Purchase genuine torsemide

Sanborn Organizational Reviewer- None Society for Cardiovascular Angiography and Interventions Organizational Reviewer- American Society of Nuclear Cardiology the Medicines Company* None None None None Gregory S. Creager None None None None None None None None Genzyme Biomarin Sanofi-aventis Sigma Tau Vascutek Merck Sanofi-aventis Gregg C. Haffey Representation Content Reviewer Consultant Merck Merck ScheringPlough Speaker AstraZeneca Merck Merck ScheringPlough Ownership/ Partnership/ Principal Colorado Heart Institute Institutional, Organizational, or Other Financial Expert Personal Research Benefit Witness GlaxoSmithKline* None None Jonathan L. Continued Ownership/ Partnership/ Principal None Institutional, Organizational, or Other Financial Expert Personal Research Benefit Witness None None None Peer Reviewer Laurence S. A relationship is considered to be modest whether it is lower than vital beneath the preceding definition. Stratification of patients into high, medium and low threat subgroups for functions of threat factor management. Major threat components as antecedents of deadly and nonfatal coronary coronary heart illness events. Heart illness and stroke statistics-2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Association of Pathobiologic Determinants of Atherosclerosis in Youth threat rating and 15-year change in threat rating with carotid artery intima-media thickness in young adults (from the Cardiovascular Risk in Young Finns Study). Pathobiological determinants of atherosclerosis in youth threat scores are related to early and advanced atherosclerosis. Public health burden of coronary illness threat components among middle-aged and aged males. Criteria for evaluation of novel markers of cardiovascular threat: a scientific statement from the American Heart Association. A consideration of lipoprotein-associated phospholipase A2 and C-reactive protein for stroke threat. Coronary calcium as a predictor of coronary events in 4 racial or ethnic teams. A genome-wide affiliation research for blood lipid phenotypes in the Framingham Heart Study. Novel and traditional biomarkers for prediction of incident cardiovascular events in the neighborhood. Development and validation of improved algorithms for the assessment of world cardiovascular threat in ladies: the Reynolds Risk Score. Accuracy and impression of threat assessment in the main prevention of cardiovascular disease: a scientific evaluate. Validation of the Framingham coronary coronary heart illness prediction scores: results of a a number of ethnic teams investigation. Comparison of estimates and calculations of threat of coronary coronary heart illness by medical doctors and nurses using different calculation instruments normally follow: cross sectional research. Improving coronary coronary heart illness threat assessment in asymptomatic individuals: function of conventional threat components and noninvasive cardiovascular exams. Framingham threat rating and prediction of coronary coronary heart illness dying in young males. Systematic examination of the updated Framingham coronary heart research general cardiovascular threat profile. Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. A comparability of optimistic household history definitions for defining threat of future illness. Family history is a coronary coronary heart illness threat factor in the Second Northwick Park Heart Study. Accuracy of offspring reviews of parental cardiovascular disease history: the Framingham Offspring Study. Research priorities for evaluating household history in the prevention of frequent persistent diseases.

