pmc_id
stringlengths 11
11
| clean_content
stringlengths 5
3.62M
|
|---|---|
PMC10000000 | Editorial CHICAGO MEDICAL SOCIETY. Jan. 18th. The regular meeting of the Society was almost wholly occupied with the subject of City Health Regulations. Dr. N. S. Davis, from the Special Committee on that subject, made the following report, which, after free discussion, was adopted. The Committee was instructed to present the same to the Common Council, with the draft of an amendment to the present laws, as indicated in the report. REPORT OF THE COMMITTEE ON THE HEALTH DEPARTMENT OF OUR CITY GOVERNMENT. Presented to the Chicago Medical Society, January 18th, 1867. The subject assigned to your Committee for consideration, is certainly one of the most important that can engage the atten- tion of the people of this, or any other large city. The adop- tion and enforcement of proper sanitary regulations is so closely connected with the preservation of health and the prolongation of life and happiness, that no community can ne,gleet them without, sooner or later, suffering the severest penalties. In fulfilling the duties assigned to your Committee, three questions require careful consideration. 1st. What are principles upon which a Municipal Health De- partment should be organized, in order to ensure the highest degree of enlightinent and efficient action? 2d. Is the present organization of the Health Department of our city defective; and if so, in what particulars? 3d. What changes are necessary to remedy its defects, and complete its efficiency? In answer to the first question, we would state, that the basis of a proper Health Organization, should consist of a Board of Commissioners, embodying in its members a high degree of ex- ecutive ability or business capacity, and a thorough knowledge of sanitary science, as applied to the preservation of the health of communities and the prevention of the spread of contagious diseases. No board can embody these qualities, without be- ing composed in part, at least, of thoroughly-educated physi- cians; simply because, In our country, no other class of men are educated to an adequate extent, in reference to those sani- tary subjects on which a Board of Health must continually act. The truth of this proposition is too plain to need either argu- ment or illustration. A Board of Health Commissioners, composed of properly educated and qualified members, should be invested with suffi- cient power to devise and carry into prompt effect, all such measures as the safety and welfare of the community requires. The term of office of its members should be long enough to in- sure a reasonable degree of permanency in whatever sanitary measures or policy may be adopted. In no department of municipal affairs, is a vaccillating, temporizing policy more dis- astrous than in that relating to the preservation of the public health. A show of energy, or a display of zeal, or a prodigal expenditure of money just while some fearful epidemic disease is threatening to commence its work of death, and a negligent indifference at all other times, is but little better than no action at all. Sanitary measures, to be successful in lessening the sickness and mortality of communities, and in protecting them from the ravages of epidemics, must be founded on an accurate knowledge of all those local causes that tend to deteriorate the public health, and then they must be rigidly and perseveringly enforced from year to year. To enable a Board of Health Commissioners to devise such measures, and establish an enlightened and permanent sanitary policy, its members should not only possess the requisite educa- tion and business capacity, with a term of office long enough to add experience to their previous knowledge, but they should be appointed in such a manner as to free them as far as possible from all partisanship, or feelings of dependence on the success or failure of mere political parties. And yet they should be fully accountable to the municipal government for all their official acts. Such are the principles on which a Board of Health Commissioners should be organized. The next question is, how far the present health department of our city government is organized in accordance with these principles, and in what particulars is it defective? Our present Health Department consists of a Board of three Commissioners, who are also at the same time Commissioners of the Police and Fire Departments; a Health-Officer; and a City Physician. The three members of the Board are elected by the people, one from each division of the city, and hold their offices for six years. The Health-Officer is appointed by the Board. The City Physician is elected by the Common Council, and holds office for two years. The present city charter confers on the Common Council power "to do all acts and make all regulations which may be necessary or expedient, for the preservation of health, and the suppression of disease." And, in accordance with this power, we find in the present laws and ordinances of the city full and ample powers conferred and duties enjoined upon the Board of of Health and Health-Officer, for the efficient and thorough regulation of everything relating to the public health and safety. After a full examination of the present laws and ordi- nances, we can see no need of further legislation, so far as relates to the conferring of power upon the Board of Health or its agents. Wherein, then, is the present organization defective? Chiefly in three important particulars. The first and most radical de- fect is, the absence of all provision for securing the selection of members of the Board of Health so thoroughly educated in san- itary matters as to fit them for an enlightened and efficient dis- charge of their duties. To make up a Board of Health, charged with the duty of making and enforcing all such regulations as are necessary to mitigate or prevent the prevalence of diseases in a great city, of men who, neither by education, occupation, nor business habits, have acquired any special knowledge of the nature and causes of disease, or of the laws by which they are developed and diffused, is just as absurd as it would be to elect a practising physician to the office of City Attorney. If there is lack of efficiency in the practical working of our pres- ent health organization, it is not because the members of the present Board of Police, acting as a Board of Health, are defi- cient in integrity or business capacity, or from deficient legal authority to-act, but simply because they have not that special sanitary or medical education which enables them to compre- hend clearly the nature, extent, and importance of the work entrusted to them. The second defect consists in an imperfect and injudicious distribution of duties between the Health-Officer, City Physi- cian, and Clerk of the Board of Health. The Health-Officer shall be simply an intelligent and efficient executive officer, to superintend the prompt enforcement of all the laws and orders of the Board of Health. The City Physician should keep at* all times a free vaccine dispensary for the poor, and have the immediate charge or superintendence of such sick persons as came under the care and authority of the Health and Police Departments of the City Government. And there should be a competent Clerk, who should perform the duties of Secretary to the Board of Health and the Health-Officer, and also the duties of Register of Vital Statistics. The third defect in the present organization is the absence of efficient regulations for the accurate registry of births, mar- riages and deaths, with the causes of the latter. The impor- tance of this needs no comment here. After a somewhat careful and candid examination of the whole subject, we feel certain that whatever inefficiency or defectiveness there is in the practical working of the present health organization of our city, can be traced directly or indirectly to the three sources just enumerated. This leads us to the third and last question' involved in this report, namely: What changes are necessary to remedy the defects to which we have alluded? We answer, so far as State legislation is concerned, we need but a single brief amendment to the laws now in force. If the present law relating to the action of the Board of Police, in the capacity of a Board of Health, was so amended as to provide for the ap- pointment of three thoroughly competent Physicians, (one from each Division of the City,) to act with said Police Commission- ers in all matters pertaining to health or sanitary regulations, to possess coequal powers and duties, and to constitute a part of said Board whenever acting in the capacity of a Board of Health, it would be all the legislation really required. This done, the other defects pointed out could be easily remedied under the authority already possessed by the Common Council and Board of Health. While the proposed amendment should leave the present mode of electing the three Police Commis- sioners undisturbed, it should provide some other and less po- litical method of appointing the three medical members of the Board acting as a Board of Health. Those members of our profession who have acquired that education, experience, and 'reputation, which would enable them to impart that kind of in- telligence and efficiency to a Board of Health, imperatively needed in all large cities, will never be found seeking nomina- tions from political parties, nor lobbying for appointments by a Governor and Senate, or a Mayor and Council. They must be sought ought and invited to accept the position, or their ser- vices will not be obtained. We would suggest whether this would not be done more judiciously and with less reference to anything of a political or partisan character, by the Judges of the Superior Court of this city, than by any other authority. It will be seen that the defects we have pointed out and the remedies proposed are few and simple; yet they are really of vital importance to the practical working and beneficial re- sults of the Health Department of our city. Should the views thus far expressed in this report meet the approbation of this Society, an amendment could be pre- pared in due form, relating to the appointment of three com- petcnt medical men as members of the Board of Health, and an ordinance in relation to the proper registry of vital statistics, and we have no doubt but both would meet the prompt sanction of the Mayor and Council. Before conclud- ing this report, it may be expected that some notice will be taken of the several amendments and health bills which have already been prepared and placed before the Legislature, the Council, and the public. There are three separate projects of this kind. The first consists in amendments to the present laws prepared and recommended by the Common Council. The only item in these, that relates to the important defects we have explained, is the section proposing to give the Common Council power, in cases of imminent danger from the preva- lence of epidemic diseases, to appoint an additional number of members of the Board of Health, to act as such simply while such danger lasts. But it is not provided that even these tem- porary appointees shall be medical men. And hence it does not in any degree remedy the radical defect in the constitution of of the present Board. The second project is in the form of a bill recently introduced into the State Senate by Senator Ward. By the provisions of this bill, everything pertaining to the Health Department, and sanitary regulations, is removed from the control of the people of the city and its municipal govern- ment, and placed in the hands of a Board of Commissioners, consisting of the President of the Board of Police, and two Commissioners appointed by the Governor and Senate, one of whom must be a physician. The two persons thus appointed by the Governor and Senate are to hold office four years, and, with the President of the Board of Police, constitute a Board of Health, with full power to make all needful rules, regula- tions, and appointments of agents, etc., sufficient to devise and execute a complete and independent sanitary system. There are two leading and fatal objections to this bill. The first is, that it deprives the people of this city of all power to regulate and control some of their most important local interests, and assumes that a Governor and Senate, at Springfield, are -better qualified to judge of the capacities and qualifications for office, of citizens of Chicago, than are the local authorities of the city, or the people themselves. The second, and more impor- tant objection is, that it creates a large number of new and ad- ditional officers and employes, requiring a regular annual addi- tional tax upon the city, of from $75,000 to $150,000, without regard to any extraordinary expenditures on account of the prevalence of severe epidemics. And yet it does not provide for the accomplishment of a single valuable object, that would not be as well and certainly accomplished, by simply adding hree thoroughly competent physicians to our present Board of Health. Serious objections could also be made to several items in the details of this bill. For instance, the section relating to the registration of births, marriages, and deaths, is utterly worthless. The third project is that presented by the Citizens' Commit- tee, and entitled the "Metropolitan Health Bill." This is amenable to precisely the same objections as we have made to the bill introduced by Senator Ward; while, practically, it would be far less efficient. Like Ward's bill, it takes from the people and local authorities the selection of a Board of Health, and confers it on the Governor and Senate, at Springfield. Like Ward's bill, it creates a long list of new and additional city officers and employees, requiring a correspondingly large additional expenditure of money annually. But, unlike Ward's bill, it does not fix the salary of the members of the Board of Health, or provide for the appointment of a full corps of San- itary Police. It allows the Common Council to fix their sala- ries, thereby making the officers perform the difficult task of serving two masters; the Governor for their appointment, and the Council for their pay. Again, by depending in part upon the ordinary police for executing the orders of the Health Board, it places the police in the equally embarassing position of obe- dience to the orders of two separate and independent Boards-- a plan that never has and never will work satisfactorily in practice. In conclusion, we cannot refrain from again expressing the opinion, that a single amendment to our present laws, provid- ing for the addition of three competent and thoroughly edu- cated members of the medical profession to the present Board of Health, with the aid of one additional Clerk, as Register of Vital Statistics, would result in rendering our Health Depart- ment as efficient and beneficial to the interests of the city, as it could be by any number of new and expensive schemes. It would require but one police organization, capable of being in- creased or diminished, as public exigencies might require, and practically amenable to but one Board. It would require a larger ratio of medical to the non-medi- cal intelligence in the Board of Health, than is proposed in either Ward's bill, or that of the Citizens' Committee. In- stead of requiring an annual aggregate increased tax upon the city of $75,000 or $100,000 for salaries of new' officers and agents, it would require for the three additional members of the Board of Health and the Register of Vital Statistics an aggre- gate of not over $5,000. It would also,leave our City Govern- ment far less complicated in its details, and, in all its strictly local interests, under the control of its own citizens, where it properly belongs. All of which is respectfully submitted. N. S. DAVIS, ) R. C. HAMILL, V Committee. J. P. ROSS, J Medical Department of University of Michigan.--We have seen in some of our exchanges, a statement of the number of Medical Students in the University of Michigan, accom- panied by the assertion that the large number congregated there could not have been drawn thither by the small pecuniary charges, as the aggregate of attendance is greater, owing to the length of the Lecture-term, than in any other school in the North-west. The entire falsity of such a statement is shown by the following facts:-- The fee for admission to the Medical Department of the Michigan University is, for students in the State $10, from out of the State $20, paid but once. The Lecture-term being six months, allowing $25 per month for board, would make a total necessary expenditure for the full term of $160 for the student of the State, and $170 for students from other States. The Chicago Medical College, in this city, has a Lecture-term of full five months. If we put board here at the same rate as supposed for Ann Arbor, namely, $25 per month, the cost of attending the regular annual course here, would be as follows:-- Five months board, at $25 per month,------$ 125 00 Lecture fees,--------------------------------- 50 00 Matriculation fee,----------------------------- 5 00 Dissecting fee, ------------------------------- 5 00 Hospital fee,---------------------------------- 6 00 Total,_______________________________ $191 00 Clinical Items.--A subscriber wishes to know how to cure "an obstinate, tormenting, intolerable itching, of years stand- ing," either in the genital organs of the female or around the anus of the male. The following cases may answer his purpose:-- Case I. Mrs. B., a married lady, aged about 25 years, had been for several years subject to periodical attacks of puritus pudendi, or intolerable itching of the labia and vulva. She generally suffered most from it after the menstrual periods, and it was generally accompanied by a thin leucorrhoeal discharge. She was placed on the following treatment:-- 1^. Ext. Hyoscyamus,---------------------- SOgrs. Sulph Ferri,------------------------- 30grs. Pulv. Aloes,------------------------- 15grs. Blue Mass, -------------------------- lOgrs. Ext. Nux Vom.,----------------------- lOgrs. Mix and di vide, into thirty pills. One to betaken before breakfast and dinner each day. For local use she was directed a solution of borate of soda (borax), 5iij and sulphate of mor- phia, 20grs., in water, one pint, the vulva to be wet with it of- ten, and a small quantity injected into the vagina each night and morning. Under this treatment the patient recovered, without any return of the disease. Case II. Mrs. W., aged 40 years, had been very severely troubled with the same disease several months, without any re- gard to the menstrual periods. The same solution of borax and morphine, applied locally, and the use of eight drops of Fowlers's arsenical solution, taken before each meal, in a spoonful of sweetened water, and continued for about four weeks, resulted in a cure. Both patients were required to live on plain food and to avoid all stimulating drinks. Case III. Mr. G., aged 30 years, sanguine temperament and full habit, had pruritis of the anus for three years. Some- times the itching would be intolerable for several days and then better for a week or ten days at a time. On examination, the skin, over a circle of an inch, around the opening of the rec- tum, was thickened, slightly fissured, and whiter than usual, lie was directed to take eight drops of Donovan's solution be- fore each meal time, and the affected surface was wet with the liquid persulphate of iron, o.f the strength usually found in the drug stores, every third day. After four local applications he was entirely relieved. He continued to take the drops inter- nally for three weeks, and although more than one year has elapsed the disease has not returned. I recollect treating several cases of old chronic cases of pru- ritis ani sucessfully, by applying locally, each night and morn- ing, the following ointment: ly. Iodide Sulphur,--------------------------- 3ij Oil Tobacco, ----------+----------------2gtts. Simple Crete,--------------------------- SSij Attention should always be paid to the general health, and especially to. the condition of the digestive organs. ^iie Chair of Surgery in Rush Medical College.-- According to statements in the daily papers of this city, the chair of Surgery made vacant by the death of the late Prof. I). Brainard, has been filled by the appointment of Moses Gunn, of Detroit, Professor of Surgery in the University of Michigan. It is also stated that Prof. Gunn has accepted the appointment. City Mortality.--The following is the report of the Health- Officer of the mortality of the City of Chicago for the month of December, 1866: CAUSES OF DEATH. Accidents,---------------------- u Asthma,------------------------- 2 Bronchitis,____________________ 1 Burned,_________________________ 1 Cancer,------------------------- 2 Childbed,----------------------- 2 Cholera Infantum,_______________ 1 Consumption, ------------------ 42 Convulsions,____________________35 Croup,-------------------------- 7 Cold____________________________ 2 Chicken Pox,____________________ 1 Congestion of Brain,____________ 3 Congestion of Lungs,____________ 2 Decline,________________________ 1 Delirium Tremens,______________ 1 Diarrhoea,______________________ 5 Diphtheria,___________________<<. 15 Disease of Heart,-------------- 8 Disease of Liver,______________ 2 Disease of Lungs,______________ 7 Disease of Brain,______________ 6 Dropsy,_________________________ 7 Drowned,________________________ 2 Erysipelas, -------------------- 3 Fever, Childbed,---------------- 2 Fever, Remittent,_______________ 4 rever, scarlet,_______________ 13 Fever, Typhoid,---------------- 4 Fever, Typhus,_________________ 1 Fever, not stated,------------- 1 Hydrocephelus,_________________ 7 Inflammation of Kidneys,_______ 1 Inflammation of Bowels,________ 9 Inflammation of Lungs,_________ 6 Inflammation of Liver,_________ 1 Marasmus,______________________ 1 Old Age,--------k-------------- 15 Palsy,_______________________ 2 Pneumonia,_____________________ 7 Phthisis Pulmonalis,___________ 1 Spasms,________,_______________ 1 Spinal Meningitis,_____________ 1 Suffocation,___________________ 2 Small Pox,_____________________ 2 Suicide, ______________________ 1 Stillborn,____________________ 10 Teething,______*_______________ 3 Whooping-Cough.________________17 Gun shot Wound,________________ 1 #White Swelling,--------------- 1 Unknown,______________________ 33 Total,_________________309 ages of the DECEASED. -- Under o years, loo ; over o and under 1U years, 19; over 10 and under 20, 15; over 20 and under 30, 28; over 30 and under 40, 34; over 4o and under 50, 16; over 50 and under 60, 11; over 60 and under 70, 11; over 70 and under 80, 12; over 80 and under 90, 6; unknown, 4. Total, 309. N \TTVTTTFS Chicago,____________128 Other States,--------63 Belgium,------------- 1 Bohemia,------------- 2 Canada,__________1__ 2 England,____________ 5 Germany,------------47 Ireland,____________38 Norway,------------- 6 On the Sea,_________ 1 Sweden,------------- 5 Scotland,___________ 4 Wales,______________ 1 Unknown,____________ 6 Total,---309 DIVISIONS OF THE CITY. North,..... 75 | South,....105 | West,....129 | Total,... 309 Total number during the month of November,_______________ 382 Decrease from last month,-------------------------------- 73 Total number last year for the month of December,________ 333 Dr. Conneau.--It bus been remarked that nearly every profession but that of medicine was represented in the French Senate. This anomaly has struck the Emperor, it would Appear, as the Evenement announces that his Majesty's physician, Dr. Conneau, is to be promoted forthwith to a seat at the Luxem- bourg. |
