Biomedical subjects

M Loeb

Publications and source records attributed to M Loeb.

At least 37 records · Page 2Linked to original sources

PubMed2000

[Hospital capacity and waiting time for treatment--is there a connection?].

BACKGROUND: The association between hospital capacity and waiting time for treatment is uncertain. MATERIAL AND METHODS: Waiting times for patients on waiting lists for inpatient treatment in 1998 were analysed to disclose possible associations with the hospitals' treatment resources, i.e., general costs, number of beds, doctors or nurses in relation to the population of its catchment area, and the relation between acute and elective admissions. Waiting times were calculated from the National Patient Register, which collects information on hospital stays. Resource data and data on acute admissions were taken from the SAMDATA publications for 1998. RESULTS: Median waiting time varied from 50 to 300 days among the hospitals. Statistical regression models were, however, unable to explain the variation in waiting time on the basis of any variable related to hospital resources or acute admissions that may influence the capacity for elective admissions. INTERPRETATION: To avoid breaches of the guarantees for patients guaranteed a maximum of three months on the waiting list, the median waiting time should be below 12-15 days. This goal may, however, be much too ambitious in view of the fact that the median waiting time for patients with mammary or colon cancer is about 30 days.

Catchment Area, Health↗

PubMed2000

Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians' and nurses' perceptions.

BACKGROUND: Antibiotic therapy for asymptomatic bacteriuria in institutionalized elderly people has not been shown to be of benefit and may in fact be harmful; however, antibiotics are still frequently used to treat asymptomatic bacteriuria in this population. The aim of this study was to explore the perceptions, attitudes and opinions of physicians and nurses involved in the process of prescribing antibiotics for asymptomatic bacteriuria in institutionalized elderly people. METHODS: Focus groups were conducted among physicians and nurses who provide care to residents of long-term care facilities in Hamilton, Ont. A total of 22 physicians and 16 nurses participated. The focus group discussions were tape-recorded, and the transcripts of each session were analysed for issues and themes emerging from the text. Content analysis using an open analytic approach was used to explore and understand the experience of the focus group participants. The data from the text were then coded according to the relevant and emergent themes and issues. RESULTS: We observed that the ordering of urine cultures and the prescribing of antibiotics for residents with asymptomatic bacteriuria were influenced by a wide range of nonspecific symptoms or signs in residents. The physicians felt that the presence of these signs justified a decision to order antibiotics. Nurses played a central role in both the ordering of urine cultures and the decision to prescribe antibiotics through their awareness of changes in residents' status and communication of this to physicians. Education about asymptomatic bacteriuria was viewed as an important priority for both physicians and nurses. INTERPRETATION: The presence of non-urinary symptoms and signs is an important factor in the prescription of antibiotics for asymptomatic bacteriuria in institutionalized elderly people. However, no evidence exists to support this reason for antibiotic treatment. Health care providers at long-term care facilities need more education about antibiotic use and asymptomatic bacteriuria.

Aged↗

PubMed2000

Surveillance for outbreaks of respiratory tract infections in nursing homes.

BACKGROUND: Outbreaks of respiratory tract infections are common in long-term care facilities for older people. The objective of our study was to determine both the frequency of such outbreaks and their clinical and epidemiological features. METHODS: Prospective surveillance for outbreaks of respiratory tract infections and a retrospective audit of surveillance records were conducted in 5 nursing homes in metropolitan Toronto over 3 years. The clinical manifestations of infected residents were identified and microbiological investigations for causal agents were conducted. RESULTS: Sixteen outbreaks, involving 480 of 1313 residents, were identified prospectively during 1 144 208 resident-days of surveillance, for an overall rate of 0.42 infections per 1000 resident-days. Another 30 outbreaks, involving 388 residents, were identified retrospectively. Outbreaks occurred year-round, with no seasonal pattern. Pathogens included influenza virus, parainfluenza virus, respiratory syncytial virus, Legionella sainthelensi and Chlamydia pneumoniae. Multiple pathogens were detected in 38% (6/16) of the prospectively identified outbreaks. Of the 480 residents in the prospectively identified outbreaks 398 (83%) had a cough, 194 (40%) had fever and 215 (45%) had coryza. Clinical findings were nonspecific and could not be used to distinguish between causal agents. Pneumonia developed in 72 (15%) of the 480 residents, and 58 (12%) required transfer to hospital. The case-fatality rate was 8% (37/480). INTERPRETATION: Our findings emphasize the importance of adequate surveillance for outbreaks of respiratory tract infections in nursing homes and of early diagnosis so that appropriate interventions can be promptly instituted.