purchase genuine torsemide

Buy torsemide with a mastercard

Two scored within the top quality group, with strengths together with robust design (prospect cohort data), large pattern size, and multiple data points. Weaknesses included lack of adequate element and considerations about blinding of the interviews to the task of members. These studies had robust analysis designs that had been able that adopted the identical people over time and used rigorous statistical strategies. Overall Assessment the majority of the studies (n=eight) found a optimistic impact of the intervention on some part of stopping repeat pregnancies together with uptake of contraception, and avoiding repeat pregnancies. A ultimate group of interventions had no outcomes reported on avoiding having multiple children throughout adolescence from which to draw conclusions (n=1). Among the studies with optimistic outcomes, only two had interventions and evaluations that scored a four or above on both the standard of the intervention and the standard of the analysis. Below we describe the intervention, analysis and outcomes from these two studies that symbolize top quality interventions and evaluations and had a optimistic impact on limiting the variety of children. Table four summarizes the excessive scoring interventions with a optimistic impact on limiting the variety of children. Table four: High Scoring Effective Interventions for Limiting the Number of Children Age Range Jamaica 15-20 County Evaluation Methodology Quantitative Grey/ Published Published Key Intervention Components Classroom instruction and support for adolescent moms; expertise training and job placement assistance. Acceptance and use of a household planning methodology is a requirement for program participation. Case Studies As we only positioned two top quality studies with an impact on repeat being pregnant, we featured both in our case studies. One was a multicomponent program based out of a clinic and the opposite was a community-based intervention. Both had an intervention group and a comparison or control group-one used a submit-only design while the opposite had a baseline/endline design. The study was a retrospective cohort study following women who had a first being pregnant in 1994 after which sought to determine the risk of one other being pregnant by program participation. The program included classroom instruction and support along with job expertise training and placement. The analysis in contrast members to non-members on the finish of the intervention. Following young women, ages 15-19, this study (Sebastian et al, 2012) sought to assess whether or not an intervention to elevate consciousness about the benefits of delivery spacing for the well being of mother and baby would promote postpartum contraception in rural India. The intervention teams had been exposed to the educational marketing campaign, described beneath and the comparison teams acquired only the federal government run well being program. The intervention consisted primarily of an educational marketing campaign, led by community well being staff. Women within the intervention teams had been considerably extra more likely to know the wholesome spacing messages four months postpartum than had been these within the comparison group (Odds Ratio=2. The outcomes also counsel that in contrast with women within the comparison group, women exposed to the educational marketing campaign had been considerably extra more likely to know of at least two wholesome spacing messages (Odds Ratio=1. After multivariable adjustment, women within the intervention group had been considerably extra more likely to be using a contraceptive methodology postpartum (Odds Ratio=three. Sebastian, Mary Philip, Khan, Mohammed Ejazduin, Kumari, Kaushal, & Idnani, Rukma. Increasing Postpartum Contraception in Rural India: Evaluation of a Community-Based Behavior Change Communication Intervention. Intervenci�n educativa en adolescentes atendidas en consulta de ginecolog�a infanto-juvenil. The Effect of Reproductive Health Communication Interventions on Age at Marriage and First Birth in Rural Bihar, India: A retrospective study Pathfinder International. Empowering married young women and enhancing their sexual and reproductive well being:Effects of the First-time Parents Project: Population Council. Reproductive Health of Young Adults in India: the Road to Public Health Pathfinder. The European Journal of Contraception and Reproductive Health Care, 15(s1), 60-201. Impact of submit-abortion household planning companies on contraceptive use and abortion fee amongst young women in China: a cluster randomised trial. We additional restricted the search to only include these studies that included phrases for analysis, assessment and impact. Given the large numbers, we determined to focus solely on interventions that focused a behavior change, quite than together with all interventions that only focusing on changing data and attitudes as outcomes.

