text:
A summary of the "must-read" articles from the journals in that pile on your desk.
Midlife Self-Care Extends Men's Life Span into 80s, 90s
Avoidance of risk factors in middle-age increases men's probability of reaching a ripe old age
Middle-aged men who avoid common risk factors for chronic disease have a better chance of achieving an "exceptional" survival, defined as living to age 85 and beyond without physical or mental impairment, according to a study published in the Nov. 15 issue of the Journal of the American Medical Association.
Bradley J. Willcox, M.D., of the Pacific Health Research Institute in Honolulu, Hawaii, and colleagues conducted a 40-year study of 5,820 Japanese-American men, of whom 2,451 (42 percent) survived to age 85. Eleven percent were defined as exceptional survivors because they did not have any of six major chronic diseases and had no physical and cognitive impairment.
The researchers found that overall and exceptional survival were associated with high grip strength, as well as avoidance of overweight, hyperglycemia, hypertension, smoking and excessive alcohol consumption. They also found that exceptional survival was associated with high education and avoidance of hypertriglyceridemia. Their analysis suggested that men with no risk factors have significantly higher probabilities of reaching age 85 than men with six or more risk factors (69 percent versus as low as 22 percent) and of exceptional survival (55 percent versus 9 percent).
"These risk factors can be easily measured in clinical settings and are, for the most part, modifiable," the authors conclude. "This may be especially important for men, few of whom survive to oldest-old age.
Drug Combination Helps Men with Overactive Bladder
Randomized controlled trial suggests patients unresponsive to standard treatment might benefit from switch
A combination of extended-release tolterodine and tamsulosin appears to be safe and effective in treating men with overactive bladder, according to a randomized, industry-funded trial reported in the Nov. 15 issue of the Journal of the American Medical Association.
Steven Kaplan, M.D., of Weill Cornell Medical College in New York City, and colleagues studied the safety and efficacy of tolterodine extended release (ER), tamsulosin, or both in 879 men with overactive bladder and benign prostatic hyperplasia. Patients were randomized to placebo, each drug alone, or the combination.
The investigators found that 80 percent of patients randomized to a combination of tolterodine ER plus tamsulosin reported treatment benefit compared with 71 percent receiving tamsulosin alone, 65 percent receiving tolterodine ER alone and 62 receiving placebo. The combination group reported significant reductions in urgency urinary episodes with and without incontinence, micturitions per 24 hours, and micturitions per night.
The authors conclude that men bothered by lower urinary tract symptoms including overactive bladder and who are unresponsive to α-adrenergic receptor antagonists or antimuscarinic agents might benefit from switching to tolterodine ER plus tamsulosin.
The study was funded by Pfizer and some of the authors are employees or have received compensation from the company.
Prostate-Specific Antigen Test Overused in Elderly Men
More than half are being tested despite guidelines, study finds
Despite guidelines suggesting the test does elderly patients more harm than good, U.S. physicians routinely perform prostate-specific antigen (PSA) screenings on males over 70, according to a report in the Nov. 15 Journal of the American Medical Association. The findings were presented Nov. 14 at a special American Medical Association men's health news briefing in New York City.
In the study, Louise C. Walter, M.D., and colleagues at the University of California San Francisco examined 2003 U.S. Department of Veterans Affairs data on nearly 600,000 male veterans, aged 70 or over, who were treated at 104 VA facilities nationwide.
Fifty-six percent of these elderly patients received a PSA test in 2003. Although the rate of testing did decline with advancing patient age, the percentage of men receiving the test did not fall with worsening health -- 34 percent of men aged 85 and older rated in "best health" were screened versus 36 percent deemed to be in worst health.
The researchers conclude that rates of PSA screening among the elderly "should be much lower than current practice given the known harms of screening."
In his editorial, Peter C. Albertsen, M.D., of the University of Connecticut Health Center in Farmington, adds that many elderly men have an exaggerated fear of the danger from prostate cancer and the effectiveness of treatment for their age group. According to Albertsen, physicians must counsel these patients that, "When the [PSA] test is applied to older men, the benefits are not likely to exceed the potential harms."
Six-Month Testosterone Therapy May Not Affect Prostate
Study found little impact on tissue androgens or other biomarkers
Six months of testosterone replacement therapy (TRT) normalizes serum androgen levels in older men with late-onset hypogonadism while having little effect on prostate tissue, according to a report in the Nov. 15 Journal of the American Medical Association. The findings were announced Nov. 14 at a special American Medical Association men's health briefing in New York City.
The study, led by Leonard S. Marks, M.D., of University of California Los Angeles School of Medicine and the Urological Sciences Research Foundation in Culver City, Calif., included 44 men ranging from 44 to 78 years of age. All had low serum testosterone (below 300 ng/dL) and related symptoms, and were randomized to receive 150 mg of testosterone enanthate or placebo every two weeks for six months.
Forty of the participants underwent prostate biopsy at baseline and at the end of the trial. TRT boosted serum testosterone to the mid-normal range, while those on placebo recorded no such change, the researchers report. Men receiving TRT displayed no significant rise in prostate tissue levels of either testosterone or dihydrotestosterone. The investigators also detected no change in prostate histology, tissue biomarkers, gene expression, or cancer incidence or severity in patients receiving TRT.
Larger, longer trials are needed to confirm the findings, the researchers stressed. However, based on the findings, they conclude that TRT "does not appear to induce any major biological change in the gland. The prostate risks to men undergoing TRT may not be as great as once believed, especially if the results of pretreatment biopsy are negative."
The study was funded by grants from the U.S. National Institutes of Health, Watson Laboratories of Salt Lake City, and Solvay Pharmaceuticals of Marietta, Ga.
Adjuvant Radiotherapy May Fight Advanced Prostate Cancer
Decade-long study finds significant decrease in tumor recurrence, but not deaths
A 10-year randomized, prospective clinical trial may provide guidance on the use of adjuvant radiotherapy after radical prostatectomy in men with pathologically advanced prostate cancer. The study, published in the Nov. 15 issue of the Journal of the American Medical Association, found the treatment could reduce prostate-specific antigen relapse and disease recurrence, but not overall patient survival.
As reported at a special American Medical Association men's health briefing in New York City on Nov. 14, Ian M. Thompson, Jr., M.D. and colleagues from the University of Texas Health Science Center at San Antonio, tracked outcomes for 425 men with pathologically advanced prostate cancer who had undergone radical prostatectomy. Patients were randomized to either 60 to 64 Gy external-beam radiation or usual care plus observation.
Over a median 10.6 years of follow-up, the researchers noted significant differences between cases and controls in terms of prostate-specific antigen relapse-free survival (10.3 years versus 3.1 years, respectively) and disease recurrence (13.8 years versus 9.9 years). However, no significant difference was found in terms of metastasis-free survival or overall survival between the two groups, with 71 deaths recorded in those receiving radiotherapy versus 83 deaths for those who did not get the treatment.
Adverse effects were significantly higher in those receiving radiotherapy (23.8 percent) compared to those who did not (11.9 percent), and included rectal and urethral complications and urinary incontinence.
"The results of this study may provide guidance for clinicians and patients considering options for adjuvant therapy for pathologically advanced disease," the authors write.
AHA: Pioglitazone Best for Slowing Artery Wall Expansion
Slower carotid intima-media thickness changes seen with pioglitazone
Pioglitazone slows the progression of carotid artery wall thickness in patients with type 2 diabetes mellitus better than glimepiride, according to a report published online Nov. 13 in the Journal of the American Medical Association. The findings were presented at the American Heart Association's Scientific Sessions in Chicago.
Theodore Mazzone, M.D., of the University of Illinois College of Medicine in Chicago, and colleagues conducted a randomized, double-blind, controlled multicenter trial to compare the effects of pioglitazone versus glimepiride on changes in common carotid artery intima-media thickness (CIMT) in 462 adult patients with type 2 diabetes mellitus.
The investigators found that at 24, 48 and 72 weeks of treatment, pioglitazone produced a smaller change in CIMT in the left and right common carotid arteries, and slowed progression of maximum CIMT compared with glimepiride. The effect was apparent across multiple subgroups including those based on age, sex, blood pressure and body mass index.
"We found that, compared with glimepiride, pioglitazone reduced CIMT progression, a validated surrogate end point for coronary artery disease and cardiovascular risk," the authors conclude. While this study was conducted with individuals having good blood pressure, low LDL-cholesterol levels and regular statin use, additional studies are needed to determine whether routine use of pioglitazone instead of glimepiride substantially reduces major cardiovascular events.
The authors report multiple financial disclosures.
AHA: Pharmacy Program Helps Elderly Adhere to Medications
Custom daily-dosed blister packs improve adherence, clinical outcome
A pharmacy care program that includes custom blister-packed medications helps elderly patients adhere to their chronic medications better than usual care, according to a report released online Nov. 13 by the Journal of the American Medical Association. The findings were presented at the American Heart Association's Scientific Sessions in Chicago.
Allen J. Taylor, M.D., and colleagues at Walter Reed Army Medical Center, Washington, D.C., conducted a multiphase trial to test the efficacy of the customized program on medication adherence and clinical measures in the elderly. The study included 200 patients taking a mean of nine medications, many of which were for hypertension and hyperlipidemia.
Medication adherence improved from 61.2 percent at baseline to 96.9 percent after six months of the treatment program, and showed significant improvements in systolic blood pressure and low-density lipoprotein cholesterol levels. Patients then randomized to continue the program sustained high levels of adherence while those switched to usual care dropped to 69.1 percent adherence after another six months and had higher blood pressures.
The results suggest that programs like these should improve health outcomes in at-risk populations such as the elderly, the authors note. In an accompanying editorial, Ross J. Simpson, Jr., M.D., Ph.D., writes, "Multifaceted interventions that incorporate structural and counseling components and include appropriately skilled and motivated pharmacists appear useful to promote medication adherence and persistence."
Taylor reports receiving grant support and honoraria from various pharmaceutical companies.
Correcting Anemia in Kidney Disease May Not Be Beneficial
Full correction of anemia may increase risk of adverse events
For patients with chronic kidney disease, fully correcting anemia may increase the risk of adverse events, according to two studies published in the Nov. 16 issue of the New England Journal of Medicine.
Ajay K. Singh, M.B., B.S., from Brigham and Women's Hospital in Boston, and colleagues assigned 1,432 patients with chronic kidney disease to a dose of epoetin alpha that maintained their hemoglobin at either 13.5 grams per deciliter (715 patients) or 11.3 g/dL (717 patients). The researchers found 125 events occurred in the high-hemoglobin group, compared with 97 events in the low-hemoglobin group. "The use of a target hemoglobin level of 13.5 g/dL (as compared with 11.3 g/dL) was associated with increased risk and no incremental improvement in the quality of life," Singh and colleagues write.
Tilman B. Drueke, M.D., from the Hopital Necker in Paris, France, and colleagues assigned 603 patients with stage 3 or 4 chronic kidney disease to treatment with epoetin beta to maintain their hemoglobin between 13 to 15 g/dL (normal range) or between 10.5 to 11.5 g/dL (subnormal range). The risk of cardiovascular events was similar in both groups. Maintaining hemoglobin in the normal range significantly increased the need for dialysis but significantly improved general health and physical function.
The first study was supported by Ortho Biotech Clinical Affairs and Johnson & Johnson Pharmaceutical Research and Development. The second study was supported by F. Hoffmann-La Roche.
AHA: Tolvaptan Can Relieve Hyponatremia
Side effects include dry mouth, increased thirst and increased urination
The vasopressin V2-receptor antagonist tolvaptan is effective in relieving hyponatremia, according to the results of a study published online Nov. 14 in the New England Journal of Medicine. The findings were reported at the American Heart Association's Scientific Sessions in Chicago.
Robert W. Schrier, M.D., of the University of Colorado Health Sciences Center in Denver, and colleagues randomly assigned 448 patients with hyponatremia (serum sodium less than 135 mmol per liter) to placebo or 15-mg oral tolvaptan daily. The tolvaptan dose was increased to 30-mg or 60-mg daily as needed based on serum sodium concentration. Changes in the serum sodium average daily area under the curve were monitored from baseline to day 4 and baseline to day 30.
There was a significant increase in serum sodium at both day 4 and day 30 in patients taking tolvaptan, although hyponatremia returned once tolvaptan was discontinued after day 30. Patients taking tolvaptan reported increased thirst, increased urination and dry mouth, the report indicates.
"The study is encouraging in terms of the efficacy of tolvaptan as a V2-receptor antagonist and its use, at least during a limited period, in the outpatient setting," Richard M. Hays, M.D., from the Albert Einstein College of Medicine, Bronx, New York, writes in an accompanying editorial. But, he adds, "careful oversight of the use of this agent is required."
The study was supported by the Otsuka Maryland Research Institute.
Paclitaxel-Coated Balloon Catheter Reduces Restenosis
