Saturday, March 31, 2007
perindopril (ACE-inhibitor)
Perindopril versus Angiotensin II Receptor Blockade in Hypertension and Coronary Artery Disease
Posted 03/21/2007
Adrian J.B. Brady
Author Information
Information from Industry
ULTRAM® ER (tramadol HCl) Extended-Release TabletsLearn more about this baseline therapy for adults with moderate to moderately severe chronic pain who need around-the-clock treatment. ULTRAM ER offers proven efficacy with extended pain relief in chronic moderate to moderately severe pain. Review:
* Full Prescribing Information
* Important Safety Information.
Abstract and Introduction
Abstract
The renin-angiotensin-aldosterone system (RAAS) is now known to play a key role in the pathogenesis of hypertension and a range of other cardiovascular diseases. Two groups of drugs, the ACE inhibitors and angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) have been developed with the aim of improving clinical outcomes by regulating the RAAS in patients with cardiovascular disease.
Initial assumptions were that these two drug types might be interchangeable, but ongoing research has revealed differences between them in terms of pharmacology and outcomes in clinical trials. Although both groups of drugs lower blood pressure, studies of the ACE inhibitor perindopril have revealed preservation of beneficial vascular and endothelial effects mediated by bradykinin and nitric oxide. The selective blockade exerted by ARBs is not associated with these effects. Furthermore, examination of clinical endpoints in major clinical trials has provoked discussion about outcomes comparing ACE inhibitors and ARBs, with recent debate focusing on the incidence of myocardial infarction (MI) in patients receiving these agents. Whether there is an actual difference in protection from MI remains unresolved, although available data confirm the benefit and safety of ACE inhibitors, in particular perindopril, for myocardial protection.
Posted 03/21/2007
Adrian J.B. Brady
Author Information
Information from Industry
ULTRAM® ER (tramadol HCl) Extended-Release TabletsLearn more about this baseline therapy for adults with moderate to moderately severe chronic pain who need around-the-clock treatment. ULTRAM ER offers proven efficacy with extended pain relief in chronic moderate to moderately severe pain. Review:
* Full Prescribing Information
* Important Safety Information.
Abstract and Introduction
Abstract
The renin-angiotensin-aldosterone system (RAAS) is now known to play a key role in the pathogenesis of hypertension and a range of other cardiovascular diseases. Two groups of drugs, the ACE inhibitors and angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) have been developed with the aim of improving clinical outcomes by regulating the RAAS in patients with cardiovascular disease.
Initial assumptions were that these two drug types might be interchangeable, but ongoing research has revealed differences between them in terms of pharmacology and outcomes in clinical trials. Although both groups of drugs lower blood pressure, studies of the ACE inhibitor perindopril have revealed preservation of beneficial vascular and endothelial effects mediated by bradykinin and nitric oxide. The selective blockade exerted by ARBs is not associated with these effects. Furthermore, examination of clinical endpoints in major clinical trials has provoked discussion about outcomes comparing ACE inhibitors and ARBs, with recent debate focusing on the incidence of myocardial infarction (MI) in patients receiving these agents. Whether there is an actual difference in protection from MI remains unresolved, although available data confirm the benefit and safety of ACE inhibitors, in particular perindopril, for myocardial protection.
All risk
Toen ik vroeger eens in de praktijk met mijn volkswagen bij het achteruit rijden een grote kan (tuit) melk omver reed, merkte de boerin op dat me dat geld zou kosten.
De boer neutraliseerde deze opmerking door te zeggen: zon lui as Gosses zien allemol in Aarle-Rixtel verzekerd.
aspirin and woman
Long-term aspirin lowers CV-related mortality in women
27 March 2007
Low-to-moderate doses of aspirin reduce women's risk of death from any cause, but especially from cardiovascular disease (CVD), study findings indicate.
Some studies have shown that aspirin reduces the risk of heart disease and cancers, but it remains unclear whether aspirin significantly affects the risk of death, explain the authors in the Journal of the American Medical Association.
Andrew Chan (Harvard Medical School, Boston, Massachusetts) and colleagues examined the association between aspirin use and death in a prospective study of 79,439 women enrolled in the Nurse's Health Study, a large cohort of female nurses who have been followed-up since 1976.
Of the participants, 45,305 did not use aspirin, while 29,132 took low-to-moderate doses defined as between one and 14 standard 325-µg tablets per week, and 5002 took high doses of more than 14 tablets per week.
By June 2004, 9477 women had died, 1991 from heart disease and 4469 from cancer.
The women who reported current aspirin use had a 25% lower adjusted relative risk (RR) of death from any cause than those who took no aspirin at all (11.0% vs 14.9%, RR=0.75).
The association was even stronger for CVD death. Women currently taking aspirin had a 38% lower RR of dying from CVD than those not taking aspirin, at 21.2% versus 32.5% (RR=0.62).
There was a significant linear relationship between the duration of aspirin use and decreasing mortality overall. But, the authors note, "for death from CVD, much of the apparent benefit from associated with aspirin was achieved within the first 5 years."
They add: "In contrast, for all cancer-related mortality, a significant trend was not evident until after at least 10 years of aspirin use."
There was a U-shaped relationship between aspirin dose and all-cause death. Among those taking just 1-2 standard tablets per week, the RR was 0.70, and for those taking those taking 3-5 standard tablets a week, the RR was 0.65.
But those taking the highest doses did not have a lower risk of death than non-users, with an RR of 1.10 among those taking more than 14 tablets a week. A similar U-shaped relationship was seen for both CVD and cancer death.
Further analysis showed that there was a significant increase in death from hemorrhagic stroke among women taking high doses.
Because the study was observational, the authors say that the results are insufficient to alter current clinical recommendations.
"Nevertheless, these data support a need for continued investigation of the use of aspirin for chronic disease prevention," they conclude.
JAMA 2007; 167: 562-572
27 March 2007
Low-to-moderate doses of aspirin reduce women's risk of death from any cause, but especially from cardiovascular disease (CVD), study findings indicate.
Some studies have shown that aspirin reduces the risk of heart disease and cancers, but it remains unclear whether aspirin significantly affects the risk of death, explain the authors in the Journal of the American Medical Association.
Andrew Chan (Harvard Medical School, Boston, Massachusetts) and colleagues examined the association between aspirin use and death in a prospective study of 79,439 women enrolled in the Nurse's Health Study, a large cohort of female nurses who have been followed-up since 1976.
Of the participants, 45,305 did not use aspirin, while 29,132 took low-to-moderate doses defined as between one and 14 standard 325-µg tablets per week, and 5002 took high doses of more than 14 tablets per week.
By June 2004, 9477 women had died, 1991 from heart disease and 4469 from cancer.
The women who reported current aspirin use had a 25% lower adjusted relative risk (RR) of death from any cause than those who took no aspirin at all (11.0% vs 14.9%, RR=0.75).
The association was even stronger for CVD death. Women currently taking aspirin had a 38% lower RR of dying from CVD than those not taking aspirin, at 21.2% versus 32.5% (RR=0.62).
There was a significant linear relationship between the duration of aspirin use and decreasing mortality overall. But, the authors note, "for death from CVD, much of the apparent benefit from associated with aspirin was achieved within the first 5 years."
They add: "In contrast, for all cancer-related mortality, a significant trend was not evident until after at least 10 years of aspirin use."
There was a U-shaped relationship between aspirin dose and all-cause death. Among those taking just 1-2 standard tablets per week, the RR was 0.70, and for those taking those taking 3-5 standard tablets a week, the RR was 0.65.
But those taking the highest doses did not have a lower risk of death than non-users, with an RR of 1.10 among those taking more than 14 tablets a week. A similar U-shaped relationship was seen for both CVD and cancer death.
Further analysis showed that there was a significant increase in death from hemorrhagic stroke among women taking high doses.
Because the study was observational, the authors say that the results are insufficient to alter current clinical recommendations.
"Nevertheless, these data support a need for continued investigation of the use of aspirin for chronic disease prevention," they conclude.
JAMA 2007; 167: 562-572
aspirin and NSAID's or coxibs
Summary and Comment
Effect of Aspirin on NSAID-Associated Ulcer Bleeding
Using low-dose aspirin concomitantly with coxibs negates coxibs’ benefit for lower bleeding risk.
Use of nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) increases risk for peptic ulcers and gastrointestinal bleeding. Selective cyclooxygenase-2 inhibitors (coxibs) confer lower risk for these complications. However, concomitant use of aspirin irreversibly and nonselectively inactivates the cyclooxygenase enzymes. Some data suggest that cotherapy with aspirin eliminates any benefit on bleeding risk that is imparted by coxibs.
To evaluate this issue, investigators performed a partially industry-supported case-control analysis. Cases were 2777 consecutive patients in the General Health System of Spain with endoscopy-proven upper gastrointestinal bleeding (UGIB) from peptic ulcers; 5532 age-matched patients without gastrointestinal disorders served as controls. All subjects were interviewed for medication use and medication history. Logistic regression analysis was used to determine odds ratios (ORs) for bleeding.
