Age and gender differences in the impact of psoriasis on quality of life

BACKGROUND: The impact of psoriasis upon the quality of life contributes significantly to the overall morbidity associated with the disease. An older age at onset of psoriasis and being a man have been associated previously with lower psychosocial morbidity. In order to further evaluate these potentially important mitigating factors, we examined the relation of age and gender on some aspects of psoriasis-related psychosocial morbidity. METHODS: Two hundred and fifteen consenting psoriasis patients, representing a wide range of disease severity, were studied. They included 110 men and 105 women, age range 19-87 years (age: mean +/- SD: 48.0 +/- 15.9 years); all endorsed a list of 30 items (by checking a "Yes" or "No") pertaining to life events related to psoriasis that they had experienced in the previous one month. The patients self-rated the severity of their psoriasis. The patients were categorized into four age groups of 18-29 years (N = 28), 30-45 years (N = 77), 46-65 years (N = 76), and > 65 years (N = 34), respectively, for the statistical analyses. RESULTS: No age or gender differences in the severity of psoriasis were observed. Patients of both sexes in the 18 to 29 and 30 to 45 year age groups reported more frequent (P < or = 0.05) problems related to both appearance/socialization and occupation/finances, in contrast to patients in the 46-65 and over-65-year age groups. No gender differences (P < or = 0.05) were observed in the frequency of items related to appearance and socialization; however, men reported greater work-related stresses. CONCLUSION: Psoriasis has a greater impact upon the quality of life of patients in the 18 to 45 year age range and affects the socialization of both sexes equally. Men face greater work-related stresses as a result of their psoriasis.     

Alveolar soft-part sarcoma with unusual mitochondrial findings: a case report

In 1996 a randomized sample of 4,020 Swedish adolescents from three birth cohorts were sent a questionnaire consisting of 50 items concerning habitual sun-related behaviours and attitudes, knowledge about melanoma, risk perception and self-image. A total of 2,615 questionnaires were returned. Girls sunbathed and used sunbeds more than boys at all ages. Sunbathing and sunbed use increased with age. Boys who were most satisfied and girls least satisfied with themselves sunbathed most. Those who were least satisfied with themselves used sunbeds most frequently. Girls reported a higher perceived susceptibility to melanoma than did boys. The perception of susceptibility increased with age. Those who were least satisfied with themselves reported feeling most susceptible. The overall main reason for sunbathing was appearance, both for own sunbathing, and to an even higher degree, as a supposed reason for other adolescents' behaviour, and was reported most frequently by girls and the older age groups. The second most 'important' reason for sunbathing was 'feeling warm and comfortable'. Preventive programmes aimed at a change of sun related behaviours among Swedish adolescents have to be tailored to the climate and cultural conditions and must take into account that having a tan, and the warmth of the sun, are highly valued by most adolescents.     

Antibodies against human putamen in children with Tourette syndrome

BACKGROUND: Similar to the model for Sydenham's chorea, antineuronal antibodies, which develop in response to a preceding streptococcal infection, have been speculated to have a role in the development of Tourette syndrome (TS). METHODS: Serum antibodies against human caudate, putamen, and globus pallidus (interna and externa) were assayed by enzyme-linked immunosorbent assay (ELISA) and Western blot techniques and results were correlated with clinical characteristics and markers of streptococcal infection. SUBJECTS: A total of 41 children with TS (mean age, 11.3 years) and 39 controls (mean age, 12.1 years) were included. RESULTS: Compared with controls, TS subjects had a significant increase in the mean (p=0.006) and median (p=0.002) ELISA optical density (OD) levels of serum antibodies against putamen, but not caudate or globus pallidus. Western blots on 20 control and 20 TS serum samples showed that specific antibodies to caudate/putamen occurred more frequently in TS subjects at 83, 67, and 60 kDa; antigens were present in a synaptosomal fraction. TS subjects with a positive family history of tics had higher OD values (p < or = 0.04), but no association was shown with age of tic onset, tic severity, sudden onset of tics, or presence of attention-deficit hyperactivity disorder or obsessive-compulsive disorder. Risk ratio calculations in TS and control groups and in study subjects dichotomized for high and low putamen OD values were similar for titers of antistreptolysin O > or = 166 or antideoxyribonuclease B > or = 170. A subgroup analysis limited to subjects with elevated streptococcal titers, however, showed a significantly (p < or = 0.004) larger number of TS subjects with elevated OD levels. CONCLUSION: Children and adolescents with TS had significantly higher serum levels of antineuronal antibodies against putamen than did controls, but their relation to clinical characteristics and markers for streptococcal infection remains equivocal.     