Preliminary data suggests promise of catheter-based drug delivery in in-stent restenosis
In patients with coronary in-stent restenosis, treatment with paclitaxel-coated balloon catheters may significantly reduce the risk of restenosis, according to a study published online Nov. 13 in the New England Journal of Medicine.
Bruno Scheller, M.D., of the Universitatsklinikum des Saarlandes in Homburg/Saar, Germany, and colleagues randomly assigned 52 patients to receive treatment with either a balloon catheter coated with paclitaxel or an uncoated balloon catheter during coronary angioplasty.
At six months, the researchers found that the mean in-segment late luminal loss was 0.03 in the coated balloon group compared to 0.74 in the uncoated balloon group. They also found that only one patient (5 percent) in the coated balloon group had restenosis compared to 10 patients (43 percent) in the uncoated balloon group. At 12 months, they also found a lower rate of major adverse cardiac events (4 percent versus 31 percent).
"The report by Scheller et al. suggests that catheter-based drug delivery is a potentially promising approach to in-stent restenosis and demonstrates that old avenues of investigation may yield new solutions to persisting problems," concludes the author of an accompanying editorial. "Although these data are preliminary and do not yet confirm the clinical validity of this approach, it may be that we can make progress in this field by going 'back to the future.'"
Authors of the study report being co-inventors of a patent application that was used in the trial. Bavaria Medizin Technologie supported the trial.
AHA: Better Never Than Late Reperfusion After MI
Reperfusion three to 28 days after myocardial infarction offers no benefit and may even be harmful for patients who are stable
Stable patients with totally occluded coronary arteries do not benefit from percutaneous coronary intervention when given three to 28 days after a myocardial infarction and may even be harmed by the practice, according to a study presented at the American Heart Association's Scientific Sessions in Chicago. The findings were also published online Nov. 14 in the New England Journal of Medicine.
Judith Hochman, M.D., of New York University School of Medicine, and colleagues from the Occluded Artery Trial (OAT) randomized 2,166 stable patients to optimal medical therapy or angioplasty plus stenting. During a mean three-year follow-up, patients treated with late reperfusion did no better than medication-treated patients in terms of mortality, repeat myocardial infarction and heart failure. And there was a trend towards more repeat myocardial infarctions in the reperfusion-treated group.
In a second study, a subset of the OAT trial known as TOSCA-2 (Total Occlusion Study of Canada), Vladimir Dzavik, M.D., of the University Health Network in Toronto reported on 381 patients who received late reperfusion or medication. Ninety-three percent of infarct-related arteries could be opened with angioplasty plus stenting and 83 percent were open one year later. In comparison, 25 percent of arteries spontaneously opened in medication-treated patients. However, both groups had similar ejection fractions after one year.
"If you are a stable patient there is no benefit to open that artery late, days to weeks after that heart attack," said Hochman. The authors emphasized that high-risk patients were excluded, including those with left main or 3-vessel disease, angina at rest or low-threshold angina, cardiogenic shock or major heart failure. "We are not in any way saying that patients who are having significant severe symptoms and have an occluded artery, that they should not have PCI," said Dzavik.
AHA: Door-to-Balloon Time Reduction Strategies Examined
Researchers identify six effective strategies, but find that most hospitals aren't using them
In managing heart attack patients with ST-segment elevation, several hospital strategies can reduce door-to-balloon time, but few hospitals use them to meet the gold standard of 90 minutes or less, according to a report released online Nov. 13 and published in the Nov. 30 issue of the New England Journal of Medicine.
Elizabeth H. Bradley, Ph.D., of the Yale University School of Medicine in New Haven, Conn., and colleagues surveyed 365 hospitals.
The researchers identified six effective strategies: emergency medicine physicians activate the catheterization laboratory (mean reduction, 8.2 minutes); a single call to a central page operator activates the laboratory (13.8 minutes); the emergency department activates the catheterization laboratory while the patient is en route to the hospital (15.4 minutes); the staff arrives in the catheterization laboratory within 20 minutes of being paged (19.3 minutes); an attending cardiologist is always on site (14.6 minutes); and emergency department and catheterization laboratory staff use real-time data feedback (8.6 minutes).
"It is now time to act," conclude the authors of an accompanying editorial. "The Centers for Medicare and Medicaid Services, the American College of Cardiology, the American Heart Association, the National Quality Forum, and many other public and private groups are aligned to move forward with efforts to improve the time to reperfusion."
Google Useful to Help Doctors Diagnose Difficult Cases
Wider Internet access on wards and in clinics are helping the Web become an important tool for doctors
The increasing availability of Internet access on hospital wards and in outpatient clinics is enabling more and more doctors to access the Web and use the search engine Google to help diagnose difficult cases, according to a study published online Nov. 10 in
Hangwi Tang, M.D., and a colleague from Princess Alexandra Hospital in Brisbane, Australia, identified three to five search terms for 26 cases of disease reported in the New England Journal of Medicine and then Google-searched each case without knowing the correct diagnoses.
Searches using Google resulted in a correct diagnosis in 15 cases (58 percent). "We suspect that using Google to search for a diagnosis is likely to be more effective for conditions with unique symptoms and signs that can easily be used as search terms," the authors comment. "Searches are less likely to be successful in complex diseases with non-specific symptoms or common diseases with rare presentations," they add.
The authors emphasize that for patients, Google is likely to be less effective as a search engine for disease diagnosis as the efficiency of the search depends on the knowledge base of the searcher, which affects the selection of documents.
Lifestyle Changes Cut Type 2 Diabetes in High-Risk People
Intense diet and exercise counseling cuts transition to type 2 diabetes in overweight subjects
Intensive diet and exercise counseling can reduce disease incidence for patients at high risk of type 2 diabetes mellitus, even long after counseling is discontinued, according to results from an extended follow-up the Finnish Diabetes Prevention Study published in the Nov. 11 issue of
Jaana Lindstrom, M.Sc., of the University of Helsinki in Finland, and colleagues randomly assigned 522 overweight men and women with impaired glucose tolerance to intensive lifestyle intervention or a control group to see whether these changes could reduce risk of progression to type 2 diabetes.
After a mean follow-up of seven years, incidence of type 2 diabetes was 4.3 per 100 person-years for the intervention group and 7.4 per 100 person-years for the control group. The success of the program was linked to weight loss, increased physical activity, reduced saturated fat and increased fiber intake.
"The evidence for sustainability of lifestyle benefit presented by the [study] investigators supports their argument for urgent widespread establishment of community-based diabetes prevention programs," Ronald Goldberg, M.D., of the University of Miami, writes in an accompanying editorial.
AHA: One COX-2 Has Heart Risk Similar to Naproxen in Study
Merck-funded, randomized trial conducted in osteoarthritis, rheumatoid arthritis patients
A randomized trial suggests that one COX-2 inhibitor, etoricoxib, may be no more likely to cause thrombotic cardiovascular events than diclofenac when used to treat osteoarthritis or rheumatoid arthritis patients, according to an industry-funded report presented at the American Heart Association's Scientific Sessions in Chicago and published online Nov. 13 in The Lancet. In addition, etoricoxib may be less likely to cause upper gastrointestinal events, such as perforations, ulcers and bleeding.
Christopher Cannon, M.D., of Brigham and Women's Hospital in Boston, presented the results of the MEDAL (Multinational Etoricoxib and Diclofenac Arthritis Long-term) program. In the study, 34,701 patients were randomized to etoricoxib at 60 mg/day (osteoarthritis) or 90 mg/day (osteoarthritis or rheumatoid arthritis) for a mean of 18 months, or diclofenac at 150 mg/day. Half of patients took a proton pump inhibitor and one-third took aspirin.
There were no significant differences between the drugs in terms of fatal thrombotic cardiovascular events (hazard ratio, 0.96), cardiac events (HR, 0.90), cerebrovascular events (HR, 1.08) or peripheral events (HR, 0.92). Confirmed upper gastrointestinal events were lower in the etoricoxib group (HR, 0.69).
Although other studies have found that etoricoxib can increase the risk of cardiovascular events, those studies were observational, said Cannon. In response to the trial, the AHA issued a statement that said, "Current evidence indicates that selective COX-2 inhibitors have important adverse cardiovascular effects including increased risk for heart attack, stroke, heart failure and hypertension."
The trial was sponsored by Merck.
Few Primary Care Doctors Prescribe Preventive Tamoxifen
Not all patients who could benefit are getting the drug
Although tamoxifen has been approved for use as a preventive measure against breast cancer, few primary care physicians are prescribing the drug, researchers report in the Nov. 13 issue of the Archives of Internal Medicine.
Katrina Armstrong, M.D., of the University of Pennsylvania in Philadelphia, and colleagues surveyed 350 primary care physicians including those who specialize in family medicine, obstetrics and gynecology, and general internal medicine. As well as being asked about past prescription of the drug, they were posed hypothetical situations to gauge their likelihood of prescribing the drug and what factors affected their decision.
In all, 96 physicians (27.4 percent) had prescribed tamoxifen at least once in the past year as a breast cancer preventive measure. Having prescribed the medication was associated with the physician having a family member with the disease and having patients who requested information about the drug. Another significant predisposing factor was the belief that tamoxifen's benefits outweighed the risks. Primary care physicians did not give as much weight to a woman's risk of endometrial cancer as they did to familial breast cancer status.
The authors express surprise at the proportion of doctors who had prescribed the drug in the last 12 months, and conclude that the proportion is "lower than might be expected based on the estimated proportion of women who would experience a net benefit from tamoxifen."
Influenza Vaccination Linked to Risk for Guillain-Barre
Small but significant increased risk after immunization in adults
A small but statistically significant increase in adult hospitalization for Guillain-Barre syndrome is linked to influenza vaccination, according to the results of a Canadian study published in the Nov. 13 issue of the Archives of Internal Medicine.
David N. Juurlink, M.D., Ph.D., of the University of Toronto, and colleagues evaluated April 1992 to March 2004 Ontario province population-based studies to determine whether influenza immunization is associated with Guillain-Barre syndrome.
Of 1,601 adult hospital admissions due to Guillain-Barre syndrome, in 269 cases the disease was diagnosed within 43 weeks of influenza vaccination. The estimated relative rate of the syndrome during weeks two through seven compared to the control interval (weeks 20 through 43) was 1.45. Separate time-series evaluation showed no evidence of seasonality and no statistically significant increase in admissions due to Guillain-Barre after influenza vaccine.
"Influenza vaccination is associated with a small but significantly increased risk for hospitalization because of Guillain-Barre syndrome," the authors conclude.
Study Finds Colonoscopy Still Underused in Veterans
Another study questions use of colonoscopy in younger patients with comorbidity and poor life expectancy
Although colonoscopy usage has significantly increased over the past several years, fecal occult blood testing dominates colorectal cancer (CRC) testing in veterans, one study finds, while another questions the benefit of colorectal screening in younger patients with reduced life expectancy. Both studies are published in the Nov. 13 Archives of Internal Medicine.
Hashem B. El-Serag, M.D., of Baylor College of Medicine in Houston, and colleagues evaluated 1998-2003 Veterans Administration CRC screening methods data and found that while the total number of colonoscopies increased from 24,955 in 1998 to 55,199 in 2003, the proportion of subjects screened with colonoscopy declined from 5.7 percent to 4.7 percent and fecal occult blood testing increased from 81.7 percent to 90.4 percent.
"It is likely that CRC screening with fecal occult blood testing will result in poorer clinical outcomes for veterans," according to an accompanying editorial.
In another Veterans Affairs study using 1996-2004 data, Shahnaz Sultan, M.D., of Duke University in Durham, N.C., and colleagues found that of 861 young patients (defined as patients 50 to 64 years of age), 45.9 percent had CRC testing within five years. Of these, screening was high in patients with moderate (44.9 percent) and severe (45.8 percent) comorbidities. Of the 52 patients who died during the five-year follow-up, 71.2 percent (37 patients) had CRC screening.
"Comprehensive assessment of health status and comorbidity should guide cancer screening decisions, especially in individuals with reduced life expectancy who may obtain the least benefit from screening," the authors conclude.
Primary Care Physicians Miss Signs of Cardiac Ischemia
About 11 percent of symptomatic patients aren't sent to the hospital before developing acute myocardial infarction
Primary care clinicians often miss early chances to send patients with cardiac ischemia to the hospital, researchers report in the Nov. 13 issue of the Archives of Internal Medicine. About 11 percent of acute myocardial infarction patients without a previous history of heart disease see their primary care doctor, nurse practitioner or physician's assistant for angina-like pain or other symptoms in the month before hospitalization, but aren't sent to the hospital.
Thomas D. Sequist, M.D., M.P.H., of Harvard Medical School in Boston, and colleagues analyzed data from 966 acute myocardial infarction patients without a prior history of heart disease. They found that 27 percent (261 patients) had seen their doctor in the previous month for chest pain. More than half of these patients were sent directly to the hospital (155 patients) and 41 percent were not (106/261, or 11 percent of the total). These patients were matched with three control patients with similar symptoms who did not develop acute myocardial infarction.
