Doctorportal

THE ROYAL WEDDING

2011-04-26T02:30:00.000-07:00

This is to let you know and update you on the biggest wedding in this dacade

The fact about Kate Middleton and Prince William

Who is Kate Middleton

POLITICS

2011-04-25T04:09:00.000-07:00

Let talk about politics,share your view and be heard

SPORTS

2011-04-25T02:18:00.000-07:00

Loose your fats faster than you think

MOVIES WORLD

2011-04-24T08:15:00.000-07:00

Top 5 Latest Hollywood movies

1 African Cats (2011)
    Release Date: 04/22/2011
    Rating: G
   Runtime: 1 hr 29 min
   Director :Alastair Fothergill

2 Incendies
   Release Date: 04/22/2011
   Rating: R
   Runtime: 2 hr 10 mins
   Director:Denis Villeneuve

3 What On Earth? Inside The Crop Circle Mystery
    Release Date: 04/22/2011
    Rating: NR
    Runtime: 1 hr 21 mins
Director :Suzanne Taylor

4 The Scenesters
   Release Date: 04/22/2011
   Rating: R
   Runtime: 1 hr 42 mins
   Genre:    Crime,Thriller,Criminal
   Director:Todd Berger

5 Crazy, Stupid, Love
   Release Date: 04/22/2011
   Rating: Not Rated
   Runtime: ?
   Genre: Comedy
   Director:John Requa

FEMALE SHOES

2011-04-23T10:49:00.000-07:00

Top 10 female party shoes

Top 5 expensive female shoes

BNIB GUCCI CROC ALLIGATOR CROCODILE BOOTS
CALVIN KLEIN SADI PUMP SLING BLACK SHOE
NIB ALAIA Aligator Lace-up Gladiator Shoes
NIB Louboutin Very BROAD Embroidered Pumps Shoes
Christian Louboutin BLUE PYTHON FONTANETE

musical world

2011-04-16T14:12:00.000-07:00

Top 5 Nigeria music

1 Fi mi le

This song is done by Kas.She is Miss Kina,but her name is actually Kofowora Shotonwa.She is a Nigerian but currently leaving in New york.

2 Steel ft shank-slow wind

3 Nice Gbamu Gbamu
Abolore Adegbola Akande popular known as 9ice was born 17 january,1980.He is a famous Nigeria singer with a classic type of music.He came from Ogbomosho in oyo state,Nigeria and grew up in bariga in Lagos born to humble family

4, Jmartims

5 OD Alujo

2011-03-19T16:19:00.000-07:00

Books

2011-03-19T09:41:00.001-07:00

Books

2011-03-19T09:40:00.001-07:00

Books

2011-03-19T09:30:00.001-07:00

Books

2011-03-19T09:28:00.000-07:00

Best 3 countries to immigrate to canada,australia and

2011-03-19T08:39:00.000-07:00

This selection of countries is base on the following cateria
1 easy adaptability

2 good and favourable imigration laws

3 propability of getting job quick

4 safe environment

5 watchout for the countries

http://bizdoctorprojects.donanza.com
This country located in the north america,share the same border with the united state of america

consisting of 3 territories and 3 provinces . Situated in the northern part of the continent, it extends from the Atlantic sea in the east to the Pacific sea in the west and northward into the Arctic sea. It is the world's 2nd largest country by total area.
Canada has a diversified economy that is reliant upon its abundant natural resources and upon trade—particularly with the United States, with which Canada has had a long and complex relationship. It is a member of the G7, G8, G20, NATO, OECD, WTO, Commonwealth, Francophonie, OAS, APEC, and UN. With the eighth-highest Human Development Index globally, it has one of the highest standards of living in the world.
Now to immigrate to this country is very easy because now they are given permanet green card or residency to people all over the world.This year alone they are issuing about 260,000 visas.For more information on this questions';

you can visit
http://www.cic.gc.ca/english/index.asp.