Early conduct problems and later life opportunities

Associations between the extent of conduct problems at age 8 years and later life opportunity outcomes at age 18 years were examined in a birth cohort of New Zealand children studied prospectively to age 18 years. Conduct problems at age 8 were assessed using a combination of parent and teacher reports of conduct disordered and oppositional behaviours. Two measures of life opportunities were assessed at age 18: (a) whether the young person had left school by age 18 without educational qualifications; (b) whether the young person had experienced a period of unemployment of 3 months or longer following school leaving. The analysis suggested the following conclusions: (1) There were clear and significant (p < .0001) tendencies for increasing levels of conduct problems at age 8 to be associated with increasing risks of leaving school without qualifications and of unemployment by age 18. (2) A substantial component of these associations was explained by a series of confounding social, family, and individual factors (notably child intelligence, early attentional problems, and family sociodemographic disadvantage) that were associated with both early conduct problems and later life opportunities. (3) Further analysis suggested that linkages between early conduct problems and later educational underattainment and unemployment (after adjustment for confounders) were mediated by a series of adolescent behavioural processes including patterns of peer affiliations, substance use, truancy, and problems with school authority.     

The metabolic anatomy of Tourette's syndrome

The functional brain networks underlying the clinical manifestations of Gilles de la Tourette's syndrome (TS) are currently unknown. To identify these networks, we studied TS patients and normal subjects with 18F-fluorodeoxyglucose (FDG) and PET employing a statistical model of regional metabolic covariation. We studied 10 TS patients (mean age, 41.5 +/- 12.7 years) who were either drug naive or medication free for at least 2 years. Ten normal volunteers (mean age, 42.5 +/- 11.5) served as controls. We used quantitative FDG/PET to calculate global, regional, and normalized rates of glucose metabolism (GMR, rCMRGlc, and rCMRGlc/GMR) in all subjects. The Scaled Subprofile Model (SSM) was used to identify specific patterns of regional metabolic covariation associated with TS. We found that global and regional metabolic rates were normal in TS. SSM analysis identified two TS-related brain networks. One pattern (15.8% variance accounted for, VAF) was characterized by covariate bilateral metabolic increases in lateral premotor and supplementary motor association cortices and in the midbrain. Individual patient expression of this pattern (subject score) was abnormally increased in the TS group (p < 0.01). A second pattern (10.5% VAF) was characterized by covariate decreases in caudate and thalamic metabolism associated with smaller reductions in lentiform and hippocampal metabolic activity. Subject scores for this pattern correlated with Tourette Syndrome Global Scale (TSGS) global ratings (r = 0.85, p < 0.005). We conclude that the metabolic landscape of TS is characterized by a nonspecific pattern of increased motor cortical activity identified in other hyperkinetic disorders. TS is also associated with a specific brain network characterized by a reduction in the activity of limbic basal ganglia-thalamocortical projection systems.     

Brain morphometry in Tourette's syndrome: the influence of comorbid attention-deficit/hyperactivity disorder

Three separate groups, using MRI, have reported basal ganglia abnormalities in Tourette's syndrome (TS). We found similar abnormalities in boys with attention-deficit/hyperactivity disorder (ADHD). Because TS and ADHD are frequently comorbid, we contrasted ADHD boys with and without TS along with control subjects. As expected, we found a significant loss of the normal globus pallidus asymmetry in the patients, but presence or absence of TS did not differentiate the ADHD groups. We conclude that accounting for ADHD comorbidity will be important in future TS morphometric studies.     

Social support for elderly patients with chronic wounds

Few attempts have been made to measure the social support received by elderly patients with chronic wounds. To focus research on these issues, an established model integrating the various roles played by social support in the adaptation of patients to stressful situations was applied. Two questionnaires were used to measure perceived social support and coping in a sample of patients with leg ulcers (N = 15, mean age 70.4 years) or diabetic foot ulcers (N = 15, mean age 63.6 years) at two time-points over a four-month period. The results indicate that there were no statistical differences between the groups. The overall levels of social support were low, with emotional support recorded most frequently. The standardised scores for types of coping indicate no unusual patterns, although the scores for logical analysis were low. However, there was considerable variation in the types of coping strategies used by individuals.     