Aged↗

PubMed2000

Antibiotic use in long-term-care facilities: many unanswered questions.

The extensive use of antibiotics in long-term-care facilities has led to increasing concern about the potential for the development of antibiotic resistance. Relatively little is known, however, about the quantitative relation between antibiotic use and resistance in this population. A better understanding of the underlying factors that account for variance in antibiotic use, unexplained by detected infections, is needed. To optimize antibiotic use, evidence-based standards for empirical antibiotic prescribing need to be developed. Limitations in current diagnostic testing for infection in residents of long-term-care facilities pose a substantial challenge to developing such standards.

Anti-Bacterial Agents↗

PubMed2000

Zanamivir use during transmission of amantadine-resistant influenza A in a nursing home.

OBJECTIVE: To describe the use of zanamivir during an influenza A outbreak. POPULATION: Residents of a 176-bed long-term-care facility for the elderly in Newmarket, Ontario, Canada, 90% of whom received influenza vaccine in the fall of 1998. OUTBREAK: When respiratory illness due to influenza A was confirmed, infection control measures and amantadine prophylaxis were initiated. Despite these measures, transmission of influenza A continued. INTERVENTION: Zanamivir inhalations, 10 mg daily for prophylaxis and 10 mg twice daily for treatment of influenza. RESULTS: There were 13 definite and 66 probable outbreak-associated cases of influenza A. Twelve (15%) cases developed pneumonia, 7 (9%) were hospitalized, and 2 (2.6%) died. All 12 culture-positive cases yielded influenza A/Sydney/H3N2/05/97-like virus, a 1998/99 vaccine component. The three isolates obtained prior to the initiation of amantadine were amantadine-susceptible; all nine obtained after prophylaxis was instituted were amantadine-resistant. One hundred twenty-nine (92%) of 140 residents who were offered zanamivir accepted it and were able to attempt inhalations. Of these 129, 78% (100) had no difficulty in complying with inhalations. Difficulty with inhalations was associated with decreased functional and mental status. Fifteen (58%) of 26 residents fully dependent in activities of daily living had difficulty compared to 14 (14%) of 100 others (P<.001). Twenty-two (45%) of 49 residents not oriented to person, place, or time had difficulty compared to 7 (10%) of 77 others (P<.001). In the 2 weeks after zanamivir prophylaxis, only 2 new cases of respiratory illness occurred, neither confirmed as influenza. No side effects were identified in 128 zanamivir-treated residents. CONCLUSION: A minority of nursing home residents have difficulty following instructions for zanamivir inhalations. Zanamivir was well tolerated, and its use was temporally associated with termination of an outbreak that amantadine had failed to control.

Activities of Daily Living↗

PubMed2000

Incidence and cause of fractures in European districts.

AIMS: To compare fracture rates in European districts. SETTING: Geographically defined areas of Wales (Swansea and Neath Port Talbot), Norway (Harstad, Trondheim, Stavanger, and Drammen), Sweden (Jamtlands), and Finland (Porvoo). METHODS: Surveillance of fractures at emergency departments and hospitals and linkage with population data. Comparison of age adjusted and crude rates. Calculation of confidence intervals for ratios. RESULTS: A total of 4113 fractures occurred in 167 560 children during 1996. Fracture rates in south Wales (36 per 1000) were substantially higher than in Scandinavian districts (which were similar). Limiting analysis to the most severe injuries to correct for the possibility of ascertainment bias reduced some of the excess rate in Wales: the Welsh:Scandinavian fracture ratio was 1.82 (95% confidence interval: 1.64 to 2.03). CONCLUSIONS: Fracture rates in Welsh children are substantially higher than in Scandinavian children.

Adolescent↗

PubMed2000

Improving doctors' prescribing behaviour through reflection on guidelines and prescription feedback: a randomised controlled study.

