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Characteristics and consequences of myocardial infarction after percutaneous coronary intervention: insights from the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT).

OBJECTIVES: We examined the results of the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) to determine the characteristics and consequences of creatine kinase (CK) and creatine kinase, MB myocardial isoenzyme fraction (CK-MB) elevations after percutaneous coronary intervention. BACKGROUND: Enzyme elevations after interventional procedures have usually been thought to be without long-term clinical consequences. However, recent preliminary reports have suggested that there are important long-term clinical sequelae in patients with even mild enzyme elevations after coronary procedures. METHODS: Patients with new native lesions undergoing coronary intervention at 35 clinical sites were randomized to undergo percutaneous coronary angioplasty (n = 500) or directional coronary atherectomy (n = 512). Cardiac enzyme levels were measured 12 and 24 h after the interventional procedure and when clinically indicated for recurrent myocardial ischemia. Enzyme profiles were analyzed using a ratio that compared the peak enzyme level and the local laboratory upper limit of normal. Standard 12-lead electrocardiograms (ECGs) recorded before and after the procedure were interpreted by two independent readers who had no knowledge of the randomization data. Postprocedural myocardial infarction was defined as the appearance of new Q waves on the ECG, CK-MB levels three or more times the upper limit of normal or a total CK concentration two or more times the upper limit of normal when CK-MB levels were unavailable. Regression models were used to evaluate the predictive significance of a postintervention myocardial infarction with respect to clinical outcomes at 30 days and 1 year. RESULTS: There were 78 myocardial infarctions in the atherectomy group and 34 in the angioplasty group (15.2% vs. 6.8%, p = 0.001). Patients with a myocardial infarction more often had a repeat intervention or emergency coronary artery bypass surgery. Hospital length of stay was increased among patients with an infarction, as were mean hospital costs ($17,340.65 vs. $11,308.47, p = 0.0003). Postprocedural myocardial infarction was highly predictive of mortality, bypass surgery or repeat intervention within 30 days (p < 0.0001). CONCLUSIONS: Myocardial infarction occurred commonly after coronary intervention in CAVEAT and was associated with a worse clinical outcome. Although the incidence of myocardial infarction was higher with atherectomy than with angioplasty, the baseline characteristics and consequences of the infarctions were similar between the treatments with regard to 30-day outcome. Myocardial enzyme elevations after an otherwise successful interventional procedure may identify a population at risk for a future cardiac event.

Angioplasty, Balloon, Coronary↗

Smoking expectancies in smokers and never smokers: an examination of the smoking Consequences Questionnaire-Spanish.

The factor structure of smoking expectancies was examined in daily smokers and never smokers. Participants completed the Smoking Consequences Questionnaire-Spanish (SCQ-Spanish; [Cepeda-Benito, A., & Reig-Ferrer, A. (2000). Smoking consequences questionnaire-Spanish. Psychology of Addictive Behaviors, 14, 219-230.]). Using confirmatory factor analysis (CFA), the eight-factor structure of the SCQ-Spanish was replicated in smokers only. Except for beliefs about negative-health outcome expectancies, daily smoking rate was strongly associated with all types of smoking outcome expectancies. In comparison to men, women smokers reported greater weight control and negative-affect reduction consequences from smoking. An exploratory factor analysis (EFA) suggested a four-factor structure for the scores of never smokers. The findings represent not only the first cross-validation of the SCQ-Spanish but they were also congruent with the notion that first-hand smoking experience is not necessary for the development of multifaceted smoking expectancies. Nonetheless, the finding of a more complex factors structure in smokers than in never smokers is in line with the hypothesis that drug-use expectancies become more complex with drug-use experience.

Adult↗

Psychometrics of the Drinker Inventory of Consequences (DrInC).

The Drinker Inventory of Consequences (DrInC) was developed for Project MATCH to assess the consequences of drinking in five domains. The present study, using baseline data from the 1382 participants involved in the COMBINE Study, analyzed the psychometrics of the 50-item DrInC and its shorter form, the 15-item SIP. Findings indicate the DrInC is reliable, valid, and clinically useful and that DrInC subscales are internally consistent and non-redundant. In an examination of the shorter version of the DrInC, findings suggest that the SIP is suitable when assessing the overall level of drinking-related consequences.

