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Biomedical subjects

W Piotrowski

Publications and source records attributed to W Piotrowski.

At least 19 recordsLinked to original sources
PubMed2001

[Influence of Chlamydia pneumoniae and cytomegalovirus infections on prevalence and the course of coronary artery disease].

Chlamydia pneumoniae (C. pneumoniae) as well as cytomegalovirus (CMV) are common pathogens found in about 50% of healthy western population. Many studies suggest a role of C. pneumoniae in development of coronary artery disease (CAD). CMV infection is also considered to increase risk of developing of CAD as well as restenosis after percutaneous coronary revascularization (PCI). The aim of our study was to evaluate a possible role of C. pneumoniae and CMV infections in both CAD development and course in patients (pts) undergoing PTCA. We enrolled 105 pts (mean age 56.4 years, 83 males) with angiographically documented CAD. Control group consisted of 63 healthy controls (mean age 47.25 years; 31 males). The study subjects were evaluated for presence of C. pneumoniae specific IgG antibodies (MIF test--MRL Diagnostic, USA; seroprevalence assumed when titre > or = 1/8). In 58 random PCI pts CMV specific IgG antibodies (ELISA Eti-Cytok-G PLUS--Dia Sorin) were evaluated. Pts were sampled at the time of PTCA. All PCI pts were assessed by angina questionnaire 5.9 +/- 2.6 months (mo) after the procedure with respect to clinical restenosis. C. pneumoniae IgG antibodies were detected in 37.1% of pts and in 22% of healthy controls (p < 0.05). After logistic regression was applied trend towards more frequent occurrence of C. pneumoniae specific IgG in CAD pts was shown (p = 0.10 OR = 2.4; 95% CI: 0.8-6.8). No significant correlation was found between anti-C. pneumoniae IgG presence or anti-CMV IgG titre and coronary atherosclerosis advancement. There was no significant difference in anti-CMV IgG titre between 9 pts who developed clinical restenosis 5.9 +/- 2.6 mo after PCI and the remaining pts. Our study results suggest a possible significant correlation between C. pneumoniae with CAD prevalence. We did not find a positive association of either infection markers with coronary atherosclerosis advancement. We did not find correlation of clinical restenosis after PCI with markers of CMV infection.

Adult↗
PubMed2001

[Krakow Program for Secondary Prevention of Ischaemic Heart Disease. Part II. Secondary prevention of ischaemic heart disease during hospitalization].

UNLABELLED: Hospitalization due to ischaemic heart disease provides a possibility to introduce patients education, to initiate non-pharmacological treatment and to assure patient compliance. The aim the study was to assess the frequency of risk factors and the quality of care in the field of secondary prevention in patients hospitalized due to acute coronary syndromes or subjected to myocardial revascularization. METHODS: The study was carried out in cardiac departments of six hospitals serving the area of the city. Consecutive patients (age < or = 70 years; residing in the Cracow province) were identified according to the following clinical diagnoses or procedures: first or recurrent acute myocardial infarction, first or recurrent unstable angina, first coronary artery bypass grafting or first percutaneous coronary intervention. RESULTS: Data of 536 patients (140 women and 396 men; mean age--56.6 +/- 8.4 years; hospitalized from 1.07.1996 to 30.09.1997) were collected from medical records. The rate of blood pressure measurement during the first 24-hours of hospitalization was 88.8%. Total cholesterol, HDL cholesterol, and triglycerides were assessed in 32.8%, 30.2%, and 32.3% of patients respectively during the first 24-hours of hospitalization. The height and weight were found in 54.9% and 85.1% of medical records. Obesity (BMI > or = 30 kg/m2) was found in 20.3% of patients, 36.7% smoked, 56.0% had hypertension, 15.5% diabetes and 79.5% had hyper-cholesterolemia. Medication at discharge was: antiplatelet drugs 86.7%, beta-blockers 66.4%, ACE inhibitors 50.2% and lipid lowering drugs 27.1%. CONCLUSION: There is a need to initiate a comprehensive programme in order to improve quality of care in the field of secondary prevention of ischaemic heart disease.

Adult↗
PubMed2001

[Krakow Program for Secondary Prevention of Ischaemic Heart Disease. Part III. Secondary prevention of ischaemic heart disease after discharge].

