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PubMed1999

Evaluation of serum levels of IgG subclasses and anti-ribosyl-ribitolphosphate IgG and IgG2 in children with Haemophilus influenzae b meningitis.

In 40 children with Haemophilus influenzae b (Hib) meningitis, we determined serum levels (mg/dl) of IgG subclasses using the radial immunodiffusion method; 67.8 per cent of these children were less than 24 months old. In 14 children of the sample we measured serum IgG and IgG2 anti-ribosyl-ribitolphosphate (anti-PRP) (by enzyme-linked immunosorbent assay, ELISA) in the acute and convalescent phases of the disease. Lower IgG2 levels than those of the control group were obtained in all age ranges: 3-12 months, 1-2 years (p < 0.01), and 2-5 years (p < 0.001). IgG4 was also present in lower levels in patients of all age ranges (p < 0.05, p < 0.001, and p < 0.01 respectively). Serum levels of IgG anti-PRP and IgG2 anti-PRP measured were very low in the acute phase of the disease in all age ranges and there was no notable increase in levels during the convalescent phase of the disease. This result indicates that children less than 24 months old do not produce sufficient levels of IgG and IgG2 anti-PRP even after Hib meningitis.

Acute Disease↗
PubMed2004

Should retroperitoneoscopic nephrectomy be the standard of care for benign nonfunctioning kidneys? An outcome analysis based on experience with 449 cases in a 5-year period.

PURPOSE: Laparoscopic nephrectomy has become a routine procedure at specialized centers with the advantages of less postoperative pain, minimal scars, rapid recovery and short convalescence. We report our experience with the establishment of retroperitoneoscopic nephrectomy as the standard of care for benign nonfunctioning kidneys. MATERIALS AND METHODS: We retrospectively compared the records of patients who underwent simple nephrectomy retroperitoneoscopically or by open surgery from January 1998 to October 2003 at our center. RESULTS: A total of 351 simple nephrectomies were done retroperitoneoscopically, while 83 were done as an open procedure. Mean operative time was significantly longer in the retroperitoneoscopic group. However, mean blood loss, complication rate, hospital stay and convalescence were significantly less in the retroperitoneoscopic group. CONCLUSIONS: Retroperitoneoscopic nephrectomy has become a standardized procedure. It should be offered as the primary treatment modality to patients with benign renal disease scheduled for elective nephrectomy except in those in whom it is contraindicated.

Blood Loss, Surgical↗
PubMed2000

Secretion of the chemokine interleukin-8 during Japanese encephalitis virus infection.

Japanese encephalitis (JE) virus infection induces infiltration of neutrophils in neural as well as extraneural tissues in patients. As interleukin-8 (IL-8) has inflammatory properties, the present study was undertaken to investigate the IL-8 concentrations in cerebrospinal fluid (CSF) and serum from patients with JE and correlate them with neutrophil counts. IL-8 was measured in the CSF or serum of 30 patients with confirmed JE. The majority (92%) of the acute CSF samples showed raised levels of IL-8 with raised numbers of polymorphonuclear leucocytes. Similarly, significantly higher serum IL-8 concentrations were detected in the acute phase of illness than in convalescent JE patients or normal healthy controls. Twenty-one of 25 patients with high concentrations of IL-8 showed significantly increased neutrophil counts in acute phase sera. A gradual decline in neutrophil counts was observed in the convalescent phase of patients who recovered. There was a significant correlation between IL-8 level and the severity of illness, as all severely ill and fatal cases showed higher levels of IL-8 in acute CSF or serum than the levels found in those who recovered. IL-8 concentrations remained high for a longer period in patients with prolonged severe illness than in those who made a complete recovery.

Acute Disease↗
PubMed1993

Conformational constraints of conserved neutralizing epitopes from a major antigenic area of human respiratory syncytial virus fusion glycoprotein.

