RESUMO
Benzimidazole (BZ) anthelmintics are among the most important treatments for parasitic nematode infections in the developing world. Widespread BZ resistance in veterinary parasites and emerging resistance in human parasites raise major concerns for the continued use of BZs. Knowledge of the mechanisms of resistance is necessary to make informed treatment decisions and circumvent resistance. Benzimidazole resistance has traditionally been associated with mutations and natural variants in the C. elegans beta-tubulin gene ben-1 and orthologs in parasitic species. However, variants in ben-1 alone do not explain the differences in BZ responses across parasite populations. Here, we examined the roles of five C. elegans beta-tubulin genes (tbb-1, mec-7, tbb-4, ben-1, and tbb-6) in the BZ response as well as to determine if another beta-tubulin acts redundantly with ben-1. We generated C. elegans strains with a loss of each beta-tubulin gene, as well as strains with a loss of tbb-1, mec-7, tbb-4, or tbb-6 in a genetic background that also lacks ben-1. We found that the loss of ben-1 conferred the maximum level of resistance following exposure to a single concentration of albendazole, and the loss of a second beta-tubulin gene did not alter the level of resistance. However, additional traits other than larval development could be affected by the loss of additional beta-tubulins, and the roles of other beta-tubulin genes might be revealed at different albendazole concentrations. Therefore, further work is needed to fully define the possible roles of other beta-tubulin genes in the BZ response.
Assuntos
Albendazol , Anti-Helmínticos , Caenorhabditis elegans , Resistência a Medicamentos , Mutação , Tubulina (Proteína) , Animais , Caenorhabditis elegans/efeitos dos fármacos , Caenorhabditis elegans/genética , Tubulina (Proteína)/genética , Resistência a Medicamentos/genética , Anti-Helmínticos/farmacologia , Albendazol/farmacologia , Proteínas de Caenorhabditis elegans/genéticaRESUMO
Left unchecked, plant-parasitic nematodes have the potential to devastate crops globally. Highly effective but non-selective nematicides are justifiably being phased-out, leaving farmers with limited options for managing nematode infestation. Here, we report our discovery of a 1,3,4-oxadiazole thioether scaffold called Cyprocide that selectively kills nematodes including diverse species of plant-parasitic nematodes. Cyprocide is bioactivated into a lethal reactive electrophilic metabolite by specific nematode cytochrome P450 enzymes. Cyprocide fails to kill organisms beyond nematodes, suggesting that the targeted lethality of this pro-nematicide derives from P450 substrate selectivity. Our findings demonstrate that Cyprocide is a selective nematicidal scaffold with broad-spectrum activity that holds the potential to help safeguard our global food supply.
Assuntos
Antinematódeos , Sistema Enzimático do Citocromo P-450 , Nematoides , Animais , Sistema Enzimático do Citocromo P-450/metabolismo , Nematoides/efeitos dos fármacos , Antinematódeos/farmacologia , Sulfetos/farmacologia , Sulfetos/químicaRESUMO
Albendazole (a benzimidazole) and ivermectin (a macrocyclic lactone) are the two most commonly co-administered anthelmintic drugs in mass-drug administration programs worldwide. Despite emerging resistance, we do not fully understand the mechanisms of resistance to these drugs nor the consequences of delivering them in combination. Albendazole resistance has primarily been attributed to variation in the drug target, a beta-tubulin gene. Ivermectin targets glutamate-gated chloride channels (GluCls), but it is unknown whether GluCl genes are involved in ivermectin resistance in nature. Using Caenorhabditis elegans, we defined the fitness costs associated with loss of the drug target genes singly or in combinations of the genes that encode GluCl subunits. We quantified the loss-of-function effects on three traits: (i) multi-generational competitive fitness, (ii) fecundity, and (iii) development. In competitive fitness and development assays, we found that a deletion of the beta-tubulin gene ben-1 conferred albendazole resistance, but ivermectin resistance required the loss of two GluCl genes (avr-14 and avr-15). The fecundity assays revealed that loss of ben-1 did not provide any fitness benefit in albendazole conditions and that no GluCl deletion mutants were resistant to ivermectin. Next, we searched for evidence of multi-drug resistance across the three traits. Loss of ben-1 did not confer resistance to ivermectin, nor did loss of any single GluCl subunit or combination confer resistance to albendazole. Finally, we assessed the development of 124 C. elegans wild strains across six benzimidazoles and seven macrocyclic lactones to identify evidence of multi-drug resistance between the two drug classes and found a strong phenotypic correlation within a drug class but not across drug classes. Because each gene affects various aspects of nematode physiology, these results suggest that it is necessary to assess multiple fitness traits to evaluate how each gene contributes to anthelmintic resistance.