Also,if your ocupation falls into any of these categories you do not need to waste time in applying

Management occupations (NOC 0)
- Senior Management Occupations (NOC 00)
  - Legislators and Senior Management (NOC 001)
- Middle and Other Management Occupations in Business, Finance and Administration (NOC 01)
  - Administrative Services Managers (NOC 011)
  - Managers in Financial and Business Services (NOC 012)
  - Managers in Communication (Except Broadcasting) (NOC 013)
    - Telecommunication Carriers Managers (NOC 0131)
    - Postal and Courier Services Managers (NOC 0132)
- Middle and Other Management Occupations in Natural and Applied Sciences (NOC 02)
  - Managers in Engineering, Architecture, Science and Information Systems (NOC 021)
- Middle and Other Management Occupations in Health (NOC 03)
  - Managers in Health, Education, Social and Community Services (NOC 031)
- Middle and Other Management Occupations in Social Science, Education, Governement Service and Religion (NOC 04)
  - Managers in Public Administration (NOC 041)
- Middle and Other Management Occupations in Art, Culture, Recreation and Sport (NOC 05)
  - Managers in Art, Culture, Recreation and Sport (NOC 051)
- Middle and Other Management Occupations in Sales and Service (NOC 06)
  - Sales, Marketing and Advertising Managers (NOC 061)
    - Sales, Marketing and Advertising Managers (NOC 0611)
  - Managers in Retail Trade (NOC 062)
    - Retail Trade Managers (NOC 0621)
  - Managers in Food Service and Accommodation (NOC 063)
    - Restaurant and Food Service Managers (NOC 0631)
    - Accommodation Service Managers (NOC 0632)
  - Managers in Protective Service (NOC 064)
  - Managers in Other Services (NOC 065)
    - Other Services Managers (NOC 0651)
- Middle and Other Management Occupations in Trades, Transport and Equipment Operators (NOC 07)
  - Managers in Construction and Transportation (NOC 071)
  - Facility Operation and Maintenance Managers (NOC 072)
    - Facility Operation and Maintenance Managers (NOC 0721)
- Middle and Other Management Occupations Unique to Primary Industry (NOC 08)
  - Managers in Primary Production (Except Agriculture) (NOC 081)
    - Primary Production Managers (Except Agriculture) (NOC 0811)
- Middle and Other Management Occupations Unique to Processing, Manufacturing and Utilities (NOC 09)
  - Managers in Manufacturing and Utilities (NOC 091)
    - Manufacturing Managers (NOC 0911)
    - Utilities Managers (NOC 0912)
Business, Finance and Administration Occupations (NOC 1)
- Professional Occupations in Business and Finance (NOC 11)
  - Auditors, Accountants and Investment Professionals (NOC 111)
  - Human Resources and Business Service Professionals (NOC 112)
    - Specialists in Human Resources (NOC 1121)
    - Professional Occupations in Business Services to Management (NOC 1122)
- Skilled Administrative and Business Occupations (NOC 12)
  - Clerical Supervisors (NOC 121)
  - Administrative and Regulatory Occupations (NOC 122)
  - Finance and Insurance Administrative Occupations (NOC 123)
  - Secretaries, Recorders and Transcriptionists (NOC 124)
- Clerical Occupations (NOC 14)
  - Clerical Occupations, General Office Skills (NOC 141)
  - Office Equipment Operators (NOC 142)
  - Finance and Insurance Clerks (NOC 143)
  - Administrative Support Clerks (NOC 144)
  - Library, Correspondence and Related Information Clerks (NOC 145)
  - Mail and Message Distribution Occupations (NOC 146)
  - Recording, Scheduling and Distributing Occupations (NOC 147)
Natural and Applied Sciences and Related Occupations (NOC 2)
- Professional Occupations in Natural and Applied Sciences (NOC 21)
  - Physical Science Professionals (NOC 211)
  - Life Science Professionals (NOC 212)
  - Civil, Mechanical, Electrical and Chemical Engineers (NOC 213)
  - Other Engineers (NOC 214)
  - Architects, Urban Planners and Land Surveyors (NOC 215)
  - Mathematicians, Statisticians and Actuaries (NOC 216)
