The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

/pdf/guidelines-for-the-prevention-of-stroke-in-patients-with-4s66xf1dte.pdf

Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

A large body of evidence indicates that women are more likely than men to show unipolar depression. Five classes of explanations for these sex differences are examined and the evidence for each class is reviewed. Not one of these explanations adequately accounts for the magnitude of the sex differences in depression. Finally, a response set explanation for the sex differences in depression is proposed. According to this explanation, men are more likely to engage in distracting behaviors that dampen their mood when depressed, but women are more likely to amplify their moods by ruminating about their depressed states and the possible causes of these states. Regardless of the initial source of a depressive episode (i.e., biological or psychological) men's more active responses to their negative moods may be more adaptive on average than women's less active, more ruminative responses. The epidemiology of a disorder can provide important clues to its etiology. When a disorder only strikes persons from one geographical region, one social class, or one gender, we can ask what characteristics of the vulnerable group might be making its members vulnerable. A frequent finding in epidemiological studies of mental disorders is that women are more prone to unipolar affective disorders than are men (Boyd & Weissman, 1981; Weissman & Klerman, 1977). A number of different explanations have been proposed to account for women's greater vulnerability to depression. Previous reviews of these explanations (e.g., Weissman & Klerman, 1977) have been quite brief and uncritical. In this article, the evidence for sex differences in unipolar depression first is summarized, then the most prominent explanations proposed for these sex differences are discussed in detail. These explanations include those attributing the differences to the response biases of subjects, as well as biological, psychoanalytic, sex role, and learned helplessness explanations. Although most of the proposed explanations for sex differences in depression have received some empirical support, not one of them has been definitively supported and not one as yet accounts for the magnitude of sex differences in depression. In the final section of this article it is suggested that differences in the ways that men and women respond to their own depressive episodes, whatever the origin of these episodes, may be an important source of the sex differences observed in depression.

Sex differences in unipolar depression: evidence and theory.

In this innovative book, a well-known feminist and sociologist-who is also the founding editor of Gender & Society-challenges our most basic assumptions about gender. Judith Lorber argues that gender is wholly a product of socialization, subject to human agency, organization, and interpretation, and that it is a social institution comparable to the economy, the family, and religion in its significance and consequences. Calling into question the inevitability and necessity of gender, she envisions a society structured for equality, where no gender, racial ethnic, or social class group is allowed to monopolize positions of power.

Paradoxes of gender

Central mechanisms of stress integration: hierarchical circuitry controlling hypothalamo-pituitary-adrenocortical responsiveness.

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches to the implementation of guidelines and their use in high-risk populations.

Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack

Canadian Contraception Consensus—Update on Depot Medroxyprogesterone Acetate (DMPA)

Insulin-induced hypoglycemia inhibits luteinizing hormone (LH) secretion and has been used as a model to study stress-induced inhibition of reproductive function. Endogenous opioid peptides have been implicated in mediating the inhibitory effect of hypoglycemia on LH secretion in sheep and rat. The objective of the present study was to determine if corticotropin-releasing hormone (CRH) and endogenous opiates are involved in the LH response to hypoglycemia in the nonhuman primate. Blood samples were collected at 15-min intervals for 6 h from ovariectomized rhesus monkeys (n = 6). Hypoglycemia was induced by injecting insulin 1 h after initiating blood collection. Animals were pretreated 15 min prior to insulin with either saline (n = 6), naloxone, a nonselective opiate receptor antagonist (n = 4), or alprazolam (n = 6), a potent benzodiazepine which has been shown to inhibit CRH. The LH, glucose, adrenocorticotropin (ACTH), and cortisol responses to insulin were determined. Insulin-induced hypoglycemia significantly inhibited LH secretion and increased ACTH and cortisol concentrations. Alprazolam prevented hypoglycemia-induced inhibition of LH independent of an effect on glucose concentrations. The mean (+/- SEM) LH pulse interval in response to hypoglycemia was decreased in the alprazolam pretreated group compared to the saline pretreated group (77.4 +/- 6.0 vs. 130.0 +/- 18.4 min), while LH pulse amplitude and mean LH levels were significantly increased (56.2 +/- 7.1 vs. 28.3 +/- 5.5 ng/ml, and 105.6 +/- 14.4 vs. 60.9 +/- 12.1 ng/ml respectively). In contrast, naloxone did not prevent hypoglycemia-induced LH inhibition. The mean LH pulse interval, LH pulse amplitude, and LH concentration in the naloxone pretreated monkeys were 152.1 +/- 33.4 min, 37.1 +/- 8.9 ng/ml, and 63.7 +/- 9.1 ng/ml respectively. Alprazolam pretreatment also markedly attenuated the ACTH response to hypoglycemia whereas the cortisol response was only moderately affected. We conclude that insulin-induced hypoglycemia in the monkey inhibits LH secretion through a mechanism involving CRH but not endogenous opiates.