Food habits of young and middle-aged women living outside the capital cities of Australia

Young (18-22 years) and middle-aged (45-49 years) women living in urban and rural areas of New South Wales completed a brief food frequency questionnaire as part of a wider health survey. Urban women in both age groups consumed meat less frequently than women in rural areas, and women in the less populated rural areas were more likely to eat green and yellow vegetables and least likely to eat dried beans. There were few other geographic differences in food habits. Middle-aged women consumed reduced-fat milk, fruit, vegetables, fish, biscuits and cakes significantly more frequently, and rice, pasta, full-cream milk, fried food and take-away food less frequently than younger women. Smokers in both age groups consumed fresh fruit, vegetables and breakfast cereals significantly less frequently than non-smokers, and women with low levels of habitual physical activity consumed fresh fruit and cereals less frequently than more active women. The findings suggest that strategies aimed at changing eating behaviours should be age-group-specific and targeted specifically to smokers and less active women.     

DNA adducts, mutant frequencies and mutation spectra in lambda lacZ transgenic mice treated with N-nitrosodimethylamine

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an increasingly recognized autosomal dominant disorder that leads to cerebrovascular manifestations in early adulthood. This study delineates the phenotypic spectrum and the natural history of the disease in 102 affected individuals from 29 families with biopsy-proven CADASIL. Recurrent ischemic episodes (transient ischemic attack [TIA] or stroke) were the most frequent presentation found in 71% of the cases (mean age at onset, 46.1 years; range, 30-66 years; SD, 9.0 years). Forty-eight percent of the cases had developed cognitive deficits. Dementia (28%) was frequently accompanied by gait disturbance (90%), urinary incontinence (86%), and pseudobulbar palsy (52%). Thirty-nine patients (38%) had a history of migraine (mean age at onset, 26.0 years; SD, 8.2 years), which was classified as migraine with aura in 87% of the cases. Psychiatric disturbances were present in 30% of the cases, with adjustment disorder (24%) being the most frequent diagnosis. Ten patients (10%) had a history of epileptic seizures. To delineate the functional consequences of ischemic deficits, we studied the extent of disability in different age groups. The full spectrum of disability was seen in all groups older than age 45. Fifty-five percent of the patients older than age 60 were unable to walk without assistance. However, 14% in this age group exhibited no disability at all. Kaplan-Meier analysis disclosed median survival times of 64 years (males) and 69 years (females). An investigation of the 18 multiplex families revealed marked intrafamilial variations.     

Risk factor reduction behaviours in coronary angioplasty and myocardial infarction patients

A recent study asked percutaneous transluminal coronary angioplasty (PTCA) patients in Saskatchewan (n = 210) to identify specific information surrounding their rehabilitation behaviours and motivation to change lifestyle. The scale used to elicit this information was developed and previously used to determine patient risk factor knowledge and lifestyle change behaviours among myocardial infarction (MI) patients during rehabilitation phases. The purpose of this article is to discuss the results of PTCA patients' responses and compare these findings to previously obtained data from MI patients. Risk factors most frequently reported by both PTCA and MI patients as causative factors of their heart problems included diet, job stress, low levels of exercise, and other patient-perceived factors. When asked about lifestyle restrictions post-hospitalization, PTCA patients reported more lifestyle restrictions in activities of daily living (recreation, job, social life, sexual activity and driving) following hospitalization than MI patients. Both groups of patients reported high levels of dietary changes made post-hospitalization but findings reflected that MI patients had initiated more modifiable risk factor changes overall than PTCA patients. Comparative results showed that MI patients were more likely to initiate risk factor reduction behaviours for modifiable factors such as smoking, weight reduction, job/family stress, and exercise than PTCA patients. These findings offer insight into differences between PTCA and MI patients with respect to cardiac rehabilitation behaviours and may suggest the need for different teaching-learning approaches and/or more focused patient education for PTCA patients. A goal of cardiac rehabilitation is to encourage patient initiation and maintenance of lifestyle modification behaviours based on identified risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)     

Neuroticism and extraversion in Turner's Syndrome.