    - Mathematicians, Statisticians and Actuaries (NOC 2161)
  - Computer and Information Systems Professionals (NOC 217)
- Technical Occupations Related to Natural and Applied Sciences (NOC 22)
  - Technical Occupations in Physical Sciences (NOC 221)
  - Technical Occupations in Life Sciences (NOC 222)
  - Technical Occupations in Civil, Mechanical and Industrial Engineering (NOC 223)
  - Technical Occupations in Electronics and Electrical Engineering (NOC 224)
  - Technical Occupations in Architecture, Drafting, Surveying and Mapping (NOC 225)
  - Other Technical Inspectors and Regulatory Officers (NOC 226)
  - Transportation Officers and Controllers (NOC 227)
  - Technical Occupations in Computer and Information Systems (NOC 228)
Health Occupations (NOC 3)
- Professional Occupations in Health (NOC 31)
  - Physicians, Dentists and Veterinarians (NOC 311)
  - Optometrists, Chiropractors and Other Health Diagnosing and Treating Professionals (NOC 312)
  - Pharmacists, Dietitians and Nutritionists (NOC 313)
    - Pharmacists (NOC 3131)
    - Dietitians and Nutritionists (NOC 3132)
  - Therapy and Assessment Professionals (NOC 314)
  - Nurse Supervisors and Registered Nurses (NOC 315)
    - Head Nurses and Supervisors (NOC 3151)
    - Registered Nurses (NOC 3152)
- Technical and Skilled Occupations in Health (NOC 32)
  - Medical Technologists and Technicians (Except Dental Health) (NOC 321)
  - Technical Occupations in Dental Health Care (NOC 322)
  - Other Technical Occupations in Health Care (Except Dental) (NOC 323)
- Assisting Occupations in Support of Health Services (NOC 34)
  - Assisting Occupations in Support of Health Services (NOC 341)
Occupations in Social Science, Education, Government Service and Religion (NOC 4)
- Professional Occupations in Social Science, Education, Government Services and Religion (NOC 41)
  - Judges, Lawyers and Quebec Notaries (NOC 411)
    - Judges (NOC 4111)
    - Lawyers and Quebec Notaries (NOC 4112)
  - University Professors and Assistants (NOC 412)
    - University Professors (NOC 4121)
    - Post-Secondary Teaching and Research Assistants (NOC 4122)
  - College and Other Vocational Instructors (NOC 413)
    - College and Other Vocational Instructors (NOC 4131)
  - Secondary and Elementary School Teachers and Educational Counsellors (NOC 414)
  - Psychologists, Social Workers, Counsellors, Clergy and Probation Officers (NOC 415)
  - Policy and Program Officers, Researchers and Consultants (NOC 416)
- Paraprofessional Occupations in Law, Social Services, Education and Religion (NOC 42)
  - Paralegals, Social Services Workers and Occupations in Education and Religion, n.e.c. (NOC 421)
Occupations in Art, Culture, Recreation and Sport (NOC 5)
- Professional Occupations in Art and Culture (NOC 51)
  - Librarians, Archivists, Conservators and Curators (NOC 511)
  - Writing, Translating and Public Relations Professionals (NOC 512)
  - Creative and Performing Artists (NOC 513)
- Technical and Skilled Occupations in Art, Culture, Recreation and Sport (NOC 52)
  - Technical Occupations in Libraries, Archives, Museums and Art Galleries (NOC 521)
    - Library and Archive Technicians and Assistants (NOC 5211)
    - Technical Occupations Related to Museums and Art Galleries (NOC 5212)
  - Photographers, Graphic Arts Technicians and Technical and Co-ordinating Occupations in Motion Pictures, Broadcasting and the Performing Arts (NOC 522)
  - Announcers and Other Performers (NOC 523)
    - Announcers and Other Broadcasters (NOC 5231)
    - Other Performers (NOC 5232)
  - Creative Designers and Craftspersons (NOC 524)
  - Athletes, Coaches, Referees and Related Occupations (NOC 525)
Sales and Service Occupations (NOC 6)
- Skilled Sales and Service Occupations (NOC 62)
  - Sales and Service Supervisors (NOC 621)
  - Technical Sales Specialists, Wholesale Trade (NOC 622)
    - Technical Sales Specialists – Wholesale Trade (NOC 6221)