Acamprosate↗

What are the consequences of early rheumatoid arthritis for the individual?

Rheumatoid arthritis (RA) has important impacts on health that can be related to the World Health Organization's new International Classification of Functioning, Disability and Health (ICF framework). The physical consequences of RA for the individual relate to body functions and structures in the ICF framework. The functional consequences of RA are related to activity in the ICF framework, and the impact of RA on society relates to participation in the ICF framework. Despite conventional treatment, early RA continues to result in significant physical consequences for most patients. From the patients' perspective, this primarily results from persistent pain, although symptoms such as fatigue and depression are also relevant. This is confirmed from the clinician's perspective by the infrequency of remission, persistence of disease activity and unrelenting radiographic progression in early RA. Patients with early RA often progress, within only a few years, to significant disability. This has mainly been shown in studies using the Health Assessment Questionnaire as the disability measure, although a small number of studies using generic health measures such as Short Form-36 have reached similar conclusions. RA patients and their friends and families incur the majority of costs associated with early RA. Many patients are not able to continue to work at the same level as they would have anticipated had they not developed RA. Later on, society bears an increased load, especially in patients with higher levels of disability; this results from major social care costs and interventions such as surgery. However, the evidence favouring expensive biological therapies, even in early RA, is likely to turn this analysis on its head in the near future.

Arthritis, Rheumatoid↗

Functional consequences of blood clotting in insects.

Recent in vitro studies have revealed several important aspects of the biochemical and cellular processes involved in insect blood clotting. However, in vivo empirical studies of the functional consequences of clotting are lacking, despite the role of coagulation in wound-healing, preventing infection, and its homology with vertebrate wound repair. Here we present results of the in vivo effects of haemolymph coagulation and its consequences on the spatial disposition of immune activity, in the American cockroach Periplaneta americana. Our results demonstrate that clotting: (1) localises immune effectors in the vicinity of a breach of the cuticle; (2) restricts the spread of invasive particles across the haemocoel, and (3) is greater when wounding is associated with non-self. Our results demonstrate that haemolymph coagulation has major functional consequences, the most important of which is the compartmentalisation of the open haemocoel.

Amaranth Dye↗

Arterial consequences of recreational drug use.

BACKGROUND: Recreational drug use is becoming an increasing problem throughout the world. Many of the drugs used and their routes of administration have the potential to cause damage to the vascular system. Intravenous drug administration with the risk of arterial puncture predisposes to the formation of infected pseudoaneurysms. Inadvertent intra-arterial injection predisposes to distal limb ischaemia. Cocaine has numerous effects not only on the heart, but also potentially on any vascular bed. METHODS: A systematic review of published literature with regard to the arterial consequences of recreational drug abuse was undertaken by undergoing an electronic search. RESULTS: Most of the available literature is in the form of case reports and case series. Pseudoaneurysm formation is a serious consequence for intravenous drug users. For femoral aneurysms vessel ligation is the safest option with a low amputation risk. A high proportion of patients do have symptoms of claudication in the long term. Intra-arterial injections can result in limb threatening ischaemia. Systemic anticoagulation forms the mainstay of treatment. Cocaine has significant effects upon both the myocardium and the arterial tree in general. Arterial problems must always be considered in cocaine users who present acutely. CONCLUSION: The consequences of recreational drug use will result in an increased exposure of vascular surgeons to its associated complications posing unique and challenging problems.

Aneurysm, False↗

Mental illness stigma: concepts, consequences, and initiatives to reduce stigma.

Persons with mental illness frequently encounter public stigma and may suffer from self-stigma. This review aims to clarify the concept of mental illness stigma and discuss consequences for individuals with mental illness. After a conceptual overview of stigma we discuss two leading concepts of mental illness stigma and consequences of stigma, focussing on self-stigma/empowerment and fear of stigma as a barrier to using health services. Finally, we discuss three main strategies to reduce stigma -- protest, education, and contact -- and give examples of current anti-stigma campaigns. Well-designed anti-stigma initiatives will help to diminish negative consequences of mental illness stigma.