Administered the Maudsley Personality Inventory to 5 groups of female Ss: (a) 13 Turner Syndrome Ss (mean age 19 yrs 2 mo) with karyotype 45X, (b) 18 Turner Syndrome (TS) Ss (mean age 26 yrs 11 mo) with other types of sex chromosomal abnormalities, (c) 16 sisters of Ss (mean age 24 yrs 2 mo), (d) 9 Ss with growth retardation and primary amenorrhea (mean age 22 yrs 4 mo), and (e) 19 nurses (mean age 22 yrs 8 mo). The results are compared to English and American normative values. The total group of TS Ss obtained a low Neuroticism (N) score compared to the control groups. When the total group was divided on the basis of their karyotypes, the low N score could be referred solely to Ss with karyotype 45X, who scored significantly lower than any other group tested so far with the MPI. TS Ss with chromosomal abnormalities other than 45X scored within normal limits. No variables other than karyotype 45X were related to an extremely low N score. It is concluded that exceptional emotional stability, as reflected in a very low N score on the MPI, is concomitant with the total absence of one sex chromosome, which is probably due to a developmental abnormality of the CNS. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

De novo mutations of the growth hormone gene: an important cause of congenital isolated growth hormone deficiency?

OBJECTIVES: To determine the epidemiological features of injuries associated with fireworks. DESIGN: A retrospective study of reported cases. SUBJECTS: Subjects were those who attended selected Victorian hospital emergency departments (n = 17) and those admitted for firework related injuries (n = 16). RESULTS: The mean (SD) age of attenders at emergency department between January 1988 and June 1996, was 8.9 (6.2) years and most (88%) were under 18 years of age. Males accounted for 71% of the cases. The most common anatomical sites and types of injury were head (47%) and burns (88%), respectively. About 53% of the injuries were caused by firecrackers, the remainder by sparklers and penny bangers. Among those admitted to hospital between July 1987 and June 1996, the mean (SD) age was 22.9 (14.8) years and 50% were under 18 years of age. Males accounted for 87% of the cases. There was a significant difference in mean age between those admitted and not admitted to hospital, the former being significantly older. CONCLUSIONS: Although relatively rare, injuries from fireworks still occur in Victoria after legislative restrictions on their sale in 1985. Consequently, there is a potential risk for injuries among children, particularly from firecrackers. More enforcement of the regulations, education, and parental supervision are needed to prevent injuries from fireworks.     

Effect of age on outcome with primary angioplasty versus thrombolysis

OBJECTIVES: The purpose of this study was to determine how risks associated with increasing age differed in patients treated with percutaneous transluminal coronary angioplasty versus thrombolysis. BACKGROUND: Advancing age is a risk factor for adverse outcome in patients with acute myocardial infarction. Primary angioplasty has been thought to be particularly beneficial in higher risk patients including the elderly. There is, however, limited data on any differential incremental benefit of angioplasty compared with thrombolysis in candidates for either treatment. METHODS: In the GUSTO-IIb angioplasty substudy, 1,138 patients were randomized to receive primary angioplasty or accelerated tissue-type plasminogen activator (t-PA). The effect of age on outcome was assessed as a discrete and continuous variable for each treatment group. Models using age as a linear factor as well as cubic spline transformations were used for the major end points of 30-day death or disabling stroke; death or reinfarction; and death, reinfarction or disabling stroke. RESULTS: For each 10-year patient group, outcome was improved with angioplasty (n = 565) compared with t-PA (n = 573). Irrespective of treatment, however, risk increased with age. After adjusting for baseline characteristics, each increment of 10 years of age increased the risk of death or myocardial infarction by 1.32 (95% confidence interval 1.04 to 1.76, p = 0.022). For all adverse outcomes, this incremental effect of increasing age was constant. CONCLUSIONS: Advancing age is associated with worse outcomes, and the risks increase in proportion to age. Although primary angioplasty improves outcomes over thrombolysis, it does not appear to be more beneficial in older than in younger patient groups. The incremental adverse effect of age does not vary by treatment strategy.     