Hypoglycemia-induced inhibition of LH and stimulation of ACTH secretion in the rhesus monkey is blocked by alprazolam.

Objective To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor symptoms or with urogenital, mood, or memory concerns, and on considerations related to cardiovascular disease, breast cancer, and bone health, including the diagnosis and clinical management of postmenopausal osteoporosis. Outcomes Lifestyle interventions, prescription medications, and complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms. Strategies for identifying and evaluating women at high risk of osteoporosis, along with options for the prevention and treatment of osteoporosis, are presented. Evidence MEDLINE was searched up to October 1, 2008, and the Cochrane databases up to issue 1 of 2008 with the use of a controlled vocabulary and appropriate key words. Research-design filters for systematic reviews, randomized and controlled clinical trials, and observational studies were applied to all PubMed searches. Results were limited to publication years 2002 to 2008; there were no language restrictions. Additional information was sought in BMJ Clinical Evidence, in guidelines collections, and from the Web sites of major obstetric and gynaecologic associations world wide. The authors critically reviewed the evidence and developed the recommendations according to the methodology and consensus development process of the Journal of Obstetrics and Gynaecology Canada. Values The quality of the evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force. See Table. Sponsor The Society of Obstetricians and Gynaecologists of Canada.

http://www.sefap.it/servizi_lineeguida_200902/Menopause_JOGC-Jan_09.pdf

Menopause and Osteoporosis Update 2009

ABSTRACT Introduction Estrogens used in women’s healthcare have been associated with increased risks of venous thromboembolism (VTE) and breast cancer. Estetrol (E4), an estrogen produced by the human fetal liver, has recently been approved for the first time as a new estrogenic component of a novel combined oral contraceptive (E4/drospirenone [DRSP]) for over a decade. In phase 3 studies, E4/DRSP showed good contraceptive efficacy, a predictable bleeding pattern, and a favorable safety and tolerability profile. Areas covered This narrative review discusses E4ʹs pharmacological characteristics, mode of action, and the results of preclinical and clinical studies for contraception, as well as for menopause and oncology. Expert opinion Extensive studies have elucidated the properties of E4 that underlie its favorable safety profile. While classical estrogens (such as estradiol) exert their actions via both activation of nuclear and membrane estrogen receptor α (ERα), E4 presents a specific profile of ERα activation: E4 binds and activates nuclear ERα but does not induce the activation of membrane ERα signaling pathways in specific tissues. E4 has a small effect on normal breast tissue proliferation and minimally affects hepatic parameters. This distinct profile of ERα activation, uncoupling nuclear and membrane activation, is unique.

Profile of estetrol, a promising native estrogen for oral contraception and the relief of climacteric symptoms of menopause

Leptin is a cytokine produced by white adipose tissue that circulates in direct proportion to adiposity and is an important signal of energy balance. Leptin inhibits food intake in rodents by inhibiting the orexigenic neuropetides neuropeptide Y (NPY) and agouti regulated peptide (AgRP) and stimulating the anorexigenic neuropeptides α-melanocyte-stimulating hormone (α-MSH) and cocaine-amphetamine-regulated transcript (CART). In order to extend our understanding of neuroendocrine regulation of appetite in the primate, we determined the effect of a metabolic challenge on CART, NPY, and leptin receptor (Ob-R) messenger ribonucleic acid (mRNA) in the nonhuman primate (NHP) hypothalamus. Ten adult female rhesus monkeys were either maintained on a regular diet or fasted for two days before euthanasia. CART, NPY, and Ob-R mRNA were measured by in situ hybridization histochemistry (ISHH). A 2-day fast decreased CART expression in the ARC, increased NPY gene expression in the supraoptic nucleus (SON) and paraventricular nucleus (PVN), and increased Ob-R expression in the ventromedial nucleus (VMN). This is the first report that fasting inhibits CART expression and stimulates Ob-R expression in monkeys. Increased NPY expression in the SON and PVN, but not the ARC of fasted monkeys also is novel. With some exceptions, our observations are confirmatory of findings in rodent studies. Similarities in the neuroendocrine responses to a metabolic challenge in monkeys and rodents support extending existing hypotheses of neuroendocrine control of energy homeostasis to primates.

Robert L. Reid

Papers

Canadian Contraception Consensus—Update on Depot Medroxyprogesterone Acetate (DMPA)

Hypoglycemia-induced inhibition of LH and stimulation of ACTH secretion in the rhesus monkey is blocked by alprazolam.

Menopause and Osteoporosis Update 2009

Profile of estetrol, a promising native estrogen for oral contraception and the relief of climacteric symptoms of menopause

Effect of fasting on cocaine-amphetamine-regulated transcript, neuropeptide Y, and leptin receptor expression in the non-human primate hypothalamus.