buy torsemide with a mastercard

Cheap torsemide 20mg overnight delivery

Sodium and water excretion Sodium and water retention are associated with an increase in blood pressure. It is postulated that sodium, via the sodium�calcium exchange mechanism, causes an increase in intracellular calcium in vascular easy muscle resulting in increased vascular tone. The primary cause of sodium and water retention may be an irregular relationship between pressure and sodium excretion ensuing from lowered renal blood flow, lowered nephron mass, and increased angiotensin or mineralocorticoids. Eicosanoids Arachidonic acid metabolites alter blood pressure via direct effects on vascular easy muscle tone and interactions with different vasoregulatory methods: autonomic nervous system, renin� angiotensin�aldosterone system, and different humoral pathways. In hypertensive sufferers, vascular endothelial cell dysfunction might result in reduction in endothelium-derived stress-free components corresponding to nitric oxide, prostacyclin, and endothelium-derived hyperpolarizing factor, or increased production of contracting components corresponding to endothelin-1 and thromboxane A2. Pathophysiology Hypertension is a chronic elevation of blood pressure that, within the lengthy-term, causes finish-organ damage and leads to increased morbidity and mortality. It follows that sufferers with arterial hypertension might have an increase in cardiac output, an increase in systemic vascular resistance, or both. In the younger age group, the cardiac output is commonly elevated, while in older sufferers increased systemic vascular resistance and increased stiffness of the vasculature play a dominant role. Vascular tone may be elevated because of increased a-adrenoceptor stimulation or increased launch of peptides corresponding to angiotensin or endothelins. The final pathway is an increase in cytosolic calcium in vascular easy muscle inflicting vasoconstriction. Several progress components, together with angiotensin and endothelins, cause an increase in vascular easy muscle mass termed vascular remodelling. Both an increase in systemic vascular resistance and an increase in vascular stiffness increase the load imposed on the left ventricle; this induces left ventricular hypertrophy and left ventricular diastolic dysfunction. In youth, the pulse pressure generated by the left ventricle is comparatively low and the waves mirrored by the peripheral vasculature Kallikrein-kinin methods Tissue kallikreins act on kininogen to kind vasoactive peptides. Kinins play a job within the regulation of renal blood flow and water and sodium excretion. Nonetheless, the deleterious vascular effects of endogenous seventy two Continuing Education in Anaesthesia, Critical Care & Pain Volume 4 Number 3 2004 Hypertension: pathophysiology and therapy happen primarily after the end of systole, thus growing pressure in the course of the early part of diastole and bettering coronary perfusion. With ageing, stiffening of the aorta and elastic arteries will increase the pulse pressure. This leads to an increase in left ventricular afterload, and contributes to left ventricular hypertrophy. The widening of the pulse pressure with ageing is a strong predictor of coronary coronary heart disease. The autonomic nervous system performs an necessary role within the management of blood pressure. In hypertensive sufferers, both increased launch of, and enhanced peripheral sensitivity to, norepinephrine may be found. Another characteristic of arterial hypertension is a resetting of the baroreflexes and decreased baroreceptor sensitivity. The renin�angiotensin system is concerned a minimum of in some forms of hypertension (e. Others have excessive-renin hypertension and these are more likely to develop myocardial infarction and different cardiovascular issues. In human essential hypertension, and experimental hypertension, quantity regulation and the connection between blood pressure and sodium excretion (pressure natriuresis) are irregular. Considerable proof signifies that resetting of pressure natriuresis performs a key role in inflicting hypertension. In sufferers with essential hypertension, resetting of pressure natriuresis is characterised either by a parallel shift to greater blood pressures and salt-insensitive hypertension, or by a decreased slope of pressure natriuresis and salt-delicate hypertension. It might begin as diastolic dysfunction and progresses to overt systolic failure with cardiac congestion. Strokes are main issues of hypertension; they end result from thrombosis, thrombo-embolism, or intracranial haemorrhage. Renal disease, initially revealed by micro-albuminaemia might progress slowly and turns into evident in later years. Long-term therapy of hypertension All anti-hypertensive medicine must act by lowering the cardiac output, the peripheral vascular resistance, or both.

cheap torsemide 20mg overnight delivery

Discount torsemide 10mg mastercard

The demands of commercial driving may complicate adherence to prescribed dosing intervals and precautions. Irregular meal timing, durations of sleep deprivation or poor sleep high quality, and irregular or prolonged work hours can alter the results of drugs and contribute to missed or irregular dosing. Three types of drugs could also be used by the business driver: � � � Prescription. Every year, extra drugs are available with out prescription and provider supervision. As the medical examiner, your elementary obligation is to establish whether a driver makes use of one or more drugs and supplements which have cognitive or physical effects or unwanted effects that intervene with safe driving, thus endangering public security. The examination is based on data supplied by the driving force (historical past), objective data (physical examination), and extra testing requested by the medical examiner. You may ask inquiries to ascertain the extent of data relating to applicable use of the medicine while driving. Regulations - You should evaluate and discuss with the driving force any "yes" answers Does the driving force use drugs to: � � � Treat cardiovascular disease? Page 209 of 260 Recommendations - Question that you may ask embody Does the driving force expertise: � � � � � � � Dizziness or gentle-headedness? Regulations - You should evaluate On examination, does the medicine have: � � the specified effect on the underlying illness (e. Important issues for medicine use while driving Does the medicine: � � � � � � � Indicate the presence of underlying disqualifying illness or damage? Have unwanted effects that intervene with way of life capabilities such that the driving force may cease to comply with remedy (e. Have potential for gradual or sudden incapacitation, or exacerbation of underlying medical situation, because of missed dose (e. Interact with other medication, meals, and/or alcohol, interfering with the power to drive? Does the driving force: � � � � � Understand and comply with medicine plan, together with monitoring? Consult the treating healthcare professional and/or a pharmacist earlier than utilizing new medicine or combining drugs while driving. Page 210 of 260 Record Regulations - You should document dialogue with the driving force about � Any affirmative historical past, together with: o o o � � Onset date, diagnosis. Necessary steps to correct the situation if applicable, or causes for disqualification. Overall necessities for business drivers in addition to the precise necessities within the driver position job description should be deciding factors within the certification course of. The drug schedules are based on dependancy potential and medical use but not on unwanted effects. These substances embody many opiates, opiate derivatives, and hallucinogenic substances. Abuse may lead to reasonable or low physical dependence or excessive psychological dependence. Schedule V medication have the bottom potential for abuse and embody narcotic compounds or mixtures. Therefore, a substance can have little risk for dependancy and abuse but still have unwanted effects that intervene with driving capability. Page 212 of 260 Appendix A: Medical Examination Report Form To print a sample Medical Examination Report type, visit:. Driver Information A full physical examination is required for brand spanking new certification and recertification. Verify that the date of the examination is accurate as a result of this is used to calculate the expiration date. Any particular person can request and be given a Federal Motor Carrier Safety Administration physical examination. Health History the well being historical past is an important part of the driving force physical examination. Discuss the security implications of effects and/or unwanted effects of prescription and over-the-counter drugs, supplements, and herbs. By signing the shape, the driving force certifies that the data and historical past are "full and true.