A PET study of Turner's syndrome: effects of sex steroids and the X chromosome on brain

Women with Turner's syndrome (TS) allow us to study the neurobiological associates of cognitive and behavioral abnormalities because they lack one/part of one X chromosome, and endogenous estrogen. We studied 13 healthy controls (mean age +/- SD, 28 +/- 6 years) and 16 TS subjects (mean age +/- SD, 26 +/- 6 years). We measured cognitive abilities using neuropsychological tests, and cerebral metabolic rates for glucose with positron emission tomography. Compared to controls, TS subjects had significant absolute hypermetabolism in most brain areas; however, normalized metabolism was significantly lower in TS subjects than controls in the insula and association neocortices bilaterally, and there were significant differences in functional metabolic associations of brain region pairs originating in occipital cortex bilaterally, and within the right hemisphere. There were significant correlations between right-left cognitive and metabolic asymmetries in the TS group. Also, within TS a preliminary analysis demonstrated "X chromosome dosage" effects in language ability and left temporal metabolism, asymmetry of right-left test scores, and parietal metabolism. We hypothesize that within TS: i) generalized brain hypermetabolism reflects global abnormalities in neuron packing; ii) neuronal abnormalities occur in association neocortex that differ in nature or extent from whole brain and are associated with significant differences in normalized metabolism; iii) cognitive deficits are related to brain metabolic abnormalities; and iv) social-behavioral problems may be related to abnormalities of brain metabolism. Moreover, in human brain the X chromosome involved in development of the association neocortices.     

A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects

BACKGROUND: Research on the dimensional structure and reliability of the Hospital Anxiety and Depression Scale (HADS) and its relationship with age is scarce. Moreover, its efficacy in determining the presence of depression in different patient groups has been questioned. METHODS: Psychometric properties of the HADS were assessed in six different groups of Dutch subjects (N = 6165): (1) a random sample of younger adults (age 18-65 years) (N = 199); (2) a random sample of elderly subjects of 57 to 65 years of age (N = 1901); (3) a random sample of elderly subjects of 66 years or older (N = 3293); (4) a sample of consecutive general practice patients (N = 112); (5) a sample of consecutive general medical out-patients with unexplained somatic symptoms (N = 169); and (6) a sample of consecutive psychiatric out-patients (N = 491). RESULTS: Evidence for a two-factor solution corresponding to the original two subscales of the HADS was found, although anxiety and depression subscales were strongly correlated. Homogeneity and test-retest reliability of the total scale and the subscales were good. The dimensional structure and reliability of the HADS was stable across medical settings and age groups. The correlations between HADS scores and age were small. The total HADS scale showed a better balance between sensitivity and positive predictive value (PPV) in identifying cases of psychiatric disorder as defined by the Present State Examination than the depression subscale in identifying cases of unipolar depression as defined by ICD-8. CONCLUSIONS: The moderate PPV suggests that the HADS is best used as a screening questionnaire and not as a 'case-identifier' for psychiatric disorder or depression.     

Exposure to missile attacks: the impact of the Persian Gulf War on physical health behaviours and psychological distress in high and low risk areas in Israel

The purpose of this study was to compare residents of an area (Tel-Aviv), which was severely afflicted by SCUD missiles during the Persian Gulf War (high risk region), to residents of a low-risk region (Jerusalem) in terms of: (a) changes in physical health, in use of medical or psychological services, and in health behaviours during the period of the war compared to the preceding month; (b) levels of psychological distress (somatization and anxiety) during the war; (c) characteristics of persons at highest risk for psychological distress. Respondents were randomly chosen and interviewed by telephone (N = 545 in Tel-Aviv, N = 406 in Jerusalem). The respondents in both regions reported significant yet similar deterioration in physical health status, and an increase in detrimental health behaviours during the Gulf War. Tel-Aviv residents had significantly higher levels of psychological distress as compared to residents of Jerusalem: in somatization 18 vs 12% respectively (OR = 2.44, CI = 1.39-4.28), in anxiety 34 vs 26% respectively (OR = 1.62, CI = 1.1-2.42). In addition to place of residence, age, ethnicity, religiosity and self-assessed health were identified as characteristics of persons at greater risk for psychological distress.     

