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Hospital emergency rooms and children's health care attitudes.

OBJECTIVE: To assess attitudes of children requiring hospital emergency room (ER) treatment for trauma injuries 5 years afterward to evaluate the long-term effect of treatment distress. For comparison, health care attitudes of a large random sample of children were assessed. METHOD: Children (N = 139, 7-19 years old) recruited from the ER completed a health care attitude questionnaire. Comparable schoolchildren (N = 1,300) completed the same questionnaire, with the addition of a few questions asking about hospital contact. The ER-recruited group was part of a 5-year follow-up study, and at the time of initial recruitment, their parents had rated their children's degree of distress at both the time of injury and of ER treatment on a 6-point scale. RESULTS: For the ER-recruited sample, the degree of distress during ER treatment did not seem to have longterm effects on children's attitudes. For the random sample, contact with the ER, especially for a trauma injury, was related to children liking the ER more. CONCLUSIONS: Although other research has shown that aversive medical experiences may negatively affect children's attitudes, these findings suggest that the nature of the medical contact is important in how children interpret medically induced pain, which is related to their attitudes.

Adaptation, Psychological↗

[Proceedings: Pacemaker implantation bradycardia and cardiac insufficiency. Preliminary report].

The longterm effects of pacemaker therapy have been investigated in 337 patients with bradycardia and congestive heart failure with or without Adams-Stokes syncope. The cumulative survival rate in patients with Adams-Stokes seizures without congestive heart failure (group I) is markedly better than in patients with Adams-Stokes seizures and congestive heart failure (group II). The death rate is highest in patients with congestive heart failure as sole indication for pacemaker implantation (Group III). In the patients from group II (mainly with slight to moderate decompensation) there was a higher percentage of improvement than in those from group III (chiefly with severe congestive heart failure), in whom cardiac decompensation improved in approximately half the cases. These findings do not prompt excessive enthusiasm about the longterm results in patients with bradycardia and severe congestive heart failure. The indication subsists where there is resistance to drug therapy, or digitalis intolerance, or where treatment with a provisional pacemaker produces good results.

Adams-Stokes Syndrome↗

The estrogen receptor in the rat kidney. Ontogeny, properties and effects of gonadectomy on its concentration.

Estrogens have been suggested as modulators of the conversion of 25-hydroxyvitamin D3 to dihydroxylated compounds in the kidney. In order to further explore this hypothesis the estrogen-binding components in the kidney were studied in adult and immature rats. The basal receptor levels in adult animals were 9.6 fmol/mg protein (female) and 21.9 (male). The receptor-ligand complex had a Kd of 0.7 nM. Furthermore, the kidney receptor displayed similar characteristics as those of the cytosol liver estrogen receptor in terms of sedimentation properties on sucrose gradients, isoelectric focusing and ligand binding specificity. The ontogeny of cytosol high affinity estrogen binding sites was elucidated in female and male animals. Detectable levels of receptors (5 fmol/mg protein) were found during the first postnatal week in both sexes. During days 22-25 receptors reached maximum concentrations at about 30 fmol/mg protein. In the male this level then remained relatively constant throughout the time of study (60 days), whereas in the female the concentration decreased gradually over a period of 12-15 days to a basal level of 10 fmol/mg protein. A temporal study on the short- and longterm effects of ovariectomy on the concentration of estrogen binding sites in the kidney cytosol was also carried out. Shortly after gonadectomy (2-12 h) no effect was detected. During 20-48 h after the operation a 75% increase in the receptor level was seen. The results indicate a multihormonal control of the estrogen binding protein in the kidney similar to that seen in the liver. Furthermore, the data suggest that estradiol down-regulate its own receptor. The results are discussed in relation to present concepts on the actions of estrogens and the metabolism of vitamin D3.

Animals↗

[Treatment and rehabilitation in an apoplexy unit increases the 5-year survival].

