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Introduction.
For many decades treatment of an acute disease or a chronic illness has been mostly accomplished by delivery of drugs to patients using various pharmaceutical dosage forms, including tablets, capsules, pills, suppositories, creams, ointments, liquids, aerosols, and injectables, as drug carriers. This type of drug delivery system is known to provide a prompt release of drug or immediate release product. Such immediate release products result in relatively rapid drug absorption and onset of accompanying pharmacodynamic effects. However, after absorption of drug from the dosage form is complete, plasma drug concentrations decline according to the drug’s pharmacokinetics profile. Eventually, plasma drug concentrations fall below the minimum effective plasma concentration (MEC), resulting in loss of therapeutic activity. Before this point is reached another dose is usually given if a sustained therapeutic effect is desired. An alternative to administering another dose is to use a dosage form that will provide sustained drug release, and therefore, maintain plasma drug concentrations, beyond what is typically seen using immediate release dosage forms1,2.
The basic rationale of a sustained drug delivery system is to optimize the Biopharmaceutic, Pharmacokinetic and Pharmacodynamic properties of a drug in such a way that its utility is maximized through reduction in side effects and cure or control of condition in the shortest possible time by using smallest quantity of drug, administered by the most suitable route
The novel system of drug delivery offer a means of improving the therapeutic effectiveness of incorporated drugs by providing sustained drug delivery to desired site. The goal of sustained drug delivery system is to provide a therapeutic amount of drug to the proper site in the body to achieve promptly and then maintain the desired drug concentration5. Typically, sustained release products provide an immediate release of drug that promptly produces the desired therapeutic effect, followed by gradual release of additional amounts of drug to maintain this effect over a predetermined period3.
A matrix is a uniform mixture of drug and excipients. e.g. polymer that is homogeneously fixed in solid dosage form.A hydrophilic matrix controlled release system is a dynamic system composed of polymer wetting, polymer hydration and polymer dissolution. At the same time other soluble excipients or drug will also wet, dissolve and diffuse out of the matrix while insoluble materials will be hold in place until the surrounding polymer/ excipients / drug complex erodes or dissolves away4.
Monolithic devices or matrices represent a substantial part of the drug delivery systems. Matrices containing swellable polymers are referred to as hydro gel matrices, polymeric matrices involving moving boundaries, hydrocolloid matrices, swellable controlled release systems or hydrophilic matrix tablets. Whereas interactions between water, polymer and drug are the primary factors for release control, various formulations variables, such as polymer grade, drug/polymer ratio, drug solubility, and drug and polymer particle size, can influence drug release rate to greater or lesser degree5.
Material and method
Materials
Tramadol Hydrochloride, Hydroxy Propyl Methyl cellulose K 100 M, Hydroxy Propyl Methyl cellulose K 15 M, Hydroxy Propyl Methyl cellulose K4M, Lactose, Microcrystalline cellulose (Avicel pH 101), PVP K 30, Magnesium Stearate, Talc was obtained as laboratory sample from Merck chemicals pvt. Ltd.
Method
Wet Granulation Method
Weight accurately Drug + HPMC K100M and HPMC K15M and lactose and Microcrystalline cellulose pass through 40 no sieves and mix properly for 3-5 minutes in a steel tub.
Prepare binder solution by dispersing PVP K30 in isopropyl alcohol.
Granulation of above mixture is done by prepared binder solution by kneading up to granulation end point is obtained (Dough mass) .Pass the dough mass through 12 mess and keep it in a tray dryer for drying and finally keep the loss on drying (LOD) up to 2-3 %.Remove the dried granules from oven and pass through 20 mess sieve to get optimum size granules. Lubrication is done by using Mg stearate and talk previously passed through 60 mess sieve of the granules for 3 to 4 min. in a steel tub and then in polybag. Compression is done by suing 16 station single rotary CADMACH machine by using 6.3 mm standard concave circular punch.
Formulations
Ingredients (mg)/tablet Formulation No.
T1 T2 T3 T4 T5 T6 T7 T8
Drug 50 50 50 50 50 50 50 50
HPMC
K 100M - - 8 10 8 8 10 10
HPMC K 15 M 10 15 5 - - 3 4 6
HPMC K4 M 8 3 5 8 10 7 4 2
Lactose 21 21 21 21 21 21 21 21
Micro crystalline cellulose 20 20 20 20 20 20 20 20
PVP K 30 6 6 6 6 6 6 6 6
Talc 3 3 3 3 3 3 3 3
Mg. Stearate 2 2 2 2 2 2 2 2
Total Weight 120 120 120 120 120 120 120 120
In-vitro Dissolution study
In in-vitro dissolution study done by eight basket dissolution apparatus and first two hours used as dissolution media was .1 N HCl then after in 6.8 pH of phosphate buffer used as dissolution media. Temperature 3702 was maintained C and set 100 rpm of paddle. Take 10ml solution of sample from each vessel and filtered and take absorbance at 271 nm on double beam UV spectrophotometer and replace the volume with dissolution medium maintaining the temperature.
Dissolution Profile of batch No. T1 to T8 and marketed sample in 0.1N HCL and 6.8 pH phosphate buffer
B.No. Time in Hours (cumulative % drug release)
0.1N HCL
6.8 pH buffer
1 2 4 6 8 10 12
T1 6.32 11.03 79.03 101.53 - - -
T2 5.67 10.89 75.66 93.77 101.82 - -
T3 3.48 09.74 62.05 72.31 81.30 89.12 94.34
T4 3.12 08.92 49.94 63.54 72.27 78.99 91.68
T5 4.48 09.24 56.90 71.82 84.42 100.3 -
T6 4.91 10.61 49.85 68.31 81.16 93.01 99.98
T7 2.98 08.48 36.20 51.63 60.43 65.72 74.81
T8 2.40 07.86 35.42 47.38 59.42 62.23 70.62
Dissolution profile of all batch T1 to T8
Dissolution profile of batch T6
Kinetic Study of batch T6 and marketed product6,7
Further to understand the order and mechanism of drug release the data was subjected to various kinetic equations and plotted according to zero order, Higuchi and Korsmeyers Peppas equation. The kinetic values obtained from different plots are listed in Table. 17
Kinetic treatment of dissolution data for batch T6 and for marketed product
B. No. Drug release kinetics correlation coefficient (R2) Release exponent
Zero order Higuchi Korsmeyers
T6 0.951 0.927 0.893 0.453
Results and discussion
The sustained release tablet of Tramadol Hydrochloride were prepared by wet granulation method.The release of tramadol hydrochloride from sustained release tablet of various formulations varied according to the ratio and degree of the polymer. In case of tablet of T1containing drug HPMCK15M HPMCK4M in quantity (mg). 50:10:8 the release profile, was showing control the release and within 6 hours the whole drug was release. In case of tablets of T2 containing drug and HPMC KL5M HPMC K4M (in mg). 50:15:3 it was showing high initial burst of 46.67% and 101.82% release in 8 hours. In case of tablets of T3 containing drug polymer’s (HPMCK100M. HPMCK15M, KPMCK4M in mg) 50:8:5:5 the effect of combination of polymers in release of drug but it was showing slower release given 94.34% up to 12 hour. In case of tablets T4 containing drug and HPMC K100M HPMCK 4M (in mg) 50: 10: 8 the release profile was showing drug release were than 12 hours. With very slower release given 91.68% up to 12 hours. In case of tablets of T5 containing drug and HPMC K 100m HPMC K4M (in mg) 50:8:10. Prepared for controlling the release but it can’t release up to 12 hours. In case of tablets of T6 containing drug and HPMC K100m HPMC K 15m and HPMC K 4m (in Mg) 50:8:3:7 It was seen the increase in release of drug and shown complete drug release in 12 hour profile. In case of tablets T7, containing drug. HPMCK100m HPMCK15m and HPMC K4 (in mg) 50:10:4:4 the release profile was showing drug release more than 12 hours. In case of Tablet’s T8 containing drug. HPMCK100M and HPMC K4m (in mg) 50:10:6:2. The release profile was showing drug release more than 12 hours. With very slower release than all formulations.
In Kinetic assessment the data was plotted according to Zero order shows R2 (0.7467 to 0.9456) suggested the rate of drug released was followed zero order for batch T6. The data was fitted with Higuchi with R2 (0.9207 to 0.9944) indicating the mechanism was diffusion controlled. To known the preciously whether the fickian and non-fickian.
Release mechanism, the data was fitted to Korsmeyer’s Peppas equation. It shows the n value lies in between 0.42 to 0.59 which indicates the fickian and non-fickian release or anomalous,
Conclusion
Dissolution of batch T6 was carried out in two different pH medias.The release mechanism was found to be predominately zero order, diffusion controlled, non-fickian.
From the above results and discussion it is concluded that formulation of sustained release tablet of Tramadol hydrochloride containing HPMC K 100M HPMC K15m HPMC K4m 50:8:3:7 (in mg) can be taken as an ideal or optimized formulation of sustained release tablets for 12 hour release as it fulfills all the requirements for sustained release tablet and our study encourages for the further in-vivo study, long term stability study clinical trials on this formulation.
References
1. Yie. W. Chien “Novel drug delivery system”, 2nd edition, Pp.1
2. “Pharmaceutical dosage forms and Drug Delivery System”, loyd V. Allen,Jr, Nchols G. Popovich, Howard C. Ansel, 8th edition, 260-275
3. Ashok V. Bhosale, Rahul V. Takawale, sanjay D. Sawamy “oral noval drug delivery system “The Eastern pharmacist”, September 2000, 41- 43
4. D. M. brahmankar, Sunil B. Jaiswal “Biopharmaceutics and Pharmacokinetics a Treatise, 2002 reprint, Vallabh prakashan, 335-337
5. Jaleh varshesaz, (2006) “ use of Hydrophilic Natural Gums in Formulation of sustained – release matrix Tablet of Tramodol Hydrochloride”, AAPS Pharm
Sci Tech; 7(1) Article 24
6. Silvina A. Bravo, Maria C. Lamas, Claudio J.Salomon, (2002) “In-Vitro Studies of Diclofenac Sodium Controlled – release from Biopolymeric Hydrophilic Matrices” J.Pharm Pharmaceutics Sci 5(3), pgno.213-219
7. Qiu Y.Chidambaram N, Porter W. Flood K (1998), “Formulation and characterization of new diffusional matrices for Zero – order sustained release” Jou. Cont. release, 52, pg.no. 149-158.
8. Jaleh varshesaz, (2006) “ use of Hydrophilic Natural Gums in Formulation of sustained – release matrix Tablet of Tramodol Hydrochloride”, AAPS Pharm
Sci Tech; 7(1) Article 24
9. Remington “The science and practice of Pharmacy” 20th edition volume- I, Page No –1030 –1033.
10. Lachman Leon, Liberman H.A and Kanig J.L., “The Theory and Practice of Industrial Pharmacy”(3rd Edn) Varghese publishing House Bombay, Pg.No. 430-456
11. Wade Ainley, Weller P.J., “Hand Book of Pharmaceutical Excipients”, 4th 1 pg.no.186-188, 223-227, 229-231, 562-563
12. D. M. brahmankar, Sunil B. Jaiswal “Biopharmaceutics and Pharmacokinetics a Treatise, 2002 reprint, Vallabh prakashan, 335-337
13. N.K.