The researchers found that such "missed opportunities" were associated with a 10 percent or higher Framingham risk score (FRS), for a 19.5 odds ratio, as well as with higher scores involving the Diamond and Forrester forecasting instrument. Pain medications and antacids were most often prescribed
"We identified low prescription rates for beta-blocker and aspirin therapy among these symptomatic outpatients with elevated risk scores, and recent guidelines suggest aspirin therapy for patients with an elevated FRS even in the absence of symptoms," the authors write. "More aggressive intervention may have prevented their acute myocardial infarction."
Red Meat Associated with Higher Risk of Breast Cancer
Risk increased only for hormone receptor-positive cancers
Increased red meat intake is associated with a higher risk of hormone receptor-positive breast cancer in relatively young, premenopausal women, according to a report in the Nov. 13 issue of the Archives of Internal Medicine.
Eunyoung Cho, Sc.D., from Harvard Medical School in Boston, and colleagues studied the risk of breast cancer in 90,659 premenopausal women aged 26 to 46 years based on red meat intake, which was assessed three times through a food-frequency questionnaire during 12 years of follow-up.
There were 1,021 cases of invasive breast carcinoma over the follow-up period. The risk of estrogen and progesterone receptor-positive cancers increased with increasing red meat intake, the researchers found. The relative risk ranged from 1.14 for three to five servings per week to 1.97 for more than 1.5 servings per day compared with three or fewer servings per week. There was no significant change in the risk of developing hormone receptor-negative cancers, according to the study.
"In conclusion, in this population of relatively young, premenopausal women, red meat intake was associated with a higher risk of hormone receptor-positive breast cancer but not with risk of hormone receptor-negative cancer," Cho and colleagues conclude. "Given that most of the risk factors for breast cancer are not easily modifiable, these findings have potential public health implications in preventing breast cancer and should be evaluated further."
Occupational Therapy Benefits Dementia Patients
Community-based intervention also reduces burden on caregivers
Despite the fact that patients with dementia have limited learning ability, community-based occupational therapy improves their daily functioning and also has benefits for their caregivers, according to research published online Nov. 17 in BMJ.
Maud J.L. Graff, M.Sc., of the University Medical Center Nijmegen in the Netherlands, and colleagues conducted a randomized controlled trial of 135 community-based patients aged 65 and older with mild to moderate dementia and their caregivers. Those in the intervention group received 10 sessions of occupational therapy over a period of five weeks. The therapy comprised cognitive and behavioral interventions aimed at compensating for cognitive decline, while caregivers were given training in coping skills and supervision.
At six weeks, 84 percent of those who received occupational therapy showed improvements in motor skills while 78 percent needed less assistance in daily tasks and the benefits remained at 12 weeks' follow-up. Caregivers' sense of competence was measured using a questionnaire and those in the intervention group also showed sustained improvements.
"Because outcomes such as improvement in activities of daily living and sense of competence are associated with a decrease in need for assistance, we believe that, in the long term, occupational therapy will result in less dependence on social and health care resources and less need for institutionalization," the authors conclude.
More People Could Benefit from Statins
Lifetime treatment of a wider population is cost-effective
A greater number of people could benefit from statins, and widening the pool of candidates for the drug would be cost-effective, according to the results of a study published online Nov. 10 in BMJ.
The study, conducted by the Heart Protection Study Collaborative Group of the University of Oxford in England, comprised 20,536 men and women aged 40 to 80 from 69 U.K. hospitals. The subjects were diagnosed with coronary disease, other occlusive arterial disease or diabetes. The cohort was randomized to receive 40 milligrams of simvastatin or placebo every day for an average of five years.
In most of the age and vascular disease groups covered by the study, lifetime treatment with simvastatin was cost-saving, even though these gains, as well as life-expectancy gains, decreased with increasing age and decreasing vascular disease risk. Those in the 40 to 49 age-group with a 42 percent five-year risk of major vascular events gained 2.49 years' life expectancy, but there were also gains for those with a much lower risk of major vascular events.
Based on current U.K. prices, the drug would be cost-saving or cost less than GBP2,500 per life-year gained for those with even a 1 percent risk of major vascular events. "Statin therapy should be considered routinely for people across a wider age range and at lower risk of vascular disease than is currently the case," the authors conclude.
The study was funded in part by Roche Vitamins Ltd. and Merck & Co., the maker of simvastatin.
Consensus Achieved on Quality in Cardiovascular Imaging
Implementation of practical safety measures will take money and strong leadership
Guidelines on quality in cardiovascular imaging have now been developed, but their implementation will require a concerted commitment of effort and time, according to a report in the Nov. 14 issue of the Journal of the American College of Cardiology.
The report lays out guidelines that resulted from a meeting of the American College of Cardiology-Duke University Medical Center Think Tank on Quality in Cardiovascular Imaging held in Washington, D.C., in January 2006. Implementation of the guidelines should improve outcomes for patients and enhance their satisfaction with the treatment they receive and its costs, the report states.
"Imaging has transformed our ability to prevent, diagnose and manage cardiovascular disease," lead author Pamela Douglas, M.D., of Duke University Medical Center in Durham, N.C., explains in a statement. "Cardiovascular imaging has enjoyed both rapid technological advances and sustained growth, yet less attention has been focused on quality than in other areas of cardiovascular medicine."
The guidelines looked at four main areas: matching patients with the most suitable imaging technique, getting the best images, correctly interpreting images and communicating the results to patients' physicians. Choosing the most appropriate technique for each individual patient was key, according to Douglas. "Our goal is to identify which patients would benefit the most from each technique while minimizing inappropriate testing," she adds.
High Cardiac Troponin T Linked to Reduced Survival
Elevated levels of cardiac troponin T found in nearly 20 percent of percutaneous coronary intervention patients
Elevated levels of cardiac troponin T following percutaneous coronary intervention is associated with reduced survival in patients with normal creatine kinase levels, according to the results of a study published in the Nov. 7 issue of the Journal of the American College of Cardiology.
Abhiram Prasad, M.D., and colleagues from the Mayo Clinic in Rochester, Minn., measured the post-procedure levels of cardiac troponin T -- a marker of myonecrosis -- in 1,949 patients who had undergone percutaneous coronary intervention and had normal pre- and post-procedure levels of creatine kinase-muscle-brain fraction.
The researchers found elevated levels of cardiac troponin T in 19.6 percent of patients, which was associated with significantly higher mortality and higher combined rates of death and myocardial infarction over the median follow-up of 26 months. Elevated cardiac troponin T levels decreased three-year survival from 93.2 percent to 86.9 percent, the investigators report.
"The present report should help refocus the stage light on post-procedural infarction," Neal S. Kleiman, M.D., from Methodist DeBakey Heart Center in Houston, writes in an accompanying editorial. "If we are to continue to reduce the long-term morbidity and mortality in patients who have had interventions, we will need to recognize that there are new markers of risk that merit our attention."
PET Imaging of Carotid Plaques Detects Inflammation
Non-invasive method correlates with macrophage staining
Positron emission tomography (PET) imaging with fluorodeoxyglucose, whose uptake has been shown to be increased in carotid plaques, is an effective and non-invasive way to assess inflammation in patients with severe carotid stenoses, researchers report in the Nov. 7 issue of the Journal of the American College of Cardiology.
Ahmed Tawakol, M.D., of Massachusetts General Hospital in Boston, and colleagues examined the ability of 18F-fluorodeoxyglucose PET imaging to detect carotid plaque inflammation in 17 patients with severe carotid stenoses. Afterward, patients underwent carotid endarterectomy and carotid specimens were examined for macrophages.
There was a strong correlation between the imaging and inflammation as assessed by the PET signal in plaques and macrophage staining, as well as the mean uptake of fluorodeoxyglucose and mean inflammation. There was no correlation between plaque area or thickness, or extent of smooth muscle staining, according to the report.
"We established that fluorodeoxyglucose-PET imaging can be used to assess the severity of inflammation in carotid plaques in patients," the authors conclude. "If subsequent natural history studies link increased fluorodeoxyglucose-PET activity in carotid arteries with clinical events, this non-invasive measure could be used to identify a subset of patients with carotid atherosclerosis in need of intensified medical therapy or carotid artery intervention to prevent stroke."
The study was supported by grants from Pfizer and GlaxoSmithKline.
AHA: Novel Anticoagulant Drug, Antidote Promising in Phase 1
RNA aptamer-based technology that targets factor IXa was tested in 85 patients
A novel anticoagulant system that relies on a shape-changing RNA aptamer and its fast-acting antidote has been tested for the first time in patients, according to a report presented at the American Heart Association's Scientific Sessions and simultaneously published in Circulation: Journal of the American Heart Association. The drug platform, known as REG1, could have applications for oncology, rheumatic disease or infections and seemed safe. However, one patient did experience transient encephalopathy that may or may not have been therapy-related, reported Richard Becker, M.D., of Duke University in Durham, N.C.
Christopher Dyke, M.D., Becker and colleagues randomized 85 healthy volunteers to receive an intravenous infusion of RB006, an oligonucleotide that binds to factor IXa, or a placebo. An escalating drug-dosage design was used, with 15, 30, 60 and 90 mg of the drug. The antidote, RB007, was administered at a 2:1 ratio three hours later.
Patients treated with 15 mg of the drug had a 1.1-fold increase in activated partial thromboplastin time (APTT) 15 minutes after administration, while those given higher doses had a more pronounced response (2.9-fold increase in mean relative APTT at 15 minutes with 90 mg dose). The antidote returned the APTT to baseline within one to five minutes.
"The drug-antidote system as we describe here could be used as a potential replacement for heparin," said Becker. Aptamers "are able to fold and they assume shapes that are directed against a target," he notes. While the current platform targets factor IXa, the use of other targets could make the drug-antidote system useful in oncology and other diseases, he said.
The study was funded by Regado Biosciences, Inc., of Durham, N.C.
Retinoic Acid Does Not Benefit Emphysema Patients
Treatment does not improve pulmonary function or quality of life
Retinoic acid treatment does not improve pulmonary function or quality of life in patients with chronic obstructive pulmonary disease (COPD) and emphysema, according to the results of a study published in the November issue of Chest.
Michael D. Roth, M.D., from the University of California Los Angeles, and colleagues randomly assigned 148 patients with moderate-to-severe COPD and a primary component of emphysema to either low-dose all-trans retinoic acid (1 mg/kg/day), high-dose all-trans retinoic acid (2 mg/kg/day), or 13-cis retinoic acid (1 mg/kg/day), with a placebo control within each group. After six months, placebo patients were crossed over to drug and drug patients were crossed over to placebo within each group for three months.
After the initial six months, there were no improvements in pulmonary function, health-related quality of life, or CT density mask score with any of the treatments. However, in the high-dose all-trans retinoic acid group, the researchers found time-dependent changes in the diffusing capacity of the lung for carbon monoxide and the St. George Respiratory Questionnaire, and five of 25 patients had delayed improvements in their CT scores. The changes correlated with plasma drug levels, the report indicates.
"No definitive clinical benefits related to the administration of retinoids were observed in this feasibility study," Roth and colleagues conclude.
Perceived Asthma Control Reduces Emergency Visits
Greater control also reduces risk of asthma hospitalization
Asthma patients who feel more in control of their asthma have better health and quality of life and are less likely to visit the emergency department or be hospitalized for asthma, according to study findings published in the November issue of Chest.
Mark D. Eisner, M.D., M.P.H., from the University of California San Francisco, and colleagues conducted telephone interviews with 865 patients who had been hospitalized for asthma. The interview included the Perceived Control of Asthma Questionnaire. They then assessed the number of emergency department visits and hospitalizations for asthma for a median of 1.9 years.
The researchers found that patients with greater perceived control were in better physical health, had less severe asthma, and had better asthma-related quality of life. Better perceived control was associated with a significantly lower risk of visiting the emergency department (hazard ratio, 0.92) and being hospitalized for asthma (HR, 0.84).
"Greater perceived control is associated with improved asthma-related health status as well as with a decreased prospective risk of severe asthma attacks resulting in emergency health care utilization," Eisner and colleagues conclude. "This difference does not appear to be mediated by changes in preventive care or asthma self-management practices."
Greater Risk of COPD in HIV-Positive Men
Risk increased by 50 to 60 percent compared with HIV-negative men