  - Insurance and Real Estate Sales Occupations and Buyers (NOC 623)
  - Chefs and Cooks (NOC 624)
    - Chefs (NOC 6241)
    - Cooks (NOC 6242)
  - Butchers and Bakers (NOC 625)
    - Butchers, Meat Cutters and Fishmongers – Retail and Wholesale (NOC 6251)
    - Bakers (NOC 6252)
  - Police Officers and Firefighters (NOC 626)
    - Police Officers (Except Commissioned) (NOC 6261)
    - Firefighters (NOC 6262)
  - Technical Occupations in Personal Service (NOC 627)
    - Hairstylists and Barbers (NOC 6271)
    - Funeral Directors and Embalmers (NOC 6272)
- Intermediate Sales and Service Occupations (NOC 64)
  - Sales Representatives, Wholesale Trade (NOC 641)
    - Sales Representatives – Wholesale Trade (Non-Technical) (NOC 6411)
  - Retail Salespersons and Sales Clerks (NOC 642)
    - Retail Salespersons and Sales Clerks (NOC 6421)
  - Occupations in Travel and Accommodation (NOC 643)
  - Tour and Recreational Guides and Casino Occupations (NOC 644)
  - Occupations in Food and Beverage Service (NOC 645)
  - Other Occupations in Protective Service (NOC 646)
  - Childcare and Home Support Workers (NOC 647)
  - Other Occupations in Personal Service (NOC 648)
- Elemental Sales and Service Occupations (NOC 66)
  - Cashiers (NOC 661)
    - Cashiers (NOC 6611)
  - Other Sales and Related Occupations (NOC 662)
  - Food Counter Attendants, Kitchen Helpers and Related Occupations (NOC 664)
    - Food Counter Attendants, Kitchen Helpers and Related Occupations (NOC 6641)
  - Security Guards and Related Occupations (NOC 665)
    - Security Guards and Related Occupations (NOC 6651)
  - Cleaners (NOC 666)
  - Other Occupations in Travel, Accommodation, Amusement and Recreation (NOC 667)
    - Operators and Attendants in Amusement, Recreation and Sport (NOC 6671)
    - Other Attendants in Accommodation and Travel (NOC 6672)
  - Other Elemental Service Occupations (NOC 668)
Trades, Transport and Equipment Operators and Related Occupations (NOC 7)
- Trades and Skilled Transport and Equipment Operators (NOC 72)
  - Contractors and Supervisors, Trades and Related Workers (NOC 721)
  - Supervisors, Railway and Motor Transportation Occupations (NOC 722)
    - Supervisors, Railway Transport Operations (NOC 7221)
    - Supervisors, Motor Transport and Other Ground Transit Operators (NOC 7222)
  - Machinists and Related Occupations (NOC 723)
    - Machinists and Machining and Tooling Inspectors (NOC 7231)
    - Tool and Die Makers (NOC 7232)
  - Electrical Trades and Telecommunication Occupations (NOC 724)
  - Plumbers, Pipefitters and Gas Fitters (NOC 725)
  - Metal Forming, Shaping and Erecting Trades (NOC 726)
  - Carpenters and Cabinetmakers (NOC 727)
    - Carpenters (NOC 7271)
    - Cabinetmakers (NOC 7272)
  - Masonry and Plastering Trades (NOC 728)
  - Other Construction Trades (NOC 729)
- Trades and Skilled Transport and Equipment Operators (NOC 73)
  - Machinery and Transportation Equipment Mechanics (Except Motor Vehicle) (NOC 731)
  - Automotive Service Technicians (NOC 732)
    - Automotive Service Technicians, Truck and Bus Mechanics and Mechanical Repairers (NOC 7321)
    - Motor Vehicle Body Repairers (NOC 7322)
  - Other Mechanics (NOC 733)
  - Upholsterers, Tailors, Shoe Repairers, Jewellers and Related Occupations (NOC 734)
  - Stationary Engineers and Power Station and System Operators (NOC 735)
    - Stationary Engineers and Auxiliary Equipment Operators (NOC 7351)
    - Power Systems and Power Station Operators (NOC 7352)
  - Train Crew Operating Occupations (NOC 736)
    - Railway and Yard Locomotive Engineers (NOC 7361)
    - Railway Conductors and Brakemen/women (NOC 7362)
  - Crane Operators, Drillers and Blasters (NOC 737)
  - Printing Press Operators, Commercial Divers and Other Trades and Related Occupations, n.e.c. (NOC 738)
- Intermediate Occupations in Transport, Equipment Operation, Installation and Maintenance (NOC 74)
  - Motor Vehicle and Transit Drivers (NOC 741)