Treatment of stroke patients in specialised stroke units has become more frequent, but the longterm effect of this treatment has not been determined. In this prospective, community-based study of 1241 unselected acute stroke patients we compared outcome between patients geographically randomised to treatment in a stroke unit or in a general neurological/medical ward, from the time of acute admission to the end of rehabilitation. Baseline characteristics were comparable between the two treatment groups regarding age, sex, marital status, pre-stroke residence, and stroke severity. Patients treated in the stroke unit had higher comorbidity with regard to hypertension and diabetes. Multivariate linear and logistic regression analyses were applied to estimate the independent influence of stroke unit treatment on outcome. Stroke unit treatment significantly reduced not only initial mortality, but also mortality within five years from stroke onset. The relative risk of dying within the first five years from stroke was reduced by 40%, p < 0.01. Treatment and rehabilitation of unselected stroke patients in a stroke unit reduces initial mortality, discharge rate to nursing home, reduces cost of treatment, and improves longterm survival up to five years after stroke.

Aged↗

Disappointing longterm results with disease modifying antirheumatic drugs. A practice based study.

OBJECTIVE: To evaluate the longterm effectiveness of disease modifying antirheumatic drugs (DMARD) in an inception cohort of patients with rheumatoid arthritis (RA) seen by rheumatologists. METHODS: We performed a retrospective audit of the records of patients with onset of RA between January 1985 and June 1994. Charts were reviewed from the time of diagnosis to the last consult. Survival analysis was performed using Kaplan-Meier and Cox proportional hazard regression to adjust for potential confounders. RESULTS: A total of 2296 DMARD therapies were analyzed. Roughly half were started within 2 years of disease onset. By 16 months, 50% of the DMARD therapy courses had been discontinued, and after 4.5 years 75% had been discontinued. Over all, methotrexate (MTX) had the highest probability of continuation. After roughly 3 years 50% of patients were still receiving MTX, compared to one-third of patients who received antimalarials or intramuscular gold, 30% D-penicillamine, 25% sulfasalazine, and 18% oral gold. After 6 years, when considering all DMARD together, only 20% of the therapies had not been discontinued, with no substantial differences between drugs. Toxicity from gold compounds occurred within the first 18 months of therapy and stabilized thereafter. For MTX, withdrawals due to toxicity continued throughout therapy. CONCLUSION: This is the largest observational study examining the longterm termination rates of DMARD in patients followed from the time of their initial consult. Our results confirm previous reports of short therapeutic times, even for patients treated early in the course of their disease. MTX appears to be the best drug within the first 5 years of disease. These differences, however, decrease in the longer term. It is unclear whether the results observed for MTX within the first years of therapy translate to better health status in the longer term when compared to other DMARD.

Antirheumatic Agents↗

Early experience and maternal behavior in rats.

This study examined the effects of early experience (early weaning with group housing in sibling groups (EG), or early weaning plus social isolation (EI) from 14 to 24 days of age) on maternal, play, and social behaviors expressed during 5 days of sensitization at 24 days, and then later at 100 days of age. Our results showed that maternal behaviors at 24 days could be altered by these early experiences. At 24 days of age fewer EI animals retrieved compared with normally weaned controls (NW), but more showed play behavior in the presence of pups. EG animals showed intermediate levels of retrieving relative to NW controls, and no concomitant changes in play behaviors. When retested as adults, females in all groups showed similar levels of all maternal behaviors. But EI adults of both sexes showed persistent intrusion of play behaviors, and higher levels of rearing and undirected activity in the presence of neonates. Factor analyses revealed that previously sensitized adult males showed patterns of organization of maternal behaviors that resembled adult females rather than those shown by control males reared without sensitization experience. Previously sensitized females also showed a retention of the play behavior patterns characteristic of juveniles, not present in females without sensitization experience. These results show that social experience during the weaning period can affect the development of maternal and play behavior elicited by neonates during the juvenile period that persist into adulthood, and the juvenile sensitization experience exerts longterm effects on adult patterns of maternal behavior in both sexes.

Animals↗

Definition of disease flare in ankylosing spondylitis: the patients' perspective.