Assuntos
Anti-Helmínticos , Caenorhabditis elegans , Resistência a Medicamentos , Ivermectina , Animais , Caenorhabditis elegans/genética , Caenorhabditis elegans/efeitos dos fármacos , Anti-Helmínticos/farmacologia , Resistência a Medicamentos/genética , Ivermectina/farmacologia , Alelos , Aptidão Genética/efeitos dos fármacos , Albendazol/farmacologia , Proteínas de Caenorhabditis elegans/genética , Proteínas de Caenorhabditis elegans/metabolismo , Canais de Cloreto/genética , Canais de Cloreto/metabolismo , Tubulina (Proteína)/genética , Tubulina (Proteína)/metabolismo , Seleção GenéticaRESUMO
Benzimidazole (BZ) anthelmintics are among the most important treatments for parasitic nematode infections in the developing world. Widespread BZ resistance in veterinary parasites and emerging resistance in human parasites raise major concerns for the continued use of BZs. Knowledge of the mechanisms of resistance is necessary to make informed treatment decisions and circumvent resistance. Benzimidazole resistance has traditionally been associated with mutations and natural variants in the C. elegans beta-tubulin gene ben-1 and orthologs in parasitic species. However, variants in ben-1 alone do not explain the differences in BZ responses across parasite populations. Here, we examine the roles of five C. elegans beta-tubulin genes (tbb-1, mec-7, tbb-4, ben-1, and tbb-6) to identify the role each gene plays in BZ response. We generated C. elegans strains with a loss of each beta-tubulin gene, as well as strains with a loss of tbb-1, mec-7, tbb-4, or tbb-6 in a genetic background that also lacks ben-1 to test beta-tubulin redundancy in BZ response. We found that only the individual loss of ben-1 conferred a substantial level of BZ resistance, although the loss of tbb-1 was found to confer a small benefit in the presence of albendazole (ABZ). The loss of ben-1 was found to confer an almost complete rescue of animal development in the presence of 30 µM ABZ, likely explaining why no additive effects caused by the loss of a second beta-tubulin were observed. We demonstrate that ben-1 is the only beta-tubulin gene in C. elegans where loss confers substantial BZ resistance.
RESUMO
Albendazole and ivermectin are the two most commonly co-administered anthelmintic drugs in mass-drug administration programs worldwide. Despite emerging resistance, we do not fully understand the mechanisms of resistance to these drugs nor the consequences of delivering them in combination. Albendazole resistance has primarily been attributed to variation in the drug target, a beta-tubulin gene. Ivermectin targets glutamate-gated chloride channel (GluCl) genes, but it is unknown whether these genes are involved in ivermectin resistance in nature. Using Caenorhabditis elegans, we defined the fitness costs associated with loss of the drug target genes singly or in combinations of the genes that encode GluCl subunits. We quantified the loss-of function effects on three traits: (i) multi-generational competitive fitness, (ii) fecundity, and (iii) development. In competitive fitness and development assays, we found that a deletion of the beta-tubulin gene ben-1 conferred albendazole resistance, but ivermectin resistance required loss of two GluCl genes (avr-14 and avr-15) or loss of three GluCl genes (avr-14, avr-15, and glc-1). The fecundity assays revealed that loss of ben-1 did not provide any fitness benefit in albendazole and that no GluCl deletion mutants were resistant to ivermectin. Next, we searched for evidence of multi-drug resistance across the three traits. Loss of ben-1 did not confer resistance to ivermectin, nor did loss of any single GluCl subunit or combination confer resistance to albendazole. Finally, we assessed the development of 124 C. elegans wild strains across six benzimidazoles and seven macrocyclic lactones to identify evidence of multi-drug resistance between the two drug classes and found a strong phenotypic correlation within a drug class but not across drug classes. Because each gene affects various aspects of nematode physiology, these results suggest that it is necessary to assess multiple fitness traits to evaluate how each gene contributes to anthelmintic resistance.
