ROSIGLITAZONE EVALUATED FOR CARDIOVASCULAR OUTCOMES IN ORAL AGENT COMBINATIONTHERAPY FOR TYPE 2 DIABETES (RECORD): A MULTI...
ROSIGLITAZONE EVALUATED FOR CARDIOVASCULAR OUTCOMES INORAL AGENT COMBINATION THERAPY FOR TYPE 2 DIABETES(RECORD): A MULTIC...
FINDINGS. 321 PEOPLE IN THE ROSIGLITAZONE GROUP AND 323 IN THEACTIVE CONTROL GROUP EXPERIENCED THE PRIMARY OUTCOMEDURING A...
ROSIGLITAZONE EVALUATED FOR CARDIOVASCULAROUTCOMES IN ORAL AGENT COMBINATION THERAPY FORTYPE       2      DIABETES       (...
THE PRIMARY ENDPOINT WAS CARDIOVASCULARHOSPITALISATION, OR CARDIOVASCULAR DEATH, WITH AHAZARD RATIO (HR) NON-INFERIORITY M...
UPPER AND DISTAL LOWER LIMB FRACTURE RATESWERE INCREASED MAINLY IN WOMEN RANDOMLYASSIGNED TO ROSIGLITAZONE. MEAN HB A1C WA...
 1 WHAT WAS THE MAIN PURPOSE OF THE STUDY? A TO TREAT PATIENTS WITH TYPE 2 DIABETES. B TO DETERMINE THE INCIDENCE OF HO...
 3 WHAT DID THE TWO GROUPS HAVE IN COMMON? A PARTICIPANTS WERE GIVEN SULFONYLUREA. B PARTICIPANTS WERE GIVEN ROSIGLITAZ...
5 THE ADDITION OF ROSIGLITAZONE TO GLUCOSELOWERING THERAPY IN PEOPLE WITH TYPE 2DIABETES IS CONFIRMED TO:A INCREASE THE RI...
1.   C2.   B3.   C4.   C5.   B
 1. Rosiglitazone evaluated for cardiovascular  outcomes in oral agent combination therapy for  type 2 diabetes 2. Rosig...
 4. Interpretation. The addition of  rosiglitazone to glucose lowering therapy for  people with type 2 diabetes is confir...
PIGMENTARY DISORDERS IN LATIN AMERICA FALABELLA, RAFAEL DERMATOLOGIC CLINICS - VOLUME 25, ISSUE3 W. B. SAUNDERS COMPANY JU...
PIGMENTARY DISORDERS IN LATIN AMERICA FALABELLA, RAFAELDERMATOLOGIC CLINICS - VOLUME 25, ISSUE 3 W. B. SAUNDERSCOMPANY JUL...
ALTHOUGH PA IMPROVES SPONTANEOUSLY AFTER PUBERTY, LOW POTENCYCORTICOSTEROIDS,      SUCH   AS    1%   HYDROCORTISONE      O...
PIGMENTARY    DISORDERS    IN   LATIN   AMERICA.FALABELLA, RAFAEL; DERMATOLOGIC CLINICS - VOLUME25, ISSUE 3 W. B. SAUNDERS...
A FOLLICULAR VARIETY WITH MILD HYPERKERATOSIS ATTHE HAIR FOLLICLE OSTIUM FREQUENTLY OCCURS. ONHISTOLOGIC EXAMINATION, EPID...
SOME OF THE INVOLVED CHEMICALS ARE CATECHOLAND BENZENE DERIVATIVES USED AS ANTISEPTICS ANDCLEANSERS,    PESTICIDES,   AND ...
 6. PITYRIASIS ALBA IS A COMMON DISORDER    FREQUENTLY OBSERVED IN:   A ARMS AND LEGS   B FACE, ARMS AND FOREARMS   C ...
 8. TO CONTROL THIS DISORDER IT IS USEFUL TO: A USE A FREQUENT EMOLLIENT APPLICATION B USE HIGH POTENCY CORTICOSTEROIDS...
 10. PITYRIASIS ALBA IS DANGEROUS BECAUSE: A PATIENTS BECOME INTOLERANT TO LIGHT B SOME OF THE TREATMENTS ARE TOXIC  C ...
6. B7. A8. A (y C)9. A10. DAcral: Relating to or affecting the peripheral parts, e.g., limbs, fingers, ears, etc.
 6. Pytiriasis alba (PA) is a common disorder  … mainly observed on facial areas and  sunlight exposed surface of arms an...
 9. Skin contact with diverse chemicals may  induce acquired skin hypopigmentation … 10. If vitiligo-like depigmentation...
 A graft/ to graft/ grafting
UPPER RESPIRATORY TRACT INFECTIONS IN CHILDREN ZORC, JOSEPH J. CLINICALPEDIATRIC EMERGENCY MEDICINE EL SERVIER DOI.10.1016...
UPPER RESPIRATORY TRACT INFECTIONS IN CHILDRENZORC, JOSEPH J. CLINICAL PEDIATRIC EMERGENCYMEDICINE    EL   SERVIER  DOI.10...
IN THIS ARTICLE, THE TERM “RHINOSINUSITIS” IS USED TODESCRIBE ILLNESSES WITH PREDOMINANTLY NASAL SYMPTOMS(INCLUDING THE CO...
UPPER     RESPIRATORY      TRACT INFECTIONS   INCHILDREN. ZORC, JOSEPH J. CLINICAL PEDIATRICEMERGENCY          MEDICINE;  ...
SOME     JUDGMENT     IS   REQUIRED     INDETERMINING     WHICH    PART    OF    THERESPIRATORY MUCOSA IS MOST AFFECTED. I...
CHILDREN WHO HAVE COUGH AS THEPREDOMINANT SYMPTOM ARE CONSIDERED TOHAVE BRONCHITIS (A LOWER RESPIRATORYTRACT INFECTION). T...
 11. WHY ARE UPPER RESPIRATORY TRACT INFECTIONS    SO DIFFICULT TO DIAGNOSE IN CHILDREN?    A THEY GET MANY OF THEM.   ...
 13. THE CAUSE OF THE ILLNESS IN RESPIRATORY    INFECTIONS IS BEST DETERMINED BY THE:    A SYMPTOMS.    B PRESENCE OF A...
15. OME, AOM, AND SCOM ALL BELONG TO THEFAMILY OF THE INFECTIONS CALLED: A BRONCHITIS B PHARYNGITIS C RHINOSINUSITIS D OTI...
11. B12. B13. A (D?)14. B15. D
 11. Within each category of illness, there is a  range of related conditions that may have  similar or overlapping clini...
 14. The term “otitis media” is used to  describe illnesses of predominantly  middle ear symptoms 15. …including acute o...
upper/lower respiratory tract infections/ up, low… they may have overlapping clinical  presentations to  overlap/overlappi...
FREQUENCY OF GERD SYMPTOMS IN ELDERLY PATIENTS WHO COME TO A FAMILYMEDICINE CLINIC. OBJECTIVES: TO ASCERTAIN THE PREVALENC...
FREQUENCY OF GERD SYMPTOMS IN ELDERLYPATIENTS WHO COME TO A FAMILY MEDICINECLINIC. OBJECTIVES: TO ASCERTAIN THEPREVALENCE ...
THEY SHOULD NOT HAVE COGNITIVEDAMAGE, WHICH WAS ASCERTAINED BY THEFOLSTEIN MINI MENTAL STATE EXAMINATION.THOSE PATIENTS TH...
GERD PREVALENCE WAS 25% (IC 95 % 21-29) THEAVERAGE AGE OF PATIENTS WITH AND WITHOUTGERD WAS 68 ± 7 YEARS AND 70 ± 7 YEARSR...
 16. ABOUT THE DESIGN OF THE STUDY: A RESEARCHERS USE A PROSPECTIVE    DESIGN, PARTICIPANTS WERE FAMILY MEDICINE    SPEC...
 18 RESEARCHERS OBTAIN THE INFORMATION ABOUT    DIAGNOSIS, DRUGS PRESCRIPTIONS, AND    PHARMACOLOGICAL AND NON PHARMACOLO...
20 THE MAIN CONCLUSION OF THE STUDY WAS:A PATIENTS WITHOUT GERD STILL RECEIVEDTREATMENT.B PARTICIPANTS OFTEN HAD GERD SYMP...
16. C17. B18. D19. A20. B
 16. The study … included patients aged sixty  and older, regardless of gender. 17. They should not have cognitive  dama...
 20. Elderly patients attending to primary care facilities often have GERD symptoms, but they are not properly diagnosed ...
Regardless/regarding, in regards to
NEW THINKING ON HOW TO PROTECT THE HEART BY JANE E. BRODY SURGERY MAY NOT BETHE BEST WAY TO AVOID A HEART ATTACK OR SUDDEN...
NEW THINKING ON HOW TO PROTECT THE HEART. BYJANE E. BRODY. SURGERY MAY NOT BE THE BEST WAYTO AVOID A HEART ATTACK OR SUDDE...
BUT BEHIND THEM A RELATIVELY NEW FACTOR HASEMERGED THAT MAY BE EVEN MORE IMPORTANT AS ACAUSE OF HEART ATTACKS THAN, SAY, H...
BUT IN COUNTRIES LIKE FINLAND AND THE UNITEDSTATES WHERE PLATES WERE TYPICALLY FILLED WITHRED MEAT, CHEESE AND OTHER FOODS...
 21. ACCORDING TO THE ARTICLE, THE BEST WAY    TO AVOID A HEART ATTACK IS:   A EATING A LOW FAT DIET AND EXERCISING    V...
 23. THE MEDITERRANEAN DIET CONSISTS    MAINLY OF:   A LOW CARBOHYDRATES   B RED MEAT AND CHEESE   C UNSATURATED FATS...
 25. FROM THE ARTICLE WE CAN CONCLUDE THAT: A IF WE FOLLOW A LOW-FAT DIET AND EXERCISE  VIGOROUSLY, WE WILL AVOID HAVING...
21. C22. D23. C24. B (Esta respuesta no está en la lectura)25. B
 21. But behind them, a relatively new factor  has emerged that may be even more  important as a cause of heart  attacks,...
 23. … the heart-healthy Mediterranean diet is not really low in fat, but its main source of fat – olive oil and oily fis...
 24. La respuesta no está en la lectura.  25. It is not that old advice, like eatinga low-fat diet or exercising vigorous...
MATERNAL MORBIDITY, MORTALITY, AND RISK ASSESSMENT. MATERNALMORTALITY IS THE TIP OF THE MATERNAL MORBIDITY ICEBERG; SEVERA...
THESE SURVEYS ON MATERNAL MORTALITY SURVEILLANCES ARELIMITED IN SCOPE BECAUSE THE INFORMATION IS OBTAINED FROMDEATH CERTIF...
MATERNAL MORBIDITY, MORTALITY, AND RISK ASSESSMENT. MATERNAL MORTALITY IS THE TIP OF THEMATERNAL MORBIDITY ICEBERG; SEVERA...
MATERNAL MORBIDITY, MORTALITY, AND RISKASSESSMENT. MATERNAL MORTALITY IS THE TIP OFTHE MATERNAL MORBIDITY ICEBERG; SEVERAL...
ALTHOUGH THE RISK FOR DEATH FROMCOMPLICATIONS OF PREGNANCY DECREASED DURINGTHE 20TH CENTURY IN THE UNITED STATES, THECENTE...
ACCURATE STATISTICS ARE LACKING, THUS RESULTING INONLY A SNAPSHOT OF THE ACTUAL MATERNAL MORBIDITYAND MORTALITY. THE RECEN...
 26. FOR MATERNAL MORTALITY, A RISK FACTOR COULD    BE:   A EXCESIVE INTERDISCIPLINARY COMMUNICATION BY    HEALTH CARE P...
 28. ACCORDING TO THE FINDINGS FROM THE    STUDY CONDUCTED BY WHO, UNICEF AND THE    UNFPA, WHAT IS THE CONCLUSION?:   A...
 29. ALTHOUGH THE U.S. DEPARTMENT OF HEALTH AND  HUMAN SERVICES HAS PROJECTED GOALS FOR 2010, WHAT IS  THE ACTUAL RATIO?:...
26. B27. A28. D29. A30. D
 26. Maternal mortality is the yardstick to  measure when health care personnel fail to  recognize risks, lack interdisci...
 28. A collaborative effort involving World  Health Organization (WHO), United  Nations Children’s Fund (UNICEF), and  Un...
 30. … and cardiomyopathy are also  significant contributors to maternal  mortality and morbidity. (A, B y C son causas....
VACCINE TAKES AIM AT HYPERTENSION. ORLANDO, FLA. SOME PATIENTS WITH HYPERTENSION HAVEINADEQUATE CONTROL OF BLOOD PRESSURE ...
VACCINE TAKES AIM AT HYPERTENSION. ORLANDO, FLA. SOME PATIENTSWITH HYPERTENSION HAVE INADEQUATE CONTROL OF BLOODPRESSURE B...
NUSSBERGER SAID HE IS NOT CONCERNED THAT THE VACCINE MIGHTCAUSE HYPOTENSION BECAUSE ANTIBODY TITERS STARTED TO DECREASESHO...
VACCINE TAKES AIM AT HYPERTENSION. ORLANDO, FLA.SOME PATIENTS WITH HYPERTENSION HAVEINADEQUATE CONTROL OF BLOOD PRESSURE B...
CYTOO6-ANGQB, WHICH IS UNDERDEVELOPMENT BY CYTOS BIOTECHNOLOGY AG(ZURICH, SWITZERLAND), IS A VIRUS-SHAPEDNONINFECTIOUS PAR...
NUSSBERGER SPECULATED THAT IF THE CYTOO6-ANGQBVACCINE IS ULTIMATELY APPROVED, PATIENTS WOULD BEABLE TO AVOID THE NEED FOR ...
 31 ABOUT PATIENTS WHO DO NOT TAKE THEIR TREATMENT    REGULARY:   A THESE PATIENTS HAVE AN ADEQUATE CONTROL OF    BLOOD ...
 33 WITH RESPECT TO THE CYT006-ANGQB    VACCINE, CONSIDERATIONS HAVE BEEN MADE THAT:   A THE VACCINE MAY PRODUCE HYPERTE...
35 WHAT SHALL BE DONE TO DETERMINE THELARGEST ANTIBODY RESPONSE AND GREATESTREDUCTIONS IN BLOOD PRESSURE?A A SMALL TRIAL T...
31. D32. B33. C (B?)34. B35. A
 31. Some patients with hypertension  have inadequate control of their blood  pressure because they are not  consistently...
 33. Nussberger said he is not concerned that the vaccine might cause hypotension because antibody titers started to decr...
 3 4. … the small size of the target molecule  limits the number of epitopes that could be  affected. 35. He said the ne...
 A booster/ to boost, a boost/ a booster shot Adherent=compliant Adherence=compliance To adhere=to comply
WILLIAM THOMAS GREEN MORTON ON OCTOBER 16, 1846, DEMONSTRATED THAT ETHER COULD INDUCEINSENSIBILITY TO THE SURGEON’S KNIFE....
WILLIAM THOMAS GREEN MORTON ON OCTOBER16, 1846, DEMONSTRATED THAT ETHER COULD INDUCEINSENSIBILITY TO THE SURGEON’S KNIFE. ...
THAT SAME JANUARY DAY, SIMPSON WAS APPOINTED THE QUEEN’SPHYSICIAN IN SCOTLAND. SIMPSON CONTINUED TO PROVIDEANESTHESIA IN C...
WILLIAM THOMAS GREEN MORTON ON OCTOBER16, 1846, DEMONSTRATED THAT ETHER COULDINDUCE INSENSIBILITY TO THE SURGEON’S KNIFE. ...
JAMES YOUNG SIMPSON, THE PROFESSOR OFMIDWIFERY IN EDINBURGH, SCOTLAND, WAS AMONGTHE FIRST TO USE ETHER FOR THE RELIEF OF L...
ON THE EVENING OF NOVEMBER 4, 1847, SIMPSON AND HISFRIENDS INHALED IT AFTER DINNER AT A PARTY INSIMPSON’S HOME. THEY PROMP...
 36. WILLIAM THOMAS GREEN MORTON USED A ETHER ON A PATIENT SO THERE WOULD BE NO    SENSIBILITY IN THE OPERATION.   B ET...
   38. SIMPSON PREFERRED TO CONTINUE   A USING ETHER FOR CHILDBIRTH   B USING ETHER AND CHLOROFORM FOR CHILDBIRTH   C ...
40. THE PAIN ASSOCIATED WITH CHILDBIRTH WASBELIEVED TO BE CAUSED ASA A CONSEQUENCE OF A DEFORMED PELVIS.B A DEVINE PUNISHM...
36. A37. B38. D39. D40. B
 36. William Thomas Green Morton on  October 16, 1846, demonstrated that ether  could induce insensibility to the surgeon...
 39. ,… Simpson published a pamphlet entitled  “Answers to the Religious Objections Advanced  against the Employment of A...
A 71-YEAR-OLD MAN PRESENTED WITH A 2-WEEK HISTORY OF PAIN ANDSWELLING OF HIS LEFT ARM. EXAMINATION REVEALED ACRAGGY, MOBIL...
SYSTEMIC THERAPY WAS NOT OFFERED ON THE BASIS OF POOR ANDDETERIORATING PERFORMANCE STATUS. UNFORTUNATELY, THEPATIENT DIED ...
A 71-YEAR-OLD MALE PRESENTED WITH A 2-WEEK HISTORY OF AHARD, PAINFUL, NONPULSATILE MASS IN HIS LEFT UPPER ARM. EXAMINATION...
A 71-YEAR-OLD MALE PRESENTED WITH A 2-WEEK HISTORYOF A HARD, PAINFUL, NONPULSATILE MASS IN HIS LEFTUPPER ARM. EXAMINATION ...
HE UNDERWENT PALLIATIVE RADIOTHERAPY TO THEMASS IN THE ARM. THIS PROVIDED GOOD RELIEF FROMPAIN AND SWELLING WITHIN 2 WEEKS...
LUNG CARCINOMA SEEMS TO BE THE UNDERLYING PRIMARYCANCER IN MOST OF THESE CASES. MANY OTHERTUMORS, SUCH AS KIDNEY, STOMACH,...
 41. BASED ON THE CLINICAL AND THE DIVERSE    IMAGING STUDY’S FINDINGS, WHICH OF THE    FOLLOWING WAS THE PRESUMPTIVE DIA...
 42. THE PATIENT WAS SUBMITTED TO PALLIATIVE    CARE AND NON SYSTEMIC THERAPY BASED ON WHAT    REASON?   A A POSITIVE CK...
 43. WHICH OF THE FOLLOWING IS NOT    DESCRIBED IN THE PRESENT ARTICLE AS A    FACTOR THAT CONTRIBUTES TO THE RARE    OCC...
 44. WHICH IS THE PRIMARY UNDERLYING CANCER IN  MOST CASES OF INTRAMUSCULAR METASTASES? A LUNG CARCINOMA. B KIDNEY AND ...
41. C42. D43. A44. A45. ACraggy: riscoso, escarpado
 41. Ultrasonography of the left arm  demonstrated … a mass … located in …  the left triceps muscle. A presumptive  diagn...
 43. Intramuscular metastases in cancer patients are rare. It is thought that muscular contractile functions, local pH en...
 44. Lung carcinoma seems to be the  underlying primary cancer in most of  these cases. 45. The most frequent presentati...
MIGRAINE IS CONSIDERED TO BE AN EPISODIC CONDITION WITH NOLONG-TERM CONSEQUENCES. HOWEVER, RECENT STUDIES SUGGESTTHAT MIGR...
THE PRESENCE OF INFARCT-LIKE LESIONS (TOTAL) ANDSPECIFICALLY LOCATED IN THE CORTICAL, SUBCORTICAL, ANDCEREBELLAR REGIONS W...
MIGRAINE IS CONSIDERED TO BE AN EPISODIC CONDITION WITH NO LONG-TERM CONSEQUENCES.HOWEVER, RECENT STUDIES SUGGEST THAT MIG...
MIGRAINE IS CONSIDERED TO BE AN EPISODICCONDITION WITH NO LONG-TERM CONSEQUENCES.HOWEVER, RECENT STUDIES SUGGEST THAT MIGR...
