Clinical presentation, course, and prognostic factors in lymphocyte-predominant Hodgkin's disease and lymphocyte-rich classical Hodgkin's disease: report from the European Task Force on Lymphoma Project on Lymphocyte-Predominant Hodgkin's Disease.
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PURPOSE: Recent studies have suggested that lymphocyte-predominant Hodgkin's disease (LPHD) is both clinically and pathologically distinct from other forms of Hodgkin's disease, including classical Hodgkin's disease (CHD). However, large-scale clinical studies were lacking. This multicenter, retrospective study investigated the clinical characteristics and course of LPHD patients and lymphocyte-rich classical Hodgkin's disease (LRCHD) patients classified according to morphologic and immunophenotypic criteria. MATERIALS AND METHODS: Clinical data and biopsy material of all available cases initially submitted as LPHD were collected from 17 European and American centers, stained, and reclassified by expert pathologists. RESULTS: The 426 assessable cases were reclassified as LPHD (51%), LRCHD (27%), CHD (5%), non-Hodgkin's lymphoma (3%), and reactive lesion (3%); 11% of cases were not assessable. Patients with LPHD and LRCHD were predominantly male, with early-stage disease and few risk factors. Patients with LRCHD were significantly older. Survival and failure-free survival rates with adequate therapy were similar for patients with LPHD and LRCHD, and were stage-dependent and not significantly better than stage-comparable results for CHD (German trial data). Twenty-seven percent of relapsing LPHD patients had multiple relapses, which is significantly more than the 5% of relapsing LRCHD patients who had multiple relapses. Lymphocyte-predominant Hodgkin's disease patients had significantly superior survival after relapse compared with LRCHD or CHD patients; however, this was partly due to the younger average age of LPHD patients. CONCLUSION: The two subgroups of LPHD and LRCHD bore a close clinical resemblance that was distinct from CHD; the course was similar to that of comparable nodular sclerosis and mixed cellularity patients. Thorough staging is necessary to detect advanced disease in LPHD and LRCHD patients. The question of how to treat such patients, either by reducing treatment intensity or following a "watch and wait" approach, remains unanswered. (+info)
Ten year follow-up of depression after diagnosis in general practice.
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BACKGROUND: Depression is a serious illness with a high recurrence rate, mortality, and suicide rate, and a substantial loss of quality of life. Long-term course of depression, in particular of patients not referred to specialist care, is not completely clear. We performed a study in which the course of depression in general practice was studied for 10 years after the first diagnosis. AIM: To learn more about long-term course and outcome of patients with depressive illness for a full 10 years after diagnosis. METHOD: A historic cohort study with 386 patients classified as depressive before January 1984, recruited from four general practices belonging to the Continuous Morbidity Registry of the University of Nijmegen in The Netherlands. This cohort was followed up for 10 years. Mortality was compared with a control group matched for age, sex, social class, and practice. Of 222 patients out of this cohort who could be followed up for a full 10 years after diagnosis, the case records were studied in detail. RESULTS: No statistically significant difference was found in mortality between the 386 patients and the control group. Recurrence of depressive episodes did not occur in about 60% of the 222 patients (confidence interval 54% to 67%). Of the depressive patients, 15% were referred to secondary care and 9% were admitted to hospital. CONCLUSION: Mortality, suicide, and recurrence rate were lower than expected, taking into account what is known from depression studies in psychiatry. These results stress the importance of long-term prospective follow-up studies of all patients with depression because of the emphasis on case-finding and treatment without exact knowledge of long-term course and outcome of patients who were not referred. (+info)
Individual and organizational predictors of depression in general practitioners.
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BACKGROUND: High levels of stress and depression are seen in both general practitioners (GPs) and hospital doctors, and this has implications for patient care. It is therefore important to discover the individual and organizational causes of elevated symptoms so they can be tackled. AIM: To discover the relative importance of individual characteristics measured 10 years earlier compared with current organizational stressors in predicting depression in GPs. METHOD: Longitudinal questionnaire study, using data from those of the original cohort of 318 medical students who are now GPs (n = 131), considering perceptions of current stressors and comparing through regression analyses the relative strength of early personality and mood with current organizational factors of sleep, hours worked, and practice size in predicting current depression levels. RESULTS: There were 22 (17%) stressors scoring above threshold for depression. Relationships with senior doctors and patients are the main reported stressors, followed by making mistakes and conflict of career with personal life. The predictors of symptom levels varied for men and women. In men, depression and self-criticism as students, and current sleep levels; and in women, sibling rivalry and current alcohol use, were the main predictors: in men, 27% of the variance was accounted for by early dispositional factors alone compared with 14% in women. A model is suggested linking sleep loss with workplace stressors, self-critical cognitions, and depression. CONCLUSION: Interventions can be made throughout training, targeting self-criticism and recognizing early depression, while later addressing the organizational stressors, particularly work relationships and sleep patterns. (+info)
The risk of serious illness among oral contraceptive users: evidence from the RCGP's oral contraceptive study.
