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Biomedical subjects

J K Madsen

Publications and source records attributed to J K Madsen.

At least 37 records · Page 2Linked to original sources
PubMed1997

Effects of the calcium antagonist felodipine on renal haemodynamics, tubular sodium handling, and blood pressure in cyclosporin-treated dermatological patients.

BACKGROUND: Deterioration of renal function and rise in blood pressure are clinically important side-effects of cyclosporin (CsA) treatment. Calcium antagonists may have a renoprotective effect against CsA nephrotoxicity. PURPOSE: To investigate the effect of the dihydropyridine calcium-channel blocker felodipine on renal haemodynamics, tubular sodium handling, and blood pressure in CsA-treated patients with no primary renal disease, 18 patients with various CsA-treated dermatological diseases were allocated to receive either felodipine 5 mg (extended release tablets) once daily for 4 weeks followed by placebo for 4 weeks, or vice versa, in a prospective, randomized, double-blind study. The patients were investigated before treatment and at the end of each treatment period. RESULTS: After felodipine, both glomerular filtration rate (GFR) and renal plasma flow (RPF) were significantly higher compared to placebo (89.4 +/- 17.5 (mean +/- SD) vs 79.0 +/- 15.9 ml/min and 412.0 +/- 107.6 vs 326.1 +/- 78.0 ml/min respectively, P < 0.001 for both), and filtration fraction (FF) was lower (0.22 +/- 0.03 vs 0.25 +/- 0.03, P < 0.001). Both systolic and diastolic blood pressure were lower after felodipine compared to placebo (116 +/- 11/71 +/- 7 vs 133 +/- 18/83 +/- 10 mmHg, P < 0.001 for both). Furthermore, proximal output of sodium, i.e. fractional excretion of lithium, was higher after felodipine (26.9 +/- 7.3% vs 20.4 +/- 5.5%, P < 0.001) as well as total sodium excretion (0.33 +/- 0.19 vs 0.19 +/- 0.08 mmol/min, P < 0.001). CONCLUSIONS: It is concluded, that felodipine 5 mg once daily for 4 weeks increased GFR, RPF, and sodium excretion in cyclosporin-treated dermatological patients with no primary renal disease. Furthermore, felodipine lowers blood pressure in these patients. The effects of felodipine may be due to an antagonizing effect against CsA-induced nephrotoxicity.

Adolescent↗
PubMed1996

Metoprolol abolishes exercise-induced left ventricular dysfunction in patients with silent ischemia.

Left ventricular systolic function is reduced during episodes of silent ischemia in patients with coronary artery disease (CAD). Left ventricular ejection fraction (LVEF) is increased at least 5 absolute percent during exercise in most normal subjects; however, in patients with CAD, LVEF often remains unchanged or decreases. The anti-ischemic effect of beta-adrenergic receptor blockade is well documented, including a reduction of exercise-induced electrocardiographic ST depressions; however, the effect of these drugs on left ventricular volume changes during exercise in patients with silent ischemia is unknown. The aim of this study was to evaluate the effect of a cardio-selective beta-blocking agent, metoprolol, on rest and exercise LVEF in patients with silent ischemia, using radionuclide cardiography. Fifteen patients with silent ischemia completed a double-blind, placebo-controlled crossover study at rest and during submaximal exercise. LVEF remained unchanged during exercise in the placebo phase (56% to 58%; p = NS), but even though LVEF tended to decrease 56% during rest after metoprolol versus 52% after placebo (p = NS), the LVEF increase from rest to exercise resembled a normal LVEF response, 52% to 58% (p = 0.005). Exercise-induced electrocardiographic ST depressions were also reduced during metoprolol treatment. In patients with silent ischemia, the exercise-induced change in LVEF rises significantly during metoprolol treatment. The mechanism may be a reduction in myocardial ischemia as indicated by a reduction in ischemic electrocardiographic findings.

Adrenergic beta-Antagonists↗
PubMed1996

Verapamil and angiotensin-converting enzyme inhibitors in patients with coronary artery disease and reduced left ventricular ejection fraction.