BETWEEN 2002 AND 2006, MORE THAN 26 YEARSLATER, BRAIN MRIs WERE PERFORMED.PARTICIPANTS REPORTING HEADACHES ONCE ORMORE PER...
AFTER ADJUSTING FOR AGE, SEX, AND FOLLOW-UPTIME, COMPARED WITH THOSE NOT REPORTINGHEADACHES ONCE OR MORE PER MONTH (N=3243...
 46 RECENT STUDIES SUGGEST THAT MIGRAINE    ATTACKS MAY BE ASSOCIATED WITH PATHOLOGIC    CHANGES IN THE BRAIN. WHICH LOCA...
 48 THOSE WITH MIDLIFE MIGRAINE WITH AURA HAD AN    ODDS RATIO OF 1.4 OF LATE-LIFE INFARCT-LIKE LESIONS.    THIS WAS MORE...
 50 WHICH OF THE FOLLOWING TYPES OF    HEADACHES WERE NOT ASSOCIATED WITH AN    INCREASED RISK OF INFARCT-LIKE LESIONS AT...
46. A47. C48. A49. B50. C
 46. However, recent studies suggest that  migraine attacks may be associated with  patological changes in the  brain, pa...
 49. … and specifically located in the  cortical, subcortical, and cerebellar  regions were the main outcome  measure. 5...
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CAM INGLES 1

  1. 1. ROSIGLITAZONE EVALUATED FOR CARDIOVASCULAR OUTCOMES IN ORAL AGENT COMBINATIONTHERAPY FOR TYPE 2 DIABETES (RECORD): A MULTICENTRE, RANDOMISED, OPEN-LABEL TRIAL.PHILIP D. HOME MD, STUART J. POCOCK PHD, AND COLLEAGUES. ROSIGLITAZONE IS AN INSULINSENSITIZER USED IN COMBINATION WITH METFORMIN, A SULFONYLUREA, OR BOTH, FORLOWERING BLOOD GLUCOSE IN PEOPLE WITH TYPE 2 DIABETES. WE ASSESSED CARDIOVASCULAROUTCOMES AFTER ADDITION OF ROSIGLITAZONE TO EITHER METFORMIN OR SULFONYLUREACOMPARED WITH THE COMBINATION OF THE OVER 5-7 YEARS OF FOLLOW-UP. WE ALSO ASSESSEDCOMPARATIVE SAFETY METHODS. IN A MULTICENTRE, OPEN-LABEL TRIAL, 4447 PATIENTS WITHTYPE 2 DIABETES ON METFORMIN OR SULFONYLUREA MONOTHERAPY WITH MEANHAEMOGLOBIN A1C (HB A1C) OF 7-9% WERE RANDOMLY ASSIGNED TO THE ADDITION OFROZIGLITAZONE (N=2220) OR TO A COMBINATION OF METFORMIN AND SULFONYLUREA (ACTIVECONTROL GROUP, 2227). THE PRIMARY ENDPOINT WAS CARDIOVASCULAR HOSPITALISATION, ORCARDIOVASCULAR DEATH, WITH A HAZARD RATIO (HR) NON-INFERIORITY MARGIN OF 1.20.ANALYSIS WAS BY INTENTION TO TREAT. THIS STUDY IS REGISTERED WITH GOVERNMENT CLINICALTRIALS NUMBER NCT00379769. FINDINGS. 321 PEOPLE IN THE ROSIGLITAZONE GROUP AND 323 INTHE ACTIVE CONTROL GROUP EXPERIENCED THE PRIMARY OUTCOME DURING A MEAN DURING A5.5 YEAR FOLLOW-UP, MEETING THE CRITERION ON NON-INFERIORITY (HR 0.99, 95% CI O.85-1.16).HR WAS 0-84 (O-59) FOR CARDIOVASCULAR DEATH, 1-14 (0.80-1.63) FOR MYOCARDIALINFARCTION, AND 0.72 (0.49-1.06) FOR STROKE. HEART FAILURE CAUSING ADMISSION TO HOSPITALOR DEATH OCCURRED IN 61 PEOPLE IN THE ROSIGLITAZONE GROUP AND 29 IN THE ACTIVECONTROL GROUP (HR 2.10, 1.35-3.27, RISK DIFFERENCE PER 1000 PERSON-YEARS 2.6, 1.1-4.1) UPPERAND DISTAL LOWER LIMB FRACTURE RATES WERE INCREASED MAINLY IN WOMEN RANDOMLYASSIGNED TO ROSIGLITAZONE. MEAN HB A1C WAS LOWER IN THE ROSIGLITAZONE GROUP THAN INTHE CONTROL GROUP AT 5 YEARS. INTERPRETATION. THE ADDITION OF ROSIGLITAZONE TOGLUCOSE LOWERING THERAPY IN PEOPLE WITH TYPE 2 DIABETES IS CONFIRMED TO INCREASE THERISK OF HEART FAILURE AND OF SOME FRACTURES, MAINLY IN WOMEN. ALTHOUGH THE DATA AREINCONCLUSIVE ABOUT ANY POSSIBLE EFFECT ON MYOCARDIAL INFARCTION, ROSIGLITAZONEDOES NOT INCREASE THE RISK OF OVERALL CARDIOVASCULAR MOBIDITY OR MORTALITYCOMPARED WITH STANDARD GLUCOSE-LOWERING DRUGS.
  2. 2. ROSIGLITAZONE EVALUATED FOR CARDIOVASCULAR OUTCOMES INORAL AGENT COMBINATION THERAPY FOR TYPE 2 DIABETES(RECORD): A MULTICENTRE, RANDOMISED, OPEN-LABEL TRIAL. PHILIPD. HOME MD, STUART J. POCOCK PHD, AND COLLEAGUES.ROSIGLITAZONE IS AN INSULIN SENSITIZER USED IN COMBINATIONWITH METFORMIN, A SULFONYLUREA, OR BOTH, FOR LOWERINGBLOOD GLUCOSE IN PEOPLE WITH TYPE 2 DIABETES. WE ASSESSEDCARDIOVASCULAR OUTCOMES AFTER ADDITION OF ROSIGLITAZONETO EITHER METFORMIN OR SULFONYLUREA COMPARED WITH THECOMBINATION OF THE OVER 5-7 YEARS OF FOLLOW-UP. WE ALSOASSESSED COMPARATIVE SAFETY METHODS. IN A MULTICENTRE, OPEN-LABEL TRIAL, 4447 PATIENTS WITH TYPE 2 DIABETES ON METFORMINOR SULFONYLUREA MONOTHERAPY WITH MEAN HAEMOGLOBIN A1C(HB A1C) OF 7-9% WERE RANDOMLY ASSIGNED TO THE ADDITION OFROZIGLITAZONE (N=2220) OR TO A COMBINATION OF METFORMIN ANDSULFONYLUREA (ACTIVE CONTROL GROUP, 2227). THE PRIMARYENDPOINT WAS CARDIOVASCULAR HOSPITALISATION, ORCARDIOVASCULAR DEATH, WITH A HAZARD RATIO (HR) NON-INFERIORITY MARGIN OF 1.20. ANALYSIS WAS BY INTENTION TO TREAT.THIS STUDY IS REGISTERED WITH GOVERNMENT CLINICAL TRIALSNUMBER NCT00379769.
  3. 3. FINDINGS. 321 PEOPLE IN THE ROSIGLITAZONE GROUP AND 323 IN THEACTIVE CONTROL GROUP EXPERIENCED THE PRIMARY OUTCOMEDURING A MEAN DURING A 5.5 YEAR FOLLOW-UP, MEETING THECRITERION ON NON-INFERIORITY (HR 0.99, 95% CI O.85-1.16). HR WAS0-84 (O-59) FOR CARDIOVASCULAR DEATH, 1-14 (0.80-1.63) FORMYOCARDIAL INFARCTION, AND 0.72 (0.49-1.06) FOR STROKE. HEARTFAILAURE CAUSING ADMISSION TO HOSPITAL OR DEATH OCCURREDIN 61 PEOPLE IN THE ROSIGLITAZONE GROUP AND 29 IN THE ACTIVECONTROL GROUP (HR 2.10, 1.35-3.27, RISK DIFFERENCE PER 1000PERSON-YEARS 2.6, 1.1-4.1) UPPER AND DISTAL LOWER LIMB FRACTURERATES WERE INCREASED MAINLY IN WOMEN RANDOMLY ASSIGNED TOROSIGLITAZONE. MEAN HB A1C WAS LOWER IN THE ROSIGLITAZONEGROUP THAN IN THE CONTROL GROUP AT 5 YEARS. INTERPRETATION.THE ADDITION OF ROSIGLITAZONE TO GLUCOSE LOWERING THERAPYIN PEOPLE WITH TYPE 2 DIABETES IS CONFIRMED TO INCREASE THERISK OF HEART FAILURE AND OF SOME FRACTURES, MAINLY INWOMEN. ALTHOUGH THE DATA ARE INCONCLUSIVE ABOUT ANYPOSSIBLE EFFECT ON MYOCARDIAL INFARCTION, ROSIGLITAZONEDOES NOT INCREASE THE RISK OF OVERALL CARDIOVASCULARMOBIDITY OR MORTALITY COMPARED WITH STANDARD GLUCOSE-LOWERING DRUGS.
  4. 4. ROSIGLITAZONE EVALUATED FOR CARDIOVASCULAROUTCOMES IN ORAL AGENT COMBINATION THERAPY FORTYPE 2 DIABETES (RECORD): AMULTICENTRE, RANDOMISED, OPEN-LABEL TRIAL. PHILIPD. HOME MD, STUART J. POCOCK PHD, AND COLLEAGUES.ROSIGLITAZONE IS AN INSULIN SENSITIZER USED INCOMBINATION WITH METFORMIN, A SULFONYLUREA, ORBOTH, FOR LOWERING BLOOD GLUCOSE IN PEOPLE WITHTYPE 2 DIABETES. WE ASSESSED CARDIOVASCULAROUTCOMES AFTER ADDITION OF ROSIGLITAZONE TOEITHER METFORMIN OR SULFONYLUREA COMPAREDWITH THE COMBINATION OF THE OVER 5-7 YEARS OFFOLLOW-UP. WE ALSO ASSESSED COMPARATIVE SAFETYMETHODS. IN A MULTICENTRE, OPEN-LABEL TRIAL, 4447PATIENTS WITH TYPE 2 DIABETES ON METFORMIN ORSULFONYLUREA MONOTHERAPY WITH MEANHAEMOGLOBIN A1C (HB A1C) OF 7-9% WERE RANDOMLYASSIGNED TO THE ADDITION OF ROZIGLITAZONE (N=2220)OR TO A COMBINATION OF METFORMIN ANDSULFONYLUREA (ACTIVE CONTROL GROUP, 2227).
  5. 5. THE PRIMARY ENDPOINT WAS CARDIOVASCULARHOSPITALISATION, OR CARDIOVASCULAR DEATH, WITH AHAZARD RATIO (HR) NON-INFERIORITY MARGIN OF 1.20.ANALYSIS WAS BY INTENTION TO TREAT. THIS STUDY ISREGISTERED WITH GOVERNMENT CLINICAL TRIALSNUMBER NCT00379769. FINDINGS. 321 PEOPLE IN THEROSIGLITAZONE GROUP AND 323 IN THE ACTIVE CONTROLGROUP EXPERIENCED THE PRIMARY OUTCOME DURING AMEAN DURING A 5.5 YEAR FOLLOW-UP, MEETING THECRITERION ON NON-INFERIORITY (HR 0.99, 95% CI O.85-1.16). HR WAS 0-84 (O-59) FOR CARDIOVASCULAR DEATH, 1-14 (0.80-1.63) FOR MYOCARDIAL INFARCTION, AND 0.72(0.49-1.06) FOR STROKE. HEART FAILURE CAUSINGADMISSION TO HOSPITAL OR DEATH OCCURRED IN 61PEOPLE IN THE ROSIGLITAZONE GROUP AND 29 IN THEACTIVE CONTROL GROUP (HR 2.10, 1.35-3.27, RISKDIFFERENCE PER 1000 PERSON-YEARS 2.6, 1.1-4.1).
  6. 6. UPPER AND DISTAL LOWER LIMB FRACTURE RATESWERE INCREASED MAINLY IN WOMEN RANDOMLYASSIGNED TO ROSIGLITAZONE. MEAN HB A1C WASLOWER IN THE ROSIGLITAZONE GROUP THAN IN THECONTROL GROUP AT 5 YEARS. INTERPRETATION. THEADDITION OF ROSIGLITAZONE TO GLUCOSELOWERING THERAPY IN PEOPLE WITH TYPE 2DIABETES IS CONFIRMED TO INCREASE THE RISK OFHEART FAILURE AND OF SOME FRACTURES, MAINLYIN WOMEN. ALTHOUGH THE DATA AREINCONCLUSIVE ABOUT ANY POSSIBLE EFFECT ONMYOCARDIAL INFARCTION, ROSIGLITAZONE DOESNOT INCREASE THE RISK OF OVERALLCARDIOVASCULAR MORBIDITY OR MORTALITYCOMPARED WITH STANDARD GLUCOSE-LOWERINGDRUGS.
  7. 7.  1 WHAT WAS THE MAIN PURPOSE OF THE STUDY? A TO TREAT PATIENTS WITH TYPE 2 DIABETES. B TO DETERMINE THE INCIDENCE OF HOSPITALIZATION IN PATIENTS TAKING ROSIGLITAZONE. C TO DISCOVER THE EFFECTS THAT ROSIGLITAZONE HAS ON HEART FAILURE IN PATIENTS WITH TYPE 2 DIABETES. D TO GET GOVERNMENT APPROVAL FOR ROSIGLITAZONE. 2 ROSIGLITAZONE IS AN INSULIN SENSITISER USED TO: A LOWER INSULIN IN PEOPLE WITH TYPE 2 DIABETES B LOWER BLOOD GLUCOSE IN PEOPLE WITH TYPE 2 DIABETES. C INCREASE BLOOD GLUCOSE IN PEOPLE WITH TYPE 2 DIABETES. D DIMINISH INSULIN IN PEOPLE WITH TYPE 1 DIABETES.
  8. 8.  3 WHAT DID THE TWO GROUPS HAVE IN COMMON? A PARTICIPANTS WERE GIVEN SULFONYLUREA. B PARTICIPANTS WERE GIVEN ROSIGLITAZONE. C PARTICIPANTS HAD NEARLY SIMILAR LEVELS OF HBA1C. D PARTICIPANTS WERE ALL FROM THE SAME CENTRE. 4 WHAT DOES THE AUTHOR CONCLUDE REGARDING THE SAFETY OF ROSIGLITAZONE IN GLUCOSE-LOWERING THERAPY FOR PATIENTS WITH TYPE-2 DIABETES? A THE PERCENTAGE OF PATIENTS RESULTING IN HEART FAILURE WAS VERY HIGH FOR BOTH GROUPS. B ROSIGLITAZONE, IN GENERAL, CAUSES HEART FAILURE. C ROSIGLITAZONE IS GENERALLY SAFE, BUT NOT FOR WOMEN. D ROSIGLATAZONE SHOULD BE USED ONLY FOR MALE PATIENTS.
  9. 9. 5 THE ADDITION OF ROSIGLITAZONE TO GLUCOSELOWERING THERAPY IN PEOPLE WITH TYPE 2DIABETES IS CONFIRMED TO:A INCREASE THE RISK OF HEART FAILURE AND OFSOME FRACTURES, MAINLY IN MEN.B INCREASE THE RISK OF HEART FAILURE AND OFSOME FRACTURES, MAINLY IN WOMEN.C THE DATA ARE CONCLUSIVE ABOUT ANYPOSSIBLE EFFECT ON MYOCARDIAL INFARCTION,D ROSIGLITAZONE INCREASES THE RISK OFOVERALL CARDIOVASCULAR MORBIDITY.
  10. 10. 1. C2. B3. C4. C5. B
  11. 11.  1. Rosiglitazone evaluated for cardiovascular outcomes in oral agent combination therapy for type 2 diabetes 2. Rosiglitazone is an insulin sensitizer used ... for lowering blood glucose in people with type 2 diabetes. 3. ... 4447 patients with type 2 diabetes on metformin or sulfonylurea monotherapy with mean haemoglobin A1C (HBA1C) of 7-9% were randomly assigned to addition of rosiglitazone ... or to a combination of a metformin and sulfonylurea ....
  12. 12.  4. Interpretation. The addition of rosiglitazone to glucose lowering therapy for people with type 2 diabetes is confirmed to increase the risk of heart failure and of some fractures, mainly in women. Although the data are inconclusive about any possible effect on myocardial infarction, rosiglitazone does not increase the risk of overall cardiovascular morbidity or mortality compared with standard glucose-lowering drugs. 5. Idem
  13. 13. PIGMENTARY DISORDERS IN LATIN AMERICA FALABELLA, RAFAEL DERMATOLOGIC CLINICS - VOLUME 25, ISSUE3 W. B. SAUNDERS COMPANY JULY 2007 PITYRIASIS ALBA (PA) IS A COMMON DISORDER OBSERVED IN LATINAMERICAN PATIENTS. LESIONS DISCLOSE HYPOPIGMENTATION, MAINLY OBSERVED ON FACIAL AREAS ANDSUNLIGHT EXPOSED SURFACE OF ARMS AND FOREARMS; THOSE ON THE TRUNK AND LOWER EXTREMITIES ARELESS COMMON. AN ATOPIC DIATHESIS IS PRESENT IN MOST PATIENTS, AND THE CONDITION FREQUENTLYDEVELOPS IN CHILDREN AND YOUNG ADULTS. THE AVERAGE LESION BEGINS WITH A SLIGHTLYHYPOPIGMENTED MACULE THAT ENLARGES GRADUALLY FROM 1 CM TO 3 CM AND MAY COALESCE WITHNEIGHBORING MACULES, RESULTING IN LARGER HYPOPIGMENTED DEFECTS. A FINE DESQUAMATION ANDDRYNESS OF SKIN ARE CHARACTERISTIC AND THE CLINICAL PICTURE USUALLY WORSENS DURING SUMMER ORDURING FREQUENT WATERSPORT ACTIVITIES. A FOLLICULAR VARIETY WITH MILD HYPERKERATOSIS AT THEHAIR FOLLICLE OSTIUM FREQUENTLY OCCURS. ON HISTOLOGIC EXAMINATION, EPIDERMAL AND FOLLICULARSPONGIOSIS, FOCAL PARAKERATOSIS, SLIGHT ACANTHOSIS, AND MILD SUPERFICIAL PERIVASCULARINFILTRATES ARE SEEN. IN A STUDY, ULTRASTRUCTURAL EXAMINATION DISCLOSED SMALL AND REDUCEDNUMBERS OF MELANOCYTES AND MELANOSOMES. ALTHOUGH PA IMPROVES SPONTANEOUSLY AFTERPUBERTY, LOW POTENCY CORTICOSTEROIDS, SUCH AS 1% HYDROCORTISONE OR 0.5% DESONIDE, FREQUENTEMOLLIENT APPLICATION, AND SUNLIGHT AVOIDANCE/PROTECTION ARE USEFUL TO CONTROL THISDISORDER. SKIN CONTACT WITH DIVERSE CHEMICALS MAY INDUCE ACQUIRED HYPOPIGMENTATION, WHICHMAY OCCUR EITHER DURING PROFESSIONAL ACTIVITIES OR AS AN INCIDENTAL EVENT. AREAS OFCONTACT, SUCH AS HANDS AND FEET, MAY BECOME AFFECTED WITH OR WITHOUT INITIAL DERMATITIS, ANDTHEREAFTER HYPOPIGMENTATION OCCURS. SOME OF THE INVOLVED CHEMICALS ARE CATECHOL ANDBENZENE DERIVATIVES USED AS ANTISEPTICS AND CLEANSERS, PESTICIDES, AND EPOXY RESINS COMMONLYUSED IN HOUSEHOLD WORK. MACULAR LESIONS SHOW DIFFERENT GRADES OF HYPOPIGMENTATION OR TRUEDEPIGMENTATION INDISTINGUISHABLE FROM VITILIGO; A PREVIOUS HISTORY OF SUBSTANCE CONTACT ANDDERMATITIS ARE IN FAVOR OF THE CHEMICAL NATURE OF DEPIGMENTATION . ON HISTOLOGICEXAMINATION, JUST A FEW MELANOCYTES ARE PRESENT AND REDUCED OR ABSENT MELANIN IS OBSERVED.TREATMENT OF DEPIGMENTATION IS DIFFICULT, BECAUSE MOST OF THE TIME ACRAL AREAS ARE INVOLVEDAND MELANOCYTES IN AFFECTED AREAS ARE SCARCE. IF VITILIGO-LIKE DEPIGMENTATION BECOMESREFRACTORY TO MEDICAL THERAPY, MELANOCYTE GRAFTING MAY BE AN IMPORTANT THERAPEUTICSOLUTION.
