Condet

David J.Moliterno, MD

• Professor and Vice-Chairman of Medicine
• Chief, Cardiovascular Medicine
• Jefferson Morris Gill Professor of Cardiology
• Gill Heart Institute and
• Division of Cardiovascular Medicine
• University of Kentucky
• Lexington, Kentucky

The National Academy of Sciences Panel on Explaining Divergent Levels of Longevity in High-Income Countries1 was convened to try to reconsider what might account for those diverging trends man health 360 purchase casodex 50mg on line, and the panel-of which I was a member-considered a very broad range of conditions prostate zones mri buy generic casodex 50 mg line. Several members identified important behavioral trends prostate korean 50 mg casodex otc, most critically tobacco consumption prostate herbs discount casodex 50 mg mastercard. These factors seemed to account for either none or very small portions of these diverging trends, although they continue to be significant risk factors for mortality within countries. Smoking clearly accounts for some of the diverging trends, but the full explanation for the diverging trends seemed still to be a mystery. At this time, we must start to consider what else has happened, especially to women, between 1980 and today, and how experiences over the last few decades might account for such diverging trends. One of the factors that must be acknowledged is that the vast majority of women have joined the workforce during this period, including those with young children. In the United States, fertility patterns have changed slightly, but they continue to be relatively steady compared to many other countries, although there is also a substantial rise is single parenthood. This pattern led to the development of a model in which work and family systems combine to influence health. Most importantly, it seemed likely that social and economic policies and practices enacted in many European countries might protect or buffer women from the strain experienced by growing demands from both work and family. There are selected State- and city-level polices and many private corporate policies that may protect women and potentially men from the joint strains of work and family demands. This situation makes the United States relatively unique among industrialized countries. With support from the National institute on Aging, I launched a project to better examine this issue. We have created a work-family strain model built closely on the model of job demands and job control developed by Karasek. In the Karasek model, often the combination of high job demands and low job control is associated with the worst health outcomes. A third dimension of job strain related to workplace social support was incorporated into the model after initial work. Here we envision a situation in which risks of poor health are particularly high among working women with dependent children or older family members who experience high demands with low control and minimal formal or informal support. For instance, while France is similar to the United States in terms of trends in fertility and work, the country has very strong social protection policies. In other countries, Population Health: Behavioral and Social Science Insights Section I: Demographic and Social Epidemiological Perspectives on Population Health 43 women join the workforce, but when they do, their fertility drops. This general framework helped us to evaluate the specific health risks and protections that were important. Our team of researchers reviewed some evidence on demographic trends and related family policy. There are clear and steady demographic trends regarding the growing number of women in the labor force with young children in United States. In the 1940s and 1950s, when most of our work policies were designed, there were very few women with young children in the workforce. By 2008, 71 percent of mothers with children under 18 and 60 percent of mothers with children age 3 or younger were working. Federal policy for granting weeks of paid parental leave between 1980 and 2000; most other countries had increased leave policies substantially during this period. Evidence that Labor Policies and Practices Impact Health In this section, recent work related to work and family policies is reviewed in terms of health impacts. Finally, some of the recent findings on retirement and cognition shed further light on the range of ways in which work might influence health. First, it is important to acknowledge that most evidence suggests that people who work and people who have children are healthier than those who do not work and who do not have children. For these purposes however, we are most interested in the interface of work and family, particularly for women who may experience role strain if formal social protection or informal social support does not buffer the demands of work and family or who may experience the benefits of multiple roles if demands are not overwhelming. The working hypothesis of the Work, Family, & Health Network is that both work and family can be health promoting in the presence of social protection or support enabling some flexibility during times when heavy work and family demands compete with each other and become stressful. We further hypothesize that in general, low and middle income working class families will benefit more from many social policies than better off families because they have less exposure to corporate social and economic policies that would be of benefit, and they have fewer financial resources to maintain work life balance. A more precise evaluation of these interactions between socioeconomic conditions and social policies is beyond the scope of this chapter but is of central importance in the long-running policy debates.