Verapamil is effective as antianginal medication but contraindicated in patients with congestive heart failure. Angiotensin-converting enzyme (ACE) inhibitors improve survival in patients with congestive heart failure but have limited effect on patients with angina pectoris. No studies have been published on the combined treatment with verapamil and ACE inhibitors in patients with stable angina pectoris and left ventricular dysfunction. We performed an open study in 14 patients with angina pectoris and ejection fraction < 40%. The patients received verapamil 180 mg and trandolapril 2 mg twice daily for 3 months. We found a significant increase in ejection fraction from 28 +/- 6 to 35 +/- 11 (p < 0.03), wall motion index from 1.0 +/- 0.3 to 1.2 +/- 0.3 (p < 0.03), exercise duration from 6.9 +/- 2.5 to 7.7 +/- 2.9 minutes (p < 0.01), and ratio of exercise to rest rate-pressure product from 2.2 +/- 0.4 to 2.5 +/- 0.6 (p < 0.02). Use of nitroglycerin and number of angina pectoris attacks were both significantly reduced after 3 months of treatment. These findings support the hypothesis that the combination of verapamil and trandolapril is useful in patients with attenuated left ventricular function and angina pectoris.

Aged↗
PubMed1996

Comparison of dose requirement, serum erythropoietin and blood pressure following intravenous and subcutaneous erythropoietin treatment of dialysis patients. IV and SC erythropoietin.

OBJECTIVE: The purpose of the study was to investigate the effect of route of administration of erythropoietin (EPO) on the dose requirement in dialysis patients after intravenous (IV) and subcutaneous (SC) therapy. METHODS: The study was performed as a single centre, prospective, open, combined parallel and cross-over study of 50 dialysis patients, consecutively randomised to IV or SC treatment with EPO. The initial dose was 49 U.kg-1 3-times weekly, adjusted to increase haemoglobin (Hgb) from a median 5.3 mmol.1(-1) to a target of haemoglobin 6.5-7.5 mmol.1(-1). After reaching the target level, the haemoglobin was maintained for 4 months (Period 1). Then IV and SC treatment was switched for a further 4 months (Period 2). The study included high risk patients. The adjustment period was completed by 38 patients, Period one by 32 patients (IV/SC = 15/17; male/female = 19/13; age = 54 (24- 71) y), and Period two by 22 patients. RESULTS: No significant difference was found between the two groups in the reticulocyte response, the rate of Hgb increase (IV 0.7 versus SC 0.5, mmol.1(-1). month-1), time to reach target level (IV 43 versus SC 60 days), or total EPO dose per increase in haemoglobin to target level (IV 663 versus SC 946 (U.kg-1) per (mmol Hgb.1(-1)). The overall median maintenance dose during the last month of the two four month periods was 105 (range IV 51-336) U.kg-1.w-1 and SC 104 (range 21-321) U.kg-1.w-1. Through serum EPO levels were significantly higher during SC treatment. The blood pressure did not change significantly from the base level after either route of administration; start 133/80 versus 143/80 mmHg, target 127/78 versus 154/85 mmHg, and maintenance period 140/84 versus 142/85 mmHg. Thus, three-times weekly IV or SC EPO did not differ significantly in efficacy or in the effect on blood pressure in dialysis patients.

Adult↗
PubMed1996

Pharmacokinetic interaction between cyclosporine and the dihydropyridine calcium antagonist felodipine.

OBJECTIVE: In a double blind, randomised, placebo-controlled, cross-over study 12 healthy male volunteers were allocated to receive felodipine + placebo, cyclosporine + placebo, and felodipine + cyclosporine in order to investigate the interaction between the calcium channel blocker felodipine and cyclosporine as it affects the pharmacokinetics of felodipine, dehydrofelodipine, and cyclosporine, and 24-hour blood pressure measurements. METHODS: Single doses of cyclosporine (capsules, 5 mg/kg body weight) and of felodipine (extended release (ER) tablets 10 mg) were given at a 1-2 week interval. Plasma drug concentrations were followed for 2 days after drug intake. RESULTS: For cyclosporine, Cmax was increased after combined treatment (16%) compared to cyclosporine alone, but felodipine did not influence other kinetic parameters of cyclosporine. For felodipine, combined treatment with cyclosporine and felodipine increased AUC and Cmax (58% and 151%, respectively) and lowered mean residence time (24%) significantly compared to felodipine alone. For the metabolite dehydrofelodipine, too, AUC and Cmax were increased after the combined treatment (43% and 94%, respectively). Mean 24-hour systolic and diastolic blood pressures were significantly lower after felodipine, both when felodipine was given alone (121/68 mmHg) and in combination with cyclosporine (122/68 mmHg) compared to cyclosporine alone (127/73 mmHg). CONCLUSION: A combined single dose of cyclosporine and felodipine in healthy subjects increased the AUC and Cmax of felodipine suggesting a cyclosporine-induced decrease in the first-pass metabolism of felodipine, whereas the AUC of cyclosporine was only slightly increased by felodipine.