  14. 14. PIGMENTARY DISORDERS IN LATIN AMERICA FALABELLA, RAFAELDERMATOLOGIC CLINICS - VOLUME 25, ISSUE 3 W. B. SAUNDERSCOMPANY JULY 2007 PITYRIASIS ALBA (PA) IS A COMMON DISORDEROBSERVED IN LATIN AMERICAN PATIENTS. LESIONS DISCLOSEHYPOPIGMENTATION, MAINLY OBSERVED ON FACIAL AREAS ANDSUNLIGHT EXPOSED SURFACE OF ARMS AND FOREARMS; THOSE ONTHE TRUNK AND LOWER EXTREMITIES ARE LESS COMMON. AN ATOPICDIATHESIS IS PRESENT IN MOST PATIENTS, AND THE CONDITIONFREQUENTLY DEVELOPS IN CHILDREN AND YOUNG ADULTS. THEAVERAGE LESION BEGINS WITH A SLIGHTLY HYPOPIGMENTED MACULETHAT ENLARGES GRADUALLY FROM 1 CM TO 3 CM AND MAY COALESCEWITH NEIGHBORING MACULES, RESULTING IN LARGERHYPOPIGMENTED DEFECTS. A FINE DESQUAMATION AND DRYNESS OFSKIN ARE CHARACTERISTIC AND THE CLINICAL PICTURE USUALLYWORSENS DURING SUMMER OR DURING FREQUENT WATERSPORTACTIVITIES. A FOLLICULAR VARIETY WITH MILD HYPERKERATOSIS ATTHE HAIR FOLLICLE OSTIUM FREQUENTLY OCCURS. ON HISTOLOGICEXAMINATION, EPIDERMAL AND FOLLICULAR SPONGIOSIS, FOCALPARAKERATOSIS, SLIGHT ACANTHOSIS, AND MILD SUPERFICIALPERIVASCULAR INFILTRATES ARE SEEN. IN ASTUDY, ULTRASTRUCTURAL EXAMINATION DISCLOSED SMALL ANDREDUCED NUMBERS OF MELANOCYTES AND MELANOSOMES.
  15. 15. ALTHOUGH PA IMPROVES SPONTANEOUSLY AFTER PUBERTY, LOW POTENCYCORTICOSTEROIDS, SUCH AS 1% HYDROCORTISONE OR 0.5%DESONIDE, FREQUENT EMOLLIENT APPLICATION, AND SUNLIGHTAVOIDANCE/PROTECTION ARE USEFUL TO CONTROL THIS DISORDER. SKINCONTACT WITH DIVERSE CHEMICALS MAY INDUCE ACQUIREDHYPOPIGMENTATION, WHICH MAY OCCUR EITHER DURING PROFESSIONALACTIVITIES OR AS AN INCIDENTAL EVENT. AREAS OF CONTACT, SUCH AS HANDSAND FEET, MAY BECOME AFFECTED WITH OR WITHOUT INITIALDERMATITIS, AND THEREAFTER HYPOPIGMENTATION OCCURS. SOME OF THEINVOLVED CHEMICALS ARE CATECHOL AND BENZENE DERIVATIVES USED ASANTISEPTICS AND CLEANSERS, PESTICIDES, AND EPOXY RESINS COMMONLYUSED IN HOUSEHOLD WORK. MACULAR LESIONS SHOW DIFFERENT GRADES OFHYPOPIGMENTATION OR TRUE DEPIGMENTATION INDISTINGUISHABLE FROMVITILIGO; A PREVIOUS HISTORY OF SUBSTANCE CONTACT AND DERMATITIS AREIN FAVOR OF THE CHEMICAL NATURE OF DEPIGMENTATION . ON HISTOLOGICEXAMINATION, JUST A FEW MELANOCYTES ARE PRESENT AND REDUCED ORABSENT MELANIN IS OBSERVED. TREATMENT OF DEPIGMENTATION ISDIFFICULT, BECAUSE MOST OF THE TIME ACRAL AREAS ARE INVOLVED ANDMELANOCYTES IN AFFECTED AREAS ARE SCARCE. IF VITILIGO-LIKEDEPIGMENTATION BECOMES REFRACTORY TO MEDICAL THERAPY, MELANOCYTEGRAFTING MAY BE AN IMPORTANT THERAPEUTIC SOLUTION.
  16. 16. PIGMENTARY DISORDERS IN LATIN AMERICA.FALABELLA, RAFAEL; DERMATOLOGIC CLINICS - VOLUME25, ISSUE 3 W. B. SAUNDERS COMPANY JULY 2007PITYRIASIS ALBA (PA) IS A COMMON DISORDEROBSERVED IN LATIN AMERICAN PATIENTS. LESIONSDISCLOSE HYPOPIGMENTATION, MAINLY OBSERVED ONFACIAL AREAS AND SUNLIGHT EXPOSED SURFACE OFARMS AND FOREARMS; THOSE ON THE TRUNK ANDLOWER EXTREMITIES ARE LESS COMMON. AN ATOPICDIATHESIS IS PRESENT IN MOST PATIENTS, AND THECONDITION FREQUENTLY DEVELOPS IN CHILDREN ANDYOUNG ADULTS. THE AVERAGE LESION BEGINS WITH ASLIGHTLY HYPOPIGMENTED MACULE THAT ENLARGESGRADUALLY FROM 1 CM TO 3 CM AND MAY COALESCEWITH NEIGHBORING MACULES, RESULTING IN LARGERHYPOPIGMENTED DEFECTS. A FINE DESQUAMATION ANDDRYNESS OF SKIN ARE CHARACTERISTIC AND THECLINICAL PICTURE USUALLY WORSENS DURING SUMMEROR DURING FREQUENT WATERSPORT ACTIVITIES.
  17. 17. A FOLLICULAR VARIETY WITH MILD HYPERKERATOSIS ATTHE HAIR FOLLICLE OSTIUM FREQUENTLY OCCURS. ONHISTOLOGIC EXAMINATION, EPIDERMAL AND FOLLICULARSPONGIOSIS, FOCAL PARAKERATOSIS, SLIGHTACANTHOSIS, AND MILD SUPERFICIAL PERIVASCULARINFILTRATES ARE SEEN. IN A STUDY, ULTRASTRUCTURALEXAMINATION DISCLOSED SMALL AND REDUCED NUMBERSOF MELANOCYTES AND MELANOSOMES. ALTHOUGH PAIMPROVES SPONTANEOUSLY AFTER PUBERTY, LOWPOTENCY CORTICOSTEROIDS, SUCH AS 1%HYDROCORTISONE OR 0.5% DESONIDE, FREQUENTEMOLLIENT APPLICATION, AND SUNLIGHTAVOIDANCE/PROTECTION ARE USEFUL TO CONTROL THISDISORDER. SKIN CONTACT WITH DIVERSE CHEMICALS MAYINDUCE ACQUIRED HYPOPIGMENTATION, WHICH MAYOCCUR EITHER DURING PROFESSIONAL ACTIVITIES OR ASAN INCIDENTAL EVENT. AREAS OF CONTACT, SUCH AS HANDSAND FEET, MAY BECOME AFFECTED WITH OR WITHOUTINITIAL DERMATITIS, AND THEREAFTERHYPOPIGMENTATION OCCURS.
  18. 18. SOME OF THE INVOLVED CHEMICALS ARE CATECHOLAND BENZENE DERIVATIVES USED AS ANTISEPTICS ANDCLEANSERS, PESTICIDES, AND EPOXY RESINSCOMMONLY USED IN HOUSEHOLD WORK. MACULARLESIONS SHOW DIFFERENT GRADES OFHYPOPIGMENTATION OR TRUE DEPIGMENTATIONINDISTINGUISHABLE FROM VITILIGO; A PREVIOUSHISTORY OF SUBSTANCE CONTACT AND DERMATITISARE IN FAVOR OF THE CHEMICAL NATURE OFDEPIGMENTATION. ON HISTOLOGICEXAMINATION, JUST A FEW MELANOCYTES AREPRESENT AND REDUCED OR ABSENT MELANIN ISOBSERVED. TREATMENT OF DEPIGMENTATION ISDIFFICULT, BECAUSE MOST OF THE TIME ACRAL AREASARE INVOLVED AND MELANOCYTES IN AFFECTED AREASARE SCARCE. IF VITILIGO-LIKE DEPIGMENTATIONBECOMES REFRACTORY TO MEDICALTHERAPY, MELANOCYTE GRAFTING MAY BE ANIMPORTANT THERAPEUTIC SOLUTION.
  19. 19.  6. PITYRIASIS ALBA IS A COMMON DISORDER FREQUENTLY OBSERVED IN: A ARMS AND LEGS B FACE, ARMS AND FOREARMS C TRUNK AND LOWER EXTREMITIES. D FACE, ARMS AND LEGS 7. THE AVERAGE LESION BEGINS WITH A SLIGHTLY HYPOPIGMENTED SPOT THAT: A GROWS FROM 1 TO 3 CM. B REDUCES FROM 1 TO 3 CM C ENLARGES TO 5 CM. INDEPENDENTLY D CHANGES COLOR
  20. 20.  8. TO CONTROL THIS DISORDER IT IS USEFUL TO: A USE A FREQUENT EMOLLIENT APPLICATION B USE HIGH POTENCY CORTICOSTEROIDS C KEEP AWAY FROM THE SUN. D LACK THE PROTECTION OF THE SUN 9. HYPOPIGMENTATION OCCURS WHEN: A SKIN HAS CONTACT WITH DIVERSE CHEMICALS B WE HAVE INCIDENTAL ACTIVITIES C WE TAKE CORTISONE. D WE USE SUN PROTECTION.
  21. 21.  10. PITYRIASIS ALBA IS DANGEROUS BECAUSE: A PATIENTS BECOME INTOLERANT TO LIGHT B SOME OF THE TREATMENTS ARE TOXIC C PRE-CANCEROUS LESIONS CAN FORM. D DELICATE SURGERY IS SOMETIMES REQUIRED.
  22. 22. 6. B7. A8. A (y C)9. A10. DAcral: Relating to or affecting the peripheral parts, e.g., limbs, fingers, ears, etc.
  23. 23.  6. Pytiriasis alba (PA) is a common disorder … mainly observed on facial areas and sunlight exposed surface of arms and forearms. 7. The average lesion begins with a slightly hypopigmented macule that enlarges gradually from 1 cm to 3 cm. 8. Frequent emollient application and sunlight avoidance/protection are useful to control this disorder.
  24. 24.  9. Skin contact with diverse chemicals may induce acquired skin hypopigmentation … 10. If vitiligo-like depigmentation becomes refractory to medical therapy, melanocyte grafting may be an important therapeutic solution. A graft/ to graft/ grafting
  25. 25.  A graft/ to graft/ grafting
  26. 26. UPPER RESPIRATORY TRACT INFECTIONS IN CHILDREN ZORC, JOSEPH J. CLINICALPEDIATRIC EMERGENCY MEDICINE EL SERVIER DOI.10.1016.CPEM.209.03.008 MARCH2009. UPPER RESPIRATORY TRACT INFECTIONS (INCLUDING OTITIS MEDIA) ARETHE MOST COMMON ILLNESSES AFFECTING CHILDREN. ON AVERAGE, CHILDRENEXPERIENCE AROUND SIX TO EIGHT UPPER RESPIRATORY TRACT INFECTIONS(URTIS) EACH YEAR. ALTHOUGH THESE INFECTIONS USUALLY ARE MILD AND SELFLIMITING, THEY OCCASIONALLY LEAD TO COMPLICATIONS THAT CAN BE LIFETHREATENING. MOST URTIS CAN BE PLACED WITHIN THREE MAIN CATEGORIES OFINFECTION: RHINOSINUSITIS, PHARYNGITIS, AND OTITIS MEDIA. WITHIN EACHCATEGORY OF ILLNESS THERE IS A RANGE OF RELATED CONDITIONS THAT MAYHAVE SIMILAR OR OVERLAPPING CLINICAL PRESENTATIONS. SOME JUDGMENT ISREQUIRED IN DETERMINING WHICH PART OF THE RESPIRATORY MUCOSA IS MOSTAFFECTED. IN THIS ARTICLE, THE TERM “RHINOSINUSITIS” IS USED TO DESCRIBEILLNESSES WITH PREDOMINANTLY NASAL SYMPTOMS (INCLUDING THE COMMONCOLD, NASOPHARYNGITIS, AND SINUSITIS). THE TERM “PHARYNGITIS” IS USED TODESCRIBE ILLNESSES WHEN SORE THROAT IS MOST PROMINENT (INCLUDINGTONSILLITIS). THE TERM “OTITIS MEDIA” IS USED TO DESCRIBE ILLNESSES WITHPREDOMINANTLY MIDDLE EAR SYMPTOMS (INCLUDING ACUTE OTITIS MEDIA[AOM], OTITIS MEDIA WITH EFFUSION [OME], AND CHRONIC SUPPURATIVE OTITISMEDIA [CSOM]). CHILDREN WHO HAVE COUGH AS THE PREDOMINANT SYMPTOMARE CONSIDERED TO HAVE BRONCHITIS (A LOWER RESPIRATORY TRACTINFECTION). TO MAKE MATTERS MORE COMPLICATED, ALL AREAS OF THERESPIRATORY MUCOSA MAY BE AFFECTED, SIMULTANEOUSLY OR AT DIFFERENTTIMES, DURING ONE ILLNESS. THE CAUSE OF THESE RESPIRATORY MUCOSALINFECTIONS MOST COMMONLY IS VIRAL BUT CAN BE BACTERIAL AND MANYINFECTIONS INVOLVE BOTH VIRUSES AND BACTERIA. IN DEVELOPEDCOUNTRIES, BOTH VIRAL AND BACTERIAL INFECTIONS ARE LIKELY TO BE SELFLIMITED. PERSISTENT DISEASE IS MOST LIKELY TO INDICATE A BACTERIALINFECTION.
  27. 27. UPPER RESPIRATORY TRACT INFECTIONS IN CHILDRENZORC, JOSEPH J. CLINICAL PEDIATRIC EMERGENCYMEDICINE EL SERVIER DOI.10.1016.CPEM.209.03.008MARCH 2009. UPPER RESPIRATORY TRACT INFECTIONS(INCLUDING OTITIS MEDIA) ARE THE MOST COMMONILLNESSES AFFECTING CHILDREN. ONAVERAGE, CHILDREN EXPERIENCE AROUND SIX TO EIGHTUPPER RESPIRATORY TRACT INFECTIONS (URTIS) EACHYEAR. ALTHOUGH THESE INFECTIONS USUALLY ARE MILDAND SELF LIMITING, THEY OCCASIONALLY LEAD TOCOMPLICATIONS THAT CAN BE LIFE THREATENING. MOSTURTIS CAN BE PLACED WITHIN THREE MAIN CATEGORIESOF INFECTION: RHINOSINUSITIS, PHARYNGITIS, ANDOTITIS MEDIA. WITHIN EACH CATEGORY OF ILLNESSTHERE IS A RANGE OF RELATED CONDITIONS THAT MAYHAVE SIMILAR OR OVERLAPPING CLINICALPRESENTATIONS. SOME JUDGMENT IS REQUIRED INDETERMINING WHICH PART OF THE RESPIRATORYMUCOSA IS MOST AFFECTED.
  28. 28. IN THIS ARTICLE, THE TERM “RHINOSINUSITIS” IS USED TODESCRIBE ILLNESSES WITH PREDOMINANTLY NASAL SYMPTOMS(INCLUDING THE COMMON COLD, NASOPHARYNGITIS, ANDSINUSITIS). THE TERM “PHARYNGITIS” IS USED TO DESCRIBEILLNESSES WHEN SORE THROAT IS MOST PROMINENT(INCLUDING TONSILLITIS). THE TERM “OTITIS MEDIA” IS USEDTO DESCRIBE ILLNESSES WITH PREDOMINANTLY MIDDLE EARSYMPTOMS (INCLUDING ACUTE OTITIS MEDIA [AOM], OTITISMEDIA WITH EFFUSION [OME], AND CHRONIC SUPPURATIVEOTITIS MEDIA [CSOM]). CHILDREN WHO HAVE COUGH AS THEPREDOMINANT SYMPTOM ARE CONSIDERED TO HAVEBRONCHITIS (A LOWER RESPIRATORY TRACT INFECTION). TOMAKE MATTERS MORE COMPLICATED, ALL AREAS OF THERESPIRATORY MUCOSA MAY BE AFFECTED, SIMULTANEOUSLYOR AT DIFFERENT TIMES, DURING ONE ILLNESS. THE CAUSE OFTHESE RESPIRATORY MUCOSAL INFECTIONS MOST COMMONLYIS VIRAL BUT CAN BE BACTERIAL AND MANY INFECTIONSINVOLVE BOTH VIRUSES AND BACTERIA. IN DEVELOPEDCOUNTRIES, BOTH VIRAL AND BACTERIAL INFECTIONS ARELIKELY TO BE SELF LIMITED. PERSISTENT DISEASE IS MOSTLIKELY TO INDICATE A BACTERIAL INFECTION.
  29. 29. UPPER RESPIRATORY TRACT INFECTIONS INCHILDREN. ZORC, JOSEPH J. CLINICAL PEDIATRICEMERGENCY MEDICINE; EL SERVIERDOI.10.1016.CPEM.209.03.008 MARCH 2009. UPPERRESPIRATORY TRACT INFECTIONS (INCLUDING OTITISMEDIA) ARE THE MOST COMMON ILLNESSESAFFECTING CHILDREN. ON AVERAGE, CHILDRENEXPERIENCE AROUND SIX TO EIGHT UPPERRESPIRATORY TRACT INFECTIONS (URTIS) EACH YEAR.ALTHOUGH THESE INFECTIONS USUALLY ARE MILDAND SELF LIMITING, THEY OCCASIONALLY LEAD TOCOMPLICATIONS THAT CAN BE LIFE THREATENING.MOST URTIS CAN BE PLACED WITHIN THREE MAINCATEGORIES OF INFECTION:RHINOSINUSITIS, PHARYNGITIS, AND OTITIS MEDIA.WITHIN EACH CATEGORY OF ILLNESS THERE IS ARANGE OF RELATED CONDITIONS THAT MAY HAVESIMILAR OR OVERLAPPING CLINICAL PRESENTATIONS .
  30. 30. SOME JUDGMENT IS REQUIRED INDETERMINING WHICH PART OF THERESPIRATORY MUCOSA IS MOST AFFECTED. INTHIS ARTICLE, THE TERM “RHINOSINUSITIS” ISUSED TO DESCRIBE ILLNESSES WITHPREDOMINANTLY NASAL SYMPTOMS(INCLUDING THE COMMONCOLD, NASOPHARYNGITIS, AND SINUSITIS). THETERM “PHARYNGITIS” IS USED TO DESCRIBEILLNESSES WHEN SORE THROAT IS MOSTPROMINENT (INCLUDING TONSILLITIS). THETERM “OTITIS MEDIA” IS USED TO DESCRIBEILLNESSES WITH PREDOMINANTLY MIDDLE EARSYMPTOMS (INCLUDING ACUTE OTITIS MEDIA[AOM], OTITIS MEDIA WITH EFFUSION[OME], AND CHRONIC SUPPURATIVE OTITISMEDIA [CSOM]).