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BACKGROUND: So far, no-one has attempted to evaluate the overall balance of serious, but not necessarily fatal, disease among a cohort of oral contraceptive users. AIM: To emprirically assess the balance of risk of serious illness among a cohort of oral contraceptive users followed up for up to 28 years. METHODS: Oral contraceptive-associated serious disease was defined as that which is often life-threatening and/or associated with long-term disability, and which has been found, or postulated, to be associated with use of combined oral contraceptives. Data from the Royal College of General Practitioners' (RCGP) Oral Contraception Study were examined to determine the rate of such conditions during 335,181 woman-years of observation in 'ever users' and 228,727 woman-years in 'never users'. The rates were standardized for age, parity, social class, and smoking. RESULTS: Compared with never users, ever users had a small increased risk of any serious disease (relative risk = 1.17; 95% confidence interval = 1.09-1.25). Ever users had an excess risk of cerebrovascular disease, pulmonary embolism, and venous thromboembolism, and reduced risk of ovarian and endometrial cancer. The increased risk was seen only in younger women; by the age of 50, ever users had the same risk as never users. The risk appeared to be confined to women using older oral contraceptives containing 50 micrograms or more of oestrogen. CONCLUSIONS: Past users of older, higher dose oral contraceptives can be reassured that the small increased risk of serious disease seen during current use does not persist after stopping, and that latent effects do not appear later in life. Currently available oral contraceptives, containing less than 50 micrograms of oestrogen accompanied by the progestogen, levonorgestrel, or norethisterone acetate, do not appear to be associated with an increased net risk of serious disease. (+info)
Age-specific decrease in seroprevalence of schistosomiasis in Puerto Rico.
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In our previous work, we reported the first systematic, island-wide, serologic survey for schistosomiasis in Puerto Rico in 40 years. In that study, approximately 3,000 serum samples from the 76 municipalities comprising the island of Puerto Rico were tested for the detection of antibodies to S. mansoni microsomal antigens by the Falcon assay screening test-enzyme-linked immunosorbent assay (FAST-ELISA) and those positive were confirmed by an enzyme-linked immunoelectrotransfer blot (EITB). The highest EITB positivity was found in 17 municipalities, which comprised 48% of all seropositive samples. An additional finding was that 10% of the 215 EITB-positive samples were from individuals 25 years or younger and were for the most part of residents from the high seroprevalence areas. Thus, for this study we focused on 766 individuals 25 years of age or younger (45.5% males and 54.4% females), two-thirds of which were from 10 municipalities with the highest EITB seropositivity, and one-third from the 10 municipalities with the lowest EITB seropositivity found in our previous study. Of all samples, the results showed an overall FAST-ELISA positivity of 11.6%, with males similar to females (12.6 versus 10.7%, respectively). Confirmation by EITB was only 1.8%, with a males three-fold higher than females (3% versus 0.7%). When seropositivity was measured by age in five-year increments, a clear age-specific decrease in seropositivity was observed. Thus, by FAST-ELISA, 16.7% of the 21-25-year-old age group was positive, decreasing to 14.6%, 9.9%, 7.9%, and 9.3% in the 16-20-, 11-15-, 6-10-, and 1-5-year-old age groups, respectively. Confirmatory EITB showed even more impressive results: 4.7%, 2.6%, 1.2%, 0.7%, and 0% in the same age brackets. With regard to the high prevalence municipalities, only four of 10 (11 of 228 = 4.8%) had confirmatory EITB-positive samples and most were from municipalities of the Rio Grande de Loiza River basin and tributaries. The male to female positivity ratio was 4:1. Of the low prevalence municipalities, only single positive cases (by EITB) were found in three disperse municipalities. These results support the concept that there has been little transmission of S. mansoni in Puerto Rico during the first half of the 1990s and confirms anecdotal comments of local physicians who have seen virtually no new infections during the past three years. This makes the documentation of eradication of schistosomiasis from Puerto Rico feasible, a goal that should be set as being before the 100th anniversary of its discovery on the island by Isaac Gonzalez-Martinez in 1904. (+info)
Validity and reproducibility of a quantitative food frequency questionnaire for a cohort study in Japan.