OBJECTIVE: Ankylosing spondylitis (AS) is a systemic disorder occurring in genetically predisposed individuals. The disease course appears to be characterized by bouts of partial remission and flares. However, we have little understanding of what is a flare, why they occur, and what lasting effects they have on the patient. We examine the patient's perception of the factors important in defining flare. METHODS: Twenty group meetings of 7-12 participants were held over a one year period. A summary statement was written at the end of each discussion and patients were asked to sign the statement if they considered it to be an accurate summary of their answers, or to amend the statement where they disagreed. RESULTS: There were 214 patients questioned (169 men, 45 women; average disease duration 25 years; age of disease onset 22 years). Data show that the main symptoms of flare are pain (100% of groups), immobility (90%), fatigue (80%), and emotional symptoms (depression, withdrawal, anger) (75%). There are 2 types of flare: (1) localized: during which the symptoms affect one area; and (2) generalized: this is a severe event including all the above symptoms and a flu-like illness (fever, sweating) with hot, burning joints, muscle spasm, and increased sensitivity. All patients experience between one and 5 localized flares per year. Fifty-five percent of groups contained patients (n = 85) who experienced a generalized flare. The main perceived triggers of flare were stress (80%) and "overdoing it" (50%). Patients reported that a flare may last anywhere from a few days to a few weeks and relief from flare can be gained by analgesic injections (including opiates) from a doctor, relaxation, sleep, and cannabis (3 individuals). Three-quarters of the groups agreed that there was no longterm effect on the AS following a flare. CONCLUSION: There are 2 forms of flare: (1) localized to one area or (2) throughout the entire body. Examining the differences between these types of flares may aid our understanding of the biological mechanism of the disease process of AS and allow us to help relieve the symptoms of flare, a highly painful and often depressing phenomenon.

Adult↗

Endothelial dysfunction in human disease.

The vascular endothelium plays a key role in the local regulation of vascular tone by the release of vasodilator substances (i.e. endothelium-derived relaxing factor (EDRF = nitric oxide, NO) and prostacyclin) and vasoconstrictor substances (i.e. thromboxane A2, free radicals, or endothelin). Using either agents like acetylcholine or changes in flow to stimulate the release of EDRF (NO), clinical studies have revealed the importance of EDRF in both basal and stimulated control of vascular tone in large epicardial coronary arteries and in the coronary microcirculation. The regulatory function of the endothelium is altered by cardiovascular risk factors or disorders such as hypercholesterolemia, chronic smoking, hypertension or chronic heart failure. Endothelial dysfunction appears to have detrimental functional consequences as well as adverse longterm effects, including vascular remodelling. Endothelial dysfunction is associated with impaired tissue perfusion particularly during stress and paradoxical vasoconstriction of large conduit vessels including the coronary arteries. These effects may cause or contribute to myocardial ischemia. Several mechanisms may be involved in the development of endothelial dysfunction, such as reduced synthesis and release of EDRF or enhanced inactivation of EDRF after its release from endothelial cells by radicals or oxidized low-density lipoprotein (LDL). Increased plasma levels of oxidized LDL have been noted in chronic smokers and are related to the extent endothelial dysfunction, raising the possibility that chronic smoking potentiates endothelial dysfunction by increasing circulating and tissue levels of oxidized LDL. In heart failure, cytokines and/or reduced flow (reflecting reduced shear stress) may be involved in the development of endothelial dysfunction and can be reversed by physical training. Other mechanisms include an activated renin-angiotensin system (i.e. postmyocardial infarction) with increased breakdown of bradykinin by enhanced angiotensin converting enzyme (ACE) activity. There is evidence that endogenous bradykinin is involved in coronary vasomotor control both in coronary conduit and resistance vessels. ACE inhibitors enhance endothelial function by a bradykinin-dependent mechanism and probably also by blunting the generation of superoxide anion. Endothelial dysfunction appears to be reversible by administering L-arginine, the precursor of nitric oxide, lowering cholesterol levels, physical training, antioxidants such as vitamin C, or ACE inhibition.

Acetylcholine↗

Chronic electrical stimulation of the thalamic unspecific activating system in a patient with coma due to midbrain and upper brain stem infarction.

Chronic intermittent bipolar electrical stimulation of the left nucleus reticulatus polaris thalami was performed in a patient in a state of subcoma due to ischaemic infarction of wide medial parts of the midbrain, mainly the tegmentum, and the right-sided mediobasal parts of the forebrain. Stimulation immediately resulted in autonomic reactions and behavioural arousal reactions during the periods of stimulation. Longterm effect consisted of a rise in the level of clinical responsiveness for a period of seven weeks. A preexistent severe pneumonia disappeared completely after one week of stimulation and returned after seven weeks. The results are discussed on the basis of the pathoanatomical findings and of the physiological functions of the damaged as well as of the stimulated areas.