discount torsemide 10mg mastercard

Buy torsemide 20mg

However, improvements have been slower in sub � Saharan African and in some Asian international locations where, during 1990 � ninety five, greater than 1 in each 10 youngsters born alive died before their first birthday. Poverty, malnutrition, a decline in breastfeeding and inadequacy or lack of sanitation and of health services are components related to high infant and child mortality. In some international locations, civil unrest and wars have additionally had main unfavorable impacts on child survival. Unwanted births, child neglect and abuse are components contributing to the rise in child mortality. Young youngsters 285 Reproductive Health whose mothers die at a very young age are at very high danger of dying themselves. Child survival is also closely linked to the timing, spacing and number of births and to the reproductive health of mothers. Early, late, quite a few, and closely spaced pregnancies are main contributors to high infant and child mortality and morbidity rates, particularly where health care services are scarce. First births might happen before a lady has reached full bodily and reproductive maturity, resulting in increased perinatal risks. Even although very young and older maternal ages at birth will proceed to be related to heightened danger of childhood mortality, the connection might be expected to differ significantly between different international locations. Where infant mortality remains high, couples usually are inclined to have extra youngsters than they in any other case would to make sure that a desired quantity survive. African youngsters bear much larger than their share of the burden of infectious illnesses. In basic, in developing international locations 39 out of 1000 live births die 289 Reproductive Health before reaching one month of age and one in each six infants is born underneath weight. A transient discussion of the epidemiology, prevention and control of these illnesses follows. If an episode of diarrhoea lasts for lower than 14 days it is named acute diarrhoea, if it lasts 14 days or extra, it is named persistent diarrhoea. Diarrhoea is the leading explanation for illness and demise among youngsters in developing international locations, where an estimated 1. The median incidence of diarrhoea is biggest for infants aged 6 - 11 months (5 episodes/child/yr). In developing international locations, a third of the paediatric beds are occupied by diarrhoea instances. Median international worth for mortality because of acute diarrhoea among underneath five old youngsters ranges from 6 to 19. Over the previous 20 years, a variety of studies have documented a decline in diarrhoeal mortality over time. Egypt (1970 - 87) complete nationwide survey showed a fall in infant and child diarrhoeal mortality from 29. Factors underlying increased danger of diarrhoeal morbidity and mortality are: � � � � � � � Low socio-financial standing Poor private and domestic hygiene Low household income Living in a crowded room and earthen ground Lower maternal schooling Lack of breastfeeding Malnutrition - will increase severity and length, additionally some studies recently (Sudan and Mexico) 295 Reproductive Health have suggested that malnutrition will increase the risk of frequent diarrhoeal episodes. When immunosuppression is severe, diarrhoea may be brought on by unusual pathogens and may also be prolonged. This pattern reflects the combined results of declining ranges of maternally acquired antibodies, the dearth of active immunity within the infant, the introduction of meals which may be contaminated with faecal micro organism, and direct contact with human or animal faeces when the infant begins to crawl. Most enteric pathogens stimulate a minimum of partial immunity in opposition to 296 Reproductive Health repeated infection or illness, which helps declining of disease in order youngsters and adults. In temperate climates, bacterial diarrhoeas, particularly diarrhoea brought on by rotavirus occurs all year long, increasing in frequency in the course of the drier, cool months, whereas bacterial diarrhoeas peak in the course of the hotter, rainy season. The incidence of persistent diarrhoea follows the identical seasonal pattern as that of acute watery diarrhoea. During asymptomatic infections, which can last for a number of days or perhaps weeks, stools contain infectious viruses, micro organism, or protozoa cysts. Epidemics Two enteric pathogens, Vibrio cholerae o1 and Shigella dysenteriae sort 1, cause main epidemics during which morbidity and mortality in all age teams may be high. Transmission of agents that cause diarrhea the infectious agents that cause diarrhoea are normally spread by the faecal oral route, which incorporates the ingestion of faecally contaminated water or meals, and direct contact with faeces. A number of behaviours promote the transmission of enteric pathogens and thus, enhance the risk of diarrhoea. These embrace: � Failing to breastfeed exclusively for the first four � 6 months of life. A longitudinal community based survey in central rural Ethiopia indicated that acute diarrhoea is the second commonest illness reported (24%) and the best incidence was among 2 - 6 months old.