Adult↗
PubMed1996

High prevalence of smoking in young patients with acute myocardial infarction.

Of 35 patients with acute myocardial infarction (AMI) at the age of 40 years or less, 32 (91%) smoked and only three patients were non-smokers. The age at AMI related significantly to the extent of smoking (p < 0.001, Kruskall-Wallis test). Five patients with AMI at the age < 30 years smoked more heavily than the 30 with AMI at the age of 30-40 years (p = 0.04, Mann Whitney U test). Heavy smoking men > 30 years at the AMI had a Q-wave infarction as often (11 of 13 (85%)) as those with multivessel disease or a coronary artery occlusion (8 of 9 (89%) and 14 of 16 (88%) respectively) on coronary arteriography after the infarction. Smoking may be the most important modifiable risk factor in young patients with AMI.

Adult↗
PubMed1996

Improvement in renal function by felodipine during cyclosporine treatment in acute and short-term studies.

The purpose was to study whether the calcium entry blocker, felodipine, could reduce the nephrotoxic and hypertensive effect of cyclosporine. The effect of felodipine on glomerular filtration rate (GFR), renal plasma flow (RPF), fractional excretion of sodium, lithium clearance and blood pressure was measured in three randomized, placebo-controlled studies of cyclosporine treated patients. In study one, 10 renal transplant recipients were examined within the first six months after transplantation in a cross-over design. Renal hemodynamics were determined after the acute ingestion of felodipine or placebo, with an interval of less than one week between the two examinations. In study two, 79 renal transplant recipients were randomized to a treatment with felodipine or placebo just before transplantation, and renal hemodynamics were determined after twelve weeks. In study three, 18 patients, who were treated with cyclosporine due to dermatological diseases, were examined in a cross-over design to determine their renal hemodynamics after four weeks of treatment with felodipine or placebo. Felodipine increased renal hemodynamics in study one (GFR 16%, RPF 33%, P < 0.01 for both), in study two (GFR 23%, RPF 28%, P < 0.05 for both), and in study three (GFR 13%, RPF 26%, P < 0.01 for both). FE(Na) was significantly increased by felodipine in studies one and three, but not in study two. Lithium clearance was significantly increased and blood pressure significantly reduced by felodipine in all three studies. It can be concluded that felodipine counteracts both the cyclosporine induced impairment in renal hemodynamics and the increase in blood pressure in acute and short-term studies.

Adult↗
PubMed1995

[10-year mortality of patients admitted to coronary units with or without confirmed diagnosis of myocardial infarction. A relation to anamnesis and diagnosis at discharge].

The ten-year mortality in patients with suspected myocardial infarction with (AMI) and without (non-AMI) confirmed diagnosis was evaluated in 1897 non-AMI patients and 1401 AMI patients who were consecutively admitted to hospital during The Danish Verapamil Infarction Study. The following risk factors contained independent prognostic information about mortality for non-AMI patients: age, previous AMI, sex and diabetes. In patients with AMI the risk factors were: age, previous AMI, clinical heart failure, diabetes and angina pectoris. When the diagnosis at discharge for non-AMI patients was included in the Cox-analysis, only the diagnoses of bronchopneumonia, musculoskeletal disorders and observation only of added prognostic information. We conclude that non-AMI patients are at high risk for mortal events in the long-term. High risk patients can be identified from the medical history and should be carefully evaluated regarding coronary artery disease at the time of discharge in order to improve the risk stratification, treatment and prognosis.

Adult↗
PubMed1995

[Should silent ischemia be diagnosed and treated?].