To study the conformational requirements of epitopes from a conserved antigenic area (area II) of respiratory syncytial (RS) virus fusion (F) glycoprotein, peptides of increasing length containing amino acids essential for these epitopes were synthesized. The synthetic peptides were tested for binding to a panel of neutralizing monoclonal antibodies (MAbs) for this area as well as to rabbit hyperimmune and human convalescent antisera. Antibody binding was dependent on peptide length; thus, a 61-residue peptide spanning amino acids 215 to 275 of the F1 subunit (peptide F215-275) reacted with more antibodies than a shorter (41-residue) peptide F235-275, and this one with more than the (21-residue) peptide F255-275. Most human convalescent sera contained antibodies that reacted with peptides F215-275 and F235-275 but failed to react with F255-275. The results of antibody binding could be related to the structure adopted by the peptides in solution, as determined by circular dichroism spectroscopy and susceptibility of peptides to trypsin digestion. Pretreatment of peptide F215-275 with SDS abolished reactivity with certain MAbs, supporting the notion that higher order structures were needed for antibody binding. High titre anti-peptide antisera were induced in rabbits inoculated with the peptides; however, these sera failed to react with the native F molecule. In mice, only the largest F215-275 peptide induced an anti-peptide response, but their sera reacted poorly with the native F protein and the animals were not protected against an RS virus challenge. These results illustrate the potential use of synthetic peptides in studies of the F protein physical and antigenic structures as well as the problems in designing synthetic RS virus vaccines.

Amino Acid Sequence↗
PubMed1994

Studies on serological cross-reaction in sequential flavivirus infections.

Acute- and convalescent-phase sera from patients with dengue (DEN) hemorrhagic fever (DHF) and Japanese encephalitis (JE) that contained pre-existing flavivirus antibodies were tested for cross-reacting antibodies to DEN, JE and yellow fever (YF) viruses by a neutralization (N) test. A fourfold or greater rise in N antibody titer in the convalescent-phase was considered significant. Of 39 DHF cases, obtained at Chiang Mai University Hospital, Thailand, 15 (38.5%) showed a rise in DEN antibody titer, while another 15 (38.5%) showed a significant rise in both DEN and JE N antibody titers. On the other hand, eight (61.5%) of 13 JE cases obtained at the same Hospital, showed a significant rise in JE antibody titer, while two (15.4%) showed a significant rise in both DEN and JE antibody titers. Sucrose gradient centrifugation and fractionation of these two cross-reactive JE sera revealed that IgM class antibody was specific for JE, while IgG class antibody was cross-reactive. Of three JE cases with pre-existing YF antibody obtained in Okinawa, Japan, two showed a significant rise in YF and JE antibodies. Both IgM and IgG class antibodies to YF virus were elevated. These results indicate that the cross-reactivity among flaviviruses in different subgroups (complexes), was observed quite often, even by the N test, in sequential flavivirus infection.

Acute Disease↗
PubMed1990

Content areas for cardiac teaching: patients' perceptions of the importance of teaching content after myocardial infarction.

This descriptive study was undertaken to investigate patients' perceptions of the seven content areas commonly included in cardiac teaching in terms of how important and how realistic they were for being learned following the experience of an acute myocardial infarction (MI). Lazarus's stress-coping theory was used as a framework for the study. A sample of 30 MI subjects were interviewed before discharge and during early convalescence. Before discharge, subjects rated six out of the seven content areas as "important" for learning. Although the information was considered important, it was not rated as equally realistic to learn. During early convalescence, mean scores under 'important to learn' were slightly lower, but all seven content areas were rated as significantly more realistic to be learned (P less than 0.05). Little variation in patients' perceptions of the importance of teaching content was noted over time. However, there was major variation between their perceptions of how important and how realistic it was to learn the material before discharge. Both dimensions, how important and how realistic, are therefore crucial to consider in cardiac teaching.

Adult↗
PubMed1995

Transvenous cardioverter defibrillators: cost implications of a less invasive approach.

To assess the economic impact of a transvenous lead system for an implantable cardioverter defibrillator (ICD), we evaluated the hospital charges for two groups of patients: group I patients (n = 23) underwent implantation of an ICD generator with an epicardial lead system via a thoracotomy and group II patients (n = 25) underwent implantation of the same generator using transvenous leads. There was no difference in demographics between the two groups. There was a 15% decrease in total charges for the transvenous group compared to the thoracotomy group ($54,142 vs $63,359, P < 0.05). Evaluation of the component charges revealed that the decline could be attributed to a reduction in implant ($27,328 vs $29,285, P < 0.02) and convalescent charges ($7,703 vs $15,179, P < 0.01) for the transvenous group. There was a corresponding decrease in length of stay for the transvenous group (22 vs 29 days, P < 0.05) largely secondary to a 38% reduction in convalescent length of stay (8 vs 13 days, P < 0.05). We conclude that the use of transvenous lead systems for the ICD results in a significant reduction in hospital charges as well as hospital length of stay.