RESUMO
Parasitic nematodes cause significant effects on humans each year, with the most prevalent being Ascaris lumbricoides. Benzimidazoles (BZ) are the most widely used anthelmintic drug in humans, and although the biology of resistance to this drug class is understood in some species, resistance is poorly characterized in ascarids. Models such as Caenorhabditis elegans were essential in developing our current understanding of BZ resistance, but more closely related model nematodes are needed to understand resistance in ascarids. Here, we propose a new ascarid model species that infects turkeys, Ascaridia dissimilis, to develop a better understanding of BZ resistance.
Assuntos
Anti-Helmínticos , Ascaridia , Animais , Humanos , Ascaridia/genética , Perus , Anti-Helmínticos/farmacologia , Benzimidazóis/farmacologia , Caenorhabditis elegans , Resistência a Medicamentos/genéticaRESUMO
OBJECTIVES: To determine whether sharing laboratory charge and personal utilization information with physicians can reduce laboratory test orders and expenditures, thereby decreasing the overutilization of laboratory testing. METHODS: This was a prospective study. By querying our electronic medical records, we calculated the median laboratory charges per patient/per day (PP/PD) and median laboratory tests ordered PP/PD for the resident general internal medicine and hospitalist services. For 10 weeks, we shared this team-based information with physicians with weekly updates. We calculated total laboratory charges for the 10 most common discharge diagnoses to capture laboratory charges for entire episodes of care. RESULTS: During the intervention, the mean number of laboratory tests ordered PP/PD by resident service decreased from 5.56 to 5.17 (-0.389, P <0.001); the mean charge PP/PD decreased from $488 to $461 (-$27, P < 0.001). The hospitalist service decreased the number of laboratory tests ordered PP/PD from 3.54 to 3.36 (-0.18, P = 0.77) and the mean charge PP/PD decreased from $331 to $301 (-$30, P = 0.96). The statistically significant decline in laboratory charges persisted after controlling for the 10 most common discharge diagnoses. Compared with the 3-month period before the study began, physicians in the 10-week intervention period ordered 1464 fewer laboratory tests, resulting in a $188,000 reduction in charges and a 3% to 4% reduction in utilization. CONCLUSIONS: Informing physicians of the charges for laboratory tests and their personal utilization patterns can reduce the number of laboratory tests ordered and laboratory expenditures, especially for physicians in training.
Assuntos
Laboratórios/economia , Laboratórios/estatística & dados numéricos , Uso Excessivo dos Serviços de Saúde/prevenção & controle , Padrões de Prática Médica , Técnicas de Laboratório Clínico/estatística & dados numéricos , Registros Eletrônicos de Saúde , Medicina Interna , Estudos Prospectivos , Estados UnidosRESUMO
Sentinel lymph node biopsy (SLNB) is an appropriate method for the evaluation of axillary status in cases of early breast cancer. We report our experience in treating cases evaluated using SLNB. We analyzed a total of 1192 cases assessed by means of SLNB from July 1999 to December 2007. SLNB processing was successfully completed in 1154 cases with the use of blue dye or radiolabeled 99mTc-Dextran-500, or both. Of these 1154 patients, 857 were N0(i-) (no regional lymph node metastasis, negative immunohistochemistry, IHC), 96 were N0(i+) (no regional lymph node metastasis histologically, positive IHC, no IHC cluster greater than 0.2 mm) and 201 were N1mi (greater than 0.2 mm, none greater than 2.0 mm). Most of the tumors (70%) were invasive ductal carcinomas and tumors were staged as T1 in 770 patients (65%). A total of 274 patients underwent SLNB and axillary dissections up to April 2003. The inclusion criteria were tumor size equal to or less than 3 cm in diameter, no clinically palpable axillary lymph nodes, no neoadjuvant therapy. In 19 cases, the SLN could not be identified intraoperatively. A false-negative rate of 11% and a negative predictive value of 88.2% were obtained for the 255 assessable patients. The overall concordance between SLNB and axillary lymph node status was 92%. SLNB sensitivity for nodes was 81% and specificity was 100%. The higher sensitivity, specificity, accuracy, and lower false-negative rates of SLNB suggest that this method may be an appropriate alternative to total axillary dissection in early breast cancer patients.
