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Biomedical subjects

J Sever

Publications and source records attributed to J Sever.

At least 19 recordsLinked to original sources
PubMed2001

Stability of diagnosis: a 20-year retrospective cohort study of Israeli psychiatric adolescent inpatients.

Outcome according to diagnosis and stability of diagnosis were investigated in a follow-back study of 351 adolescents with various psychiatric disorders hospitalized in a closed psychiatric ward. The duration of follow-back was 15-19 years. All diagnoses were based on the ICD-9. Data were collected from the Health Ministry registry and, in the patients who could be located, by structured telephone interview. Special attention was directed at the diagnosis of transient adolescent psychosis (TAP) vs. schizophrenia and prognostic indicators of suicide. The results showed that the most stable diagnosis was anxiety disorder. The stability of the different diagnoses over time was greater between the second and last admission than between the first and last (for patients with three or more admissions). Number of hospitalizations correlated negatively with prognosis. TAP at second admission was an unstable diagnosis; 66% of these patients had a final diagnosis of schizophrenia. However, patients with a diagnosis of TAP at first admission had a higher predictive index score and a higher outcome score than schizophrenic patients. TAP appeared to be a valid diagnostic entity, distinguishable from schizophrenia in course, frequency of suicidal behaviour and social-occupational outcome. Suicide victims had a higher cumulative length of stay than age- and sex-matched non-suicidal patients. Fifty per cent of the suicide victims had a final diagnosis of schizophrenia, compared to 30 per cent for the whole sample. In conclusion, these findings indicate that TAP is associated with a relatively good prognosis and should probably be differentiated from schizophrenia. Further retrospective and prospective studies of adolescent psychiatric inpatients may help delineate the nature and course of psychosis and other psychopathology in this age group.

Adolescent↗
PubMed2001

Hypnotherapy in adolescents with trichotillomania: three cases.

Trichotillomania is not rare in adolescence. Psychotherapy is often ineffective, and cognitive behavioral therapy in combination with serotonin-specific reuptake inhibitors seems to be the treatment of choice. Some cases are resistant to all therapy. This paper reports on three adolescents with pure trichotillomania who responded to the imaginative hypnotherapy technique with Ericksonian suggestions. The patients described their hair as weak and vulnerable and needy of protection. In therapy, the patient was assigned the role of "patron of the hair" thereby giving him/her control of the situation. Hair pulling was significantly reduced, and the improvement was sustained throughout the 6-month follow-up. These cases suggest that imaginative techniques may be effective in adolescents with trichotillomania. Further controlled studies in adolescent population are needed to confirm this assumption.

Adolescent↗
PubMed2001

Renal dysfunction after cardiac surgery.

OBJECTIVE: To assess the causes and outcomes of patients with postcardiac surgery renal dysfunction. PATIENTS AND METHODS: A large cardiovascular data- base including pre-, peri- and postoperative serum creatinine concentrations from 2214 consecutive cardiac surgery patients was analyzed. RESULTS: Sixty-nine patients developed postoperative renal dysfunction, defined as at least a 15 mL/min decline in the creatinine clearance rate resulting in a value of less than 40 mL/min. These patients were significantly older, and had a higher incidence of previous cardiac surgery, diabetes, obesity, peripheral vascular disease, hypertension and poor ventricular function. Postoperatively, these patients had a higher occurrence of low output syndrome and myocardial infarction. Stepwise logistic regression predictors of postoperative renal dysfunction included the following: postoperative low output syndrome; repeat cardiac surgery; being older than 65 years; having diabetes; having poor left ventricular function; and having had valve surgery. Preoperative renal dysfunction (defined as a creatinine clearance of less than 40 mL/min) was not found to be one of the predictors. The mean creatinine concentrations of patients with mild postoperative renal dysfunction (defined as a creatinine concentration of less than 200 mmol/L on the fourth or fifth postoperative day) decreased significantly at the fifth postoperative day, while that of patients with severe postoperative renal dysfunction rose to a mean of 300 mmol/L six months postoperatively. The incidence of late dialysis (defined as a need for dialysis after postoperative day 10) approached 30% among patients with severe postoperative renal dysfunction and only 2% among patients with mild postoperative renal dysfunction. The early mortality rate (during the first postoperative month) was similar in both groups and approached 30%. CONCLUSIONS: Patients who develop postoperative renal dysfunction have a high mortality rate. Postoperative low cardiac output is the most important cause of postoperative renal dysfunction and, therefore, should be avoided. Patients with creatinine concentrations of less than 200 mmol/L at postoperative day 4 or 5 will probably resume normal renal function. Patients with creatinine concentrations of more than 200 mmol/L at days 4 and 5 have a 30% chance of needing long term dialysis.