Aged↗

The influence of prenatal or neonatal administration of 2-bromo-alpha-ergocryptine on pituitary prolactin secretion and normal and neoplastic mammary growth in adult mice.

In view of the clinical use of 2-bromo-alpha-ergocryptine (CB-154) during pregnancy, longterm effects of perinatal exposure to this drug on pituitary prolactin secretion and mammary tumorigenesis were studied experimentally using a high mammary tumor strain of SHN female mice. Pregnant mice were given daily subcutaneous injections of 0.3 mg CB-154 for 4 days from day 12 to day 15 of pregnancy (prenatal treatment). Another group of mice received daily dose of 0.06 mg CB-154 for the first 5 days of postnatal life (neonatal treatment). Either prenatal or neonatal treatment with CB-154 resulted in little alteration of the pattern of estrous cycle, ovarian structure and pituitary and plasma levels of prolactin. There was no difference between the control and mice treated neonatally with CB-154 in mammary tumorigenesis. On the other hand, somewhat delayed mammary tumor appearance was observed in mice treated prenatally with CB-154. These findings postulate that there is little deleterious influence of perinatal exposure to CB-154 on pituitary-ovary-mammary gland systems at advanced ages.

Animals↗

[20 years unsuccessful prevention of bipolar affective psychosis recurrence].

A now 73-year-old female patient suffered from bipolar affective disorder for the first time at the age of 28. Despite treatment with all known phase-prophylactic agents (i.e., lithium, carbamazepine, valproate, and various antidepressants) she relapsed frequently. To render matters even more difficult, she easily developed side effects with most medications, particularly anticholinergic ones. In order to reach effective longterm prophylactic treatment, we tried several not yet established therapeutic regimens like clozapine, high-dose L-thyroxine, and maintenance ECT. In this case report we discuss the available literature with special respect to clozapine and maintenance ECT.

Aged↗

Carotid endarterectomy and gliofibrillar S100b protein release.

Increased levels of the gliofibrillar S100b protein can be detected during carotid endarterectomy (CEA). Whether the S100b protein increase is marker of brain ischemic sufferance and predictor of cognitive decline is controversial. Twenty-eight patients underwent clinical assessment and cranial computed tomography (CT) 24-48 hours before and 3 months after CEA. S100b serum levels were evaluated before surgery, at cross-clamping, 10 minutes later, at declamping, and 24-48 hours and 10-12 weeks after CEA. Increased S100b levels were detected in 11 patients (39%); eight (73%) of these patients had symptomatic carotid artery disease. Increased S100b level correlated with history of TIA or stroke ( p=0.005), low mini-mental state examination score ( p=0.02), and ischemic infarctions at preoperative CT ( p=0.03). Slight and transient increased S100b levels were detected in 39% of patients during CEA. The protein levels increased despite the absence of clinical events during surgery. Our findings suggest a failure of compensatory hemodynamic or metabolic mechanisms in peri-ischemic tissue, whose longterm effects on cognition remain to be investigated.

Adaptation, Physiological↗

Discontinued use of intrauterine contraceptive device and pregnancy loss.

To evaluate the risk of spontaneous abortion among former intrauterine contraceptive device (IUD) users, we compared the contraceptive history of 328 women with a spontaneous abortion up to 28 weeks' gestation with that of 1715 women having a term delivery. A similar percentage of case and comparison subjects reported prior IUD use as well as IUD use within the year before pregnancy. However, IUD use lasting more than 12 months was associated with a 1.5-fold increase in the crude risk of spontaneous abortion up to 28 weeks' gestation (p less than 0.05), a 1.8-fold increased risk of first-trimester spontaneous abortion, and a 1.7-fold increased risk of incomplete abortion (p less than 0.01). The results were not altered by control of individual confounding factors. When confounding factors were controlled simultaneously in a multiple logistic regression analysis, the relative risks were 1.4, 1.7 and 1.6, respectively; however, they were no longer statistically significant. The results suggest that prolonged IUD use may be associated with a modest increase in risk of subsequent spontaneous abortion.

Abortion, Incomplete↗

Pregnancy after removal of Norplant implants contraceptive.