Current use of nonaspirin nonselective NSAIDs was associated with a fivefold increase in risk for bleeding (adjusted OR, 5.3; 95% CI, 4.5–6.2). Rofecoxib had a smaller effect (adjusted OR, 2.1; 95% CI, 1.1–4.0). Celecoxib and acetaminophen did not increase risk for bleeding; concomitant use of a proton-pump inhibitor (PPI) plus an NSAID also eliminated excess bleeding risk. Low-dose aspirin alone independently increased risk for bleeding, and also increased risk (with more than a simple additive effect) when combined with either nonselective NSAIDs or coxibs. The adjusted OR for nonselective NSAIDs went from 5.3 to 12.7 (95% CI, 7.0–23.0) with the addition of low-dose aspirin, and the adjusted OR for coxibs went from 1.0 to 14.5 (95% CI, 3.3–63.9). The authors concluded that prescribing coxibs instead of nonselective NSAIDs or prescribing PPIs as cotherapy with nonselective NSAIDs can lower risk for bleeding compared with nonselective NSAIDs alone, but the addition of low-dose aspirin negates these relative protective effects.
Comment: The mechanism of action responsible for aspirin’s antiplatelet effect —covalent alteration of the cyclooxygenase enzymes — logically would produce nonselective inactivation that would negate the selectivity of coxibs. This effect was seen early in trials of coxibs, when a relative reduction for bleeding was noted only among celecoxib patients who did not use low-dose aspirin (JAMA 2000; 284:1247). These results add further evidence that the benefits of the more-expensive coxibs disappear when used in conjunction with aspirin, even at low doses.
— David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)
Published in Journal Watch Gastroenterology March 30, 2007
Effect of Aspirin on NSAID-Associated Ulcer Bleeding
Using low-dose aspirin concomitantly with coxibs negates coxibs’ benefit for lower bleeding risk.
Use of nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) increases risk for peptic ulcers and gastrointestinal bleeding. Selective cyclooxygenase-2 inhibitors (coxibs) confer lower risk for these complications. However, concomitant use of aspirin irreversibly and nonselectively inactivates the cyclooxygenase enzymes. Some data suggest that cotherapy with aspirin eliminates any benefit on bleeding risk that is imparted by coxibs.
To evaluate this issue, investigators performed a partially industry-supported case-control analysis. Cases were 2777 consecutive patients in the General Health System of Spain with endoscopy-proven upper gastrointestinal bleeding (UGIB) from peptic ulcers; 5532 age-matched patients without gastrointestinal disorders served as controls. All subjects were interviewed for medication use and medication history. Logistic regression analysis was used to determine odds ratios (ORs) for bleeding.
Current use of nonaspirin nonselective NSAIDs was associated with a fivefold increase in risk for bleeding (adjusted OR, 5.3; 95% CI, 4.5–6.2). Rofecoxib had a smaller effect (adjusted OR, 2.1; 95% CI, 1.1–4.0). Celecoxib and acetaminophen did not increase risk for bleeding; concomitant use of a proton-pump inhibitor (PPI) plus an NSAID also eliminated excess bleeding risk. Low-dose aspirin alone independently increased risk for bleeding, and also increased risk (with more than a simple additive effect) when combined with either nonselective NSAIDs or coxibs. The adjusted OR for nonselective NSAIDs went from 5.3 to 12.7 (95% CI, 7.0–23.0) with the addition of low-dose aspirin, and the adjusted OR for coxibs went from 1.0 to 14.5 (95% CI, 3.3–63.9). The authors concluded that prescribing coxibs instead of nonselective NSAIDs or prescribing PPIs as cotherapy with nonselective NSAIDs can lower risk for bleeding compared with nonselective NSAIDs alone, but the addition of low-dose aspirin negates these relative protective effects.
Comment: The mechanism of action responsible for aspirin’s antiplatelet effect —covalent alteration of the cyclooxygenase enzymes — logically would produce nonselective inactivation that would negate the selectivity of coxibs. This effect was seen early in trials of coxibs, when a relative reduction for bleeding was noted only among celecoxib patients who did not use low-dose aspirin (JAMA 2000; 284:1247). These results add further evidence that the benefits of the more-expensive coxibs disappear when used in conjunction with aspirin, even at low doses.
— David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)
Published in Journal Watch Gastroenterology March 30, 2007
Friday, March 30, 2007
statins
Dr. J. Wouter Jukema, MD, PhD
Head Section Invasive Cardiology, Leiden University Medical Center
Dr. Wouter JukemaAbstract
Statins have provided the breakthrough needed in regulating plasma lipid levels to prevent CHD. Their main mechanism of action is known but the fact that they influence a central pathway important for cell growth and division opens up the possibility of further beneficial effects. Which of the host of pleiotropic actions of these drugs, if any, contributes to clinical benefit in patients with CHD is yet to be established. Given their exemplary safety and efficiency record, it is hard to envisage any new agents supplanting these drugs in their central role in coronary disease prevention. However, the size of the market means that pharmaceutical companies will continue to develop more powerful statins and adjunctive treatment. The need to demonstrate superior additional clinical effectiveness is a significant hurdle for any new compound. It will require substantial investment in large-scale clinical trials. The caveat here is that ever lower LDL levels (i.e. < 3.0 mmol/l) may not generate dramatic, or even worthwhile, decreases in CHD incidence. However, the actions of 'superstatins' on VLDL and HDL metabolism and on inflammation and endothelial dysfunction may yet open the way to widespread use of novel compounds. On the other hand, many health authorities look forward to the day when the original statins go off patent and become considerably cheaper to prescribe.
The latest beautiful news in "statin land" comes from the Heart Protection Study The MRC/BHF Heart Protection Study (HPS) involved 20,000 volunteers aged 40-80 years for whom there was substantial uncertainty about the balance of benefits and safety of cholesterol-lowering therapy. It specifically targeted groups of patients in which there was relatively little direct evidence of benefit including women, the over 70s, people with diabetes, those with non-coronary vascular disease, and those with average or below-average cholesterol levels. Volunteers were allocated either 40mg daily simvastatin as cholesterol-lowering therapy, or matching placebo. Study treatment and follow-up continued for an average of five and a half years in 69 UK hospitals. The funding of £21 million (euro 34 million) was provided by the UK¹s Medical Research Council (MRC), the British Heart Foundation (BHF), and the pharmaceutical companies Merck & Co. Inc. and Roche Vitamins Ltd. The study was, however, designed, conducted and analysed entirely independently of all funding sources by the Clinical Trial Service Unit of Oxford University. It started in 1994 and ended only October 2001. The major findings in HPS were:
* Cholesterol lowering with 40 mg of simvastatin treatment reduced the risk of heart attacks and of strokes by at least one-third, as well as reducing the need for arterial surgery, angioplasty and amputations.
* Reductions of at least one-third in these 'major vascular' events were found in a very wide range of high-risk patients for whom there had previously been uncertainty about using cholesterol-lowering therapy:
o women as well as men;
o people aged over 70 as well as younger people;
o people with blood levels of total cholesterol below approx. 5 mmol/l or LDL cholesterol below approx. 3 mmol/l, as well as those considered having 'high' levels.
* The benefits increased throughout the study treatment period (so more prolonged therapy might be expected to produce even bigger benefits), and are additional to those of other treatments used to prevent heart attacks and strokes.
Thus, a very large statin trial provides reliable evidence about the safety of simvastatin 40 mg daily regimen, with no support for previous concerns about possible adverse effects of lowering cholesterol on particular non-vascular causes of death, on cancers or on strokes due to bleeding. Also no severe rhabdomyolysis problems were encountered. Statins definitely earned their place
It is arguable that of all the 'new' manipulations of lipoprotein metabolism likely to give rise to substantial clinical benefit additional to that achieved with statins, promotion of reverse cholesterol transport shows the most promise. If it is accepted that statins can adequately control levels of apo-B-containing atherogenic lipoproteins (chylomicron and VLDL remnants, IDL, LDL), then the next challenge is to increase the flow of cholesterol from the artery wall through the HDL system back to the liver (a.o. CETP inhibitors).
Fibrates already have properties that suggest they do this to some extent; however, the clinical efficiency of these drugs seems limited to patients with initially high plasma triglyceride and low HDL cholesterol. New drugs in the fibrate class that affect peroxisome proliferator-activated receptors (PPARs) are currently being studied.
In general, agents with a wider spectrum of activity and benefit are needed. New developments have emerged or are underway such as drugs acting in the intestine (a/o. enterocyte ACAT inhibitors, stanol- and sterolesters, selective cholesterol absorption inhibitors (ezitimibe), and drugs acting in the liver (a/o. hepatic ACAT inhibitors, MTP inhibitors). As stated, the need to demonstrate superior additional clinical effectiveness is a significant hurdle for any new compound.
Head Section Invasive Cardiology, Leiden University Medical Center
Dr. Wouter JukemaAbstract
Statins have provided the breakthrough needed in regulating plasma lipid levels to prevent CHD. Their main mechanism of action is known but the fact that they influence a central pathway important for cell growth and division opens up the possibility of further beneficial effects. Which of the host of pleiotropic actions of these drugs, if any, contributes to clinical benefit in patients with CHD is yet to be established. Given their exemplary safety and efficiency record, it is hard to envisage any new agents supplanting these drugs in their central role in coronary disease prevention. However, the size of the market means that pharmaceutical companies will continue to develop more powerful statins and adjunctive treatment. The need to demonstrate superior additional clinical effectiveness is a significant hurdle for any new compound. It will require substantial investment in large-scale clinical trials. The caveat here is that ever lower LDL levels (i.e. < 3.0 mmol/l) may not generate dramatic, or even worthwhile, decreases in CHD incidence. However, the actions of 'superstatins' on VLDL and HDL metabolism and on inflammation and endothelial dysfunction may yet open the way to widespread use of novel compounds. On the other hand, many health authorities look forward to the day when the original statins go off patent and become considerably cheaper to prescribe.