UNLABELLED: Even though the majority of actions undertaken within the secondary prevention of ischaemic heart disease should be initiated while the patient is still hospitalized, the maximum benefit (measured as decreased cardiovascular risk) achieved depends mostly on the continuation and modification of these actions in the postdischarge period. There is not much known about the quality of medical care provided for patients after hospitalization due to ischaemic heart disease. The aim of the study was to assess the quality of postdischarge care in the field of secondary prevention of ischaemic heart disease. METHODS: Consecutive patients (age > or = 70 years; residing in the Cracow province) were identified according to the following clinical diagnoses or procedures: acute myocardial infarction, unstable angina, CABG and PCI. Out of 536 patients 418 took part in the control visit 6-18 months after discharge. Risk factors and medication used were assessed. RESULTS: High total cholesterol (> or = 5.2 mmol/l) was found in 65.8% of patients, high blood pressure (> or = 140/90 mmHg) in 46.2%, obesity (BMI > or = 30 kg/m2) in 24.6%, fasting glucose over 6.0 mmol/l in 17.7% and smoking in 16.3%. The frequency of antiplatelet drugs and beta-blockers use decreased whereas that of lipid-lowering drugs increased in the postdischarge period. The highest frequency of use of antiplatelets and lipid-lowering drugs, as well as the best control of hypercholesterolemia was found in the PCI group, whereas the lowest frequency of smoking was found in the CABG group. CONCLUSIONS: Insufficient control of risk factors and the frequency of secondary prevention using drugs was found. There is a need to intensify secondary prevention in patients with ischaemic heart disease in the postdischarge period.

Adrenergic beta-Antagonists↗
PubMed2001

[Changes in dietary habits and selected cardiovascular risk factors of the Warsaw population over the 5-year observation period (1993-97/98)].

The aim of the study was to characterise changes in dietary habits and cardiovascular risk factors of the Warsaw cohort population over a 5-year observation period. Two Warsaw population samples (249 men and 259 women), aged 35-64, were surveyed in 1993 and resurveyed in years 1997/98. Over a five-year observation period, daily dietary cholesterol decreased from 363 mg to 319 mg in men and from 263 mg to 232 mg in women, the percentage of energy from fat decreased from 38.8% to 34.7% in men and from 37.1% to 31.2% in women, the percentage of energy from saturated fatty acids from 13.6% to 11.7% and from 12.9% to 10.5% respectively. These changes resulted in a significant reduction in atherogenicity of the average diet as expressed by Keys score. Intakes of vitamins B1 and B2, calcium, magnesium and iron was consistently below Recommended Dietary Allowances (RDA) for the Polish population. Participants of both genders consumed significantly greater amounts of total bread (35%), milk (50%) and butcher meat products (22%). In the same time increase of HDL-cholesterol level (average of 2.0 mg/dl in men and 3.1 mg/dl in women) and decrease of LDL-cholesterol by 5 mg/dl in men was noted.

Adult↗
PubMed2000

Myocardial perfusion and function of the systemic right ventricle in patients after atrial switch procedure for complete transposition: long-term follow-up.

OBJECTIVES: Our purpose was to assess the right ventricular (RV) function and identify patients with RV impairment long after the Mustard or Senning operation. BACKGROUND: Systemic ventricular failure can cause myocardial perfusion abnormalities in thallium scintigraphy correlating with hemodynamic deterioration. METHODS: Myocardial perfusion at rest and at peak exercise was assessed in 61 patients, aged 7 to 23 years in mean time 10.0 +/- 2.9 years after surgery using technetium-99m methoxyisobutyl isonitrile single-photon emission computed tomography. Ventricular function was assessed by first-pass radionuclide angiography at rest. Exercise capacity was determined with a modified Bruce protocol. RESULTS: The mean RV ejection fraction was 36.1 +/- 7.7%, and left ventricular (LV) ejection fraction was 52.1 +/- 9.4%. Moderate or severe perfusion abnormalities on the rest scan were observed in 20 patients (33%). On exercise perfusion worsened in another 13 patients (21.3%). Patients with perfusion defects on stress scan had significantly lower RV and LV ejection fraction (33.2 vs. 39.4%; p = 0.002 and 49.2 vs. 55.5%; p = 0.01, respectively). They were also older (16.6 vs. 13.0 years; p = 0.002), operated on at an older age (4.0 vs. 2.4 years; p = 0.05) and had longer follow-up (12.5 vs. 10.5 years; p = 0.003). CONCLUSIONS: Myocardial perfusion defects are common findings in patients in long-term follow-up after atrial switch operation. Despite excellent exercise tolerance, the extent of myocardial perfusion abnormalities correlated well with impaired RV and LV function, and greater perfusion defects were seen more frequently in older patients with longer follow-up. It is likely that myocardial perfusion defects could be a sensitive predictor of systemic ventricular impairment.