Syndromes

• Narrowed blood vessel
• Cor pulmonale (a form of heart failure found on the right side of the circulation system)
• It begins breaking down waste products such as excess red blood cells.
• Bone scan
• Food poisoning
• Drink plenty of fluids every day. Drink more fluids before, during, and after physical activity.
• Endometriosis
• Sudden weakness, numbness, or tingling in an arm or leg

Although numerous models are available for use prostate biopsy video proven casodex 50mg, most are based on the same two fundamental principles: (1) metals are ubiquitous in the environment androgen hormone network casodex 50mg for sale, as they are found in the aquatic prostate youtube buy 50 mg casodex with visa, terrestrial prostate kegel exercise for men effective 50 mg casodex, and atmospheric compartments; (2) within each compartment, they are present in association with water (freely dissolved metal or as organic and inorganic metal complexes), particles (sorbed, precipitated, or incorporated within a mineral phase), and air. The evaluation of metal transport therefore requires evaluation of the distribution of the metal among these phases, within each compartment (air, water, soil), as well as the movement. The analyst represents the environmental setting of interest as a series of discrete, interconnected volumes. Mass balance equations for air, water, solids, and metal are then formulated for each volume to obtain a system of mass balance equations that may then be solved for the concentrations of interest over both time and space. For example, models for a site that is impacted by a smelter might call for use of a model of an atmospheric compartment. Alternatively, for an aquatic setting dominated by previously contaminated sediments, it may be sufficient to consider water and sediment transport alone and to neglect the atmospheric and terrestrial compartments. Although the underlying principles of most models are similar, the included features vary widely from one model to the next. The output from a relatively simple model may be adequate for decision-making purposes in some instances. Some relatively simple models are limited in their applicability to steady-state analyses and spatially uniform conditions, but if this will provide a reasonable and/or conservative representation of conditions at a site, it may provide the analyst with a useful and cost-effective modeling alternative. In other cases, the analysis may require the completion of time-variable simulations to properly represent conditions that vary over time, such as daily or seasonal variations in flow and upstream boundary concentrations, point source loads, and pulse exposures. The analyst should select an appropriate model because not all models will be applicable to every situation. Although, in principle, the more sophisticated models provide the risk assessor with the capability to complete a more detailed and mechanistically based analysis than will a simple model, successful application of these models will require greater resources (data, time, and funding) than will the use of a simpler model. The analyst must also possess a relatively high level of modeling expertise to use the more sophisticated modeling approaches. It is for this reason that the more sophisticated models are usually reserved for use in higher level, definitive assessments. Many of the models available for use in evaluating the transport and fate of metals were originally developed for application to neutral organic chemicals. As a result, these models frequently include a variety of reactions that are not necessarily relevant to an analysis of metal transport and fate. Although these models still may be of use in an exposure assessment for metals (the nonapplicable processes often may be bypassed), a more significant problem is that they often fail to represent some important metal-specific processes. For example, the evaluation of metal speciation and metal partitioning between dissolved and particulate phases will be represented only in a very simple manner in such models. This limitation may be overcome, at least in part, by performing the requisite metal-specific analyses with a stand-alone chemical equilibrium model, but this approach will place an added burden on the analyst to integrate the results of the two models in a technically defensible manner. Although models that include some metal-specific capabilities will be discussed as part of this Framework, no single model that is currently available for use includes all the metal-specific features that would be desirable for use. More detailed discussions of these and other transport and fate models, as well as a number of chemical equilibrium models, may be found in Paquin et al. Additionally, work is in progress to develop updated models that will offer improved metal-specific capabilities. As a result, metal fate and transport models should be viewed as an evolving tool, and new models may be expected in the near future. Aquatic Transport Models Modeling of metal transport and fate within aquatic systems involves the representation of hydrodynamic transport to simulate movement of water, particulate transport to simulate the movement of particles, and chemical transfers and kinetics to simulate exchange of metal between dissolved and particulate phases and between the water column and benthic sediment (Figure 3-2). The risk assessor has the option of using independent hydrodynamic transport, sediment transport and chemical fate models, or an integrated model that incorporates all these processes. A generalized model framework for chemical fate and transport in an aquatic system. Modeling the movement of metals through an aquatic system begins with a characterization of the water movement through the system. The time scale for the hydrodynamic analysis should be represented in a way that will satisfy the needs of the sediment transport and chemical fate analyses that are also being performed. For example, low-flow 3-26 conditions associated with minimum dilution may be judged to Integrated Models be the most critical conditions in a setting involving a point the fate and transport of source discharge, while peak flow conditions may need to be metals in aquatic systems is most reliably predicted using simulated in a setting where resuspension of contaminated integrated models rather than sediments is the primary concern.