The latest beautiful news in "statin land" comes from the Heart Protection Study The MRC/BHF Heart Protection Study (HPS) involved 20,000 volunteers aged 40-80 years for whom there was substantial uncertainty about the balance of benefits and safety of cholesterol-lowering therapy. It specifically targeted groups of patients in which there was relatively little direct evidence of benefit including women, the over 70s, people with diabetes, those with non-coronary vascular disease, and those with average or below-average cholesterol levels. Volunteers were allocated either 40mg daily simvastatin as cholesterol-lowering therapy, or matching placebo. Study treatment and follow-up continued for an average of five and a half years in 69 UK hospitals. The funding of £21 million (euro 34 million) was provided by the UK¹s Medical Research Council (MRC), the British Heart Foundation (BHF), and the pharmaceutical companies Merck & Co. Inc. and Roche Vitamins Ltd. The study was, however, designed, conducted and analysed entirely independently of all funding sources by the Clinical Trial Service Unit of Oxford University. It started in 1994 and ended only October 2001. The major findings in HPS were:
* Cholesterol lowering with 40 mg of simvastatin treatment reduced the risk of heart attacks and of strokes by at least one-third, as well as reducing the need for arterial surgery, angioplasty and amputations.
* Reductions of at least one-third in these 'major vascular' events were found in a very wide range of high-risk patients for whom there had previously been uncertainty about using cholesterol-lowering therapy:
o women as well as men;
o people aged over 70 as well as younger people;
o people with blood levels of total cholesterol below approx. 5 mmol/l or LDL cholesterol below approx. 3 mmol/l, as well as those considered having 'high' levels.
* The benefits increased throughout the study treatment period (so more prolonged therapy might be expected to produce even bigger benefits), and are additional to those of other treatments used to prevent heart attacks and strokes.
Thus, a very large statin trial provides reliable evidence about the safety of simvastatin 40 mg daily regimen, with no support for previous concerns about possible adverse effects of lowering cholesterol on particular non-vascular causes of death, on cancers or on strokes due to bleeding. Also no severe rhabdomyolysis problems were encountered. Statins definitely earned their place
It is arguable that of all the 'new' manipulations of lipoprotein metabolism likely to give rise to substantial clinical benefit additional to that achieved with statins, promotion of reverse cholesterol transport shows the most promise. If it is accepted that statins can adequately control levels of apo-B-containing atherogenic lipoproteins (chylomicron and VLDL remnants, IDL, LDL), then the next challenge is to increase the flow of cholesterol from the artery wall through the HDL system back to the liver (a.o. CETP inhibitors).
Fibrates already have properties that suggest they do this to some extent; however, the clinical efficiency of these drugs seems limited to patients with initially high plasma triglyceride and low HDL cholesterol. New drugs in the fibrate class that affect peroxisome proliferator-activated receptors (PPARs) are currently being studied.
In general, agents with a wider spectrum of activity and benefit are needed. New developments have emerged or are underway such as drugs acting in the intestine (a/o. enterocyte ACAT inhibitors, stanol- and sterolesters, selective cholesterol absorption inhibitors (ezitimibe), and drugs acting in the liver (a/o. hepatic ACAT inhibitors, MTP inhibitors). As stated, the need to demonstrate superior additional clinical effectiveness is a significant hurdle for any new compound.
Monday, March 26, 2007
Echo-cardiography
Transthoracic Echocardiography and Radionuclide Ventriculography. Transthoracic (standard surface) echocardiography is noninvasive and provides diagnostic information readily and safely. It gives information about ventricular function, chamber size and shape, wall thickness and valvular function. All such information is helpful in the management of patients with heart failure. Transthoracic echocardiography is inexpensive, reliable and widely available. Radionuclide ventriculography also may be used to assess left ventricular and right ventricular ejection fractions. Although this modality provides reproducible quantification of the ejection fraction, it does not yield information about valvular function or wall thickness. Echocardiography should be performed to guide management in patients with a presumed diagnosis of heart failure. The results can help to differentiate systolic from diastolic dysfunction and clarify relevant valvular dysfunction, as these disorders may be managed quite differently from systolic dysfunction.
Saturday, March 24, 2007
statins en bloeddruk
Statins lower blood pressure
19 March 2007
Statins produce small but clinically meaningful reductions in blood pressure (BP), meta-analysis results indicate.
The statin-induced BP changes are unrelated to effects on cholesterol, report Pasquale Strazzullo (Federico II University of Naples Medical School, Italy) and co-authors in the journal Hypertension.
The researchers conducted a meta-analysis of 20 randomized, controlled trials and found a small but significant reduction in systolic (S)BP and a trend towards a reduction in diastolic (D)BP with statin therapy.
Several studies have already documented the antihypertensive effects of statins, Strazzullo and colleagues explain, but these have been inconclusive owing to limitations such as small sample size, short treatment periods, and changes to concomitant antihypertensive therapy.
The team therefore conducted a systematic review of existing trials of statin therapy, including studies in which concomitant antihypertensive therapy was used only if this was not altered during follow-up.
The 20 trials included a total of 828 patients, 291 of whom were allocated to statin treatment groups and 272 to control groups, while 265 participated in crossover trials. The control groups received placebo in 18 trials, the lipid-lowering drug probucol in one, and fluvastatin plus orlistat (an inhibitor of intestinal lipid digestion) in another.
Overall, SBP was significantly lower in statin-treatment groups than in placebo or control hypolipidemic drug groups, by 1.9 mmHg. Statin therapy also lowered DBP, but to a lesser extent, with a mean overall reduction of 0.9 mmHg.
The effect of statin therapy on BP was greater in studies that included patients with higher baseline BP levels. For example, when the researchers restricted their analysis to studies including patients with baseline SBP >130 mmHg, statin therapy reduced SBP by an average of 4 mmHg.
Meanwhile, in studies including patients with average baseline DBP >80 mmHg, statin therapy reduced DBP by 1.2 mmHg.
In contrast, in studies where SBP was <130 mmHg, and/or DBP <80 mmHg, the average net effect of statins on either SBP or DBP was negligible.
Meta-regression analysis showed no evidence of any relationship between the response to statin therapy and age, length of the trial, baseline serum cholesterol, change in serum total cholesterol or low-density lipoprotein cholesterol, presence of diabetes, or use of antihypertensive drugs by at least some patients.
“Whatever the mechanism(s), our meta-analysis provided evidence of a favorable effect of statins on BP, particularly SBP, and indicated that the effect was larger in individuals with elevated BP,” the authors conclude.
Hypertension 2007; Advance online publication
© Copyright Current Medicine Group Ltd, 2006
19 March 2007
Statins produce small but clinically meaningful reductions in blood pressure (BP), meta-analysis results indicate.
The statin-induced BP changes are unrelated to effects on cholesterol, report Pasquale Strazzullo (Federico II University of Naples Medical School, Italy) and co-authors in the journal Hypertension.
The researchers conducted a meta-analysis of 20 randomized, controlled trials and found a small but significant reduction in systolic (S)BP and a trend towards a reduction in diastolic (D)BP with statin therapy.
Several studies have already documented the antihypertensive effects of statins, Strazzullo and colleagues explain, but these have been inconclusive owing to limitations such as small sample size, short treatment periods, and changes to concomitant antihypertensive therapy.
The team therefore conducted a systematic review of existing trials of statin therapy, including studies in which concomitant antihypertensive therapy was used only if this was not altered during follow-up.
The 20 trials included a total of 828 patients, 291 of whom were allocated to statin treatment groups and 272 to control groups, while 265 participated in crossover trials. The control groups received placebo in 18 trials, the lipid-lowering drug probucol in one, and fluvastatin plus orlistat (an inhibitor of intestinal lipid digestion) in another.
Overall, SBP was significantly lower in statin-treatment groups than in placebo or control hypolipidemic drug groups, by 1.9 mmHg. Statin therapy also lowered DBP, but to a lesser extent, with a mean overall reduction of 0.9 mmHg.
The effect of statin therapy on BP was greater in studies that included patients with higher baseline BP levels. For example, when the researchers restricted their analysis to studies including patients with baseline SBP >130 mmHg, statin therapy reduced SBP by an average of 4 mmHg.
Meanwhile, in studies including patients with average baseline DBP >80 mmHg, statin therapy reduced DBP by 1.2 mmHg.
In contrast, in studies where SBP was <130 mmHg, and/or DBP <80 mmHg, the average net effect of statins on either SBP or DBP was negligible.
Meta-regression analysis showed no evidence of any relationship between the response to statin therapy and age, length of the trial, baseline serum cholesterol, change in serum total cholesterol or low-density lipoprotein cholesterol, presence of diabetes, or use of antihypertensive drugs by at least some patients.
“Whatever the mechanism(s), our meta-analysis provided evidence of a favorable effect of statins on BP, particularly SBP, and indicated that the effect was larger in individuals with elevated BP,” the authors conclude.