PMC10000003 | CHICAGO MEDICAL EXAMINER. N. S. DAVIS, MD, Editor. VOL. VIII. JANUARY, 1867. NO. 1. wnninat (iHtnmim ARTICLE I. THE MECHANICAL TREATMENT NECESSARY IN INFLAMMATION OF THE KNEE JOINT; WITH A DESCRIPTION OF A NEW APPARATUS FOR MA- KING EXTENSION. By JULIEN S. SHERMAN, M.D., Chicago, Ill. The exposed position of this articulation, the thinness of the tissues surrounding, and the amount of labor performed by it, render it a very frequent seat of those diseases and deformities consequent upon injury. Inflammation of this joint is gener- ally more severe and disastrous than of most others, on account of its large size and the extent of the synovial sack involved in the disease. The well-known pathological fact, that inflamma- tion of joints is always followed by reflex contraction of the muscles in its vicinity, is well exemplified in the knee by the strong contraction of the powerful flexors, bending the leg fre- quently to a right angle with the thigh. The injurious effect of pressure is also well shown, and the necessity for its removal as urgent as in hip-disease. Specific inflammations artf sometimes met with, but are not as frequent as generally supposed, most cases being traumatic in their ori- gin. Yet inflammations occurring in constitutions either scrof- ulous or syphilitic, are more prone to suppuration and caries than when this element is absent. Notwithstanding the advantages of medical treatment, there are indications which must be overcome by mechanical means. They are not only necessary for subduing disease in its early developement, but are indispensable for the correction and prevention of deformities following in severe cases. Inflamma- tion of this joint, even in its first stage, is always accompanied by contraction of the flexors, aggravating the pain and increas- ing the pressure, thereby either wholly preventing, or greatly retarding, spontaneous recovery. This contraction increases with the violence of the inflammation, and should be overcome by tenotomy of all the tendons offering resistance to the exten- sion of the limb. If ether is administered, the particular ten- dons requiring division should be ascertained before anaesthesia is produced, as, when that stage is reached, the muscles become relaxed, and we may be at loss to determine where division is necessary. Special care must be taken to avoid wounding, the peroneal nerve, situated just internal to the biceps tendon. This tendon should be divided from without inwards, at the same time that extension is being made, the sheath and inner fibres of which will then be ruptured before the knife passes completely through, and all danger to the nerve avoided. The limb should then be placed upon an air-cushion, protected by oil-silk, in order that local dressings may be used without soil- ing the bedding. The relief of pressure in inflamed joints is the most important part of the treatment; the diseased surfaces must be separated to allow of recovery or to prevent unfavorable results. The means for accomplishing this desired end are strictly mechani- cal. Adhesive straps may be applied to the leg, below the knee, and the surfaces of the joints separated by making exten- sion with the pulley and weight, as in adhesive strap dressing for fractures of the thigh. The limb may be placed in the hor- izontal position or upon an inclined plane, as circumstances may indicate. This treatment will be found to greatly relieve the pain and entirely remove the pressure. If it be adopted at the outset of the attack, the flexing of the limb will be pre- vented and division of the tendons rendered unnecessary. Should suppuration occur and the joint become greatly dis- tended with pus, it should be carefully evacuated by means of a trochar, avoiding the admission of air into the synovial sack, and the extension persevered in. Moderate pressure upon the femoral artery is advised by good authority, as diminishing the flow of blood to the part, but it is difficult to maintain and fre- quently adds to the discomfort of the patient. The accompanying cuts represent an apparatus for making extension. It consists of a wooden socket, constructed to accu- rately fit the thigh and similar to those used for artificial legs, against this the counter-extension is made, and thus evenly dis- tributed over the thigh and tuberosity of the ischium. A steel rod is attached to each side of the socket, reaching to within a few inches of the ankle, and the two rods are joined behind by a broad band of sheet-iron, which is moulded to fit the posterior part of the leg; on the front, and joining the sheet-iron band, is a strap which, being buckled, holds the leg firmly in the appara- tus. It is applied as follows:--Six adhesive straps are cut, two inches in width at the top and tapering to one at the bot- tom, and should be long enough to reach from about one inch below the knee to the ankle; they are then applied to the.leg, as represented in the cut, and secured by a bandage; the socket is then placed upon the thigh, the strap at the bottom of the instrument buckled, and the lower ends of the adhesive plaster turned over the bottom of the instrument and also attached to buckles upon its sides. The amount of extension is regulated by the degree of tightness to which the straps are drawn. The figure upon the right represents the same apparatus, with the exception that the side rods are extended and fastened to the sole of the shoe, while the adhesive straps are also at- tached to the buckles upon the sides. This will allow the patient to walk about and bear all his weight upon the socket and not any upon the knee-joint. This modification renders it more applicable to the chronic inflammations, when we desire the patient to have out-door exercise, which he can enjoy with as much ease as the wearer of an artificial leg. The advantages gained by this mode of extension are, the large surface to which the counter-extending force is applied, its security, and the ease with which the pa- tient can tolerate it. When the socket is well fitted, there is no tendency for the instrument to rotate or twist upon the leg. This same principle can be used in the construction of numer- ous instruments for the relief of deformities of the knee. |
PMC10000005 | ARTICLE III. CASE OF OVARIOTOMY. By D. MASON, M.D., Prairie du Chien, Wis. Was called to see Mrs. II., October 21st, 1865, and found her suffering from ovarian dropsy. The history she gave of herself is briefly as follows:--She is now 52 years of age; first noticed a tumor in her right side, 26 years ago, which, at times, seemed to enlarge, and then rap- idly recede, and so continued until October, 1864, about 25 years from its first appearance, when a decided and steady growth commenced. In February, 1865, the growth increased more rapidly, and continued until October, when the distress from distension became almost insupportable. She had been attended during the summer by various eclectics, galvanists, mesmerists, and homoeopaths, but without any benefit. On the 21st of October, 1865, as stated above, I first saw her, inviting my friend, Dr. Conant, to accompany me. The diagnosis was clearly established, and I tapped immediately, drawing off 14 tbs. of gray, turbid fluid, which reduced the tumor to about one-third its former size, very much to the re- lief of the patient. Her general health had been very much reduced by her suffering through the summer, but rapidly im- proved after the tapping. I then explained to her the cer- tainty of its refilling, and proposed its removal; at the same time explaining to her the danger, and probabilities of success of the operation. On the 10th of January, 1866, I was called to see her again, and found her much improved in health, and in good spirits. She expressed herself ready for, and anxious to have the ope- ration done. I proposed the operation for the 18th. On the 17th, gave a full dose of castor oil, which thoroughly emptied the bowels. On the 18th, accompanied by Drs. Andros, Lowe, and IIazeltine, of McGregor, Iowa, and Dr. Conant, of Prairie du Chien, I proceeded to operate. Having the tem- perature of the room at 70deg, gave the patient a mixture of equal parts of chloroform and sulphuric ether to complete anaesthesia; made, the incision on the linea alba, from about an inch above the pubis, upwards about 12 inches in length. The tumor pre- sented itself covered by the omentum and with pretty firm adhesions, the most of which were broken up with the finger, but a few points, more firm, were dissected away. In breaking up these adhesions, a portion of the omentum was slightly torn, and was cut away. Two small arteries were divided in this procedure and threatened to be a little troublesome, but the hemorrhage was arrested by the application of a little persul- phate of iron. Following the tumor down to its pedicle, it was found to be quite small, about four lines in diameter, two inches in length, and round. It was tied by one strong ligature, the pedicle severed and the tumor lifted out, and was found to weigh seven pounds. During this procedure, the exposed bowels were cov- ered by? napkins dipped in warm water; they were now care- fully sponged, all little particles of clots removed, and returned to their natural position. The wound was now closed by eight silver wire sutures, the ligature of the pedicle being brought out of the lower angle of the wound; adhesive straps were placed between the sutures; a lint compress; and a broad ban- dage pinned snugly around the whole. At this time, the effects of the chloroform had pretty wrell passed off; the pulse 98. Sulph. morph., J gr., was given immediately, and repeated in an hour, after which, gr. was given every two hours until the following day. 19th. Has had some vomiting; pulse 100. Sulph. morph. J gr. every four hours. 20th. Pulse 102; respiration 28; vomiting continues at in- tervals; not much pain. Suspend the morph. 21st. Restless; pulse 104; considerable tympanitis. Gave enema of tepid water; bowels moved, which greatly relieved the tympanitis. 22d. Has passed a comfortable night; pulse 104; pain slight. Dressed the wound, which is healing very kindly. 23d. Much tympanitis, though not much pain; pulse 110; tepid water enema relieves the tympanitis. 21flh. Has passed a comfortable night; pulse 108. 25th. Pulse 100; pain slight. R. Sp. vini Gallici SSij. every two hours. 26th. Considerable pain from distension of the bowels; en- ema moves the bowels and relieves all the symptoms. 28th. Has been very comfortable since the last record; remove the sutures; wound pretty firmly united. 30th. Pulse 94; give Rhine wine, SSj. every two hours, in place of brandy, and beef-tea ad libitum. I would here state, that, up to this date, the diet had been toast-water, farina gruel, with small particles of ice to allay thirst. Feb. 7th. Has been very comfortable since last record; pulse 80; ligature gave away upon a little traction to-day. 12th. Wound entirely healed; appetite good. 20th. Patient returned to her home, 10 miles in the country. 26th. Visited patient at her home. I found her moving about the house, and she expressed herself as feeling quite well, though a little weak. I would here tender my great obligations to Dr. Andros, for his assistance in conducting the after treatment. |
PMC10000006 | ARTICLE VI. CASE OF DEATH FROM CHLOROFORM. By. C. R. PARKE, M.D., Bloomington, Ill. Read to the Illinois State Medical Society, June, 1866. Mr. President:--Permit me to report the following case of leath from the inhalation of chloroform:-- On Saturday, June 2d, I was called to administer chloroform to Miss-------, age about 20 years, apparently in good health. Object, the extraction of teeth. On the previous Wednesday, chloroform had been adminis- tered by a dentist, and six molar teeth extracted, without any deleterious effects. On Saturday, she seated herself in a regular dental chair, was quite cheerful, and anxious to get under the influence of chloroform. I placed about J of a drachm of chloroform on a sponge and applied it to the nose in the usual way, covered by a towel. This quantity not being sufficient to produce the de- sired result, an additional J of a drachm was poured upon the sponge, which, amount, in a few minutes, sufficiently affected her so as to enable the dentist to extract three molar teeth, with but little pain. She sat up and spit out the blood that accu- mulated in the mouth, after which she gave me to understand that I must give her more chloroform before she could submit to the further extraction of any more teeth. The remainder of the drachm of chloroform was then poured upon the sponge and given as before. In a few minutes, she wras considered suffi- ciently under its influence, to have the remaining teeth (three) extracted. Just before the doctor succeeded in extracting the last tooth, I noticed a deathly pallor of the countenance; complete cessa- tion of respiration; pulse scarcely perceptible for a minute, when it ceased entirely. There was also considerable capillary congestion about the skin of the upper portion of the chest, also dilatation of the pupils. Prior to the appearance of the pallor of the face, there was not an unfavorable symptom present. Immediately upon the presentation of the above symptoms, 1 drew the tongue as far out of the mouth as was necessary to allow the air to enter freely, and, with the assistance of Dr. II. Luce, kept up artificial respiration. Applied aqua ammonia to the nostrils and introduced a small quantity of brandy into the mouth. A catheter was also introduced down into the pharynx, through which we blew, thinking the air might the more readily enter the lungs; at the same time we applied the electro-galvanic battery to the spine and muscles of respiration, all of which means were used diligently for three-quarters of an hour without avail, she only making three attempts at inspira- tion during the commencement of our efforts at artificial respi- ration. The pulse acted as it commonly does, during the administration of chloroform, first being excited, then depressed, nothing indicating cardiac trouble of any kind. There was none of that lividity of countenance witnessed in asphyxia. The whole transaction, up to the fatal minute, was not over twenty-five minutes; and the amount of chloroform used, only one drachm. This is the first fatal case I ever witnessed from the inhala- tion of chloroform, and I suppose I have administered it, and seen it administered, in this country and in Europe, nearly a thousand times. Any suggestions thrown out by this Society, as to the partic- ular action of the anaesthetic, and the cause of death in this case, will be thankfully received. My opinion is, it was paral- ysis of the heart, with congestion of lungs. |
PMC10000007 | ARTICLE II. A PAPER ON EPIDEMICS. By H. NANCE, M.D., Kewanee, Ill. Read to the Military Tract Medical Society. Having been selected by this Association to report, at the. semi-annual meeting, at Galesburgh, on Epidemics and En- demics, I owe an apology for not making this paper more in- teresting. I cannot make it interesting, for the good reason, that we really have not had a severe epidemic, of any disease, for two or three years. In taking a retrospect of the health of our community for the last two years, I would pronounce it un- usually good. Our community, I think, have suffered much less than many others situated quite contiguous to us; this may be owing to the particular topography of our village and its environs. Kewanee is situated on the Chicago,* Burlington, & Quincy Railroad, immediately on the dividing ridge between the Illinois and Mississippi Rivers. The south part of the vil- lage discharges its sewers into the tributaries of the Illinois River, and the north part enter the tributaries of the Missis- sippi River, thus leaving us almost entirely free from any stag- nant pools of water. Physicians advocating a miasmatic ori- gin of the usual autumnal fevers, would promptly come to the conclusion that we would suffer but little from this class of dis- eases, and this conclusion would be nearly correct. Our village is underlaid with an immense field of bituminous coal, being from eight to ten feet below the surface to eighty or ninety feet, according to the grade of the land. How far this mineral or vegetable production may affect the health of our community, I shall not pretend to say; I will only remark that the health of our mining population is equally as good, if not better, than that of the rural population, who are engaged in cultivating the soil. I think they are remarkably exempt from koino-iniasmatic diseases. It is very unusual to see any of them suffering with intermittent diseases; and I can say the same of typhoid fever. I have resided here more than six years, and during that time I do not remember of having treated a case of typhoid fever in the house of any miner. In the fall of 1864, I treated about a dozen cases of genuine ty- phus fever in the mining region, but it was introduced by a patient brought from off a ship sick with the disease, and from this case the others originated. Notwithstanding we are on the dividing ridge between the two great rivers, and that our county is nearly -all underlaid with coal, which may have a modifying influence upon the vari- ous epidemics of our county, yet we occasionally have epidemics. We have had cerebro-spinal meningitis, typhoid fever, measles, pertussis, dysentery, and, probably, some other diseases pre- vailing as epidemics since I have resided in Henry County; and I should not fail to mention the general prevalence of intermit- tents, remittents, infantile diarrhoeas, and general derangements of the alimentary canal of children, usually under two years of age. During the winter, when the weather is mild and the atmosphere is overloaded with a redundancy of moisture, pneu- monia and bronchial affections always prevail. Phthisis pul- monalis is becoming a much more general disease than it was at the first settling of the country, and I am sorry to add, with all our improvements in medicines, including the vaunted rem- edies, oleum jecoris anselli and the phosphites, that tuberculosis advances as rapidly as it did before the introduction of these lauded " specifies." I mention these remedies, not to entirely condemn them, but to put the young and inexperienced prac- titioner on his guard, not to place too much confidence in them when prescribing for his phthisical patient. There is, doubtless, a tendency on the part of some of our leading physicians to eulogize the virtues of some of our medi- cines too much. This excess of praise of these remedies is confined principally to professors in our medical colleges, in order to create a reputation, not only for themselves but for their institutions. I am frequently disgusted in reading in our medical journals of some remedy being recommended so highly for some epidemic which is prevailing at the time. Who of you now believe that the phosphites will eradicate tuberculosis, ren- ovate the general system, and make a healthy, athletic man of a poor anaemic person? Who of you now believe that cod-liver oil is a specific in all pulmonary diseases? I tell you, gentle- men, that we should not be so easily deceived by pretenders in medicine who are trying to build themselves up, nor by profes- sors in our medical colleges who are using every effort, not only to enhance their own reputations, but the reputation of the institution they