Assuntos
Neoplasias da Mama/patologia , Biópsia de Linfonodo Sentinela , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/cirurgia , Feminino , Humanos , Excisão de Linfonodo , Metástase Linfática/patologia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto JovemRESUMO
Sentinel lymph node biopsy (SLNB) is an appropriate method for the evaluation of axillary status in cases of early breast cancer. We report our experience in treating cases evaluated using SLNB. We analyzed a total of 1192 cases assessed by means of SLNB from July 1999 to December 2007. SLNB processing was successfully completed in 1154 cases with the use of blue dye or radiolabeled 99mTc-Dextran-500, or both. Of these 1154 patients, 857 were N0(i-) (no regional lymph node metastasis, negative immunohistochemistry, IHC), 96 were N0(i+) (no regional lymph node metastasis histologically, positive IHC, no IHC cluster greater than 0.2 mm) and 201 were N1mi (greater than 0.2 mm, none greater than 2.0 mm). Most of the tumors (70 percent) were invasive ductal carcinomas and tumors were staged as T1 in 770 patients (65 percent). A total of 274 patients underwent SLNB and axillary dissections up to April 2003. The inclusion criteria were tumor size equal to or less than 3 cm in diameter, no clinically palpable axillary lymph nodes, no neoadjuvant therapy. In 19 cases, the SLN could not be identified intraoperatively. A false-negative rate of 11 percent and a negative predictive value of 88.2 percent were obtained for the 255 assessable patients. The overall concordance between SLNB and axillary lymph node status was 92 percent. SLNB sensitivity for nodes was 81 percent and specificity was 100 percent. The higher sensitivity, specificity, accuracy, and lower false-negative rates of SLNB suggest that this method may be an appropriate alternative to total axillary dissection in early breast cancer patients.
Assuntos
Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Adulto Jovem , Neoplasias da Mama/patologia , Biópsia de Linfonodo Sentinela , Neoplasias da Mama/cirurgia , Excisão de Linfonodo , Metástase Linfática/patologia , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto JovemRESUMO
Development of hypertension stems from both environmental and genetic factors wherein the kidney plays a central role. Spontaneously hypertensive rats (SHR) and the nonhypertensive Wistar-Kyoto (WKY) controls are widely used as a model for studying hypertension. The present study examined the renal gene expression profiles between SHR and WKY at a prehypertensive stage (3 wk of age) and hypertensive stage (9 wk of age). Additionally, age-related changes in gene expression patterns were examined from 3 to 9 wk in both WKY and SHR. Five to six individual kidney samples of the same experimental group were pooled together, and quadruplicate hybridizations were performed using the National Institute of Environmental Health Sciences Rat version 2.0 Chip, which contains approximately 6,700 genes. Twenty two genes were found to be differentially expressed between SHR and WKY at 3 wk of age, and 104 genes were differentially expressed at 9 wk of age. Soluble epoxide hydrolase (Ephx2) was found to be significantly upregulated in SHR at both time points and was the predominant outlier. Conversely, elastase 1 (Ela1) was found to be the predominant gene downregulated in SHR at both time points. Analysis of profiles at 3 vs. 9 wk of age identified 508 differentially expressed genes in WKY rats. In contrast, only 211 genes were found to be differentially expressed during this time period in SHR. The altered gene expression patterns observed in the age-related analysis suggested significant differences in the vascular extracellular matrix system between SHR and WKY kidney. Together, our data highlight the complexity of hypertension and the numerous genes involved in and affected by this condition.
Assuntos
Perfilação da Expressão Gênica , Hipertensão Renal/genética , Rim/fisiologia , Fatores Etários , Animais , Análise por Conglomerados , Feminino , Expressão Gênica/fisiologia , Masculino , Análise de Sequência com Séries de Oligonucleotídeos , Ratos , Ratos Endogâmicos SHR , Ratos Endogâmicos WKY , Especificidade da EspécieRESUMO
We have presented a unique case of isolated renal artery dissection in an otherwise healthy young man, whose diagnosis was demonstrated by renal angiography. He was anticoagulated with warfarin for one year with resolution of the false channel in his renal artery as demonstrated by magnetic resonance angiography. Duplex ultrasonography of his renal artery was important in monitoring his renal artery flow velocities.