Attitude↗

Mechanical consequences of short gastric vessel division at the time of laparoscopic total fundoplication.

Laparoscopic Nissen fundoplication is currently the most commonly practiced antireflux operation. Some adverse consequences of the operation remain in the form of mechanical side effects, labeled postfundoplication complaints, of which dysphagia and gas bloat seem to predominate. Measures have been suggested to counteract some of these and one frequently advocated has been division of the short gastric vessels to create a short-floppy wrap. The advantages of this are still debated, particularly in the long-term perspective. The aim of the present study was to evaluate the mechanical consequences of dividing all short gastric vessels at the time of a laparoscopic total fundoplication. Ninety-nine patients with chronic gastroesophageal reflux disease (GERD) were originally allocated on a random basis to have either all short gastric vessels divided or left intact at the time of a laparoscopic total fundoplication. A subsample of these patients, again selected at random, were recruited for a comprehensive manometric investigation 1 year after the operation. In this cohort, 12 patients had all short gastrics divided and in 12 patients, the wrap was done with intact vessels by use of the anterior portion of the fundus. Manometry was carried out by the use of a sleeve sensor to straddle the lower esophageal sphincter (LES), and gastric distension (750 ml air) was used to trigger transient LES relaxations (TLESR). The basal LES tone was similar in the two groups (14.2 +/- 2.4 and 18.8 +/- 4.3, mean +/- SE), respectively. Accordingly, all other relevant manometric variables were equal when the two groups were compared, except for the total number of TLESRs (triggered by gastric distension by air) that were significantly higher (p < 0.02) in patients having their short gastric vessels intact. Consequently, numerically more common cavities were recorded in the latter group. Very similar outcomes in terms of motor function of the LES and esophageal body were observed after a total fundoplication irrespective of whether a complete division of all gastric vessels had been carried out or not. However, after gastric distension with air, more TLESRs were recorded in the latter group suggesting a better maintained ability to vent air from the stomach.

Adult↗

The consequences of spasmodic dysphonia on communication-related quality of life: a qualitative study of the insider's experiences.

UNLABELLED: The purpose of this study was to explore the biopsychosocial consequences of spasmodic dysphonia (SD) as experienced by people with SD. Qualitative research methods were used to investigate the insider's perspective of living with SD. Six adults with SD participated in face-to-face phenomenological interviews. The results are summarized in a model of personal experiences of SD which shows that communication-related quality of life (QOL) is shaped by experiences with multiple physiologic (voice quality, effort, voice dependability); personal (affective responses, changes in self-view, coping strategies) and social (physical environment, other people, participation in social roles) factors. Communication-related QOL is a complex and individualized construct with multidimensional contributors. This study suggests that understanding the nature of communication-related QOL for each individual requires exploration of each component of the model, exploration of the unique relationships among components for each person, and recognition of the multidimensional factors that shape the experience of SD. LEARNING OUTCOMES: As a result of this activity the reader will be able to (1) identify general features of the phenomenological research method; (2) identify the three general categories of psychosocial consequences of SD; (3) identify those psychosocial consequences of SD that are under-represented in the literature; and (4) identify key conclusions of the communication-related quality of life model.

Adaptation, Psychological↗

Assessment of the effects of release variables on the consequences of LNG spillage onto water using FERC models.

Liquefied natural gas (LNG) release, spread, evaporation, and dispersion processes are illustrated using the Federal Energy Regulatory Commission models in this paper. The spillage consequences are dependent upon the tank conditions, release scenarios, and the environmental conditions. The effects of the contributing variables, including the tank configuration, breach hole size, ullage pressure, wind speed and stability class, and surface roughness, on the consequence of LNG spillage onto water are evaluated using the models. The sensitivities of the consequences to those variables are discussed.