Aged↗
PubMed2000

Predictability of dysphagia after laparoscopic nissen fundoplication.

OBJECTIVE: Dysphagia is the most common complication of antireflux surgery. Temporary dysphagia occurs in addition to persistent dysphagia because of technical or physiological problems. Temporary dysphagia may be due to the patient's personal perception or faulty eating habits. The aim of this study was to investigate the impact of the patient's personality as it relates to temporary dysphagia and individual impairment. METHODS: Several studies have used the construct of personality known as "health locus of control" to predict health-related behavior and convalescence after medical or surgical treatments. This study investigates the predictability of the subjective degree of dysphagia and its perceived degree of impairment in relation to the health locus of control after laparoscopic so-called "floppy" Nissen fundoplication in 90 patients. Several questionnaires and single-item questions were given to the patients preoperatively, and 1 wk, 6 wk, and 3 months after surgery. The answers to the questions provided the data for this study. RESULTS: Preoperatively, 92% of the patients had no dysphagia and 8% had a mild subjective degree of dysphagia. Temporary postoperative dysphagia was found in approximately 50% of the patients 1 wk after surgery. The intensity of the dysphagia ranged among mild (18%), moderate (15%), and severe (16%). Three months postoperatively about 80% had no dysphagia and only 2% severe dysphagia. Correlations between the construct of personality and the intensity of postoperative dysphagia and its impairment revealed a significant relationship at all times. Patients with high expectations for their own health-related abilities (internal control) had less dysphagia (r = -0.78 after 1 wk [p<0.001], r = -0.71 after 6 wk [p<0.001], and r = -0.64 after 3 months [p<0.001]), compared with patients who believed that their convalescence depended more on luck, chance, or fate (external control) (r = 0.67 after 1 wk [p<0.01], r = 0.72 after 6 wk [p<0.001], and r = 0.63 after 3 months [p<0.01]). These results are highly significant. The correlation between health locus of control the degree of a subjective impairment from perceived dysphagia showed similar results (p<0.01). CONCLUSIONS: The subjective degree of dysphagia and the perceived impairment as a result of laparoscopic antireflux surgery can be predicted according to the personality of the patient. Those patients with low expectations for their own abilities can be identified before surgery, thereby allowing adaptation techniques to be applied that could improve the results and well-being of patients after antireflux surgery.

Attitude↗
PubMed1974

Diagnosis of California (La Crosse) encephalitis by precipitin techniques: a prospective study.

Counterelectrophoresis (CEP) and immunodiffusion (ID) were evaluated prospectively as methods for the early and rapid laboratory diagnosis of California encephalitis (CE). CEP and ID studies were done on paired sera from 127 patients with acute central nervous system infections. After the precipitin tests were completed, conventional hemagglutination-inhibition, neutralizing, and complement fixing antibody titers were measured. The CEP system detected antibodies in 7 (41%) of 17 CE patients during their acute illness and in all 17 patients during convalescence. The ID method was less sensitive; 3 of 17 acute sera and 16 of 17 convalescent sera were ID positive. Comparative precipitin studies indicated that La Crosse virus was the infecting California group subtype in all 17 CE patients. Because CEP can be performed in 1.5 h, is at least as sensitive as hemagglutination-inhibition, neutralizing, and complement fixing tests, and can detect prospectively 41% of CE patients during their acute illness, it is recommended as a rapid diagnostic test for CE.

Antibodies, Viral↗
PubMed1995

Down-regulation of gamma interferon, tumor necrosis factor type I, interleukin 1 (IL-1) type I, IL-3, IL-4, and transforming growth factor beta type I receptors at the local site during the acute phase of Shigella infection.