HIV-positive men have a 50 percent to 60 percent higher risk of developing chronic obstructive pulmonary disease (COPD) than HIV-negative men, according to a study in the November issue of Chest.
Amy C. Justice, M.D., Ph.D., from the Veterans Affairs Connecticut Healthcare System in West Haven, and colleagues examined the prevalence of COPD in 1,014 HIV-positive and 713 HIV-negative men based on both patient self-report and by diagnostic codes from the International Classification of Diseases, ninth revision (ICD-9).
The researchers found that the prevalence of COPD was similar by the ICD-9 criteria (10 percent in HIV-positive versus 9 percent in HIV-negative men) but significantly different by self-report (15 percent versus 12 percent, respectively). However, after adjusting for demographic factors, smoking, alcohol abuse and injection drug use, they found that the risk of COPD was significantly higher in HIV-positive men by both the ICD-9 criteria (odds ratio 1.47) and self-report (OR, 1.58).
"Health care providers should be aware of the increased likelihood of COPD among their HIV-positive patients," Justice and colleagues conclude. "The possibility that HIV infection increases susceptibility to and/or accelerates COPD deserves further investigation and has implications regarding the pathogenesis of COPD."
Botulism Outbreak in Four Receiving Unlicensed Botox
Suspended clinician injects self, three others with concentrated, research-only toxin
Four cases of botulism occurred when a suspended clinician used an unlicensed preparation of botulinum toxin A for cosmetic purposes, with some patients receiving doses more than 40 times the estimated lethal dose in humans, according to the Nov. 22/29 issue of Journal of the American Medical Association.
Daniel Chertow, M.D., M.P.H., of the U.S. Centers for Disease Control and Prevention in Atlanta, and colleagues studied the clinical aspects of four patients given unlicensed, "for research use only" botulinum toxin A in November 2004 by a suspended clinician. One of the patients was the clinician himself.
All patients reported clinical symptoms consistent with naturally occurring botulism, including progressive weakness and cranial neuropathies affecting facial movements and swallowing. Two of the patients reported shortness of breath and all required mechanical ventilation at some point. While pretreatment serum toxin levels ranged from 21 to 43 times the lethal dose, the investigators suspect some of the patients may have received doses up to 2,857 times the estimated lethal dose by injection.
"Physicians and patients must be aware of the hazards associated with illegitimate use of unlicensed botulinum toxin products," the authors write. "Only licensed products should be used clinically. Entities inappropriately marketing, selling, or using unlicensed botulinum toxin products should be sought and subjected to full criminal and civil penalties."
Oral Rinse Cuts Nosocomial Infection After Cardiac Surgery
Decontamination of nasopharynx and oropharynx seems to decrease respiratory and surgical site infections
Cardiac surgery patients who undergo chlorhexidine gluconate decontamination of the nasopharynx and oropharynx have lower rates of post-surgery nosocomial infections, including lower respiratory tract and surgical site infections, according to the results of a study published in the Nov. 22/29 issue of the Journal of the American Medical Association.
Patrique Segers, M.D., of the University of Amsterdam in the Netherlands, and colleagues evaluated the incidence of nosocomial infection, the Staphylococcus aureus rate in the nasal carriage, as well as the length of hospitalization in 954 patients (485 chlorhexidine group, 469 controls) having open heart surgery between August 2003 and September 2005. Patients used an oral rinse and nose ointment four times daily from the time they entered the hospital to soon after the surgery.
In the chlorhexidine gluconate group, 96 patients (19.8 percent) had 116 nosocomial infections compared to 123 controls (26.2 percent) who had 164 infections. The lower respiratory tract infection rate was 9.3 percent in the treated group and 15.8 percent for controls, resulting in an absolute risk reduction of 6.5 percent. The rate of surgical site infection was not significantly different. However, nine treated patients (1.9 percent) had deep surgical site infections compared to 24 controls (5.1 percent), a 3.2 percent absolute risk reduction. Hospitalization was 9.5 days for the treated patients and 10.3 days for controls.
"This safe and inexpensive disinfectant is effective in decontaminating the nasopharynx and oropharynx and should be considered in the preoperative preparation of a patient undergoing cardiac surgery," the authors conclude.
Trial Questions Benefits of Herniated Disc Surgery
SPORT trial shows limited benefit of surgery compared with non-operative treatment
The benefits of surgery compared with non-operative treatment for lumbar disc herniation appear to be limited, or at least inconclusive, according to two reports in the Nov. 22/29 issue of the Journal of the American Medical Association.
James Weinstein, D.O., M.Sc., of Dartmouth Medical School in Hanover, N.H., and the Spine Patient Outcomes Research Trial (SPORT) investigators found that 472 patients with lumbar disc herniation randomized to either surgical or non-operative treatment had similar improvements in clinical outcome after two years. Adherence to treatment was limited and slight improvements from surgery were found to be statistically insignificant.
In a second observational study of SPORT that included 743 patients initially refusing randomization, surgery showed improvement in bodily pain, physical function and disability index at three months compared with usual care. The differences narrowed after two years, however, and the authors caution against interpretation of non-randomized self-reported outcomes.
"These findings suggest that in most cases there is no clear reason to advocate strongly for surgery apart from patient preference," writes Eugene Carragee, M.D., of Stanford University Medical Center in Stanford, Calif., in an accompanying editorial. "For the patient with emotional, family and economic resources to handle mild or moderate sciatica, surgery may have little to offer."
Majority of Physicians Take on Public Roles
Community activities and collective advocacy viewed as very important by most
About two-thirds of physicians report being actively involved in public roles related to the community, including political involvement and collective advocacy, according to study findings published in the Nov. 22/29 issue of the Journal of the American Medical Association.
Russell Gruen, Ph.D., of the University of Melbourne in Victoria, Australia, and colleagues mailed surveys to 1,662 primary care and non-primary care specialist physicians in the United States to determine their views on the importance of community participation, political involvement and collective advocacy, how often they assumed a public role and what factors were related to these activities.
More than 90 percent of respondents rated public activities as important, with a majority rating community activity and collective advocacy as very important. Two-thirds of respondents reported participating in one of the three types of public roles within the last three years. Age, female sex and graduation from a non-U.S. or non-Canadian medical school were linked to assigning high importance to public participation.
"A variety of personal, professional and practice characteristics may influence physicians' civic mindedness and civic activity," the authors conclude. "Confirming and understanding these potential influences could provide important guidance to leaders and policy makers who want to enlist the positive energy of physicians in promoting public health at a societal level."
Support Can Ease Stress for Ethnic Dementia Caregivers
Multifaceted interventions improve quality of life for Hispanic and white caregivers
Hispanics and whites, but not blacks, who care for relatives with dementia have significant quality-of-life improvements when supported by a multifaceted intervention that includes in-home and telephone discussions, researchers report in the Nov. 21 Annals of Internal Medicine.
Steven H. Belle, Ph.D., of the University of Pittsburgh Medical Center, and colleagues evaluated caregiver quality of life and clinical depression in a randomized, controlled trial of 212 Hispanic, 219 white and 211 black dementia caregivers. The six-month intervention included dealing with caregiver depression, self-care and social support using in-home and telephone discussions. Controls received two short telephone calls.
In the intervention group, Hispanic and white caregivers, but not blacks, had statistically significant increased quality of life improvement compared to controls. However, black spouse caregivers did report improved quality of life. Clinical depression was lower in the intervention group (12.6 percent) than in controls (22.7 percent).
"A structured multicomponent intervention adapted to individual risk profiles can increase the quality of life of ethnically diverse dementia caregivers," the authors conclude.
Avian Flu Clusters Found in Turkey and Indonesia
Studies raise question about viral evolution toward consistent human-to-human transmission
Clusters of human H5N1 virus infection have been identified in Turkey and Indonesia, although the diagnoses in Turkey were at first difficult to make, according to two studies published in the Nov. 23 issue of the New England Journal of Medicine.
Ahmet Faik Oner, M.D., of Yuzuncu Yil University in Van, Turkey, and colleagues diagnosed eight patients aged 5 to 15 years with H5N1 virus infection who had a history of close contact with diseased or dead chickens. All had fever and seven had evidence of pneumonia, though initial influenza tests were negative, leading researchers to conclude that H5N1 can be difficult to diagnose. Four patients died.
I. Nyoman Kandun, M.D., M.P.H., of the Directorate General of Disease Control and Environmental Health in Jakarta, Indonesia, and colleagues investigated three clusters of H5N1 virus infection that affected eight patients (median age 8.5 years) and resulted in four deaths. In each cluster, the researchers found that infected patients were members of the same family, and most lived in the same home.
"The continuing evolution of H5N1 viruses and the clusters of human infections in Indonesia and Turkey raise important questions," state the authors of an accompanying editorial. "First, can the source of H5N1 be eliminated? And second, is the increasing number of clusters of human infection an indicator of evolution toward consistent human-to-human transmission?"
Researchers Question Benefit of Fetal Oximetry
Clinician knowledge of fetal oxygen saturation has no effect on Caesarean rates or infant outcomes
Clinician awareness of fetal oxygen saturation does not lead to a reduced rate of Caesarean delivery or improvements in the condition of newborns, researchers report in the Nov. 23 issue of the New England Journal of Medicine.
Steven L. Bloom, M.D., of the University of Texas Southwestern Medical Center in Dallas, and colleagues randomly assigned 5,341 nulliparous women who were at term and in early labor to either "open" fetal pulse oximetry, in which fetal oxygen saturation values were displayed to the clinician, or "masked" fetal pulse oximetry, in which hidden values were recorded by a computer.
The researchers found similar rates of Caesarean delivery between the open and masked groups (26.3 percent and 27.5 percent, respectively) and no significant group differences in the condition of the infants at birth.
"Low oxygen saturation, although common in women with fetal heart-rate abnormalities, was also quite frequent in women with normal fetal heart-rate patterns," the authors write. "These results may explain our finding that fetal oximetry was of no benefit as an adjunct for the interpretation of electronic fetal heart-rate patterns."
"This case does offer the opportunity to discuss the appropriate role of the Food and Drug Administration in approving new medical devices," states the author of an accompanying editorial.
Bivalirudin Monotherapy Benefits Cardiac Patients
Study supports use of bivalirudin as a substitute for heparin plus glycoprotein IIb/IIIa inhibitors
In patients with moderate- or high-risk acute coronary syndromes, treatment with bivalirudin alone is associated with similar rates of ischemia, significantly lower rates of bleeding and an improved net outcome compared to heparin plus glycoprotein IIb/IIIa inhibitors, according to a study in the Nov. 23 issue of the New England Journal of Medicine.
Gregg W. Stone, M.D., of the Columbia University Medical Center in New York City, and colleagues assigned 13,819 patients with acute coronary syndromes to one of three antithrombotic regimens: unfractionated heparin or enoxaparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin plus a glycoprotein IIb/IIIa inhibitor, or bivalirudin alone.
A nominal 7 percent decrease in bleeding events was seen with bivalirudin, plus a glycoprotein IIb/IIIa inhibitor offset the nominal 7 percent increase in ischemic events. A significant 47 percent reduction in bleeding with bivalirudin monotherapy offset the non-inferior 8 percent increase in ischemic events and produced a small but significant 14 percent reduction in net clinical outcomes at 30 days.
"The ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial provides strong support for the use of bivalirudin as a substitute for heparin plus glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndromes who undergo early invasive management, in particular if they are pretreated with clopidogrel," states an accompanying editorial.
The study was supported by the Medicines Company and Nycomed.
Switch to Anastrozole Helps Breast Cancer Survival
Benefit observed for postmenopausal women who switch to anastrozole after two to three years of tamoxifen
Women with breast cancer who switch to anastrozole after two to three years of treatment with tamoxifen have improved event-free and overall survival, possibly avoiding side-effects and drug resistance associated with tamoxifen, according to a report published online Nov. 17 in The Lancet Oncology.
Walter Jonat, M.D., from the University of Kiel in Germany, and colleagues performed a meta-analysis of three clinical trials including 4,006 postmenopausal women with hormone-sensitive early-stage breast cancer. The women had been treated with tamoxifen for two to three years and had either switched to anastrozole (1 mg/day) or had continued 20 to 30 mg/day of tamoxifen, for a total of five years.
The researchers found that switching to anastrozole significantly improved disease-free, event-free, distant recurrence-free, and overall survival (hazard ratios 0.59, 0.55, 0.61, and 0.71, respectively).
"These findings confirm that clinicians should consider switching postmenopausal women who have taken adjuvant tamoxifen for two to three years to anastrozole," Jonat and colleagues conclude.
The study was funded by AstraZeneca.
Prepared jointly by the editors of Medical Economics and HealthDay's Physicians' Briefing (www.physicianbriefing.com).