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Prescribing physicians tell me that twice the number of reps visit their offices everyday, than just 7 years ago. As a result, theyre overwhelmed and frustrated. In fact, 35% of physicians will not even allow for an appointment! And 65% of physicians say they would stop seeing reps today if they didnt bring samples.
The most alarming observation was that they said less than 10% of interactions with reps are ever helpful. They say that the reps that call on them are less believable today when discussing their products, competitor products, and the disease states their products are intended to treat.
You Have 80 Seconds.

Your reps have just 80 seconds to present to a physician, thats it. What is accomplished during those 80 seconds can be the moment of IMPACT or DISCONNECT for a physician.

How Many of Your Sales People

Didnt Reach Their Goals This Year?

Are they approaching your customers, the right way? Do they know the first thing to say to get the physicians attention? Are they presenting themselves in a compelling manner? Are they constantly asking for the next 10 scripts? Are they pushy?
Make no mistake, with only 80 seconds - if theyre not doing what it takes to garner the attention and respect of your customer its over before it ever begins.
After personally spending countless hours working and consulting directly with physicians I have come to appreciate that physicians are a unique and special customer. They are scientists and MUST have certain information before they can make a decision to write for your product. With all of the different pharmaceutical reps visiting your customers you need something to make your team stand out and get the physicians attention. They need to be able to understand and speak the language of the physician. Physicians, as well as all healthcare professionals, communicate using a language known as SOAP. SOAP is an acronym for Subjective, Objective, Assessment and Plan. During the subjective portion of an office visit a physician will take a patient history and ask questions to determine the problem the patient is presenting with.
It is during the objective part of the exam that the doctor will gather information by conducting a physical exam and tests. Once the information is gathered the doctor will make an assessment of the problem called a diagnosis and put a treatment plan into place to solve the problem. Doctors use this process to diagnose and treat patients, decide to change their prescribing habits, document patient records and present clinical literature. During a typical day seeing patients a doctor might go through this process 30-40 times.
This process starts with a problem and ends with a product as the solution. The reason 9 out of 10 sales reps fail at getting the doctors attention is because they are talking about products and the doctor is focused on problems. I was conducting a focus group with about 25 doctors and I asked the question, What can a sales representative do during their presentation that would be beneficial to you? One doctor raised his hand and said, Solve a clinical problem for me. All of his colleagues agreed. TAP Consulting conducted a survey of over 350 doctors in January of 2008 and discovered that a trait doctors would like in an industry representative is the ability to problem solve. When we asked them to be more specific and share with us what problems they needed solved they couldnt name any. This says that doctors depend on sales representatives to identify and solve clinical problems for them. The representatives who can solve clinical problems for a doctor will gain the doctors attention and their business during the sales call!
Jim Price has been in the healthcare industry for over eighteen years. His experience encompasses numerous pharmaceutical and surgical sales positions As a practice management consultant, Jim has worked with physicians to improve a variety of practice issues from workflow to marketing. He has also advised hospitals on vendor consolidation and procedure efficiencies.
Most recently, Jim served as Director of North American Training and Development for Novartis Ophthalmics. In this position, he was responsible for the training and development of Sales Representatives and Area Sales Managers for the North American markets.
Currently, Jim provides contract training and consultation services for clients in the pharmaceutical, biotech and medical device industry, including: Novartis Ophthalmics, Pfizer Consumer Health, Alimera Sciences, Alliant Pharmaceuticals, Eisai, NovaVision and Ciba Vision.
As a presenter at The Society of Pharmaceutical and Biotech Trainers, Jim has been able to share his extensive experience with other sales training professionals.
TAP Consulting was created to leverage Jims extensive experience in physician/representative interactions. The courses offered by TAP Consulting have been designed specifically for the pharmaceutical and medical industry. Drawing on over 500 physician/rep role plays and feedback gathered from physician focus groups, Jim has been able to translate this knowledge into courses which are real time, actionable and drive results. TAP offers courses in understanding your physician customer, basic and advanced selling skills, selling with clinical reprints and leadership training. Contact Jim Price for more information on TAP services.
TAP Consulting
Pharmaceutical Sales Training And Performance Consulting
770-596-1498
price56@comcast.net
http://www.tapconsultingcompany.