  31. 31. CHILDREN WHO HAVE COUGH AS THEPREDOMINANT SYMPTOM ARE CONSIDERED TOHAVE BRONCHITIS (A LOWER RESPIRATORYTRACT INFECTION). TO MAKE MATTERS MORECOMPLICATED, ALL AREAS OF THE RESPIRATORYMUCOSA MAY BE AFFECTED, SIMULTANEOUSLY ORAT DIFFERENT TIMES, DURING ONE ILLNESS. THECAUSE OF THESE RESPIRATORY MUCOSALINFECTIONS MOST COMMONLY IS VIRAL BUT CANBE BACTERIAL AND MANY INFECTIONS INVOLVEBOTH VIRUSES AND BACTERIA. IN DEVELOPEDCOUNTRIES, BOTH VIRAL AND BACTERIALINFECTIONS ARE LIKELY TO BE SELF LIMITED.PERSISTENT DISEASE IS MOST LIKELY TOINDICATE A BACTERIAL INFECTION.
  32. 32.  11. WHY ARE UPPER RESPIRATORY TRACT INFECTIONS SO DIFFICULT TO DIAGNOSE IN CHILDREN? A THEY GET MANY OF THEM. B THE SYMPTOMS OF DIFFERENT URTIS OVERLAP. C THERE ARE DIFFERENT KINDS OF URTIS. D VIRAL AND BACTERIAL INFECTIONS EXIST. 12. AN EXAMPLE OF A LOWER RESPIRATORY INFECTION IS: A NASOPHARYNGITIS. B BRONCHITIS. C SINUSITIS. D TONSILLITIS.
  33. 33.  13. THE CAUSE OF THE ILLNESS IN RESPIRATORY INFECTIONS IS BEST DETERMINED BY THE: A SYMPTOMS. B PRESENCE OF A VIRAL INFECTION. C PRESENCE OF A BACTERIAL INFECTION. D AFFECTED PART OF THE RESPIRATORY MUCOSA. 14. THE MAIN AREA AFFECTED IN INFECTIONS TERMED "OTITIS MEDIA" IS THE: A EYE B EAR C NOSE D THROAT
  34. 34. 15. OME, AOM, AND SCOM ALL BELONG TO THEFAMILY OF THE INFECTIONS CALLED: A BRONCHITIS B PHARYNGITIS C RHINOSINUSITIS D OTITIS MEDIA
  35. 35. 11. B12. B13. A (D?)14. B15. D
  36. 36.  11. Within each category of illness, there is a range of related conditions that may have similar or overlapping clinical presentations. 12. Children who have cough as the predominant symptom are considered to have bronchitis (a lower respiratory tract infection). 13. Within each category of illness, there is a range of related conditions that may have similar or overlapping clinical presntations / Some judgment is required in determining which part of the respiratory mucosa is most affected.
  37. 37.  14. The term “otitis media” is used to describe illnesses of predominantly middle ear symptoms 15. …including acute otitis media (AOM), otitis media with effusion (AME), and chronic suppurative otitis media (CSOM).
  38. 38. upper/lower respiratory tract infections/ up, low… they may have overlapping clinical presentations to overlap/overlapping/overlapped…, they occasionally lead to complications that can be life threatening …a threat/ to threaten/ threateningSome judgment is required in determining which part of the mucosa ...to judge, a judge/ judgment, judgementTo make matters more complicated, …
  39. 39. FREQUENCY OF GERD SYMPTOMS IN ELDERLY PATIENTS WHO COME TO A FAMILYMEDICINE CLINIC. OBJECTIVES: TO ASCERTAIN THE PREVALENCE OFGASTROESOPHAGEAL REFLUX DISEASE (GERD) IN ELDERLY PEOPLE ATTENDING TOFAMILY MEDICINE CLINICS. MATERIAL AND METHODS: THE STUDY WASCONDUCTED BY USING A PROSPECTIVE DESIGN IN WHICH PARTICIPANTS WERERANDOMLY SELECTED FROM A FAMILY MEDICINE CLINIC LOCATED IN MEXICOCITY. THE STUDY WAS RUN FROM AUGUST TO SEPTEMBER 2003, AND INCLUDEDPATIENTS AGED SIXTY YEARS OR OLDER, REGARDLESS OF GENDER. THEY SHOULDNOT HAVE COGNITIVE DAMAGE, WHICH WAS ASCERTAINED BY THE FOLSTEIN MINIMENTAL STATE EXAMINATION. THOSE PATIENTS THAT DID NOT ACCEPT TOPARTICIPATE AND THOSE HAVING INCOMPLETE OR ILLEGIBLE MEDICAL RECORDSWERE EXCLUDED. THE SOCIO-DEMOGRAPHIC CHARACTERISTICS TEST ANDCARLSSON-DENT TEST WERE APPLIED. THE INFORMATION ABOUTDIAGNOSIS, DRUGS PRESCRIPTIONS, AND PHARMACOLOGICAL AND NOPHARMACOLOGICAL GASTROESOPHAGEAL PROTECTION WAS OBTAINED FROM THEMEDICAL CHARTS AND PRESCRIPTIONS. RESULTS: 400 ELDERLY PATIENTS WEREEVALUATED BY USING THE CARLSSON-DENT TEST. GERD PREVALENCE WAS 25% (IC95 % 21-29) THE AVERAGE AGE OF PATIENTS WITH AND WITHOUT GERD WAS 68 ± 7YEARS AND 70 ± 7 YEARS RESPECTIVELY (P = .002). WOMEN SUFFERED GERD MOREFREQUENTLY THAN MEN (P = 0.001). GERD DIAGNOSIS WAS NOT FOUND IN ANY OFTHE REVIEWED MEDICAL CHARTS. ANTACIDS, HISTAMINE- 2 RECEPTORANTAGONISTS (H2 AS) AND WERE PRESCRIBED IN 39% (IC 95 % 34-44) OF PATIENTSWITH GERD AND IN 18% (IC 95 % 15-21) WITHOUT GERD. CONCLUSIONS: ELDERLYPATIENTS ATTENDING TO PRIMARY CARE FACILITIES OFTEN HAVE GERDSYMPTOMS, BUT THEY ARE NOT PROPERLY DIAGNOSED OR FOLLOWED UP. THECARLSSON-DENT QUESTIONNAIRE IS AN ALTERNATIVE TO IDENTIFY GERDPATIENTS.
  40. 40. FREQUENCY OF GERD SYMPTOMS IN ELDERLYPATIENTS WHO COME TO A FAMILY MEDICINECLINIC. OBJECTIVES: TO ASCERTAIN THEPREVALENCE OF GASTROESOPHAGEAL REFLUXDISEASE (GERD) IN ELDERLY PEOPLE ATTENDINGTO FAMILY MEDICINE CLINICS. MATERIAL ANDMETHODS: THE STUDY WAS CONDUCTED BYUSING A PROSPECTIVE DESIGN IN WHICHPARTICIPANTS WERE RANDOMLY SELECTED FROMA FAMILY MEDICINE CLINIC LOCATED IN MEXICOCITY. THE STUDY WAS RUN FROM AUGUST TOSEPTEMBER 2003, AND INCLUDED PATIENTS AGEDSIXTY YEARS OR OLDER, REGARDLESS OF GENDER.
  41. 41. THEY SHOULD NOT HAVE COGNITIVEDAMAGE, WHICH WAS ASCERTAINED BY THEFOLSTEIN MINI MENTAL STATE EXAMINATION.THOSE PATIENTS THAT DID NOT ACCEPT TOPARTICIPATE AND THOSE HAVING INCOMPLETE ORILLEGIBLE MEDICAL RECORDS WERE EXCLUDED.THE SOCIO-DEMOGRAPHIC CHARACTERISTICSTEST AND CARLSSON-DENT TEST WERE APPLIED.THE INFORMATION ABOUT DIAGNOSIS, DRUGSPRESCRIPTIONS, AND PHARMACOLOGICAL ANDNON PHARMACOLOGICAL GASTROESOPHAGEALPROTECTION WAS OBTAINED FROM THE MEDICALCHARTS AND PRESCRIPTIONS. RESULTS: 400ELDERLY PATIENTS WERE EVALUATED BY USINGTHE CARLSSON-DENT TEST.
  42. 42. GERD PREVALENCE WAS 25% (IC 95 % 21-29) THEAVERAGE AGE OF PATIENTS WITH AND WITHOUTGERD WAS 68 ± 7 YEARS AND 70 ± 7 YEARSRESPECTIVELY (P = .002). WOMEN SUFFERED GERDMORE FREQUENTLY THAN MEN (P = 0.001). GERDDIAGNOSIS WAS NOT FOUND IN ANY OF THEREVIEWED MEDICAL CHARTS. ANTACIDS, HISTAMINE-2 RECEPTOR ANTAGONISTS (H2 AS) AND WEREPRESCRIBED IN 39% (IC 95 % 34-44) OF PATIENTS WITHGERD AND IN 18% (IC 95 % 15-21) WITHOUT GERD.CONCLUSIONS: ELDERLY PATIENTS ATTENDING TOPRIMARY CARE FACILITIES OFTEN HAVE GERDSYMPTOMS, BUT THEY ARE NOT PROPERLYDIAGNOSED OR FOLLOWED UP. THE CARLSSON-DENTQUESTIONNAIRE IS AN ALTERNATIVE TO IDENTIFYGERD PATIENTS.
  43. 43.  16. ABOUT THE DESIGN OF THE STUDY: A RESEARCHERS USE A PROSPECTIVE DESIGN, PARTICIPANTS WERE FAMILY MEDICINE SPECIALISTS FROM MEXICO CITY SELECTED AT RANDOM. B PARTICIPANTS ARE SELECTED AT RANDOM FROM A FAMILY MEDICINE CLINIC FROM AN ELDERLY FEMALE POPULATION. C ELDERLY PATIENTS WERE INCLUDED WITHOUT CONSIDERING GENDER. D IT WAS ORIGINALLY PLANNED TO BE DONE IN THREE MONTHS. 17. THE INCLUSION OF PATIENT CRITERIA WAS: A CERTAINLY NOT TO HAVE ANY BRAIN DAMAGE. B TO HAVE COGNITIVE COMPETENCE PROVEN BY THE FOLSTEIN MINI MENTAL STATE EXAMINATION. C NOT TO ACCEPT TO PARTICIPATE IN THE STUDY. D THERE WERE INCOMPLETE OR ILLEGIBLE MEDICAL RECORDS.
  44. 44.  18 RESEARCHERS OBTAIN THE INFORMATION ABOUT DIAGNOSIS, DRUGS PRESCRIPTIONS, AND PHARMACOLOGICAL AND NON PHARMACOLOGICAL GASTROESOPHAGEAL PROTECTION FROM: A A SOCIO-DEMOGRAPHIC CHARACTERISTICS TEST. B A CARLSSON-DENT TEST. C CLINIC DATABASES. D PATIENT RECORDS. 19 THE AIM OF THE STUDY GAVE AS A RESULT: A GERD PREVALENCE WAS 25%. B AVERAGE AGE OF PATIENTS WITH AND WITHOUT GERD WAS 68 ± 7 YEARS AND 70 ± 7 YEARS RESPECTIVELY. C WOMEN SUFFERED GERD MORE FREQUENTLY THAN MEN. D ANTACIDS, H2 AS AND WERE PRESCRIBED IN 39% OF PATIENTS WITH GERD.
  45. 45. 20 THE MAIN CONCLUSION OF THE STUDY WAS:A PATIENTS WITHOUT GERD STILL RECEIVEDTREATMENT.B PARTICIPANTS OFTEN HAD GERD SYMPTOMS.C PATIENTS IDENTIFIED WITH GERD SYMPTOMSWERE DIAGNOSED AND FOLLOWED UP CORRECTLY.D THE CARLSSON-DENT QUESTIONNAIRE WAS THEBEST ALTERNATIVE TO IDENTIFY GERD PATIENTS.
  46. 46. 16. C17. B18. D19. A20. B
  47. 47.  16. The study … included patients aged sixty and older, regardless of gender. 17. They should not have cognitive damage, which was ascertained by the Folstein mini mental state examination. 18. The information about diagnosis, drug prescriptions, and pharmocological and non pharmacological gastroesophageal protection was obtained from the medical charts and prescriptions. 19. GERD prevalence was 25%.
  48. 48.  20. Elderly patients attending to primary care facilities often have GERD symptoms, but they are not properly diagnosed or followed up. Regardless/ regarding, in regards to
  49. 49. Regardless/regarding, in regards to
  50. 50. NEW THINKING ON HOW TO PROTECT THE HEART BY JANE E. BRODY SURGERY MAY NOT BETHE BEST WAY TO AVOID A HEART ATTACK OR SUDDEN CARDIAC DEATH, THE NEXT STEP ISFINDING OUT WHAT CAN WORK AS WELL OR BETTER TO PROTECT YOUR HEART. MANYMEASURES ARE PROBABLY FAMILIAR: NOT SMOKING, CONTROLLING CHOLESTEROL ANDBLOOD PRESSURE, EXERCISING REGULARLY AND STAYING AT A HEALTHY WEIGHT. BUT SOMENEWER SUGGESTIONS MAY SURPRISE YOU. IT IS NOT THAT THE OLD ADVICE, LIKE EATING ALOW-FAT DIET OR EXERCISING VIGOROUSLY, WAS BAD ADVICE; IT WAS BASED ON THE BESTAVAILABLE EVIDENCE OF THE TIME AND CAN STILL BE VERY HELPFUL. THE WELL-ESTABLISHEDRISK FACTORS FOR HEART DISEASE REMAIN INTACT: HIGH CHOLESTEROL, HIGH BLOODPRESSURE, SMOKING, DIABETES, ABDOMINAL OBESITY AND SEDENTARY LIVING. BUT BEHINDTHEM A RELATIVELY NEW FACTOR HAS EMERGED THAT MAY BE EVEN MORE IMPORTANT AS ACAUSE OF HEART ATTACKS THAN, SAY, HIGH BLOOD LEVELS OF ARTERY-DAMAGINGCHOLESTEROL. THAT FACTOR IS C-REACTIVE PROTEIN, OR CRP, A BLOOD-BORNE MARKER OFINFLAMMATION THAT, ALONG WITH COAGULATION FACTORS, IS NOW INCREASINGLYRECOGNIZED AS THE DRIVING FORCE BEHIND CLOTS THAT BLOCK BLOOD FLOW TO THEHEART. EVEN IN PEOPLE WITH NORMAL CHOLESTEROL, IF CRP IS ELEVATED, THE RISK OFHEART ATTACK IS TOO. DIET REVISITED THE NEW DIETARY ADVICE IS ACTUALLY BASED ON ARATHER OLD FINDING THAT PREDATES THE MANTRA TO EAT A LOW-FAT DIET. IN THE SEVENCOUNTRIES STUDY STARTED IN 1958 FOUND THAT HEART DISEASE WAS RARE IN THEMEDITERRANEAN AND ASIAN REGIONS WHERE VEGETABLES, GRAINS, FRUITS, BEANS AND FISHWERE THE DIETARY MAINSTAYS. BUT IN COUNTRIES LIKE FINLAND AND THE UNITED STATESWHERE PLATES WERE TYPICALLY FILLED WITH RED MEAT, CHEESE AND OTHER FOODS RICH INSATURATED FATS, HEART DISEASE AND CARDIAC DEATHS WERE EPIDEMIC. THE FINDINGRESULTED IN THE WELL-KNOWN ADVICE TO REDUCE DIETARY FAT AND ESPECIALLYSATURATED FATS (THOSE THAT ARE FIRM AT ROOM TEMPERATURE), AND TO REPLACE THESEHARMFUL FATS WITH UNSATURATED ONES LIKE VEGETABLE OILS. WHAT WAS MISSED AT THETIME AND HAS NOW BECOME INCREASINGLY APPARENT IS THAT THE HEART-HEALTHYMEDITERRANEAN DIET IS NOT REALLY LOW IN FAT, BUT ITS MAIN SOURCES OF FAT — OLIVEOIL AND OILY FISH AS WELL AS NUTS, SEEDS AND CERTAIN VEGETABLES — HELP TO PREVENTHEART DISEASE BY IMPROVING CHOLESTEROL RATIOS AND REDUCING INFLAMMATION.
  51. 51. NEW THINKING ON HOW TO PROTECT THE HEART. BYJANE E. BRODY. SURGERY MAY NOT BE THE BEST WAYTO AVOID A HEART ATTACK OR SUDDEN CARDIACDEATH. THE NEXT STEP IS FINDING OUT WHAT CANWORK AS WELL OR BETTER TO PROTECT YOUR HEART.MANY MEASURES ARE PROBABLY FAMILIAR: NOTSMOKING, CONTROLLING CHOLESTEROL AND BLOODPRESSURE, EXERCISING REGULARLY AND STAYING AT AHEALTHY WEIGHT. BUT SOME NEWER SUGGESTIONSMAY SURPRISE YOU. IT IS NOT THAT THE OLDADVICE, LIKE EATING A LOW-FAT DIET OR EXERCISINGVIGOROUSLY, WAS BAD ADVICE; IT WAS BASED ON THEBEST AVAILABLE EVIDENCE OF THE TIME AND CANSTILL BE VERY HELPFUL. THE WELL-ESTABLISHED RISKFACTORS FOR HEART DISEASE REMAIN INTACT: HIGHCHOLESTEROL, HIGH BLOODPRESSURE, SMOKING, DIABETES, ABDOMINAL OBESITYAND SEDENTARY LIVING.
  52. 52. BUT BEHIND THEM A RELATIVELY NEW FACTOR HASEMERGED THAT MAY BE EVEN MORE IMPORTANT AS ACAUSE OF HEART ATTACKS THAN, SAY, HIGH BLOODLEVELS OF ARTERY-DAMAGING CHOLESTEROL. THATFACTOR IS C-REACTIVE PROTEIN, OR CRP, A BLOOD-BORNE MARKER OF INFLAMMATION THAT, ALONGWITH COAGULATION FACTORS, IS NOW INCREASINGLYRECOGNIZED AS THE DRIVING FORCE BEHIND CLOTSTHAT BLOCK BLOOD FLOW TO THE HEART. EVEN INPEOPLE WITH NORMAL CHOLESTEROL, IF CRP ISELEVATED, THE RISK OF HEART ATTACK IS TOO. DIETREVISITED THE NEW DIETARY ADVICE IS ACTUALLYBASED ON A RATHER OLD FINDING THAT PREDATESTHE MANTRA TO EAT A LOW-FAT DIET. IN THE SEVENCOUNTRIES STUDY STARTED IN 1958 FOUND THATHEART DISEASE WAS RARE IN THE MEDITERRANEANAND ASIAN REGIONS WHEREVEGETABLES, GRAINS, FRUITS, BEANS AND FISH WERE
  53. 53. BUT IN COUNTRIES LIKE FINLAND AND THE UNITEDSTATES WHERE PLATES WERE TYPICALLY FILLED WITHRED MEAT, CHEESE AND OTHER FOODS RICH INSATURATED FATS, HEART DISEASE AND CARDIACDEATHS WERE EPIDEMIC. THE FINDING RESULTED INTHE WELL-KNOWN ADVICE TO REDUCE DIETARY FATAND ESPECIALLY SATURATED FATS (THOSE THAT AREFIRM AT ROOM TEMPERATURE), AND TO REPLACETHESE HARMFUL FATS WITH UNSATURATED ONES LIKEVEGETABLE OILS. WHAT WAS MISSED AT THE TIME ANDHAS NOW BECOME INCREASINGLY APPARENT IS THATTHE HEART-HEALTHY MEDITERRANEAN DIET IS NOTREALLY LOW IN FAT, BUT ITS MAIN SOURCES OF FAT —OLIVE OIL AND OILY FISH AS WELL AS NUTS, SEEDSAND CERTAIN VEGETABLES — HELP TO PREVENT HEARTDISEASE BY IMPROVING CHOLESTEROL RATIOS ANDREDUCING INFLAMMATION.
  54. 54.  21. ACCORDING TO THE ARTICLE, THE BEST WAY TO AVOID A HEART ATTACK IS: A EATING A LOW FAT DIET AND EXERCISING VIGOROUSLY. B HAVING A SURGERY. C CONTROLLING YOUR CRP D CONTROLLING YOUR CHOLESTEROL 22. ACCORDING TO THE ARTICLE, THE BEST DIET TO FOLLOW IS: A A LOW-FAT DIET B SATURATED FATS C RED MEAT AND CHEESE D A MEDITERRANEAN DIET.