Adolescent↗
PubMed2000

Weight gain and its correlates in Poland between 1983 and 1993.

BACKGROUND: Weight gain and its unfavorable consequences on coronary heart disease (CHD) risk have been observed worldwide. Determinants of weight gain were studied in a Polish cohort of 1042 men and women age 35-64 at baseline. Participants were randomly selected from an urban population in Warsaw and a rural population in Tarnobrzeg Province surveyed by investigators in Krakow. The surveys, part of the Pol-MONICA project, were conducted in 1983-1984, 1987-1988, and 1992-1993. The purpose of this report is to gain insight into the dynamics of weight gain in this population that could be helpful in identifying high-risk groups for intervention, and to determine if economic changes that took place shortly after the second survey had any impact on weight gain. METHODS: Weight, height and demographic characteristics were measured at each visit according to Pol-MONICA standard protocol. Body mass index (BMI) was calculated as kg/m2. Years of schooling, 7-day alcohol history and smoking history were self-reported. RESULTS: Sixty percent of the cohort gained some weight, averaging 0.3-0.7kg/y. Weight gain was highest in younger rural women, in urban men and in rural women with low education. In multiple linear regression, low education was related to a 1.29 kg greater weight gain (P<0.01), ex-smoking status was related to a 2.54 kg greater weight gain (P<0.001), and younger age was related to a 1.14 kg greater weight gain (P<0.001). CONCLUSION: Our results indicate a need to target intervention programs at young low SES adults. Developing effective means of reaching these vulnerable groups is a critical research goal.

Adult↗
PubMed2000

Left ventricular outflow tract gradient decrease with non-surgical myocardial reduction improves exercise capacity in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: This study was undertaken to evaluate mid-term clinical results of non-surgical myocardial reduction in patients with hypertrophic obstructive cardiomyopathy. METHODS: Twenty-five patients with left ventricular outflow tract obstruction (mean gradient of 84. 54+/-31.38 mmHg) and symptoms of dyspnoea, angina and/or syncope were treated with non-surgical myocardial reduction. The patients were followed-up for a mean period of 10.44+/-1.8 months. In all patients clinical examination with echocardiography was repeated after every 3 months of follow-up, and a symptom-limited treadmill test was repeated at the 6 month follow-up. Eighteen patients underwent simultaneous respiratory gas analysis. RESULTS: Clinical follow-up examinations were achieved in all 25 patients. Persistent left ventricular outflow tract gradient reduction was seen in 23 patients. Seventeen patients had a reduction of left ventricular outflow tract gradient >50% of baseline value. Twenty patients showed a clinical improvement from 2.8+/-0.5 up to 1.2+/-0.5 NYHA class (P<0.001). The clinical improvement was matched by an improvement in objective measures of exercise capacity in patients with significant left ventricular outflow tract gradient reduction. Exercise time increased from 571.9+/-192.2 to 703.5+/-175.4 s, P<0. 001, and peak VO(2)increased from 14.6+/-5.2 to 20.5+/-8.6 ml. kg(-1)min(-1), P<0.05. CONCLUSION: Significant left ventricular outflow tract gradient reduction with exercise capacity improvement was achieved in the majority of patients treated with non-surgical myocardial reduction. We recommend this method as an alternative to surgery for symptomatic patients with hypertrophic obstructive cardiomyopathy.

Cardiac Catheterization↗
PubMed2000

Incidence and correlates of hypertension in the Atherosclerosis Risk in Communities (ARIC) study and the Monitoring Trends and Determinants of Cardiovascular Disease (POL-MONICA) project.