Accidents↗

Health care costs and financial consequences of epidemiological changes in chronic diseases in Latin America: evidence from Mexico.

OBJECTIVE: To determine the costs of health services and the financial consequences of changes in the epidemiological profile of chronic diseases in Latin America. STUDY DESIGN: We conducted longitudinal analyses of costs and of the economic impact of the epidemiological transition in healthcare services for diabetes and hypertension in the Mexican health system. The study population included both the insured and uninsured populations. METHODS: The cost-evaluation method was based on the instrumentation and consensus techniques. To estimate the epidemiological changes and financial consequences for 2004-2006, six models were constructed according to the Box-Jenkins technique, using confidence intervals of 95% and the Box-Pierce test. FINDINGS: Costs ranged from US$613 to US$887 for diabetes, and from US$485 to US$622 for hypertension. Regarding epidemiological changes for 2004 compared with 2006, an increase is expected in both cases, although results predict a greater increase for diabetes, 10-15% in all three institutions (P<0.05). Comparing the financial consequences of health services required by insured and uninsured populations, the greater increase (17%) will be for the insured population (P<0.05). The financial requirements for both diseases will amount to 9.5% of the total budget for the uninsured population and 13.5% for the insured population. CONCLUSIONS: If the risk factors and the different healthcare models remain as they are at present, the economic impact of expected epidemiological changes on the social security system will be particularly strong. Another relevant financial factor is the appearance of internal competition in the use and allocation of financial resources among the main providers in the health services; this factor becomes even more complicated within each provider. In effect, within each institution, hypertension and diabetes programmes must compete for resources with other programmes for chronic and infectious diseases.

Case Management↗

[Cardiac consequences of primary hyperaldosteronism].

The activation of the renin-angiotensin system is associated with vascular and cardiac hypertrophy. But there are few data on the renal and cardiac consequences of the hypersecretion of aldosterone. In the experimental setting, hyperaldosteronism leads to an excess of fibrous interstitial tissue and cardiac hypertrophy. In man, these consequences are those of hyperaldosteronism. The aim of this study was to assess the cardiac consequences of hyperaldosteronism in a series of 31 patients with a documented Conn adenoma, in comparison with a matched population of 31 patients with primary hypertension. For the same level of blood pressure, cardiac hypertrophy is more prominent in hyperaldosteronism and there is a positive correlation between the level of plasma aldosterone and left ventricular wall thickness. Left ventricular hypertrophy is of the concentric type. In addition, an increase in myocardial fibrosis (that can now be quantified by echocardiography) is observed, with a positive correlation between plasma aldosterone and reflected ultrasound which might correspond to increased myocardial collagen. These anatomic modifications of myocardial structure result in diastolic dysfunction. Overall, Conn adenoma is associated in accelerated disease, which is partly independent of the level of blood pressure.

Adenoma↗

UCS expectancy biases in spider phobics: underestimation of aversive consequences following fear-irrelevant stimuli.

This paper reports the results of two studies investigating judgements made by spider phobics about the potential threatening consequences (unconditioned stimulus, UCS, expectancies) associated with their phobic stimulus, fear-relevant (FR) stimuli, and fear-irrelevant (FI) stimuli. Using a 'thought experiment' UCS expectancy paradigm, the studies reported found that (1) spider phobics reported significantly higher UCS expectancies to spider stimuli than nonphobics, (2) spider phobics consistently underestimated the probability of aversive consequences following FI stimuli and (3) this underestimation of UCS expectancies to FI stimuli in phobics was not the result of a contrast effect resulting from sequential FR and FI judgements. This differential effect may have important implications for the kind of mechanism which mediates judgements about phobic consequences. These findings suggest that the dimensions on which phobic stimuli are categorised may be 'stretched' in the case of phobics and that this gives rise to the comparative underestimation of threat associated with FI stimuli but also makes phobics more vulnerable to acquiring other phobias.

Adolescent↗

[Daytime consequences of insomnia complaints in the French general population].

