Age-associated changes in cardiovascular structure/ function are implicated in the markedly increased risk for cardiovascular disease in older persons. Aging not only prolongs exposure to several other cardiovascular ...Age-associated changes in cardiovascular structure/ function are implicated in the markedly increased risk for cardiovascular disease in older persons. Aging not only prolongs exposure to several other cardiovascular risks, but also leads to intrinsic cardiac changes, which reduces cardiac functional reserve, predisposes the heart to stress and contributes to increased cardiovascular mortality in the elderly. Intrinsic cardiac aging in the murine model closely recapitulates age-related cardiac changes in humans, includ- ing left ventricular hypertrophy, fibrosis and diastolic dysfunction. Cardiac aging in mice is accompanied by accumulation of mitochondrial protein oxidation, increased mitochondrial DNA mutations, increased mitochondrial biogenesis, as well as decreased cardiac SERCA2 protein. All of these age-related changes are significantly attenu- ated in mice overexpressing catalase targeted to mitochondria （mCAT）. These findings demonstrate the critical role of rnitochondrial reactive oxygen species （ROS） in cardiac ag ing and support the potential antioxidants to cardiac aging lar diseases. application of mitochondrial and age-related cardiovascular diseases.展开更多
ObjectiveToinvestigate whether depression, anxiety and stress increase the risk for delirium and poor quality of life （QOL） after co-ronary artery bypass （CABG） surgery.MethodsA total of 180 CABG patients （mean a...ObjectiveToinvestigate whether depression, anxiety and stress increase the risk for delirium and poor quality of life （QOL） after co-ronary artery bypass （CABG） surgery.MethodsA total of 180 CABG patients （mean age of 63.5 ± 10.1 years, 82.2% males） completed baseline and postoperative self-report questionnaires to assess distress and QOL. Incident delirium was diagnosed postoperatively with a structured clinical interview and patients were monitored every day post-operatively for confusion and disturbance in consciousness.Results Delirium developed in 63 persons （35% of sample）. After adjustment for covariates, delirium was significantly associated with depression [odds ratio （OR）： 1.08; 95% confidence interval （CI）： 1.03-1.13,P = 0.003], anxiety （OR： 1.07; 95% CI： 1.02-1.13,P= 0.01） and stress （OR： 1.05; 95% CI： 1.00-1.09,P= 0.03）. Preoperative depression scores were associated with poorer QOL including bodily pain （β =-0.39,P = 0.013）, vitality （β=-0.32,P = 0.020）, social functioning （β=-0.51,P≤0.001）, emotional role function （β=-0.44,P = 0.003） and general health （β=-0.33,P = 0.038）. Among the covariates, harmful levels of alcohol use was consistently associated with poorer QOL.Conclusions Depression and harmful levels of alcohol use were consistently associated with poorer QOL whereas depression, anxiety and stress were associated with delirium risk. These findings point to further research examining depression and harmful levels of alcohol use in coronary heart disease populations undergoing coronary revascularization.展开更多
In the last two or three decades,physical activity(PA) has gained increasing recognition as being essential for maintaining good health and improving quality of life for all ages.Children have traditionally been activ...In the last two or three decades,physical activity(PA) has gained increasing recognition as being essential for maintaining good health and improving quality of life for all ages.Children have traditionally been active in both free play and organized sports.However,there has been a recent decline in the PA levels among children for various reasons.This lifestyle change has resulted in increased obesity accompanied by a rise in diabetes and cardiovascular risk among otherwise healthy children.These lifestyle changes have been shown to be even more a problem when the child is already affected by a chronic disease.Due to medical limitations and contraindications,much care must be taken to make certain that these children are involved in the appropriate volume and intensity of exercise.The type of activity must also be given careful consideration to avoid undue risk for the child who may have problems such as poor balance,limited strength,poor vision,or cognitive disability.Further complications are either caused or exacerbated by lack of sufficient PA.The priority beyond concern for safety should be focused on ensuring the highest quality of life possible.The purpose of this review is to examine how PA can benefit children with selected chronic health conditions.展开更多