Age Distribution↗
PubMed2000

Combination nucleoside analog reverse transcriptase inhibitor(s) plus nevirapine, nelfinavir, or ritonavir in stable antiretroviral therapy-experienced HIV-infected children: week 24 results of a randomized controlled trial--PACTG 377. Pediatric AIDS Clinical Trials Group 377 Study Team.

One hundred eighty-one antiretroviral-experienced, protease inhibitor-naive, clinically stable HIV-infected children between 4 months and 17 years of age were randomly assigned to receive one of four combination regimens to evaluate the change in plasma HIV RNA, safety, and tolerance when changing antiretroviral therapy to a protease inhibitor-containing combination regimen. All four regimens contained stavudine; in addition children received nevirapine plus ritonavir, lamivudine plus nelfinavir, nevirapine plus nelfinavir, or lamivudine plus nevirapine plus nelfinavir. Twelve additional children chose to receive stavudine plus lamivudine plus nelfinavir, with nelfinavir given bid, rather than tid as for the main regimens. Overall, 51% (89/176; 95% CI 43-58%) of the children on the randomized portion of the study had an HIV RNA response (< or =400 copies/ml) on at least two of the three HIV RNA determinations taken at Weeks 8, 12, and 16. At Week 24 the proportion of children with an HIV RNA response still on initial therapy was 47% (83/176; 95% CI 40-55%) and ranged from 41 to 61% for the four randomized treatment arms. Rash was frequently seen (27%) on the treatment arms containing nevirapine. At Week 24 64% (7/11, 95% CI 31-89%) of the children on the bid nelfinavir combination regimen were still on initial therapy with an HIV RNA response as compared with 46% (23/50; 95% CI 32-61%) on the corresponding tid nelfinavir combination regimen. A change in antiretroviral therapy to a protease inhibitor-containing regimen was associated with a virological response rate of approximately 50% for this patient population.

Anti-HIV Agents↗
PubMed1999

A novel comparison of stentless versus stented valves in the small aortic root.

BACKGROUND: Previous studies have compared prosthetic valves on the basis of industry-labeled valve sizes. Unfortunately, the relationship between the labeled size and the true measured external or internal diameter differs between valve manufacturers. Therefore hemodynamic comparisons between prosthetic valves are inaccurate if based solely on industry-labeled valve sizes. METHODS: We have previously demonstrated that the internal diameter of a 21-mm Carpentier-Edwards pericardial stented valve is similar to that of a 25-mm Toronto stentless porcine valve. Therefore we chose to compare postoperative hemodynamics in patients who received 19-, 21-, or 23-mm Carpentier-Edwards pericardial stented valves (inner diameter 18-22 mm, n = 69) with those in patients who received 23- or 25-mm stentless porcine valves (internal diameter 19-21 mm, n = 41). RESULTS: Patients in the Carpentier-Edwards group were more likely to be elderly and more likely to require concomitant revascularization. Operative mortality was lower in the stentless porcine valve group (0% vs 9%, P =.06). Hospital stay and ventilation requirements were shorter in the stentless porcine valve group. Postoperative hemodynamics were similar in the two groups. CONCLUSIONS: These data provide evidence that stentless and stented valves have similar hemodynamic profiles in the small aortic root when matched on true measured internal diameters. The clinical benefit of the stentless porcine valve may be due to patient selection or the lack of a rigid stent in the small aortic root, but it is not due to hemodynamic superiority over stented aortic valves of similar sizes.

Aged↗
PubMed1998

Multiple arterial grafts. Radial versus right internal thoracic arteries.