Hypertension 2007; Advance online publication
© Copyright Current Medicine Group Ltd, 2006
anatomie hart.
klik op Google: left anterior coronary artery en je ziet alles over de anatomie van het hart
zie ook item twee voor hart centrum Texas voor E-mail informatie
zie ook item twee voor hart centrum Texas voor E-mail informatie
Friday, March 23, 2007
occult blood teste colon
1. Home>
2. Primary Care>
3. General Medicine>
4. Summary and Comment
Quantitative Fecal Occult Blood Testing Promising
A noninvasive screening test for colorectal cancer would be useful.
Guaiac-based fecal occult blood tests (FOBTs) are nonspecific and insensitive. Researchers with support from the maker of a quantitative immunochemical FOBT specific for human hemoglobin tested its performance in 1000 ambulatory adults undergoing elective colonoscopy. Some patients were asymptomatic, some were at high risk for cancer, and some were symptomatic.
At colonoscopy, cancer was detected in 17 patients, and advanced polyps in 74. Fecal hemoglobin concentrations were significantly higher in these patients than in others. A fecal hemoglobin threshold of 75 ng/dL (as measured in 3 samples) was used to define an abnormal result; at this level, the immunochemical FOBT had a sensitivity of 67% and specificity of 91% for advanced neoplasia. For cancer, sensitivity and specificity were 94% and 88%.
Comment: Because the quantitative immunochemical FOBT appears to have reasonable sensitivity and specificity for a screening test, some people might use it to select patients for colonoscopy. But people who desire greater certainty will likely forgo this test, as they forgo the guaiac-based tests. An editorialist recommends that quantitative FOBTs be preferred to guaiac-based tests whenever an FOBT is a component of a screening strategy. In the U.S., some currently available immunochemical FOBTs can be reported quantitatively, but they are not generally used that way yet.
— Richard Saitz, MD, MPH, FACP, FASAM
Published in Journal Watch General Medicine March 22, 2007
Citation(s):
2. Primary Care>
3. General Medicine>
4. Summary and Comment
Quantitative Fecal Occult Blood Testing Promising
A noninvasive screening test for colorectal cancer would be useful.
Guaiac-based fecal occult blood tests (FOBTs) are nonspecific and insensitive. Researchers with support from the maker of a quantitative immunochemical FOBT specific for human hemoglobin tested its performance in 1000 ambulatory adults undergoing elective colonoscopy. Some patients were asymptomatic, some were at high risk for cancer, and some were symptomatic.
At colonoscopy, cancer was detected in 17 patients, and advanced polyps in 74. Fecal hemoglobin concentrations were significantly higher in these patients than in others. A fecal hemoglobin threshold of 75 ng/dL (as measured in 3 samples) was used to define an abnormal result; at this level, the immunochemical FOBT had a sensitivity of 67% and specificity of 91% for advanced neoplasia. For cancer, sensitivity and specificity were 94% and 88%.
Comment: Because the quantitative immunochemical FOBT appears to have reasonable sensitivity and specificity for a screening test, some people might use it to select patients for colonoscopy. But people who desire greater certainty will likely forgo this test, as they forgo the guaiac-based tests. An editorialist recommends that quantitative FOBTs be preferred to guaiac-based tests whenever an FOBT is a component of a screening strategy. In the U.S., some currently available immunochemical FOBTs can be reported quantitatively, but they are not generally used that way yet.
— Richard Saitz, MD, MPH, FACP, FASAM
Published in Journal Watch General Medicine March 22, 2007
Citation(s):
Friday, March 16, 2007
warfarin en aspirin
Publication Logo
Ximelagatran Comparable to Warfarin in Stroke Prevention
Reuters Health Information 2007. © 2007 Reuters Ltd.
Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.
NEW YORK (Reuters Health) Mar 12 - Ximelagatran compares favorably to warfarin for secondary stroke prevention in patients with atrial fibrillation. However, the combination of warfarin plus aspirin appears unsafe, researchers report in the March issue of Stroke.
Ximelagatran was withdrawn from the market and clinical development by AstraZeneca in February of last year, but the current findings suggest that other direct thrombin inhibitors may have therapeutic potential in this high-risk population.
Lead investigator Dr. Paul T. Akins told Reuters Health that this was a rigorous test of "whether oral direct thrombin inhibitors, a new class of drugs, can compete with warfarin in stroke prevention without an increase in bleeding or other adverse effects."
Dr. Akins of the Mercy Stroke Center, Sacramento, California and colleagues pooled data from two trials involving more than 7000 patients with or without a previous stroke or transient ischemic attack.
The annual rate of stroke or systemic embolic events in those who had a history of stroke was 2.83% with ximelagatran and 3.27% with warfarin. For those without prior stroke, the corresponding proportions were 1.31% and 1.26%.
"Ximelagatran proved to be quite effective at stroke prevention with a similar bleeding profile to warfarin," added Dr. Akins. "Unfortunately, adverse liver effects kept ximelagatran from market approval."
However, another key finding from this study was the hazard associated with combination aspirin/anticoagulant therapy, a common but unproven clinical practice.
"Combining low-dose aspirin with warfarin did not boost stroke prevention," continued Dr. Akins, "but bleeding jumped three-fold, from 1.5% per year to 4.95% per year."
He concluded that "combination aspirin/warfarin was not better than individual agents, and doctors need to understand it is dangerous."
Stroke 2007;38:874-880.
Ximelagatran Comparable to Warfarin in Stroke Prevention
Reuters Health Information 2007. © 2007 Reuters Ltd.
Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.
NEW YORK (Reuters Health) Mar 12 - Ximelagatran compares favorably to warfarin for secondary stroke prevention in patients with atrial fibrillation. However, the combination of warfarin plus aspirin appears unsafe, researchers report in the March issue of Stroke.
Ximelagatran was withdrawn from the market and clinical development by AstraZeneca in February of last year, but the current findings suggest that other direct thrombin inhibitors may have therapeutic potential in this high-risk population.
Lead investigator Dr. Paul T. Akins told Reuters Health that this was a rigorous test of "whether oral direct thrombin inhibitors, a new class of drugs, can compete with warfarin in stroke prevention without an increase in bleeding or other adverse effects."
Dr. Akins of the Mercy Stroke Center, Sacramento, California and colleagues pooled data from two trials involving more than 7000 patients with or without a previous stroke or transient ischemic attack.
The annual rate of stroke or systemic embolic events in those who had a history of stroke was 2.83% with ximelagatran and 3.27% with warfarin. For those without prior stroke, the corresponding proportions were 1.31% and 1.26%.
"Ximelagatran proved to be quite effective at stroke prevention with a similar bleeding profile to warfarin," added Dr. Akins. "Unfortunately, adverse liver effects kept ximelagatran from market approval."
However, another key finding from this study was the hazard associated with combination aspirin/anticoagulant therapy, a common but unproven clinical practice.
"Combining low-dose aspirin with warfarin did not boost stroke prevention," continued Dr. Akins, "but bleeding jumped three-fold, from 1.5% per year to 4.95% per year."
He concluded that "combination aspirin/warfarin was not better than individual agents, and doctors need to understand it is dangerous."
Stroke 2007;38:874-880.
Thursday, March 15, 2007
the third gender
Being A Eunuch
By Siddarth Narrain
Frontline
14 October,2003
"Ever since I can remember, I have always identified myself as a woman. I lived in Namakkal, a small town in Tamil Nadu. When I was in the 10th standard I realised that the only way for me to be comfortable was to join the hijra community. It was then that my family found out that I frequently met hijras who lived in the city. One day, when my father was away, my brother, encouraged by my mother, started beating me with a cricket bat. I locked myself in a room to escape from the beatings. My mother and brother then tried to break into the room to beat me up further. Some of my relatives intervened and brought me out of the room. I related my ordeal to an uncle of mine who gave me Rs.50 and asked me to go home. Instead, I took the money and went to live with a group of hijras in Erode."
* "My name is Sachin and I am 23 years old. As a child I always enjoyed putting make-up like `vibhuti' or `kum kum' and my parents always saw me as a girl. I am male but I only have female feelings. I used to help my mother in all the housework like cooking, washing and cleaning. Over the years I started assuming more of the domestic responsibilities at home. The neighbours started teasing me. They would call out to me and ask: `Why don't you go out and work like a man?' or `Why are you staying at home like a girl?' But I liked being a girl. I felt shy about going out and working. Relatives would also mock and scold me on this score. Every day I would go out of the house to bring water. And as I walked back with the water I would always be teased. I felt very ashamed. I even felt suicidal. How could I live like that? But my parents never protested. They were helpless."
- From the Peoples Union of Civil Liberties (Karnataka) Report on Human Rights Violations Against the Transgender Community, released in September 2003.
Hijras (Eunuchs) in India have virtually no safe spaces, not even in their families, where they are protected from prejudice and abuse. The recently released PUCL(K) Report on Human Rights Violations Against the Transgender Community has documented the kind of prejudice that hijras face in Bangalore. The report shows that this prejudice is translated into violence, often of a brutal nature, in public spaces, police stations, prisons and even in their homes. The main factor behind the violence is that society is not able to come to terms with the fact that hijras do not conform to the accepted gender divisions. In addition to this, most hijras have a lower middle-class background, which makes them susceptible to harassment by the police. The discrimination based on their class and gender makes the hijra community one of the most disempowered groups in Indian society.
However, the human rights movement in India has begun to take notice of the concerns of the community only recently. Legal scholar Upendra Baxi, in the foreword to the PUCL(K) report, says: "The dominant discourse on human rights in India has yet to come to terms with the production/reproduction of absolute human rightlessness of transgender communities.... At stake is the human right to be different, the right to recognition of different pathways of sexuality, a right to immunity from the oppressive and repressive labelling of despised sexuality. Such a human right does not exist in India."