BACKGROUND: It is difficult to put research findings into clinical practice by either guidelines or prescription feedback. AIM: To study the effect on the quality of prescribing by a combined intervention of providing individual feedback and deriving quality criteria using guideline recommendations in peer review groups. METHODS: 199 general practitioners in 32 groups were randomised to participate in peer review meetings related to either asthma or urinary tract infections. The dispensing by the participating doctors of antiasthmatic drugs and antibiotics during the year before the intervention period provided the basis for prescription feedback. The intervention feedback was designed to describe the treatment given in relation to recommendations in the national guidelines. In each group the doctors agreed on quality criteria for their own treatment of the corresponding diseases based on these recommendations. Comparison of their prescription feedback with their own quality criteria gave each doctor the proportion of acceptable and unacceptable treatments. MAIN OUTCOME MEASURE: Difference in the prescribing behaviour between the year before and the year after the intervention. RESULTS: Before intervention the mean proportions of acceptably treated asthma patients in the asthma group and urinary tract infection (control) group were 28% and 27%, respectively. The mean proportion of acceptably treated patients in the asthma group was increased by 6% relative to the control group; this difference was statistically significant. The mean proportions of acceptable treatments of urinary tract infection before intervention in the urinary tract infection group and asthma (control) group were 12% for both groups which increased by 13% in the urinary tract infection group relative to the control group. Relative to the mean pre-intervention values this represented an improvement in treatment of 21% in the asthma group and 108% in the urinary tract infection group. CONCLUSIONS: Deriving quality criteria of prescribing by discussing guideline recommendations gave the doctors a basis for judging their treatment of individual patients as acceptable or unacceptable. Presented with feedback on their own prescribing, they learned what they did right and wrong. This provided a foundation for improvement and the process thus instigated resulted in the doctors providing better quality patient care.

Asthma↗

PubMed2000

Suicidal behavior in the municipality of Baerum, Norway: a 12-year prospective study of parasuicide and suicide.

The present 12-year (1984-1995) surveillance study includes all hospitalized parasuicide patients (n = 1,031) as well as all suicides (n = 161) in the municipality of Baerum, a suburb of Oslo. The parasuicide rate decreased from 170 per 100,000 in 1984 to 79 per 100,000 in 1995 (53.5%). The parasuicide rates were lower than those in several comparable studies. Rates were higher for divorced females and separated males compared to married and other marital states, and the pattern of relative risk of parasuicide with respect to marital status was stable. Unemployment and substance abuse were positively correlated with parasuicidal behavior for both males and females. Approximately 33% reported one or more previous parasuicidal acts, and 21% repeated the parasuicide during the observation period. Ninety-four percent used self-poisoning as parasuicide method. A total of 2.4% of the parasuiciders committed suicide during the observation period. The mean annual suicide rate in Baerum was 19.0 per 100,000 compared to the national average of 14.7. The results support the notion of parasuicide and suicide being two different but overlapping populations. The implementation of a follow-up system for parasuiciders may have contributed to the reduced parasuicide rate during the study period.

Adolescent↗

PubMed1999

Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.

BACKGROUND: Little is known about the risk factors, outcome, and impact of pneumonia and other lower respiratory tract infections (LRTIs) in residents of long-term care facilities. OBJECTIVE: To determine the risk factors and the effect of these infections on functional status and clinical course. METHODS: Active surveillance for these infections was conducted for 475 residents in 5 nursing homes from July 1, 1993, through June 30, 1996. Information regarding potential risk factors for these infections, functional status, transfers to hospital, and death was also obtained. RESULTS: Two hundred seventy-two episodes of pneumonia and other LRTIs occurred in 170 residents during 228 757 days of surveillance for an incidence of 1.2 episodes per 1000 resident-days. Multivariable analysis revealed that older age (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.6 per 10-year interval; P = .01), male sex (OR, 1.9; 95% CI, 1.1-3.5; P = .03), swallowing difficulty (OR, 2.0; 95% CI, 1.2-3.3; P = .01), and the inability to take oral medications (OR, 8.3; 95% CI, 1.4-50.3; P = .02) were significant risk factors for pneumonia; receipt of influenza vaccine (OR, 0.4; 95% CI, 0.3-0.5; P = .01) was protective. Age (OR, 1.6 [95% CI, 1.0-2.5] per 10-year interval; P = .05) and immobility (OR, 2.6; 95% CI, 1.8-3.8; P = .01) were significant risk factors for other LRTIs, and influenza vaccination was protective (OR, 0.3; 95% CI, 0.2-0.4; P = .01). Residents with pneumonia (OR, 0.7; 95% CI, 0.3-1.4; P = .31) or with other LRTIs (OR, 0.5; 95% CI, 0.2-1.1; P = .43) were no more likely to have a deterioration in functional status than individuals in whom infection did not develop. CONCLUSIONS: Swallowing difficulty and lack of influenza vaccination are important, modifiable risks for pneumonia and other LRTIs in elderly residents of long-term care facilities. Our findings challenge the commonly held belief that pneumonia leads to long-term decline in functional status in this population.