  55. 55.  23. THE MEDITERRANEAN DIET CONSISTS MAINLY OF: A LOW CARBOHYDRATES B RED MEAT AND CHEESE C UNSATURATED FATS D VEGETABLES 24. DRINKING RED WINE IS GOOD FOR YOU BECAUSE: A IT MAKES YOU RELAX B IT HAS ANTIOXIDANT PROPERTIES C IT PREVENTS THE FORMATION OF CHOLESTEROL D IT IS EASY TO DIGEST
  56. 56.  25. FROM THE ARTICLE WE CAN CONCLUDE THAT: A IF WE FOLLOW A LOW-FAT DIET AND EXERCISE VIGOROUSLY, WE WILL AVOID HAVING A HEART ATTACK B GOING TO THE PERIODONTIST, EXERCISING 15 MINUTES A DAY, RELAXING, AND FOLLOWING A MEDITERRANEAN DIET, WE WILL AVOID HAVING AHEART ATTACK C TAKING A VACATION, EXERCISING VIGOROUSLY AND FOLLOWING A MEDITERRANEAN DIET, WE WILL AVOID HAVING A HEART ATTACK D PRACTICING THE RELAXATION RESPONSE ONCE OR TWICE A DAY BY BREATHING DEEPLY AND RHYTHMICALLY IN A QUIET PLACE WILL AVOID HAVING A HEART ATTACK.
  57. 57. 21. C22. D23. C24. B (Esta respuesta no está en la lectura)25. B
  58. 58.  21. But behind them, a relatively new factor has emerged that may be even more important as a cause of heart attacks, than, say, high blood levels of artery-damaging cholesterol. That factor is C-reacting protein, or CRP. 22. … the study … found that heart disease was rare in the Mediterranean and Asian regions where vegetables, grains, fruits, beans, and fish were the dietary mainstays.
  59. 59.  23. … the heart-healthy Mediterranean diet is not really low in fat, but its main source of fat – olive oil and oily fish as well as nuts, seeds and certain vegetables - help to prevent heart disease by improving cholesterol ratios and reducing inflammation.
  60. 60.  24. La respuesta no está en la lectura. 25. It is not that old advice, like eatinga low-fat diet or exercising vigorouslywas bad advice; it was based on the bestavailable advice of the time and can stillbe very helpful.
  61. 61. MATERNAL MORBIDITY, MORTALITY, AND RISK ASSESSMENT. MATERNALMORTALITY IS THE TIP OF THE MATERNAL MORBIDITY ICEBERG; SEVERALOBSETRIC, ANESTHETIC AND SOCIAL CHALLENGES IMPACT MORBIDITYAND MORTALITY IN WOMEN. MATERNAL MORTALITY IS THE YARDSTICKTO MEASURE WHEN HEALTH CARE PERSONNEL FAIL TO RECOGNIZERISKS, LACK INTERDISCIPLINARY COMMUNICATION, OR PROVIDESUBSTANDARD CARE, THUS RESULTING IN COMPLICATIONS DURINGPREGNACY, LABOR, OR DELIVERY. PREGNANCY-RELATED DEATH ISDEFINED BY THE INTERNATIONAL CLASSIFICATION OF DISEASES, 10THREVISION (ICD-10) AS THE DEATH OF A WOMAN WHILE PREGNANT ORWITHIN 42 DAYS OF TERMINATION OF PREGNANCY, DESPITE THE CAUSEOF DEATH. ALTHOUGH THE RISK FOR DEATH FROM COMPLICATIONS OFPREGNANCY DECREASED DURING THE 20TH CENTURY IN THE UNITEDSTATES, THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)REPORTS A FAIRLY STATIC MATERNAL MORTALITY RATIO (MMR) OFAPPROXIMATELY 7.5 MATERNAL DEATHS PER 100,000 LIVE BIRTHS. IN THEYEAR 2000, A COLLABORATIVE EFFORT INVOLVING WORLD HEALTHORGANIZATION (WHO), UNITED NATIONS CHILDREN’S FUND(UNICEF), AND UNITED NATIONS POPULATION FUND (UNFPA) ESTIMATED660 MATERNAL DEATHS, THUS AVERAGING 11 MATERNAL DEATHS PER100,000 LIVE BIRTHS, PLACING THE MMR ABOVE THE STATISTICSREPORTED BY THE CDC.
  62. 62. THESE SURVEYS ON MATERNAL MORTALITY SURVEILLANCES ARELIMITED IN SCOPE BECAUSE THE INFORMATION IS OBTAINED FROMDEATH CERTIFICATES, AND VARIOUS STATES OR ACADEMICINSTITUTIONS COULD BE UNDERREPORTING. ACCURATE STATISTICS ARELACKING, THUS RESULTING IN ONLY A SNAPSHOT OF THE ACTUALMATERNAL MORBIDITY AND MORTALITY. THE RECENT WHO ESTIMATE INTHE UNITED STATES SHOWS THAT MATERNAL MORTALITY ISAPPROXIMATELY 17 IN 100,000 PREGNANCIES. THIS ESTIMATE ISSIGNIFICANTLY HIGHER THAN THE GOAL SET BY THE U.S. DEPARTMENTOF HEALTH AND HUMAN SERVICES IN HEALTHY PEOPLE 2010, WHICHSETS THE TARGET FOR MATERNAL MORTALITY AT LESS THAN 3.3 IN100,000 LIVE BIRTHS. SOME REGIONAL REPORTS DOCUMENT RATIOS ASHIGH AS 22.8 PER 100,000 LIVE BIRTHS, WHICH IS AN UNACCEPTABLY HIGHRATE. IN UNITED STATES, THE MOST COMMON CAUSES OF MATERNALDEATHS, ALTHOUGH THEY VARY AMONG STATES, INCLUDETHROMBOEMBOLISM; AMNIOTIC FLUID EMBOLISM; HEMORRHAGE;COMPLICATIONS OF HYPERTENSION, INCLUDING PREECLAMPSIA ANDECLAMPSIA; AND INFECTION, PULMONARY DISEASE, ANESTHESIA-RELATED DEATHS, AND CARDIOMYOPATHY ARE ALSO SIGNIFICANTCONTRIBUTORS TO MATERNAL MORBIDITY AND MORTALITY.
  63. 63. MATERNAL MORBIDITY, MORTALITY, AND RISK ASSESSMENT. MATERNAL MORTALITY IS THE TIP OF THEMATERNAL MORBIDITY ICEBERG; SEVERAL OBSETRIC, ANESTHETIC AND SOCIAL CHALLENGES IMPACTMORBIDITY AND MORTALITY IN WOMEN. MATERNAL MORTALITY IS THE YARDSTICK TO MEASUREWHEN HEALTH CARE PERSONNEL FAIL TO RECOGNIZE RISKS, LACK INTERDISCIPLINARYCOMMUNICATION, OR PROVIDE SUBSTANDARD CARE, THUS RESULTING IN COMPLICATIONS DURINGPREGNACY, LABOR, OR DELIVERY. PREGNANCY-RELATED DEATH IS DEFINED BY THE INTERNATIONALCLASSIFICATION OF DISEASES, 10TH REVISION (ICD-10) AS THE DEATH OF A WOMAN WHILE PREGNANTOR WITHIN 42 DAYS OF TERMINATION OF PREGNANCY, DESPITE THE CAUSE OF DEATH. ALTHOUGH THERISK FOR DEATH FROM COMPLICATIONS OF PREGNANCY DECREASED DURING THE 20TH CENTURY INTHE UNITED STATES, THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) REPORTS A FAIRLYSTATIC MATERNAL MORTALITY RATIO (MMR) OF APPROXIMATELY 7.5 MATERNAL DEATHS PER 100,000LIVE BIRTHS. IN THE YEAR 2000, A COLLABORATIVE EFFORT INVOLVING WORLD HEALTHORGANIZATION (WHO), UNITED NATIONS CHILDREN’S FUND (UNICEF), AND UNITED NATIONSPOPULATION FUND (UNFPA) ESTIMATED 660 MATERNAL DEATHS, THUS AVERAGING 11 MATERNALDEATHS PER 100,000 LIVE BIRTHS, PLACING THE MMR ABOVE THE STATISTICS REPORTED BY THE CDC.THESE SURVEYS ON MATERNAL MORTALITY SURVEILLANCES ARE LIMITED IN SCOPE BECAUSE THEINFORMATION IS OBTAINED FROM DEATH CERTIFICATES, AND VARIOUS STATES OR ACADEMICINSTITUTIONS COULD BE UNDERREPORTING. ACCURATE STATISTICS ARE LACKING, THUS RESULTING INONLY A SNAPSHOT OF THE ACTUAL MATERNAL MORBIDITY AND MORTALITY. THE RECENT WHOESTIMATE IN THE UNITED STATES SHOWS THAT MATERNAL MORTALITY IS APPROXIMATELY 17 IN 100,000PREGNANCIES. THIS ESTIMATE IS SIGNIFICANTLY HIGHER THAN THE GOAL SET BY THE U.S.DEPARTMENT OF HEALTH AND HUMAN SERVICES IN HEALTHY PEOPLE 2010, WHICH SETS THE TARGETFOR MATERNAL MORTALITY AT LESS THAN 3.3 IN 100,000 LIVE BIRTHS. SOME REGIONAL REPORTSDOCUMENT RATIOS AS HIGH AS 22.8 PER 100,000 LIVE BIRTHS, WHICH IS AN UNACCEPTABLY HIGH RATE.IN UNITED STATES, THE MOST COMMON CAUSES OF MATERNAL DEATHS, ALTHOUGH THEY VARYAMONG STATES, INCLUDE THROMBOEMBOLISM; AMNIOTIC FLUID EMBOLISM; HEMORRHAGE;COMPLICATIONS OF HYPERTENSION, INCLUDING PREECLAMPSIA AND ECLAMPSIA; ANDINFECTION, PULMONARY DISEASE, ANESTHESIA-RELATED DEATHS, AND CARDIOMYOPATHY ARE ALSOSIGNIFICANT CONTRIBUTORS TO MATERNAL MORBIDITY AND MORTALITY.
  64. 64. MATERNAL MORBIDITY, MORTALITY, AND RISKASSESSMENT. MATERNAL MORTALITY IS THE TIP OFTHE MATERNAL MORBIDITY ICEBERG; SEVERALOBSETRIC, ANESTHETIC AND SOCIAL CHALLENGESIMPACT MORBIDITY AND MORTALITY IN WOMEN.MATERNAL MORTALITY IS THE YARDSTICK TOMEASURE WHEN HEALTH CARE PERSONNEL FAILTO RECOGNIZE RISKS, LACK INTERDISCIPLINARYCOMMUNICATION, OR PROVIDE SUBSTANDARDCARE, THUS RESULTING IN COMPLICATIONSDURING PREGNACY, LABOR, OR DELIVERY.PREGNANCY-RELATED DEATH IS DEFINED BY THEINTERNATIONAL CLASSIFICATION OFDISEASES, 10TH REVISION (ICD-10) AS THE DEATHOF A WOMAN WHILE PREGNANT OR WITHIN 42DAYS OF TERMINATION OF PREGNANCY, DESPITETHE CAUSE OF DEATH.
  65. 65. ALTHOUGH THE RISK FOR DEATH FROMCOMPLICATIONS OF PREGNANCY DECREASED DURINGTHE 20TH CENTURY IN THE UNITED STATES, THECENTERS FOR DISEASE CONTROL AND PREVENTION(CDC) REPORTS A FAIRLY STATIC MATERNALMORTALITY RATIO (MMR) OF APPROXIMATELY 7.5MATERNAL DEATHS PER 100,000 LIVE BIRTHS. IN THEYEAR 2000, A COLLABORATIVE EFFORT INVOLVINGWORLD HEALTH ORGANIZATION (WHO), UNITEDNATIONS CHILDREN’S FUND (UNICEF), AND UNITEDNATIONS POPULATION FUND (UNFPA) ESTIMATED 660MATERNAL DEATHS, THUS AVERAGING 11 MATERNALDEATHS PER 100,000 LIVE BIRTHS, PLACING THE MMRABOVE THE STATISTICS REPORTED BY THE CDC. THESESURVEYS ON MATERNAL MORTALITY SURVEILLANCESARE LIMITED IN SCOPE BECAUSE THE INFORMATION ISOBTAINED FROM DEATH CERTIFICATES, AND VARIOUSSTATES OR ACADEMIC INSTITUTIONS COULD BEUNDERREPORTING.
  66. 66. ACCURATE STATISTICS ARE LACKING, THUS RESULTING INONLY A SNAPSHOT OF THE ACTUAL MATERNAL MORBIDITYAND MORTALITY. THE RECENT WHO ESTIMATE IN THEUNITED STATES SHOWS THAT MATERNAL MORTALITY ISAPPROXIMATELY 17 IN 100,000 PREGNANCIES. THIS ESTIMATEIS SIGNIFICANTLY HIGHER THAN THE GOAL SET BY THE U.S.DEPARTMENT OF HEALTH AND HUMAN SERVICES INHEALTHY PEOPLE FOR 2010, WHICH SETS THE TARGET FORMATERNAL MORTALITY AT LESS THAN 3.3 IN 100,000 LIVEBIRTHS. SOME REGIONAL REPORTS DOCUMENT RATIOS ASHIGH AS 22.8 PER 100,000 LIVE BIRTHS, WHICH IS ANUNACCEPTABLY HIGH RATE. IN UNITED STATES, THE MOSTCOMMON CAUSES OF MATERNAL DEATHS, ALTHOUGH THEYVARY AMONG STATES, INCLUDE THROMBOEMBOLISM;AMNIOTIC FLUID EMBOLISM; HEMORRHAGE;COMPLICATIONS OF HYPERTENSION, INCLUDINGPREECLAMPSIA AND ECLAMPSIA; ANDINFECTION, PULMONARY DISEASE, ANESTHESIA-RELATEDDEATHS, AND CARDIOMYOPATHY ARE ALSO SIGNIFICANTCONTRIBUTORS TO MATERNAL MORBIDITY AND
  67. 67.  26. FOR MATERNAL MORTALITY, A RISK FACTOR COULD BE: A EXCESIVE INTERDISCIPLINARY COMMUNICATION BY HEALTH CARE PERSONNEL. B FAILURE TO RECOGNIZE RISKS BY HEALTH CARE PERSONNEL . C HEALTH CARE PERSONNEL PROVIDE STANDARD CARE. D ALL THE ABOVE ARE RISK FACTORS. 27. THE MAIN REASON WHY THE MATERNAL MORTALITY SURVEILLANCES ARE LIMITED IN SCOPE WOULD BE: A BECAUSE THE INFORMATION IS OBTAINED FROM DEATH CERTIFICATES. B A SITUATION OF UNDERREPORTING. C BECAUSE VARIOUS STATES OR ACADEMIC INSTITUTIONS COULD BE OVERREPORTING. D THE MATERNAL MORTALITY SURVEILLANCES ARE ACCURATE.
  68. 68.  28. ACCORDING TO THE FINDINGS FROM THE STUDY CONDUCTED BY WHO, UNICEF AND THE UNFPA, WHAT IS THE CONCLUSION?: A PREGNANCY RELATED DEATH IS THE DEATH OF A PREGNANT WOMAN . B PREGNANCY RELATED DEATH IS THE DEATH OF A WOMAN WITHIN 42 DAYS OF TERMINATION OF PREGNANCY, DESPITE THE CAUSE OF DEATH. C THE RISK OF DEATH FROM COMPLICATIONS OF PREGNANCY DECREASED DRAMATICALLY DURING THE 20TH CENTURY IN THE UNITED STATES. D THE MMR STATISTICS ARE ABOVE THE CDC STATISTICS.
  69. 69.  29. ALTHOUGH THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES HAS PROJECTED GOALS FOR 2010, WHAT IS THE ACTUAL RATIO?: A MATERNAL MORTALITY IS APPROXIMATELY 17 IN 100,000 PREGNANCIES. B MATERNAL MORTALITY IS AT LESS THAN 3.3 IN 100,000 LIVEBIRTHS. C THE RESULTS HAVE NOT BEEN WHAT THEY EXPECTED. D MATERNAL MORTALITY IS 22.8 PER 100,000 LIVE BIRTHS.30. ABOUT THE CAUSES OF MATERNAL DEATHS, WHICHWOULD BE CONSIDERED A CONTRIBUTOR FROM THEFOLLOWING?: A THROMBOEMBOLISM. B AMNIOTIC FLUID EMBOLISM. C PREECLAMPSIA AND ECLAMPSIA. D CARDIOMYOPATHY.
  70. 70. 26. B27. A28. D29. A30. D
  71. 71.  26. Maternal mortality is the yardstick to measure when health care personnel fail to recognize risks, lack interdisciplinary communication, or provide substandard care. 27. These surveys on maternal mortality surveillances are limited in scope because the information is obtained from death certificates, and various states or academic institutions could be underreporting.
  72. 72.  28. A collaborative effort involving World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and United Nations Population Fund(UNFPA) estimated 660 maternal deaths, thus averaging 11 maternal deaths per 100,000 live births, placing the MMR above the statistics by the CDC. 29. The recent WHO estimate in the United States shows that maternal mortality is approximately 17 in 100,000 pregnancies.
  73. 73.  30. … and cardiomyopathy are also significant contributors to maternal mortality and morbidity. (A, B y C son causas. La D es el único contribuyente de los mencionados en el texto.)actual, actually/current, currently
  74. 74. VACCINE TAKES AIM AT HYPERTENSION. ORLANDO, FLA. SOME PATIENTS WITH HYPERTENSION HAVEINADEQUATE CONTROL OF BLOOD PRESSURE BECAUSE THEY ARE NOT CONSISTENTLY ADHERENT INTAKING THEIR MEDICATIONS. BUT HELP MAY BE ON THE WAY IN THE FORM OF A VACCINE THATLOWERS BLOOD PRESSURE BY CONTROLLING ANGIOTENSIN II, SUGGEST FINDINGS FROM A SMALLSAFETY STUDY PRESENTED AT THE SCIENTIFIC SESSIONS OF THE AMERICAN HEART ASSOCIATION INNOVEMBER. THE STUDY OF 72 PATIENTS WITH MILD-TO-MODERATE HYPERTENSION PRESENTED BYJURG NUSSBERGER, MD, PROFESSOR OF MEDICINE AT THE UNIVERSITY HOSPITAL OF THE CANTON OFVAUD, LAUSANNE, SWITZERLAND, FOUND THAT AT 14 WEEKS, THOSE INJECTED WITH CYTOO6-ANGQB(AT 0, 4 AND 12 WEEKS) HAD A SYSTOLIC BLOOD PRESSURE THAT WAS 5.6 MM HG LOWER AND ADIASTOLIC BLOOD PRESSURE 2.8 MM HG LOWER THAN THOSE OF PATIENTS WHO RECEIVED PLACEBO.CYTOO6-ANGQB, WHICH IS UNDER DEVELOPMENT BY CYTOS BIOTECHNOLOGY AG(ZURICH, SWITZERLAND), IS A VIRUS-SHAPED NONINFECTIOUS PARTICLE THAT IS COUPLED WITHANGIOTENSIN II, AN OCTAPEPTIDE VASOCONSTRICTOR. SUCH COUPLING INDUCES THE BODY TOPRODUCE ANTIBODIES AGAINST THIS SMALL MOLECULE TO MINIMIZE ITS EFFECTS ON CONSTRICTINGBLOOD VESSELS. NUSSBERGER SAID HE IS NOT CONCERNED THAT THE VACCINE MIGHT CAUSEHYPOTENSION BECAUSE ANTIBODY TITERS STARTED TO DECREASE SHORTLY AFTER THE BOOSTER OFTWELVE WEEKS INDUCED PEAK ANTIBODY LEVELS. HE ALSO SAID THE LIKELIHOOD OF VACCINE-INDUCED ANTIBODIES CROSS-REACTING WITH OTHER PROTEINS WAS MINIMAL BECAUSE THE SMALLSIZE OF THE TARGET MOLECULE LIMITS THE NUMBER OF EPITOPES THAT COULD BE AFFECTED.NUSSBERGER SPECULATED THAT IF THE CYTOO6-ANGQB VACCINE IS ULTIMATELY APPROVED, PATIENTSWOULD BE ABLE TO AVOID THE NEED FOR MEDICATION BUT WOULD REQUIRE A BOOSTER SHOT 2 0R 3TIMES A YEAR. HE SAID THE NEXT STEP IN STUDYING THE VACCINE WILL BE TO CONDUCT ANOTHERSMALL TRIAL TO DETERMINE THE APPRPRIATE DOSING TO CREATE THE LARGEST ANTIBODY RESPONSEAND GREATEST REDUCTIONS IN BLOOD PRESSURE. MORRIS J. BROWN, MD, PROFESSOR OF CLINICALPHARMACOLOGY AT THE UNIVERSITY OF CAMBRIGE IN ENGLAND AND PAST PRESIDENT OF THEBRITISH HYPERTENSION SOCIETY, SAID THE FINDINGS OF THE STUDY (WHICH WAS FUNDED BY CYTOS)ARE “INTRIGUING” BUT OFFERED A CAVEAT. “I AM A LITTLE WARY OF TOP-LINE RESULTS FROMBIOTECHS, ESPECIALLY SECONDARY EFFICACY VARIABLES IN A PRIMARY SAFETY STUDY,” HE SAID.BROWN HAS ALSO HAD A HAND IN ATTEMPTS TO CREATE A HYPERTENSION VACCINE, PMD3117, UNDERDEVELOPMENT BY PROTHERICS PLC IN RUNCORN, ENGLAND (BROWN MJ ET AL. CLIN SCI).