Objective:This study aimed to examine the effects of mindfulness meditation on trait mindfulness,perceived stress,emotion regulation,and quality of life in end-stage renal disease patients undergoing hemodialysis.Meth...Objective:This study aimed to examine the effects of mindfulness meditation on trait mindfulness,perceived stress,emotion regulation,and quality of life in end-stage renal disease patients undergoing hemodialysis.Methods:An experimental study with repeated measures design was conducted among a sample of 74 end-stage renal disease patients undergoing hemodialysis between January and May 2021 in the dialysis center at Jahra hospital,Kuwait.The patients were randomly assigned to the experimental(n?37)and control groups(n?37).The experimental group participated in 30-min mindfulness meditation sessions(three sessions a week for five weeks)held during their hemodialysis sessions;the participants in the control group were instructed to sit with their eyes closed and relaxed for 30 min three times a week for five weeks during hemodialysis sessions.The dependent variables of both groups were measured at baseline(T0),middle of intervention(T1),and end of intervention(T2)using the Mindful Attention Awareness Scale(MAAS),Perceived Stress Scale(PSS),Emotion Regulation Questionnaire(ERQ),and Kidney Disease Quality of Life(KDQOL-36)questionnaire.The study was registered in the ClinicalTrial.gov(Identifier:NCT05176730).Results:The repeated measures ANOVA(within-subject)results for the experimental group showed that mindfulness meditation had significantly decreased perceived stress by the end of the intervention.Also,mindfulness meditation improved mindfulness,emotion regulation,and kidney disease-related quality of life in the experimental group,and this improvement occurred significantly at both T1 and T2.The repeated measures ANOVA(within and between-subject)results showed that the experimental group,as compared to the control group,had lower perceived stress,higher trait mindfulness,higher emotional regulation,and higher kidney disease-related quality of life over time.Conclusions:The positive findings of this study offer health policy-makers and hospital administrators a promising tool to use with patients undergoing hemodialysis as a way to manage stress and improve quality of life.However,this study should be replicated in multiple settings with follow-up assessments.展开更多
Cardiovascular disease （CVD） is the leading cause of death and disability worldwide. The primary prevention of CVD is dependent upon the ability to identify high-risk individuals long before the development of overt...Cardiovascular disease （CVD） is the leading cause of death and disability worldwide. The primary prevention of CVD is dependent upon the ability to identify high-risk individuals long before the development of overt events. This highlights the need for accurate risk strati- fication. An increasing number of novel biomarkers have been identified to predict cardiovascular events. Biomarkers play a critical role in the definition, prognostication, and decision-making regarding the management of cardiovascular events. This review focuses on a variety of promising biomarkers that provide diagnostic and prognostic information. The myocardial tissue-specific biomarker cardiac troponin, high- sensitivity assays for cardiac troponin, and heart-type fatty acid binding proteinall help diagnose myocardial infarction （MI） in the early hours following symptoms. Inflammatory markers such as growth differentiation factor-15, high-sensitivity C-reactive protein, fibrinogen, and uric acid predict MI and death. Pregnancy-associated plasma protein A, myeloperoxidase, and matrix metalloproteinases predict the risk of acute cor- onary syndrome. Lipoprotein-associated phospholipase A2 and secretory phospholipase A2 predict incident and recurrent cardiovascular events. Finally, elevated natriuretic peptides, ST2, endothelin-1, mid-regional-pro-adrenomedullin, copeptin, and galectin-3 have all been well validated to predict death and heart failure following a MI and provide risk stratification information for heart failure. Rapidly develop- ing new areas, such as assessment ofmicro-RNA, are also explored. All the biomarkers reflect different aspects of the development ofather- osclerosis.展开更多
OBJECTIVE: To observe the effect of Liandouqingmai recipe(Chinese herbal medicine compound preparation) on the quality of life(QOL) and inflammatory reaction of patients with coronary heart disease(CHD).METHODS: A tot...OBJECTIVE: To observe the effect of Liandouqingmai recipe(Chinese herbal medicine compound preparation) on the quality of life(QOL) and inflammatory reaction of patients with coronary heart disease(CHD).METHODS: A total of 101 CHD patients were randomized into two groups: treatment group(n=45)receiving standard treatment for CHD plus Liandouqingmai recipe, and control group(n=56) receiving standard treatment only. The control group contained 16 normal healthy subjects. Changes in hs-C-reactive protein(CRP), peripheral blood leucocytes(PBL), and interleukin(IL)-6 and IL-10 levels were measured. The Seattle Angina