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130A Fundamentals of Mathematics I (3-2). Fundamental operations involving whole numbers and fractions; decimals and percents; ratio and proportion; interpretation of graphs; metric and nonmetric geometry; counting; combinations and permutations; introduction to algebra. (Laboratory activities will supplement classroom instruction.)
130B Fundamentals of Mathematics II (3-2). Axioms and properties of the real number system; fundamental operations involving algebraic expressions; first degree equations and inequalities in one unknown; products and factoring; algebraic fractions; exponents and radicals; quadratic equations; functions and graphs; systems of equations; applications. (Laboratory activities will supplement classroom instruction.)
1302 College Algebra (3-0). Exponents and radicals, logarithms, factoring, algebraic quotients, systems of equations, inequalities, absolute value, complex numbers, quadratic equations, binomial theorem, progressions, theory of equations, and determinants.
Prerequisite: Mathematics 130B or equivalent, or an acceptable score on the mathematics section of the ACT or the quantitative section of the SAT I.
1303 Plane Trigonometry (3-0). Trigonometric functions, radian measure, logarithms, solutions of triangles, functions of composite angles, identities, trigonometric equations, and complex numbers.
Prerequisite: Mathematics 130B or equivalent, or an acceptable score on the mathematics section of the ACT or the quantitative section of the SAT I.
1311 Mathematics for Business I (3-0). Review of algebra, business mathematics, mathematics of finance, matrix theory, and linear programming.
Prerequisite: Mathematics 130B or equivalent, or an acceptable score on the mathematics section of the ACT or the quantitative section of the SAT I.
1312 Mathematics for Business II (3-0). Set theory, counting techniques and probability, random variables and distribution functions, and differential and integral calculus.
Prerequisite: Mathematics 1302 or 1311.
1321 Analytic Geometry (3-0). Coordinate systems, translations, rotations, lines, circles, conics, parametric equations, and elementary three-dimensional geometry.
Prerequisites: Mathematics 1302, 1303; or equivalent.
1332 Introduction to Contemporary Mathematics (3-0). A course designed for liberal arts and other non-mathematics and non-science majors who wish to satisfy the three-hour core curriculum mathematics requirement. Topics include graphs and networks, theory of elections and apportionment, statistics, mathematical models.
Prerequisite: Mathematics 130B or equivalent, or an acceptable score on the mathematics section of the ACT or the quantitative section of the SAT I.
1341 Mathematics for Elementary/Middle School Teachers I (2-2). Sets and relations, the system of whole numbers, numeration systems, the system of integers, elementary number theory, fractions and rational numbers, decimals and real numbers. Lab activities will include making and using math manipulatives, comparing different problem solving techniques, making interdisciplinary connections, and experiencing math concepts through auditory, visual, and kinesthetic approaches to inquiry-based activities.
Prerequisite: Mathematics 1302.
1342 Mathematics for Elementary/Middle School Teachers II (2-2). Decimals and real numbers, nonmetric geometry, metric geometry, measurement, graphs, probability and statistics. Lab activities will include making and using math manipulatives, comparing different problem solving techniques, making interdisciplinary connections, and experiencing math concepts through auditory, visual, and kinesthetic approaches to inquiry-based activities.
Prerequisite: Mathematics 1341.
1361 Precalculus I (3-0). An intensive overview of the algebraic concepts needed for calculus, including algebraic expressions, equations and inequalities, complex numbers, polynomials, rational functions, exponential and logarithmic functions, inverse functions, systems of equations and inequalities, matrices, sequences and series, binomial theorem.
Prerequisite: Mathematics 1302 with a grade of C or better, or a score of 26 or higher on the mathematics section of the ACT, or a score of 580 or higher on the mathematics section of the SAT I, or equivalent.
1362 Precalculus II (3-0). A survey of topics from trigonometry and analytic geometry, including trigonometric functions, graphs, identities, and equations; trigonometric form of complex numbers; powers and roots of complex numbers; parabolas, ellipses, hyperbolas; parametric equations; polar coordinates; applications.
Prerequisite: Mathematics 1361 or equivalent.
2331 Calculus I (3-0). Differential calculus for functions of one variable including a study of limits, continuity, derivatives of different classes of functions, maxima and minima, concavity, related rates, and optimization problems.
Prerequisites: Mathematics 1361 and 1362, or equivalent.
2332 Calculus II (3-0). Introduction to the (Riemann) integral and the relationship between the derivative and integral; techniques for evaluating integrals using the fundamental theorem of calculus; applications of the integral to physical and geometrical problems.
Prerequisite: Mathematics 2331.
3300 Introduction to Abstract Mathematics (3-0). Logic, set operations, equivalence relations, properties of the real number system, cardinality of sets, and related topics, with an emphasis throughout on developing the necessary skills to read and construct formal mathematical arguments. To ensure timely progress toward the degree, this course should be taken as soon as possible after completion of Mathematics 2331.
Prerequisite: Mathematics 2331 or equivalent.
3301 Linear Algebra (3-0). The algebra and geometry of finite dimensional vector spaces; determinants; linear transformations and matrices; characteristic values and vectors of linear transformations.
Prerequisite: Mathematics 2331.
3307 Probability and Statistics I (3-0). Mathematical models of random events; probability spaces; random variables; dependence and independence; mean values and moments of random variables; distribution functions, and characteristic functions.
Prerequisite: Mathematics 3333.
3310 Introduction to Problem Solving (3-0). Designed to help the student develop analytical skills through exposure to a variety of problem solving techniques utilizing algebra, geometry, trigonometry, and other areas of precalculus mathematics. Includes graphing calculator and instructional software applications. For students pursuing secondary or middle school teacher certification in mathematics. To ensure timely progress toward the degree, this course should be taken as soon as the prerequisites have been completed.