represent. Look guardedly to the interests of your patient, and let us not vie with those who would rise to fame in their profession, regardless of the good they may do in curing their patients. We would not regard consumption as either an endemic or epidemic disease, but as it frequently becomes a sequel of bron- chitis, pneumonia, pleuritis, etc., especially in persons possess- ing a hereditary taint, I mention it in this connection. Since the introduction of auscultation and percussion by Laennec and Louis, we have had but little difficulty in diagnosing pul- monary diseases. At the early stage of the formation of tuber- cle, some difficulty may be experienced, but when we look to the general symptoms, including quick pulse, general wasting of the fatty tissues, cough, especially in removing the clothing on going to bed, occasional night sweats, and repeated attacks of haemoptysis, we may most certainly come to the conclusion that our diagnosis will be correct if we call the disease con- sumption*. But when we have properly applied the stethoscope, or used immediate auscultation, a doubt no longer remains. I would dismiss the subject of phthisis, by hastily mentioning the treatment in general. Out-door exercise, when the weather is pleasant; good, rich diet, including meat of various kinds, also eggs, butter, and milk; I would give my patient but little medicine if he was comfortable; treat the urgent symptoms as they arise; if the cough troubles him much, give him a mild expectorant combined with an opiate--the latter will do more good than all the expectorants treated of in the U.S. Dispen- satory. My usual form for an expectorant in phthisis is, mor- phia sul. grs.vj., aqua 5'j-, shake and add syrup ipecac, syrup tolu aaSij., tinct. sanguinaria 5j., mix, and take one teaspoon- ful every 20 or 30 minutes, until the cough is relieved. When hectic symptoms make their appearance, I find much advantage from quinine with aromat. sul. acid, given in the stage of apy- rexia. The haemoptysis, I would treat with acetate plumbi et sul. morphia, nit. potash, miqute doses of tart. anti, et pot., or, sometimes, a teaspoonful of common salt, swallowed suddenly, will promptly arrest it. The patient should be kept quiet, with his head and shoulders raised up in bed, jugs of hot water to his feet, and sinapisms to the thoracic region; cold drinks should be used, and the patient cautioned not to exercise much, not to cough, only when involuntarily compelled to, and to avoid the habit which many phthisical patients have of hawking. My general treatment, if any is thought advisable, would, of course, be stimulating and tonic. I would permit the use of wine, good stock ale, and would not discourage the use of good cognac brandy and milk, made in the form of egg-nog or milk- punch. I have sometimes given, with apparent advantage, Nich's prep. cin. and ferri. But I would remark that I have but little confidence in any general treatment. Good warm clothing; flannels next to the skin, and the general hygienic rules which all physicians are supposed to understand, is the safest course, in my opinion, we can pursue in this dreadful disease. My own observation has taught me that patients treated on this plan have lived as long and suffered as little as those who have been the victims of Rushton & Clark's'spurious cod liver oil, or Prof. Churchill's phosphites. In leaving the subject of phthisis, I touch on other pulmo- nary diseases, and the first I mention is hooping-cough. This disease has prevailed somewhat as an epidemic for the last six or eight months; there have been no peculiarities attending it; most of the cases have been light and uncomplicated; but few cases have required the protracted visits of the medical at- tendant. My treatment in uncomplicated cases has been an expectorant composed of com. s. scillae, with syrup tolu, and tinct. opii camph. It has been rarely necessary to administer any laxative or cathartic. I am down on all specifics for this disease. The idea advanced by some of our medical men, that cochineal, belladonna, nitric acid, and several other vaunted remedies, will cut short the disease we are considering, is all bosh, as the politicians say. Treat the disease as a pulmonary, self-limited one, and our rational is correct. Complicated cases of hooping-cough are always serious, es- pecially when connected with diseases of the brain. Arachni- tis, with effusion, is apt to follow; then come spasms, general convulsions, and death. Our treatment should be shaped to meet these symptoms as they arise, and I would refer you all to diseases of the brain, for treatment under their proper heads. During the late epidemic I had the misfortune to have two such cases come under my care, both of which died. All the symptoms of arachnitis presented themselves before death, in- cluding severe convulsions, haemaplegia, blindness, etc., etc. Catarrhal fever, or acute bronchitis, prevails in this section of country every winter and spring. It is confined, principally, to children under eight or ten years of age. The prominent symptoms are dry, hacking cough, quick pulse, flushed face, dry and hot skin, white or yellow fur on the tongue, bowels usually constipated, slight mucus rale. If the disease is ne- glected it results in pneumonia; then we have added to the physical symptoms dullness on percussion, with complete bron- chophony, or in milder cases crepital rale. Occasionally I no- tice rusty colored sputa, though this latter is very rare. My treatment is simple and successful. I very rarely loose a pa- tient with it, and when this does occur it is when complicated with pneumonia, as the bowels are constipated, and the liver in an unhealthy state, which is evinced by the light or green col- ored operations. I give to a child, two or three years old, a laxative composed of grs. iv. hyd. clo. mite., rhei pulv. grs. xv., mag. calc. grs. v., mix and divide in chart No. 5, one every four hours, until the bowels move. After administering one or two of these powders 1 prescribe an expectorant composed of com. syrup scill. oiij., tinct. opi. camph. SSj., mix and give from one-quarter to one-third teaspoonful every hour and a half. If the child has a high grade of fever, which is generally the case, I give one or two drops of the tinct. veratrum in each alternate dose. This treatment, with very little variation, I have found very successful in these catarrhal or pulmonic diseases, usually styled catarrhal fever, pneumonia, or acute bronchitis of chil- dren. Adults are very rarely thus affected, if they have ca- tarrhal fever. It is usually severely complicated with pneumo- nia or acute bronchitis, and sometimes congestion of the lungs, making it a case of serious import, which should be met accord- ing to the type of the disease. The idea of treating all cases of pneumonia with quinine, or all cases with tart. anti, et pot., or with tint. ver. viride and venesection, epispastics, etc., is nothing but empiricism; and he who pursues such a course must expect to hear the church-bell tolling over his misfortunes, and he need not be surprised, in a short time, to find himself pre- paring to emigrate. Congestion of the lungs rarely appears as an epidemic. Let it appear either sporadically or epidemically, it is always a serious disease, and much depends upon the good judgment of the intelligent practitioner to combat it successfully. At one time, it might require the free use of the lancet, and upon this, nearly alone, should we depend; at another time, as we might expect, the free use of quinine, or the more diffusible stimulants, carb, ammo., or wine, or even good brandy; sinapisms, or epi- spastics should be freely applied over the lungs. When the lips become purple, the mind inactive, coma and somnolency making their appearance, the breathing becoming stertorous, let the pulse be either full and slow, or quick and feeble, you may soon expect dissolution. There is one symptom, indicat- ing nearly certain death, not confined entirely to pulmonary diseases, and that is the rising and falling of the pomurn Adami. When you observe this symptom, let other symptoms be as they may, you can quite safely pronounce your patient in, or not far from, artieulo mortis. Twenty-one years ago, when I first entered the profession, pleuritis was quite a frequent disease, but it has grown less and less frequent, until it is almost unknown. The lancet and opium were our sheet-anchors. The disease, in my practice, hardly known any more. Can any of you assign a reason why? In the winter of 1861-2, diphtheria made its appearance, not only in Henry County, but it became a general epidemic throughout a great portion of the United States, in fact, it was not confined alone to our hemisphere, but much of it prevailed in England, France, and many other portions of Europe. It is a disease sui generis, that is, it has many peculiarities belong- ing to itself, unlike any other disease. It has been said by some of our profession, that it is identical with scarlatina. I can see but little resemblance, letting alone the identity. The only thing in the disease that in the least assimilates scarlatina, is the inflammation of the tonsils and fauces, and this, to an acute observer, is easily diagnosed. Diphtheria is a sub-inflam- matory asthenic disease, in which the nervous and circulatory systems are seriously involved. The small and rapid action of the pulse would indicate some serious lesion to the circulation, some general breaking down of the whole system. The general symptoms are indicative of some blood-poison, and such it seems to be. As is the case with other epidemics, so with this! We know not the cause. Why the poison should spend itself locally upon the uvula, tonsils, palate, and, sometimes, the glottis, epi- glottis, and trachea, I leave to wiser men than I am to reason upon. That the nervous system participates largely in this disease, is known by the great debility and irritability, also by the condition the nervous system is left in, in the sequel; for it is not uncommon to find partial paralysis of the organs of de- glutition, and we occasionally find partial or complete amau- rosis. I have also, in a few instances in my practice, observed partial paraplegia. These sequelae, under a continued use of quinine, the ferruginous preparations, or the more powerful tonic and tetanic strychnia, have usually yielded, though I have found it necessary to continue them for weeks, and sometimes several months. As diphtheria is conceded by all to be an asthenic disease, and one of general debility, we would readily come to the con- clusion that a tonic and stimulating course would be the sine qua non in its treatment, and such is my belief. When first visiting patients with diphtheria, I immediately place them upon large doses of quinine every two hours--if the patient is a child six or seven years old, I would give it from 1| to 2 grs. at each dose, and alternate with half a spoonful of the saturated solu- tion of the chlorate of potash, requesting the patient to gargle the latter before swallowing each dose. If there is great debil- ity, as evinced by rapid pulse, general pallor, sordes, etc., I would use brandy in conjunction with the quinine. In 24 hours' time, I have seen very marked effects from this treatment, and I attribute the improvement principally to the quinine. I be- lieve it is worth everything else in the treatment of diphtheria. Of course I would not ignore the use of probangs and gargles, but would use the first very rarely indeed, and the latter pre- pared of some mild astringent or antiseptic. Tannic acid and capsicum, in the proportions of one drachm of each to one tea- cupful of water, makes a very good gargle; and if the patients cannot be taught to gargle, let them swallow it. In this way it will prove equally as effectual as if only used as a gargle, and not prove detrimental to the system. The treatment recommended when diphtheria first made its appearance, of swTabbing out the throat once, twice, or three times a-day with solution of argent, nitratum; muriated tinct. ferri; tinct. iodine; permanganate of potash, etc., etc., was, in my opinion a very bad one, and in many instances, I believe, resulted seriously. For if, by these means, we removed the pseu- do-membranous formation, it only left a raw, granulating sur- face, ready, if the system was in the condition, to very soon pro- duce another membrane probably worse than the one removed. Let me say to you, let the membrane alone until it becomes loose and nearly detached, and then, with a pair of forceps, we can easily remove it from the throat. The main point in the treatment of diphtheria is, to support the general system while the disease is preying upon it, and if we do our duty here, in most cases in a few days, we will have the happiness of visiting our patient in a convalescent state. Local external applica- tions I hold to be of but little value, a flannel cloth moistened with ammonia or camphor liniment, or a piece of fat pork sprinkled with pepper and salt, are probably as good as any- thing. In the winter of 18G3-4, cercbro-spinal meningitis made its appearance in our county. The symptoms are so well known to most, if not all of you, that it is not necessary for me to rehearse them. I had six cases of the disease, well-marked, and out of this number five of them died. Their ages varied from fifteen months old up to ten years. The one that recov- ered was a young man, aged about twenty-one. He had the most aggravated symptoms, including opisthotonos, trismus, coma, entire loss of sensibility, including loss of speech, etc., etc., and these symptoms remained for five or six days, and yet under treatment he recovered. I was called to three other patients during the time the epi- demic was prevailing, with severe pain in the head and cervical i region, face flushed, head drawn back, full and rapid pulse, de- lirium, etc. I immediately bled each one of them, and gave tinct. ver. veridi in full doses; at the same time ordered an active cathartic. Under this treatment they all recovered. The six cases first spoken of were not treated in this active an- tiphlogistic way, for the reason that their symptoms would not admit of such activity. They were treated with laxatives-- quinine, belladonna, mild opiates, carb, amo., etc., etc., with stimulating liniments, epispastics, etc., to the cervico-spinal region. Notwithstanding such authority as Dr. Davis has highly recommended--belladonna in the treatment of cerebro- spinal meningitis--I cannot see the rationality of it, and should feel very much indisposed again to try it. You may urge me for my treatment in this disease. I can frankly reply that I have none. I should treat mv cases according to the symptoms. If active symptoms prevail, indicating congestion of the brain, with full pulse, flushed face, etc., I should cer- tainly use the lancet and ver. viride; but if the type is asthen- ic, a tonic and stimulating treatment would look most plausible. I am firmly of the opinion, knowing the pathology of cerebro- spinal meningitis, that it will never be treated with much suc- cess. How can we successfully combat an inflammatory disease of the brain and spinal marrow, and their membranes, espe- cially when it is an epidemic, and supposed to originate from some unknown aerial cause? Epidemics of all kinds are usually more virulent than when the same disease occurs sporadically, and this remark applies especially to the one under consider- ation. Typhoid fever, which has prevailed in Illinois for a great number of years, and has been so very fatal in many localities, has nearly disappeared from this section of country. How long this immunity may continue none of us can tell. I have seen but five well-marked cases of typhoid fever in the last two years. Two of them were patients of my friend, Dr. Scott. They came under my care for ten or twelve days, during his short absence in Minnesota. They were genuine cases, as marked by petechia, sudamina, tympanites, hebetude, loss of memory, quick pulse, stupor, haemorrhage, etc., etc.; in the sequal, abscess occurred in the perinial region. The other cases I saw in consultation with Dr. Smead, of Lafayette, in Stark County. One of them had haemorrhage from the bow- els, and immediately after convalesced. My treatment in ty- phoid fever is quite simple. If the case is mild, I simply give spts. mindereri and nitre; if the pulse is quick and full I would add two or three drops of ver. viride every two or three hours. When diarrhoea makes its appearance, I would use an emulsion of spts. turpentine, with tinct. opii; would continue this treatment through the disease if the diarrhoea remains. The patient should be well supported on milk-broth, wine, etc.; should the vital forces seem to be giving away, quinine, brandy, etc., are indicated. Typhoid fever is a self-limited disease, and the idea of breaking it up in a few days is untrue. Many empyrics, when this disease is epidemic, call nearly everything typhoid, and hence establish a reputation for treating this dis- ease. I would particularly urge upon the young physician not to give much cathartic medicine. If a laxative is imperatively d 'inanded, (which is rarely the case,) give about half a tea- spoonful of oleun ricini, with from ten to twenty drops of oleum terebinth.; this quantity will rarely fail to operate sufficiently thorough. Typhoid fever being an enteric disease, or dothi- nenteritus, we can easily conceive that a cathartic or laxative would move the bowels very readily, and such is the case. I never gives laxatives so long as the patient feels easy and com- fortable, if the bowels should remain unopened for several days. A species of stomatitis has prevailed as an epidemic since early in the spring, confined to no particular age. It produces ulceration about the roots of the teeth, on the palate, tongue, and, in fact, all over the mucous membrane of the mouth. In some cases the system seems to sympathize, producing a loss of tone, strength, and approaching anaemia. In such cases I have used quinine and the preparations of iron. Locally I have found more good derived from penciling the gums and ulcers on the cheeks with muriated tincture of iron, than from anything else, though I have used, with much benefit, sul. cupri and nitrate of silver. Some cases I treated with chlorate of potash, as a wash, and gave it at the same time as a blood pu- rifier. It has not only acted as an epidemic, but has seemed to me to be contagious, spreading from one member of the family to another, by using the same drinking utensil, or from the parents kissing their children. Many cases have been stub- born, but all have yielded to the above treatment. It remains for me to treat of two more classes of diseases which prevail in our county occasionally as epidemics, which I shall treat of very succinctly (as my essay has already grown too long). I allude to the exanthemata and diseases of the stomach and boivels. In the winter of 1862-3, rubeola prevailed very generally, as an epidemic, not only in Henry County, but, I believe, very generally throughout the State. I think I must have treated more than a hundred patients, and, amongst that number, sev- eral in my own family. The type was remarkably mild, and, consequently, my treatment, to correspond, was equally simple. Where no complications existed, I simply prescribed cool drinks, ad libitum, equal temperature of the room, and the patients to remain indoors for a week or ten days- after the exanthema dis- appeared. I rarely gave even a dose of sul. magnesia. When the catarrhal symptoms were troublesome, I gave a simple ex- pectorant, composed of com. syrup scillee and tinct. opii camp. As a general thing, I discard the idea of prescribing laxatives in rubeola, for the tendency, in the sequel, is diarrhoea in nearly all cases. Under this kind of treatment, I had the satisfaction of consoling myself that all my patients recovered, but one, and he was a boy of 10 or 12 years old, who had been subject to epilepsy from early infancy. Congestion of the brain and, finally, arachnitis made its appearance, and death soon closed the scene. We have occasional cases of variola every year, but our peo- ple are so well protected by vaccination that we need have no fears of its appearing as an epidemic. My treatment is very similar to what it is in rubeola, when uncomplicated, and, con- sequently, need not be rehearsed. 