  - Heavy Equipment Operators (NOC 742)
    - Heavy Equipment Operators (Except Crane) (NOC 7421)
    - Public Works Maintenance Equipment Operators (NOC 7422)
  - Other Transport Equipment Operators and Related Workers (NOC 743)
  - Other Installers, Repairers and Servicers (NOC 744)
  - Longshore Workers and Material Handlers (NOC 745)
    - Longshore Workers (NOC 7451)
    - Material Handlers (NOC 7452)
- Trades Helpers, Construction Labourers and Related Occupations (NOC 76)
  - Trades Helpers and Labourers (NOC 761)
    - Construction Trades Helpers and Labourers (NOC 7611)
    - Other Trades Helpers and Labourers (NOC 7612)
  - Public Works and Other Labourers, n.e.c. (NOC 762)
    - Public Works and Maintenance Labourers (NOC 7621)
    - Railway and Motor Transport Labourers (NOC 7622)
Occupations Unique to Primary Industry (NOC 8)
- Skilled Occupations in Primary Industry (NOC 82)
  - Supervisors, Logging and Forestry (NOC 821)
    - Supervisors, Logging and Forestry (NOC 8211)
  - Supervisors, Mining, Oil and Gas (NOC 822)
    - Supervisors, Mining and Quarrying (NOC 8221)
    - Supervisors, Oil and Gas Drilling and Service (NOC 8222)
  - Underground Miners, Oil and Gas Drillers and Related Workers (NOC 823)
    - Underground Production and Development Miners (NOC 8231)
    - Oil and Gas Well Drillers, Servicers, Testers and Related Workers (NOC 8232)
  - Logging Machinery Operators (NOC 824)
    - Logging Machinery Operators (NOC 8241)
  - Contractors, Operators and Supervisors in Agriculture, Horticulture and Aquaculture (NOC 825)
  - Fishing Vessel Masters and Skippers and Fishermen/women (NOC 826)
    - Fishing Masters and Officers (NOC 8261)
    - Fishing Vessel Skippers and Fishermen/women (NOC 8262)
- Intermediate Occupations in Primary Industry (NOC 84)
  - Mine Service Workers and Operators in Oil and Gas Drilling (NOC 841)
    - Underground Mine Service and Support Workers (NOC 8411)
    - Oil and Gas Well Drilling Workers and Services Operators (NOC 8412)
  - Logging and Forestry Workers (NOC 842)
    - Chain Saw and Skidder Operators (NOC 8421)
    - Silviculture and Forestry Workers (NOC 8422)
  - Agriculture and Horticulture Workers (NOC 843)
    - General Farm Workers (NOC 8431)
    - Nursery and Greenhouse Workers (NOC 8432)
  - Other Fishing and Trapping Occupations (NOC 844)
    - Fishing Vessel Deckhands (NOC 8441)
    - Trappers and Hunters (NOC 8442)
- Labourers in Primary Industry (NOC 86)
  - Primary Production Labourers (NOC 861)
Occupations Unique to Processing, Manufacturing and Utilities (NOC 9)
- Processing, Manufacturing and Utilities Supervisors and Skilled Operators (NOC 92)
  - Supervisors, Processing Occupations (NOC 921)
  - Supervisors, Assembly and Fabrication (NOC 922)
  - Central Control and Process Operators in Manufacturing and Processing (NOC 923)
- Processing and Manufacturing Machine Operators and Assemblers (NOC 94)
  - Machine Operators and Related Workers in Metal and Mineral Products Processing (NOC 941)
  - Machine Operators and Related Workers in Chemical, Plastic and Rubber Processing (NOC 942)
  - Machine Operators and Related Workers in Pulp and Paper Production and Wood Processing (NOC 943)
  - Machine Operators and Related Workers in Textile Processing (NOC 944)
  - Machine Operators and Related Workers in Fabric, Fur and Leather Products Manufacturing (NOC 945)
  - Machine Operators and Related Workers in Food, Beverage and Tobacco Processing (NOC 946)
  - Printing Machine Operators and Related Occupations (NOC 947)
  - Mechanical, Electrical and Electronics Assemblers (NOC 948)
  - Other Assembly and Related Occupations (NOC 949)
- Processing and Manufacturing Machine Operators and Assemblers (NOC 95)
  - Machining, Metalworking, Woodworking and Related Machine Operators (NOC 951)
- Labourers in Processing, Manufacturing and Utilities (NOC 96)
  - Labourers in Processing, Manufacturing and Utilities (NOC 961)