Silent ischaemia (objective signs of myocardial ischaemia without symptoms) can be diagnosed using a conventional exercise-test or ambulatory Holter monitoring. Silent ischaemia is a frequent phenomenon in patients with ischaemic heart disease, i.e. patients with angina pectoris or previous myocardial infarction. The reason why ischaemia is symptomatic in some cases, and asymptomatic in others is unknown. Different possible mechanisms are discussed. Myocardial ischaemia, symptomatic or not is accompanied by a compromised function of the left ventricle, including reduced ejection fraction during exercise. In selected groups of patients, silent ischaemia is related to an impaired prognosis, while it does not seem to carry any prognostic information in other groups of patients. Silent ischaemia can be treated/reduced using antianginal medication or revascularization, but for the time being it is not known if treatment can improve prognosis. Studies concerning the latter are under way.

Humans↗
PubMed1995

Long-term risk factors from non-invasive evaluation of patients with acute chest pain, but without myocardial infarction.

The aims were to identify long-term risk factors for cardiac events, i.e. cardiac death and non-fatal acute myocardial infarction (AMI), and for development of angina pectoris among patients admitted with acute chest pain, but without confirmed AMI (non-AMI). A total of 257 consecutive non-AMI patients without other severe disease and below 76 years of age were included. Medical history and variables from the ECG while exercising, thallium scintigrams, Holter-monitoring, echocardiography and chest X-ray were recorded. The patients were followed for 7 years regarding cardiac death, non-fatal AMI and development of angina pectoris. The variables recorded at admission were compared to follow-up results by means of Uni- and multivariate analyses. During follow-up, 69 cardiac events, 44 cardiac deaths and 25 non-fatal AMIs occurred. The following variables provided independent prognostic information (relative risk factors with 95% confidence limits in brackets): age (1.05, 1.01-1.09), abnormal ECG at rest (2.81, 1.33-5.90), low increase in rate pressure product (4.57, 2.21-9.44), multiform premature ventricular beats (VPB) (2.61, 1.34-5.09) and transient thallium defects (2.64, 1.33-5.24). Sub-analysis of patients with and without a history of coronary artery disease (CAD) prior to admission identified the following risk factors: (1) Patients with previous CAD: abnormal ECG on admission, low increase in rate pressure product, ST depression during exercise. (2) Patients without previous CAD: abnormal ECG at rest, multiform VPBs and low increase in rate pressure product. Development of angina pectoris during follow-up of patients without previous CAD could not be predicted by any of the variables.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1995

The metabolism of erythropoietin in liver cirrhosis patients compared with healthy volunteers.

The purpose of the investigation was to study the metabolism of erythropoietin (EPO) in patients with liver disease. Twelve patients with liver cirrhosis and 10 healthy volunteers were studied. The patients were moderately anemic with a hematocrit of 33 vs 42% (medians) in the volunteers. The pharmacokinetic parameters were calculated after an intravenous (i.v.) injection of 100 U/kg of recombinant human EPO. The serum EPO was measured by radioimmunoassay at regular intervals until 48 h. The median terminal elimination half life in the cirrhosis patients was 5.15 h vs 5.37 h in the control subjects. The clearance was 7.78 vs 7.52 ml/min/1.73 m2 (ns). The steady-state volume of distribution was 3.69 vs 3.09 1/1.73 m2 (ns). The estimated endogenous EPO production was significantly higher in liver cirrhosis (486 vs 290 U/d/1.73m2, p < 0.01). The basal serum EPO was significantly higher in the cirrhosis patients (43.5 vs 26.3 U/l, p < 0.01). The hematocrit correlated inversely with the basal serum EPO level in the cirrhosis patients (r = -0.63, p < 0.04). The EPO-clearance was not related to the presence of ascites, esophageal varices, or to abnormal blood chemistry. It was concluded that normal metabolism of EPO was maintained in liver cirrhosis and that the cirrhotic patients had a moderate compensatory increase of EPO production in response to anemia.

Adult↗
PubMed1995

Short-term effects of captopril on exercise tolerance in patients with chronic stable angina pectoris and normal left ventricular function.