text:
DERMAL FILLER TREATMENTS
PRE-POST CARE INSTRUCTIONS
Welcome to self-love and thank you for taking the time to read over the most important part of your treatment-pre and post-care instructions. Please alert the office if you have any symptoms not listed here and if you feel any concerns about a symptom you are experiencing at 416-238-6773.
Please allow 14 days to realize the full result of this treatment. Dermal filler is a smooth injectable gel containing hyaluronic acid. Hyaluronic acid is a naturally occurring substance that is found within all mammals and its material is contained in various soft tissue. It does this by filling the space of volume loss which improves folds and wrinkles, as well as attracting water to replenish moisture to your skin. Filler restores volume loss and fills naturally occurring static lines. Lots of water is recommended to keep long-lasting results.
PLEASE ENSURE YOU HAVE A LIGHT SNACK AND PLENTY OF FLUIDS PRIOR TO TREATMENT. PLEASE ADVISE US IF YOU HAVE A HISTORY OF FAINTING SPELLS.
1. PRECARE (a) do not consume alcohol at least 24 hours before treatment.
(b)schedule your filler appointment at least 2 weeks prior to a special event and vacation.
(c) discontinue Retin-A 2 days before and 2 days after treatment.
(d) if you are receiving a history of cold sores advise the office so the MD can prescribe Valtrex prior to your appointment.
(e) no dental work 2-4 weeks pre and post-treatment
(f) no active acne, skin irritations or skin inflammation
(e) avoid the following pre and post-treatment 7 days or up to 2 weeks prior to the appointment: avoid anti-inflammatory, blood thinning medication and diabetic meds, Advil, Aspirin, Motrin, Ibuprofen, Motrin, Aleve and other NSAIDS meds, Vitamins- avoid Vitamin E, Garlic, Ginkgo biloba, ginseng, St. John's Wart, Omegas 3/6/9, salmon oil, dark chocolate, grapefruit. As listed above will increase your risk of bruising and swelling at the injection site. Any autoimmune disease of the following should be reported to the health care provider Rheumatoid Arthritis, Lupus, ScIeroderma, no breastfeeding/pregnancy, objection to human albumin. Vaccine timeline ie: Covid vaccine -2 weeks before/after, reschedule your treatment if you are on antibiotics- 2 weeks after medication is finished.
2. POST-BARE FIRST HOUR AFTER FILLER THE FOLLOWING MAY APPEAR: redness, bruising, swelling, red pinpoint pokes(needle marks), mosquito bites, tenderness, itchiness at the site, asymmetries,
3. POST-CARE SHOULD NOT APPEAR: bumps, blisters, edema, vision changes (contact office a.s.a.p.), referring pain, skin discolouration (scarring, pale white —blanching, blotchy, deep bluish, greyish hue known as Tyndall effect), sudden dramatic bruising, do a pinch the skin test-if skin takes time to bounce back, skin feels chilled at or around the injection site, rash, cellulitis (infections) granulomas, visual you can see the filler material, hypersensitivity (allergic reaction) migration of filler.
4. POST-CARE- Avoid hot beverages for 4 hours after lip filler. The lidocaine in filler needs time to wear off, remain upright do not lie down,
5. POST-CARE- Avoid for 24 hours - alcohol, strenuous exercising, no hot-tubs, no hot yoga, no hot
baths, steam room, sauna, sunbathing, no hot wax, no extremely cold outdoor sports, no harsh scrubs/facial products, if you are getting lip fill you must purchase a NEW lip balm to avoid a bacterial infection-do not use or apply lipstick, avoid being scratched by pets around or at the injection site, and avoid touching the injection site.
6. POST-CARE- Avoid for 2 weeks- laser treatments, chemical skin peels, microdermabrasion, derma planning, and micro-needling.
If you are concerned with bruising and/or bruising easily please inform us and we will recommend Arnica ointment or gel. You can purchase Arinca at MDs on The Queensway, local pharmacy, Sage. Pineapple juice has been studied to break down the by-products of hemoglobin in your blood and minimize visible bruising.
Apply a light cold compression or ice pack- 10 mins on 15 mins off. 3 to 4 x daily up to 48 hours. Minimize movement of the treated area, however if there is a visible bump/lump you can massage
the area with clean hands. The product will soften within a few days naturally into the skin. Protect the skin by wearing sunscreen daily. Makeup can be applied only in areas not treated.
CONTRADICTIONS: (a) If you have an allergic reaction to avian products or eggs and have sensitivity to gram-positive bacteria proteins you should not be receiving filler with hyaluronic acid.
(b) If you had hyaluronic acid fillers you cannot mix Juvederm's Vycross line.
(c) You cannot receive filler if you have implants in the area being treated.
(d) If you are pregnant or breastfeeding
(f) Any allergies to lidocaine — as the filler has lidocaine mixed with hyaluronic acid
The results of dermal filler are best with a regular and continued self-care routine at LOTUS by MDs@ QUEENSWAY EMPHASIS THE IMPORTANCE OF COMMUNICATION AND FRBILIENCY FOLLOW-OP MINI CARE Be sure to schedule your next appointment within 3-4 months to help sustain the desired level of correction and 2 weeks follow-up appointment to discuss your future care plan and desired outcomes. I understand that this is a cosmetic treatment and payment is my responsibility. There is a fee for every injection procedure.