  75. 75. VACCINE TAKES AIM AT HYPERTENSION. ORLANDO, FLA. SOME PATIENTSWITH HYPERTENSION HAVE INADEQUATE CONTROL OF BLOODPRESSURE BECAUSE THEY ARE NOT CONSISTENTLY ADHERENT IN TAKINGTHEIR MEDICATIONS. BUT HELP MAY BE ON THE WAY IN THE FORM OF AVACCINE THAT LOWERS BLOOD PRESSURE BY CONTROLLINGANGIOTENSIN II, SUGGEST FINDINGS FROM A SMALL SAFETY STUDYPRESENTED AT THE SCIENTIFIC SESSIONS OF THE AMERICAN HEARTASSOCIATION IN NOVEMBER. THE STUDY OF 72 PATIENTS WITH MILD-TO-MODERATE HYPERTENSION PRESENTED BY JURGNUSSBERGER, MD, PROFESSOR OF MEDICINE AT THE UNIVERSITYHOSPITAL OF THE CANTON OF VAUD, LAUSANNE, SWITZERLAND, FOUNDTHAT AT 14 WEEKS, THOSE INJECTED WITH CYTOO6-ANGQB (AT 0, 4 AND12 WEEKS) HAD A SYSTOLIC BLOOD PRESSURE THAT WAS 5.6 MM HGLOWER AND A DIASTOLIC BLOOD PRESSURE 2.8 MM HG LOWER THANTHOSE OF PATIENTS WHO RECEIVED PLACEBO. CYTOO6-ANGQB, WHICHIS UNDER DEVELOPMENT BY CYTOS BIOTECHNOLOGY AG(ZURICH, SWITZERLAND), IS A VIRUS-SHAPED NONINFECTIOUS PARTICLETHAT IS COUPLED WITH ANGIOTENSIN II, AN OCTAPEPTIDEVASOCONSTRICTOR. SUCH COUPLING INDUCES THE BODY TO PRODUCEANTIBODIES AGAINST THIS SMALL MOLECULE TO MINIMIZE ITS EFFECTSON CONSTRICTING BLOOD VESSELS.
  76. 76. NUSSBERGER SAID HE IS NOT CONCERNED THAT THE VACCINE MIGHTCAUSE HYPOTENSION BECAUSE ANTIBODY TITERS STARTED TO DECREASESHORTLY AFTER THE BOOSTER OF TWELVE WEEKS INDUCED PEAKANTIBODY LEVELS. HE ALSO SAID THE LIKELIHOOD OF VACCINE-INDUCED ANTIBODIES CROSS-REACTING WITH OTHER PROTEINS WASMINIMAL BECAUSE THE SMALL SIZE OF THE TARGET MOLECULE LIMITSTHE NUMBER OF EPITOPES THAT COULD BE AFFECTED. NUSSBERGERSPECULATED THAT IF THE CYTOO6-ANGQB VACCINE IS ULTIMATELYAPPROVED, PATIENTS WOULD BE ABLE TO AVOID THE NEED FORMEDICATION BUT WOULD REQUIRE A BOOSTER SHOT 2 0R 3 TIMES AYEAR. HE SAID THE NEXT STEP IN STUDYING THE VACCINE WILL BE TOCONDUCT ANOTHER SMALL TRIAL TO DETERMINE THE APPROPRIATEDOSING TO CREATE THE LARGEST ANTIBODY RESPONSE AND GREATESTREDUCTIONS IN BLOOD PRESSURE. MORRIS J. BROWN, MD, PROFESSOROF CLINICAL PHARMACOLOGY AT THE UNIVERSITY OF CAMBRIGE INENGLAND AND PAST PRESIDENT OF THE BRITISH HYPERTENSIONSOCIETY, SAID THE FINDINGS OF THE STUDY (WHICH WAS FUNDED BYCYTOS) ARE “INTRIGUING” BUT OFFERED A CAVEAT. “I AM A LITTLE WARYOF TOP-LINE RESULTS FROM BIOTECHS, ESPECIALLY SECONDARYEFFICACY VARIABLES IN A PRIMARY SAFETY STUDY,” HE SAID. BROWN HASALSO HAD A HAND IN ATTEMPTS TO CREATE A HYPERTENSIONVACCINE, PMD3117, UNDER DEVELOPMENT BY PROTHERICS PLC INRUNCORN, ENGLAND (BROWN MJ ET AL. CLIN SCI).
  77. 77. VACCINE TAKES AIM AT HYPERTENSION. ORLANDO, FLA.SOME PATIENTS WITH HYPERTENSION HAVEINADEQUATE CONTROL OF BLOOD PRESSURE BECAUSETHEY ARE NOT CONSISTENTLY ADHERENT IN TAKINGTHEIR MEDICATIONS. BUT HELP MAY BE ON THE WAY INTHE FORM OF A VACCINE THAT LOWERS BLOODPRESSURE BY CONTROLLING ANGIOTENSIN II, SUGGESTFINDINGS FROM A SMALL SAFETY STUDY PRESENTED ATTHE SCIENTIFIC SESSIONS OF THE AMERICAN HEARTASSOCIATION IN NOVEMBER. THE STUDY OF 72 PATIENTSWITH MILD-TO-MODERATE HYPERTENSION PRESENTEDBY JURG NUSSBERGER, MD, PROFESSOR OF MEDICINE ATTHE UNIVERSITY HOSPITAL OF THE CANTON OFVAUD, LAUSANNE, SWITZERLAND, FOUND THAT AT 14WEEKS, THOSE INJECTED WITH CYTOO6-ANGQB (AT 0, 4AND 12 WEEKS) HAD A SYSTOLIC BLOOD PRESSURE THATWAS 5.6 MM HG LOWER AND A DIASTOLIC BLOODPRESSURE 2.8 MM HG LOWER THAN THOSE OF PATIENTSWHO RECEIVED PLACEBO.
  78. 78. CYTOO6-ANGQB, WHICH IS UNDERDEVELOPMENT BY CYTOS BIOTECHNOLOGY AG(ZURICH, SWITZERLAND), IS A VIRUS-SHAPEDNONINFECTIOUS PARTICLE THAT IS COUPLEDWITH ANGIOTENSIN II, AN OCTAPEPTIDEVASOCONSTRICTOR. SUCH COUPLING INDUCESTHE BODY TO PRODUCE ANTIBODIES AGAINSTTHIS SMALL MOLECULE TO MINIMIZE ITS EFFECTSON CONSTRICTING BLOOD VESSELS. NUSSBERGERSAID HE IS NOT CONCERNED THAT THE VACCINEMIGHT CAUSE HYPOTENSION BECAUSE ANTIBODYTITERS STARTED TO DECREASE SHORTLY AFTERTHE BOOSTER OF TWELVE WEEKS INDUCED PEAKANTIBODY LEVELS. HE ALSO SAID THELIKELIHOOD OF VACCINE-INDUCED ANTIBODIESCROSS-REACTING WITH OTHER PROTEINS WASMINIMAL BECAUSE THE SMALL SIZE OF THETARGET MOLECULE LIMITS THE NUMBER OFEPITOPES THAT COULD BE AFFECTED.
  79. 79. NUSSBERGER SPECULATED THAT IF THE CYTOO6-ANGQBVACCINE IS ULTIMATELY APPROVED, PATIENTS WOULD BEABLE TO AVOID THE NEED FOR MEDICATION BUT WOULDREQUIRE A BOOSTER SHOT 2 0R 3 TIMES A YEAR. HE SAIDTHE NEXT STEP IN STUDYING THE VACCINE WILL BE TOCONDUCT ANOTHER SMALL TRIAL TO DETERMINE THEAPPROPRIATE DOSING TO CREATE THE LARGEST ANTIBODYRESPONSE AND GREATEST REDUCTIONS IN BLOODPRESSURE. MORRIS J. BROWN, MD, PROFESSOR OF CLINICALPHARMACOLOGY AT THE UNIVERSITY OF CAMBRIGE INENGLAND AND PAST PRESIDENT OF THE BRITISHHYPERTENSION SOCIETY, SAID THE FINDINGS OF THESTUDY (WHICH WAS FUNDED BY CYTOS) ARE “INTRIGUING”BUT OFFERED A CAVEAT. “I AM A LITTLE WARY OF TOP-LINERESULTS FROM BIOTECHS, ESPECIALLY SECONDARYEFFICACY VARIABLES IN A PRIMARY SAFETY STUDY,” HE SAID.BROWN HAS ALSO HAD A HAND IN ATTEMPTS TO CREATE AHYPERTENSION VACCINE, PMD3117, UNDER DEVELOPMENTBY PROTHERICS PLC IN RUNCORN, ENGLAND (BROWN MJ ETAL. CLIN SCI).
  80. 80.  31 ABOUT PATIENTS WHO DO NOT TAKE THEIR TREATMENT REGULARY: A THESE PATIENTS HAVE AN ADEQUATE CONTROL OF BLOOD PRESSURE. B THEY ARE CONSISTENTLY ADHERENT IN TAKING THEIR MEDICATIONS. C THEY MUST HAVE A REGULAR DIET CONTROL. D THEY HAVE AN INADEQUATE CONTROL OF BLOOD PRESSURE. 32 ABOUT THE WORKING MECHANISM OF THE VACCINE: A ITS WORKING MECHANISM IS BY CONTROLLING ANGIOTENSIN I. B ITS WORKING MECHANISM IS BY CONTROLLING ANGIOTENSIN II. C ITS WORKING MECHANISM IS BY CONSTRICTING BLOOD VESSELS. D IT INDUCES ANTIBODIES CROSS-REACTING WITH OTHER PROTEINS.
  81. 81.  33 WITH RESPECT TO THE CYT006-ANGQB VACCINE, CONSIDERATIONS HAVE BEEN MADE THAT: A THE VACCINE MAY PRODUCE HYPERTENSION. B THE VACCINE DOES NOT INDUCE ANTIBODIES CROSS-REACTING WITH PROTEINS. C THE VACCINE MAY CAUSE HYPOTENSION. D THE VACCINE MIGHT CAUSE IMPOTENCY. 34 WHAT IS THE REASON OF THE REDUCED NUMBER OF AFFECTED EPITOPES ? A BECAUSE OF THE SMALL SIZE OF THE EPITOPES. B BECAUSE OF THE SMALL SIZE OF THE TARGET MOLECULE. C BECAUSE ANTIBODY TITERS STARTED TO DECREASE. D THE NUMBER OF EPITOPES WAS NEVER AFFECTED.
  82. 82. 35 WHAT SHALL BE DONE TO DETERMINE THELARGEST ANTIBODY RESPONSE AND GREATESTREDUCTIONS IN BLOOD PRESSURE?A A SMALL TRIAL TO DETERMINE THE RIGHTDOSING HAD TO BE CONDUCTED.B A BOOSTER SHOT 2 OR 3 TIMES A YEAR.C ANGIOTENSIN II AND OCTAPEPTIDEVASOCONSTRICTOR INDUCE THE BODY TOPRODUCE ANTIBODIES.D ANGIOTENSIN II WOULD ALONE REGULATE THEBLOOD PRESSURE.
  83. 83. 31. D32. B33. C (B?)34. B35. A
  84. 84.  31. Some patients with hypertension have inadequate control of their blood pressure because they are not consistently adherent in taking their medications. 32. But help may be on the way in the form of a vaccine that lowers blood pressure by controlling angiotensin II, …
  85. 85.  33. Nussberger said he is not concerned that the vaccine might cause hypotension because antibody titers started to decrease shortly after the booster of twelve weeks induced peak antibody levels. He also said the likelihood of vaccine-induced antibodies cross-reacting with other proteins was minimal because …
  86. 86.  3 4. … the small size of the target molecule limits the number of epitopes that could be affected. 35. He said the next step in studying the vaccine will be to conduct another small trial to determine the appropriate dosing to create the largest antibody response and greatest reductions in blood pressure. A booster/ to boost, a boost/ a booster shot
  87. 87.  A booster/ to boost, a boost/ a booster shot Adherent=compliant Adherence=compliance To adhere=to comply
  88. 88. WILLIAM THOMAS GREEN MORTON ON OCTOBER 16, 1846, DEMONSTRATED THAT ETHER COULD INDUCEINSENSIBILITY TO THE SURGEON’S KNIFE. A JAW TUMOR WAS REMOVED FROM GILBERT ABBOT BY JOHNCOLLINS WARREN AT THE MASSACHUSETTS GENERAL HOSPITAL IN FRONT OF AN AUDIENCE OF MEDICALPROFESSIONALS. THE NEWS OF THIS PUBLIC DEMONSTRATION TRAVELED QUICKLY, GIVEN THE NATURE OFCOMMUNICATION IN THE 184Os. ON DECEMBER 16, 1846, THE INFORMATION IN THE FORM OF A LETTERARRIVED IN LONDON. ON DECEMBER 19, THE FIRST ETHER ANESTHETIC WAS GIVEN IN THE UNITEDKINGDOM FOR THE REMOVAL OF A TOOTH. ON DECEMBER 21, THE FAMOUS SURGEON ROBERT LISTONAMPUTATED THE LEG OF A BUTLER, AND UTTERED THE FAMOUS WORDS, “THIS YANKEE DODGE BEATSMESMERISM HOLLOW.” JAMES YOUNG SIMPSON, THE PROFESSOR OF MIDWIFERY INEDINBURGH, SCOTLAND, WAS AMONG THE FIRST TO USE ETHER FOR THE RELIEF OF LABOR PAIN. ONJANUARY 19, 1847, HE USED ETHER TO AMELIORATE THE PAIN OF LABOR. THIS FIRST CASE, THAT OF AYOUNG WOMAN WITH RICKETS AND SEVERELY DEFORMED PELVIS, WAS AT GRAVE RISK OF DYING ANDTHERE WAS NO HOPE FOR A LIVE BIRTH. BY USING ETHER, THE MOTHER SURVIVED THE COMPLICATEDDELIVERY PAIN-FREE. THAT SAME JANUARY DAY, SIMPSON WAS APPOINTED THE QUEEN’S PHYSICIAN INSCOTLAND. SIMPSON CONTINUED TO PROVIDE ANESTHESIA IN CHILDBIRTH FOR BOTH COMPLICATEDAND NORMAL DELIVERIES; HOWEVER, HE RAPIDLY BECAME DISSATISFIED WITH ETHER AND SOUGHT AMORE PLEASANT, RAPID-ACTING ANESTHETIC. AT THE SUGGESTION OF DAVID WALDIE, HE EXPERIMENTEDWITH CHLOROFORM, WHICH HAD FIRST BEEN PREPARED IN 1831. ON THE EVENING OF NOVEMBER4, 1847, SIMPSON AND HIS FRIENDS INHALED IT AFTER DINNER AT A PARTY IN SIMPSON’S HOME. THEYPROMPTLY FELL UNCONSCIOUS AND, WHEN THEY AWOKE UNDER THE TABLE AND CLEARLY OFF THEIRDINING ROOM CHAIRS, WERE DELIGHTED WITH THEIR SUCCESS. WITHIN 2 WEEKS, SIMPSON SUBMITTEDHIS FIRST ACCOUNT OF THE CHLOROFORM’S USE TO THE LANCET. IN THE NINETEENTH CENTURY, THERELIEF OF OBSTETRIC PAIN HAD SIGNIFICANT SOCIAL AND RELIGIOUS CONSEQUENCES, WHICH MADEANESTHESIA DURING CHILDBIRTH A CONTENTIOUS SUBJECT. THE BATTLE CENTERED ON WHETHERRELIEVING LABOR PAIN WAS CONTRARY TO GOD’S WILL. THE PAIN ASSOCIATED WITH CHILDBIRTH WASBELIEVED TO BE A DEVINE PUNISHMENT FOR ORIGINAL SIN. SHORTLY AFTER GIVING HIS FIRSTOBSTERTRIC ANESTHETICS, SIMPSON PUBLISHED A PAMPHLET ENTITLED “ANSWERS TO THE RELIGIOUSOBJECTIONS ADVANCED AGAINST THE EMPLOYMENT OF ANESTHETIC AGENTS INMIDWIFERY, SURGERY, AND OBSTETRICS,” WHICH ARGUED AGAINST THESE RELIGIOUS PROHIBITIONS.
  89. 89. WILLIAM THOMAS GREEN MORTON ON OCTOBER16, 1846, DEMONSTRATED THAT ETHER COULD INDUCEINSENSIBILITY TO THE SURGEON’S KNIFE. A JAW TUMOR WASREMOVED FROM GILBERT ABBOT BY JOHN COLLINS WARREN ATTHE MASSACHUSETTS GENERAL HOSPITAL IN FRONT OF ANAUDIENCE OF MEDICAL PROFESSIONALS. THE NEWS OF THISPUBLIC DEMONSTRATION TRAVELED QUICKLY, GIVEN THE NATUREOF COMMUNICATION IN THE 184Os. ON DECEMBER 16, 1846, THEINFORMATION IN THE FORM OF A LETTER ARRIVED IN LONDON.ON DECEMBER 19, THE FIRST ETHER ANESTHETIC WAS GIVEN INTHE UNITED KINGDOM FOR THE REMOVAL OF A TOOTH. ONDECEMBER 21, THE FAMOUS SURGEON ROBERT LISTONAMPUTATED THE LEG OF A BUTLER, AND UTTERED THE FAMOUSWORDS, “THIS YANKEE DODGE BEATS MESMERISM HOLLOW.”JAMES YOUNG SIMPSON, THE PROFESSOR OF MIDWIFERY INEDINBURGH, SCOTLAND, WAS AMONG THE FIRST TO USE ETHERFOR THE RELIEF OF LABOR PAIN. ON JANUARY 19, 1847, HE USEDETHER TO AMELIORATE THE PAIN OF LABOR. THIS FIRSTCASE, THAT OF A YOUNG WOMAN WITH RICKETS AND SEVERELYDEFORMED PELVIS, WAS AT GRAVE RISK OF DYING AND THERE WASNO HOPE FOR A LIVE BIRTH. BY USING ETHER, THE MOTHERSURVIVED THE COMPLICATED DELIVERY PAIN-FREE.