Aged↗

PubMed1999

[Drug prescription to 4-year-old children in the county of Vestfold].

We carried out a study of four-year-old children's general health, diseases and use of medicines over a 12-month period in 1995-96. The study was based on a questionnaire administered in connection with the regular health controls. Questionnaires from 1,912 children were returned, representing 79% of children born during one year in the county. More than half the children had received medicine prescribed by a physician, corresponding to 557 preparations per 1,000 children. Some children had used several types of drugs, with a mean of 1.4 preparations per child. Antibiotics were prescribed to 63% of the children. Compared to what has been found in other studies, the use of prescribed medicine was moderate. More pharmacoepidemiological studies are needed to assess whether the use of medicine in children is at an acceptable level.

Anti-Asthmatic Agents↗

PubMed1999

The Norwegian naturalistic treatment study of depression in general practice (NORDEP)-I: randomised double blind study.

OBJECTIVE: To evaluate the efficacy of emotional support and counselling combined with placebo or antidepressants with single or dual mechanism of action in the treatment of depression in primary care. DESIGN: Randomised double blind study. SETTING: Several locations in Norway. SUBJECTS: 372 patients with depression. MAIN OUTCOME MEASURES: Improvement (clinical remission) reported both by the patient (Montgomery Asberg depression rating scale) and the physician (clinical global improvement and impression scales). RESULTS: Intention to treat analyses showed 47% remission in patients randomised to placebo compared with 61% remission in patients randomised to sertraline (odds ratio 0.56, 95% confidence interval 0.33 to 0.96) and 54% in patients randomised to mianserin (0.75, 0.44 to 1.27). Women responded better than men (1.86, 1.17 to 2.96). Subgroup analyses showed that subjects with recurrent depression (n=273) responded more frequently to sertraline than to placebo (0.43, 0.23 to 0.82) than those having their first episode of depression (1.18, 0.39 to 3.61). Statistically significant interactions between type of drug treatment and history of depression were not shown by logistic regression. CONCLUSION: The combination of active drug and simple psychological treatment (counselling, emotional support, and close follow up over a 24 week period) was more effective than simple psychological treatment alone, in particular for those with recurrent depression. Overall, women may benefit more than men. If confirmed in future studies, the findings should lead to more differentiated treatment guidelines for depression in primary care.

Adolescent↗

PubMed1999

A comparison of model-building strategies for lower respiratory tract infection in long-term care.

Five strategies for creating predictive models of lower respiratory tract infection in residents of long-term care facilities were compared. A linear judgment model was derived by administering clinical vignettes to physicians who indicated the risk of infection based on the presence or absence of five predictor variables. A model based on physician consensus was created using the same variables. Three models based on empirical data (logistic regression, proportional hazards, and recursive partitioning) were created from a "derivation" sample of data from a cohort study of lower respiratory tract infections in nursing homes using the five predictor variables. All models were applied to a validation set and compared using receiver operating characteristic (ROC) curves. The data-derived and consensus models showed the highest discriminative ability while the linear judgment model showed inferior performance.

Canada↗

PubMed1999

Seven-year clinical follow-up after lumbar disc surgery: results and predictors of outcome.