Prerequisites: Mathematics 1361 and 1362; or Mathematics 1302, 1303, and 1321; or equivalent. (Formerly MATH 2302)
3311 Elementary Number Theory (3-0). Tests for divisibility, unique factorization, integer representations, greatest common divisors, least common multiples, congruences, and the distribution of primes.
Prerequisites: Mathematics 1302, 1341, and 1342.
3313 The Evolution of Mathematics (3-0). Historical development of selected mathematical concepts, terminology and algorithms; impact of mathematics on the development of our culture.
Prerequisites: Mathematics 1302, 1341, and 1342.
3321 Statistics (3-0). A survey of basic statistical methods, including distributions, central tendency, variability, hypothesis testing and correlation; brief introduction to sampling techniques and nonparametric methods. For nursing students.
Prerequisite: Mathematics 130B or equivalent, or an acceptable score on the mathematics section of the ACT or the quantitative section of the SAT I.
3323 Exploring Middle School Mathematics (3-0). Mathematical reasoning and problem solving; numerical systems, structure, operations, and algorithms; patterns, relations and functions, algebraic concepts and applications; geometry, measurement, and spatial reasoning; probability and statistics. Graphing calculators and other supporting technologies will be incorporated where appropriate. For students pursuing middle school certification in mathematics.
Prerequisites: Mathematics 1312, 1321, 3310, 3311, and 3321; 2.50 GPA, with no grade lower than C in all required mathematics courses attempted, cumulative and in residence. Concurrent registration in Mathematics 3311 or 3321 may be permitted in special circumstances with consent of instructor.
3333 Calculus III (3-0). Multivariate calculus and applications; indeterminate forms, multiple integrals, infinite series, and approximation techniques.
Prerequisite: Mathematics 2332.
3335 Differential Equations (3-0). Solution of differential equations, with geometric and physical applications.
Prerequisite: Mathematics 3333, or Mathematics 2332 with consent of instructor.
4301 Abstract Algebra (3-0). Elementary number theory including integer congruences and modular arithmetic, equivalence relations, basic topics in ring and group theory including the fundamental homorphism theorems, structure and basic properties of fields.
Prerequisite: Mathematics 3300 or 3310; Mathematics 3301.
4311 Numerical Analysis (3-0). Number representations, error analysis; roots of equations; numerical integration, approximation, and differentiation; systems of equations; approximation by spline functions; ordinary differential equations; Monte Carlo methods and simulation.
Prerequisites: Mathematics 3333 and Computer Science 2301.
4321 College Geometry (3-0). A study of Euclidean, non-Euclidean, and transformational geometry. For students seeking middle school or secondary school teacher certification in mathematics.
Prerequisites: Mathematics 1361 and 1362; or Mathematics 1302, 1303, and 1321; or equivalent.
4322 A Survey of Mathematics with Applications (3-0). Logic and set theory, algebraic and transcendental functions, inverse functions, limits, the derivative and integral, sequences and series, linear systems, vectors, geometry, probability and statistics. Emphasis on applications utilizing the graphics calculator.
Prerequisites: Mathematics 3301, 3333, and 3307; 2.50 GPA, with no grade lower than C in all required mathematics courses attempted, cumulative and in residence. Mathematics 3307 and 4322 may be taken concurrently.
4331 Analysis (3-0). The real and complex number systems, Euclidean spaces, countable and uncountable sets, metric spaces, compactness, convergent sequences, Cauchy sequences, limits and continuity, uniform continuity, the derivative, the Riemann-Stieltjes integral, sequences and series of functions, uniform convergence.
Prerequisites: Mathematics 3300 or 3310; Mathematics 3301, 3333.
4351 Topology (3-0). Sets and functions, metric spaces, topological spaces, compactness, separation, connectedness, approximation.
Prerequisites: Mathematics 3300 or 3310; Mathematics 3301, 3333.
4361 Complex Variables (3-0). Complex numbers, analytic functions, complex integration, power series, residues, conformal mapping, and applications.
Prerequisite: Mathematics 3333.
4391 Research. Individual research problems. (May be repeated to a total of six semester hours credit.)
Prerequisite: Junior standing.

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A practical "ABCDE" approach to the metabolic syndrome.
Mayo Clin Proc. 2008 Aug;83(8):932-41
Authors: Blaha MJ, Bansal S, Rouf R, Golden SH, Blumenthal RS, Defilippis AP
The metabolic syndrome comprises a cluster of risk factors for cardiovascular disease and type 2 diabetes mellitus that are due to abdominal obesity and insulin resistance. This increasingly important proinflammatory condition remains both underrecognized and undertreated. To aid physicians in their approach to the metabolic syndrome, we assessed and synthesized the literature on cardiovascular risk assessment and early intervention for risk reduction. We performed a comprehensive search of MEDLINE and the Cochrane database for peer-reviewed clinical studies published from January 1, 1988, to December 31, 2007, augmented by consultation with content experts. We used the search terms metabolic syndrome, abdominal obesity, waist circumference, insulin resistance, cardiovascular disease, prediabetes, diabetes, treatment, prevention, aspirin, hypertension, cholesterol, atherogenic dyslipidemia, lifestyle therapy, diet, and exercise. Criteria used for study review were controlled study design, English language, relevance to clinicians, and validity based on experimental design and appropriateness of conclusions. Although growing evidence supports early intervention in patients with the metabolic syndrome, many physicians do not recognize the risk associated with this condition and fail to initiate early treatment. A comprehensive management plan can be assembled through an "ABCDE" approach: "A" for assessment of cardiovascular risk and aspirin therapy, "B" for blood pressure control, "C" for cholesterol management, "D" for diabetes prevention and diet therapy, and "E" for exercise therapy. This ABCDE approach provides a practical and systematic framework for encouraging metabolic syndrome recognition and for implementing a comprehensive, evidence-based management plan for the reduction of cardiovascular risk.