OBJECTIVE: The purpose of this research is to assess short-term blood pressure change and hypertension incidence, and identify correlates of incident hypertension in the USA and Poland. DESIGN AND METHODS: Population-based samples aged 45-64 years at enrollment from the Atherosclerosis Risk in Communities (ARIC) and the Pol-MONICA studies: including 3777 whites from Minneapolis, Minnesota, USA suburbs (urban), 3635 whites from Washington County, Maryland, USA (semi-rural) and 3109 blacks from Jackson, Mississippi, USA surveyed in 1987-1989 and 1990-1992; and 389 persons from Warsaw, Poland (urban) and 322 from Tarnobrzeg Province, Poland (semi-rural) surveyed in 1987-1988 and 1992-1993. RESULTS: Age-standardized systolic and diastolic blood pressures at both screens were 9-20 and 5-9 mmHg higher in the Polish samples than in US blacks, who had higher levels than US whites. Age-adjusted annual hypertension incidence in both Polish male cohorts (6-8%) was higher than that in US white men (4%) and approaching that of US black men (7%); rates were also higher in Polish female cohorts (8-9%) than in US black women (8%), but nearly twice those in US white women (4%). Factors independently related to hypertension incidence included age, family history, smoking, baseline blood pressures and body mass index, and increase in body mass index and alcohol consumption between screenings. After adjustment for these factors, annualized hypertension incidence was similar in US white and Polish men (2.3 and 2.7%) compared with US black men (3.4%), and in US white and Polish women (1.5 and 1.3%) compared with US black women (3.9%). CONCLUSIONS: Despite substantial differences in blood pressure levels and age-standardized hypertension incidence rates, the differences in incidence between Polish and US white men appear to be explained largely by differences in risk factors for hypertension.

Adult↗
PubMed2000

[Elevated levels of homocysteine in plasma as a risk factor for coronary artery disease].

This study was performed to assess the significance of association between coronary artery disease (CAD) and circulating homocysteine concentrations. 100 consecutive CAD patients (78 men and 22 women, aged 31 to 79 years) qualified for PTCA were investigated. At the time of PTCA, the risk factors for CAD and plasma for homocysteine and vitamins were obtained. The controls were without clinical evidence of coronary artery disease and hypertension (90 men and 30 women aged 32 to 81 years). Homocysteine was assayed using ELISA test. Red cell folate and plasma vitamin B12 were assayed by immunofluoroscency (Delphia test). Homocysteine concentrations were higher in patients than in controls (13.61 +/- 4.5 vs 10.99 +/- 4.49 mumol/L, p < 0.001, adjusted for age). Male patients had nonsignificantly higher homocysteine levels than females (13.94 +/- 5.21 vs 11.46 +/- 5.16 mumol/L, p = 0.05, adjusted for age). Elevated homocysteine level--defined as one in the top fifth of the control distribution > or = 12.83 mumol/L--was seen in 46% of the patients compared with 20% of the control group (p = 0.001). The odds ratio (OR) for CAD in persons with elevated homocysteine level was 3.1 (95% Cl 1.6-5.8, p < 0.001, adjusted for age). The OR for CAD of 5 mumol/L increment in homocysteine level was 2.1 (95% Cl 1.4-3.1 p < 0.001, adjusted for age). After adjustment for conventional risk factors (age, smoking, hypertension, family history of CAD, hyperlipidemia), elevated homocysteine level remained independent risk factor for CAD (OR 2.88, 95% Cl 1.1-7.8, p < 0.05). We observed inverse correlation between homocysteine and folate level (r = -0.32, p = 0.005) and between homocysteine and vitamin B12 concentrations (r = -0.24, p = 0.03), especially in men. Patients with elevated homocysteine level had lower levels of folate (629.6 +/- 241.2 nmol/L vs 735.1 +/- 252.4 nmol/L, p < 0.05), and vitamin B12 (213.6 +/- 64.4 pmol/L vs 246.6 +/- 62.3 pmol/L, p < 0.05) than patients with normal level of homocysteine. Elevated plasma homocysteine level is a strong risk factor for coronary artery disease. A 5 mumol/L increment in total homocysteine level may be associated with twofold increase of risk for the disease.

Adult↗
PubMed2000

[Controlled release diltiazem in monotherapy of hypertension--time of drug administration and circadian blood pressure pattern].