BACKGROUND: Left internal thoracic artery (LITA) grafts to the left anterior descending coronary artery (LAD) during coronary bypass surgery (CABG) have greater patency rates than saphenous vein grafts and reduce long-term cardiac morbidity and mortality rates. The benefits of multiple versus single arterial grafts and the role of different arterial conduits with respect to short- and medium-term outcome remains controversial. The purpose of this study was to compare the perioperative and intermediate-term results of: (1) patients receiving 2 arterial grafts versus 1 arterial graft and (2) patients receiving a right internal thoracic artery (RITA) versus a radial artery (RA) as the second arterial graft. METHODS AND RESULTS: Retrospective analysis of prospectively gathered data on consecutive patients undergoing isolated CABG at our institution between 1989 and 1996 was conducted. The first section of the study compared outcomes for 1 arterial graft (LITA to LAD, n = 2333) versus 2 arterial grafts (LITA + RA or LITA + RITA, n = 378). The second section of the study compared outcomes for the RITA (n = 132) versus the RA (n = 171) as second arterial grafts since 1992, when the radial series was initiated. Part I: By multivariable stepwise logistic regression, the use of 1 arterial graft was associated with an increased incidence of perioperative cardiac morbidity and mortality (odds ratio 2.2, 95% confidence interval 1.4 to 3.3), with the use of our current patient selection criteria. Double-arterial graft patients had a nonsignificant trend toward increased intermediate-term actuarial survival (P = 0.12) and cardiac event-free survival (P = 0.09). Part II: Comparison of preoperative demographics revealed a higher incidence of diabetes (27% vs 11%, P < 0.001), peripheral vascular disease (16% vs 8%, P = 0.03), and elderly age (13% vs 2%, P = 0.001) in patients receiving an RA versus those receiving a RITA as the second arterial graft. Perioperative outcome analysis revealed a decreased intensive care unit stay in the RA versus RITA group (median 30.4 vs 36.2 hours, respectively, P = 0.005) but no significant difference in hospital length of stay. There was no significant difference in perioperative mortality or cardiac morbidity rates. RITA patients had a higher incidence of sternal wound infection (5.3% vs 0.6%, P = 0.01), however, and tended to have increased blood product transfusion rates (51% vs 40%, P = 0.06). CONCLUSIONS: The use of 2 arterial grafts is safe, with a reduction in perioperative cardiac morbidity or mortality rates compared with 1 arterial graft after adjustment for other risk variables. When comparing RITA to RA as second arterial grafts, patients receiving an RA have a lower incidence of sternal wound infection and decreased transfusion requirements, with no difference in perioperative or intermediate-term cardiac morbidity or mortality rates.

Aged↗
PubMed1998

Coronary bypass with arterial conduits.

To assess the efficacy of arterial revascularization 368 patients were studied who underwent myocardial revascularization with two or more arterial conduits (group M) and compared with 2092 patients in whom a single internal mammary artery +/- veins (group S), and to a third group in which only saphenous vein conduits (group V, n = 602) were used. Group M patients were younger (aged 54.0(9.5) years; 4.1% aged > 70 years) than either group V (67.6(8.9) years, 40.7% > 70 years, P < 0.0001) or group S patients (62.0(8.5) years, 15.7% > 70 years, P < 0.0001). Furthermore, this cohort group had the lowest percentage of females (8.4%), of urgent cases (21.7%), of preoperative myocardial infarction (6.0%), and of redo surgery (0.8%). In contrast, patients who received only saphenous vein conduits had the highest proportion of female patients (29.2%), of urgent cases (47.4%), of preoperative myocardial infarction (16.5%), and of redo surgery (5.5%). By multivariate logistic regression analysis (odds ratio in parentheses), redo surgery (6.06, P = 0.0001), preoperative intra-aortic balloon pump assist (6.11, P = 0.0001), diabetes (1.97, P = 0.03), urgent surgery (1.80, P = 0.05), and advanced age (2.14, P = 0.01) were all predictors of operative mortality. In contrast, while choice of conduit appeared to influence outcome by univariate analysis (4.2% mortality in group V, P < 0.001), it was not found to be a predictor of either mortality or morbidity by regression analysis. The present results indicate that, in carefully selected patients, despite increased technical demands with longer periods of aortic occlusion and longer pump times, multi-arterial grafting (compared with conventional revascularization) is a safe and efficacious procedure. Whether or not this approach to revascularization will increase long-term survival and freedom from reoperation will require further study.

Aged↗
PubMed1996

Can patients with left main stenosis wait for coronary artery bypass grafting?