Transgender communities have existed in most parts of the world with their own local identities, customs and rituals. They are called baklas in the Philippines, berdaches among American Indian tribes, serrers in Africa and hijras, jogappas, jogtas, shiv-shaktis and aravanis in South Asia. The hijra community in India, which has a recorded history of more than 4,000 years, was considered to have special powers because of its third-gender status. It was part of a well-established `eunuch culture' in many societies, especially in West Asia, and its members held sanctioned positions in royal courts.
Hijras trace their origins to myths in the Ramayana and the Mahabharata. Rama, while leaving for the forest upon being banished from the kingdom for 14 years, turns around to his followers and asks all the `men and women' to return to the city. Among his followers the hijras alone do not feel bound by this direction and decide to stay with him. Impressed with their devotion, Rama sanctions them the power to confer blessings on people on auspicious occasions like childbirth and marriage, and also at inaugural functions. This set the stage for the custom of badhai in which hijras sing, dance and confer blessings.
The legend in the Mahabharata is that Aravan, the son of Arjuna and Nagakanya, offers to be sacrificed to Goddess Kali to ensure the victory of the Pandavas in the Kurukshetra war. The only condition that he made was to spend the last night of his life in matrimony. Since no woman was willing to marry one who was doomed to be killed, Krishna assumes the form of a beautiful woman called Mohini and marries him. The hijras of Tamil Nadu consider Aravan their progenitor and call themselves aravanis.
The hijra community is divided into seven houses, each headed by a `nayak' who appoints gurus or spiritual leaders to train their wards or `chelas' in badhai and protect them. Hijras in South India do not have the same cultural role as their counterparts in North India and most of them take up sex work as a means of earning a living.
Kothi is a term used to describe male homosexuals who take on the female role; they are largely from a non-English-speaking lower middle-class background. Many kothis marry owing to family pressure but continue to have same sex relationships. There is a symbolic relationship between kothis and hijras, which has been strengthened because of the lack of other support systems for kothis in cities and smaller towns.
For many hijras and kothis, sex work is the only option because no one is willing to employ them because of their gender identity. Even as commercial sex workers, hijras are the most vulnerable group as they are placed right at the bottom of the hierarchy of sex workers. This results in their having little bargaining power and being unable to ensure that their customers practise safe sex. They are also at risk of violence both from customers and the police.
According to the PUCL(K) report, violence is a widespread and everyday reality for hijra and kothi sex workers in Bangalore. Owing to the intolerance they face from their families, hijras and kothis often use public spaces like parks and toilets to entertain sexual partners, lovers and sometimes even clients. The lack of protection or privacy afforded by their own accommodation, makes them vulnerable to violence, inflicted largely by the police.
The harassment and surveillance by the police sometimes extends into the privacy of their homes. The place with the most scope for abuse is the police station where the police, on a regular basis, violate all canons of civilised behaviour by physically, sexually and verbally abusing and humiliating hijras and kothis.
Prisons are also places where anyone who is seen as not being `masculine enough' is harassed and often physically and sexually abused. According to the PUCL(K) report, the deeply sexual nature of the violence indicates that the sexuality of the hijra becomes the target of prurient curiosity, which could in its extreme form manifest itself as brutal violence. Sexual abuse and violence, apart from being the most systematic tool for dehumanising an individual, can be understood as a punishment for not conforming to the gender roles laid down by society.
According to the two main diagnostic systems used in the Indian medical establishment, transsexualism is defined as a `gender identity disorder'. The doctors usually prescribe a sexual reassignment surgery (SRS), which currently resorts to hormone therapy and surgical reconstruction and may include electrolysis, speech therapy and counselling. Surgical construction could include the removal of male sex organs and the construction of female ones. Since government hospitals and qualified private practitioners do not usually perform SRS, many hijras go to quacks, thus placing themselves at serious risk. Neither the Indian Council for Medical Research (ICMR) nor the Medical Council of India (MCI) have formulated any guidelines to be followed in SRS. The attitude of the medical establishment has only reinforced the low sense of self-worth that many hijras have at various moments in their lives.
The media have also reinforced stereotypes about hijras. In December 2002, Chandini, a hijra from Bangalore, died of severe burns in her home. The hijra community alleged that her husband, who had a long-standing relationship with her, had murdered her for money, and demanded that an impartial probe be held. The police refused and stuck to their version that it was a case of suicide. The local newspapers, including Police News, portrayed the incident as an exciting romantic tryst between two strangers, in which the unsuspecting man discovered the true sexual identity of the wily hijra. Even a progressive and anti-establishment publication, in its story, described hijras as a race apart, freaks of the underworld, half-man half-woman, almost devilish in their customs and practices. This kind of gender stereotyping was seen in many local English newspapers as well.
The systematic violence that hijras face is reinforced by institutions such as the family, media and the medical establishment, and is given legitimacy by the legal system. The violence that the hijra community faces from the police can be traced to the 1897 amendment to the Criminal Tribes Act of 1871, which was subtitled "An Act for the Registration of Criminal Tribes and Eunuchs". Under this law, the local government was required to keep a register of the names and residences of all eunuchs who were "reasonably suspected of kidnapping or castrating children or committing offences under Section 377 of the Indian Penal Code". The law also decreed eunuchs as incapable of acting as a guardian, making a gift, drawing up a will or adopting a son.
The law that is used most to threaten the hijra and kothi communities, as well as the homosexual community in India, is Section 377 of the IPC, which criminalises "carnal intercourse against the order of nature with any man, woman or animal" even if it is voluntary. In effect, it criminalises certain kinds of sexual acts that are perceived to be `unnatural'. The law, which has its origin in colonial ideas of morality, in effect presumes that a hijra or a homosexual person is engaging in `carnal intercourse against the order of nature", thus making this entire lot of marginalised communities vulnerable to police harassment and arrest.
The Immoral Traffic Prevention Act (ITPA) of 1956 (amended in 1986), whose stated objective is to criminalise brothel-keeping, trafficking, pimping and soliciting, in reality targets the visible figure of the sex worker and enables the police to arrest and intimidate the transgender sex-worker population.
T. SINGARAVELOU
Winners of the Miss Koovakkam 2003 beauty pageant for eunuchs held at Villupuram, Tamil Nadu, in April. Hijras converge at Koovakkam every year.
The hijra community is deprived of several rights under civil law because Indian law recognises only two sexes. This means that hijras do not have the right to vote, marry and own a ration card, a passport or a driving licence, or claim employment and health benefits.
In north and central India, hijras, who have contested and won elections to local and State bodies, are now facing legal challenges. In February 2003, the Madhya Pradesh High Court struck down the election of Kamala Jaan as the Mayor of the Municipal Corporation of Katni. The court's logic was that since Kamala Jaan was not a woman, she could not contest the seat, which was reserved for women. Lawyer Pratul Shandilya, who is arguing Kamala Jaan's case, said: "I have already filed the Special Leave Petition (SLP) before the Supreme Court, and the court has also granted leave in the petition."
The High Court verdict came despite a direction from the Election Commission (E.C.) in September 1994 that hijras can be registered in the electoral roles either as male or female depending on their statement at the time of enrolment. This direction was given by the E.C. after Shabnam, a hijra candidate from the Sihagpur Assembly constituency in Madhya Pradesh, wrote to the Chief Election Commissioner enquiring about which category hijras were classified under.
BUT around the world, countries are beginning to recognise the rights of transgender people. In a landmark judgment (Christine Goodwin vs. the United Kingdom, 2002) the European Court of Human Rights declared that the U.K. government's failure to alter the birth certificates of transsexual people or to allow them to marry in their new gender role was a breach of the European Convention on Human Rights. It said that a test of biological factors could no longer be used to deny recognition legally to the change of gender that a transsexual had undergone. In New Zealand, in New Zealand Attorney General vs. the Family Court at Otahuhu (1994), the court upheld the principle that for purposes of marriage, transsexual people should be legally recognised in their re-assigned sex.
In Victoria, Australia, the Equal Opportunity (Gender Identity and Sexual Orientation) Bill, debated and amended in the State Assembly in 2000, has laid down a comprehensive definition of gender identity by incorporating various social and cultural factors that shape a person's gender and sexual identity. The International Bill of Gender Rights, adopted in 1995, provides for the right to define and express freely one's gender identity, and is therefore a model for progressive legislative change.
OF late the Indian hijra community has begun to mobilise themselves through the formation of a collective. Sangama, an organisation working with hijras, kothis and sex workers in Bangalore, has played an important role by helping them organise and fight for their rights. Its services include organising a drop-in centre for hijras and kothis, conducting a series of public rallies and marches, using legal assistance in case of police harassment, and establishing links with other social movements. When the owners' association of the apartment complex where the Sangama office was located objected to hijras visiting the premises, the organisation sent letters to, among others, the Chief Minister and the National Human Rights Commission (NHRC). The Chief Minister responded saying that he would ensure that the matter was investigated. A letter from the NHRC to the police station concerned resulted in the police assuring Sangama that the rights of all residents of the building, including the employees and visitors to Sangama, would be protected.
In December 2002, hijras, kothis and other sexual minorities in Bangalore formed a collective called Vividha. Its charter of demands includes the repeal of Section 377 and the ITPA. It has also demanded that hijras be recognised as women, be given equal opportunities, with entitlement to housing, employment benefits and rail travel concession.