1 would 'especially enjoin upon all the profession the propriety of urging upon the people the benefit of vaccination and re-vaccination, until the system seems to be insusceptible to its effects. This course being rigidly pursued, it would seem that small-pox, in a few years, would be unknown. Would it not be well to urge upon our representatives the propriety of enacting a law compelling the vaccination of all persons? Scarlatina has not prevailed as an epidemic in this section of country since the years 1857--8--9. It then appeared in a ma- lignant form, and many died. I see sporadic cases of it every year, and it is at the present time prevailing to some extent, though in a very mild form. My treatment is remarkably sim- ple, and, since I have been using it, very successful. I would urge upon the members of this Society to give it a fair trial. When called, I order a solution of carb, of ammo, in doses of from 3 grs. to 5 or 7, according to the age of the patient, every hour and a-half or two hours. This treatment I give, regard- less of the rapidity of the pulse, or the redness of the surface, and I must say, that my success has been unequalled since I commenced this mode of treatment. I use gargles of capsicum and chloride of soda, with vinegar and water, or simply a satu- rated solution of chlorate of potash, discarding the use of the swab or probang. Diarrhoeas, with adults and children, make their annual sum- mer and autumnal visits, but their treatment varies so much that time will not permit me to treat of them. Dysentery prevailed as an epidemic in the summer and fall of 1864. In adults, I usually give at the commencement, a good-sized dose of sul. magnesia; if this fails to check the dis- ease, I order a powder composed of sul. morphia, acetate plurabi, and minute doses of calomel given every three or four hours, alternating every day or two with a portion of oleum ricini or sul. magnesia. This treatment will rarely fail to cut the disease short. The treatment in children and infants is not so successful, and I would respectfully refer you to the books. I have seen infantile dysentery as fatal as epidemic cholera, ac- cording to the number of cases attacked. I know of no treat- ment that has been very successful in this fatal form of dysen- tery, and would respectfully urge this Society to give their views on this part of my report. The dreaded epidemic, cholera, has not made its appearance in our village this season, and I have heard of but one case in the county, and that occurred at Galva. The gentleman came through Chicago during the night, arrived in Galva in the morning, and died the same night, or early the next morning. Not having treated any cases of cholera during the present epidemic, I am poorly prepared to give my views; but, notwith- standing this, probably I am as well prepared as many of you, and, possibly, as well as many who have been treating a great number of cases. Who of you would apply ice bags to your patients in collapse with this disease? Who of you w'ould give castor-oil to your patients when the bowels were already pro- fusely running off and the stomach rejecting everything that is swallowed? Who of you would expect to cure your patients when in a state of collapse by the administration of spirits of turpentime and strychnia? And yet such is the treatment recommended by some of the most learned men in our profes- sion. In brief, I have no time to dwell upon this King of Ter- rors. I would treat my patients, if found in the cholerine or diarrhoea stage, with small portions of calomel, acetate of lead, and sul. morphine, given every two or three hours, until the diarrhoea was arrested; would order strict quietude and rest, in the recumbent position; very light diet, and small quantity of drinks of any kind--probably small quantities of iced-water, or even ice itself might be considered preferable. A treatment of this kind will usually succeed, but if we are so unfortunate as to lose this valuable time, or our patient sinks at once into vomiting, purging, cramps, and collapse, what is to be done? "Echo answers, what?" Now the critical time has come, and most of such cases die, regardless of the various treatments which have been proposed and used. Opium, or sul. morphia, so valuable in the first, or diarrhoea, stage, now is of much less value; if it is now given in large doses, or small ones frequently repeated, we produce comatose symptoms, loss of general vital force, a predisposition to arachnitis, and it also enhances the chances for a consecutive fever being set up, in case the patient rallies from collapse. In this stage, I would give tinct. capsicum, tinct. camphor, ess. mentha, ss., and chloroform, combined with a very small quantity of tinct. opii; this preparation I would administer after every spell of vomiting, and if the vomiting ceased, I would give it as often as the cramps, diarrhoea, and pain seemed to indicate. I should be very careful not to produce the nar- cotic effects of this opiate. Stimulating injections might, with propriety, be given. Sinapisms and dry warmth should be used freely. I would give but little, if any water, preferring my patients should use ice in small *pellicles to quench the raging thirst. |
PMC10000009 | ARTICLE VII. A CASE OF ELEPHANTIASIS--SUCCESSFUL RECOVERY. By R. DEXTER, M.D., Chicago. Carrie G., cet. 20, an inmate of the Erring Women's Refuge, gives the following history of herself and the outgrowth':-- Is a native of Rochester, N.Y.; has resided in the southern part of Illinois several years. A little more than a year ago, she observed that the external labia were somewhat increased in size, and presented an unusually rough appearance. The rapid growth of the parts induced her to seek medical advice. The external application of iodine was prescribed, together with the exhibition of internal remedies, but without any beneficial results. The advice of another physician was sought, but change of treatment brought no relief. Our attention was called to the case about two months since. Found the external labia enormously hypertrophied, presenting every appearance and symptom of elephantiasis. Each lip was about five inches long, and one and a-balf inches through. It seemed that but one alternative remained, viz.:--excision. The counsel of a medical gentleman was obtained, who fully con- curred in the opinions above given. Accordingly, on the 21st of December last, we removed the entire mass. Hemorrhage was controlled during the operation by tying the arteries as they were divided. There were four on each side, but were not enlarged. Recovery will be perfect, with but trifling deformity. |
PMC10000010 | QUINCY MEDICAL SOCIETY. The semi-annual meeting of the Quincy Medical Society was held-at the office of Dr. Zimmermann, in Quincy, Nov. 18th, 1866. A quorum being present, the President, Dr. C. A. W. Zim- mermann, called the meeting to order. The proceedings of the annual meeting having been read and approved, the President proceeded to deliver his able and elaborate essay upon Bright's Diseasei The manner in which he treated the subject may be inferred from the following extract from the exordium:-- "I discharge this obligation with no inconsiderable degree of pleasure, inasmuch as this subject is classed among the most interesting in pathology; and I intend discussing it by strictly following the medical literature as far as it deals with facts, and particularly as far as it touches the anatomy of this dis- ease, and eschews hypothesis; while I shall sometimes mention my own experience, which is naturally .enough based on obser- vations in view of the sick couch, and the therapeutics of the disease, which are without exception open for discussion." The President entered at length into the consideration of the causes, pathology,- diagnosis, prognosis, and treatment of Bright's disease. On 'motion, resolved, that the thanks of this Society be ten- dered to the President for his able essay, and that a copy is hereby requested for publication. rhe Secretary then read the history and treatment of two cases which had come under his observation since the annual meeting:-- Case I. June 21st, 1866. Was requested to visit Mrs. S., aged 25 years. I learned from her that she had been confined to the bed seven weeks, and had vomited, most of the time, every hour. The matter ejected is described as green and yel- low; urine natural in quantity, specific gravity 1.011, acid, not albuminous. The last menstrual period occurred about four months since, as near as she recollects. She is greatly emaci- ated, very feeble, and takes but little nourishment. The mamma is flaccid and wasted, no change has occurred in the nipple or in the areola about it. On vaginal examination, the uterus was found enlarged, and the os hard and fissured. Prescribed one teaspoonful of Ellis' wine of pepsin in a wineglass of water three times a-day, and one tablespoonful of lime-water and two of milk every two hours, with beef-tea for nourishment. 22d. The symptoms not materially changed. Directed the treatment to be continued. 23d. Patient no better; has vomited every hour, anti has not slept during the night. A consultation was agreed, upon, and Dr. L. II. Baker of this city called. After a careful ex- amination, it was decided that there is no evidence of a living foetus in the uterus, but even if there were, the dangerous con- dition of the mother demands interference. A speculum was introduced and the os brought to view, and a sound passed into the uterus three inches, no fluid followed its withdrawal. A sponge tent was then passed into the os and the patient directed to take the medicine as before. 21f,th. The patient has not vomited as much as formerly, and has taken more nourishment. The tent is not to be found in the vagina, and cannot be seen in the os through the speculum, and the supposition is entertained that it may have passed away unobserved. Introduced a larger tent, and directed treatment to be continued. 25th. The vomiting ceased during the day and returned at night. On examination, the tent cannot be found; introduced another with a small cord attached to it. 26th, 9 o'clock A.M. Has vomited less than formerly. Re- moved the tent and introduced another. 2 o'clock P.M. Quite an offensive discharge has occurred, and the patient complains of pain in the back. Removed the tent and found the os con- siderably dilated; on passing the finger, the two tents first used were found within the os and removed. 27. The patient is more quiet and vomits less. Continue the medicine. 28. The remains of a foetus passed away during the night; it is six inches in length, and weighs one ounce troy; it is much wasted; the skin is wanting; the head collapsed; the walls of the chest and abdomen wanting; no trace is found of the lungs, diaphragm, stomach, or intestines; the heart, liver, and kidneys were observed in their natural, positions. The foetus has, doubt- less, been dead several weeks, and the placenta probably been absorbed, as it has not passed away, and cannot be discovered on examination. No flooding has occurred. Prescribed 5 grs. of pulvis ergot, to be taken every three hours, and a teaspoon- ful of a saturated solution of-sulphite of soda three times a-day. 30th. The vomiting continues frequently, and is supposed to be excited by the medicine, which was discontinued, and the Wine of pepsin and lime-water resumed, and milk freely taken for nourishment. July 1st. The vomiting has now ceased, and the patient's condition satisfactory in every respect. No unfavorable symp- toms afterwards occurred, and the patient made a very rapid recovery. Remarks.--The irritation of a dead foetus in the uterus has been referred to by authors as one of the causes of abortion; but it is evident that- it does not always give rise to this result. Tyler Smith refers to a case, in which the foetus died at the fourth month, but was not expelled until the full term. As the sound of the foetal heart cannot ordinarily be heard until after the fourth month, we have no certain evidence by which we can infer the death of the foetus. In the cases which have come under my observation, I have found the mamma flaccid, the nipple and its areola without any of the ordinary indications of pregnancy, the neck of the uterus harder, and the os more pat- ulous than usual in that condition. It seems desirable that more careful and extended observations be made, as to the symptoms which indicate the presence of a blighted foetus in utero. In this case, if its presence had been known at an ear- lier period, the patient might have been saved several w'eeks of distressing illness. Case II. Was called to visit Mr. B., aged 35, in consulta- tion with Dr. L. H. Baker, of this city, September 3d, 1866, and found the patient suffering from narcotism. The following is the history of the case, as given by the attendants:-- The attention of his wife was called to him by an unusual snoring, and, on going into his room, she found him quite in- sensible, and nearly black in the face and neck. Supposing him to be in a fit, she attempted to give him some wine, spirits of camphor, and other restoratives, of which he swallowed but little, and that at the risk of strangling. Just at that time, she found in his pocket an empty bottle, labelled laudanum. Dr. Baker was called immediately, and gave him, 10 minutes before 4 o'clock, 20 grs. of sulphate of zinc, and repeated the dose in 5 minutes, without effect. I arrived 25 minutes after the emetic had been given. Not having had its effect, it was thought best to use the stomach pump. About one quart of warm water was thrown by it into the stomach and immediately pumped out with the whole of its contents, which gave a strong odor of laudanum. This was repeated three times, and about a gallon of water, in all, was used, the last of which was re- turned nearly clean and devoid of smell of laudanum. During this time, the patient remained entirely insensible, with the eyes closed, the pupils contracted, respiration slow and stertor- ous, pulse slow, with other symptoms of narcotism. After thoroughly emptying the stomach, a galvanic' battery was used for nearly two hours, one pole applied to the upper part of the spine and the other to the front of the chest. About one hour after the stomach was evacuated, and while using the battery, the patient began to sink, the respiration became re- duced to four in a minute. Dr. Baker resorted to artificial JL Uopi 1 cLLlUlL cltlvlltlUll LU L11C UcLLLtH J ) WHICH Wd>>0 KLj/L Lip Uj by Hall's method, about a-quarter of an hour, until an improve- ment occurred in the respiration, which continued until the patient was fully restored. No unpleasant symptoms followed excepting vomiting, which occurred at intervals during the night. It was subsequently ascertained that the patient took two ounces of tincture of opium at 10 o'clock A.M., and also two ounces at 1 o'clock P.M; and that he was not in the habit of taking opium or laudanum; that he took it for a diarrhoea, which he had for three or four days. The apothecary says the tincture of opium sold the patient contained just one-half the officinal quantity of opium. On motion, Dr. J. F. McCormic was appointed essayist for the next meeting. On motion, Dr. A. Niles was appointed delegate to the State Society. On motion, resolved, that the proceedings of this meeting be published in the Chicago Medical Examiner, and an abstract of them in our city papers. ADDISON NILES, Secy. |
PMC10000014 | Rev Bras Epidemiol Rev Bras Epidemiol rbepid Revista Brasileira de Epidemiologia (Brazilian Journal of Epidemiology) 1415-790X 1980-5497 Associacao Brasileira de Saude Coletiva 10.1590/1980-549720230021 00420 Artigo Original Emergency department use and Artificial Intelligence in Pelotas: design and baseline results Uso servicos de servicos de urgencia e emergencia e Inteligencia Artificial em Pelotas: protocolo e resultados iniciais Delpino Felipe Mendes Conceptualization Formal analysis Methodology Writing - original draft Writing - review & editing I Figueiredo Lilian Munhoz Methodology Writing - review & editing I Costa Andria Krolow Methodology Writing - review & editing I Carreno Iona Methodology Writing - review & editing I da Silva Luan Nascimento Methodology Writing - review & editing I Flores Alana Duarte Methodology Writing - review & editing I Pinheiro Milena Afonso Methodology Writing - review & editing I da Silva Eloisa Porciuncula Methodology Writing - review & editing I Marques Gabriela Avila Methodology Writing - review & editing I Saes Mirelle de Oliveira Methodology Writing - review & editing I Duro Suele Manjourany Silva Methodology Writing - review & editing I Facchini Luiz Augusto Methodology Writing - review & editing I Vissoci Joao Ricardo Nickenig Methodology Writing - review & editing II Flores Thayna Ramos Methodology Writing - review & editing I Demarco Flavio Fernando Methodology Writing - review & editing I Blumenberg Cauane Methodology Writing - review & editing I Chiavegatto Alexandre Dias Porto Filho Methodology Writing - review & editing III da Silva Inacio Crochemore Methodology Writing - review & editing I Batista Sandro Rodrigues Methodology Writing - review & editing IV Arcencio Ricardo Alexandre Methodology Writing - review & editing V Nunes Bruno Pereira Formal analysis Methodology Writing - review & editing I Universidade Federal de Pelotas - Pelotas (RS), Brazil. Duke University School of Medicine - Durham (NC), United States. Universidade de Sao Paulo - Sao Paulo (SP), Brazil. Universidade Federal de Goias - Goiania (GO), Brazil. Universidade de Sao Paulo - Ribeirao Preto (SP), Brazil. CORRESPONDING AUTHOR: Felipe Mendes Delpino. Rua Gomes Carneiro, 1, Centro, CEP: 96010-610, Pelotas (RS), Brazil. E-mail: [email protected] CONFLICT OF INTERESTS: nothing to declare 10 3 2023 2023 26 e23002123 9 2022 05 1 2023 09 1 2023 Este e um artigo publicado em acesso aberto sob uma licenca Creative Commons RESUMO Objetivo: To describe the initial baseline results of a population-based study, as well as a protocol in order to evaluate the performance of different machine learning algorithms with the objective of predicting the demand for urgent and emergency services in a representative sample of adults from the urban area of Pelotas, Southern Brazil. Methods: The study is entitled "Emergency department use and Artificial Intelligence in PELOTAS (RS) (EAI PELOTAS)" ). Between September and December 2021, a baseline was carried out with participants. A follow-up was planned to be conducted after 12 months in order to assess the use of urgent and emergency services in the last year. Afterwards, machine learning algorithms will be tested to predict the use of urgent and emergency services over one year. Results: In total, 5,722 participants answered the survey, mostly females (66.8%), with an average age of 50.3 years. The mean number of household people was 2.6. Most of the sample has white skin color and incomplete elementary school or less. Around 30% of the sample has obesity, 14% diabetes, and 39% hypertension. Conclusion: The present paper presented a protocol describing the steps that were and will be taken to produce a model capable of predicting the demand for urgent and emergency services in one year among residents of Pelotas, in Rio Grande do Sul state. RESUMO Objetivo: Descrever os resultados iniciais da linha de base de um estudo de base populacional, bem como um protocolo para avaliar o desempenho de diferentes algoritmos de aprendizado de maquina, com o objetivo de predizer a demanda de servicos de urgencia e emergencia em uma amostra representativa de adultos da zona urbana de Pelotas, no Sul do Brasil. Metodos: O estudo intitula-se "Emergency department use and Artificial Intelligence in PELOTAS (RS) (EAI PELOTAS)" ). Entre setembro e dezembro de 2021, foi realizada uma linha de base com os participantes. Esta previsto um acompanhamento apos 12 meses para avaliar a utilizacao de servicos de urgencia e emergencia no ultimo ano. Em seguida, serao testados algoritmos de machine learning para predizer a utilizacao de servicos de urgencia e emergencia no periodo de um ano. Resultados: No total, 5.722 participantes responderam a pesquisa, a maioria do sexo feminino (66,8%), com idade media de 50,3 anos. O numero medio de pessoas no domicilio foi de 2,6. A maioria da amostra tem cor da pele branca e ensino fundamental incompleto ou menos. Cerca de 30% da amostra estava com obesidade, 14% com diabetes e 39% eram hipertensos. Conclusao: O presente trabalho apresentou um protocolo descrevendo as etapas que foram e serao tomadas para a producao de um modelo capaz de prever a demanda por servicos de urgencia e emergencia em um ano entre moradores de Pelotas, no estado do Rio Grande do Sul. Keywords: Machine learning Chronic diseases Multimorbidity Urgent and emergency care Palavras-chave: Aprendizado de maquina Doencas cronicas Multimorbidade Urgencia e emergencia pmcINTRODUCTION Chronic diseases affect a large part of the population of adults and older adults, leading these individuals to seek urgent and emergency care. The implementation in 1988 of the Unified Health System (SUS) resulted in a model aimed at prevention and health promotion actions based on collective activities 1 - starting at Basic Health Units (UBS). There is also the National Emergency Care Policy, which advanced in the construction of the SUS, and has as guidelines universality, integrity, decentralization, and social participation, alongside humanization, the right of every citizen 2 . In a study that evaluated the characteristics of users of primary health care services in a Brazilian urban-representative sample, it was found that the vast majority were women and part of poorer individuals, in addition to almost 1/4 of the sample receiving the national income distribution program (family allowance) 3 . Brazil is a country highly unequal in socioeconomic terms; approximately 75% of the Brazilian population uses the SUS and depends exclusively on it, and do not have private health insurance 4,5 . Individuals with multimorbidity are part of the vast majority who seek urgent and emergency services 6 . Multimorbidity is a condition that affects a large part of the population 7 , especially older adults 7 . In addition, the association of multimorbidity with higher demand for emergency services is a challenge to appropriately manage and prevent these problems 8,9 . Innovative approaches may allow health professionals to provide direct care to individuals who are more likely to seek urgent and emergency services. The use of artificial intelligence can make it possible to identify and monitor a group of individuals with a higher probability of developing multimorbidity. In this context, machine learning (ML), an