Many concerns have been expressed regarding the introduction of a new contraceptive method into family planning programmes. One of the concerns is the return of fertility after discontinuing the method. To evaluate the subsequent fertility status of the Indonesian women after removal of Norplant, a prospective longitudinal study was undertaken in Klinik Radeb Saleh, Jakarta. Fifty-one women whose Norplant were removed because of their wish to become pregnant were followed-up for a period of two years or until pregnancy occurred, whichever was earlier. Two groups of women who had Lippes C IUD removed or discontinued the use of DMPA for planning pregnancy served as control and were followed-up for equal length of time. The cumulative conception rate for ex-Norplant users, ex-IUD users and ex-DMPA users at one year was 76.5, 74.7 and 70.2 per 100 women, respectively. There was no significant difference between the groups (p greater than 0.05). The present study, along with other studies, indicate that the prolonged use of Norplant do not impair the return of fertility.

Adult↗

The effects of Norplant on clinical chemistry in Singaporean acceptors after 1 year of use: I. Haemostatic changes.

A longitudinal study of coagulation parameters was carried out on 100 Singaporean acceptors using the levonorgestrel subdermal implants NORPLANT for contraceptive purposes. At the end of 1 year of use, results from this on-going study indicate that these subjects may have an increased predisposition to thrombosis as evidenced by significant increase in platelet count and aggregability. The results also show that NORPLANT acceptors may have an enhanced potential for hypercoagulation - with a significant shortening of their Prothrombin Time and Activated Partial Thromboplastin Time and increases in Factors V and X. As previously documented, mean values for haemoglobin and haematocrit were significantly elevated by the end of 1 year. A number of other parameters achieved statistically significant differences by the end of 1 year but these were probably due to the large sample size involved and were therefore not likely to be of much clinical importance.

Adult↗

Five years experience of intrauterine contraception with the Nova-T.

This study was conducted to evaluate the clinical performance of the Nova-T IUD. The insertion period was from November 1981 to November 1982. Two-hundred-and-one (201) consecutive IUDs were inserted in women attending a family planning clinic and they were followed for a period of 5 years. Most events occurred in the first 2 years of the study and there were no pregnancies in the 3rd, 4th or 5th year. The pregnancy rate after 5 years was 3.2 or a Pearl index of 1.21 which is very good compared to other methods of contraception now available. Our conclusion is that the Nova-T IUD is an excellent method of contraception and it can be left in place for a period of 5 years.

Adolescent↗

Long-term use of depot-norethisterone enanthate: effect on blood lipid fractions.

This is the third report of a metabolic study on 56 long-term users (24 for 2-5 yr; 32 for over 5 yr) of the injectable contraceptive norethisterone enanthate (Net-En) and deals with the effects on the blood levels of lipoprotein fractions. There was no significant difference between this group and a group of 30 non-users in serum concentrations of triglycerides, total cholesterol, low density and very low density lipoproteins. There was a significant reduction in mean high density lipoprotein levels between the controls and the user groups (16% for the intermediate duration and 12% for the longer duration). Age, ethnic group, body-mass index and a close family history of cardiovascular disease were taken into account, as were various lifestyle factors: diet, exercise, alcohol consumption and smoking. In a smaller group, levels of apoproteins A and B were also assayed. There was a significant reduction in apoprotein A between controls and all users, but the significance was lost on adjusting for confounding variables. Consideration was given to the ratio of total cholesterol to high density lipoprotein cholesterol as an index of coronary risk. There were no significant differences in the total cholesterol:HDL-C ratio between controls and user groups. There was a significant interaction with ethnic group (Caucasian or Afro-Caribbean) in the response to duration of use.

Adult↗

Menstrual bleeding patterns in Norplant-2 implant users.

The objective of the present study was to analyze the patterns of menstrual bleeding in Singaporean women using Norplant-2 contraceptive implants over a five-year period. Of the 100 women recruited for the study, 62 were still using the implant at the end of five years. Only 9 women discontinued for menstrual reasons and they did so within the first 21 months of implant use. Although a normal menstrual bleeding pattern was uncommon during the first three months of use, 69.4% had normal menstruation at the end of five years. Irregular bleeding was the most common form of menstrual abnormality throughout the study period. Infrequent periods and amenorrhoea were distinctly uncommon, especially after the first two years of use. The pattern of bleeding with Norplant-2 was not significantly different from that previously observed with Norplant.

Adolescent↗