buy torsemide 20mg

Purchase torsemide on line amex

The meta-regression outcomes had been in keeping with a doseresponse relationship in normotensive pts 39 � 2017 American College of Cardiology Foundation and American Heart Association, Inc. There had been small significant will increase in plasma renin exercise, aldosterone, and noradrenaline levels however these had been in keeping with expected physiologic responses to sodium discount. The hormone modifications on this meta-evaluation doubtless replicate a physiologic response to sodium discount, particularly in research of quick duration and rapid modifications in sodium intake. It additionally suggests the relative effect of lowered sodium intake is greater in persons with a typical U. The assumptions for a main results factorial evaluation (independence of the forty one � 2017 American College of Cardiology Foundation and American Heart Association, Inc. Size: 2,382 pts, of whom 594 had been randomized to sodium discount (alone) and 596 had been randomized to ordinary care. Vital status was obtained for one hundred% of the pts and data on morbidity was obtained from 2,415 (seventy seven%) of the pts. Trials had methodological weaknesses and had been subject to potential bias because of the affiliation of authors to the transcendental meditation group. This was true for both the normotensive and hypertensive pts, with the effect size being bigger in the hypertensive group. The number of eligible trials was small and the examine samples had been heterogeneous (2 2� and 4 1� prevention trials). However, the trials had been typically small, heterogeneous of their design and conduct, and of questionable high quality. Average Patient Population Study Intervention (# patients) / Study Comparator (# patients) Intervention: Reduction in alcohol consumption. Relevant 2� Endpoint (if any); Study Limitations; Adverse Events � this is the newest meta-evaluation of this subject. Although this meta-evaluation stories % discount in alcohol intake, most trials aimed toward reducing the number of alcoholic drinks consumed achieved a discount of about 3 drinks/d. Size: 4 trials which collectively studied 305 pts Aim: Study effectiveness of common practitioner recommendation to scale back heavy consuming. Intervention: Physician and employee counselling aimed toward lowered consumption of alcohol. Exclusion standards: None talked about Intervention: Physician counselling aimed toward lowered consumption of alcohol. Comparator: Usual care Endpoints: � 1� consequence was discount in p.c with heavy consumption of alcohol (mean net change=46%). The objective was to blind these conducting the end result assessment to therapy task however by 6 mo task was identified in 20-30% of the members. Similar patterns of the effect of baseline alcohol intake on therapy effect had been noted for a wide range of subgroups. Strategy various from managed inpatient administration to randomization to "mild" alcohol to pragmatic primary care trials with counselling to scale back alcohol intake. Better proof supports the position of calcium dietary supplements, in conjunction with vitamin D, in strengthening bone density. In subgroup evaluation, the effect was noted in several ethnic groups, in trials that employed different designs, durations, and pattern sizes, in trials with overweight, chubby or regular weight pts, and in trials that employed different types, depth levels, and duration of aerobic exercise. Safety endpoint: N/A � Most recent in a series of progressively up to date publications from Dr. Comparator: Use of a management group was a requirement however no additional specific info offered. However, given the small amount of isometric research out there, additional research are warranted to confirm this discovering. Study kind: Metaanalysis Size: 28 randomized, managed trials, involving 33 examine groups and 1,012 pts. Relevant 2� Endpoint (if any); Study Limitations; Adverse Events � this is the newest systematic evaluate/meta-evaluation on this subject. The authors noted the research had been of poor high quality, with considerable heterogeneity, and felt the outcomes had been doubtless biased. Size: 2,382 pts, of whom 1,192 had been randomized to a weight loss intervention and 1,a hundred ninety had been randomized to a no weight loss intervention. Given this discovering, probably the most reliable evaluation of this trial was comparability of the experience in each active intervention group with the usual care group.