Vaginal douching as a risk factor for cervical Chlamydia trachomatis infection

Females with Turner syndrome (TS) are alleged to have increased numbers of melanocytic naevi. Although a high count of acquired melanocytic naevi (AMN) is one of the major risk factors for melanoma, this malignancy has been reported only rarely in patients with TS. The purpose of this study was to explore the effects of environmental and genetic factors on AMN count and density in TS. AMN count and density in 24 patients with TS treated with growth hormone (GH). 24 GH-treated females with GH deficiency (GHD) and 24 normal females were compared in a cross-sectional study. The average AMN density in TS was 50 naevi/m2 as compared with 18 naevi/m2 in the GHD group and 24 naevi/m2 in normal controls (P = 0.001 and P = 0.004, respectively). Duration of GH therapy did not correlate with AMN count (P = 0.44) or AMN density (P = 0.81). The pattern of distribution of naevi between constantly exposed, intermittently exposed and unexposed skin was similar in all groups. Sun exposure was the major factor that affected the regional AMN densities in the control groups, but not in the TS group. The findings of our study indicate that the effects of environmental factors on AMN count and density may vary among genetically different populations. A review of the literature suggested that melanoma is no more prevalent in TS than in the general population.     

Drug abuse day treatment: a randomized clinical trial comparing day and residential treatment programs

Clients entering a therapeutic community (TC)-oriented drug treatment program were randomly assigned to day or residential conditions and interviewed at 2 weeks and 6 months after admission. Outcomes included Addiction Severity Index composite scores and summary scores for the Beck Depression Inventory, Symptom Checklist-90-R, and a social support scale. Only clients who remained in treatment for at least 2 weeks were included. The mean age of the sample (N = 261) was 32.9 (SD = 6.7 years) and the mean education level was 12.1 years (SD = 1.9 years); 30% were women. Comparison of outcome scores at 6 months between groups, while controlling for baseline values, indicated greater improvement for residential clients on social problems and psychiatric symptoms. The groups were similar on the 8 remaining outcomes, including measures of alcohol and drug problems. Overall, the level of improvement among day treatment clients was not significantly different from that of residential clients.     

Potentially asphyxiating conditions and spastic cerebral palsy in infants of normal birth weight

OBJECTIVE: Our purpose was to examine the association of cerebral palsy with conditions that can interrupt oxygen supply to the fetus as a primary pathogenetic event. STUDY DESIGN: A population-based case-control study was performed in four California counties, 1983 through 1985, comparing birth records of 46 children with disabling spastic cerebral palsy without recognized prenatal brain lesions and 378 randomly selected control children weighing > or = 2500 g at birth and surviving to age 3 years. RESULTS: Eight of 46 children with otherwise unexplained spastic cerebral palsy, all eight with quadriplegic cerebral palsy, and 15 of 378 controls had births complicated by tight nuchal cord (odds ratio for quadriplegia 18, 95% confidence interval 6.2 to 48). Other potentially asphyxiating conditions were uncommon and none was associated with spastic diplegia or hemiplegia. Level of care, oxytocin for augmentation of labor, and surgical delivery did not alter the association of potentially asphyxiating conditions with spastic quadriplegia. Intrapartum indicators of fetal stress, including meconium in amniotic fluid and fetal monitoring abnormalities, were common and did not distinguish children with quadriplegia who had potentially asphyxiating conditions from controls with such conditions. CONCLUSION: Potentially asphyxiating conditions, chiefly tight nuchal cord, were associated with an appreciable proportion of unexplained spastic quadriplegia but not with diplegia or hemiplegia. Intrapartum abnormalities were common both in children with cerebral palsy and controls and did not distinguish between them.     

Pathways to Violence in the Children of Mothers Who Were Depressed Postpartum.

The impact of postnatal depression on a child's risk for violent behavior was evaluated in an urban British community sample (N=122 families). Mothers were interviewed during pregnancy, at 3 months postpartum, and when the child was 1, 4, and 11 years of age. Mothers, teachers, and children reported on violent symptoms at age 11. Structural equation modeling revealed that the child's violence was predicted by the mother's postnatal depression even when her depression during pregnancy, her later history of depression, and family characteristics were taken into account. Violence was associated with symptoms of attention-deficit/hyperactivity disorder and problems with anger management. Children were most violent if mothers had been depressed at 3 months and at least once thereafter. (PsycINFO Database Record (c) 2010 APA, all rights reserved)