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BACKGROUND: A self-administered quantitative food frequency questionnaire (Qx) was developed for a population-based cohort study on cancer in Takayama, Japan. METHODS: The Qx was tested among 58 male and 59 female volunteers. Average daily nutrient intakes for the previous year calculated from the Qx were compared with those from 3-day food records and four 24-h recalls. The Qx was also validated among 37 volunteers by comparing the nutrient intakes calculated from the Qx with 12 1-day food records during a year. We also calculated the intra-class correlation coefficients for various nutrients between the Qx and the second Qx administered by the same volunteers 1 year after the first survey. RESULTS: Pearson correlation coefficients between total energy from the Qx and 3-day records were 0.38 for men and 0.25 for women and those between the Qx and 24-h recalls were 0.19 and -0.02 for men and women, respectively. Correlations between the several nutrients from the Qx and 3-day records ranged from 0.2 to 0.5 for both men and women. These correlations after energy adjustment ranged from 0.2 to 0.6 for men and from 0.1 to 0.7 for women. In general, the correlations for various nutrients between the Qx and 12 1-day records were higher than those described above. The intra-class correlation coefficients ranged from 0.46 to 0.78 in men and from 0.36 to 0.67, except for vitamin C in women. When the information on portion size was excluded, almost all of the above indices showed somewhat lower figures. CONCLUSION: These results suggest that our food frequency questionnaire with portion size information can be used to estimate nutrient intakes of each individual. (+info)
Prevalence and clinical outcome associated with preexisting malnutrition in acute renal failure: a prospective cohort study.
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Malnutrition is a frequent finding in hospitalized patients and is associated with an increased risk of subsequent in-hospital morbidity and mortality. Both prevalence and prognostic relevance of preexisting malnutrition in patients referred to nephrology wards for acute renal failure (ARF) are still unknown. This study tests the hypothesis that malnutrition is frequent in such clinical setting, and is associated with excess in-hospital morbidity and mortality. A prospective cohort of 309 patients admitted to a renal intermediate care unit during a 42-mo period with ARF diagnosis was studied. Patients with malnutrition were identified at admission by the Subjective Global Assessment of nutritional status method (SGA); nutritional status was also evaluated by anthropometric, biochemical, and immunologic parameters. Outcome measures included in-hospital mortality and morbidity, and use of health care resources. In-hospital mortality was 39% (120 of 309); renal replacement therapies (hemodialysis or continuous hemofiltration) were performed in 67% of patients (206 of 309); APACHE II score was 23.1+/-8.2 (range, 10 to 52). Severe malnutrition by SGA was found in 42% of patients with ARF; anthropometric, biochemical, and immunologic nutritional indexes were significantly reduced in this group compared with patients with normal nutritional status. Severely malnourished patients, as compared to patients with normal nutritional status, had significantly increased morbidity for sepsis (odds ratio [OR] 2.88; 95% confidence interval [CI], 1.53 to 5.42, P < 0.001), septic shock (OR 4.05; 95% CI, 1.46 to 11.28, P < 0.01), hemorrhage (OR 2.98; 95% CI, 1.45 to 6.13, P < 0.01), intestinal occlusion (OR 5.57; 95% CI, 1.57 to 19.74, P < 0.01), cardiac dysrhythmia (OR 2.29; 95% CI, 1.36 to 3.85, P < 0.01), cardiogenic shock (OR 4.39; 95% CI, 1.83 to 10.55, P < .001), and acute respiratory failure with mechanical ventilation need (OR 3.35; 95% CI, 3.35 to 8.74, P < 0.05). Hospital length of stay was significantly increased (P < 0.01), and the presence of severe malnutrition was associated with a significant increase of in-hospital mortality (OR 7.21; 95% CI, 4.08 to 12.73, P < 0.001). Preexisting malnutrition was a statistically significant, independent predictor of in-hospital mortality at multivariable logistic regression analysis both with comorbidities (OR 2.02; 95% CI, 1.50 to 2.71, P < 0.001), and with comorbidities and complications (OR 2.12; 95% CI, 1.61 to 2.89, P < 0.001). Malnutrition is highly prevalent among ARF patients and increases the likelihood of in-hospital death, complications, and use of health care resources. (+info)
Hematocrit level and associated mortality in hemodialysis patients.
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Although a number of clinical studies have shown that increased hematocrits are associated with improved outcomes in terms of cognitive function, reduced left ventricular hypertrophy, increased exercise tolerance, and improved quality of life, the optimal hematocrit level associated with survival has yet to be determined. The association between hematocrit levels and patient mortality was retrospectively studied in a prevalent Medicare hemodialysis cohort on a national scale. All patients survived a 6-mo entry period during which their hematocrit levels were assessed, from July 1 through December 31, 1993, with follow-up from January 1 through December 31, 1994. Patient comorbid conditions relative to clinical events and severity of disease were determined from Medicare claims data and correlated with the entry period hematocrit level. After adjusting for medical diseases, our results showed that patients with hematocrit levels less than 30% had significantly higher risk of all-cause (12 to 33%) and cause-specific death, compared to patients with hematocrits in the 30% to less than 33% range. Without severity of disease adjustment, patients with hematocrit levels of 33% to less than 36% appear to have the lowest risk for all-cause and cardiac mortality. After adjusting for severity of disease, the impact of hematocrit levels of 33% to less than 36% is vulnerable to the patient sample size but also demonstrates a further 4% reduced risk of death. Overall, these findings suggest that sustained increases in hematocrit levels are associated with improved patient survival. (+info)