Assuntos
Dissecção Aórtica , Artéria Renal , Adulto , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/tratamento farmacológico , Angiografia , Anticoagulantes/uso terapêutico , Humanos , Masculino , Ultrassonografia Doppler Dupla , Varfarina/uso terapêuticoRESUMO
There is no shortage of sustained inquiry into the nature and evaluation of teaching in medical education. For the most part, however, this growing and respectable body of inquiry has uncritically adopted a single model of effective teaching that is assumed to be appropriate across variations in context, learners, and teachers. This article presents five alternative views of "good teaching" and challenges the trend toward any single, dominant view of what constitutes good teaching. Based on 10 years of research, in five different countries, studying hundreds of educators in adult and higher education across a wide range of disciplines, contexts, and cultures, we have evidence of five different perspectives on good teaching: transmission, developmental, apprenticeship, nurturing, and social reform. Each perspective represents a philosophical orientation to knowledge, learning, and the role and responsibility of being an educator. A "snapshot" of each perspective is provided, including an example from continuing medical education (CME), a set of key beliefs, primary responsibilities, typical strategies, and common difficulties. Readers are encouraged to use the five perspectives as a means of identifying, articulating, and revisiting assumptions and beliefs they hold regarding their view of effective teaching. They are also encouraged to resist a "one-size-fits-all" approach to the investigation, improvement, or evaluation of teaching in CME.
Assuntos
Educação Médica , Ensino/métodos , Educação Médica Continuada , Humanos , Modelos Educacionais , FilosofiaRESUMO
The incorporation of quality improvement methods into the practice of laboratory medicine has become widespread in recent years. However, a significant number of laboratory professionals feel that quality improvement efforts take an excessive amount of time to achieve results. Using quality improvement methods and tools will have limited success without first creating the proper environment. Steps that we have found to be beneficial in creating the environment for successful improvement activities using the FOCUS-PDSA model include having senior leaders perform specific activities, aiming the team, and strategic contracting.
Assuntos
Coleta de Amostras Sanguíneas/normas , Laboratórios Hospitalares/normas , Manejo de Espécimes/normas , Gestão da Qualidade Total , Hospitais com mais de 500 Leitos , Hospitais Privados , Hospitais Filantrópicos , Humanos , Laboratórios Hospitalares/organização & administração , Modelos Organizacionais , North Carolina , Objetivos Organizacionais , Resolução de ProblemasRESUMO
The rapid development and incorporation of minimally invasive surgical techniques has abruptly changed adult surgical practices. These minimally invasive procedures are now being successfully applied to pediatric surgical problems. The anticipated benefits of these techniques include less postoperative pain, quicker return of bowel function, shorter hospital stay, and lower hospital costs, with a quicker return to normal activity. This report compares the first 60 infants and children to undergo laparoscopic gastrostomy and/or fundoplication at our institution with the same number of patients that underwent these procedures in the traditional open fashion. The two groups were similar with respect to age, sex, concurrent illness, presenting symptoms, neurological status, and procedures performed. Patients in the laparoscopic group were found to have shorter mean hospital and postoperative stays and tolerated feeding earlier. The mean hospital stay was 13.8 days for the laparoscopic group versus 16.4 days in the open group. The mean postoperative stay was 6.8 days for the laparoscopic group versus 10.7 days for the open group. The mean postoperative day on which feeding was tolerated was 2.3 in the laparoscopic group versus 4.8 in the open group. Postoperative complications were similar between the two groups. These results seem to reflect the less traumatic nature of the laparoscopic procedures as compared with the open procedures. Laparoscopic fundoplication and gastrostomy is an attractive alternative to open fundoplication and gastrostomy in infants and children.