A double-blind, placebo-controlled, crossover study was carried out to evaluate the short-term effects of captopril on exercise tolerance in 18 normotensive patients with chronic stable angina pectoris and normal left ventricular function. Captopril 25 mg (or placebo) was given twice, i.e. in the evening (10 p.m.) and the following morning (8 a.m.), prior to a maximal symptom-limited bicycle exercise test (11 a.m.). Captopril reduced the systolic and diastolic blood pressures at rest (p < 0.01) without causing any reflex tachycardia. The time to onset of S-T depression was prolonged (p < 0.05), and the maximal S-T depression was reduced (p < 0.02). No differences were found between captopril and placebo in total exercise duration or time to onset of angina. The effects of captopril on exercise-induced ischemia were demonstrated most clearly in patients who responded with a greater than 10 mm Hg fall in the resting systolic blood pressure. In conclusion, this study suggests that captopril has anti-ischemic properties, which may be of importance in the treatment of patients with chronic stable angina and normal left ventricular function. These beneficial effects probably relate to a reduction in afterload and myocardial wall stress and therefore a reduction in myocardial oxygen demand.

Adult↗
PubMed1995

Effect of felodipine on renal haemodynamics and tubular sodium handling after single-dose cyclosporin infusion in renal transplant recipients treated with azathioprine and prednisolone.

A total of 25 renal transplant recipients, treated solely with prednisolone and azathioprine, were investigated in a randomized, double-blind, placebo-controlled, cross-over study. The effect of a single oral dose of felodipine 5 mg or placebo on: glomerular filtration rate (GFR); renal plasma flow (RPF); renal vascular resistance (RVR); renal tubular sodium and water handling, measured by the lithium clearance technique; plasma levels of angiotensin II (AngII), aldosterone (Aldo), atrial natriuretic factor (ANF) and arginine vasopressin (AVP); blood pressure (BP), and heart rate (HR) was studied before, during, and after an intravenous infusion of cyclosporin (CyA). Three consecutive clearance periods were performed, each lasting 1 h. During the second period, CyA (0.75 mg kg-1 body weight) was infused. Before infusion of CyA, felodipine caused a significant rise (6.7%) in RPF and lowered RVR, but did not change GFR significantly. The rise in RPF was abolished by infusion of CyA. After infusion, both GFR (7.8%) and RPF (9.4%) were significantly higher and RVR lower after felodipine than after placebo. Proximal tubular output and total sodium excretion were higher on the felodipine day before and after, but not during CyA infusion. In all three periods felodipine reduced both systolic and diastolic BP. In conclusion, a single dose of felodipine increases RPF and decreases blood pressure in renal transplant recipients not treated with CyA. Although some of these changes are abolished by an acute intravenous infusion of CyA, the effects of felodipine are present again also during the 1st hour after the infusion and thereby indicate at least in part some renal protective effect of felodipine. It is suggested that a higher dose of felodipine might also have been preventive against CyA renal side-effects during the acute infusion.

Administration, Oral↗
PubMed1995

Effect of isradipine on renal haemodynamics and systemic blood pressure changes induced by intravenous infusion of endothelin in healthy humans.

BACKGROUND: In some vascular beds calcium-channel-blocking agents have been shown to possess some antagonism to endothelin-1 (ET-1)-induced vasoconstriction. This issue has not been well investigated in humans, however. METHODS: The study had a double-blind cross-over design. In 12 healthy human volunteers we investigated the effect of pretreatment with either isradipine 10 mg daily for 1 week or placebo on changes in (i) systemic and renal haemodynamics and (ii) renal handling of sodium and water induced by intravenous infusion of ET-1 at a rate of 1 pmol/min/kg for 60 min. RESULTS: Infusion of ET-1 affected systemic haemodynamics. The increase in diastolic blood pressure was similar after pretreatment with placebo (+6.8%) or isradipine (+5.3%). The changes in renal haemodynamics in response to ET-1 infusion were also familiar, e.g. renal plasma flow (-32.1% versus -31.2%), glomerular filtration rate (-8.8% versus -10.9%) and renal vascular resistance (+55.1% versus +52.7%). Likewise the changes in renal handling of sodium and water in response to ET-1 infusion were unaffected by pretreatment with placebo or isradipine, e.g. sodium excretion (-44.6% versus -40.8%), urine flow rate (-49.8% versus -38.9%) and clearance of lithium (-32.0% versus -29.1%). CONCLUSIONS: Intravenous infusion of ET-1 in healthy humans discretely increases diastolic blood pressure and profoundly decreases renal haemodynamics and excretion of sodium and water. Pretreatment with the calcium-channel blocking agent isradipine for 1 week in a clinically relevant dose does not interfere with the action of ET-1.