  90. 90. THAT SAME JANUARY DAY, SIMPSON WAS APPOINTED THE QUEEN’SPHYSICIAN IN SCOTLAND. SIMPSON CONTINUED TO PROVIDEANESTHESIA IN CHILDBIRTH FOR BOTH COMPLICATED AND NORMALDELIVERIES; HOWEVER, HE RAPIDLY BECAME DISSATISFIED WITHETHER AND SOUGHT A MORE PLEASANT, RAPID-ACTING ANESTHETIC.AT THE SUGGESTION OF DAVID WALDIE, HE EXPERIMENTED WITHCHLOROFORM, WHICH HAD FIRST BEEN PREPARED IN 1831. ON THEEVENING OF NOVEMBER 4, 1847, SIMPSON AND HIS FRIENDS INHALEDIT AFTER DINNER AT A PARTY IN SIMPSON’S HOME. THEY PROMPTLYFELL UNCONSCIOUS AND, WHEN THEY AWOKE UNDER THE TABLE ANDCLEARLY OFF THEIR DINING ROOM CHAIRS, WERE DELIGHTED WITHTHEIR SUCCESS. WITHIN 2 WEEKS, SIMPSON SUBMITTED HIS FIRSTACCOUNT OF THE CHLOROFORM’S USE TO THE LANCET. IN THENINETEENTH CENTURY, THE RELIEF OF OBSTETRIC PAIN HADSIGNIFICANT SOCIAL AND RELIGIOUS CONSEQUENCES, WHICH MADEANESTHESIA DURING CHILDBIRTH A CONTENTIOUS SUBJECT. THEBATTLE CENTERED ON WHETHER RELIEVING LABOR PAIN WASCONTRARY TO GOD’S WILL. THE PAIN ASSOCIATED WITH CHILDBIRTHWAS BELIEVED TO BE A DEVINE PUNISHMENT FOR ORIGINAL SIN.SHORTLY AFTER GIVING HIS FIRST OBSTERTRICANESTHETICS, SIMPSON PUBLISHED A PAMPHLET ENTITLED “ANSWERSTO THE RELIGIOUS OBJECTIONS ADVANCED AGAINST THEEMPLOYMENT OF ANESTHETIC AGENTS IN MIDWIFERY, SURGERY, ANDOBSTETRICS,” WHICH ARGUED AGAINST THESE RELIGIOUS
  91. 91. WILLIAM THOMAS GREEN MORTON ON OCTOBER16, 1846, DEMONSTRATED THAT ETHER COULDINDUCE INSENSIBILITY TO THE SURGEON’S KNIFE. AJAW TUMOR WAS REMOVED FROM GILBERT ABBOTBY JOHN COLLINS WARREN AT THE MASSACHUSETTSGENERAL HOSPITAL IN FRONT OF AN AUDIENCE OFMEDICAL PROFESSIONALS. THE NEWS OF THISPUBLIC DEMONSTRATION TRAVELEDQUICKLY, GIVEN THE NATURE OF COMMUNICATIONIN THE 184Os. ON DECEMBER 16, 1846, THEINFORMATION IN THE FORM OF A LETTER ARRIVEDIN LONDON. ON DECEMBER 19, THE FIRST ETHERANESTHETIC WAS GIVEN IN THE UNITED KINGDOMFOR THE REMOVAL OF A TOOTH. ON DECEMBER21, THE FAMOUS SURGEON ROBERT LISTONAMPUTATED THE LEG OF A BUTLER, AND UTTEREDTHE FAMOUS WORDS, “THIS YANKEE DODGE BEATSMESMERISM HOLLOW.”
  92. 92. JAMES YOUNG SIMPSON, THE PROFESSOR OFMIDWIFERY IN EDINBURGH, SCOTLAND, WAS AMONGTHE FIRST TO USE ETHER FOR THE RELIEF OF LABORPAIN. ON JANUARY 19, 1847, HE USED ETHER TOAMELIORATE THE PAIN OF LABOR. THIS FIRSTCASE, THAT OF A YOUNG WOMAN WITH RICKETS ANDSEVERELY DEFORMED PELVIS, WAS AT GRAVE RISK OFDYING AND THERE WAS NO HOPE FOR A LIVE BIRTH. BYUSING ETHER, THE MOTHER SURVIVED THECOMPLICATED DELIVERY PAIN-FREE. THAT SAMEJANUARY DAY, SIMPSON WAS APPOINTED THE QUEEN’SPHYSICIAN IN SCOTLAND. SIMPSON CONTINUED TOPROVIDE ANESTHESIA IN CHILDBIRTH FOR BOTHCOMPLICATED AND NORMAL DELIVERIES;HOWEVER, HE RAPIDLY BECAME DISSATISFIED WITHETHER AND SOUGHT A MORE PLEASANT, RAPID-ACTINGANESTHETIC. AT THE SUGGESTION OF DAVIDWALDIE, HE EXPERIMENTED WITHCHLOROFORM, WHICH HAD FIRST BEEN PREPARED IN
  93. 93. ON THE EVENING OF NOVEMBER 4, 1847, SIMPSON AND HISFRIENDS INHALED IT AFTER DINNER AT A PARTY INSIMPSON’S HOME. THEY PROMPTLY FELL UNCONSCIOUSAND, WHEN THEY AWOKE UNDER THE TABLE AND CLEARLYOFF THEIR DINING ROOM CHAIRS, WERE DELIGHTEDWITH THEIR SUCCESS. WITHIN 2 WEEKS, SIMPSONSUBMITTED HIS FIRST ACCOUNT OF THE CHLOROFORM’SUSE TO THE LANCET. IN THE NINETEENTH CENTURY, THERELIEF OF OBSTETRIC PAIN HAD SIGNIFICANT SOCIAL ANDRELIGIOUS CONSEQUENCES, WHICH MADE ANESTHESIADURING CHILDBIRTH A CONTENTIOUS SUBJECT. THEBATTLE CENTERED ON WHETHER RELIEVING LABOR PAINWAS CONTRARY TO GOD’S WILL. THE PAIN ASSOCIATEDWITH CHILDBIRTH WAS BELIEVED TO BE A DEVINEPUNISHMENT FOR ORIGINAL SIN. SHORTLY AFTER GIVINGHIS FIRST OBSTERTRIC ANESTHETICS, SIMPSONPUBLISHED A PAMPHLET ENTITLED “ANSWERS TO THERELIGIOUS OBJECTIONS ADVANCED AGAINST THEEMPLOYMENT OF ANESTHETIC AGENTS INMIDWIFERY, SURGERY, AND OBSTETRICS,” WHICH ARGUEDAGAINST THESE RELIGIOUS PROHIBITIONS.
  94. 94.  36. WILLIAM THOMAS GREEN MORTON USED A ETHER ON A PATIENT SO THERE WOULD BE NO SENSIBILITY IN THE OPERATION. B ETHER ON A PATIENT TO REDUCE THE SENSIBILITY DURING THE OPERATION C ETHER TO DISINFECT THE KNIFE IN THE OPERATION AND OTHER OPERATING EQUIPMENT D ETHER INSTEAD OF AN ANESTHETIC. 37. JAMES YOUNG SIMPSON WAS THE FIRST TO USE ETHER FOR A CURING A PATIENT WHO HAD RICKETS B REDUCING THE LABOR PAIN OF A WOMAN WHEN GIVING BIRTH WITH A DEFORMED PELVIS C REDUCING THE PAIN OF SURGERY D SAVING THE NEWBORN FROM DYING IN CHILDBIRTH
  95. 95.  38. SIMPSON PREFERRED TO CONTINUE A USING ETHER FOR CHILDBIRTH B USING ETHER AND CHLOROFORM FOR CHILDBIRTH C TO ONLY USE CHLOROFORM FOR CHILDBIRTH D PROVIDE ANESTHESIA IN CHILDBIRTH FOR BOTH COMPLICATED AND NORMAL DELIVERIES 39. IT IS EVIDENT THAT THIS NEW PRACTICE OF USING ANESTHESIA IN CHILDBIRTH HAD SOCIAL AND RELIGIOUS CONSEQUENCES A SIMPSON WAS IN FAVOR OF RELIGIOUS BELIEFS IN CHILDBIRTH PRACTICE B SIMPSON WAS IN FAVOR OF SOCIAL BELIEFS ABOUT CHILDBIRTH PRACTICE C SIMPSON WAS AGAINST RELIGIOUS BELIEFS IN CHILDBIRTH PRACTICE D SIMPSON WAS AGAINST THESE RELIGIOUS PROHIBITIONS
  96. 96. 40. THE PAIN ASSOCIATED WITH CHILDBIRTH WASBELIEVED TO BE CAUSED ASA A CONSEQUENCE OF A DEFORMED PELVIS.B A DEVINE PUNISHMENT FOR ORIGINAL SIN.C BECAUSE OF LACK OF ANESTHETICS.D AN OVERSIZED PRODUCT.
  97. 97. 36. A37. B38. D39. D40. B
  98. 98.  36. William Thomas Green Morton on October 16, 1846, demonstrated that ether could induce insensibility to the surgeon’s knife. 37. James Young Simpson, the professor of midwifery in Edinburgh, Scotland, was among the first to use ether for the relief of labor pain. 38. Simpson continued to provide anesthesia in deliveries for both complicated and normal deliveries.
  99. 99.  39. ,… Simpson published a pamphlet entitled “Answers to the Religious Objections Advanced against the Employment of Anesthetic Agents in Midwifery and Surgery and Obstetrics,” which argued against these religious prohibitions. 40. The pain associated with childbirth was believed to be a devine punishment for original sin. Midwifery/midwife delivery=childbirth
  100. 100. A 71-YEAR-OLD MAN PRESENTED WITH A 2-WEEK HISTORY OF PAIN ANDSWELLING OF HIS LEFT ARM. EXAMINATION REVEALED ACRAGGY, MOBILE MASS WITH IRREGULAR BORDERS IN THE EXTENSORCOMPARTMENT OF THE LEFT ARM MEASURING 6 × 4 CM.ULTRASONOGRAPHY OF THE LEFT ARM DEMONSTRATED THE PRESENCEOF DEEP OVOID HYPERECHOIC MASS LOCATED IN THE LONG AXIS OFTHE LEFT TRICEPS MUSCLE, MEASURING 5 × 3 CM. THIS LED TO FURTHERRADIOLOGIC EVALUATION IN THE FORM OF MRI OF THE LEFT ARM. MRISHOWED INTERMEDIATE SIGNAL MASS IN THE TRICEPS MUSCULATUREON T1-WEIGHTED IMAGES WITH FAT SATURATION. THIS LESION ISCONFINED TO THE EXTENSOR COMPARTMENT OF THE ARM. APRESUMPTIVE DIAGNOSIS OF SOFT TISSUE SARCOMA WAS MADE. ANINCISIONAL BIOPSY WAS PERFORMED. THIS WAS FOUND TO BECONSISTENT WITH METASTATIC SQUAMOUS CELL CARCINOMA WITH APOSSIBLE LUNG PRIMARY, FURTHER SUPPORTED DUE TO A POSITIVECK7 AND NEGATIVE CK20 STAIN ON IMMUNOHISTOCHEMISTRY. CT SCANOF THE CHEST REVEALED A LESION MEASURING 4 × 2 CM IN THE LEFTUPPER LOBE. FIBER-OPTIC BRONCHOSCOPY AND BIOPSY CONFIRMEDTHE DIAGNOSIS OF STAGE IV SQUAMOUS CELL CARCINOMA OF THELUNG. HE UNDERWENT PALLIATIVE RADIOTHERAPY TO THE MASS INTHE ARM, 20 GY IN 4 FRACTIONS. THIS PROVIDED GOOD RELIEF FROMPAIN AND SWELLING WITHIN 2 WEEKS OF COMPLETING TREATMENT.
  101. 101. SYSTEMIC THERAPY WAS NOT OFFERED ON THE BASIS OF POOR ANDDETERIORATING PERFORMANCE STATUS. UNFORTUNATELY, THEPATIENT DIED WITHIN 10 WEEKS OF PRESENTATION. INTRAMUSCULARMETASTASES IN CANCER PATIENTS ARE RARE. THIS IN ITSELF IS QUITEPECULIAR BECAUSE MUSCULAR MASS ACCOUNTS FOR APPROXIMATELY50% OF TOTAL BODY WEIGHT. IT IS THOUGHT THAT MUSCULARCONTRACTILE ACTIONS, LOCAL PH ENVIRONMENT, AND ACCUMULATIONOF LACTIC ACID AND OTHER METABOLITES CONTRIBUTE TO THE RAREOCCURRENCE OF THIS PHENOMENON. THE TRUE INCIDENCE OFMUSCULAR METASTASIS REMAINS UNKNOWN, BUT AN AUTOPSY SERIESSUGGESTS THAT ITS INCIDENCE COULD BE AS LOW AS 0.8%. LUNGCARCINOMA SEEMS TO BE THE UNDERLYING PRIMARY CANCER IN MOSTOF THESE CASES. MANY OTHER TUMORS, SUCH ASKIDNEY, STOMACH, PANCREAS, THYROIDGLAND, BREAST, OVARY, PROSTATE, AND BLADDER CANCERS HAVE ALSOBEEN SPORADICALLY DESCRIBED IN ASSOCIATION WITHINTRAMUSCULAR SECONDARIES. HOWEVER, PRIMARY PRESENTATIONOF AN INTRAMUSCULAR METASTASIS, SUCH AS DEMONSTRATED BY OURPATIENT, REMAINS AN EXCEPTIONALLY UNUSUAL OCCURRENCE. THEMOST FREQUENT PRESENTATION OF MUSCULAR METASTASIS IS PAINWITH OR WITHOUT SWELLING. DIAGNOSIS, EVEN WITH RADIOLOGICIMAGING IS OFTEN TRICKY BECAUSE IT CAN BE CONFUSED WITH ANABSCESS OR SOFT TISSUE TUMORS.
  102. 102. A 71-YEAR-OLD MALE PRESENTED WITH A 2-WEEK HISTORY OF AHARD, PAINFUL, NONPULSATILE MASS IN HIS LEFT UPPER ARM. EXAMINATION REVEALED ACRAGGY, MOBILE MASS OF IRREGULAR BORDERS IN THE LEFT ARM MEASURING 6 × 4 CM.ULTRASONOGRAPHY OF THE LEFT ARM DEMONSTRATED A DEEP OVOID HYPERECHOIC MASSLOCATED IN THE LONG AXIS OF THE LEFT TRICEPS MUSCLE. MRI SHOWED INTERMEDIATESIGNAL MASS IN THE TRICEPS MUSCULATURE ON T1-WEIGHTED IMAGES WITH FATSATURATION. THIS LESION WAS CONFINED TO THE EXTENSOR COMPARTMENT OF THE ARM. APRESUMPTIVE DIAGNOSIS OF SOFT TISSUE SARCOMA WAS CONSIDERED. AN INCISIONAL BIOPSYREPORTED METASTATIC SQUAMOUS CELL CARCINOMA WITH A POSSIBLE LUNGPRIMARY, FURTHER SUPPORTED DUE TO A POSITIVE CK7 AND NEGATIVE CK20 STAIN ONIMMUNOHISTOCHEMISTRY. CT SCAN OF THE CHEST REVEALED A LEFT UPPER LOBE LESIONMEASURING 4 × 2 CM. FIBER-OPTIC BRONCHOSCOPY AND BIOPSY CONFIRMED THE DIAGNOSISOF STAGE IV SQUAMOUS CELL LUNG CARCINOMA. HE UNDERWENT PALLIATIVERADIOTHERAPY TO THE MASS IN THE ARM. THIS PROVIDED GOOD RELIEF FROM PAIN ANDSWELLING WITHIN 2 WEEKS OF COMPLETING TREATMENT. SYSTEMIC THERAPY WAS NOTOFFERED ON THE BASIS OF POOR AND DETERIORATING PERFORMANCE STATUS.UNFORTUNATELY, THE PATIENT DIED WITHIN 10 WEEKS OF PRESENTATION. INTRAMUSCULARMETASTASES IN CANCER PATIENTS ARE RARE. THIS IN ITSELF IS QUITE PECULIAR BECAUSEMUSCULAR MASS ACCOUNTS FOR APPROXIMATELY 50% OF TOTAL BODY WEIGHT. IT ISTHOUGHT THAT MUSCULAR CONTRACTILE ACTIONS, LOCAL PH ENVIRONMENT, ANDACCUMULATION OF LACTIC ACID AND OTHER METABOLITES CONTRIBUTE TO THE RAREOCCURRENCE OF THIS PHENOMENON. THE TRUE INCIDENCE OF MUSCULAR METASTASISREMAINS UNKNOWN, BUT AN AUTOPSY SERIES SUGGESTS THAT ITS INCIDENCE COULD BE ASLOW AS 0.8%. LUNG CARCINOMA SEEMS TO BE THE UNDERLYING PRIMARY CANCER IN MOST OFTHESE CASES. MANY OTHER TUMORS, SUCH AS KIDNEY, STOMACH, PANCREAS, THYROIDGLAND, BREAST, OVARY, PROSTATE, AND BLADDER CANCERS HAVE BEEN SPORADICALLYDESCRIBED IN ASSOCIATION WITH INTRAMUSCULAR SECONDARIES. HOWEVER, PRIMARYPRESENTATION OF AN INTRAMUSCULAR METASTASIS, SUCH AS DEMONSTRATED BY OURPATIENT, REMAINS AN EXCEPTIONALLY UNUSUAL OCCURRENCE. THE MOST FREQUENTPRESENTATION OF MUSCULAR METASTASIS IS PAIN WITH OR WITHOUT SWELLING. DIAGNOSISOF THIS CONDITION, EVEN WITH RADIOLOGIC IMAGING IS OFTEN TRICKY BECAUSE IT CAN BECONFUSED WITH AN ABSCESS OR SOFT TISSUE TUMORS, HIGHLIGHTING THE VALUE OFHISTOLOGIC DIAGNOSIS. TREATMENT IN THE FORM OF RADIOTHERAPY, CHEMOTHERAPY, OREVEN METASTASECTOMY OFTEN PROVIDES PALLIATION ONLY. MOST PATIENTS DIE IN LESSTHAN A YEAR FROM DIAGNOSIS.
  103. 103. A 71-YEAR-OLD MALE PRESENTED WITH A 2-WEEK HISTORYOF A HARD, PAINFUL, NONPULSATILE MASS IN HIS LEFTUPPER ARM. EXAMINATION REVEALED A CRAGGY, MOBILEMASS OF IRREGULAR BORDERS IN THE LEFT ARMMEASURING 6 × 4 CM. ULTRASONOGRAPHY OF THE LEFTARM DEMONSTRATED A DEEP OVOID HYPERECHOIC MASSLOCATED IN THE LONG AXIS OF THE LEFT TRICEPS MUSCLE.MRI SHOWED INTERMEDIATE SIGNAL MASS IN THE TRICEPSMUSCULATURE ON T1-WEIGHTED IMAGES WITH FATSATURATION. THIS LESION WAS CONFINED TO THEEXTENSOR COMPARTMENT OF THE ARM. A PRESUMPTIVEDIAGNOSIS OF SOFT TISSUE SARCOMA WAS CONSIDERED.AN INCISIONAL BIOPSY REPORTED METASTATICSQUAMOUS CELL CARCINOMA WITH A POSSIBLE LUNGPRIMARY, FURTHER SUPPORTED DUE TO A POSITIVE CK7AND NEGATIVE CK20 STAIN ON IMMUNOHISTOCHEMISTRY.CT SCAN OF THE CHEST REVEALED A LEFT UPPER LOBELESION MEASURING 4 × 2 CM. FIBER-OPTICBRONCHOSCOPY AND BIOPSY CONFIRMED THE DIAGNOSISOF STAGE IV SQUAMOUS CELL LUNG CARCINOMA.
  104. 104. HE UNDERWENT PALLIATIVE RADIOTHERAPY TO THEMASS IN THE ARM. THIS PROVIDED GOOD RELIEF FROMPAIN AND SWELLING WITHIN 2 WEEKS OFCOMPLETING TREATMENT. SYSTEMIC THERAPY WASNOT OFFERED ON THE BASIS OF POOR ANDDETERIORATING PERFORMANCE STATUS.UNFORTUNATELY, THE PATIENT DIED WITHIN 10 WEEKSOF PRESENTATION. INTRAMUSCULAR METASTASES INCANCER PATIENTS ARE RARE. THIS IN ITSELF IS QUITEPECULIAR BECAUSE MUSCULAR MASS ACCOUNTS FORAPPROXIMATELY 50% OF TOTAL BODY WEIGHT. IT ISTHOUGHT THAT MUSCULAR CONTRACTILEACTIONS, LOCAL PH ENVIRONMENT, ANDACCUMULATION OF LACTIC ACID AND OTHERMETABOLITES CONTRIBUTE TO THE RAREOCCURRENCE OF THIS PHENOMENON. THE TRUEINCIDENCE OF MUSCULAR METASTASIS REMAINSUNKNOWN, BUT AN AUTOPSY SERIES SUGGESTS THATITS INCIDENCE COULD BE AS LOW AS 0.8%
  105. 105. LUNG CARCINOMA SEEMS TO BE THE UNDERLYING PRIMARYCANCER IN MOST OF THESE CASES. MANY OTHERTUMORS, SUCH AS KIDNEY, STOMACH, PANCREAS, THYROIDGLAND, BREAST, OVARY, PROSTATE, AND BLADDER CANCERSHAVE BEEN SPORADICALLY DESCRIBED IN ASSOCIATIONWITH INTRAMUSCULAR SECONDARIES. HOWEVER, PRIMARYPRESENTATION OF AN INTRAMUSCULAR METASTASIS, SUCHAS DEMONSTRATED BY OUR PATIENT, REMAINS ANEXCEPTIONALLY UNUSUAL OCCURRENCE. THE MOSTFREQUENT PRESENTATION OF MUSCULAR METASTASIS ISPAIN WITH OR WITHOUT SWELLING. DIAGNOSIS OF THISCONDITION, EVEN WITH RADIOLOGIC IMAGING IS OFTENTRICKY BECAUSE IT CAN BE CONFUSED WITH AN ABSCESSOR SOFT TISSUE TUMORS, HIGHLIGHTING THE VALUE OFHISTOLOGIC DIAGNOSIS. TREATMENT IN THE FORM OFRADIOTHERAPY, CHEMOTHERAPY, OR EVENMETASTASECTOMY OFTEN PROVIDES PALLIATION ONLY.MOST PATIENTS DIE IN LESS THAN A YEAR FROMDIAGNOSIS.