BACKGROUND: The economic impact of health care reforms may result in waiting lists for coronary artery bypass grafting. This study was designed to examine the clinical results of patients with left main stenosis who were placed on a triaged wait list for operation. METHODS: Data were collected prospectively on 2,145 patients undergoing isolated coronary artery bypass grafting between 1989 and 1994. Critical left main stenosis (LMS, 50% or more stenosis) was present in 281 patients, and 1,864 patients had no left main disease, or a left main stenosis of less than 50% (no LMS). RESULTS: The average time from angiography to operation was shorter in patients with LMS (LMS 38 +/- 46 days versus no LMS 84 +/- 71 days; p = 0.0001). Two patients in the LMS group died; they had declined operation. Four patients suffered non-Q wave myocardial infarctions, all of whom subsequently underwent operation with no perioperative complications. The presence of LMS did not influence operative mortality (LMS 2.8% versus no LMS 1.3%), the incidence of low output syndrome (LMS 8.3% versus no LMS 5.4%), or the incidence of perioperative myocardial infarction (LMS 3.8% versus no LMS 4.2%). To examine the effect of waiting time on outcomes, patients with LMS were divided into early (operation 10 days or less after angiography) and late revascularization groups (more than 10 days). Operative mortality, low output syndrome, and myocardial infarction were similar in the early and late groups. Patients in the early group were more likely to have New York Heart Association functional class IV symptoms (64% versus late 22%; p < 0.0001), unstable angina (87% versus late 65%; p < 0.0001), or a recent preoperative myocardial infarction (17% versus late 2%; p < 0.0001). CONCLUSIONS: Carefully selected patients with significant left main stenosis can safely wait for operation with a low risk of complications. Early surgical intervention is allocated to patients with severe symptoms or recent preoperative myocardial infarction.

Aged↗
PubMed1996

Seven-year follow-up of child survivors of a bus-train collision.

OBJECTIVE: To assess the long-term effects of a traumatic bus-train collision and to examine the effect of levels of exposure and immediate reactions on long-term adjustment. METHOD: Seven years after the accident, 389 subjects, all doing compulsory army service, filled out self-report questionnaires assessing symptoms of posttraumatic stress disorder (PTSD), psychiatric symptomatology, and military functioning. In addition, subjects were questioned about their immediate reactions to the traumatic event. RESULTS: The most highly exposed subjects reported the highest levels of somatization, depression, phobic anxiety, and psychoticism and more PTSD symptoms. Acute stress symptoms and manifestations of fear immediately after the accident were strongly related to long-term maladjustment CONCLUSIONS: The results suggest that the investigation and assessment of long-term adjustment after traumatic events should take into account both contextual factors, such as the level of exposure to the event, and personal factors, such as the victims' immediate reactions.

Accidents, Traffic↗
PubMed1995

Ex vivo human placental transfer of human immunodeficiency virus-1 p24 antigen.

OBJECTIVE: Our purpose was to determine whether human immunodeficiency virus-1 p24 antigen crosses the human placenta and, if so, to determine its clearance index relative to antipyrine. STUDY DESIGN: Eight term human placentas from uncomplicated vaginal or cesarean section deliveries were studied by ex vivo placental perfusion to determine the incidence and concentration required to obtain passage of p24 antigen into the fetal circulation. The concentration of p24 antigen was determined by antigen-capture enzyme immunoassay. RESULTS: The passage of p24 antigen into the fetal circulation was observed in three of five placentas studied when the p24 antigen concentration in the maternal circulation was 2942.8 +/- 401 pg/ml. When the p24 concentration in the maternal circulation was raised approximately fourfold to 14506 +/- 4124 pg/ml, p24 antigen passed to the fetal circulation in two of three placentas and in three of three placentas in the closed perfusion system. CONCLUSIONS: p24 antigen crossed the human placenta to the fetal circulation in what appears to be a concentration-dependent manner.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Initial clinical experience with the Toronto Stentless Porcine Valve.