Adult↗
PubMed1994

[The effect of thrombolytic therapy on the outcome of early exercise test in patients with acute myocardial infarction].

UNLABELLED: Exercise test variables, such as an impaired heart rate response, are known to be related to left ventricular function and patient prognosis following acute myocardial infarction. The present study was performed to compare exercise test variables in acute myocardial infarct patients following either intravenous thrombolysis or placebo. Symptom-limited bicycle ergometer tests, carried out one to two weeks from the infarction, were performed in 85 patients randomized to intravenous streptokinase (n = 41) or placebo (n = 44) given within 12 hours from onset of symptoms. Resting heart rate, systolic blood pressure and rate-pressure product were similar in the two groups. At maximum workload the streptokinase treated patients had a significantly higher median maximal heart rate than controls (136 vs. 126 min-1; p < 0.01) but only a trend towards higher systolic blood pressure was seen (175 vs. 163 mmHg; p = 0.09). Rate-pressure product at maximal exercise was 23.620 vs. 20.100 mmHg x min-1; p < 0.01). A significantly smaller number of patients in the streptokinase group had exercise capacity below 50 W (0% vs. 15.9%; p < 0.01). IN CONCLUSION: patients treated with intravenous streptokinase for acute myocardial infarction reach both higher heart rates and rate-pressure products at maximum workload than their controls thus indicating that the beneficial effects of thrombolysis after acute myocardial infarction are reflected in an improved heart rate response during exercise.

Aspirin↗
PubMed1994

Ten year mortality in patients with suspected acute myocardial infarction.

OBJECTIVE: To describe the 10 year mortality in patients with suspected acute myocardial infarction. DESIGN: Follow up of all patients below 76 years of age admitted with acute chest pain to 16 coronary care units participating in the Danish verapamil infarction trial in 1979-81. SUBJECTS: Of the 5993 patients included, 2586 had definite infarction, 402 had probable infarction, and 3005 did not have infarction. MAIN OUTCOME MEASURES: Death and cause of death. Standardised mortality ratio (observed mortality/expected mortality in background population). RESULTS: The estimated 10 year mortalities were 58.8%, 55.5%, and 42.8% in patients with definite, probable, and no infarction, respectively (P < 0.0001). Stratified Cox's analysis identified a hazard ratio for mortality of 1.25 (95% confidence interval 1.08 to 1.44) for probable infarction compared with no infarction and of 1.15 (1.00 to 1.32) for definite compared with probable infarction. The standardised mortality ratio in the first year was 7.1 (6.5 to 7.8) for definite infarction, 5.0 (3.6 to 6.3) for probable infarction, and 4.7 (4.2 to 5.2) for no infarction. From the second year and onwards the annual standardised mortality ratio in the three groups did not differ significantly. Cardiac causes of deaths were recorded in 89%, 84%, and 71% of the deaths in patients with definite, probable, and no infarction, respectively. CONCLUSIONS: The 10 year mortality of patients with and without infarction is significantly higher than in the background population. Most deaths are caused by coronary heart disease, and these patients should consequently be further evaluated at the time of discharge and followed up closely.

Adult↗
PubMed1994

[Long-term prognosis in patients with acute chest pain. The predictive value of myocardial scintigraphy].

UNLABELLED: In order to perform risk stratification 158 patients with acute chest pain, but without myocardial infarction (non-AMI) underwent exercise 201-thallium scintigraphy at the time of discharge. The patients, of whom 38 (24%) were women, were followed for seven years. The diagnostic sensitivity, specificity and predictive values of the outcome of the examination for identification of patients, who had a cardiac event (cardiac death or later non-fatal AMI) during follow-up, was calculated. Forty-one had a cardiac event during follow-up. The highest sensitivity (85%) was achieved by the combination of transient defect and/or persistent defect and/or abnormal ST-segment response. The highest specificity was provided by a transient defect (90%) and the predictive value of a positive test was 60%-17 of 29 patients with a transient defect had a cardiac event during follow-up. Patients with a normal test had an excellent prognosis, 94% of 82 patients were free of cardiac events during follow-up. CONCLUSIONS: Exercise 201-thallium scintigraphy is suitable for long-term risk stratification in patients with chest pain and suspicion of but unconfirmed myocardial infarction, because high and very low risk subsets can be identified at the time of discharge.

Adult↗