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American Heart Journals Publishes Results From ERATO Trial Showing Dronedarone (Multaq(R)) Improves Ventricular Rate Control
The ERATO study published in the American Heart Journal demonstrated, for the first time in patients with permanent atrial fibrillation, that dronedarone (Multaq(R)) significantly reduces mean 24 hour ventricular rate, on top of other rate control agents. The mean heart rate reduction was 11.

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Similar posts: american cardiology

Ken Burns' brilliant PBS film series about World War II brought back memories of my return home after more than two years Army service in India. I still remember the exact date I landed in the U.S., Feb. 11, 1946. I arrived in San Francisco after a month-long voyage from Calcutta aboard a Navy troop ship, the General Ballou--or "the ba-ba-lu," as we fondly called it.

Most of the men in my outfit, the 903rd Signal Co., and I had waited five months after the Japanese surrender in August 1945 for a ship to take us home. As the frustration grew over the delay, the "political activists" in my outfit began to bombard members of Congress with letters urging them to do something about the shortage of ships.

They also enlisted Drew Pearson, the influential syndicated newspaper columnist, to take up our cause. He wrote a series of columns demanding that ships be sent to bring "the men in the forgotten theater of war [China-Burma-India]" home.

Some men on our base finally began to shipped back to the States after a priority system was set up based on total time served in the Army and the amount of time overseas. Additional credit was given for combat experience. None of the men in my outfit earned priority for the return home because we had not seen combat.

For about three months, we were kept occupied closing our facilities and destroying equipment that was no longer needed. I will never forget the sight of bulldozers driving over countless millions of dollars worth of radar apparatus, radio gear, and other once vital equipment, lined up on an air strip, converting them into scrap.

Before the war, our base had been the giant Kharda Mills, which produced jute. The U.S. Army acquired the property and converted it into the CBI's main air depot. Now we were getting the facility ready to resume its original, pre-war business.

Even though the war was over, hundreds of men were assigned to guard duty to protect our base. Indian independence was to be declared in the next year or two. But bloody communal riots were already breaking out between Bengali Hindus and Bengali Muslims in the villages surrounding the base, as the two communities maneuvered to claim territory. There was concern that the violence would spill over into our base. And occasionally it did.

The first step in our prolonged return to the States finally came in December 1945, when we were shipped to a staging area named Kanchrapara, located in the jungles of eastern Bengal. For me, it was sort of a homecoming. I had spent a month there soon after my arrival in India, waiting to be assigned to an operational unit.

In my first stay at Kanchrapara, I had been assigned to guard duty almost every day. After conquering Burma, the Japanese army was invading eastern India. It had already occupied part of the state of Manipur. And there I was, armed with a Thompson sub-machine gun, standing in its way. The Japanese failed to get any closer, but I do not take any credit for that.

But this time my stay at Kancharapra was a far more joyous one. Shortly after New Year's Day 1946, we were piled into trucks and driven to the port of Calcutta to board the General Ballou for the voyage home. During the two-hour drive, we were attacked by a shower of rocks thrown at us by Indian militants who mistook us to be British troops. At least a half dozen men were injured and required medical attention as soon as we boarded the troop ship.

After about a week at sea, the ship arrived in Singapore. The harbor was littered with wrecked Japanese vessels. (Singapore had been a major target of U.S. bombers based in India.) I don't recall that anyone on the ship was allowed to go ashore, but a fleet of small boats sailed out to us with supplies. From what we could see from a distance, the city of Singapore looked like Hiroshima.

Departing from Singapore, we sailed into the South China Sea, where we were immediately hit by a typhoon. The storm was so furious that our ship seemed to turn over on its port side. For those of us courageous enough to be on deck, the sea was no longer on the same level as our vessel. It was as if we were on a skyscraper peering down on the stormy water below.

Virtually everyone aboard the ship became sea sick. I had the misfortune of being in the vessel's compartment that had been arbitrarily assigned to KP duty. It was a repeat of the misfortune I had suffered two years earlier on the voyage to India, when I was in the ship's compartment that had been arbitrarily assigned to serve as the vessel's MPs. In each case, I had to enviously watch the other troops enjoying the luxury of endless leisure time at sea while I was on duty.

The KP duty in the South China sea was a special ordeal, as we had to contend with the hordes of seasick soldiers vomiting in the mess hall. And now, unlike our stay in India, we did not have native coolies to clean up. My compartment mates on KP--most of us staff sergeants or above--were humbled. We had expected to be immune to such unpleasant duty because of our exalted rank.

As the typhoon subsided we entered the port of Manila in the Philippines. We anchored close to the island of Corregidor, the site of the U.S. surrender to the Japanese shortly after the Pearl Harbor attack. Like the Singapore harbor, the Manila harbor was littered with the wrecks of Japanese ships, and the city was similarly devastated.

The closest that I have ever seen to what might be considered an Army mutiny broke out when dozens of officers boarded launches taking them ashore, while enlisted men were not allowed to leave the ship. Angrily watching from the ship's railings above, dozens of enlisted men began throwing fruit crates and other trash at the officers. I do not recall any disciplinary action taken against them.

Our stay in Manila was a brief one. Sailing eastward across the Pacific, our ship passed close enough to the Hawaiian Islands so that we could see land. Now that the ocean waters had calmed, I felt comfortable in my off-duty hours reading on my hammock. I recall that I was able to finish Somerset Maugham's The Razor's Edge.

At last we reached San Francisco Bay, passing beneath the Golden Gate Bridge. The same guys who had thrown refuse at the officers in Manila were now lined up on the same ship's railings, weeping that we were finally back home in the States. I have never seen so many grown men crying, and I will never forget the highly emotional scene.