Questionnaire(SAQ) was used to determine patient QOL before and after treatment for 2 weeks.RESULTS: Before treatment, SAQ scores [physical limitation(PL), angina stability(AS), angina frequen-cy(AF), treatment satisfaction(TS), and disease perception(DP)] were not statistically different between groups. After treatment, AS and DP levels of controls were significantly increased compared with the other groups, while PL, AS, AF, TS, and DP levels of the treatment group were significantly increased compared with controls. Treatment group SAQ scores(PL, AS, AF, TS, and DP) were significantly higher than for controls. CHD patient IL-6 and IL-10 levels were significantly higher than controls.Before treatment, mean levels of IL-6, hs-CRP and PBL of the two groups were not statistically different. After treatment, mean levels of IL-6, IL-10,hs-CRP and PBL of the two groups were significantly decreased compared with their before treatment values, and levels of IL-6, hs-CRP, and PBL of the treatment group were lower than controls. Although mean IL-10 levels of both groups decreased, there was no significant difference in between-group and in-group comparisons before and after treatment. Mean levels of IL-6 and IL-10 in the normal group were lower than in CHD patients.SAQ scores of QOL were negatively associated with the inflammatory index(IL-6/IL-10), and there was a significant negative association of IL-10 with AS(r=﹣0.15, P<0.05).CONCLUSION: Inflammatory reactions in CHD patients are related to angina status. Coadministration of CHD standard treatment and Liandouqingmai recipe increased patient SAQ scores by decreasing IL-6, IL-10, hs-CRP, and PBL levels in CHD patients, which might inhibit endothelial inflammation to improve patient QOL.展开更多
OBJECTIVE:To observe the effects of Liandouqingmai Recipe on life quality and vascular endothelial injury in patients with coronary heart disease.METHODS:Capitalized 101 patients with coronary heart disease were rando...OBJECTIVE:To observe the effects of Liandouqingmai Recipe on life quality and vascular endothelial injury in patients with coronary heart disease.METHODS:Capitalized 101 patients with coronary heart disease were randomly divided into a treatment group(n=45) treated with Liandouqingmai Recipe and a standard treatment group(control group,n=56).A normal group of 16 healthy persons was additionally set up.Changes in ET-1 and NO levels were measured and Seatle Angina Questionnaire(SAQ) was adopted in studying life quality before and after treatment for two weeks.The data were analyzed with SPSS 16.0 statistic software.RESULTS:The average level of ET-1 in the normal group was lower and NO higher than that of patients with coronary heart disease.There was no significant difference in the average level of ET-1 and NO and in the scores of SAQ [physical limitation(PL),pngina stability(AS),apngina frequency(AF),treatment satisfaction(TS) and disease perception(DP)] between the two groups before treatment(P>0.05).But after treatment,the scores of SAQ(PL,AS,AF,TS,DP) and NO level were higher than those in the control group,and ET-1 average level in the treatment group was lower than that in the control group.The negative relations between PL and ET-1 and between AF and ET-1 were found in this study.CONCLUSION:Liandouqingmai Recipe can raise scores of SAQ and NO level and decline ET level in patients with coronary heart disease on the basis of convertional standard treatment,thus improving vascular endothelial function and life quality.Life quality is related to vascular endothelial function.展开更多
The plasma membrane calcium ATPases(PMCA) are a family of genes which extrude Ca2+from the cell and are involved in the maintenance of intracellular free calcium levels and/or with Ca2+signalling,depending on the cell...The plasma membrane calcium ATPases(PMCA) are a family of genes which extrude Ca2+from the cell and are involved in the maintenance of intracellular free calcium levels and/or with Ca2+signalling,depending on the cell type.In the cardiovascular system,Ca2+ is not only essential for contraction and relaxation but also has a vital role as a second messenger in signal transduction pathways.A complex array of mechanisms regulate intracellular free calcium levels in the heart and vasculature and a failure in these systems to maintain normal Ca2+homeostasis has been linked to both heart failure and hypertension.This article focuses on the functions of PMCA,in particular isoform 4(PMCA4) ,in the heart and vasculature and the reported links between PMCAs and contractile function,cardiac hypertrophy,cardiac rhythm and sudden cardiac death,and blood pressure control and hypertension.It is becoming clear that this family of calcium extrusion pumps have essential roles in both cardiovascular health and disease.展开更多