Insomnia is a frequent symptom in the general population; numerous studies have proven this. In the past years, classifications have gradually given more emphasis to daytime repercussions of insomnia and to their consequences on social and cognitive functioning. They are now integrated in the definition of insomnia and are used to quantify its severity. If the daytime consequences of insomnia are well known at the clinical level, there are few epidemiological data on this matter. The aim of this study was to assess the daytime repercussions of insomnia complaints in the general population of France. A representative sample (n=5,622) aged 15 or older was surveyed by telephone with the help of the sleep-EVAL expert system, a computer program specially designed to evaluate sleep disorders and to manage epidemiological investigations. Interviews have been completed for 80.8% of the solicited subjects (n=5,622). The variables considered comprised insomnia and its daytime repercussions on cognitive functioning, affective tone, daytime sleepiness and diurnal fatigue. Insomnia was found in 18.6% of the sample. The prevalence was higher in women (22.4%) than in men (14.5%, p<0.001) with a relative risk of 1.7 (95% confidence interval 1.5 to 2) and was twice more frequent for subjects 65 years of age or older compared to subjects younger than 45 years. Approximately 30% of subjects reporting insomnia had difficulties initiating sleep. Nearly 75% of insomnia complainers reported having a disrupted sleep or waking up too early in the morning and about 40% said they had a non-restorative sleep. Repercussions on daytime functioning were reported by most insomnia subjects (67%). Repercussions on cognitive functioning changed according age, number of insomnia symptoms and the use of a psychotropic medication. A decreased efficiency was more likely to be reported by subjects between 15 and 44 years of age (OR: 2.9), those using a psychotropic (OR: 1.5), those reporting at least three insomnia symptoms (OR: 1.4) and women (OR: 1.4). The highest probability of the appearance of concentration difficulties was found in subjects younger than 65 Years, having a depressive disorder and using a psychotropic (15-44 years: OR 19.1; 45-64 years: OR 46.6). Difficulties maintaining attention were 15 times higher in subjects aged between 45 and 64 who were using a psychotropic and had also a depressive disorder. Memory difficulties were three times more likely to be reported by subjects using a psychotropic. At the affective level, irritability was 10 times more likely to be reported by subjects younger than 65 Years who were also using a psychotropic and had a depressive disorder. Independent of the presence of a mental disorder and the use of a psychotropic, subjects between 15 and 44 Years were five times more likely to be irritable following a bad sleep. Feeling depressed after a bad night's sleep was 18 times more likely to occur in subjects aged between 45 and 64 who were using a psychotropic and had a depressive disorder. Feeling anxious after a bad night's sleep was seven times more likely to occur in subjects with a depressive disorder. Daytime sleepiness was reported by approximately 20% of insomnia subjects. This rate was relatively comparable among gender, age groups, presence/absence of a mental disorder and use or not of a psychotropic. However, taking into account the interaction between age, use of a psychotropic and the presence of a mental disorder, subjects younger than 65 years, using a psychotropic and having a depressive disorder were at least 10 times more likely to report daytime sleepiness. Subjects who were suffering the most diurnal symptoms of insomnia were those younger than 65 years. Several factors can be evoked to explain this fact. These subjects were, for the most part, likelier to have a stricter sleep/wake schedule because of constraints imposed by work, studies, child care, etc. Subjects older than 65 Years were generally retired and therefore less prone to sleepiness and to cognitive difficulties. Insomnia consequences were limited due to their inactivity. Complementary studies should be undertaken to describe the daytime repercussions of insomnia for this specific age group of the general population and to measure these repercussions.

Adolescent↗

[Consensus, hedonism: the characteristics of new family and their consequences for the development of children].