As we debarked from the ship, loaded down with heavy duffle bags over our shoulders, we were surrounded by huge, cheering crowds on the docks. Some people were evidently relatives of the troops and had been alerted to our arrival. As we stood on the docks relaxing, a team of American Red Cross women arrived with coffee and doughnuts. I was annoyed that we had to pay for these modest offerings.

We were quickly loaded on to a ferry boat which took us up the San Francisco Bay to Camp Stoneham in Pittsburgh, Calif., which had been a major military port of embarkation during the war. Now it was functioning in the happier role as a port of debarkation for troops about to be discharged from military service.

As we marched into Camp Stoneham, we were not exactly healthy-looking specimen. Most of us had suffered malaria, dengue fever, dysentery and other tropical diseases. Many were emaciated because of their illnesses. When we entered the camp's mess hall to eat, we were infuriated to see robust, healthy-looking German prisoners-of-war who were KPs serving the food. They had survived the war in far better shape than we had.

A few days later we boarded troop trains arranged to go to discharge centers closest to our homes. My train was headed for Ft. Dix, N.J. I finally had a chance there to phone my family in the Bronx. I had expected to be discharged and on my way to them in a day or two. Part of the discharge process involved a lengthy physical examination. After the exam, I saw that most of my buddies had been given their discharge papers and were packing up to leave.

As the others left, I was told to remain in my barracks. My chest x-rays showed a suspicious spot on my lungs. I was told that I would have to remain in the camp until a lung specialist would arrive to examine me. When he finally arrived a few days later and examined the x-rays, he quickly decided that the x-ray technician had accidentally scratched the film. On March 16, 1946, I was given my honorable discharge papers and allowed to go home as a civilian. I was only 21 years old. I felt at least 10 years older.

A train took me to Pennsylvania Station in Manhattan, and the subway delivered me to the 167th Street station on the Independent line. Despite the weight of the duffle bag over my shoulder, I jogged the two blocks from the subway station to my parents' apartment house.

I rang the downstairs bell to announce my arrival, and began running up the three steep flights of stairs to their apartment. At the same time, my father came rushing down to meet me. In his excitement, he almost knocked me down a flight of stairs. He embraced and kissed me, crying as a he pulled me up the stairs where my mother and grandmother waited eagerly at our door. Their only son had finally come home from the war.

Similar posts: american cardiology

Ken Burns' brilliant PBS film series about World War II brought back memories of my return home after more than two years Army service in India. I still remember the exact date I landed in the U.S., Feb. 11, 1946. I arrived in San Francisco after a month-long voyage from Calcutta aboard a Navy troop ship, the General Ballou--or "the ba-ba-lu," as we fondly called it.

Most of the men in my outfit, the 903rd Signal Co., and I had waited five months after the Japanese surrender in August 1945 for a ship to take us home. As the frustration grew over the delay, the "political activists" in my outfit began to bombard members of Congress with letters urging them to do something about the shortage of ships.

They also enlisted Drew Pearson, the influential syndicated newspaper columnist, to take up our cause. He wrote a series of columns demanding that ships be sent to bring "the men in the forgotten theater of war [China-Burma-India]" home.

Some men on our base finally began to shipped back to the States after a priority system was set up based on total time served in the Army and the amount of time overseas. Additional credit was given for combat experience. None of the men in my outfit earned priority for the return home because we had not seen combat.

For about three months, we were kept occupied closing our facilities and destroying equipment that was no longer needed. I will never forget the sight of bulldozers driving over countless millions of dollars worth of radar apparatus, radio gear, and other once vital equipment, lined up on an air strip, converting them into scrap.

Before the war, our base had been the giant Kharda Mills, which produced jute. The U.S. Army acquired the property and converted it into the CBI's main air depot. Now we were getting the facility ready to resume its original, pre-war business.

Even though the war was over, hundreds of men were assigned to guard duty to protect our base. Indian independence was to be declared in the next year or two. But bloody communal riots were already breaking out between Bengali Hindus and Bengali Muslims in the villages surrounding the base, as the two communities maneuvered to claim territory. There was concern that the violence would spill over into our base. And occasionally it did.

The first step in our prolonged return to the States finally came in December 1945, when we were shipped to a staging area named Kanchrapara, located in the jungles of eastern Bengal. For me, it was sort of a homecoming. I had spent a month there soon after my arrival in India, waiting to be assigned to an operational unit.

In my first stay at Kanchrapara, I had been assigned to guard duty almost every day. After conquering Burma, the Japanese army was invading eastern India. It had already occupied part of the state of Manipur. And there I was, armed with a Thompson sub-machine gun, standing in its way. The Japanese failed to get any closer, but I do not take any credit for that.

But this time my stay at Kancharapra was a far more joyous one. Shortly after New Year's Day 1946, we were piled into trucks and driven to the port of Calcutta to board the General Ballou for the voyage home. During the two-hour drive, we were attacked by a shower of rocks thrown at us by Indian militants who mistook us to be British troops. At least a half dozen men were injured and required medical attention as soon as we boarded the troop ship.

After about a week at sea, the ship arrived in Singapore. The harbor was littered with wrecked Japanese vessels. (Singapore had been a major target of U.S. bombers based in India.) I don't recall that anyone on the ship was allowed to go ashore, but a fleet of small boats sailed out to us with supplies. From what we could see from a distance, the city of Singapore looked like Hiroshima.

Departing from Singapore, we sailed into the South China Sea, where we were immediately hit by a typhoon. The storm was so furious that our ship seemed to turn over on its port side. For those of us courageous enough to be on deck, the sea was no longer on the same level as our vessel. It was as if we were on a skyscraper peering down on the stormy water below.

Virtually everyone aboard the ship became sea sick. I had the misfortune of being in the vessel's compartment that had been arbitrarily assigned to KP duty. It was a repeat of the misfortune I had suffered two years earlier on the voyage to India, when I was in the ship's compartment that had been arbitrarily assigned to serve as the vessel's MPs. In each case, I had to enviously watch the other troops enjoying the luxury of endless leisure time at sea while I was on duty.

The KP duty in the South China sea was a special ordeal, as we had to contend with the hordes of seasick soldiers vomiting in the mess hall. And now, unlike our stay in India, we did not have native coolies to clean up. My compartment mates on KP--most of us staff sergeants or above--were humbled. We had expected to be immune to such unpleasant duty because of our exalted rank.

As the typhoon subsided we entered the port of Manila in the Philippines. We anchored close to the island of Corregidor, the site of the U.S. surrender to the Japanese shortly after the Pearl Harbor attack. Like the Singapore harbor, the Manila harbor was littered with the wrecks of Japanese ships, and the city was similarly devastated.

