered by this unpleasant and stigmatizing disease. As population movement is clearly a contributing factor to its transmission, this threat is very real.

Adolescent↗

Almost 'like family': emergency nurses and 'frequent flyers'.

OBJECTIVE: Heavy users (HUs) of emergency services ("repeaters" or "frequent flyers") are often regarded by emergency nurses as "problem patients." Yet, these patients also solicit deeper clinician involvement because of their familiarity and their often intractable medical and social problems. The primary objective of this study was to contribute to improved understanding of the phenomenon of heavy ED use by describing the context within which such use occurs and its meanings to patients and to clinicians. METHODS: Observational and narrative data were collected during ethnographic fieldwork in two inner-city trauma center emergency departments. Data were interpreted using interpretive phenomenological strategies. FINDINGS: Relationships between ED clinicians and HU patients in the study hospitals were characterized by complexity and ambivalence, but thematic analysis of interviews revealed commonalities. Recognition practices, discussed in this article, were central to both centers. DISCUSSION: Frustration with a system that focuses on control but often leaves ED clinicians feeling like failures as they try to pick up the pieces for failing or absent families, communities, and social programs can contribute to stigmatization of HU patients, missed clinical diagnoses, and reduced nurse morale. Acknowledging the reasonable limits of control, and engaging in simple recognition and inclusion practices, may be more meaningful in furthering changes in HU patients behavior than biomedically oriented interventions.

Adult↗

Resisting the stigma of incest: an experiment in personal construct psychotherapy.

This paper describes a psychotherapeutic attempt to help an adolescent girl, incestuously assaulted by her father for over a decade, rebuild a satisfactory sense of self and escape to some degree the debilitating and stigmatizing effects of her experience. The course of events described was primarily determined by the young woman's own sense of what she needed from psychotherapy but was also informed by the theoretical framework of Personal Construct Theory. In terms of methodology the paper is a personal account of a personal experience and draws on a narrative rather than experimental tradition in clinical psychology. The paper ends with an uncertain picture of outcome and prognosis with which most clinicians will be familiar.

Adolescent↗

Social interventions in the care of human immunodeficiency virus (HIV)-infected pregnant women.

The incidence of infection with the human immunodeficiency virus (HIV) is increasing among women of childbearing age. Women now account for 18% of the total number of cases of the acquired immunodeficiency syndrome (AIDS), compared with 9% a decade ago. The medical care of pregnant HIV-infected women must take into account the high prevalence of substance abuse, preceded and often accompanied by significant levels of physical, emotional, and sexual trauma, and the concomitant stigmatization of these women in their families and communities. Pregnancy is often a time when women are motivated to make major positive behavioral and life-style changes. To do this, they need ongoing, multidisciplinary counseling and support, with recognition that progress may be intermittent and slow. The Special Prenatal Care Program at Bellevue Hospital is described to show the level of resource commitment that is needed as well as the nearly universal acceptance of voluntary HIV counseling and testing in these conditions. Trends in permanency planning for the children of HIV-infected women are described. Future research needs are outlined, including female-specific drug treatment and more effective contraceptive technology for both men and women.

Adult↗