In 2002, the hijra community in Bangalore organised `Hijra Habba', a festival of sports and cultural events, which was covered extensively and positively by the media. In 2003, the festival was staged again in Bangalore's Town Hall and over 100 hijras participated in the meet. Kajol, a hijra who addressed the packed hall on the occasion, said: "I was initially told not to speak in front of the media because it would affect my family. But I decided that it was important for me to speak and assert my identity." She added that "hijras were part of a wider community of sexual minorities" and singled out society's treatment of lesbians for whom there exist very few spaces.
The organisations of the hijra community can be seen as constituting a larger movement of sexual minority groups in India. They are challenging the constitutional validity of Section 377 and are organising a campaign questioning the government's stand that the law should remain. The discrimination and violence that hijras face show that it is high time that both the government and the human rights movement in the country begin to take this issue with the seriousness it deserves.
Copyright © 2003, Frontline.
Send this page to a friend
By Siddarth Narrain
Frontline
14 October,2003
"Ever since I can remember, I have always identified myself as a woman. I lived in Namakkal, a small town in Tamil Nadu. When I was in the 10th standard I realised that the only way for me to be comfortable was to join the hijra community. It was then that my family found out that I frequently met hijras who lived in the city. One day, when my father was away, my brother, encouraged by my mother, started beating me with a cricket bat. I locked myself in a room to escape from the beatings. My mother and brother then tried to break into the room to beat me up further. Some of my relatives intervened and brought me out of the room. I related my ordeal to an uncle of mine who gave me Rs.50 and asked me to go home. Instead, I took the money and went to live with a group of hijras in Erode."
* "My name is Sachin and I am 23 years old. As a child I always enjoyed putting make-up like `vibhuti' or `kum kum' and my parents always saw me as a girl. I am male but I only have female feelings. I used to help my mother in all the housework like cooking, washing and cleaning. Over the years I started assuming more of the domestic responsibilities at home. The neighbours started teasing me. They would call out to me and ask: `Why don't you go out and work like a man?' or `Why are you staying at home like a girl?' But I liked being a girl. I felt shy about going out and working. Relatives would also mock and scold me on this score. Every day I would go out of the house to bring water. And as I walked back with the water I would always be teased. I felt very ashamed. I even felt suicidal. How could I live like that? But my parents never protested. They were helpless."
- From the Peoples Union of Civil Liberties (Karnataka) Report on Human Rights Violations Against the Transgender Community, released in September 2003.
Hijras (Eunuchs) in India have virtually no safe spaces, not even in their families, where they are protected from prejudice and abuse. The recently released PUCL(K) Report on Human Rights Violations Against the Transgender Community has documented the kind of prejudice that hijras face in Bangalore. The report shows that this prejudice is translated into violence, often of a brutal nature, in public spaces, police stations, prisons and even in their homes. The main factor behind the violence is that society is not able to come to terms with the fact that hijras do not conform to the accepted gender divisions. In addition to this, most hijras have a lower middle-class background, which makes them susceptible to harassment by the police. The discrimination based on their class and gender makes the hijra community one of the most disempowered groups in Indian society.
However, the human rights movement in India has begun to take notice of the concerns of the community only recently. Legal scholar Upendra Baxi, in the foreword to the PUCL(K) report, says: "The dominant discourse on human rights in India has yet to come to terms with the production/reproduction of absolute human rightlessness of transgender communities.... At stake is the human right to be different, the right to recognition of different pathways of sexuality, a right to immunity from the oppressive and repressive labelling of despised sexuality. Such a human right does not exist in India."
Transgender communities have existed in most parts of the world with their own local identities, customs and rituals. They are called baklas in the Philippines, berdaches among American Indian tribes, serrers in Africa and hijras, jogappas, jogtas, shiv-shaktis and aravanis in South Asia. The hijra community in India, which has a recorded history of more than 4,000 years, was considered to have special powers because of its third-gender status. It was part of a well-established `eunuch culture' in many societies, especially in West Asia, and its members held sanctioned positions in royal courts.
Hijras trace their origins to myths in the Ramayana and the Mahabharata. Rama, while leaving for the forest upon being banished from the kingdom for 14 years, turns around to his followers and asks all the `men and women' to return to the city. Among his followers the hijras alone do not feel bound by this direction and decide to stay with him. Impressed with their devotion, Rama sanctions them the power to confer blessings on people on auspicious occasions like childbirth and marriage, and also at inaugural functions. This set the stage for the custom of badhai in which hijras sing, dance and confer blessings.
The legend in the Mahabharata is that Aravan, the son of Arjuna and Nagakanya, offers to be sacrificed to Goddess Kali to ensure the victory of the Pandavas in the Kurukshetra war. The only condition that he made was to spend the last night of his life in matrimony. Since no woman was willing to marry one who was doomed to be killed, Krishna assumes the form of a beautiful woman called Mohini and marries him. The hijras of Tamil Nadu consider Aravan their progenitor and call themselves aravanis.
The hijra community is divided into seven houses, each headed by a `nayak' who appoints gurus or spiritual leaders to train their wards or `chelas' in badhai and protect them. Hijras in South India do not have the same cultural role as their counterparts in North India and most of them take up sex work as a means of earning a living.
Kothi is a term used to describe male homosexuals who take on the female role; they are largely from a non-English-speaking lower middle-class background. Many kothis marry owing to family pressure but continue to have same sex relationships. There is a symbolic relationship between kothis and hijras, which has been strengthened because of the lack of other support systems for kothis in cities and smaller towns.
For many hijras and kothis, sex work is the only option because no one is willing to employ them because of their gender identity. Even as commercial sex workers, hijras are the most vulnerable group as they are placed right at the bottom of the hierarchy of sex workers. This results in their having little bargaining power and being unable to ensure that their customers practise safe sex. They are also at risk of violence both from customers and the police.
According to the PUCL(K) report, violence is a widespread and everyday reality for hijra and kothi sex workers in Bangalore. Owing to the intolerance they face from their families, hijras and kothis often use public spaces like parks and toilets to entertain sexual partners, lovers and sometimes even clients. The lack of protection or privacy afforded by their own accommodation, makes them vulnerable to violence, inflicted largely by the police.
The harassment and surveillance by the police sometimes extends into the privacy of their homes. The place with the most scope for abuse is the police station where the police, on a regular basis, violate all canons of civilised behaviour by physically, sexually and verbally abusing and humiliating hijras and kothis.
Prisons are also places where anyone who is seen as not being `masculine enough' is harassed and often physically and sexually abused. According to the PUCL(K) report, the deeply sexual nature of the violence indicates that the sexuality of the hijra becomes the target of prurient curiosity, which could in its extreme form manifest itself as brutal violence. Sexual abuse and violence, apart from being the most systematic tool for dehumanising an individual, can be understood as a punishment for not conforming to the gender roles laid down by society.
According to the two main diagnostic systems used in the Indian medical establishment, transsexualism is defined as a `gender identity disorder'. The doctors usually prescribe a sexual reassignment surgery (SRS), which currently resorts to hormone therapy and surgical reconstruction and may include electrolysis, speech therapy and counselling. Surgical construction could include the removal of male sex organs and the construction of female ones. Since government hospitals and qualified private practitioners do not usually perform SRS, many hijras go to quacks, thus placing themselves at serious risk. Neither the Indian Council for Medical Research (ICMR) nor the Medical Council of India (MCI) have formulated any guidelines to be followed in SRS. The attitude of the medical establishment has only reinforced the low sense of self-worth that many hijras have at various moments in their lives.
The media have also reinforced stereotypes about hijras. In December 2002, Chandini, a hijra from Bangalore, died of severe burns in her home. The hijra community alleged that her husband, who had a long-standing relationship with her, had murdered her for money, and demanded that an impartial probe be held. The police refused and stuck to their version that it was a case of suicide. The local newspapers, including Police News, portrayed the incident as an exciting romantic tryst between two strangers, in which the unsuspecting man discovered the true sexual identity of the wily hijra. Even a progressive and anti-establishment publication, in its story, described hijras as a race apart, freaks of the underworld, half-man half-woman, almost devilish in their customs and practices. This kind of gender stereotyping was seen in many local English newspapers as well.
The systematic violence that hijras face is reinforced by institutions such as the family, media and the medical establishment, and is given legitimacy by the legal system. The violence that the hijra community faces from the police can be traced to the 1897 amendment to the Criminal Tribes Act of 1871, which was subtitled "An Act for the Registration of Criminal Tribes and Eunuchs". Under this law, the local government was required to keep a register of the names and residences of all eunuchs who were "reasonably suspected of kidnapping or castrating children or committing offences under Section 377 of the Indian Penal Code". The law also decreed eunuchs as incapable of acting as a guardian, making a gift, drawing up a will or adopting a son.
The law that is used most to threaten the hijra and kothi communities, as well as the homosexual community in India, is Section 377 of the IPC, which criminalises "carnal intercourse against the order of nature with any man, woman or animal" even if it is voluntary. In effect, it criminalises certain kinds of sexual acts that are perceived to be `unnatural'. The law, which has its origin in colonial ideas of morality, in effect presumes that a hijra or a homosexual person is engaging in `carnal intercourse against the order of nature", thus making this entire lot of marginalised communities vulnerable to police harassment and arrest.