An immunohistochemical technique was used to examine whether there was a colocalization of cytokine-specific receptors with cytokine-expressing cells. We have previously shown that there is extensive cytokine production and secretion in the rectal mucosa in shigellosis (interleukin 1 alpha [IL-1 alpha], IL-1 beta, IL-1ra, IL-4, IL-6, IL-8, IL-10, tumor necrosis factor alpha [TNF-alpha], TNF-beta, gamma interferon, granulocyte-macrophage colony-stimulating factor, and transforming growth factor beta [TGF-beta]) (R. Raqib, A. A. Lindberg, B. Wretlind, P. K. Bardhan, U. Andersson, and J. Andersson, Infect. Immun. 63:289-296, 1995; R. Raqib, B. Wretlind, J. Andersson, and A. A. Lindberg, J. Infect. Dis. 171:376-384, 1995). Kinetics for receptor expression was compared with that for cytokine synthesis in the inflamed rectal mucosa from Shigella-infected patients during acute (2 to 6 days after onset of diarrhea) and convalescent (30 to 40 days after onset) stages. Quantification of receptor expression was assessed by computer-assisted analysis of video microscopic images. A selective down-regulation of the receptors for gamma interferon, tumor necrosis factor (TNF receptor [TNFR] type I), IL-1 (IL-1 receptor [IL-1R] types I and type II), IL-3, IL-4, and TGF-beta (TGF-beta receptor type I) was observed at the onset of the disease, with a gradual reappearance during the convalescent stage. However, IL-2R, IL-6R, granulocyte-macrophage colony-stimulating factor receptor, TNFR type II, and TGF-beta receptor type II showed no change in expression during the study period and were comparable to controls. Cytokine receptors were predominantly located to the epithelial layer of the mucosal surface and crypts, with variable expression patterns in the lamina propria. A time-dependent kinetic curve was seen for the soluble IL-2R (sIL-2R), sIL-6R, and sTNFR types I and type II shed in stool at the acute stage similar to that observed for cytokine secretion in stool but at four- to six-times-lower concentration. In contrast, soluble receptor levels in plasma were 100-fold higher than the cytokine levels. The results suggest a dissociation in immune regulation between cytokine production and cytokine receptor expression. The down-regulation of the receptors in acute shigellosis was probably a consequence of cytokine-induced internalization and shedding of the receptors during signal transduction as well as due to programmed regulatory roles played by cytokines and the bacterial antigens.

Acute Disease↗
PubMed2001

Reciprocal protective immunity against Bordetella pertussis and Bordetella parapertussis in a murine model of respiratory infection.

The protective immunity induced by infection with Bordetella pertussis and with Bordetella parapertussis was examined in a murine model of respiratory infection. Convalescent mice that had been infected by aerosol with B. pertussis or with B. parapertussis exhibited a protective immune response against B. pertussis and also against B. parapertussis. Anti-filamentous hemagglutinin (anti-FHA) serum immunoglobulin G (IgG) and anti-FHA lung IgA antibodies were detected in both mice infected with B. pertussis and those infected with B. parapertussis. Antibodies against pertussis toxin (anti-PT) and against killed B. pertussis cells were detected in mice infected with B. pertussis. Pertactin-specific antibodies and antibodies against killed B. parapertussis cells were detected in mice infected with B. parapertussis. Spleen cells from mice infected with B. pertussis secreted interferon-gamma (IFN-gamma) in response to stimulation by FHA or PT. Spleen cells from mice infected with B. parapertussis also secreted IFN-gamma in response to FHA. Interleukin-4 was not produced in response to any of the antigens tested. The profiles of cytokine secretion in vitro revealed induction of a Th1-biased immune response during convalescence from infection by B. pertussis and by B. parapertussis. It is possible that Th1 and Th2 responses against FHA might be related to the reciprocal protection achieved in our murine model.

Adhesins, Bacterial↗
PubMed2001

Salmonella enterica serovar Pullorum persists in splenic macrophages and in the reproductive tract during persistent, disease-free carriage in chickens.

Salmonella enterica serovar Pullorum is worldwide a poultry pathogen of considerable economic importance, particularly in those countries with a developing poultry industry. In addition to the characteristic high mortality rates among young chicks, one of the features of Salmonella serovar Pullorum infection is that it persists for long periods in convalescent chicks in the absence of clinical disease. This can lead to colonization of the reproductive tract of chickens and at sexual maturity can result in infected progeny through transovarian transmission to eggs. The sites of Salmonella serovar Pullorum persistence in convalescent birds are not known, and the mechanisms of persistence are not understood. Here we show that Salmonella serovar Pullorum can persist in both the spleen and the reproductive tract for over 40 weeks following experimental infection in chickens. During the period of sexual maturity, Salmonella serovar Pullorum colonized both the ovary and the oviduct of hens and led to 6% of laid eggs being infected by Salmonella serovar Pullorum. The colonization of several different sites of the reproductive tract suggests that Salmonella serovar Pullorum may employ more than one mechanism of egg infection. Persistence occurred despite a strong humoral response, suggesting an intracellular site of infection. By use of a Salmonella serovar Pullorum strain containing a plasmid stably expressing green fluorescent protein, we demonstrated that the main site of carriage in the spleen is within macrophages. This raises interesting questions about the biology of Salmonella serovar Pullorum, including why there is an increase in bacterial numbers when birds become sexually mature and in particular how Salmonella serovar Pullorum avoids clearance by macrophages and whether it modulates the immune system in other ways.