Note: The National Occupational Classification (NOC) is the system that regroups and describes all occupations in Canada.

However,if you need more information from the author,you can post your comment hear and also register to be the follower

2) AUSTRALIA

This country is another highly rated place to migrate to base on some many attributes.
It is a country in the southern atmosphere consisting of the island of Tasmania,the mainland of Australia continent and numerous small islands in the pacific and india oceans

A very economically stable country and is the world thirteenth largest economy

Australia ranks highly in many international comparisons of national performance such as human development, quality of life, health care, life expectancy, public education, economic freedom and the protection of civil liberties and political rights.

Largest populated areas in Australia
Rank	City Name	State	Pop.	Rank	City Name	State	Pop.
1	Sydney	NSW	4,504,469	11	Hobart	TAS	212,019
2	Melbourne	VIC	3,995,537	12	Geelong	VIC	175,803
3	Brisbane	QLD	2,004,262	13	Townsville	QLD	168,402
4	Perth	WA	1,658,992	14	Cairns	QLD	147,118
5	Adelaide	SA	1,187,466	15	Toowoomba	QLD	128,600
6	Gold Coast-Tweed	QLD / NSW	577,977	16	Darwin	NT	124,760
7	Newcastle	NSW	540,796	17	Launceston	TAS	105,445
8	Canberra-Queanbeyan	ACT / NSW	403,118	18	Albury-Wodonga	NSW / VIC	104,609
9	Wollongong	NSW	288,984	19	Ballarat	VIC	94,088
10	Sunshine Coast	QLD	245,309	20	Bendigo

Commonwealth of Australia


Flag	Coat of arms

Anthem: "Advance Australia Fair"^{[N 1]}

Capital

Canberra

Largest city

Sydney

Official language(s) None

National language English (de facto)

Demonym Australian, Aussie

Government Federal parliamentary democracy and constitutional monarchy

- Monarch Elizabeth II

- Governor-General Quentin Bryce

- Prime Minister Julia Gillard

Legislature

Parliament

- Upper House Senate

- Lower House House of Representatives

Independence from the United Kingdom

- Constitution 1 January 1901

- Statute of Westminster 11 December 1931

- Statute of Westminster Adoption Act 9 October 1942 (with effect from 3 September 1939)

- Australia Act 3 March 1986

Area

- Total 7,617,930 km² 2,941,299 sq mi

Population

- 2011 estimate 22,614,275

- 2006 census 19,855,288

- Density 2.833/km² 7.3/sq mi

GDP (PPP) 2010 estimate

- Total $882.344 billion

- Per capita $39,692

GDP (nominal) 2010 estimate

- Total $1,219.722 billion

- Per capita $54,868

Gini (2006) 30.5

HDI (2010) 0.937 (very high)

Currency Australian dollar (AUD)

Time zone various (UTC+8 to +10.5)

- Summer (DST) various(UTC+8 to +11.5)

Drives on the left

Migrating to Australia

Watch this video

HEALTH AND SAFETY

2011-03-09T08:10:00.000-08:00

Do you know your right as worker.

Do you know what your working environment should be like.

Do you know as an employer your right as in regard to your employee

For,more information on this issues and many more,you are all invited to follow this trends here.

CAN YOU BELIEVE THESE MADNESS

We need very good health and safety legislation in Nigeria.What is car racing without proper organisation and training.

well you can drop your comment on this

THE EPWORTH SLEEPINESS SCALE

2011-02-21T08:12:00.000-08:00

This scale is to evaluate sleeping problem in an individual which could be either CRSD or ES

1 - 6	Congratulations, you are getting enough sleep!
7 - 8	Your score is average
9 and up	Seek the advice of a sleep specialist without delay

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

0 = no chance of dozing

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

SITUATION	CHANCE OF DOZING
Sitting and reading	____________
Watching TV	____________
Sitting inactive in a public place (e.g a theater or a meeting)	____________
As a passenger in a car for an hour without a break	____________
Lying down to rest in the afternoon when circumstances permit	____________
Sitting and talking to someone	____________
Sitting quietly after a lunch without alcohol	____________
In a car, while stopped for a few minutes in traffic	____________

Cardiovascular accident in women

2011-02-21T04:20:00.000-08:00

Threshold for 'High Risk' Reduced in New AHA Guidance on CVD Prevention for Women

The first overhaul in four years of the American Heart Association guidelines on cardiovascular disease prevention in women has lowered the threshold for who is considered "high risk," says the chair of the writing committee, Dr Lori Mosca (Columbia University, New York, NY), who is also lead author of the manuscript, which is published online February 16, 2011 in Circulation [1].
Mosca explained in an interview with heartwire that the new recommendations are based upon an extensive literature search since the last guidance for women, in 2007. "There have been a couple of major changes," she notes. "As well as the lowering of this threshold, we also focus on what can be accomplished in the 'real world' as opposed to what is achievable in clinical trials, and we highlight the fact that women who have had pregnancy complications are at increased risk of CVD."