30 patients with primary mild to moderate hypertension (DBP 95-110 mm Hg) were treated with long acting diltiazem (120 or 240 mg) once daily in the morning (7.00-8.00 a.m.) for at least 3 weeks and after that the administration time was changed to evening dose (19.00-20.00 p.m.) for next 3 weeks. 24-hours ABPM was performed in all patients on the last day of each period. Obtained recordings were compared in different periods of time: total 24 hours, 6.00-23.00, 23.00-6.00, 4.30-8.00, 5.00-11.00, 20.00-2.00. Mean values of systolic and diastolic blood pressure, heart rate and pressure load (defined as percentage of records above 140/90 mm Hg in day and above 120/80 mm Hg at night) did not differ significantly between investigated dosage regimens. The evening administration of diltiazem did not produce greater decrease of BP at night than the morning dose. For this reason slow release formulation of diltiazem (oxycardil in doses of 120 to 240 mg) can be safely administered in the evening if needed.

Adult↗
PubMed1999

Association of lipids and lipoprotein level with total mortality and mortality caused by cardiovascular and cancer diseases (Poland and United States collaborative study on cardiovascular epidemiology).

This study evaluates the relation between total serum cholesterol, triglycerides, and high-density lipoprotein (HDL) cholesterol, and subsequent total, cardiovascular, and cancer mortality. These data are from 4,946 US and 5,198 Polish men and women aged 35 to 64 years at baseline with mortality follow-up over 13 years. Total cholesterol showed a U-shaped or J-shaped relation to age-adjusted total and cancer mortality across all samples, with significance only in Polish women. The multivariable adjusted relative risk for total and cancer mortality was higher in the lowest cholesterol category only in Poland and significant only for cancer. Cardiovascular mortality was positively related to cholesterol, but only in Polish men and US women was mortality significantly higher in the highest versus the lowest cholesterol category. The multivariable adjusted relative risk of cardiovascular death was greater in the highest versus the lowest cholesterol category, but this trend was significant only in the US. HDL cholesterol was inversely related to total (significant only in US men) and cardiovascular mortality (significant only in US and Polish men). A similar, but not significant, association of HDL cholesterol was found with cancer mortality. The multivariable adjusted relative risk of total mortality was inversely related to HDL cholesterol significant in both the US and Poland. The relative risk of cardiovascular mortality was significantly lower at higher HDL cholesterol levels in all samples. The relative risk of cancer mortality was highest and significant at the lowest HDL cholesterol level in the US and Poland. Elevated triglycerides were associated with increased risk of total and cardiovascular mortality, but this trend was significant only in the US. Cancer mortality was not significantly related to triglycerides. The present study indicates that in geographically and culturally diverse populations, the relation of lipids with cardiovascular mortality is similar. The relation with total and cancer mortality varies by country, gender, and lipids. This suggests that relations of total and cancer mortality with lipids or lipoproteins are weaker than associations with cardiovascular mortality.

Adult↗
PubMed1999

Increased serum concentrations of conjugated diens and malondialdehyde in patients with pulmonary tuberculosis.

During pulmonary inflammation increased amounts of reactive oxygen species (ROS) and reactive nitrogen intermediates (RNI) are produced as a consequence of phagocyte respiratory burst. One of the manifestation of these free radical-mediated processes is lipid peroxidation (LP). The aim of our study was to assess the concentration of lipid peroxidation products (LPPs), conjugated diens (CD) and malondialdehyde (MDA), in patients with active TB. Forty-two patients were enrolled into the study. Half (group I) had advanced TB and were sputum smear-positive. The remainder (group II) had only small radiographical changes and were sputum smear-negative. Serum concentrations of CD and MDA were measured at days 0, 7, 14 and 28 in group I and day 0 in group II. We found that in all patients with active TB CCD (1.0 +/- 0.05A233) and CMDA (2.01 +/- 0.16 nmol dl-1) were significantly elevated compared to healthy controls (0.67 +/- 0.03A233 and 1.36 +/- 0.08 nmol dl-1, respectively) (P < 0.001). The highest levels of LPPs were in patients with advanced TB. These concentrations were stable during the first month of anti-tuberculous therapy. Our data indicated that, as in bacterial pneumonia, LPPs were enhanced in active TB. The levels of LPPs depended on the form of the disease as they were higher in subjects with advanced disease than in those with only small radiographical changes. Further studies are needed to assess the role of antioxidants as adjuvant therapy in patients with pulmonary TB.