Over the last three decades, the marital family model described by Durkheim at the end of the nineteenth century has undergone numerous changes, e.g. questioning about the principle of authority, women emancipation, occurrence of the "new fathers", the growing influence of the media on the daily life of families, the less frequent and most precious child (due to the reduced number of children per family),... Through clinical, psychoanalytical and developmental models we, here, analyze these changes together with their impact on child. Historical and sociological approaches also allowed us to examine some of the effects induced by consensus and hedonism, the new familial parameters, on the child's life and development. The modern family being classically founded upon duty (central value) and the principle of authority to settle relationships between individuals, its main features are opposed to those of the contemporary family. The latter, which started to emerge over the sixties, is characterized by both the prevalence of parent-child relationships symmetrization and the emergence of the search for immediate pleasure. The change from parental authority to consensus as a principle ruling the relationships within families leads to many consequences later noticed through changes in the construction of the child's psyche along his development and in the relationships dynamics. Authority imposes on child to submit to the parents-mediatized requirements of the society and implies a change in impulses through the setting of Superego agencies and Ego Ideal, which (both ?) represent taboos and social ideals in the psyche. When consensus is at the center of the family, and according to concrete meetings with the other offered by the thousand and one situations met in the daily life, the aims and satisfaction modalities of the child's impulses will evolve into a relation often based on either strength or seduction. As a result, the settlement of classical instances will be affected. It will result in. Considering hedonism as the central value in child education leads one to support the pleasure principle and contributes to making more difficult the switching to the reality principle. The couple " I want, I don't want" is at the origin of most behaviors, and then further leads to the development of the assertive agency, "I do what I want, and thus I am". The libidinal excitation is, therefore, little restricted and reinforced by the media-based environment. The child's Superego is built on the concrete practices of his parents, but not on their Superego, whereas the Ideal of Ego is poorly socialized and driven towards the ideal Ego, early narcissist formation with the signs of child megalomania. Due to these early years of life throughout which the pleasure principle has been favored by their environment, the children are not prepared for life with its restrictions and unavoidable frustrations possibly experienced as persecutions. In the same way, when they have to meet the requirements of life in community, eg the discipline imposed within a college, these rules are more and more often felt by a pupil as unfair, arbitrary persecutions sometimes related to his own personality, "the teacher doesn't like me" of course, it is all the more legitimate to rebel against them as the charter of the pupils' rights, posted up in the school, has been read through very quickly by the teenagers. This mechanism takes one back to the archaically perception of environment by the very young child and to the projection developed by S. Freud in his description of the building "Ego-pure pleasure", (moi-plaisir purifie) (The Ego and the id, 1920). The opposed mechanism is expressed through an experience of shame felt by the subject when he is unable to satisfy, not the requests of his own impulses, but the social group's requirements. From the libidinal point of view, advertisements stimulate one's desires, incite one to consume and are at the origin of consumer needs. As a consequence, there is a resonance between the individual pleasure principle and the promotion of hedonism suggested by the society. The modern children have their mastery of impulse motions hampered by this phenomenon. The temporality of , new children " in new families sounds centered on the present, which is made of moments of eternity, always restarted (cyclic time of the first ages of life) ; it overrides historical time with a start, an end and references to intergeneration difference and filiations. This prevalence of present offers few support to neurotic defenses, with predictable problems in social interactions due to an inability to manage the tensions issued from the time discrepancies between one and his alter ego. Tran cultural studies have shown that to any social and cultural organization corresponds one or several basic personalities; among them, modem society has exuded the standard neurotic personality characterized by an ample mental space, a strict modulation of behaviors governed by the representations play and spreading out in Le théâtre du Je (The I theatre, Mac Dougall, 1982), a conflict between desire and internalized taboo, and the problematic of transgression and guilt. The modern family produces different personality structures. This led us to assume new basic personalities as follows, and to envision some psychopathological consequences: The passive dependent personality with an extreme narcissist fragility and at high risks of depressive disorders; The perverse-anarchistic personality characterized by subjects unable to feel guilty, taking at the best advantage of others to achieve his own ends thanks to his grasping of social situations and to his own seduction, lacking of true empathy; The slightly-psychopathic personality: these subjects can integrate well, but for a short time, in a social structure. They need to frequently find a new job, move in another place or country. Their relationships with others are always disrupted and changing for they can be involved in only short commitments. They are very susceptible to immediate gratifications.