This paper has focused on applying mathematical techniques to address fundamental question in therapy planning when to switch, and how to sequence therapies. We consider switching and sequencing available therapies so...This paper has focused on applying mathematical techniques to address fundamental question in therapy planning when to switch, and how to sequence therapies. We consider switching and sequencing available therapies so as to maximize a patient＇s expected total lifetime. We assume knowledge only about the lifetime distributions induced by the therapies. We discuss a specialization of this model that is tailored to a frequently reoccurring type of management problem, where our goal is to determine the best timing for testing and treatment decisions for patients with ischemic heart disease. Typically, decisions are made with an overall, goal of maximizing the patient＇s expected lifetime or quality-adjusted lifetime.展开更多
文摘Age-associated changes in cardiovascular structure/ function are implicated in the markedly increased risk for cardiovascular disease in older persons. Aging not only prolongs exposure to several other cardiovascular risks, but also leads to intrinsic cardiac changes, which reduces cardiac functional reserve, predisposes the heart to stress and contributes to increased cardiovascular mortality in the elderly. Intrinsic cardiac aging in the murine model closely recapitulates age-related cardiac changes in humans, includ- ing left ventricular hypertrophy, fibrosis and diastolic dysfunction. Cardiac aging in mice is accompanied by accumulation of mitochondrial protein oxidation, increased mitochondrial DNA mutations, increased mitochondrial biogenesis, as well as decreased cardiac SERCA2 protein. All of these age-related changes are significantly attenu- ated in mice overexpressing catalase targeted to mitochondria （mCAT）. These findings demonstrate the critical role of rnitochondrial reactive oxygen species （ROS） in cardiac ag ing and support the potential antioxidants to cardiac aging lar diseases. application of mitochondrial and age-related cardiovascular diseases.
文摘ObjectiveToinvestigate whether depression, anxiety and stress increase the risk for delirium and poor quality of life （QOL） after co-ronary artery bypass （CABG） surgery.MethodsA total of 180 CABG patients （mean age of 63.5 ± 10.1 years, 82.2% males） completed baseline and postoperative self-report questionnaires to assess distress and QOL. Incident delirium was diagnosed postoperatively with a structured clinical interview and patients were monitored every day post-operatively for confusion and disturbance in consciousness.Results Delirium developed in 63 persons （35% of sample）. After adjustment for covariates, delirium was significantly associated with depression [odds ratio （OR）： 1.08; 95% confidence interval （CI）： 1.03-1.13,P = 0.003], anxiety （OR： 1.07; 95% CI： 1.02-1.13,P= 0.01） and stress （OR： 1.05; 95% CI： 1.00-1.09,P= 0.03）. Preoperative depression scores were associated with poorer QOL including bodily pain （β =-0.39,P = 0.013）, vitality （β=-0.32,P = 0.020）, social functioning （β=-0.51,P≤0.001）, emotional role function （β=-0.44,P = 0.003） and general health （β=-0.33,P = 0.038）. Among the covariates, harmful levels of alcohol use was consistently associated with poorer QOL.Conclusions Depression and harmful levels of alcohol use were consistently associated with poorer QOL whereas depression, anxiety and stress were associated with delirium risk. These findings point to further research examining depression and harmful levels of alcohol use in coronary heart disease populations undergoing coronary revascularization.
文摘In the last two or three decades,physical activity(PA) has gained increasing recognition as being essential for maintaining good health and improving quality of life for all ages.Children have traditionally been active in both free play and organized sports.However,there has been a recent decline in the PA levels among children for various reasons.This lifestyle change has resulted in increased obesity accompanied by a rise in diabetes and cardiovascular risk among otherwise healthy children.These lifestyle changes have been shown to be even more a problem when the child is already affected by a chronic disease.Due to medical limitations and contraindications,much care must be taken to make certain that these children are involved in the appropriate volume and intensity of exercise.The type of activity must also be given careful consideration to avoid undue risk for the child who may have problems such as poor balance,limited strength,poor vision,or cognitive disability.Further complications are either caused or exacerbated by lack of sufficient PA.The priority beyond concern for safety should be focused on ensuring the highest quality of life possible.The purpose of this review is to examine how PA can benefit children with selected chronic health conditions.
基金funding from Jordan University of Science and Technology,Deanship of Research.