We highlight the fact that women who have had pregnancy complications are at increased risk of CVD.

In addition, "we've softened the recommendations on certain advice in women," she says, including the use of aspirin in diabetics and the stringency of diabetic control, and introduced new but "soft" guidance on statin use for primary prevention in those with normal cholesterol but raised C-reactive protein (CRP) levels.
"And we have made a call for future research to publish not just efficacy results by gender, but also sex-specific adverse drug reactions [ADRs]," she notes. Having all of this information will help doctors to make better decisions on how best to treat an individual woman, based on a proper assessment of the risk/benefit profile in each case, she says.
Threshold for Treatment Lowered to >10% Risk Over 10 Years
Mosca explains that the previous threshold for what is considered "high risk" among women has been lowered, from a >20% risk of dying from a heart attack in the next 10 years to a >10% risk of dying from any cardiovascular event in the next 10 years.

The ratio of stroke to heart attacks is always higher in women than in men.

"There are two main reasons for this," she says. "First, the primary risk-assessment tools that are used tend to underestimate risk in women, and second, women are more likely than men to experience a stroke vs a heart attack, so we wanted to make sure we encompass that in the risk assessment."
Mosca says that women and even most doctors are "definitely not aware that older women are more likely to have a stroke than a heart attack and that the ratio of stroke to heart attacks is always higher in women than in men."
Pregnancy Complications up CV Risk for Women; Real World Stressed
Mosca continues: "Another important change in terms of risk assessment is that we've now categorized women who have had pregnancy complications as being 'at risk.'
"This is important because often we don't take a pregnancy history. Primary-care physicians in particular, but also cardiologists, should know that preeclampsia or gestational diabetes during pregnancy, and/or birth of a preterm infant or an infant who is small for their gestational age, or bleeding in the third trimester are all associated with increased cardiovascular risk.
"This represents a unique opportunity to identify women at an earlier life stage than they might normally present, so we can institute more aggressive preventive therapy and control of risk factors," she stresses.

We are asking physicians to really look at the balance of benefits and risks in the real-world setting.

The other important change in the guidelines is this "paradigm shift from evidence-based to effectiveness-based," says Mosca. "We recognize that the guidelines themselves are based on science, but we also acknowledge that the results that we see in clinical practice are often less impressive than what we would see in clinical trials, because women are often older and have more comorbidities, so we are asking physicians to really look at the balance of benefits and risks in the real-world setting. There are certain conditions where they might not want to be as aggressive as the guidelines suggest--for example, older frail women who are more likely to have side effects," she notes.
Thresholds Softened for Aspirin and Glycemic Control in Diabetes
The new guidance also includes the softening of a number of prior recommendations. First, the use of aspirin in diabetics, which used to be a class I recommendation, "is now a class IIa," says Mosca, adding, "The data on the benefits of aspirin for diabetics and balancing the risks are not as strong as they are for women with CVD."

The data on the benefits of aspirin for diabetics and balancing the risks are not as strong as they are for women with CVD.

The recommendation for glycemic control in diabetes (HbA1c <7%) is also softened, she says, because again, "there may be adverse effects of too aggressive control in some women."
And although there has been no change on the recommendations for the use of aspirin for primary prevention in women generally, "most people don't realize we don't strongly recommend it for women under 65," Mosca says.
Another new but "fairly soft recommendation" is for the use of statins in primary prevention in women without raised cholesterol but who have an elevated CRP level, the JUPITER-type population, she says.
"The rationale for this is that the absolute benefit is very small, even though the proportional risk reduction is very high. We want doctors to recognize that the long-term side effects and cost [of statins] might outweigh the benefits. We give it a softer recommendation than we might have because of our shift toward 'real-world' issues."
And finally, she says, "We really make a call to action that future research should publish both efficacy and ADRs by gender. While doctors are getting better at publishing sex-specific efficacy analyses, it's very rare to see side-effect data by gender, and that's important," she concludes.
Mosca declares she has no conflicts of interest; disclosures for the coauthors are listed in the paper.

INTRODUCTION

2011-02-21T03:36:00.000-08:00

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