  106. 106.  41. BASED ON THE CLINICAL AND THE DIVERSE IMAGING STUDY’S FINDINGS, WHICH OF THE FOLLOWING WAS THE PRESUMPTIVE DIAGNOSIS OF THE ATTENDING MEDICAL TEAM? A A DEEP OVOID MASS LOCATED IN THE LEFT TRICEPS MUSCLE CONSIDERED A PROBABLE STAPHYLOCOCCUS AUREUS ABSCESS. B A MASS OF FAT SATURATION OBSERVED ON MRI ON T1-WEIGHTED IMAGES. C A PRESUMPTIVE DIAGNOSIS OF SOFT TISSUE SARCOMA LOCATED IN THE LEFT TRICEPS MUSCLE. D A DIAGNOSIS OF METASTATIC SQUAMOUS CELL CARCINOMA, WITH A POSSIBLE PRIMARY OF THE LUNG.
  107. 107.  42. THE PATIENT WAS SUBMITTED TO PALLIATIVE CARE AND NON SYSTEMIC THERAPY BASED ON WHAT REASON? A A POSITIVE CK7 AND NEGATIVE CK20 STAIN ON IMMUNOHISTOCHEMISTRY IS OF POOR PROGNOSIS. B THE DIAGNOSIS OF STAGE IV SQUAMOUS CELL LUNG CARCINOMA WAS NOT CONFIRMED ON FIBER- OPTIC BRONCHOSCOPY. C HE ONLY UNDERWENT PALLIATIVE RADIOTHERAPY BECAUSE OF COST-BENEFIT REASONS. D BASED ON A POOR AND DETERIORATING PERFORMANCE STATUS SYSTEMIC THERAPY WAS DEFERRED FOR QUALITY OF LIFE PALLIATIVE THERAPY.
  108. 108.  43. WHICH OF THE FOLLOWING IS NOT DESCRIBED IN THE PRESENT ARTICLE AS A FACTOR THAT CONTRIBUTES TO THE RARE OCCURRENCE OF INTRAMUSCULAR METASTASES? A THE MUSCULAR MASS ACCOUNTS FOR APPROXIMATELY 50% OF TOTAL BODY WEIGHT. B MUSCULAR CONTRACTILE ACTIONS. C LOCAL PH ENVIRONMENT. D ACCUMULATION OF LACTIC ACID AND OTHER METABOLITES.
  109. 109.  44. WHICH IS THE PRIMARY UNDERLYING CANCER IN MOST CASES OF INTRAMUSCULAR METASTASES? A LUNG CARCINOMA. B KIDNEY AND BLADDER CANCER. C STOMACH AND PANCREATIC CARCINOMA. D BREAST AND OVARIAN CANCER.45. THE MOST FREQUENT PRESENTATION OFINTRAMUSCULAR METASTASES SEEN IS?A PRESENTATION OF THE AFFECTED SITE WITHPAIN, WITH OR WITHOUT SWELLING.B THROMBOSIS OF THE AFFECTED EXTREMITY.C FEVER AND SEPSIS.D USUALLY INDOLENT AND ONLY FOUND AT AUTOPSY
  110. 110. 41. C42. D43. A44. A45. ACraggy: riscoso, escarpado
  111. 111.  41. Ultrasonography of the left arm demonstrated … a mass … located in … the left triceps muscle. A presumptive diagnosis of soft tissue sarcoma was made. 42. Systemic therapy was not offered on the basis of poor and deteriorating performance status.
  112. 112.  43. Intramuscular metastases in cancer patients are rare. It is thought that muscular contractile functions, local pH environment, and accumulation of lactic acid and other metabolites contribute to the rare occurrence of this phenomenon.
  113. 113.  44. Lung carcinoma seems to be the underlying primary cancer in most of these cases. 45. The most frequent presentation of muscular metastasis is pain, with or without swelling.
  114. 114. MIGRAINE IS CONSIDERED TO BE AN EPISODIC CONDITION WITH NOLONG-TERM CONSEQUENCES. HOWEVER, RECENT STUDIES SUGGESTTHAT MIGRAINE ATTACKS MAY BE ASSOCIATED WITH PATHOLOGICALCHANGES IN THE BRAIN, PARTICULARLY IN THE CEREBELLUM. THEOBJECTIVE OF THE PRESENT STUDY WAS TO DETERMINE WHETHERINDIVIDUALS NOT REPORTING HEADACHE COMPARED WITHINDIVIDUALS REPORTING MIGRAINE SYMPTOMS, PARTICULARLYAURA, IN MIDLIFE ARE AT INCREASED RISK OF LATE-LIFE INFARCT-LIKELESIONS FOUND ON MAGNETIC RESONANCE IMAGING (MRI) WITHOUTCONSIDERATION OF CLINICAL SYMPTOMS. A POPULATION-BASED STUDYOF MEN AND WOMEN IN REYKJAVIC, ICELAND (COHORT BORN 1907-1935;RANGE, N=4689; 57% WOMEN) WERE FOLLOWED UP SINCE1967, EXAMINED AND INTERVIEWED ABOUT MIGRAINE SYMTPOMS INMIDLIFE (MEAN AGE, 51 YEARS; RANGE, 33-65). BETWEEN 2002 AND2006, MORE THAN 26 YEARS LATER, BRAIN MRIs WERE PERFORMED.PARTICIPANTS REPORTING HEADACHES ONCE OR MORE PER MONTHWERE ASKED ABOUT MIGRAINE SYMPTOMS, INCLUDINGNAUSEA, UNILATERAL LOCATION, PHOTOPHOBIA, AND NUMBNESS.THESE INDIVIDUALS WITH HEADACHE WERE CLASSIFIED AS HAVINGMIGRAINE WITHOUT AURA, MIGRAINE WITH AURA, OR NONMIGRAINEHEADACHE. A COMPREHENSIVE CARDIOVASCULAR RISK ASSESSMENTWAS PERFORMED AT BOTH EXAMINATIONS.
  115. 115. THE PRESENCE OF INFARCT-LIKE LESIONS (TOTAL) ANDSPECIFICALLY LOCATED IN THE CORTICAL, SUBCORTICAL, ANDCEREBELLAR REGIONS WERE THE MAIN OUTCOME MEASURE.INFARCT-LIKE LESIONS WERE PRESENT IN 39.3% OF MEN AND24.6% OF WOMEN. AFTER ADJUSTING FOR AGE, SEX, ANDFOLLOW-UP TIME, COMPARED WITH THOSE NOT REPORTINGHEADACHES ONCE OR MORE PER MONTH (N=3243), THOSE WITHMIDLIFE MIGRAINE WITH AURA (N=361) HAD AN INCREASED RISKOF LATE-LIFE INFARCT-LIKE LESIONS (ADJUSTED ODDS RATIOOR , 1.4 CONFIDENCE INTERVAL CI , 1.1-I.8) THAT SPECIFICALLYREFLECTED AN ASSOCIATION WITH CEREBELLAR LESIONS INWOMEN (PREVALENCE OF INFARCTS 23.05% FOR WOMEN WITHMIGRAINE WITH AURA VS 14.5% FOR WOMEN NOT REPORTINGHEADACHES; ADJUSTED OR, 1.9; 95% CI, 1.4-2.6 VS A 19.3%PREVALENCE OF INFARCTS FOR MEN WITH MIGRAINE WITHAURA VS 21.3% FOR MEN NOT REPORTING HEADACHES; ADJUSTEDOR, 1.0; 95% CI, 0.6-1.8, P 0.4 FOR INTERACTION BY SEX). MIGRAINEWITHOUT AURA AND NONMIGRAINE HEADACHE WERE NOTASSOCIATED WITH AN INCREASED RISK. MIGRAINE WITH AURAIN MIDLIFE WAS ASSOCIATED WITH LATE-LIFE CEREBELLARINFARCT-LIKE LESIONS ON MRI. THIS ASSOCIATION WASSTATISTICALLY SIGNIFICANT ONLY FOR WOMEN.
  116. 116. MIGRAINE IS CONSIDERED TO BE AN EPISODIC CONDITION WITH NO LONG-TERM CONSEQUENCES.HOWEVER, RECENT STUDIES SUGGEST THAT MIGRAINE ATTACKS MAY BE ASSOCIATED WITHPATHOLOGICAL CHANGES IN THE BRAIN, PARTICULARLY IN THE CEREBELLUM. THE OBJECTIVE OF THEPRESENT STUDY WAS TO DETERMINE WHETHER INDIVIDUALS NOT REPORTING HEADACHE COMPAREDWITH INDIVIDUALS REPORTING MIGRAINE SYMPTOMS, PARTICULARLY AURA, IN MIDLIFE ARE ATINCREASED RISK OF LATE-LIFE INFARCT-LIKE LESIONS FOUND ON MAGNETIC RESONANCE IMAGING(MRI) WITHOUT CONSIDERATION OF CLINICAL SYMPTOMS. A POPULATION-BASED STUDY OF MENAND WOMEN IN REYKJAVIC, ICELAND (COHORT BORN 1907-1935; RANGE, N=4689; 57% WOMEN) WEREFOLLOWED UP SINCE 1967, EXAMINED AND INTERVIEWED ABOUT MIGRAINE SYMTPOMS IN MIDLIFE(MEAN AGE, 51 YEARS; RANGE, 33-65). BETWEEN 2002 AND 2006, MORE THAN 26 YEARS LATER, BRAINMRIs WERE PERFORMED. PARTICIPANTS REPORTING HEADACHES ONCE OR MORE PER MONTH WEREASKED ABOUT MIGRAINE SYMPTOMS, INCLUDING NAUSEA, UNILATERALLOCATION, PHOTOPHOBIA, AND NUMBNESS. THESE INDIVIDUALS WITH HEADACHE WERE CLASSIFIEDAS HAVING MIGRAINE WITHOUT AURA, MIGRAINE WITH AURA, OR NONMIGRAINE HEADACHE. ACOMPREHENSIVE CARDIOVASCULAR RISK ASSESSMENT WAS PERFORMED AT BOTH EXAMINATIONS.THE PRESENCE OF INFARCT-LIKE LESIONS (TOTAL) AND SPECIFICALLY LOCATED IN THECORTICAL, SUBCORTICAL, AND CEREBELLAR REGIONS WERE THE MAIN OUTCOME MEASURE. INFARCT-LIKE LESIONS WERE PRESENT IN 39.3% OF MEN AND 24.6% OF WOMEN. AFTER ADJUSTING FORAGE, SEX, AND FOLLOW-UP TIME, COMPARED WITH THOSE NOT REPORTING HEADACHES ONCE ORMORE PER MONTH (N=3243), THOSE WITH MIDLIFE MIGRAINE WITH AURA (N=361) HAD AN INCREASEDRISK OF LATE-LIFE INFARCT-LIKE LESIONS (ADJUSTED ODDS RATIO OR , 1.4 CONFIDENCE INTERVAL CI , 1.1-I.8) THAT SPECIFICALLY REFLECTED AN ASSOCIATION WITH CEREBELLAR LESIONS IN WOMEN(PREVALENCE OF INFARCTS 23.05% FOR WOMEN WITH MIGRAINE WITH AURA VS 14.5% FOR WOMENNOT REPORTING HEADACHES; ADJUSTED OR, 1.9; 95% CI, 1.4-2.6 VS A 19.3% PREVALENCE OF INFARCTSFOR MEN WITH MIGRAINE WITH AURA VS 21.3% FOR MEN NOT REPORTING HEADACHES; ADJUSTEDOR, 1.0; 95% CI, 0.6-1.8, P 0.4 FOR INTERACTION BY SEX). MIGRAINE WITHOUT AURA ANDNONMIGRAINE HEADACHE WERE NOT ASSOCIATED WITH AN INCREASED RISK. MIGRAINE WITH AURAIN MIDLIFE WAS ASSOCIATED WITH LATE-LIFE CEREBELLAR INFARCT-LIKE LESIONS ON MRI. THISASSOCIATION WAS STATISTICALLY SIGNIFICANT ONLY FOR WOMEN.
  117. 117. MIGRAINE IS CONSIDERED TO BE AN EPISODICCONDITION WITH NO LONG-TERM CONSEQUENCES.HOWEVER, RECENT STUDIES SUGGEST THAT MIGRAINEATTACKS MAY BE ASSOCIATED WITH PATHOLOGICALCHANGES IN THE BRAIN, PARTICULARLY IN THECEREBELLUM. THE OBJECTIVE OF THE PRESENT STUDYWAS TO DETERMINE WHETHER INDIVIDUALS NOTREPORTING HEADACHE COMPARED WITHINDIVIDUALS REPORTING MIGRAINESYMPTOMS, PARTICULARLY AURA, IN MIDLIFE ARE ATINCREASED RISK OF LATE-LIFE INFARCT-LIKE LESIONSFOUND ON MAGNETIC RESONANCE IMAGING (MRI)WITHOUT CONSIDERATION OF CLINICAL SYMPTOMS.A POPULATION-BASED STUDY OF MEN AND WOMEN INREYKJAVIC, ICELAND (COHORT BORN 1907-1935;RANGE, N=4689; 57% WOMEN) WERE FOLLOWED UPSINCE 1967, EXAMINED AND INTERVIEWED ABOUTMIGRAINE SYMTPOMS IN MIDLIFE (MEAN AGE, 51YEARS; RANGE, 33-65).
  118. 118. BETWEEN 2002 AND 2006, MORE THAN 26 YEARSLATER, BRAIN MRIs WERE PERFORMED.PARTICIPANTS REPORTING HEADACHES ONCE ORMORE PER MONTH WERE ASKED ABOUT MIGRAINESYMPTOMS, INCLUDING NAUSEA, UNILATERALLOCATION, PHOTOPHOBIA, AND NUMBNESS.THESE INDIVIDUALS WITH HEADACHE WERECLASSIFIED AS HAVING MIGRAINE WITHOUTAURA, MIGRAINE WITH AURA, OR NONMIGRAINEHEADACHE. A COMPREHENSIVE CARDIOVASCULARRISK ASSESSMENT WAS PERFORMED AT BOTHEXAMINATIONS. THE PRESENCE OF INFARCT-LIKELESIONS (TOTAL) AND SPECIFICALLY LOCATED INTHE CORTICAL, SUBCORTICAL, AND CEREBELLARREGIONS WERE THE MAIN OUTCOME MEASURE.INFARCT-LIKE LESIONS WERE PRESENT IN 39.3% OFMEN AND 24.6% OF WOMEN.
  119. 119. AFTER ADJUSTING FOR AGE, SEX, AND FOLLOW-UPTIME, COMPARED WITH THOSE NOT REPORTINGHEADACHES ONCE OR MORE PER MONTH (N=3243), THOSEWITH MIDLIFE MIGRAINE WITH AURA (N=361) HAD ANINCREASED RISK OF LATE-LIFE INFARCT-LIKE LESIONS(ADJUSTED ODDS RATIO OR , 1.4 CONFIDENCE INTERVAL CI , 1.1-I.8) THAT SPECIFICALLY REFLECTED AN ASSOCIATIONWITH CEREBELLAR LESIONS IN WOMEN (PREVALENCE OFINFARCTS 23.05% FOR WOMEN WITH MIGRAINE WITH AURAVS 14.5% FOR WOMEN NOT REPORTING HEADACHES;ADJUSTED OR, 1.9; 95% CI, 1.4-2.6 VS A 19.3% PREVALENCE OFINFARCTS FOR MEN WITH MIGRAINE WITH AURA VS 21.3%FOR MEN NOT REPORTING HEADACHES; ADJUSTED OR, 1.0;95% CI, 0.6-1.8, P 0.4 FOR INTERACTION BY SEX). MIGRAINEWITHOUT AURA AND NONMIGRAINE HEADACHE WERE NOTASSOCIATED WITH AN INCREASED RISK. MIGRAINE WITHAURA IN MIDLIFE WAS ASSOCIATED WITH LATE-LIFECEREBELLAR INFARCT-LIKE LESIONS ON MRI. THISASSOCIATION WAS STATISTICALLY SIGNIFICANT ONLY FORWOMEN.
  120. 120.  46 RECENT STUDIES SUGGEST THAT MIGRAINE ATTACKS MAY BE ASSOCIATED WITH PATHOLOGIC CHANGES IN THE BRAIN. WHICH LOCALIZATION IN PARTICULAR IS CONSIDERED? A THE CEREBELLUM. B THE WHITE MATTER. C THE HYPOCAMPUS. D THE FRONTAL LOBE. 47 IN THE POPULATION-BASED STUDY OF MEN AND WOMEN IN REYKJAVIK, ICELAND, WITH A MEAN AGE OF 51 YEARS AND RANGING FROM 33-65 YEARS, WHAT STUDY WAS CONDUCTED APPROXIMATELY 26 YEARS LATER? A BRAIN COMPUTERIZED AXIAL TOMOGRAPHY. B BRAIN BIOPSY. C BRAIN MAGNETIC RESONANCE IMAGING. D ELECTROENCEPHALOGRAM
  121. 121.  48 THOSE WITH MIDLIFE MIGRAINE WITH AURA HAD AN ODDS RATIO OF 1.4 OF LATE-LIFE INFARCT-LIKE LESIONS. THIS WAS MORE SPECIFICALLY OBSERVED IN WHICH GROUP? A CEREBELLAR LESIONS IN WOMEN. B CEREBELLAR LESIONS IN MEN. C CORTICAL LESIONS IN WOMEN. D SUBCORTICAL LESIONS IN MEN. 49 THE MAIN OUTCOME MEASURES OF THE STUDY WERE THE PRESENCE OF INFARCT-LIKE LESIONS SPECIFICALLY LOCATED IN WHICH REGIONS? A CORTICAL, CEREBELLAR AND MEDULLA OBLONGATA REGIONS. B CORTICAL, SUBCORTICAL, AND CEREBELLAR REGIONS. C CEREBELLAR, SUBCORTICAL AND WHITE MATTER REGIONS. D PERIVENTRICULAR, HYPOCAMPUS AND OCCIPITAL REGIONS.
  122. 122.  50 WHICH OF THE FOLLOWING TYPES OF HEADACHES WERE NOT ASSOCIATED WITH AN INCREASED RISK OF INFARCT-LIKE LESIONS AT FOLLOW-UP? A POST-TRAUMATIC HEADACHE B HEADACHE AND MIGRAINE WITH AURA. C MIGRAINE WITHOUT AURA AND NON- MIGRAINE HEADACHE. D SINUSITIS AND MIGRAINE
  123. 123. 46. A47. C48. A49. B50. C
  124. 124.  46. However, recent studies suggest that migraine attacks may be associated with patological changes in the brain, particularly in the cerebellum. 47. … more than 26 years later, brain MRIs were performed. 48. …, those with midlife migraine with aura … had an increased risk of late-life infarct- like lesions … that specifically reflected an association with cerebellar lesions in women ….
  125. 125.  49. … and specifically located in the cortical, subcortical, and cerebellar regions were the main outcome measure. 50. …, migraine without aura and non-migraine headache were not associated with an increased risk.a CT scan/ a CAT scan

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