Animals↗
PubMed1979

Solid-phase radioimmunoassay of serum immunoglobulin A antibodies to respiratory syncytial virus and adenovirus.

A solid-phase radioimmunoassay for detecting respiratory syncytial virus and adenovirus serum immunoglobulin A (IgA) antibodies was developed. An antigen consisting of purified adenovirus type 2 hexons or a crude lysate of respiratory syncytial virus-infected cells was first adsorbed onto polystyrene beads. The coated beads were then incubated with dilutions of serum, and IgA antibodies which attached to the solid-phase virus antigen were subsequently detected with 125I-labeled anti-human alpha antibodies. The anti-human alpha antibodies used were isolated by immunosorbent chromatography from rabbit antiserum produced by immunization with IgA purified from serum of an IgA myeloma patient. A total of 46 serum specimens from 13 patients with respiratory syncytial virus infections and 10 patients with adenovirus infections were tested. Complement fixation, homologous IgG and IgM radioimmunoassay, and heterologous IgA radioimmunoassay testing were also done. Specific values higher than 10,000 cpm were often reached with convalescent serum specimens, and positive-to-negative serum binding ratios of 50 or more were frequently obtained with lower serum dilutions. IgA titers of convalescent sera were from 1,000 to 16,000, and with few exceptions a fourfold or greater rise in the IgA titer was detected in the homologous IgA radioimmunoassay.

Acute Disease↗
PubMed2000

Serodiagnosis of Louse-Borne relapsing fever with glycerophosphodiester phosphodiesterase (GlpQ) from Borrelia recurrentis.

Human louse-borne relapsing fever occurs in sporadic outbreaks in central and eastern Africa that are characterized by significant morbidity and mortality. Isolates of the causative agent, Borrelia recurrentis, were obtained from the blood of four patients during a recent epidemic of the disease in southern Sudan. The glpQ gene, encoding glycerophosphodiester phosphodiesterase, from these isolates was sequenced and compared with the glpQ sequences obtained from other relapsing-fever spirochetes. Previously we showed that GlpQ of Borrelia hermsii is an immunogenic protein with utility as a serological test antigen for discriminating tick-borne relapsing fever from Lyme disease. In the present work, we cloned and expressed the glpQ gene from B. recurrentis and used recombinant GlpQ in serological tests. Acute- and convalescent-phase serum samples obtained from 42 patients with louse-borne relapsing fever were tested with an indirect immunofluorescence assay (IFA) and an enzyme-linked immunosorbent assay (ELISA) that used whole cells of B. recurrentis and with immunoblotting to whole-cell lysates of the spirochete and Escherichia coli producing recombinant GlpQ. The geometric mean titers of the acute- and convalescent-phase serum samples measured by IFA were 1:83 and 1:575, respectively. The immunoblot analysis identified a high level of reactivity and seroconversion to GlpQ, and the assay was more sensitive than the whole-cell IFA and ELISA using purified, recombinant histidine-tagged GlpQ. Serum antibodies to GlpQ and other antigens persisted for 27 years in one patient. We conclude that assessment of anti-GlpQ antibodies will allow serological confirmation of louse-borne relapsing fever and determination of disease prevalence.

Amino Acid Sequence↗
PubMed2000

An antigen capture enzyme-linked immunosorbent assay reveals high levels of the dengue virus protein NS1 in the sera of infected patients.