The closest that I have ever seen to what might be considered an Army mutiny broke out when dozens of officers boarded launches taking them ashore, while enlisted men were not allowed to leave the ship. Angrily watching from the ship's railings above, dozens of enlisted men began throwing fruit crates and other trash at the officers. I do not recall any disciplinary action taken against them.

Our stay in Manila was a brief one. Sailing eastward across the Pacific, our ship passed close enough to the Hawaiian Islands so that we could see land. Now that the ocean waters had calmed, I felt comfortable in my off-duty hours reading on my hammock. I recall that I was able to finish Somerset Maugham's The Razor's Edge.

At last we reached San Francisco Bay, passing beneath the Golden Gate Bridge. The same guys who had thrown refuse at the officers in Manila were now lined up on the same ship's railings, weeping that we were finally back home in the States. I have never seen so many grown men crying, and I will never forget the highly emotional scene.

As we debarked from the ship, loaded down with heavy duffle bags over our shoulders, we were surrounded by huge, cheering crowds on the docks. Some people were evidently relatives of the troops and had been alerted to our arrival. As we stood on the docks relaxing, a team of American Red Cross women arrived with coffee and doughnuts. I was annoyed that we had to pay for these modest offerings.

We were quickly loaded on to a ferry boat which took us up the San Francisco Bay to Camp Stoneham in Pittsburgh, Calif., which had been a major military port of embarkation during the war. Now it was functioning in the happier role as a port of debarkation for troops about to be discharged from military service.

As we marched into Camp Stoneham, we were not exactly healthy-looking specimen. Most of us had suffered malaria, dengue fever, dysentery and other tropical diseases. Many were emaciated because of their illnesses. When we entered the camp's mess hall to eat, we were infuriated to see robust, healthy-looking German prisoners-of-war who were KPs serving the food. They had survived the war in far better shape than we had.

A few days later we boarded troop trains arranged to go to discharge centers closest to our homes. My train was headed for Ft. Dix, N.J. I finally had a chance there to phone my family in the Bronx. I had expected to be discharged and on my way to them in a day or two. Part of the discharge process involved a lengthy physical examination. After the exam, I saw that most of my buddies had been given their discharge papers and were packing up to leave.

As the others left, I was told to remain in my barracks. My chest x-rays showed a suspicious spot on my lungs. I was told that I would have to remain in the camp until a lung specialist would arrive to examine me. When he finally arrived a few days later and examined the x-rays, he quickly decided that the x-ray technician had accidentally scratched the film. On March 16, 1946, I was given my honorable discharge papers and allowed to go home as a civilian. I was only 21 years old. I felt at least 10 years older.

A train took me to Pennsylvania Station in Manhattan, and the subway delivered me to the 167th Street station on the Independent line. Despite the weight of the duffle bag over my shoulder, I jogged the two blocks from the subway station to my parents' apartment house.

I rang the downstairs bell to announce my arrival, and began running up the three steep flights of stairs to their apartment. At the same time, my father came rushing down to meet me. In his excitement, he almost knocked me down a flight of stairs. He embraced and kissed me, crying as a he pulled me up the stairs where my mother and grandmother waited eagerly at our door. Their only son had finally come home from the war.

Similar posts: american cardiology

Public Health Advocates Deliver Demand during the Democratic National Convention Calling on Senators Barack Obama and John McCain to Support a Comprehensive National AIDS Strategy
In a historically unprecedented move, over 30 national HIV/AIDS organizations and leaders representing African-American, Latino, Native American/Alaska Native, and Asian Pacific Islander communities have joined forces in an urgent call for the development and implementation of a comprehensive national AIDS strategy. The demands to the Democratic and Republican presidential nominees come in response to long-standing concerns about unmet needs for targeted HIV research, treatment access, medical care and prevention in communities of color. A recently-released report from the U.S. Center for Disease Control and Prevention (CDC) on estimates of new HIV infections in the United States amplifies the crises faced in communities of color.
According to the CDCs alarming new estimates, communities of color account for a combined total of 65% of the approximately 56,300 new HIV infections occurring in the United States. By the CDCs own admission, this new estimate is 40% higher than the CDCs earlier estimate of 40,000 infections per year. The startling new HIV rates are of special concern for people of color who are more likely to die from the disease than HIV-infected whites. AIDS advocates representing communities of color have long expressed dissatisfaction with the current lethargic, fragmented and unaccountable U.S. response to the epidemic, which they point out, is a direct result of the non- existent national plan.
Leading national HIV organizations and leaders representing communities of color convened at the Ford Foundation in New York City in August 2008 to formulate a national HIV response to the new administration that will take office in January 2009. Pledging to work together to strengthen the HIV/AIDS response nationally, and in their own communities, these organizations agreed on an urgent seven-point action plan.
The action points stipulate first and foremost the urgent need for the next administration to rapidly initiate a National AIDS Strategy that engages the entire federal government in the fight against HIV and holds each department accountable for improved results in communities of color. Ironically, the U.S. government requires foreign countries receiving American HIV/AIDS assistance to have a national strategy for addressing the epidemic, where there is none in place in our own country. The action plan also demands that the federal government improve its inadequate data gathering methods, currently accounting for only 33 out of the 50 states and 5 dependent territories, excluding other states and territories severely impacted by the epidemic. This flawed process results in the underestimation of HIV rates and impedes efforts to allocate adequate resources to address HIV/AIDS prevention, treatment, and care for all at-risk Americans.
Public health advocates also stress that the socio-economic drivers of the epidemic disproportionately impact communities of color. Such factors include poverty, limited educational opportunities, gender inequities, homophobia, HIV stigma and inadequate health access. The needs of communities of color are further compromised by the current administrations response to the epidemic including a derisory allocation of only 4% of HIV-related domestic spending towards HIV prevention efforts and the flat-funding of the Minority HIV/AIDS Initiative for the past six years despite increasing rates of transmission in people of color communities during that time.
The partnering organizations and leaders stand together to demand concrete action from the new President and his administration. The organizations and leaders represent various individuals, including health service providers, policy makers, physicians, medical schools and people living with HIV/AIDS. The representatives come together from across the country including Hawaii. Together, they bring a voice to the needs of people in urban, rural and native reservation communities.
The time has come for all American leaders, regardless of political affiliation, to support the development and implementation of a comprehensive national plan focused on prevention, treatment, and care for communities of color.
Partnering organizations include: Asian Pacific Islander Wellness Center, BIENESTAR, Black AIDS Institute, Black Leadership Commission on AIDS, Inc., National Minority AIDS Council, National Native American AIDS Prevention Center, The Balm In Gilead and National Association of People with AIDS.