The Immoral Traffic Prevention Act (ITPA) of 1956 (amended in 1986), whose stated objective is to criminalise brothel-keeping, trafficking, pimping and soliciting, in reality targets the visible figure of the sex worker and enables the police to arrest and intimidate the transgender sex-worker population.
T. SINGARAVELOU
Winners of the Miss Koovakkam 2003 beauty pageant for eunuchs held at Villupuram, Tamil Nadu, in April. Hijras converge at Koovakkam every year.
The hijra community is deprived of several rights under civil law because Indian law recognises only two sexes. This means that hijras do not have the right to vote, marry and own a ration card, a passport or a driving licence, or claim employment and health benefits.
In north and central India, hijras, who have contested and won elections to local and State bodies, are now facing legal challenges. In February 2003, the Madhya Pradesh High Court struck down the election of Kamala Jaan as the Mayor of the Municipal Corporation of Katni. The court's logic was that since Kamala Jaan was not a woman, she could not contest the seat, which was reserved for women. Lawyer Pratul Shandilya, who is arguing Kamala Jaan's case, said: "I have already filed the Special Leave Petition (SLP) before the Supreme Court, and the court has also granted leave in the petition."
The High Court verdict came despite a direction from the Election Commission (E.C.) in September 1994 that hijras can be registered in the electoral roles either as male or female depending on their statement at the time of enrolment. This direction was given by the E.C. after Shabnam, a hijra candidate from the Sihagpur Assembly constituency in Madhya Pradesh, wrote to the Chief Election Commissioner enquiring about which category hijras were classified under.
BUT around the world, countries are beginning to recognise the rights of transgender people. In a landmark judgment (Christine Goodwin vs. the United Kingdom, 2002) the European Court of Human Rights declared that the U.K. government's failure to alter the birth certificates of transsexual people or to allow them to marry in their new gender role was a breach of the European Convention on Human Rights. It said that a test of biological factors could no longer be used to deny recognition legally to the change of gender that a transsexual had undergone. In New Zealand, in New Zealand Attorney General vs. the Family Court at Otahuhu (1994), the court upheld the principle that for purposes of marriage, transsexual people should be legally recognised in their re-assigned sex.
In Victoria, Australia, the Equal Opportunity (Gender Identity and Sexual Orientation) Bill, debated and amended in the State Assembly in 2000, has laid down a comprehensive definition of gender identity by incorporating various social and cultural factors that shape a person's gender and sexual identity. The International Bill of Gender Rights, adopted in 1995, provides for the right to define and express freely one's gender identity, and is therefore a model for progressive legislative change.
OF late the Indian hijra community has begun to mobilise themselves through the formation of a collective. Sangama, an organisation working with hijras, kothis and sex workers in Bangalore, has played an important role by helping them organise and fight for their rights. Its services include organising a drop-in centre for hijras and kothis, conducting a series of public rallies and marches, using legal assistance in case of police harassment, and establishing links with other social movements. When the owners' association of the apartment complex where the Sangama office was located objected to hijras visiting the premises, the organisation sent letters to, among others, the Chief Minister and the National Human Rights Commission (NHRC). The Chief Minister responded saying that he would ensure that the matter was investigated. A letter from the NHRC to the police station concerned resulted in the police assuring Sangama that the rights of all residents of the building, including the employees and visitors to Sangama, would be protected.
In December 2002, hijras, kothis and other sexual minorities in Bangalore formed a collective called Vividha. Its charter of demands includes the repeal of Section 377 and the ITPA. It has also demanded that hijras be recognised as women, be given equal opportunities, with entitlement to housing, employment benefits and rail travel concession.
In 2002, the hijra community in Bangalore organised `Hijra Habba', a festival of sports and cultural events, which was covered extensively and positively by the media. In 2003, the festival was staged again in Bangalore's Town Hall and over 100 hijras participated in the meet. Kajol, a hijra who addressed the packed hall on the occasion, said: "I was initially told not to speak in front of the media because it would affect my family. But I decided that it was important for me to speak and assert my identity." She added that "hijras were part of a wider community of sexual minorities" and singled out society's treatment of lesbians for whom there exist very few spaces.
The organisations of the hijra community can be seen as constituting a larger movement of sexual minority groups in India. They are challenging the constitutional validity of Section 377 and are organising a campaign questioning the government's stand that the law should remain. The discrimination and violence that hijras face show that it is high time that both the government and the human rights movement in the country begin to take this issue with the seriousness it deserves.
Copyright © 2003, Frontline.
Send this page to a friend
Saturday, March 10, 2007
warfarin hemorrhages
Total of 170 major hemorrhages were identified during 15,300 person-years of warfarin therapy and 162 major hemorrhages during 15,530 person-years off warfarin therapy. Hemorrhage rates rose with older age, with an average increase in hemorrhage rate of 1.2 (95% confidence interval (CI) 1.0-1.4) per older age category in patients taking warfarin and 1.5 (95% CI=1.3-1.8) in those not taking warfarin. Intracranial hemorrhage rates were significantly higher in those aged 80 and older (adjusted rate ratio=1.8, 95% CI=1.1-3.1 for those taking warfarin, adjusted rate ratio=4.7, 95% CI=2.4-9.2 for those not taking warfarin) than in those younger than 80. CONCLUSION:
Older age increases the risk of major hemorrhage, particularly intracranial hemorrhage, in patients with atrial fibrillation, whether or not they are taking warfarin. Hemorrhage rates were generally comparable with those reported in previous randomized trials, indicating that carefully monitored warfarin therapy can be used with reasonable safety in older patients.
Older age increases the risk of major hemorrhage, particularly intracranial hemorrhage, in patients with atrial fibrillation, whether or not they are taking warfarin. Hemorrhage rates were generally comparable with those reported in previous randomized trials, indicating that carefully monitored warfarin therapy can be used with reasonable safety in older patients.
warfarin en AF
Antithrombotic Therapy for Atrial Fibrillation
To determine whether antithrombotic therapy is appropriate, physicians should evaluate patients' stroke risk, not just their AF classification.
Patients with atrial fibrillation (AF) are at high risk for thromboembolism if they are older (age, >75); have cardiovascular risk factors such as prior ischemic stroke, transient ischemic attack, systemic embolism, left ventricular systolic dysfunction, or congestive heart failure; or have hypertension or diabetes (Chest 2004; 126:429S). Logically, all such patients should be protected with antithrombotic therapy, but, in a recent study, investigators found otherwise.
Researchers from the Group Health Cooperative in Seattle reviewed the records of 596 patients with newly diagnosed AF. Of 437 patients (76%) who were at high risk for thromboembolism, 24% did not receive antithrombotic therapy, and the rest were treated with warfarin (48%), aspirin (17%), or both agents (11%). The data indicated that only AF classification was significantly related to whether warfarin was prescribed: More than 70% of patients with intermittent or sustained AF were prescribed warfarin, compared with 25% of those with transitory AF, regardless of thromboembolism risk. However, even among patients who received warfarin, the target international normalized ratio (INR) was within the therapeutic range only 48% of the time. Although contraindications to warfarin use, such as renal insufficiency, prior hemorrhage, predisposition to falls, barriers to adherence, or alcohol or drug abuse, were noted in 32% of all cases, 28% of warfarin users had such contraindications. The exclusion of 181 subjects with possible contraindications to warfarin use did not substantially change the distribution of warfarin or aspirin use across risk groups. The authors concluded that many patients at high risk for stroke failed to receive antithrombotic therapy and that warfarin use was associated with AF classification, rather than stroke risk.
Comment: Physicians often are reluctant to prescribe warfarin anticoagulation to frail elders because of concerns about bleeding; however, such bleeding is most likely to occur in patients whose INRs exceed the therapeutic range. Another article in this issue of Archives of Internal Medicine confirms that risk for death, major bleeding, and stroke in patients with AF is related to INR control (Arch Intern Med 2007; 167:239). A major reason for physicians’ lack of adherence to anticoagulant guidelines is the dearth of dedicated anticoagulation clinics in the U.S. An important goal is to establish a network of such clinics to assist health professionals in the management of the growing number of patients with AF.
— David Green, MD, PhD
Published in Journal Watch Oncology and Hematology February 12, 2007
Citation(s):
Glazer NL et al. Newly detected atrial fibrillation and compliance with antithrombotic guidelines. Arch Intern Med 2007 Feb 12; 167:246-52.
Original article (Subscription may be required)
To determine whether antithrombotic therapy is appropriate, physicians should evaluate patients' stroke risk, not just their AF classification.
Patients with atrial fibrillation (AF) are at high risk for thromboembolism if they are older (age, >75); have cardiovascular risk factors such as prior ischemic stroke, transient ischemic attack, systemic embolism, left ventricular systolic dysfunction, or congestive heart failure; or have hypertension or diabetes (Chest 2004; 126:429S). Logically, all such patients should be protected with antithrombotic therapy, but, in a recent study, investigators found otherwise.