We report our initial experience from April 1992 to November 1993 with a stentless porcine valve (Toronto SPV Valve, St. Jude Medical) for aortic valve replacement (AVR) in 21 consecutive patients and compare this group to a matched cohort that underwent AVR with a Hancock II (Medtronic) bioprosthesis. There were no hospital deaths in either group. Postoperative hospitalization was 5.5 +/- 0.8 versus 7.0 +/- 2.3 days (p = 0.004). Aortic cross-clamp time was 114.5 +/- 15.7 min in the SPV group and 96.0 +/- 25.0 min in the Hancock II group (p = 0.003). Complications in the SPV group were: one patient suffered perioperative infarction, one patient required late reoperation for left main stenosis, and one patient died suddenly following femoral thrombectomy at another center. Complications in the Hancock II group included: one patient with postoperative low output syndrome, and two late deaths (one from an aortic dissection and the other from chronic liver disease secondary to alcohol abuse). Comparison data indicate that the average size valve implanted in the SPV group was higher than in the Hancock II group (26.3 +/- 1.9 vs 24.0 +/- 1.9, p = 0.001). In the SPV group, 16 patients had 0 or trivial regurgitation and 1+ regurgitation was seen in 5 patients; regurgitation did not change over a 12-month follow-up. We observed a decrease in gradients over time (p < 0.01). Our results are compatible with a hypothesis that the ventricle undergoes remodeling over time, once the obstruction is relieved. We think the stentless design is an important feature that allows this to occur.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Stentless porcine bioprosthesis for aortic valve replacement.

We report herein our experience with the Toronto Stentless Porcine Valve (Toronto SPV, manufactured by St. Jude Medical Inc., Minneapolis, MN, USA) for aortic valve replacement (AVR). To date 146 SPV valves have been implanted, 29 in an initial clinical trial (from October 1987 to April 1987) and 117 in the current FDA trial (September 1991 to January 1994). In the current trial the majority of patients were male (76%), aortic stenosis was the dominant lesion (73%) and 68% of the patients received a valve size 27 mm or greater. The mean age was 61.3 +/- 12.0 years. For the entire group there has been no hospital death and no patient has required a pacemaker. Perioperative complications were myocardial infarction in three patients and suspect subacute bacterial endocarditis (medically treated) in three patients. There have been two late deaths (2%), two patients have had transient ischemic attacks (2%), and one patient suffered stroke with complete neurological recovery (1%). To date there has been no case of primary valve failure. Echocardiographic assessment of the SPV valve has demonstrated excellent effective valve orifice areas with very low transvalvular gradients and 95% of the patients had either 0 or 1+ insufficiency. These results are encouraging and justify the continued use of this valve in clinical trials. Further follow-up is required to determine its durability.

Adult↗
PubMed1993

Evaluating the best interests of the child--a model of multidisciplinary teamwork.

This article describes the rationale, goals and procedure of a working model of multidisciplinary teamwork in conducting clinical evaluations of children and families and preparing expert testimony. Over the past five years, the team has evaluated over 60 cases involving child abuse and neglect, and questions of parental ability. Teamwork can reduce the distorting effects of personal biases, beliefs and countertransference issues. The contribution of integrating different theoretical viewpoints (theories of development, object relations, family systems, etc) is discussed. Recommendations include: (a) separation of roles of expert witness and therapist: (b) utilization of different diagnostic tools (psychodiagnostic tests, observations of interaction, joint clinical interviews, etc); (c) value of examining the feasibility of the recommendations with parents, care givers and community workers; and (d) strategies of dispute resolution and attainment of parental consent, utilizing the effects of potential judicial power and focusing on the best interests of the child.

Child↗
PubMed1990

Serological survey for two simian retroviruses in macaques and African green monkeys.

Colonies of nonhuman primates at the Bowman Gray School of Medicine (BGSM) were tested for antibodies to two retroviruses associated with immunodeficiency by indirect immunofluorescence (IFA) and western blot. A total of 471 cynomolgus macaques (Macaca fascicularis), 144 rhesus monkeys (M. mulatta) and 67 stumptail monkey M. arctoides) were tested for SRV-1, and 152 African green monkeys (Cercopithecus aethiops) were tested for SIV. Of the macaques tested, 170 (36%) cynomolgus, 5 (3%) rhesus and 8 (12%) stumptails were positive for SRV-1 antibodies by IFA. Of the African green monkeys, 54 (36%) were IFA positive for SIV antibodies. A total of 143 African green monkeys tested by IFA also were tested by western blot. In the African green monkeys, the IFA had a positive predictive value of 98% and a negative predictive value of 96%. Of 176 IFA positive macaque sera tested by western blot, 49 (28%) were positive, 55 (31%) were considered equivocal (only one band, usually to p27 core protein), and 72 (41%) were negative.

Animals↗