domain: medical


Skip to main content
7: Continuous-Time Models II - Analysis
- Last updated
Save as PDF
- 7.1: Finding Equilibrium Points
- Finding equilibrium points of a continuous-time model dx/dt = G(x) can be done in the same way as for a discrete-time model, i.e., by replacing all x’s with xeq’s (again, note that these could be vectors). This actually makes the left hand side zero, because xeq is no longer a dynamical variable but just a static constant. Therefore, things come down to just solving the following equation
- 7.2: Phase Space Visualization
- A phase space of a continuous-time model, once time is discretized, can be visualized in the exact same way as it was in Chapter 5, using Codes 5.1 or 5.2. This is perfectly ﬁne. In the meantime, Python’s matplotlib has a specialized function called streamplot, which is precisely designed for drawing phase spaces of continuous-time models.
- 7.3: Variable Rescaling of Continuous-Time Models
- Variable rescaling of continuous-time models has one distinct difference from that of discrete-time models. That is, you get one more variable you can rescale: time. This may allow you to eliminate one more parameter from your model compared to discretetime cases.
- 7.4: Asymptotic Behavior of Continuous-Time Linear Dynamical Systems
- A general formula for continuous-time linear dynamical systems is given by dx /dt = Ax, where x is the state vector of the system and A is the coefﬁcient matrix. As discussed before, you could add a constant vector a to the right hand side, but it can always be converted into a constant-free form by increasing the dimensions of the system, as follows:
- 7.5: Linear Stability Analysis of Nonlinear Dynamical Systems
- Finally, we can apply linear stability analysis to continuous-time nonlinear dynamical systems.