Condyloma acuminatum

Purchase torsemide without prescription

An estimated 12,8oo new cases of cervical most cancers are anticipated to be identified in 1999. The Pap smear and pelvic examination are solely partially successful at detecting endometrial (uterine lining) most cancers, which claimed an estimated 37,4oo new cases in 1999 and led to 6,4oo deaths. Although the incidence of ovarian most cancers is decrease, ovarian most cancers is the most deadly of all of the cancers of the female reproductive system. Melanoma-the most critical form of skin most cancers-is the most frequent most cancers in girls 25 to 29 years of age and the second most frequent (after breast most cancers) in girls ages 30 to 34. While men as a group usually tend to develop skin most cancers than are girls, girls beneath the age of forty comprise the fastest rising group of skin most cancers sufferers. Stroke is the third leading reason for dying for American girls, and it kills more than twice as many ladies annually as breast most cancers. Women account for 43 % (or 240,000) of the 550,000 strokes that occur annually and sixty one % of stroke deaths (ninety seven,227 of 159,791 annual deaths). Stroke occurs at a better fee amongst African American and Hispanic girls than amongst white girls. More than one lady in 5 in this nation has some form of main heart or blood vessel (cardiovascular) illness. It is the fifth leading reason for dying amongst girls ages 25 to 44 and the third leading reason for dying amongst African American girls in this age group. Significant gender variations are manifest throughout the course of the illness in addition to within the mode of an infection. However, taken collectively as a group, they represent the fourth largest reason for disability amongst girls within the United States. Major despair and dysthymia (a much less severe, extra chronic form of despair) have an effect on approximately twice as many ladies as men. An estimated 12 % of women within the United States experience a serious despair throughout their lifetimes, compared with 7 % of men; and four. Women are 2 to 3 times extra prone to have certain types of nervousness problems, together with nervousness, panic, and phobic problems. In addition, a excessive correlation seems to exist between eating problems and despair and between eating problems and substance abuse. Suicide was the fifth leading reason for dying amongst girls ages 25 to 44 in 1994 and the fourth leading reason for dying for young girls ages 15 to 24. However, girls are far much less prone to die from their try(s), largely because men usually tend to use a firearm. In 1998, the health and societal costs of alcohol and substance abuse were estimated at $238 billion. Death rates amongst female alcoholics, nevertheless, are 50 to loo % larger than these of their male counterparts. Among teenage women in 1997,forty % reported some alcohol consumption prior to now month, and 29 % reported binge ingesting. Heavy ingesting throughout pregnancy has been clearly associated with severe start defects, together with mental retardation, nervous system problems, abnormal features of the face and head, and retarded development. Unlike their adult counterparts, the speed of smoking amongst teenage women has been increasing, rising from 27 % in 1991 to 37 % in 1997. Smoking throughout pregnancy considerably will increase health dangers to the developing fetus. It is the leading reason for untimely births, and it greatly will increase the dangers of mental retardation, miscarriage, low start weight, and other critical health situations in infants. This statistic signifies that some girls could abstain from smoking throughout pregnancy, but resume smoking after their baby is born. Of these girls, almost two of every three are attacked by a relative or somebody they know. Women are 6 times extra prone to be abused by somebody they know than are men and io times extra prone to be victims of sexual assault. It is estimated that 10 to 20 % (or one to two young girls in 1o) are the victims of sexual abuse. In 1997, murder was the second leading reason for dying amongst girls ages 15 to 24 and the sixth leading reason for dying amongst girls ages 25 to 44.