Biomarkers↗
PubMed1999

Low-dose glucose-insulin-potassium is ineffective in acute myocardial infarction: results of a randomized multicenter Pol-GIK trial.

We aimed to assess the clinical efficacy of glucose-insulin-potassium (GIK) in acute myocardial infarction. Experimental data provided evidence of the beneficial effects of GIK on ischemic myocardium. The clinical trials, mostly uncontrolled and conducted mainly before the thrombolytic era, were inconclusive due to the small number of patients and discrepancies in protocols. In order to evaluate the efficacy of this intervention, we have performed a prospective multicenter randomized study. The study consisted of 954 patients with acute myocardial infarction (MI) randomized within 24 hours from the onset of symptoms to low-dose GIK (n = 494), which consisted of 1000 mL 10% dextrose, 32-20 U insulin, and 80 mEq K-, or to the control group (n = 460), which was given 1000 mL 0.89% sodium chloride, by intravenous 24-hour infusion at a rate of 42 mL/h. Cardiac mortality and the occurrence of cardiac events at 35 days did not differ between GIK and control-allocated patients (32 (6.5%) vs. 21 (4.6%), respectively; OR 1.45, 95% CI 0.79-2.68, P = 0.20; and 214 (43.3%) vs. 192 (41.7%), OR 1.07, 95% CI 0.82-1.38, P = 0.62). Total mortality at 35 days was significantly higher in the GIK than in the control group (44 (8.9%) vs. 22 (4.8%), respectively, OR 1.95, 95% CI 1.12-3.47, P = 0.01). The excess of non-cardiac deaths in the GIK group may have occurred by chance. Low-dose GIK treatment does not improve the survival and clinical course in acute MI.

Aged↗
PubMed1999

[Medical associations in the period of Polish enlightenment].

The author presents the beginnings of scientific medical associations in Poland in the 18th century. The associations contributed significantly to popularization of the achievements of medicine and were uniting the medical circle when medical schools were closed. Medical magazines edited and published by these associations were the platform of the exchange of scientific experiences what approached Polish science to European level.

History, 18th Century↗
PubMed1997

[Relationship between heart rate and general mortality and that caused by cardiovascular diseases].

The sample of 1309 men and 1337 women, aged 35-64, randomly selected for the first Warsaw Pol-Monica screening performed in 1984, was followed up in 1992. All deaths were registered according to the cause of death based on death certificate diagnosis. The proportional hazard Cox model was used for univariate heart rate (HR) analysis and for multivariate analysis after adjustment for covariates (HR divided into 4 subgroups). Out of screened subjects 263 persons died (139 due to cardiovascular disease CVD). Mean baseline HR of persons who died was 76.8 (+/- 11.5) versus 73.9 (+/- 10.2) for subjects who survived (p = 0.0001). In the univariate analysis the heart rate was significantly positively related both to all cause mortality (relative risk RR = 1.29, p = 0.0001) as well as to cardiovascular mortality (RR = 1.31, p = 0.0025). In the multivariate analysis HR was significantly positively related to all cause mortality (standardized RR = 1.24, p = 0.0012), but almost significantly related to cardiovascular mortality (SRR = 1.20, p = 0.052).

Adult↗
PubMed1997

[Inborn hip ectopy of one flat kidney].

Congenital hip ectopy of one flat kidney is an excessively seldom developmental anomaly considering abnormal shape and ectopy with agenesia of one kidney. However, in literature, the kidney malformations are described very well, especially the ectopy of one of the kidneys and two-sided agenesia, but the presented case is exceptionally seldom anomaly. That is why it should be shown in the context of other defects of urinary tract. Abnormalities of urinary tract are the most often congenital defects among children. For example, two-sided agenesia occurs in 1, per 4800 live born children, while one-sided at 1:2500 to 1:2800. This defect occurs more often among boys 1.8:1 and on the left side 1.5:1. The tendency of family heredity was also noticed. Structural changes of right-sided ureteric bud accompany the defect very often. Usually it is an asymptomatic defect but in 50% girls and 10%-15% boys, other congenital defects occur together with this one. The lack of homonymous suprarenal gland, spermatic cord seminal vesicles and right testicle in boys is the most often accompanying anomaly. Organogenesis disorders connected with organs developing from Muller's tract are seen in girls.

Abnormalities, Multiple↗