Assuntos
Fundoplicatura/métodos , Gastrostomia/métodos , Laparoscopia , Atividades Cotidianas , Adolescente , Estudos de Casos e Controles , Criança , Pré-Escolar , Ingestão de Alimentos , Feminino , Seguimentos , Fundoplicatura/efeitos adversos , Gastrostomia/efeitos adversos , Custos Hospitalares , Humanos , Lactente , Intestinos/fisiologia , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos , Exame Neurológico , Dor Pós-Operatória/prevenção & controle , Complicações Pós-Operatórias , Estudos RetrospectivosRESUMO
Improvements in parenteral nutrition and supportive therapy have led to a growing population of patients who survive for prolonged periods with short bowel syndrome. Definitive treatment for these patients requires innovative therapy based on a sound knowledge of small intestinal physiology and adaptation. Current understanding of short bowel pathophysiology and of intestinal adaptation are reviewed. Medical and surgical therapeutic options are described, highlighting the promotion of small bowel adaptation and methods to increase the small intestinal mucosal mass.
Assuntos
Síndrome do Intestino Curto , Adaptação Fisiológica , Animais , Humanos , Lactente , Recém-Nascido , Intestinos/fisiopatologia , Intestinos/cirurgia , Apoio Nutricional , Síndrome do Intestino Curto/fisiopatologia , Síndrome do Intestino Curto/terapiaAssuntos
Satisfação do Paciente , Médicas , Serviços de Saúde da Mulher , Saúde da Mulher , Feminino , HumanosRESUMO
The NIMH Diagnostic Interview Schedule (n = 43), and the Hopkins Symptom Checklist and Weissman Social Adjustment Scale (n = 35) was administered to assess the prevalence of psychiatric disorders and psychosocial maladjustment present in women seeking treatment in a multidisciplinary Premenstrual Syndrome Clinic. We found a 67 percent lifetime prevalence of DIS/DSM-III psychiatric disorders: 50 percent Major Affective Disorder (primarily Depression), 53 percent Anxiety Disorder (primarily Phobias or Generalized Anxiety Disorder), and 40 percent Psychosexual Dysfunction (notably Inhibited Sexual Desire or Excitement). Our group had significantly greater Major Depression, Dysthymia, and any one psychiatric disorder compared with female general population samples. Two-thirds of women with premenstrual symptoms had true Premenstrual Syndrome. In our sample, social maladjustment as well as psychiatric symptomatology was significantly greater than in normals and closer to that in psychiatric out-patient norms, and was independent of cycle phase. Presence or absence of PMS, social maladjustment and sexual dysfunction was each not significantly different in women with or without psychiatric disorder.
Assuntos
Transtornos Mentais/psicologia , Síndrome Pré-Menstrual/psicologia , Disfunções Sexuais Psicogênicas/psicologia , Ajustamento Social , Adulto , Feminino , Identidade de Gênero , Humanos , Transtornos Mentais/terapia , Inventário de Personalidade/estatística & dados numéricos , Síndrome Pré-Menstrual/terapia , Psicometria , Comportamento Sexual , Disfunções Sexuais Psicogênicas/terapiaRESUMO
The body of evidence now swings the scale toward the benefit of HRT for women beginning at the menopause. Based on newer studies, the risks for osteoporosis, cardiovascular morbidity, breast carcinoma, symptomatic vasomotor and anatomic changes occurring postmenopausally outweigh the risks of hormone replacement therapy in the end of the 20th century. Women should be instructed in adequate calcium intake, 1000 mg per day premenopausally and 1500 mg per day postmenopausally. Osteoporotic, breast carcinoma, and cardiovascular risks should be investigated at age 35 with appropriate lab screening, including lipoprotein analysis. Screening mammography should begin at age 40, continuing every 5 years until age 50, and yearly between ages 50 and 65. A diet high in calcium, low in cholesterol and fat, and a weight reduction program should be made available as early as possible and continued indefinitely. HRT should be made available beginning at menopause and continued to age 70. Moderate exercise should be encouraged at all ages. The next 5 to 10 years will answer some of the questions about the benefits of long-term HRT postmenopausally, especially with respect to its influence on cardiovascular risk. New progestational agents will probably be developed that will have fewer adverse effects on lipid profiles, while maintaining the protective effect on the endometrium and breast and further influencing the benefits of HRT postmenopausally. Modern medicine certainly cannot ensure living forever. The body of knowledge now available can modify the major causes for morbidity and mortality as the baby boom population reaches their middle age and golden years.