文摘Objective:This study aimed to examine the effects of mindfulness meditation on trait mindfulness,perceived stress,emotion regulation,and quality of life in end-stage renal disease patients undergoing hemodialysis.Methods:An experimental study with repeated measures design was conducted among a sample of 74 end-stage renal disease patients undergoing hemodialysis between January and May 2021 in the dialysis center at Jahra hospital,Kuwait.The patients were randomly assigned to the experimental(n?37)and control groups(n?37).The experimental group participated in 30-min mindfulness meditation sessions(three sessions a week for five weeks)held during their hemodialysis sessions;the participants in the control group were instructed to sit with their eyes closed and relaxed for 30 min three times a week for five weeks during hemodialysis sessions.The dependent variables of both groups were measured at baseline(T0),middle of intervention(T1),and end of intervention(T2)using the Mindful Attention Awareness Scale(MAAS),Perceived Stress Scale(PSS),Emotion Regulation Questionnaire(ERQ),and Kidney Disease Quality of Life(KDQOL-36)questionnaire.The study was registered in the ClinicalTrial.gov(Identifier:NCT05176730).Results:The repeated measures ANOVA(within-subject)results for the experimental group showed that mindfulness meditation had significantly decreased perceived stress by the end of the intervention.Also,mindfulness meditation improved mindfulness,emotion regulation,and kidney disease-related quality of life in the experimental group,and this improvement occurred significantly at both T1 and T2.The repeated measures ANOVA(within and between-subject)results showed that the experimental group,as compared to the control group,had lower perceived stress,higher trait mindfulness,higher emotional regulation,and higher kidney disease-related quality of life over time.Conclusions:The positive findings of this study offer health policy-makers and hospital administrators a promising tool to use with patients undergoing hemodialysis as a way to manage stress and improve quality of life.However,this study should be replicated in multiple settings with follow-up assessments.
文摘Cardiovascular disease （CVD） is the leading cause of death and disability worldwide. The primary prevention of CVD is dependent upon the ability to identify high-risk individuals long before the development of overt events. This highlights the need for accurate risk strati- fication. An increasing number of novel biomarkers have been identified to predict cardiovascular events. Biomarkers play a critical role in the definition, prognostication, and decision-making regarding the management of cardiovascular events. This review focuses on a variety of promising biomarkers that provide diagnostic and prognostic information. The myocardial tissue-specific biomarker cardiac troponin, high- sensitivity assays for cardiac troponin, and heart-type fatty acid binding proteinall help diagnose myocardial infarction （MI） in the early hours following symptoms. Inflammatory markers such as growth differentiation factor-15, high-sensitivity C-reactive protein, fibrinogen, and uric acid predict MI and death. Pregnancy-associated plasma protein A, myeloperoxidase, and matrix metalloproteinases predict the risk of acute cor- onary syndrome. Lipoprotein-associated phospholipase A2 and secretory phospholipase A2 predict incident and recurrent cardiovascular events. Finally, elevated natriuretic peptides, ST2, endothelin-1, mid-regional-pro-adrenomedullin, copeptin, and galectin-3 have all been well validated to predict death and heart failure following a MI and provide risk stratification information for heart failure. Rapidly develop- ing new areas, such as assessment ofmicro-RNA, are also explored. All the biomarkers reflect different aspects of the development ofather- osclerosis.