This study evaluates the 7-year outcome of lumbar disc surgery and the predictive value of pre- and perioperative risk factors. The 7-year follow-up rate of a sample of 122 patients was 93% (n = 114). Six per cent of the patients had undergone repeat surgery. Approximately 90% reported that they were satisfied with having undergone surgery. The clinical outcome was evaluated in 96 patients (54 men and 42 women) by means of patient-scores (VAS) of low back and leg pain, and a Clinical Overall Score (COS). In multivariate regression analyses, women were shown to have poorer outcome than men. Preoperative psychological distress and impaired fibrinolytic activity were predictors of poor 7-year outcome. Age, weight, smoking habits and physical fitness had no statistically significant prognostic value. Whether the patients were operated for one or two herniated discs, or whether surgery involved a full or partial laminectomy, did not influence the outcome significantly.

Adaptation, Psychological↗

PubMed1999

A case-control study to detect modifiable risk factors for colonization with vancomycin-resistant enterococci.

A case-control study was conducted to determine the modifiable risk factors associated with vancomycin-resistant Enterococcus (VRE) colonization during a hospital outbreak. Cephalosporin use was identified as the only independent risk factor (odds ratio, 13.8; 95% confidence interval, 2.5-76.3; P = .01). Nursing work-load intensity was not associated with VRE colonization in this study.

Aged↗

PubMed1999

Cutaneous malignant melanoma in Norway: experiences from the Norwegian Melanoma Project.

The Norwegian Melanoma Project was conducted during 1989-1993 as a co-operative study by the dermatological, surgical, oncological and pathological departments of the five university hospitals in Norway. We present the results from the patients diagnosed and treated in our dermatological department at Ullevaal Hospital. During the study period 4582 patients received a clinical evaluation of pigmented lesions and 1347 patients were included in follow-up analyses, which consisted of a complete anamnestical evaluation and a clinical and pathological investigation of excised pigmented lesions. In all, 66 cutaneous malignant melanomas, 50 superficial spreading melanomas, seven lentigo maligna melanomas, eight nodular melanomas and one acral lentiginous melanoma were diagnosed. Correlation of the clinical and anamnestical information demonstrated an increased risk of developing malignant melanoma in persons with red hair and skin type I/II. When the histological thickness of superficial spreading melanomas diagnosed before the start of the project was compared with that of those treated during the project, there was a significant decrease in thickness in the project period.

Female↗

PubMed1999

Two nursing home outbreaks of respiratory infection with Legionella sainthelensi.

OBJECTIVE: To describe outbreaks of infection caused by Legionella sainthelensi occurring in older residents of two nursing homes and to determine risk factors for the development of infection. DESIGN: Descriptive epidemiology and a case-control study. SETTING: Two nursing homes (140 beds and 254 beds in nursing homes A and B, respectively) located in southern Ontario, Canada, experiencing outbreaks of respiratory tract infection in July and August 1994. SUBJECTS: Case-residents of the two nursing homes who met clinical and laboratory criteria for Legionella infection. Control-residents were defined as those who were in the homes during the outbreaks and were asymptomatic. MEASUREMENTS: Active surveillance was conducted in both nursing homes to identify symptomatic residents. Residents with fever or respiratory tract symptoms had nasopharyngeal swabs taken for viral antigen detection and culture, urine for Legionella antigen detection, and acute and convalescent serology for viruses, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella. Chest X-rays were performed, and an attempt was made to obtain blood and sputum cultures. Water samples from shower heads, faucets, and air conditioning units were collected for Legionella culture and polymerase chain reaction (PCR) assay. A case-control study was done to assess possible risk factors for legionellosis. RESULTS: Twenty-nine cases -- 17 in nursing home A; 12 in nursing home B - were identified. Four (14%) case-residents had documented pneumonia and four case-residents died. Univariate analysis revealed that a history of stroke (odds ratio (OR) 2.3 (95% CI, 1.0-5.3)), eating pureed food (OR 4.6 (95% CI, 1.6-12.7)), and having fluids administered with medication (OR 2.5 (95% CI, 1.0-5.9)) were significant risk factors. Cases were less likely to wear dentures (OR .4 (95% CI, .2-.9)) or to eat solid food (OR .3, (95% CI, .1-.6)). Only eating pureed food remained significant in a multivariable analysis (OR 4.6 (95% CI, 1.6-13.0, P = .01)). CONCLUSION: This report describes outbreaks of legionellosis in two nursing homes, representing the first reported outbreaks of infection caused by Legionella sainthelensi. The association with illness of dietary characteristics indicative of swallowing disorders suggests that aspiration was the most likely mode of infection. The diagnosis of legionellosis should be considered during outbreaks of respiratory infection in nursing homes.