Adult↗

Incidence and consequences of falls among elderly people living in the community.

BACKGROUND AND OBJECTIVES: To evaluate the incidence of falls according to socio-demographic and health factors, and to determine their physical, psychological and social consequences. SUBJETS AND METHOD: Population-based prospective study, which included a representative cohort of 448 elderly community-dwellers, aged 65 or more living in the city of Mataró (Spain). We made a baseline evaluation, which was repeated after a one-year follow up, consisting of a standardized questionnaire on socio-demographic characteristics, physical activity, tests of physical and cognitive function, history of falls during the previous year, the Falls Efficacy Scale, and associated chronic conditions. Follow-up interviews at intervals of one month over 12 months, consisting of a standardized questionnaire aimed at detecting and describing any fall occurred during the previous month. RESULTS: 25.1% (95% CI, 18.8-31.4) of males and 37.0% (95% CI, 31.2-42.8) of females fell. Multiple falls were observed in 3.8% of men and 10.9% of women. 203 falls were reported, providing a crude incidence rate of 30.9 falls per 100 men-years (95% CI, 23.3-41.0) and 56.5 falls per 100 women-years (95% CI, 46.5-68.8). A positive association with falls was found with age, reduced physical and cognitive function, associated chronic conditions and previous falls. 71.1% of falls had physical consequences, with 7.7% of fractures, and 21.7% needed medical aid. 64.4% of fallers feared of falling again. CONCLUSIONS: Our study shows a pattern of high incidence of falls among the elderly living in the Spanish non-institutionalized community. Our data confirm that adverse consequences derived from the falls are frequent and often severe, which makes falls one of the major problems of elderly people.

Accidental Falls↗

Osteoporosis as a model for the long-term clinical consequences of the menopause.

The decrease in ovarian function culminating in the last menstrual period, the menopause, in women in their forties and fifties takes place over a period of 3 to 5 years. There are several immediate clinical consequences of the menopause that are easy to detect and treat, usually with hormone replacement. In contrast, the longer term consequences of the menopause, cardiovascular disease and osteoporosis, are usually clinically silent during these early postmenopausal years. As a result, it has proven difficult to get physicians and their patients to accept this cause-and-effect relationship between the menopause and the development of osteoporosis or heart disease a decade or more later. The details concerning the menopause and osteoporosis are by now so well established that this disease can serve as a model for studies linking the menopause to heart disease. This article, with its focus on osteoporosis, serves as an introduction to the later articles detailing the cardiovascular consequences of the menopause.

Bone Remodeling↗

Unintended pregnancy. Consequences and solutions for a worldwide problem.

Unintended pregnancy is a worldwide problem that affects women, their families, and society. Unintended pregnancy can result from contraceptive failure, non-use of contraceptive services, and, less commonly, rape. Abortion is a frequent consequence of unintended pregnancy and, in the developing world, can result in serious, long-term negative health effects including infertility and maternal death. In many developing countries, poverty, malnutrition, and lack of sanitation and education contribute to serious health consequences for women and their families experiencing an unintended pregnancy. Regardless of the cause, unintended pregnancy and its negative consequences can be prevented by access to contraceptive services including emergency contraception, safe and legal abortion services, and a society that allows women to determine their own reproductive choices. Addressing unintended pregnancy and its substantial human and dollar costs should be a priority in every country. The availability of reliable contraception for all, regardless of age or ability to pay, is an essential first step. Women and adolescents require access to age-appropriate and culturally sensitive reproductive health care services, including emergency contraception. Access to safe, legal abortion services is necessary to impact the staggering maternal mortality rates worldwide. Midwives throughout the world provide the majority of care for women of reproductive age. It is essential to identify those at risk for unintended pregnancy, provide the services they require, and remain diligent to ensure that those women and their families have safe options to consider when faced with an unintended pregnancy. In 1920, Magaret Sanger said, "No women can call herself free who does not control her own body." Although great strides have been made to improve the health and status of women since Ms. Sanger spoke those words, there remains much work to be done.

Contraception↗