application of artificial intelligence, is a promising and feasible tool to be used on large scale to identify these population subgroups. Some previous studies have demonstrated that ML models can predict the demand for urgent and emergency services 10,11 . Besides, a systematic review showed that ML could accurately predict the triage of patients entering emergency care 12 . However, in a search for studies in Brazil, we found no published article on the subject. In Brazil, urgent and emergency services are a fundamental part of the health care network, ensuring timely care in cases of risk to individuals' lives 9 . Urgent and emergency services are characterized by overcrowding and high demand. In addition, with the current pandemic of COVID-19, updated evidence on the characteristics of the users seeking these services is timely and necessary. The objective of this article was to describe the initial baseline results of a population-based study, as well as a protocol in order to evaluate the performance of different ML algorithms with the objective of predicting the demand for urgent and emergency services in a representative sample of adults from the urban area of Pelotas. METHODS The present cohort study is entitled "Emergency department use and Artificial Intelligence in PELOTAS-RS (EAI PELOTAS)" ). The baseline was conducted between September and December 2021, and a follow-up was planned to be conducted 12 months later. We utilized the cross-sectional study to measure the prevalence of urgent and emergency care and the prevalence of multimorbidity, in addition to other variables and instruments of interest. The prospective cohort design intends to estimate the risk of using and reusing urgent emergency services after 12 months. Contact information, collected to ensure follow-up, included telephone, social networks, and full address. In addition, we also collected the latitude and longitude of households for control of the interviews. Study location and target population The present study was conducted in adult households in the Pelotas, Rio Grande do Sul (RS), Southern Brazil. According to estimates by the Brazilian Institute of Geography and Statistics (IBGE) in 2020, Pelotas had an estimated population of 343,132 individuals ). Figure 1 shows the location of the city of Pelotas in Brazil. Figura 1. Map of Brazil highlighting the city of Pelotas (RS). Source: Pelotas has a human development index (HDI) of 0.739 and a gross domestic product per capita (GDP) of BRL 27,586.96 ). The municipality has a Municipal Emergency Room that operates 24 hours a day, seven days a week, and serves about 300 patients a day, according to data provided by the unit. Criteria for inclusion and exclusion of study participants We included adults aged 18 years or older residing in the urban area of Pelotas. Children and individuals who were mentally unable to answer the questionnaire were not included in the sample. Sample calculation, sampling process, and data collection The sample size was calculated considering three objectives. First, to determine the sample size required to assess the prevalence of urgent and emergency services use, it was considered an estimated prevalence of 9%, with+-two percentage points as a margin of error and a 95% confidence level 13 , concluding that 785 individuals would be necessary. Second, for multimorbidity prevalence, an estimated prevalence of 25%, with +- three percentage points as a margin of error and a confidence level of 95% was used 14,15 ; reaching again, a total of 785 individuals needed. Finally, for the association calculations, similar studies in Brazil were assessed, and the following parameters were considered: significance level of 95%, power of 80%, exposed/unexposed ratio of 0.1, percentage of the outcome in the unexposed 20%, and a minimum prevalence ratio of 1.3. With these parameters, 5,104 individuals would be necessary to study the proposed associations. Adding 10 to 20% for losses and/or refusals, the final sample size would be composed of 5,615-5,890 participants. The process to provide a population-based sample was carried out in multiple stages. The city of Pelotas has approximately 550 census tracts, according to the last update estimates provided by IBGE in 2019. From there, we randomly selected 100 sectors. Since the sectors vary in size, we defined a proportional number of households for each. Thus, it was estimated that, in total, the 100 sectors had approximately 24,345 eligible households. To interview one resident per household, we divided the total number of households by the sample size required, which resulted in 4.3. Based on this information, we divided each of the 100 sectors by 4.3 to reach the necessary number of households for each sector. One resident per household was interviewed, resulting in a total of 5,615 households. If there was more than one eligible resident, the choice was made by a random number generator application. Residents were placed in order, a number was assigned for each one, and one of them was selected according to the result of the draw. The first household interviewed in each sector was selected through a draw, considering the selected jump (4.3 households). Trades and empty squares were considered ineligible, and thus, the next square was chosen. Due to a large number of empty houses, it was necessary to select another 50 sectors to complete the required sample size. The additional households were drawn according to the same methodological criteria as the first draw to ensure equiprobability. Data collection instrument We collected the data with the Research Electronic Data Capture (REDCap), a data collection program using smartphones 16,17 . Experienced and trained research assistants collected the data. The questionnaire from EAI PELOTAS was prepared, when possible, based on standardized instruments, including questions about chronic diseases, physical activity, food security, use of urgent and emergency services, functional disability, frailty syndrome, self-perception of health, COVID-19, in addition to sociodemographic and behavioral questions. Supplementary Table 1 shows the instruments utilized in the present study. Table 1. First descriptive results and comparison with a population-based study. Characteristics EAI PELOTAS* PNS 2019+ Crude % (95%CI) Survey design % (95%CI) % (95%CI) Mean age, years 50.3 (49.9-50.8) 46.2 (45.5-47.0) 46.7 (45.9-47.5) Mean number of household people 2.6 (2.5-2.7) 2.7 (2.6-2.8) 3.0 (2.9-3.1) Female (%) 66.8 (65.6-68.0) 54.2 (52.4-55.6) 54.1 (51.7-56.4) Skin color (%) White 78.2 (77.1-79.2) 77.3 (74.9-79.5) 76.8 (74.6-78.7) Black 15.0 (14.1-16.0) 15.3 (13.5-17.3) 8.3 (7.0-9.8) Brown 6.1 (5.5-6.7) 6.7 (5.7-7.9) 14.5 (12.9-16.3) Other 0.7 (0.5-1.0) 0.7 (0.4-1.1) 0.4 (0.2-0.8) Schooling (%) Incomplete elementary school or less 35.7 (34.5-37.0) 31.3 (28.6-34.2) 30.2 (28.1-32.4) Complete elementary school/incomplete high school 16.2 (15.3-17.2) 16.4 (15.1-17.7) 15.7 (14.0-17.5) Complete high school/incomplete higher education 33.5 (32.3-34.7) 37.6 (35.6-39.6) 36.9 (34.6-39.2) Complete higher education or more 14.6 (13.7-15.5) 14.7 (12.4-17.4) 17.2 (15.7-18.9) *n=5.722; +n=3.002. PNS: Brazilian National Health Survey. PNS 2019 includes residents (selected to interview) from the urban area from the Rio Grande do Sul State; Survey design: weighted for primary unit sampling and post-weight estimates Dependent variables The use of urgent and emergency services was assessed on a baseline using the following question: "In the last 12 months, how many times have you sought urgent and emergency services, such as an emergency room?". This was followed by the characterization of the service used, city of service, frequency of use, and referral after use. One year after the study baseline, we will contact again the respondents to inquire about the use of urgent and emergency care services (number of times and type of service used). Independent variables We assessed multimorbidity as the main exposure using a list of 22 chronic diseases and others (asthma/bronchitis, osteoporosis, arthritis/arthrosis/rheumatism, hypertension, diabetes, cardiac insufficiency, pulmonary emphysema/chronic obstructive pulmonary disease, acute kidney failure, Parkinson's disease, prostate disease, hypo/hyperthyroidism, glaucoma, cataract, Alzheimer's disease, urinary/fecal incontinence, angina, stroke, dyslipidemia, epileptic fit/seizures, depression, gastric ulcer, urinary infection, pneumonia, and the flu). The association with urgent and emergency services will be performed with different cutoff points, including total number, >=2, >=3, and combinations of morbidities. We will also perform network analyzes to assess the pattern of morbidities. Other independent variables were selected from previous studies in the literature 18-21 , including demographic, socioeconomic information, behavioral characteristics, health status, access, use and quality of health services. Data analysis We will test artificial intelligence algorithms, ML, to predict the use of urgent and emergency services after 12 months. The purpose of ML is to predict health outcomes through the basic characteristics of the individuals, such as sex, education, and lifestyle. The algorithms will be trained to predict the occurrence of health outcomes, which will contribute to decision-making. With a good amount of data and the right algorithms, ML may be able to predict health outcomes with satisfactory performance. The area of ML in healthcare has shown rapid growth in recent years, having been used in significant public health problems such as diagnosing diseases and predicting the risk of adverse health events and deaths 22-24 . The use of predictive algorithms aims to improve health care and support decision-making by health professionals and managers. For the present study, individuals' baseline characteristics will be used to train popular ML algorithms such as Support Vector Machine (SVM), Neural Networks (ANNs), Random Forests, Penalized Regressions, Gradient Boosted Trees, and Extreme Gradient Boosting (XGBoost). These models were chosen based on a previous review in which the authors identified the most used models in healthcare studies 25 . We will use the Python programming language to perform the analyzes. To test the predictive performance of the algorithms in new unseen data, individuals will be divided into training (70% of patients, which will be used to define the parameters and hyperparameters of each algorithm) and testing (30%, which will be used to test the predictive ability of models in new data). We will also perform all the preliminary steps to ensure a good performance of the algorithms, especially those related to the pre-processing of predictor variables, such as the standardization of continuous variables, separation of categorical predictors with one-hot encoding, exclusion of strongly correlated variables, dimension reduction using principal component analysis and selection of hyperparameters with 10-fold cross-validation. Different metrics will evaluate the predictive capacity of the models, the main one being the area under the receiver operating characteristic (ROC) curve (AUC). In a simplified way, the AUC is a value that varies from 0 to 1, and the closer to 1 the better the model's predictive capacity 26 . The other metrics will be F1-score, sensitivity, specificity, and accuracy. As measures of model fit, we will perform hyperparameters and balancing fit, as well as K-fold (cross-validation). COVID-19 The current pandemic, caused by the SARS-CoV-2 virus, has brought uncertainty to the world population. Although vaccination coverage is already high in large parts of the population, the arrival of new variants and the lack of other essential measures to face the pandemic still create uncertainty about the effects of the pandemic on people. General questions about symptoms, tests, and possible effects caused by coronavirus contamination were included in our baseline survey. We will also use SARS-CoV-2-related questions to evaluate the performance of ML algorithms. In September 2021, restrictive measures were relaxed due to a decrease in COVID-19 cases in Pelotas, allowing the study to begin. A vaccination passport was required from the interviewers to ensure the safety of both participants and interviewers. In addition, all interviewers received protective equipment against COVID-19, including masks, face shields, and alcohol gel. Finally, the interviewers were instructed to conduct the research in an open and airy area, ensuring the protection of the participants. Quality assurance and control The activities to allow for control and data quality were characterized by a series of measures aimed at ensuring results without the risk of bias. Initially, we developed a research protocol, followed by an instruction manual for each interviewer. Thereafter, interviewers were trained and standardized in all necessary aspects. REDCap was also important to garanteee the control and quality of responses as the questions were designed using validation checks according to what was expected for each answer. Another measure that ensured the control of interviews was the collection of latitude and longitude of households, which was plotted by two members of the study coordination weekly on maps, to ensure that the data collection was performed according to the study sample. With latitude and longitude data, it is also intended to carry out spatial analysis articles with techniques such as sweep statistics and Kernel. The database of the questions was checked daily to find possible inconsistencies. Finally, two members of the study coordination made random phone calls to 10% of the sample, in which a reduced questionnaire was applied, with the objective of comparing the answers with the main questionnaire. Ethical principles We carried out this study using free and informed consent, as determined by the ethical aspects of Resolution No. 466/2012 of the National Council of the Ministry of Health and the Code of Ethics for Nursing Professionals, of the duties in Chapter IV, Article 35, 36 and 37, and the prohibitions in chapter V, article 53 and 54. After identifying and selecting the study participants, they were informed about the research objectives and signed the Informed Consent Form (ICF). The project was referred to the Research Ethics Committee via the Brazilian platform and approved under the CAAE 39096720.0.0000.5317. Schedule Initially, we conducted a stage for the preparation of an electronic questionnaire at the beginning of 2021. In February 2021, we initiated data collection after preparing the online questionnaire. The database verification and cleaning steps occurred simultaneously with the collection, and continued until March 2022. After this step, data analysis and writing of scientific articles began. RESULTS First descriptive results and comparison with a population-based study Of approximately 15,526 households approached, 8,196 were excluded -- 4,761 residents were absent at the visit, 1,735 were ineligible, and 1,700 were empty . We identified 7,330 eligible participants, of which 1,607 refused to participate in the study, totalizing 5,722 residents. Comparing the female gender percentage of the refusals with the completed interviews, we observed a slightly lower prevalence with 63.2% (95%CI 60.7-65.5) among the refusals, and 66.8% (95%CI 65.6-68.0) among the complete interviews. The mean age was similar between participants who agreed to participate (50.3; 95%CI 49.9-50.8) and those who refused (50.4; 95%CI 49.0-51.9). Figura 2. Flowchart describing the sampling process. To evaluate the first descriptive results of our sample, we compared our results with the 2019 Brazilian National Health Survey (PNS) database. The PNS 2019 was collected by the IBGE in partnership with the Ministry of Health. The data are in the public domain and are available in the IBGE website ). To ensure the greatest possible comparability between studies, we used only residents of the urban area of the state of Rio Grande do Sul, aged using the command svy from Stata, resulting in 3,002 individuals (residents selected to interview). We developed two models to compare our data with the PNS 2019 survey: Crude model (crude results from the EAI PELOTAS study, without considering survey design estimates); Model 1 using survey design: primary sampling units (PSUs) using census tracts as variables and post-weight variables based on estimates of Pelotas population projection for 2020 (Table 1). We evaluated another model using individual sampling weight (i.e., the inverse of the probability of being interviewed in each census tract). These models are virtually equal to the above estimates (data not shown). The mean age of our sample was 50.3 years (Table 1), 46.2 for model 1, which was similar to PNS 2019 (46.7 years). Our weighted estimates presented a similar proportion of females compared to the PNS 2019 sample. The proportions of skin colors were similar in all categories and models. Our crude model presented a higher proportion of participants with incomplete elementary school or less compared to model 1 and PNS 2019. Table 2 describes the prevalence of chronic diseases and lifestyle factors in our study and the PNS 2019 sample. Our prevalence of diabetes was higher in the crude model compared to weighted estimates and PNS 2019 sample. In both models, we had a higher proportion of individuals with obesity and hypertension than in PNS 2019. Asthma and/or bronchitis presented similar proportions in our results compared to PNS 2019; the same occurred for cancer. Our study presented a higher proportion of smoking participants in both models than in the PNS 2019 sample. Table 2. First descriptive results and comparison with a population-based study. Chronic diseases and lifestyle factors EAI PELOTAS* PNS 2019+ Crude Survey design 1 % (95%CI) % (95%CI) % (95%CI) Diabetes 14.2 (13.3-15.1) 11.5 (10.6-12.4) 9.0 (8.9-11.1) Obesity 30.4 (29.2-31.7) 29.2 (27.7-30.8) 24.8 (22.6-27.1) Hypertension 39.0 (37.7-40.3) 32.4 (31.0-33.9) 28.1 (25.9-30.5) Asthma or chronic bronchitis 9.3 (8.6-10.1) 9.3 (8.4-10.4) 8.7 (7.3-10.3) Cancer 4.2 (3.7-4.7) 3.4 (2.9-4.0) 3.8 (2.9-4.9) Current smoking 20.6 (19.6-21.7) 20.4 (18.9-22.0) 16.3 (14.6-18.1) *n=5.722; +n=3.002. PNS: Brazilian National Health Survey. PNS 2019 includes residents (selected to interview) from the urban area from the Rio Grande do Sul State; Survey design 1: weighted for primary unit sampling and post-weight estimates. DISCUSSION We described the initial descriptive results, methodology, protocol, and the steps required to perform the ML analysis for predicting the use of urgent and emergency services among the residents of Pelotas, Southern Brazil. We expect to provide subsidies to health professionals and managers for decision-making, helping to identify interventions targeted at patients more likely to use urgent and emergency services, as well as those more likely to develop multimorbidity and mortality. We also expect to help health systems optimize their space and resources by directing human and physical capital to those at greater risk of developing multiple chronic diseases and dying. Recent studies in developed countries have found this a feasible challenge with ML 21,27 . If our study presents satisfactory results, we intend to test its practical applicability and acceptance to assist health professionals and managers in decision-making in emergency services among residents of Pelotas. The baseline and methods used to select households resemble the main population-based studies conducted in Brazil, such as the Brazilian Longitudinal Study of Aging (ELSI-Brazil) 28 , the EPICOVID 29 , and the PNS. The applicability of ML requires suitable predictive variables. Our study included sociodemographic and behavioral variables related to urgent and emergency services, and chronic diseases. EAI PELOTAS study also includes essential topics that deserve particular importance during the COVID-19 pandemic, such as food insecurity, decreased income, physical activity, access to health services, and social support. We also presented one weighting option in order to obtain sample estimates considering the complex study design. All estimates have their strength and limitation. Each research question answered through this study may consider these possibilities and choose the most suitable one. The estimates were similar without weighting and those considering the primary sampling unit (PSU) and sampling weight. Using the census tract in the PSU is fundamental to consider the sampling design in the estimates of variability (standard error, variance, 95%CI, among others). In addition, due to the possible selection bias in the sample, which contains more women and older people than expected, the use of a post-weighting strategy becomes necessary to obtain estimates adjusted for the sex and age distributions of the target population (due to the lack of census data, we used population projections). However, it should be noted that this strategy can produce estimates simulating the expected distribution only by sex and age. Still, we do not know how much this strategy can distort the estimates since the demographic adjustment cannot reproduce adjustment in all sample characteristics, especially for non-measured variables that may have influenced the selection of participants. Thus, we recommend defining the use of each strategy on a case-by-case basis, depending on the objective of the scientific product. Finally, we suggest reporting the different estimates according