Aged↗

PubMed1999

Vancomycin use in 2 Ontario tertiary care hospitals: a survey.

OBJECTIVE: Use of vancomycin is a risk factor for acquiring vancomycin-resistant enterococci (VRE). To optimize the use of vancomycin in hospitals, the Hospital Infection Control Practices Advisory Committee (HICPAC) published recommendations in 1995. The objectives of this study were to determine the frequency, indications, and risk factors for inappropriate inpatient vancomycin prescriptions before and after publication of the HICPAC recommendations. DESIGN: Cross-sectional study. SETTING: Two tertiary care hospitals in Ontario. INTERVENTIONS: Vancomycin prescriptions were randomly sampled and hospital chart view performed for two 12-month periods, one before and one after publication of the HICPAC recommendations on vancomycin use. RESULTS: Based on the review of 189 charts from hospital A and 190 from hospital B, there was no significant change in the proportion of inappropriate vancomycin prescriptions at either hospital from before publication of the HICPAC recommendations to afterward (63% v. 71% at hospital A, p = 0.21; 48% v. 37% at hospital B, p = 0.11). In 51% of all vancomycin prescriptions, the drug was prescribed instead of another antibiotic because of a recorded penicillin allergy. Surgical prophylaxis with more than 1 or 2 doses of vancomycin accounted for 66% (hospital A) and 58% (hospital B) of inappropriate prescriptions. In a multivariate analysis, surgical prophylaxis remained a significant risk factor for inappropriate use of vancomycin at both hospitals (odds ratio [OR] 5.6, 95% confidence interval [CI] 2.8 to 11.3, p = 0.01 for hospital A; OR 13.9, 95% CI 4.9 to 39.5, p = 0.01 for hospital B). Prescription by the orthopedic service also remained a significant risk factor in the final logistic regression model for hospital B (OR 3.9, 95% CI 1.1 to 13.9, p = 0.01). CONCLUSIONS: A high proportion of vancomycin prescriptions, surveyed before and after publication of the HICPAC recommendations on vancomycin use, were inappropriate. Excessive vancomycin use in surgical prophylaxis was an important factor. Our findings suggest that the use of standardized peri-operative order forms and of penicillin-allergy testing may help optimize vancomycin use in tertiary care hospitals.

Anti-Bacterial Agents↗

PubMed1998

Influence of fibrinolytic factors on scar formation after lumbar discectomy. A magnetic resonance imaging follow-up study with clinical correlation performed 7 years after surgery.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To assess the amount of scar tissue by viewing magnetic resonance images, and to evaluate the correlation between the amount of scar tissue and clinical outcome, surgical technique, and fibrinolytic factors. SUMMARY OF BACKGROUND DATA: The influence of fibrinolytic factors on magnetic resonance images has not been investigated previously. The relation between clinical outcome and findings on magnetic resonance imaging remains uncertain. METHODS: Magnetic resonance imaging at 0.5 Tesla was performed to produce sagittal and axial spin-echo T1-weighted images before and after contrast enhancement on 78 patients 7 years after traditional lumbar discectomy with partial or full laminectomy. Before surgery all patients had been tested for fibrinolytic factors. RESULTS: The overall clinical success rate of the surgery was 73%. No evidence of scar formation was seen in 19 patients, a small amount was seen in 36 patients, a moderate amount in 17 patients, and a large amount was observed in 6 patients. Ten patients who had undergone surgery at two disc levels and 18 who had been treated with full laminectomy exhibited more scar tissue than those patients who had undergone surgery on a single level (P = 0.033) and those who had undergone a partial laminectomy, respectively (P = 0.017). The amount of scar formation also was associated with a poor outcome (P = 0.017) and with low preoperative values of tissue plasminogen activator antigen (P = 0.003) and tissue plasminogen activity (P = 0.048) in samples collected after venous occlusion. The intensity of contrast enhancement, however, was not influenced by these or any other parameters. CONCLUSION: The amount of scar formation after lumbar discectomy seems to be related to the clinical outcome, the size of the surgical exposure, and some fibrinolytic factors.

Adolescent↗