Researchers from the Group Health Cooperative in Seattle reviewed the records of 596 patients with newly diagnosed AF. Of 437 patients (76%) who were at high risk for thromboembolism, 24% did not receive antithrombotic therapy, and the rest were treated with warfarin (48%), aspirin (17%), or both agents (11%). The data indicated that only AF classification was significantly related to whether warfarin was prescribed: More than 70% of patients with intermittent or sustained AF were prescribed warfarin, compared with 25% of those with transitory AF, regardless of thromboembolism risk. However, even among patients who received warfarin, the target international normalized ratio (INR) was within the therapeutic range only 48% of the time. Although contraindications to warfarin use, such as renal insufficiency, prior hemorrhage, predisposition to falls, barriers to adherence, or alcohol or drug abuse, were noted in 32% of all cases, 28% of warfarin users had such contraindications. The exclusion of 181 subjects with possible contraindications to warfarin use did not substantially change the distribution of warfarin or aspirin use across risk groups. The authors concluded that many patients at high risk for stroke failed to receive antithrombotic therapy and that warfarin use was associated with AF classification, rather than stroke risk.
Comment: Physicians often are reluctant to prescribe warfarin anticoagulation to frail elders because of concerns about bleeding; however, such bleeding is most likely to occur in patients whose INRs exceed the therapeutic range. Another article in this issue of Archives of Internal Medicine confirms that risk for death, major bleeding, and stroke in patients with AF is related to INR control (Arch Intern Med 2007; 167:239). A major reason for physicians’ lack of adherence to anticoagulant guidelines is the dearth of dedicated anticoagulation clinics in the U.S. An important goal is to establish a network of such clinics to assist health professionals in the management of the growing number of patients with AF.
— David Green, MD, PhD
Published in Journal Watch Oncology and Hematology February 12, 2007
Citation(s):
Glazer NL et al. Newly detected atrial fibrillation and compliance with antithrombotic guidelines. Arch Intern Med 2007 Feb 12; 167:246-52.
Original article (Subscription may be required)
Warfarin hersenbloedingen
Anticoagulant-Associated Intracerebral Hemorrhage
The incidence increased in greater Cincinnati during the 1990s, coinciding with increasing warfarin use in the community.
In this serial, cross-sectional study, the authors determined the incidence of anticoagulant-associated intracerebral hemorrhage in Cincinnati during three periods: 1988, 1993–1994, and 1999.
During the entire study period, the annual incidence of anticoagulant-associated intracerebral hemorrhage increased 5.5-fold, while the national dispensation of warfarin increased 4.4-fold. More of the hemorrhages were associated with warfarin use in 1999 than in 1993–1994 (98% vs. 91%). Extrapolating to 2004, the authors estimated an annual incidence of anticoagulation-associated hemorrhage in the Cincinnati area (5.1 to 6.5 cases per 100,000) similar to that of subarachnoid hemorrhage (6.6 cases per 100,000).
Comment: Warfarin is highly effective at reducing the risk for ischemic stroke in the presence of atrial fibrillation (Chest 2004; 126:429S). Warfarin use has increased substantially in the past decade in response to clinical trial data and expert guidelines. This increased use has, not surprisingly, led to an increase in the incidence of anticoagulant-associated intracerebral hemorrhage. The reason for the disproportionate increase in Cincinnati-area anticoagulant-associated intracerebral hemorrhage, relative to the increase expected based on the national warfarin dispensation rate, is unknown. But it likely reflects differences between local and national warfarin use or increasing warfarin use in the elderly, who are at elevated risk for warfarin-related intracerebral hemorrhage.
Despite the known risks, warfarin should continue to be used for stroke prevention in atrial fibrillation, in accordance with guidelines. The magnitude of the problem of warfarin-related intracerebral hemorrhage, well documented in this study, suggests that prevention of warfarin-related hemorrhage would substantially reduce the burden of hemorrhagic stroke. Further research is sorely needed to prevent warfarin-related hemorrhage and to develop safer, equally effective alternatives to warfarin, which we currently lack (Lancet 2006; 367:1903).
— Eric E. Smith, MD, MPH, FRCP(C)
Dr. Smith is Associate Director of Acute Stroke Services, Massachusetts General Hospital, and Assistant Professor of Neurology, Harvard Medical School, Boston.
Published in Journal Watch Neurology February 20, 2007
The incidence increased in greater Cincinnati during the 1990s, coinciding with increasing warfarin use in the community.
In this serial, cross-sectional study, the authors determined the incidence of anticoagulant-associated intracerebral hemorrhage in Cincinnati during three periods: 1988, 1993–1994, and 1999.
During the entire study period, the annual incidence of anticoagulant-associated intracerebral hemorrhage increased 5.5-fold, while the national dispensation of warfarin increased 4.4-fold. More of the hemorrhages were associated with warfarin use in 1999 than in 1993–1994 (98% vs. 91%). Extrapolating to 2004, the authors estimated an annual incidence of anticoagulation-associated hemorrhage in the Cincinnati area (5.1 to 6.5 cases per 100,000) similar to that of subarachnoid hemorrhage (6.6 cases per 100,000).
Comment: Warfarin is highly effective at reducing the risk for ischemic stroke in the presence of atrial fibrillation (Chest 2004; 126:429S). Warfarin use has increased substantially in the past decade in response to clinical trial data and expert guidelines. This increased use has, not surprisingly, led to an increase in the incidence of anticoagulant-associated intracerebral hemorrhage. The reason for the disproportionate increase in Cincinnati-area anticoagulant-associated intracerebral hemorrhage, relative to the increase expected based on the national warfarin dispensation rate, is unknown. But it likely reflects differences between local and national warfarin use or increasing warfarin use in the elderly, who are at elevated risk for warfarin-related intracerebral hemorrhage.
Despite the known risks, warfarin should continue to be used for stroke prevention in atrial fibrillation, in accordance with guidelines. The magnitude of the problem of warfarin-related intracerebral hemorrhage, well documented in this study, suggests that prevention of warfarin-related hemorrhage would substantially reduce the burden of hemorrhagic stroke. Further research is sorely needed to prevent warfarin-related hemorrhage and to develop safer, equally effective alternatives to warfarin, which we currently lack (Lancet 2006; 367:1903).
— Eric E. Smith, MD, MPH, FRCP(C)
Dr. Smith is Associate Director of Acute Stroke Services, Massachusetts General Hospital, and Assistant Professor of Neurology, Harvard Medical School, Boston.
Published in Journal Watch Neurology February 20, 2007
Thursday, March 08, 2007
beta-blocker carvedilol
Carvedilol May Be More Anti-Ischemic Than Other Beta-Blockers
Sue Hughes
Heartwire 2007. © 2007 Medscape
February 26, 2007 (Rhoon, the Netherlands) - A new analysis of the COMET study shows that carvedilol reduces vascular events to a greater extent than metoprolol, an effect that the authors suggest likely contributes to the superior therapeutic profile of carvedilol in the treatment of heart failure.
The current analysis, published in the March 6, 2007 issue of the Journal of the American College of Cardiology [1], was conducted by a group led by Dr Willem J Remme (Sticares Cardiovascular Research Institute, Rhoon, the Netherlands).
They note that carvedilol has a unique pharmacologic profile, blocking both beta-1 and -2 adrenergic receptors, and has tighter, more prolonged binding to the beta-1 receptor than metoprolol, which results in a greater sympathoinhibitory activity. The COMET trial was conducted to investigate whether these properties would lead to better outcomes with carvedilol compared with metoprolol tartrate, a beta-1-selective beta blocker, in more than 3000 heart-failure patients, and the primary results, published in 2003, did indeed show improved rates of survival and cardiovascular hospitalizations in patients receiving carvedilol. But the results have been challenged by some other heart-failure experts, who have pointed out that metoprolol was not given at the optimum dose or formulation in COMET and that the better effect of carvedilol could have been caused simply by a greater effect on beta-1 blockade alone, which could be seen with optimum doses of any beta blocker.
The current analysis was conducted to investigate whether vascular protection could have contributed to the superior effect of carvedilol in the COMET trial and therefore focused on the vascular end points of cardiovascular death, stroke, stroke death, MI, and unstable angina. Results showed a consistently greater effect on these events with carvedilol than with metoprolol.
Sue Hughes
Heartwire 2007. © 2007 Medscape
February 26, 2007 (Rhoon, the Netherlands) - A new analysis of the COMET study shows that carvedilol reduces vascular events to a greater extent than metoprolol, an effect that the authors suggest likely contributes to the superior therapeutic profile of carvedilol in the treatment of heart failure.
The current analysis, published in the March 6, 2007 issue of the Journal of the American College of Cardiology [1], was conducted by a group led by Dr Willem J Remme (Sticares Cardiovascular Research Institute, Rhoon, the Netherlands).
They note that carvedilol has a unique pharmacologic profile, blocking both beta-1 and -2 adrenergic receptors, and has tighter, more prolonged binding to the beta-1 receptor than metoprolol, which results in a greater sympathoinhibitory activity. The COMET trial was conducted to investigate whether these properties would lead to better outcomes with carvedilol compared with metoprolol tartrate, a beta-1-selective beta blocker, in more than 3000 heart-failure patients, and the primary results, published in 2003, did indeed show improved rates of survival and cardiovascular hospitalizations in patients receiving carvedilol. But the results have been challenged by some other heart-failure experts, who have pointed out that metoprolol was not given at the optimum dose or formulation in COMET and that the better effect of carvedilol could have been caused simply by a greater effect on beta-1 blockade alone, which could be seen with optimum doses of any beta blocker.
The current analysis was conducted to investigate whether vascular protection could have contributed to the superior effect of carvedilol in the COMET trial and therefore focused on the vascular end points of cardiovascular death, stroke, stroke death, MI, and unstable angina. Results showed a consistently greater effect on these events with carvedilol than with metoprolol.