Similar posts: american cardiology

The League of Women Voters of Norman will host a forum entitled "Safeguarding Freedom: Is There an Assault on the Independent Judiciary?" It will take place on Constitution Day, Wednesday, September 17, 2008, at 7:00 p.m. The location is the Bell Courtroom at the University of Oklahoma Law Center, Norman. A reception will be held at 6:00 p.m. in the Sneed Lounge in the Law Center. The public is invited.

Presenters will be Judge Lee West, retired United States District Judge for the Western District of Oklahoma; Andrew Tevington, Chief Counsel to former Governor Henry Bellmon of Oklahoma and currently counsel to the Oklahoma Corporation Commission and Deputy Director of the Public Utilities Division of the Corporation Commission; Arnold Hamilton, editor of the Oklahoma Observer and formerly with Dallas Morning News. The moderator will be Randy Coyne, Professor of Law at the University of Oklahoma.

Sponsors who have provided funding for the event are the League of Women Voters Education Fund and the Program on Constitutional and Legal Policy of the Open Society Institute, the University of Oklahoma Honors College, American Civil Liberties Union of Oklahoma and Common Cause Oklahoma. Additional sponsors are the League of Women Voters of Norman, League of United Latin American Citizens, Peace House, Peace Education Institute, Unitarian University Community Church, Norman Unitarian Universalist Fellowship, The Interfaith Alliance and others.

For more information view the LWVN website by clicking here.

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care everywhere, said Angelo Masciantonio, CEO and co-founder of HTH Worldwide. The doctors in the mPassport database are the highest quality specialists, emergency practitioners and family physicians. About half of Americans who go on vacation for two weeks or more get sick or have some sort of medical problem. Thats why mPassport should be at the top of everyones packing list.
The convergence of two major trends makes mPassport the right tool at the right time. First, the number of Americans traveling overseas is higher than ever - 64 million in 2007. Second, web-enabled mobile phones have become ubiquitous around the world. Most people have one in their pocket, purse or backpack.
Besides the HTH Worldwide searchable physician database, mPassport also features other helpful medical tools for travel abroad:
* Personalized health and Security Alerts published daily via SMS text
messaging and email. The alerts highlight breaking news about risks that
arise along the travelers personal itinerary.
* Searchable Hospitals, Clinics and Pharmacies profiles for over 3,400
notable facilities around the world. Many are contracted directly with
HTH.
- Emergency Room Hospitals - selected hospitals have 24/7 emergency
rooms.
- Urgent Care (Walk-In) Clinics - urgent care/walk-in clinics associated
with notable hospitals worldwide.
- Notable Local Pharmacies - important information on over 500 selected
pharmacies in 126 countries.
* Medication Translation covers over 400 brand-name drugs in the 24 most-
visited countries and yields the country-specific brand names under
which common prescription and over-the-counter medications are sold.
* Medical Term/Condition Translation captures idiomatic healthcare terms
(hay fever,"CAT scan) and critical healthcare phrases (When can I
travel?) in ten languages.
* CityHealth Profiles convey critical information about healthcare
services in hundreds of the worlds most popular destinations: emergency
numbers - local emergency numbers for ambulance, police and fire,
emergency and urgent care options, vaccination requirements, local
pharmacy practices and more.
* Security Profiles contain up-to-date accounts of security risks for
hundreds of frequently visited destinations outside the U.S. Topics
include: terrorism, kidnapping, crime, political stability, reliability
of local police and transportation, preferred lodging
* txt5(SM) Group Text (SMS) Messaging allows subscribers to keep up to
five friends and family members informed of their travels via text
messaging or email. The subscribers save money by sending five messages
for the price of one.
* Featured Columns authored by physicians on healthy travel tips.
All of the mPassport features were designed with the global traveler in mind, said Andrew Orr, product manager for mPassport. For more than ten years, weve been developing technologies to help business people, vacationers and students manage their health far from home. The mobile technology is convenient, cutting-edge, and our databases are expanding. These ingredients make mPassport the mobile way to trusted medical care, health and happiness. Its the first of its kind.
mPassport can be purchased online at mPassport.com. Pricing is subscription-based, and costs $9.95 for 30 days, $15.95 for 60 days, and $49.95 for a year.
About HTH Worldwide
HTH Worldwide provides health insurance plans and global medical assistance services for business and leisure travelers as well as students abroad. HTH programs are distinguished by a contracted community of hospitals and doctors in 180 countries.

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Estrostep fe drug risk of heart attack.
Guidelines Issued Regarding Blood Clots In Pregnant Women. Elkayam, who is a professor of Medicine and Obstetrics and Gynecology at USC. These findings signify the need to establish the cause of AMI in pregnancy in order to decide on appropriate therapy. The report is based on a review of women with pregnancy related AMI in the last decade and outlines key recommendations for the diagnosis and treatment of this condition in pregnant women that also considers the health and safety of the developing baby.
Our initial report indicated a mortality rate of percent, and nearly percent was reported by other studies. Its Semen Sexing TechnologyTM SSTTM. Likewise, the technology will assist beef producers in producing primarily. The BBC is not responsible for the content of external internet sites. And the AMF made by sanofi aventis, including those listed under Risk Factors and. If women substitute heparin prior to pregnancy and have difficulties conceiving, they may find themselves taking the medication for a much longer timeframe than expected, said guideline coauthor Shannon Bates, MD, McMaster University and Henderson Research Centre, Hamilton, Ontario, Canada.
The mission of the ACCP is to promote the prevention and treatment of diseases of the chest through leadership, education, research, and communication. Font family Tahoma, Lucida Grande, sans serif. Twomey, whose early findings are mentioned in the Utah study, said the treatment for frostbite has been limited to warming the affected tissue and waiting to see how much would survive. Hey, Rudy, what luxurious bubble do you live in nbsp. However, that MRI is precautionary only nbsp. I can not figure this out.
While I was there, the hospital case worker came unsolicited to my bedside to tell me about the benefits and services I was entitled to under the Japanese national health insurance system, which are considerable. I don't wanna be offensive but US society talk about commom problems in rd world, it's weird. They do not care about Health Care and never did. In fact, in Canada, we pay between to more tax than Americans except our wealthiest who pay. Seniors working in Wal Marts and elsewhere make a paltry minimum wage because they cannot retire, until they die of course.
If you think that the US government can see the numbers on a license plate from outer space and they cannot find Osama, don't blame the Canadians. Potter fans from Kansas meet JK Rowling. Infarction a meta analysis of randomized trials. More results from Todd Neale Staff Writer medpage Today thrombolytic.
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