to the sample design for specific outcomes (e.g., the prevalence of a specific condition) that aim to extrapolate the data to the target population (adults of the city of Pelotas). In conclusion, the present article presented a protocol describing the steps that were and will be taken to produce a model capable of predicting the demand for urgent and emergency services in one year among residents in Pelotas (RS), Southern Brazil. SUPPLEMENTARY DATA: Supplementary data are available at IJE online. DATA AVAILABILITY: All data used in this manuscript are found in the manuscript or in the supplementary material. FUNDING: Research Support Foundation of Rio Grande do Sul, Brazil (FAPERGS) - grant number 21/2551-0000066-0 - Programa Pesquisa para o SUS: gestao compartilhada em saude - PPSUS). Felipe Mendes Delpino received a doctoral fellowship from the National Council for Scientific and Technological Development (CNPq) during the writing of the manuscript. This work was supported by the Research Support Foundation of the State of Rio Grande do Sul (FAPERGS) on the public edict 08/2020 - PPSUS (grant 21/2551-0000066-0). The study was conducted by researchers from the Postgraduate Program of Nursing and the Faculty of Nursing from the Federal University of Pelotas (UFPel). REFERENCES 1. Valentim IVL Kruel AJ The importance of interpersonal trust for the consolidation of Brazil's Family Health Program Cien Saude Colet 2007 12 3 777 88 17680135 2. Brasil. Ministerio da Saude Politica nacional de atencao as urgencias Brasilia Editora do Ministerio da Saude; 2006 3. Guibu IA Moraes JC Guerra AA Junior Costa EA Acurcio FA Costa KS Main characteristics of patients of primary health care services in Brazil Rev Saude Publica 2017 51 suppl 2 17s 29160451 4. Paim J Travassos C Almeida C Bahia L Macinko J The Brazilian health system:history,advances,and challenges Lancet 2011 377 9779 1778 1797 10.1016/S0140-6736(11)60054-8 21561655 5. Castro MC Massuda A Almeida G Menezes-Filho NA Andrade MV Noronha KVMS Brazil's unified health system:the first 30 years and prospects for the future Lancet 2019 394 10195 345 356 10.1016/S0140-6736(19)31243-7 31303318 6. Agborsangaya CB Lau D Lahtinen M Cooke T Johnson JA Health-related quality of life and healthcare utilization in multimorbidity:results of a cross-sectional survey Qual Life Res 2013 22 4 791 799 10.1007/s11136-012-0214-7 22684529 7. Nguyen H Manolova G Daskalopoulou C Vitoratou S Prince M Prina AM Prevalence of multimorbidity in community settings:a systematic review and meta-analysis of observational studies J Comorb 2019 9 2235042X19870934 10.1177/2235042X19870934 8. Nunes BP Thume E Facchini LA Multimorbidity in older adults: magnitude and challenges for the Brazilian health system BMC Public Health 2015 15 1172 10.1186/s12889-015-2505-8 26602756 9. Brasil. Ministerio da Saude Secretaria de Atencao a Saude. Departamento de Atencao Especializada. Manual instrutivo da Rede Atencao as Urgencias e Emergencias no sistema Unico de Saude [Internet] Brasilia Editora do Ministerio da Saude; 2013 [cited on Feb 2, 2023] Available from: 10. King Z Farrington J Utley M Kung E Elkhodair S Harris S Machine learning for real-time aggregated prediction of hospital admission for emergency patients NPJ Digit Med 2022 5 1 104 10.1038/s41746-022-00649-y 35882903 11. Qiao Z Sun N Li X Xia E Zhao S Qin Y Using machine learning approaches for emergency room visit prediction based on electronic health record data Stud Health Technol Inform 2018 247 111 5 29677933 12. Miles J Turner J Jacques R Williams J Mason S Using machine-learning risk prediction models to triage the acuity of undifferentiated patients entering the emergency care system:a systematic review Diagn Progn Res 2020 4 16 10.1186/s41512-020-00084-1 33024830 13. Acosta AM Lima MADS Frequent users of emergency services:associated factors and reasons for seeking care Rev Lat Am Enfermagem 2015 23 2 337 44 10.1590/0104-1169.0072.2560 26039306 14. Rzewuska M Azevedo-Marques JM Coxon D Zanetti ML Zanetti ACG Franco LJ Epidemiology of multimorbidity within the Brazilian adult general population:evidence from the 2013 National Health Survey (PNS 2013) PLoS One 2017 12 2 e0171813 10.1371/journal.pone.0171813 28182778 15. Carvalho JN Roncalli AG Cancela MC Souza DLB Prevalence of multimorbidity in the Brazilian adult population according to socioeconomic and demographic characteristics PLoS One 2017 12 4 e0174322 10.1371/journal.pone.0174322 28384178 16. Harris PA Taylor R Thielke R Payne J Gonzalez N Conde JG Research electronic data capture(REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support J Biomed Inform 2009 42 2 377 81 10.1016/j.jbi.2008.08.010 18929686 17. Harris PA Taylor R Minor BL Elliott V Fernandez M O'Neal L The REDCap consortium:building an international community of software platform partners J Biomed Inform 2019 95 103208 10.1016/j.jbi.2019.103208 31078660 18. Carret MLV Fassa AG Domingues MR Prevalencia e fatores associados ao uso inadequado do servico de emergencia: uma revisao sistematica da literatura Cad Saude Publica 2009 25 1 7 28 10.1590/S0102-311X2009000100002 19180283 19. Carret MLV Fassa AG Kawachi I Demand for emergency health service: Factors associated with inappropriate use BMC Health Serv Res 2007 131 10.1186/1472-6963-7-131 17705873 20. Alonso-Moran E Nuno-Solinis R Onder G Tonnara G Multimorbidity in risk stratification tools to predict negative outcomes in adult population Eur J Intern Med 2015 26 3 182 9 10.1016/j.ejim.2015.02.010 25753935 21. Rojas JC Carey KA Edelson DP Venable LR Howell MD Churpek MM Predicting intensive care unit readmission with machine learning using electronic health record data Ann Am Thorac Soc 2018 15 7 846 53 10.1513/AnnalsATS.201710-787OC 29787309 22. Gulshan V Peng L Coram M Stumpe MC Wu D Narayanaswamy A Development and validation of a deep learning algorithm for detection of diabetic retinopathy in retinal fundusphotographs JAMA 2016 316 22 2402 10 10.1001/jama.2016.17216 27898976 23. Motwani M Dey D Berman DS Germano G Achenbach S Al-Mallah MH Machine learning for prediction of all-cause mortality in patients with suspected coronary artery disease: a 5-year multicentre prospective registry analysis Eur Heart J 2017 38 7 500 7 10.1093/eurheartj/ehw188 27252451 24. Pan I Nolan LB Brown RR Khan R van der Boor P Harris DG Machine learning for social services: a study of prenatal case management in Illinois Am J Public Health 2017 107 6 938 44 10.2105/AJPH.2017.303711 28426306 25. Delpino FM Costa AK Farias SR Chiavegatto ADP Filho Arcencio RA Nunes BP Machine learning for predicting chronic diseases: a systematic review Public Health 2022 205 14 25 10.1016/j.puhe.2022.01.007 35219838 26. Batista AFM Machine Learning aplicado a saude. In: 19 Simposio Brasileiro de Computacao Aplicado a Saude Sociedade Brasileira de Computacao; 2019 jun 11 14 Niteroi, Rio de Janeiro Brasil 27. Sahni N Simon G Arora R Development and validation of machine learning models for prediction of 1-year mortality utilizing electronic medical record data available at the end of hospitalization in multicondition patients: a proof-of-concept study J Gen Intern Med 2018 33 6 921 8 10.1007/s11606-018-4316-y 29383551 28. Lima-Costa MF Andrade FB Souza PRB Jr Neri AL Duarte YAO Castro-Costa E The brazilian longitudinal study of aging (ELSI-Brazil): objectives and design Am J Epidemiol 2018 187 7 1345 53 10.1093/aje/kwx387 29394304 29. Hallal PC Barros FC Silveira MF Barros AJD Dellagostin OA Pellanda LC EPICOVID19 protocol: repeated serological surveys on SARS-CoV-2 antibodies in Brazil Cien Saude Colet 2020 25 9 3573 8 10.1590/1413-81232020259.25532020 32876244 |
PMC10000015 | Cureus Cureus 2168-8184 Cureus 2168-8184 Cureus Palo Alto (CA) 10.7759/cureus.34766 Obstetrics/Gynecology Oncology Clear Cell Ovarian Carcinoma With C1 Lateral Mass Metastasis and Pathologic Fracture: A Case Report Muacevic Alexander Adler John R Sassine Dib 1 Rogerson Daniella 2 Banu Matei 3 Reid Patrick 4 St. Clair Caryn 1 1 Gynecologic Oncology, Columbia University Department of Obstetrics and Gynecology, New York, USA 2 Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, USA 3 Neurosurgery, Columbia University Department of Neurological Surgery, New York, USA 4 Neurosurgery, Columbia University, New York, USA Caryn St. Clair [email protected] 8 2 2023 2 2023 15 2 e347668 2 2023 Copyright (c) 2023, Sassine et al. 2023 Sassine et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This article is available from Osseous metastasis (OM) in ovarian cancer (OC) are rare, with an incidence ranging from 0.8% to 2.6%, and are associated with poor prognosis. The available literature on their management and associated complications is scarce. We report a case of International Federation of Gynecology and Obstetrics (FIGO) stage IVB clear cell epithelial OC (EOC) who presented with neck pain. Imaging revealed multiple cervical spine metastases with left vertebral artery encasement and concurrent C1 lateral mass compression fracture, without neurological deficit, requiring occiput to C2 posterior instrumentation and fusion. Early OM may be associated with shorter overall survival, and survival after OM diagnosis is on the order of months. Management of OM should include a multidisciplinary team and may require surgical stabilization in addition to systemic chemotherapy, local radiotherapy, and osteoclast inhibitors. ovarian clear cell carcinoma vertebral fusion pathological fracture osseous metastasis ovarian carcinoma The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus. pmcIntroduction Ovarian cancer (OC) is the most common cause of gynecological cancer death . Direct spread to adjacent pelvic organs, peritoneal spread, and metastasis via the lymphatic route are common, while hematogenous spread to further sites such as the liver, lung, bone and brain occur less commonly and have a poor prognosis [2-4]. Osseous metastases (OM) in OC are among the rarest, with incidences between 0.82% and 4.0%, and may occur by direct invasion, hematogenous, lymphatic, and transperitoneal spread . The vertebral column is the most common site, though case reports document findings throughout the axial skeleton and pelvis . OMs are associated with shorter overall survival . A recent study found the 1-, 3- and 5-year survival after OM diagnosis were 33%, 15%, and 8%, respectively . Skeletal-related events (SREs) and neurovascular compromise secondary to OM have rarely been described. Here, we report a case of International Federation of Gynecology and Obstetrics (FIGO) stage IVB clear cell epithelial ovarian cancer (EOC) complicated by C1 vertebral metastases with vertebral artery involvement and C1 vertebral fracture, necessitating occiput to C2 posterior instrumentation and fusion and palliative C2 neurectomy. Case presentation A 59-year-old African American P0 (nulliparous) with a history of uterine leiomyoma presented with abdominal pain and bloating. A transabdominal sonogram demonstrated multiple large, complex adnexal masses. Staging computed tomography (CT) chest, abdomen and pelvis was suspicious for metastatic ovarian carcinoma, with bilateral complex adnexal masses, peritoneal carcinomatosis, omental caking, and pericardiac, abdominal, peripancreatic, mesenteric, retroperitoneal, and pelvic lymphadenopathy. No osseous lesions were identified at the time of the initial scan. An initial consult with gynecological oncology revealed an abdominal mass above the umbilicus, pelvic masses, and a palpable left supraclavicular node. Ca-125 was 6,773. Pathological examination of interventional radiology-guided peritoneal mass biopsies had an immunoprofile compatible with a high-grade adenocarcinoma of Mullerian origin, favoring clear cell carcinoma. The tumor showed preserved mismatch repair (MMR) proteins expression (positive for MLH1, PMS2, MSH2, MSH6). Immunostain for human epidermal growth factor receptor 2 (HER-2) was equivocal and difficult to interpret on the scant cell block material with mostly cytoplasmic staining, no convincing membranous staining, score 0-1, and immunostaining for PD-L1 was limited by scant cellularity in the cell block, focal positivity with an estimated combined positive score (CPS) 3-4. Further genetic testing did not show any mutations for possible targeted therapy. The patient was diagnosed with FIGO stage IVB clear cell EOC. She received her first cycle of carboplatin, paclitaxel, and bevacizumab, with a plan for 3-4 cycles of neoadjuvant chemotherapy and interval debulking pending clinical response. After her first cycle of chemotherapy, the patient endorsed persistent neck pain of moderate severity. Magnetic resonance imaging (MRI) cervical spine revealed contrast-enhancing osseous lesions within the anterior arch and left lateral mass of C1, as well as in the C4 and C7 vertebral bodies, left articulating facet of C6 and T4 vertebral body extending into the left pedicle. There was lateral tumor extension with encasement of the vertebral artery at the C1 level. There was no evidence of epidural disease or spinal cord impingement . CT angiogram (CTA) demonstrated multiple osseous lytic lesions and a C1 lateral mass compression fracture extending to the left transverse foramen, with asymmetry of the lateral atlantodental interval measuring 8 mm on the right and 2 mm on the left. There was circumferential tumor encasement of the left vertebral artery in the sulcus arteriosus, with severe narrowing with preserved flow and no evidence of dissection . Metastatic cervical and supraclavicular lymphadenopathy were confirmed. The total body bone scan did not show further OM. Figure 1 Sagittal (left) and axial (right) MRI of the patient A. T2-weighted and B. T1 fat saturation MRI sequences demonstrating C1 lateral mass lesion (red arrow) and displacement of the vertebral artery with no epidural tumor extension or cord compression. C. Parasagittal T1 sequence demonstrating lateral tumor extension with encasement of the vertebral artery (red arrow). D. Coronal (left) and axial (right) CT angiogram demonstrating osteolytic left lateral mass lesion encasing and narrowing the vertebral artery (red arrows). The patient was admitted to neurosurgery with gynecological oncology consultation, where she continued to endorse left-sided cervical pain radiating to the occiput which worsened with movement and improved with opioids, steroids and immobilization with a hard collar. There were no focal neurological deficits, paresthesias, anesthesia, gait difficulties, or bowel or bladder dysfunction. The patient had full strength in the upper and lower extremities and an intact gait. She had no signs of myelopathy and had a negative Hoffman's sign. Given normal cervical alignment, with imaging demonstrating articular facet involvement and lateral mass fracture, this pain was considered to be caused by cervical spine instability . Figure 2 Preoperative (A) and postoperative (B and C) radiographs A. Preoperative anterior-posterior (left) and upright lateral (right) radiographs demonstrating normal cervical spine alignment. B. Postoperative anterior-posterior (left) and lateral (right) cervical spine radiographs demonstrating appropriate instrumentation placement and alignment after posterior hardware fixation of the occiput to C2. C. Postoperative anterior-posterior (left) and lateral (right) standing scoliosis series illustrating normal alignment. Urgent surgery was not indicated without neurological deficits or compressive pathology. A multidisciplinary team discussed the case to determine if surgical decompression was required prior to local radiation, and surgical intervention with occiput to C2 instrumentation and fusion was decided upon. Surgery was performed two days after diagnosis. Intraoperatively, there was extensive tumor involvement of the C1 lateral mass and posterior arch, encasing the vertebral artery and extending towards the occipital condyle. A palliative C2 neurectomy was performed for pain control. A right C1 lateral mass screw, bilateral C2 pedicle screws, and occipital keel plate with three bicortical screws were placed. The fusion bed was prepared by decorticating the occiput and bilateral C1-2 joint spaces with the placement of allograft over the decorticated spaces. Intraoperative monitoring was stable throughout and the patient awoke at neurological baseline. Postoperatively, the patient endorsed significant improvement of her cervical pain. Incisional pain was controlled with methocarbamol, gabapentin and hydromorphone PCA (patient-controlled analgesia). Radiographs demonstrated excellent instrumentation placement and alignment . The patient ambulated without assistance on postoperative day (POD) 1 and was discharged in stable condition on POD3. Radiographs of the spine confirmed stable spinal fusion rods three weeks postoperatively . There was complete resolution of the cervical pain. The patient received her second cycle of carboplatin and paclitaxel four weeks postoperatively; at that time, progression of cervical lymphadenopathy was noted on exam. She since received two additional cycles three and six weeks later, with a downtrending CA-125 of 2,301. Bevacizumab has been held to allow for surgical healing. Denosumab injection of 120 mg every 4 weeks, calcium, and vitamin D were initiated postoperatively, with a plan for palliative radiation therapy (RT) of 20 Gy in 5 fractions to C1-2 and associated hardware to prevent disease progression. Discussion This report illustrates a unique complication of OM in EOC. Given the rare nature of these lesions, the literature is sparse. Four retrospective studies comment on OM in the context of other rare OC metastases . In these, the incidence of OM ranged between 1.2% and 4%. Deng et al. analyzed 1481 patients with stage 4 ovarian carcinoma using the Surveillance, Epidemiology, and End Results (SEER) database. OM was found in 3.74% of the entire cohort with a median survival time of 11 months for the patients with OM. Dauplat et al. examined 255 patients with EOC with stage 4 disease. Only four patients (1.6%) had OM with a median survival of 9 months. Gardner et al. used the SEER database to determine the pattern of the distant metastases at the initial presentation in patients with gynecological cancer and found that OM was present in 4% of the patients with ovarian carcinoma, vs 13% and 23% of patients with uterine and cervical cancer, respectively. Additionally, four retrospective studies looked specifically at OM in OC (Table 1). Table 1 Four retrospective studies examine osseous metastasis (OM) in ovarian carcinoma Publication - Author, Year Cohort - No OM - No (%) Overall Survival - Months Survival After OM Diagnosis - Months Most Commonly Involved Site Ak et al., 2021 (2) 736 19 (2.60) 38.1 13.6 Vertebral Sehouli et al., 2013 (5) 1,717 26 (1.50) 50.5 7.2 Vertebral Zhang, C. et al., 2019 (6) 32,178 352 (1.09) 50.0 5.0 Not Reported Zhang, M. et al., 2013 (7) 2,189 26 (0.82) Not Reported Not Reported Vertebral Ak et al. examined 736 OC patients and found OM in 2.6%; OM was mostly seen with clear cell histology similar to our case report. The vertebrae, as in our patient, were most commonly involved, though patients often had multiple sites of involvement. Pain was the most common presenting symptom, but was absent in over 50%. Unlike our case, out of the two patients presenting with pathologic fractures, one had neurologic deficit. Patients were managed with palliative RT and bisphosphonates. Only advanced, inoperable disease at presentation was associated with a shorter time to development of OM. Median overall survival in OC patients with OM was 38.1 months and median survival after OM diagnosis was 13.6 months. Patients who had OM at the time of diagnosis of their OC had a shorter median OS than those who developed OM later on, 6.1 vs 63 months, respectively. To note, although insignificant, overall survival was shorter in patients with clear cell histology after OM than in patients with a different histologic subtype ( 7 vs 22 months) . Sehouli et al. examined 1,717 patients and found OM in 1.5%. The vertebral column was the most common site, most frequently in the lumbar, followed by the thoracic and cervical regions. Multiple OM were seen in the majority of patients, as in our case. Pain was the presenting symptom in 66%; 9% had impaired mobility unlike our patient, and 4% had neurologic symptoms. Pathologic fractures were reported in 33%. Most patients were treated with bisphosphonates; of those treated, 26% went on to develop pathological fractures and required surgical intervention. RT of OM was performed in a minority of cases for pain control and for SRE prevention. OM was noted to progress in 75% of cases despite systemic and local therapy. The median overall survival of the entire cohort was 50.5 months; patients with early OM had significantly shorter overall survival than those with later OM, 11.2 vs 78.4 months; to note, the overall survival rates were calculated regardless of the histology of the disease. By far, the largest study on this topic, Zhang, C. et al. , examined 32,178 Surveillance, Epidemiology, and End Results (SEER) database OC patients and found the prevalence of OM was 1.09%. OM were more common in women over 65, Black and unmarried women. Similar to our patient, most of those patients had an advanced stage, poorly differentiated grade, non-serous type, elevated CA-125 and had concurrent distant metastasis. The median overall survival for the entire cohort was 50 months, whereas the median overall survival after OM diagnosis was 5 months only. Among examined variables, only surgery