基金Supported by the Bureau of Traditional Chinese Medicine of Jiangsu Province(No.HZ07097)
文摘OBJECTIVE: To observe the effect of Liandouqingmai recipe(Chinese herbal medicine compound preparation) on the quality of life(QOL) and inflammatory reaction of patients with coronary heart disease(CHD).METHODS: A total of 101 CHD patients were randomized into two groups: treatment group(n=45)receiving standard treatment for CHD plus Liandouqingmai recipe, and control group(n=56) receiving standard treatment only. The control group contained 16 normal healthy subjects. Changes in hs-C-reactive protein(CRP), peripheral blood leucocytes(PBL), and interleukin(IL)-6 and IL-10 levels were measured. The Seattle Angina Questionnaire(SAQ) was used to determine patient QOL before and after treatment for 2 weeks.RESULTS: Before treatment, SAQ scores [physical limitation(PL), angina stability(AS), angina frequen-cy(AF), treatment satisfaction(TS), and disease perception(DP)] were not statistically different between groups. After treatment, AS and DP levels of controls were significantly increased compared with the other groups, while PL, AS, AF, TS, and DP levels of the treatment group were significantly increased compared with controls. Treatment group SAQ scores(PL, AS, AF, TS, and DP) were significantly higher than for controls. CHD patient IL-6 and IL-10 levels were significantly higher than controls.Before treatment, mean levels of IL-6, hs-CRP and PBL of the two groups were not statistically different. After treatment, mean levels of IL-6, IL-10,hs-CRP and PBL of the two groups were significantly decreased compared with their before treatment values, and levels of IL-6, hs-CRP, and PBL of the treatment group were lower than controls. Although mean IL-10 levels of both groups decreased, there was no significant difference in between-group and in-group comparisons before and after treatment. Mean levels of IL-6 and IL-10 in the normal group were lower than in CHD patients.SAQ scores of QOL were negatively associated with the inflammatory index(IL-6/IL-10), and there was a significant negative association of IL-10 with AS(r=﹣0.15, P<0.05).CONCLUSION: Inflammatory reactions in CHD patients are related to angina status. Coadministration of CHD standard treatment and Liandouqingmai recipe increased patient SAQ scores by decreasing IL-6, IL-10, hs-CRP, and PBL levels in CHD patients, which might inhibit endothelial inflammation to improve patient QOL.
基金supported by Bureau of Traditional Chinese Medicine of Jiangsu Province(No.HZ07097)
文摘OBJECTIVE:To observe the effects of Liandouqingmai Recipe on life quality and vascular endothelial injury in patients with coronary heart disease.METHODS:Capitalized 101 patients with coronary heart disease were randomly divided into a treatment group(n=45) treated with Liandouqingmai Recipe and a standard treatment group(control group,n=56).A normal group of 16 healthy persons was additionally set up.Changes in ET-1 and NO levels were measured and Seatle Angina Questionnaire(SAQ) was adopted in studying life quality before and after treatment for two weeks.The data were analyzed with SPSS 16.0 statistic software.RESULTS:The average level of ET-1 in the normal group was lower and NO higher than that of patients with coronary heart disease.There was no significant difference in the average level of ET-1 and NO and in the scores of SAQ [physical limitation(PL),pngina stability(AS),apngina frequency(AF),treatment satisfaction(TS) and disease perception(DP)] between the two groups before treatment(P>0.05).But after treatment,the scores of SAQ(PL,AS,AF,TS,DP) and NO level were higher than those in the control group,and ET-1 average level in the treatment group was lower than that in the control group.The negative relations between PL and ET-1 and between AF and ET-1 were found in this study.CONCLUSION:Liandouqingmai Recipe can raise scores of SAQ and NO level and decline ET level in patients with coronary heart disease on the basis of convertional standard treatment,thus improving vascular endothelial function and life quality.Life quality is related to vascular endothelial function.
文摘The plasma membrane calcium ATPases(PMCA) are a family of genes which extrude Ca2+from the cell and are involved in the maintenance of intracellular free calcium levels and/or with Ca2+signalling,depending on the cell type.In the cardiovascular system,Ca2+ is not only essential for contraction and relaxation but also has a vital role as a second messenger in signal transduction pathways.A complex array of mechanisms regulate intracellular free calcium levels in the heart and vasculature and a failure in these systems to maintain normal Ca2+homeostasis has been linked to both heart failure and hypertension.This article focuses on the functions of PMCA,in particular isoform 4(PMCA4) ,in the heart and vasculature and the reported links between PMCAs and contractile function,cardiac hypertrophy,cardiac rhythm and sudden cardiac death,and blood pressure control and hypertension.It is becoming clear that this family of calcium extrusion pumps have essential roles in both cardiovascular health and disease.
文摘This paper has focused on applying mathematical techniques to address fundamental question in therapy planning when to switch, and how to sequence therapies. We consider switching and sequencing available therapies so as to maximize a patient＇s expected total lifetime. We assume knowledge only about the lifetime distributions induced by the therapies. We discuss a specialization of this model that is tailored to a frequently reoccurring type of management problem, where our goal is to determine the best timing for testing and treatment decisions for patients with ischemic heart disease. Typically, decisions are made with an overall, goal of maximizing the patient＇s expected lifetime or quality-adjusted lifetime.