text:
Baildon Heritage Trails
Here you will find links to the text and in many cases images of walks around Baildon.
In 2008 the Baildon Local History Society contacted Baildon Parish Council and asked about producing Heritage Trail booklets based on the walks that the History Society sometimes conducted people on. The History Society showed examples of what they had put together. Baildon Parish Council agreed to fund the the first batch of booklets.
The first six walks (printed in Nov 2009 by Moorprint at a cost of £695) were made available, free of charge, from various places in Baildon including the library. Demand was high and the first 600 had all gone within 3 weeks. After a reprint the booklets were made available from the library at a price that just covered the cost of the printing - £1 each.
PDF versions of these walks were made available from their website and Baildon Town Council have continued this. You can find these files in their document management system here. The Town Council website may change over time so if that link doesn't work you may need to search for them. The latest version should always be somewhere on the Town Council website but I have made versions available from here. Each entry below has a link to a local PDF file if I have been able to get one.
The pages linked to in the wiki below will contain the text of the booklets and should also include the images but the intention is that they will include links to other pages to create a wider experience for the visitor. (This may be limited to the ones that Paul Marfell worked on.)
- Railway Walk Heritage Trail - the arches at Woodbottom to the great Viaduct at Tong Park. A PDF version of this is available here.
- The Turnpike Walk Heritage Trail - takes you between the old turnpike road milestones on Otley Road. A PDF version of this is available here.
- Kirklands Walk Heritage Trail - St John's Court to St James;s, Kirklands and Hoyle Court. A PDF version of this is available here.
- Baildon Village Walk Heritage Trail - visits the old lanes, folds and corners around the centre of Baildon. A PDF version of this is available here.
- Riverside Walk Heritage Trail - will take you from Roundwood Road to Charlestown centre along the River Aire. A PDF of the 2018 version is available here or the older 2009 version here.
- The Charlie Thompson Walk Heritage Trail - takes you round the places of interest around the St John's Court area of Charlestown. A PDF version of this is available here.
- Threshfield and Low Baildon Walk - from Brook Hill Stores to Threshfield and back. A PDF version of this is available here.
- The Ferniehurst and Baildon Green Walk - A walk looking principally at the sites of two Victorian mansions with Salt family connections. A PDF version of this is available here.
- Lost Hamlets Walk - This walk is in two loops: the first visits some of the hamlets which used to thrive on the edge of Baildon Moor; the second looks at some of the the history and archaeology on the higher reaches of the Moor itself. A PDF version of this is available here.
- Coach Road to Shipley Glen - A walk from Higher Coach Road through woods up into Shipley Glen and the Bracken Hall Centre, and back. A PDF version of this is available here.
- The Salt Market Walk - Sconce, Birch Close and Faweather by old lanes. A PDF version of this is available here.
The Baildon Local History Society have also released some of the walks that will probably not be made available in the same way but can be read here.
- Baildon Moor Walk
- Baildon Green Walk
- Shipley Glen and Trench
- Shipley Glen and Milner Field
- The Baildon Peace Walk - a walk to see the three war memorials. This was produced in conjunction with Baildon Community Link. A PDF version of this is available here.
- Exploring Baildon - A Guide to Public Open Spaces. People from the local history society were involved in this but it was commissioned by Baildon Town Council in 2015. PDF version is available here.
- Parish Council Minutes

domain: library


text:
Friday, April 13, 2012
Medellin what a great place to experience so much. First and foremost everyone I've talked to since I've been in Colombia they have all been asking if it is safe in Colombia? Answer: Yes... but if you want to find trouble, like anywhere in the world, you will find it! So that is why I don't go searching for trouble. I look for good people and good times and I find them. Here are some things to do in Medellin if you decide to travel there, which you should. First off I stayed in Zona Rosa in Poblado which is where there are a ton of hostels, hotels and restaurants. A special shout out to Alejandro at Saman Hostel on Calle 10 y Carrero 36. One of the best hostels I stayed in during my whole trip. I took a trip up the Metro Cable to the favella and to the library there and then further up to the National Park up top which was very beautiful and had a great market with amazing food for next to nothing. I also went to Botero Square in El Centro at Parque Berrio which was really cool and had some cool sculptures. I alllso recommend hitting up Salsa Dancing on Tuesday or Wednesday nights in El Centro circa de Parque Periodista. The place was packed but it was a great time inside the bar and there was a party out on the street as well. If you do stay in Zona Rosa hit up the Medellin Beer Factory for some great Colombian Beer and some great Chicken Wings. From Medellin I took off for Salento that will be in the next update.

domain: geography


text:
In this issue we bring the AtmA shrsti kathnam chapter from the jnAnA yOga khANDam of sUta samhitA. This chapter explains in detail the manifestation of the AtmA. A hymn by bruhaspati towards shivA is included in this chapter.
From this issue, we will be starting a new section to give a word by word meaning of dhyAna shlokAs so that it will be helpful for the upAsakAs to understand the physical form of the dEvatA during their meditation.
We thank ShrI yOgAmbA samEta AtmAnandanAthA (Shri Ramesh Kutticad) for authoring the Q&A section.
Lalithai vEdam sarvam.
Click here to download


text:
3.5 x 3.5 inch punch needle, background crochet thread
The little dolls have a new punch needle rug.
|Alas, January 2021 this Michaels is closing |
Today, October 25, 2009 a Michaels opened in Manhattan. Here is the story of my visit. The store is located on Columbus Avenue near 100 St. I took the 1 train to 103 St. The 231 St. station is where I began my trip.
Fabric from City Quilter

domain: artistic


text:
Before we even meet her in Hush, Hush, death has impacted Nora's life in a major way since her father was murdered. For much of the book, she tries to sweep all discussion of his death under the rug, shutting down questions whenever they arise. Nevertheless, brushes with death continue to creep into the story, and by the end, Nora is forced to contemplate her own death. She doesn't want to die, but when the time comes, she accepts her fate and takes her death into her own hands, throwing herself from the rafters. In this moment, she confronts and accepts mortality.
Also important in the mortality theme is the fact that Patch, an immortal, wants to become a mortal human. Unlike, say, Voldemort, Patch finds mortality more attractive. Poor dude never gets his wish, though. Instead of becoming human, he morphs into Nora's guardian angel, a job which includes staving off death. In an interesting twist, then, once Nora accepts her mortality, she no longer has to worry about dying because she has her own personal guardian angel to keep death away from her.
Questions About Mortality
How do you interpret Nora's many near misses with death? How do her repeated interactions with death shape her character and your understanding of her character? Why?
Why isn't more time spent on Nora's father's murder? What does it mean that his murder hangs out in the background of the story?
Why does Patch want to become human? What is the appeal of a mortal human life over an immortal life?
What does Patch's immortality versus Nora's mortality mean for their relationship?
Chew on This
As Patch's desire to become human suggests, being mortal is better than being immortal.
Death itself isn't frightening; only violent and unexpected death is.


text:
Judicial externships allow students, beginning the summer after their 1L year, to work in the chambers of a state or federal judge. These externships provide an opportunity for students to experience intellectual property practice in a real-world setting. They are also a chance for students to utilize their legal skills by assisting the Judge and his/her law clerks with legal research and the preparation of draft briefs for use in court. For instance, Judge Randall Rader, Chief Judge of the United States Court of Appeals for the Federal Circuit in Washington, D.C., is very open to judicial extern applications from both Utah & BYU. Recently, PDO, SIPLA & Whit Johnson from Stoel Rives, LLP, hosted a panel on Careers in IP with a focus on judicial externships. The panelists—practicing IP attorneys and Professor Amelia Rinehart—provided the following tips for students regarding judicial externships with the Federal Circuit, including those with Judge Rader:
- Students should apply early—for summer, apply as soon as you can beginning in January!
- Clerks play an active role in the hiring process for judges on the Federal Circuit, so if you can talk to a current or former clerk about what to highlight, all the better.
- Indicate whether you have taken the Patent Bar.
- Define in your cover letter exactly when you are available. Some judges offer 4-6 week externships, allowing you to complete both an externship as well as a legal opportunity elsewhere during the same semester.

domain: law


text:
Oats cereal recipe for babies
Oats cereal recipe for babies with step by step pictures.
Servings 1 cup
*It is advisable to avoid sweeteners till the baby turns 1 year
For the porridge:
Take oats cereal mix in a pan, add water to it and start cooking.
Cook in low flame. It will start getting thick.Add sweetner if you are adding at this stage.
Cook till the porridge coats the ladle, adjust consistency according to your baby's preference.Serve warm!
- Roasting helps in adding flavour to the mix also gives more shelf life.
- Can be stored and used for a month in room temperature
- Keep changing the texture of the food, start with smooth purees and porridges slowly change it to coarse then biting texture so that the baby get used to eat varieties.