at the primary site was associated with significantly longer survival, 18 vs 3 months for primary site surgery versus no surgery. Survival was significantly shorter in patients with a non-serous histology without commenting specifically on the clear cell carcinoma histology . Lastly, Zhang, M. et al. found OM in 0.82% of 2,189 OC cases. The majority of OM were vertebral (12 cervical, 10 lumbar, seven thoracic), eight were pelvic, five were limb, two were sternal, and one was rib. Over half presented with pain, 35% with difficulty walking, and 15% were asymptomatic. Similar to our case report, the majority of cases with OM were in advanced disease and EOC, and most of them were managed with chemotherapy and RT. Cases that were managed with combined chemotherapy and RT had significantly longer survival than those treated with either agent alone, 14.2 versus 11 versus 8.4 months for combined therapy, RT alone, and chemotherapy alone, respectively . There is a paucity of data regarding the management of OM with or without SRE in OC, and the current management of lesions is based on that for other solid tumors. Diagnosis includes history and physical, and imaging options include radiographs, CT and MRI; MRI is the modality of choice for vertebral lesions. A multidisciplinary team approach is often needed for the management of such rare cases, including radiology, orthopedic surgery, neurosurgery, radiation oncology , gynecological oncology, palliative and pain medicine . All of these modalities were utilized as illustrated in this case. Conclusions In conclusion, we present a unique case of clear cell EOC with vertebral OM resulting in pathologic C1 fracture requiring surgical stabilization, further complicated by vertebral artery encasement and narrowing. OM secondary to OC are rare and often present with pain though rarely with neurologic deficit. The risk factors for the development of OM are poorly understood but may include clear cell EOC as in this case, and lesions are more commonly described in those with late-stage disease. Patients who present with OM at the time of diagnosis or early in their disease course may have shorter overall survival than those with later OM. However, survival after OM diagnosis is on the order of months. Surgery at the primary site and combination chemotherapy and RT may prolong survival. These findings are based on limited retrospective studies, and further examination of risk factors and prognostic implications of OM in OC is needed. Human Ethics The authors have declared that no competing interests exist. Consent was obtained or waived by all participants in this study References 1 Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012 Int J Cancer Ferlay J Soerjomataram I Dikshit R 0 86 136 2015 2 Skeletal system as a rare metastatic site in patients with ovarian carcinoma Int J Gynecol Cancer Ak N Minareci Y Saip P 1125 1131 31 2021 33962997 3 Rare distant metastatic disease of ovarian and peritoneal carcinomatosis: a review of the literature Cancers (Basel) Thomakos N Diakosavvas M Machairiotis N Fasoulakis Z Zarogoulidis P Rodolakis A 11 2019 4 Sites of distant metastases and overall survival in ovarian cancer: a study of 1481 patients Gynecol Oncol Deng K Yang C Tan Q 460 465 150 2018 30001833 5 Prognostic role of early versus late onset of bone metastasis in patients with carcinoma of the ovary, peritoneum and fallopian tube Ann Oncol Sehouli J Olschewski J Schotters V Fotopoulou C Pietzner K 3024 3028 24 2013 24130264 6 The prevalence, associated factors for bone metastases development and prognosis in newly diagnosed ovarian cancer: a large population based real-world study J Cancer Zhang C Guo X Peltzer K 3133 3139 10 2019 31289583 7 Bone metastasis from ovarian cancer. Clinical analysis of 26 cases Saudi Med J Zhang M Sun J 1270 1273 34 2013 24343467 8 Survival after bone metastasis by primary cancer type: a Danish population-based cohort study BMJ Open Svensson E Christiansen CF Ulrichsen SP Rorth MR Sorensen HT 0 7 2017 9 Distant metastases in epithelial ovarian carcinoma Cancer Dauplat J Hacker NF Nieberg RK Berek JS Rose TP Sagae S 1561 1566 60 1987 3621129 10 Ovarian, uterine, and cervical cancer patients with distant metastases at diagnosis: most common locations and outcomes Clin Exp Metastasis Gardner AB Charo LM Mann AK Kapp DS Eskander RN Chan JK 107 113 37 2020 31758289 11 Distant metastases in ovarian carcinoma Int J Gynecol Cancer Cormio G Rossi C Cazzolla A Resta L Loverro G Greco P Selvaggi L 125 129 13 2003 12657111 12 Current overview of treatment for metastatic bone disease Curr Oncol Tsukamoto S Kido A Tanaka Y Facchini G Peta G Rossi G Mavrogenis AF 3347 3372 28 2021 34590591 |
PMC10000017 | Rev Bras Epidemiol Rev Bras Epidemiol rbepid Revista Brasileira de Epidemiologia (Brazilian Journal of Epidemiology) 1415-790X 1980-5497 Associacao Brasileira de Saude Coletiva 10.1590/1980-549720230020 00419 Original Article Difficulties in the use of medications by elderly people followed up in a cohort study in Southern Brazil Dificuldades no uso de medicamentos por idosos acompanhados em uma coorte do Sul do Brasil Guttier Marilia Cruz Analise formal Conceituacao Escrita - primeira redacao Escrita - revisao e edicao Metodologia Validacao I Silveira Marysabel Pinto Telis Analise formal Conceituacao Escrita - primeira redacao Escrita - revisao e edicao Metodologia Validacao II Tavares Noemia Urruth Leao Analise formal Conceituacao Escrita - revisao e edicao Metodologia Validacao III Krause Matheus Carrett Analise formal Conceituacao Escrita - revisao e edicao Metodologia Validacao IV Bielemann Renata Moraes Escrita - revisao e edicao Investigacao Metodologia Obtencao de financiamento Supervisao Validacao V Gonzalez Maria Cristina Escrita - revisao e edicao Investigacao Metodologia Obtencao de financiamento Supervisao Validacao VI Tomasi Elaine Escrita - revisao e edicao Investigacao Metodologia Obtencao de financiamento Supervisao Validacao I Demarco Flavio Fernando Escrita - revisao e edicao Investigacao Metodologia Obtencao de financiamento Supervisao Validacao I Bertoldi Andrea Damaso Escrita - primeira redacao Escrita - revisao e edicao Investigacao Metodologia Obtencao de financiamento Supervisao Validacao I Universidade Federal de Pelotas, Programa de Pos-Graduacao em Epidemiologia -Pelotas (RS), Brasil. Universidade Federal de Pelotas, Instituto de Biologia, Departamento de Fisiologia e Farmacologia, Programa de Pos-Graduacao Multicentrico em Ciencias Fisiologicas - Pelotas (RS), Brasil. Universidade de Brasilia, Faculdade de Farmacia - Brasilia (DF), Brasil. Universidade Federal de Pelotas, Faculdade de Medicina - Pelotas (RS), Brasil. Universidade Federal de Pelotas, Programa de Pos-Graduacao em Nutricao e Alimentos - Pelotas (RS), Brasil. Universidade Catolica de Pelotas, Programa de Pos-Graduacao em Saude e Comportamento - Pelotas (RS), Brasil. AUTORA CORRESPONDENTE: Marilia Cruz Guttier. Rua Marechal Deodoro, 1160, 3o Piso, Centro, CEP: 96020-220, Pelotas (RS), Brasil. E-mail: [email protected] CONFLITO DE INTERESSES: nada a declarar 10 3 2023 2023 26 e23002029 9 2022 12 11 2022 18 11 2022 Este e um artigo publicado em acesso aberto sob uma licenca Creative Commons ABSTRACT Objective: This study aimed to assess the need for help by elderly people to take their medications, the difficulties related to this activity, the frequency of forgotten doses, and factors associated. Methods: Cross-sectional study conducted with a cohort of elderly people (60 years and over -- "COMO VAI?" [How do you do?] study), where the need for help to properly take medication and the difficulties faced in using them were evaluated. The Poisson regression model was used to estimate the crude and adjusted prevalence ratios (PR) of the outcomes and respective 95% confidence intervals according to the characteristics of the sample. Results: In total, 1,161 elderly people were followed up. The prevalence of participants who reported requiring help with medication was 15.5% (95%CI 13.5-17.8), and the oldest subjects, with lower educational levels, in worse economic situations, on four or more medications and in bad self-rated health were the ones who needed help the most. Continuous use of medication was reported by 83.0% (95%CI 80.7-85.1) of the sample and most participants (74.9%; 95%CI 72.0-77.5) never forgot to take their medications. Conclusion: The need for help to use medications was shown to be influenced by social and economic determinants. Studies assessing the difficulties in medication use by the elderly are important to support policies and practices to improve adherence to treatment and the rational use of medications. RESUMO Objetivo: Este estudo visou avaliar a necessidade de ajuda dos idosos para tomar seus medicamentos, bem como as dificuldades relacionadas com a sua utilizacao, e a frequencia de esquecimento de doses. Ainda, avaliar fatores associados a necessidade de ajuda dos idosos com os medicamentos. Metodos: Corte transversal em uma coorte de idosos (60 anos ou mais -- estudo "COMO VAI?"), em que foi avaliada a necessidade de ajuda para tomar medicamentos de forma adequada e as dificuldades apresentadas na sua utilizacao. Utilizou-se regressao de Poisson para estimar as razoes de prevalencia (RP) brutas e ajustadas dos desfechos e seus intervalos de confianca de 95% (IC95%) de acordo com as caracteristicas da amostra. Resultados: Participaram 1.161 idosos. A prevalencia de idosos que relataram necessidade de ajuda com os medicamentos foi de 15,5% (IC95% 13,5-17,8), sendo que os mais idosos, com menor escolaridade e em pior situacao economica, em uso de quatro medicamentos ou mais e com pior autoavaliacao de saude foram os que mais necessitaram de ajuda. O uso continuo de medicamentos foi referido por 83,0% (IC95% 80,7-85,1) e a maioria (74,9%; IC95% 72,0-77,5) nunca se esqueceu de tomar seus medicamentos. Conclusao: Observou-se a influencia de determinantes sociais e economicos e de saude sobre a necessidade de ajuda para a utilizacao dos medicamentos. Estudos que estimem as dificuldades no uso de medicamentos por idosos sao importantes para subsidiar politicas e praticas norteadoras de acoes para melhorar a adesao e o uso racional de medicamentos. Keywords: Old age assistance Elderly Cohort studies Drug utilization Palavras-chave: Assistencia a idosos Idoso Estudos de coortes Uso de medicamentos pmcINTRODUCTION Aging with quality of life is an important challenge when it comes to the care for the elderly. Policies have been developed seeking to promote health and aging with autonomy in the elderly population 1 , as well as to help caregivers, as there is an increase in the incidence of chronic diseases and, consequently, the need for medication to treat them 1-3 . In Brazil, the prevalence of use of at least one continuous-use medication among the elderly ranges from 80 to 93% 4-6 . In Italy, this prevalence was similar (88%) 7 . Elderly people make use of multiple medications and are exposed to complex therapeutic regimes 6-11 , which can be unfavorable to treatment effectiveness. Considering that the barriers to accessing health services and medication have been overcome and that the elderly have their drug treatment in hand, there are still other difficulties faced by them. Decline in cognitive status 12 , need for greater attention 13 , loss of visual acuity 14 and loss of ability to handle medication packages 15 , as well as difficulties related to memory and time organization and management, can also be complicating factors for the correct use of medication 16 . In a cross-sectional study carried out in the city of Marilia (SP), 59.8% of the elderly reported difficulties related to the use of medications, with forgetfulness being cited by a quarter of them 16 . A study carried out in Sweden pointed out that the majority (66.3%) of the elderly population had some limitation in the ability to manage their treatments 17 . Another difficulty cited by the elderly was the lack of belief in their efficacy 18 . The main result of these difficulties is the lack of adherence to treatment, but they also contribute to errors in medication administration 16,17 , leading to unsatisfactory clinical results, adverse reactions and drug interactions 9,19 . Bearing in mind that the literature deals with these difficulties within adherence assessment scores 18,20,21 or in studies assessing the instrumental activities of daily living (IADL) of the elderly 13,22-24 , this study aimed to assess the need for help by the elderly to take medications, as well as the difficulties faced when using them, and the frequency doses skipped or forgotten, after having overcome barriers to accessing health services and acquiring medication. Furthermore, the purpose was to evaluate factors associated with the need for help when taking medication at the correct dose and time. METHODS Cross-sectional study with a cohort of elderly people, conducted in the urban area of the city of Pelotas, state of Rio Grande do Sul, Brazil (approximately 340,000 inhabitants in 2016). According to the Brazilian Institute of Geography and Statistics (IBGE) 25 , in 2010, 93% of the population of Pelotas lived in urban areas and approximately 50,000 were aged 60 years or older. The sample recruitment and the first visit of the study called "COMO VAI?" ("How do you do?") took place from January to August 2014. In total, 1,451 non-institutionalized elderly aged 60 years or older were included. The sampling process was carried out in two stages. Initially, clusters were selected using data from the 2010 Census 25 , with census groups being selected by lot. In the second stage, listed and systematically drawn households were selected--31 per sector--to enable the identification of at least 12 elderly people in each of them. The second follow-up took place between November 2016 and April 2017, by telephone interviews; household visits were made in cases where telephone contact was not possible. Calls were made on different days and times, and participants not contacted by telephone had at least four visit attempts at the addresses made available to the study. The understanding of the questions was tested in a pilot study applied in face-to-face and telephone interviews. Demographic, socioeconomic, and behavioral characteristics were the independent variables selected based on studies assessing adherence to treatment 18,20,21 and IADL 13,22-24 . The following characteristics were collected in the first interview, to assist in the description of the sample: biological sex (male, female); age (60-69, 70-79, >=80 years); skin color (self-reported, using the following categories: white, black, brown, yellow and indigenous, with the elderly self-declared as brown, yellow and indigenous grouped under the "mixed" category, due to the low frequency); education, defined as the highest level of education achieved in years of study (later categorized as none, <8 and >=8 years); marital status (married/with a partner, single/divorced/widowed--considered "no partner"); economic situation (A/B -- richer; and C, D/E -- poorer), according to the criteria of the Brazilian Association of Companies and Research 26 . Behavioral and health variables were also considered, given their importance in the evaluation of health care for the elderly. Characteristics such as current smoking (yes, no) were evaluated, considering daily cigarette consumption for more than one month; and alcohol consumption (yes, no), considering consumption of at least one dose of alcoholic beverage in the last 30 days. In addition, the concept of "polypharmacy" was evaluated, that is, simultaneous use of four or more medications 27 . Health perception was measured in 2016 by the question "How do you rate your health?", with the following response options: very good, good, regular, poor and very poor, later recategorized as very good/good, fair, bad/very bad. Outcomes were obtained at the second follow-up with the following filter question: "Do you need help taking your meds at the right dose and time?" (yes/no), which indicated the need for help with medication. Among those who needed help with their treatments, the three outcomes related to difficulties in taking medications were evaluated using the following questions: "Thinking about your medication, could you tell me if the following actions are 'very difficult', 'a little difficult' or if 'not difficult'? removing the medicine from package; reading the medicine package, to assess difficulties with handling, and understanding the package; taking too many medications at the same time, or difficulty with the amount of medications in use. Continuous medication was also evaluated using the question "Do you take any continuous use medicine regularly, with no date to stop?" (Yes/No). For those who were on continuous medication, the following question was asked: a) "Do you sometimes forget to take your medicine?" (Yes/No); b) "How often do you have trouble remembering to take all your medications?", with five response options: never/rarely, from time to time, sometimes, usually, always. Then, the responses were grouped into three categories (never/rarely, occasionally/sometimes, usually/always). These categories have been renamed to never, occasionally, and usually, respectively. Only elderly people who met the outcome and were followed up at both moments were included in the analyses. The analytical sample maintained the characteristics of the original cohort, with the exception of age, since there was a significant decrease in the proportion of elderly aged 80 years or older (p=0.044) (Supplementary Table). Analyses were performed using the Stata statistical package, version 16.0 (Stata Corporation, College Station, USA). First, the sample was described (followed up in 2016 and 2017). Afterwards, the prevalence and 95% confidence intervals (95%CI) of the main outcome were obtained according to the characteristics of the sample. Poisson regression with forward selection was used to estimate the crude and adjusted prevalence ratios (PR), and the adjusted model included the variables that presented p<0.20 in the crude analysis to control for possible confounding factors. The respective 95%CI of each predictor's PR were estimated. Descriptive analyses of the frequencies of outcomes were performed. Proportions were compared using the Pearson's kh2 test. Linear trend was assessed for significant associations between outcomes and exposure to more than two categories. The level of statistical significance was set at p<0.05. The study was approved by the Research Ethics Committee of the Medical School of Universidade Federal de Pelotas--CAAE: 54141716.0.0000.5317. The participants or caregivers signed an informed consent form, guaranteeing data confidentiality. In 2016 and 2017, for the elderly interviewed by telephone, consent was provided verbally with acceptance to answer the questionnaire. RESULTS The initial sample, in 2014, consisted of 1,451 elderly people. Of these, in 2016, 1,306 participants were located (145 obits identified). The follow-up rate was 90%, with the 1,161 elderly people who were alive being followed up. Most interviews (74.4%) took place over the phone. Table 1 shows the analysis of the outcome "Need for help to take medication at the right dose and time", according to demographic and socioeconomic characteristics in 2016. Most participants were females (63.7%) aged between 60 and 69 years (56.0%), white (83.6%), with less than 8 years of schooling (54.2%), married or with a partner (55.9%), and in level C economic status (57.6%). Altogether, 15.5% of the elderly (95%CI 13.5-17.8) reported needing help with medication use. There was no significant difference in the prevalence of help needed according to biological sex and skin color. Age, educational level and economic situation were important predictors for this outcome. The prevalence of elderly aged 80 years or older who reported needing help was 2.3 times higher (95%CI 1.6-3.5) than among subjects aged between 60 and 69 years, and 3.0 times higher (95%CI 1.6-5.4) among participants with no schooling, compared to those with 8 years or more of schooling. The prevalence of elderly people who reports needing help with their medications in economic strata D/E was 70% higher (PR=1.7; 95%CI 1.0-2.8) than among those in economic strata A/B. Marital status, after adjustment, lost statistical significance (Table 1). Table 1 Sample description, with prevalence, crude and adjusted prevalence ratios of help needed to take medication at the right dose and time and respective 95% confidence intervals according to demographic and socioeconomic characteristics. Pelotas (RS), 2016. Sample n Prevalence % (95%CI) Crude PR 95%CI Adjusted PR * 95%CI Sex 0.672 Male 421 (36.3) 14.9 (11.7-18.7) 1.0 Female 740 (63.7) 15.9 (13.4-18.7) 1.1 (0.8-1.5) Age (years) <0.001 <0.001 60-69 648 (56.0) 10.1 (8.0-12.7) 1.0 1.0 70-79 363 (31.3) 17.4 (13.8-21.7) 1.7 (1.2-2.4) 1.3 (0.9-1.9) 80 and older 147 (12.7) 34.5 (27.1-42.7) 3.4 (2.3-4.9) 2.3 (1.6-3.5) Skin color 0.285 White 969 (83.6) 14.7 (12.5-17.1) 1.0 Black 132 (11.4) 18.7 (12.9-26.5) 1.3 (0.8-2.0) Mixed 58 (5.0) 21.8 (12.8-34.6) 1.5 (0.8-2.7) Education (Years of study) <0.001 0.002 None 147 (12.8) 30.7 (26.6-38.8) 5.5 (3.2-9.2) 3.0 (1.6-5.4) Less than 8 625 (54.2) 17.8 (15.0-21.1) 3.2 (2.0-5.1) 2.3 (1.3-3.8) 8 and more 380 (33.0) 5.6 (3.7-8.5) 1.0 1.0 Marital Status 0.021 0.846 Partner 648 (55.9) 13.1 (10.7-15.9) 1.0 1.0 No partner 511 (44.1) 18.5 (15.4-22.2) 1.4 (1.1-1.9) 1.0 (0.7-1.3) Economic status + <0.001 0.029 A/B 311 (28.2) 10.5 (7.5-14.4) 1.0 1.0 C 634 (57.6) 14.0 (11.5-17.0) 1.3 (0.9-2.0) 1.0 (0.7-1.6) D/E 156 (14.2) 30.9 (24.0-38.7) 3.0 (1.9-4.6) 1.7 (1.0-2.8) Total 15.5 (13.5-17.8) * Analysis adjusted for age, education, marital status, economic status, alcohol consumption in the last 30 days, polypharmacy, and self-rated health; + A/B -- richest, C, D/E -- poorest, according to the Brazilian Association of Companies and Research26; PR: prevalence ratio; 95%CI: 95% confidence interval. Table 2 addresses the same outcome according to behavioral and health characteristics of participants. Most did not smoke (88.4%) or drink (76.5%), were under the concept of polypharmacy (53.7%), and perceived their health as very good or good (56.5%). Polypharmacy and self-rated health were important predictors for this outcome. The prevalence of elderly people who needed help was 1.6 times higher (95%CI 1.1-2.3) among those on four or more medications, compared to those on less than four medications. The worse the self-perception of health, the greater the need for help to take the medication, and among those who perceived their health as poor or very poor, the prevalence of help needed was 100% higher (PR=2.0; 95%CI 1.2-3.2) than among those who perceived their health as very good or good. Alcohol consumption in the last 30 days lost statistical significance after adjustment (Table 2). Table 2 Description of the sample, prevalence, crude and adjusted prevalence ratios of help needed to take medication at the right dose and time with respective 95% confidence intervals according to behavioral characteristics. Pelotas (RS), 2016. Sample n Prevalence % (95%CI) Crude PR 95%CI Adjusted PR * 95%CI Smoking currently 0.450 No 1.024 (88.4) 15.8 (13.6-18.2) 1.2 (0.7-2.0) Yes 135 (11.6) 13.1 (8.3-20.0) 1.0 Alcohol intake in the last 30 days 0.002 0.372 No 886 (76.5) 17.3 (14.9-20.0) 1.9 (1.2-2.8) 1.2 (0.8-2.0) Yes 272 (23.5) 9.3 (6.4-13.4) 1.0 1.0 Polypharmacy 0.002 0.006 No 483 (46.3) 11.6 (9.0-14.8) 1.0 1.0 Yes 561 (53.7) 20.9 (17.7-24.5) 1.8 (1.3-2.5) 1.6 (1.1-2.3) Self-rated health status <0.001 0.012 Very good/good 654 (56.5) 9.9 (7.8-12.5) 1.0 1.0 Regular 414 (35.8) 20.4 (16.7-24.6) 2.1 (1.5-2.8) 1.5 (1.1-2.1) Bad/very bad 89 (7.7) 35.4 (25.7-46.5) 3.6 (2.3-5.6) 2.0 (1.2-3.2) Total 15.5 (13.5-17.8) * Analysis adjusted for age, education, marital status, economic situation, alcohol consumption in the last 30 days, polypharmacy, and self-rated health; PR: prevalence ratio; 95%CI: 95% confidence interval. Figure 1 shows the difficulties cited by the 176 elderly people who reported needing help to use medication, stratified by age. No significant difference was observed in the difficulty of removing medications from the package between age groups (p=0.55), to read package instructions (p=0.09) or to take many medications at the same time (p=0.55). For all ages, most participants do not find it difficult to unpack medications and take many at the same time. However, the most prevalent answer for reading the package was "very difficult" at all ages . Figure 1. Level of difficulties faced by the elderly who reported needing help to use medication according to age (n=176). Pelotas (RS), 2016. Pearson's kh2 test to compare the proportions of each outcome with age. In assessing the use of continuous medication, 962 (83.0%; 95%CI 80.7-85.1) participants used them, among which 23.4% (95%CI 20.8-26, 1) reported occasionally forgetting to take doses. Figure 2 shows the proportion of elderly people on continuous medication who reported needing help to take them as forgetting is concerned. Among these users, 17.0% (95%CI 14.7-19.5) reported needing help and 83.0% (95%CI 80.5-85.3) reported not needing help. The proportion of forgetting doses among participants who needed help (35.0%) was significantly higher than among those who did not need help (20.5%; p<0.001) . Figure 2. Proportion of elderly people on continuous medication who reported needing help to take their medications, according to the report of eventually forgetting doses (yes/no) (n=962) Pelotas (RS), 2016 (p<0.001). Pearson's kh2 test. Figure 3 shows the frequency of forgetting doses according to age, for those on continuous medication. Among 956 users, most of them (74.9%; 95%CI 72.0-77.5) never forgot to take any doses. For the 60- 69 age group, 19.3% (95%CI 16.2-23.0) occasionally forget and 2.9% (95%CI 1.7-4.8), usually forget. In the age group 70-79 years old, 26.1% (95%CI 21.4-31.3) occasionally forget and 5.2% (95%CI 1.7-4.7), usually forget. Among the aged 80 years or older, 14.4% (95%CI 9.4-21.5) eventually forget and 8.3% (95%CI 4.7-14.4) usually forget (p=0.002) . Figure 3. Frequency of forgetting medications according to age groups (n=959) Pelotas (RS), 2016 (p=0.002). Pearson's kh2 test to compare outcome proportions with age. DISCUSSION This study shows that 15.5% of the elderly needed help to use their medication in the right dose and at the right time, and the greater the age, the lower the level of education and the worse the economic situation, the greater the proportion of elderly people who reported the need for help. Although there are methodological differences in studies that evaluate outcomes regarding the need for help and difficulty in using medications, in a population-based study carried out with elderly people aged 60 years or older in the city of Sao Paulo (SP), 8.5% of them had difficulty taking their medication and 89.3% received some sort of help in this task 28 . The need for help with medications is a delicate issue, as when misused, they predispose the elderly population to the risks of polypharmacy and the possibility of developing more intense adverse or therapeutic effects, in addition to the likely increase in cost, both individually and for the health system 4 . In addition, the need for help with medication can result in the need to expand the care network for the elderly and, in most cases, this network starts with family members, who leave aside their profession, leisure activities, and self-care to meet the needs of the elderly, often for prolonged periods, often until their deaths, which can lead to damage to the quality of life of the caregiver and the family 29 . Another study, carried out in basic health units in the city of Sao Paulo (SP), used the Lawton Scale to identify the degree of dependence for IADL, and one of the evaluated items was whether the individual was able to take their medication in correct doses and in at correct times. It was observed that 46.8% of the elderly cannot, 28.2% need partial help, and only a quarter can use their medication without any help 24 . Several factors are associated with impairment of functional capacity, such as advanced age, female gender, low income and education 24 . Low educational level was also associated with the inability to take medication in a descriptive study carried out with 95 elderly people treated at a Family Health Strategy (FHS) unit in Goiania (GO) 13 , showing that adverse social and economic conditions negatively influence issues related to health, such as the need for help to use medications at correct dose and time. In that study, 30.0% of the elderly needed reminders to take their medications at the right time and 13.0% were unable to take them by themselves 13 . The need for help from the elderly to deal with their treatments due to difficulty in handling medication packages, reading the packaging or taking too many medications directly interferes with adherence to treatment. Adherence to treatment is a complex, multifactorial matter that is essential for therapeutic results. When the patient does not adhere to treatment, there may be changes of various types, such as reduced benefits, increased risks, or both, which contributes to increased treatment costs for the elderly and for health services 30 . In this sense, understanding the factors that prevent the patient from following the recommendations of health professionals is important. The need for help to take the medication in this study can be explained, in part, by difficulties in activities of daily living identified in the first follow-up, which were also associated with older age, lower education, and presence of multimorbidities 22 ; however, this information was not collected in the follow-up from 2016, not allowing for these analyses. Considering that this is a longitudinal follow-up and aging being a limitation for the use of medication, it is likely that there will be an increase in the difficulties faced while using medication in the upcoming follow-ups. Regarding the difficulties with the therapeutic regimen presented by the elderly who reported needing help, the greater difficulty was related to removing the medication from the package and reading it among elderly people aged 80 years or older. These difficulties may be associated with the loss of fine motor skills and reduced visual acuity in this population, although this study has not found a significant difference. There is evidence that physiological aging can lead to decline in some tasks 31-33 . A systematic review aimed at analyzing factors associated with the autonomy of the elderly showed that the oldest (over 80 years old) are 40% more likely to let other people decide for them, when compared to those aged 60-69 years. That is, with aging, the probability of loss of autonomy increases, as well as the perception of autonomy worsens 34 . Also, visual acuity can decrease with age and this can affect the ability of the elderly to read information on the medicine package, leading to errors or confusions, especially with those whose names are similar. A study carried out with 96 elderly people aged 65 and older from a community in the countryside of Sao Paulo showed a significant increase in the prevalence of low vision, compromising activities of daily living 35 . Other important points refer to continuous medications, polypharmacy, and the self-perception of health. The elderly population lives with chronic health problems, being a great consumer of health services and medicines 36 , especially those for continuous use. This study showed that most elderly people aged 60 and older use this type of medication and that polypharmacy and poorer health perception were also associated with a greater need for help with medication. The high prevalence of polypharmacy among the elderly population points to the importance of identifying the needs of this population in order to make rational use of treatment 37,38 . However, the results of this study showed that, of those on continuous medication, about a quarter eventually forget to take their medication, although most of them reported never forgetting (74.9%; 95%CI 72.0- 77.5). These results were lower than those reported by Bezerra et al. 39 and Rocha et al. 5 , and higher than those reported by Marin et al. 16 Forgetting is a serious problem, as it can directly impact adherence to treatment and, consequently, the effectiveness of medications, leading to unsatisfactory control of multimorbidities 40 . It is estimated that, in high-income countries, adherence to long-term therapies accounts to only 50% on average. In middle-income countries, the rates are even lower, which seriously compromises the efficacy of treatments and has important implications in quality of life, the economy, and public health 1 . One of the limitations are the impossibility of collecting all behavioral and health characteristics in the same follow-up in which the outcome was collected, which may have underestimated or overestimated the relation of these variables with the outcome, even though the interval between follow-ups was of only two years. Not having evaluated the functional limitations of the elderly can also be a limitation, as these characteristics can directly influence the outcomes. However, the study has strengths: a population-based longitudinal study sample was used, with frequent follow-ups; however, hospitalized or institutionalized elderly were not included in the study. Even working with the elderly and the study not being initially planned to have a cohort design, the follow-up rate was high. Social and economic determinants were found to influence on the elderly's need for help to use their medications, and a high prevalence of elderly people on continuous treatment (with a quarter of these forgetting to take doses eventually, significantly higher among those who need help). Studies that estimate the difficulties faced with medications by the elderly are important to support health policies and practices aimed at minimizing issues and guiding actions to improve adherence to treatment and rational use of medication. ACKNOWLEDGMENTS The authors would like to thank all participants of the cohort study "COMO VAI?" ("How do you do?") conducted in 2014 with elderly people living in Pelotas, RS, Brazil, and the entire team, including interviewers, archivists and volunteers FUNDING: the baseline of the study "HOW ARE YOU GOING?" was funded by master's students and the Academic Excellence Program (PROEX) of the Coordination for the Improvement of Higher Education Personnel (CAPES). In addition, the research coordinators (ADB, FFD, ET, MCG, RB) are research productivity fellows from the National Council for Scientific and Technological Development (CNPq). REFERENCIAS 1. World Health Organization Envelhecimento ativo: uma politica de saude Traducao: Suzana Gontijo Brasilia Organizacao Pan-Americana da Saude 2005 2. Shahin W Kennedy GA Stupans I The impact of personal and cultural beliefs on medication adherence of patients with chronic illnesses: a systematic review. Patient Prefer Adher 2019 13 1019 35 10.2147/PPA.S212046 3. Masnoon N Shakib S Kalisch-Ellett L Caughey GE What is polypharmacy? A systematic review of definitions. BMC Geriatr 2017 17 1 230 10.1186/s12877-017-0621-2 29017448 4. Teixeira JJV Lefevre F A prescricao medicamentosa sob a otica do paciente idoso. Rev Saude Publica 2001 35 2 207 13 10.1590/S0034-89102001000200016 11359209 5. Rocha CH Oliveira APS Ferreira C Faggiani FT Schroeter G Souza ACA Medication adherence of elderly in Porto Alegre, RS Cien Saude Colet 2008 13Suppl 703 10 10.1590/s1413-81232008000700020 6. Ramos LR Tavares NUL Bertoldi AD Farias MR Oliveira MA Luiza VL Polifarmacia e polimorbidade em idosos no Brasil: um desafio em saude publica. Rev Saude Publica 2016 50 supl 2 9s 10.1590/S1518-8787.2016050006145 7. Nobili A Franchi C Pasina L Tettamanti M Baviera M Monesi L Drug utilization and polypharmacy in an Italian elderly population: the EPIFARM-elderly project Pharmacoepidemiol Drug Saf 2011 20 5 488 96 10.1002/pds.2108 21264988 8. Kim J Parish AL Polypharmacy and medication management in older adults. Nurs Clin North Am 2017 52 3 457 68 10.1016/j.cnur.2017.04.007 28779826 9. Carvalho MFC Romano-Lieber NS Bergsten-Mendes G Secoli SR Ribeiro E Lebrao ML Polifarmacia entre idosos do municipio de Sao Paulo-Estudo SABE. Rev Bras Epidemiol 2012 15 4 817 27 10.1590/S1415-790X2012000400013 23515777 10. Almeida NA Reiners AAO Azevedo RCS Silva AMC Cardoso JDC Souza LC Prevalencia e fatores associados a polifarmacia entre os idosos residentes na comunidade. Rev Bras Geriatr Gerontol 2017 20 1 143 53 10.1590/1981-22562017020.160086 11. Pereira KG Peres MA Iop D Boing AC Boing AF Aziz M Polifarmacia em idosos: um estudo de base populacional. Rev Bras Epidemiol 2017 20 2 335 44 10.1590/1980-5497201700020013 28832855 12. Gould ON Todd L Irvine-Meek J Adherence devices in a community sample: how are pillboxes used? Canadian Pharmacists Journal/Revue des Pharmaciens du Canada 2009 142 1 28 35 10.3821/1913-701X-142.1.28 13. Costa EC Nakatani AYK Bachion MM Capacidade de idosos da comunidade para desenvolver atividades de vida diaria e atividades instrumentais de vida Diaria. Acta Paul Enferm 2006 19 1 43 8 10.1590/S0103-21002006000100007 14. Daien V Peres K Villain M Colvez A Carriere I Delcourt C Visual acuity thresholds associated with activity limitations in the elderly. The Pathologies Oculaires Liees a l'Age study. Acta Ophthalmol 2014 92 7 e500 6 10.1111/aos.12335 24428942 15. Giordani B Cinelli M Interacao idoso-embalagem: uma reflexao sobre a ergonomia no design de embalagens. In: 13o Congresso Brasileiro de Pesquisa e Desenvolvimento em Design Univille Joinville (SC) 2018 16. Marin MJS Cecilio LCO Perez AEWUF Santella F Silva CBA Goncalves JR Filho Caracterizacao do uso de medicamentos entre idosos de uma unidade do Programa Saude da Familia. Cad Saude Publica 2008 24 7 1545 55 10.1590/S0102-311X2008000700009 18670678 17. Beckman AGK Parker MG Thorslund M Can elderly people take their medicine? Patient Educ Couns 2005 59 2 186 91 10.1016/j.pec.2004.11.005 16257624 18. Borba AKOT Marques APO Ramos VP Leal MCC Arruda IKG Ramos RSPS Fatores associados a adesao terapeutica em idosos diabeticos assistidos na atencao primaria de saude. Cien Saude Colet 2018 23 3 953 61 10.1590/1413-81232018233.03722016 29538575 19. World Health Organization Adherence to long-term therapies: evidence for action: World Health Organization 2003 20. Tavares NUL Bertoldi AD Thume E Facchini LA Franca GVA Mengue SS Fatores associados a baixa adesao ao tratamento medicamentoso em idosos. Rev Saude Publica 2013 47 6 1092 101 10.1590/S0034-8910.2013047004834 24626547 21. Tavares NUL Bertoldi AD Mengue SS Arrais PSD Luiza VL Oliveira MA Fatores associados a baixa adesao ao tratamento farmacologico de doencas cronicas no Brasil. Rev Saude Publica 2016 50 suppl 2 10s 10.1590/S1518-8787.2016050006150 22. Farias-Antunez S Lima NP Bierhals IO Gomes AP Vieira LS Tomasi E Incapacidade funcional para atividades basicas e instrumentais da vida diaria: um estudo de base populacional com idosos de Pelotas, Rio Grande do Sul, 2014 Epidemiol Serv Saude 2018 27 2 e2017290 10.5123/S1679-49742018000200005 29898166 23. Barbosa FDS Melo CL Silva RJS Factors associated with instrumental activities of daily living functional capacity in brazilian older adults. Research, Society and Development 2021 10 4 e39410414144 10.33448/rsd-v10i4.14144 24. Santos GS Cunha ICKO Avaliacao da capacidade funcional de idosos para o desempenho das atividades instrumentais da vida diaria: um estudo na atencao basica em saude. Rev Enferm Cent Oeste Min 2013 3 3 820 8 25. Instituto Brasileiro de Geografia e Estatistica. Censo demografico 2010. Caracteristicas da populacao e dos domicilios: resultados do universo. Rio de Janeiro Instituto Brasileiro de Geografia e Estatistica 2010 26. Associacao Brasileira de Empresas de Pesquisa Criterio de classificacao economica Brasil. Alteracoes na aplicacao do Criterio Brasil, validas a partir de 01/01/2014 [Internet] acessado em 23 nov. 2019 Disponivel em: 27. Patterson SM Hughes C Kerse N Cardwell CR Bradley MC Interventions to improve the appropriate use of polypharmacy for older people Cochrane Database Syst Rev 2012 5 CD008165 10.1002/14651858.CD008165.pub2 22592727 28. Duarte YAO Lebrao ML Lima FD Contribuicao dos arranjos domiciliares para o suprimento de demandas assistenciais dos idosos com comprometimento funcional em Sao Paulo, Brasil. Rev Panam Salud Publica 2005 17 5/6 370 8 16053647 29. Martins OSP A familia do idoso dependente: analise das necessidades/dificuldades no cuidar no domicilio [dissertacao de mestrado] Viana do Castelo Instituto Politecnico de Viana do Castelo 2014 30. Freitas JGA Nielson SEO Porto CC Adesao ao tratamento farmacologico em idosos hipertensos: uma revisao integrativa da literatura. Rev Soc Bras Clin Med 2015 13 1 75 84 31. Summers JJ Lewis J Fujiyama H Aging effects on event and emergent timing in bimanual coordination. Hum Mov Sci 2010 29 5 820 30 10.1016/j.humov.2009.10.003 19931202 32. Jimenez-Jimenez FJ Calleja M Alonso-Navarro H Rubio L Navacerrada F Pilo-de-la-Fuente B Influence of age and gender in motor performance in healthy subjects. J Neurol Sci. 2011 302 1-2 72 80 10.1016/j.jns.2010.11.021 21183189 33. Clares JWB Freitas MC Borges CL Fatores sociais e clinicos que causam limitacao da mobilidade de idosos. Acta Paul Enferm 2014 27 3 237 42 10.1590/1982-0194201400040 34. Gomes GC Moreira RS Maia TO Santos MAB Silva VL Fatores associados a autonomia pessoal em idosos: revisao sistematica da literatura. Cien Saude Coletiva 2021 26 3 1035 46 10.1590/1413-81232021263.08222019 35. Luiz LC Rebelatto JR Coimbra AMV Ricci NA Associacao entre deficit visual e aspectos clinico-funcionais em idosos da comunidade. Braz J Phys Ther 2009 13 5 444 50 10.1590/S1413-35552009005000049 36. Menezes TMO Lopes RLM Azevedo RF A pessoa idosa e o corpo: uma transformacao inevitavel. Rev Eletr Enferm 2009 11 3 598 604 10.5216/ree.v11.47123 37. Santos TRA Lima DM Nakatani AYK Pereira LV Leal GS Amaral RG Consumo de medicamentos por idosos, Goiania, Brasil. Rev Saude Publica 2013 47 1 94 103 10.1590/S0034-89102013000100013 23703135 38. Silva GOB Gondim APS Monteiro MP Frota MA Meneses ALL Uso de medicamentos continuos e fatores associados em idosos de Quixada, Ceara. Rev Bras Epidemiol 2012 15 2 386 95 10.1590/S1415-790X2012000200016 22782104 39. Bezerra TA Brito MAA Costa KNFM Caracterizacao do uso de medicamentos entre idosos atendidos em uma unidade basica de saude da familia. Cogitare Enferm 2016 21 1 1 11 10.5380/ce.v21i1.43011 40. Silva CH Spinillo CG Dificuldades e estrategias no uso de multiplos medicamentos por idosos no contexto do design da informacao. Estudos em Design 2016 24 3 130 44 |
End of preview. Expand
in Dataset Viewer.
A cleaned Pubmed commercial available files dataset. Will update the script used to clean soon. There are instances where "- " and the text goes to next line are not cleaned, will be changing those and upload a new version..
- Downloads last month
- 4