We describe the development of a capture enzyme-linked immunosorbent assay for the detection of the dengue virus nonstructural protein NS1. The assay employs rabbit polyclonal and monoclonal antibodies as the capture and detection antibodies, respectively. Immunoaffinity-purified NS1 derived from dengue 2 virus-infected cells was used as a standard to establish a detection sensitivity of approximately 4 ng/ml for an assay employing monoclonal antibodies recognizing a dengue 2 serotype-specific epitope. A number of serotype cross-reactive monoclonal antibodies were also shown to be suitable probes for the detection of NS1 expressed by the remaining three dengue virus serotypes. Examination of clinical samples demonstrated that the assay was able to detect NS1 with minimal interference from serum components at the test dilutions routinely used, suggesting that it could form the basis of a useful additional diagnostic test for dengue virus infection. Furthermore, quantitation of NS1 levels in patient sera may prove to be a valuable surrogate marker for viremia. Surprisingly high levels of NS1, as much as 15 microg/ml, were found in acute-phase sera taken from some of the patients experiencing serologically confirmed dengue 2 virus secondary infections but was not detected in the convalescent sera of these patients. In contrast, NS1 could not be detected in either acute-phase or convalescent serum samples taken from patients with serologically confirmed primary infection. The presence of high levels of secreted NS1 in the sera of patients experiencing secondary dengue virus infections, and in the context of an anamnestic antibody response, suggests that NS1 may contribute significantly to the formation of the circulating immune complexes that are suspected to play an important role in the pathogenesis of severe dengue disease.

Acute Disease↗
PubMed1977

Solid-phase radioimmunoassay of rubella virus immunoglobulin M antibodies: comparison with sucrose density gradient centrifugation test.

The solid-phase radioimmunoassay (RIA) method developed in our laboratory for demonstrating rubella virus-specific immunoglobulin G (IgG) antibodies (Kalimo et al., 1976) was further developed for demonstrating IgM antibodies. A total of 188 serum specimens were tested. The statistical probability of obtaining a false-positive IgM result, based on determinations of 100 rubella-negative sera, was below 0.001. Nonspecific inhibitors and IgM antibodies against other viruses tested did not interfere in the assay. In 2 out of 20 (10%) serum specimens with rheumatoid factor, a false-positive IgM result was obtained. The new RIA method was compared with sucrose density gradient centrifugation, followed by hemagglutination inhibition testing of the separated immunoglobulins with respect to demonstrating IgM antibodies. In patients with acute rubella infection, IgM antibodies were demonstrated by RIA in 9 out of 20 acute-phase sera and in all 20 early-convalescent-phase sera, compared with 7 out of 20 acute-phase sera and 19 out of 20 early-convalescent-phase sera by sucrose density gradient centrifugation. The results obtained indicate that the RIA method is reliable and sensitive and suitable for routine diagnostic use.

Antibodies, Viral↗
PubMed1979

Serodiagnosis of viral hepatitis A by a modified competitive binding radioimmunoassay for immunoglobulin M anti-hepatitis A virus.

A competitive binding radioimmunoassay (CBA) for antibody to hepatitis A virus (HAV) was evaluated and compared with a standard solid-phase radioimmunoassay for anti-HAV, CBA was found to be sensitive and specific for the detection of anti-HAV, as demonstrated by the 98% concordance of CBA and solid-phase radioimmunoassay test results. The standard CBA test was modified for the differential detection of acute (immunoglobulin M) and convalescent (immunoglobulin G) anti-HAV by incorporation of a step in which immunoglobulin G anti-HAV was preferentially absorbed with S. aureus cells (protein A). The modified CBA test was shown to be capable of differentiating between acute- and convalescent-phase sera. The modified CBAM test was able to detect immunoglobulin M anti-HAV up to approximately 4 weeks after the onset of illness.

Acute Disease↗
PubMed1978

The psychological and social effects of myocardial infarction on wives.

Eighty-two wives of men suffering a first myocardial infarction were interviewed while their husbands were in hospital, and again two months and a year after they went home. The wives had substantial and persistent psychological symptoms, and the husbands' illness had continuing effects on their work, leisure and social activities, and family life and marriage, their psychosocial disability being comparable to that of the patients. Measures of psychosocial adjustment before the illness and the quality of the marriage and of family life were good predictors of outcome for the wives. The women had a major role in the patients' readjustment during convalescence, and their attitudes and behaviour as well as the general quality of family life were important determinants of the rate and extent of the patients' recovery. The wives of patients with myocardial infarction should have more practical help and advice during the hospital period, and the whole family should be given advice and help throughout the convalescence.

Activities of Daily Living↗