domain: food


text:
product description page
Dog Grooming for Dummies (Paperback) (Margaret H. Bonham)
About this item
Brush, bathe, and clip your dog like a pro!
Whether your dog is destined for a career in the show ring or a spot on the living room couch, good grooming is important. This friendly guide shows you how to develop a grooming routine that will keep your dog clean - and strengthen the bond between you. It includes detailed, step-by-step grooming instructions for all types of coats.
Discover how to
- Train your dog for grooming
- Care for nails, teeth, and ears
- Use clippers and scissors
- Groom specific types of coats
- Prepare a dog for the show ring
The fun and easy way to keep a dog looking clean, neat, and healthy
This year, Americans will spend $8.8 billion for supplies for their pets, including grooming aids and services. Now, Dog Grooming For Dummies shows readers how to get professional results at home. Featuring step-by-step instructions and a coat-specific grooming guide for over 150 breeds of dog, this friendly guide covers basic grooming for good health, the latest grooming equipment, bathing, nail care, skin care, and dental care for dogs. Plus, there’s also helpful advice on how to become a professional groomer and breed-specific tips on grooming dogs for competition.
Margaret H. "Maggie" Bonham (Conifer, CO) is an award-winning professional dog writer and trainer. She has worked as a vet tech, grooming dogs for clients, and has groomed dogs for show.

domain: pet


text:
LG just announced its latest Full HD SMART Monitors – the W53 series. Expected to be available around the globe this month, the monitors are available in sizes range between 18.5 and 27 inches. Highlights: Auto Brightness, Cinema Mode, up to 50,000:1 contrast ratio, a 2ms response time, and more.
“LG conducted extensive research throughout Europe and Asia, and learned that one major complaint people had about their monitors was eyestrain from the screen being either too bright or too dark,” said B.B. Hwang, President and CEO of LG Electronics Business Solutions Company. “Because of this, LG’s W53 SMART Monitors are packed with the world’s first full suite of intelligent features that optimize the screen’s brightness to reduce eyestrain. This also significantly reduces power consumption by lowering the intensity of the backlight.”

domain: news


text:
This week marks six months since the Rocky shut down, and to commemorate the occasion, IWantMyRocky.com is publishing a series of pieces on the subject, beginning with one from Humphreys entitled, "Six Months After the Final Edition, What Have We Learned?" Her view: "Journalists cannot be objective about our right to exist. We must engage the forces that put profit ahead of public service, and we must do it by taking an active, informed role in shaping public policy and the business practices of our industry." But she doesn't see these statements as the final words on the subject. On Thursday at 3 p.m. Mountain Time, she'll join other blog authors for a live chat co-sponsored by IWantMyRocky.com and a partner site, SaveTheNews.org. The idea is to discuss where newspapering is headed next.
Here's hoping the answer won't be "oblivion."


text:
This exciting little canvas tent with a door is a great home for your bird to sleep, hide, play, and nest in. It has java wood slices and small rattan balls hung with a chain on inside & outside of tent for added fun! Great for small size birds to sleep, hide & nest.
This toy won Best Bird Product at the 2010/2011 world renown SuperZoo trade show!
Sm Tinker Tent-A&E Java Wood measures: approx. 9" tall x 6" wide and has a door that is 3" diameter (Recommended for small sized birds)


text:
The LEAF Team is pleased to announce the latest posted article to the Library of Educational Articles Feature (The LEAF).
This time, it is the Art of War - Tomb Kings which finally sees the light of day. We hope this article will help you understand, visualize and beat the armies of the foul Undead.
As always, the article may contain spelling errors, grammatical errors and other flaws. If you find any, this thread is the best place to report them and the LEAF Team will fix them as soon as possible.
Thanks for reading!


text:
In GRIFF's Prayer, he explains that he heard a hilarious conversation in the grocery store.
In this edition of GRIFF's Prayer, GRIFF explains how powerful he feels when he rides his bike.
As one year turns into another, there is always that problem of the new year’s resolution. While some people won’t even cosign on the concept, others find themselves tasked with the objective of picking a resolution that will push them to grow, while also avoiding setting unrealistic goals for themselves. In this edition of GRIFF’s […]
In this edition of GRIFF’s Prayer, GRIFF opens up to God about his pettiness. He explains that he tends to retaliate in a petty manner when he doesn’t get his way, or feels wronged by others. He knows he’s not alone in his pettiness, either. So he decides to dedicate this prayer to all the […]

domain: literature


text:
Glens Falls Hospital has received the designation as a Center of Excellence for Alzheimer’s Disease by the state Department of Health to serve the Northeastern region of the state.
It is one of 10 such centers in New York State.
Funded through a five-year, $2.1 million grant, the center offers an interdisciplinary approach to diagnose and manage Alzheimer’s Disease and other dementias. The program’s mission is to identify the disease early in its progression, provide education to patients, families, and caregivers, and offer updates to physicians on diagnostic procedures.
For people experiencing symptoms of dementia, an initial consult with the Glens Falls Neurology team occurs and a series of baseline assessments are administered.
Depending on the individual’s need, additional visits to other areas of the program might be warranted. These include neuropsychology and geriatric psychiatry, all of which are located in one centralized location.
The center also accepts patients with an existing diagnosis who require additional services.
Once a diagnosis is made, it is important for planning to occur. Embedded in the program is a care manager who meets with patients and families to discuss priorities and to provide framework on what to expect.
The center collaborates with community entities to link patients and caregivers to the many resources that are designed to assist patients and families affected by the disease. These resources range from available clinical trials to legal counsel for estate planning and elder law, to options for home care, respite care, skilled and long-term facilities, as well as caregiver support groups.
“As an organization, we have been extremely fortunate to have great talent, capable of serving this patient population,” said Heather O’Connor, program director, Center of Excellence for Alzheimer’s Disease. “The designation and funding by the Department of Health helps to transform these resources into an interdisciplinary program, providing a breadth of diagnostic skill and care management to support patients and their families.”
The Center of Excellence for Alzheimer’s Disease is located at Glens Falls Hospital on the third floor of the Pruyn Pavilion. Appointments can be made by physician referral or directly by patients and family members by calling (518)-926-2940.
The office recommends that relevant notes, imaging and laboratory results be obtained from the patients’ primary care provider, in advance of the initial visit and that patients are accompanied by a family member, friend or care companion where possible.
For more information, please visit www.glensfallshospital.org/AlzheimersCenter.


text:
Tesla Inc.’s decision to restrict employees from wearing pro-union shirts was unlawful, the National Labor Relations Board or NLRB ruled.
In a 2017 dispute between the luxury electric car maker and the United Automobile Workers or UAW union, the board said the company violated labor law by restricting display of union insignia, including wearing union apparel.
In the ruling, Chairman Lauren McFerran and Members Wilcox and Prouty found that it was unlawful for Tesla to maintain a policy requiring employees to wear a plain black t-shirt or one imprinted with the employer’s logo. This prohibits employees from substituting a shirt bearing union insignia.
In a statement, the independent federal agency reaffirmed longstanding precedent holding that employer attempts to impose any restriction on the display of union insignia, including by wearing union apparel, are presumptively unlawful, absent special circumstances that justify such a restriction.
The Board said the employer has the burden to establish special circumstances that make the rule necessary to maintain production or discipline, but Tesla failed to establish special circumstances in this case.
In its latest ruling, the Board overruled Wal-Mart Stores, Inc., 368 NLRB No. 146 (2019) that allowed the retail giant to limit employees from wearing pro-union insignia at work.
Wal-Mart Stores had previously held that the “special-circumstances” test applies only when an employer completely prohibits union insignia, and that lesser size-and-appearance restrictions on union insignia could be deemed lawful based on less compelling employer interests.
McFerran said, “Wearing union insignia, whether a button or a t-shirt, is a critical form of protected communication. For many decades, employees have used insignia to advocate for their workplace interests – from supporting organizing campaigns, to protesting unfair conditions in the workplace – and the law has always protected them. With today’s decision, the Board reaffirms that any attempt to restrict the wearing of union clothing or insignia is presumptively unlawful and – consistent with Supreme Court precedent – an employer has a heightened burden to justify attempts to limit this important right.”
The NLRB had reportedly ruled earlier that Tesla CEO Elon Musk violated labor laws with his tweet regarding Tesla workers’ stock options.
Source: Read Full Article


text:
MOIN Akhter, who died on this day in 2011, ruled over the hearts of people through his brilliant acting, stand-up comedy and unique hosting of TV shows. He is considered one of the most versatile actors of Pakistan’s showbiz industry and a fine human being who was always willing to go the extra mile for the less unfortunate.
Moin could perform emotional characters with equal ease and ability while his humour and wit brought laughter to millions of faces over decades. There is no doubt he was the complete entertainer.
His teaming up with veteran Anwer Maqsood gave the people many masterpieces like ‘Loose Talk’, ‘Angan Tera’, ‘Half Plate’, ‘Studio Dhai’ and many more.
Moin’s acting and hosting skills had many admirers in India as well. The legendary Dlip Kumar greatly admired Moin who will always be remembered for his qualities of head and heart.
Kamran Khamiso Khowaja
Published in Dawn, April 22nd, 2019

domain: celebrity


text:
Winter fun in Rosemont! Complete with ice skating, hockey games and more. Free holiday fun for the whole family!
Open skate during hockey hours
Sundays: 2pm - 10pm
Dates: January 28th, February 4th, 18th and 25th
President’s Day, Feb. 19th: 2pm - 10pm
Chicago Wolves Practice Feb. 11th
The Chicago Wolves will be practicing in the park from 3pm - 4pm.
Open skating will resume at 4:30pm - 10pm

domain: hobby


text:
Higher expenses weighed on the results of American Tower, which posted sharply lower third-quarter earnings.
The company earned $180.1 million, or 45 cents per share, down from earnings of $232.1 million, or 58 cents per share, in the 2012 third quarter..
Adjusted Funds From Operations increased 24 percent to $367.3 million, from $295.3 million last year. FFO is considered a key financial measure for real estate investment trusts like American Tower. It adds back such items as amortization and depreciation to net income.
Analysts, on average, expected FFO of 91 cents per share, according to FactSet.