B A major source of allergen in house dust is the fecal residue of dust mites belonging to the genus Dermatophagoides prostate female cheap 50 mg casodex amex. Consequently prostate otc medication buy casodex 50 mg without prescription, mites are most abundant in locations where skin cells are shed such as bedding prostate yahoo casodex 50mg low price, fabric covered furniture mens health eating plan generic casodex 50mg mastercard, soft toys, and carpeting. These include enhanced energy efficiency in buildings leading to reduced ventilation and increased humidity, wall-to-wall carpeting, furnished basements, and use of water for laundry that is not hot enough to kill mites. Humidity can be reduced with air conditioning or a dehumidifier and can easily be measured with an inexpensive hygrometer. Common reservoirs to be avoided include upholstered furniture, carpeting, bedding, and stuffed toys. Dust mite fecal pellets easily become airborne when their reservoir is disturbed, although they rapidly settle once the disturbance stops. Ordinary vacuuming and dusting therefore have little effect on mite allergen concentrations because the mites themselves are not removed and the pellets easily pass through low-efficiency vacuum bags, becoming widely dispersed throughout the room. Ideally, housecleaning should be performed when the allergic person is not at home, although patients who do their own cleaning may benefit from wearing a face mask. If a mattress is old, replacement should be considered, but even new hypoallergenic mattresses and pillows should be encased because mite colonization occurs within weeks. Because elimination of mites in upholstered furniture is extremely difficult, plastic, leather or wood furniture is recommended. When upholstered furniture cannot be avoided, a 3% tannic acid solution may be used to denature mite and other allergens on these furnishings. Because this does not kill the mites, the allergen reaccumulates over time, necessitating repeated treatments. Stuffed toys that cannot be washed can be placed in plastic bags and frozen to kill dust mites. D Because of the popularity of indoor pets, allergens from cats, dogs, and other domestic animals are important triggers of allergic rhinitis. All warm-blooded animals, including birds, potentially are capable of sensitizing susceptible patients with allergy. Animal allergens are a significant occupational hazard for workers exposed to mice, rats, guinea pigs, and so forth. Although furs processed for use in clothing are no longer allergenic, feather products retain significant allergenicity. Because allergen-bearing particles of animal origin are generally quite small and low-density, they remain suspended in air for extended periods and disseminate widely in homes and other facilities. Symptoms of allergic rhinoconjunctivitis may occur within minutes of entering a contaminated area. The major antigen in cat allergen, Fel d 1, is found on cat skin/ dander and in saliva and urine. Cat allergen has been identified in homes and other locations where cats were never present and occasionally may reach concentrations found in homes where cats are kept. Such contamination may be an unsuspected cause of symptoms in sensitive individuals. The major dog allergen, Can f 1, is found in dog skin/dander and saliva and is present in varying amounts in all breeds tested. Many dogsensitive patients claim to respond differently to various breeds of dogs or even specific dogs of a single breed. Like cat allergen, Can f 1 has been found in rooms in which dogs were never present, suggesting passive transport on clothing. Patients and their families should be advised to consider removing an animal to reduce exposure. A trial removal of a pet for a few days or even weeks may be of little value or, worse, misleading, because cat allergen can be detected an average of 20 weeks (and in some cases much longer) before reaching concentrations found in homes without cats. Frequent bathing of dogs (at least twice a week) similarly has been found to be effective for reducing dog allergen exposure.

Dobson regards four papers from this more recent research as directly following on from the case study grant: Najafi prostate 73 effective 50 mg casodex, F androgen hormone vs neurotransmitter casodex 50 mg with mastercard. Another example provided by Professor Dobson of follow-on research was to do with exploring the seasonal variations in heart attack in Australia mens health adam levine buy cheap casodex 50 mg line. She said androgen hormone inhibitor finasteride buy casodex 50 mg visa, `Very quickly [the postdoctoral fellow] got hold of the international data as well and started looking at seasonality, and we know quite a lot about seasonality in blood pressure. He has published extensively on the effect of seasonality using the international data. The seasonal variation in incidence and mortality differs a lot between countries, but the other thing that he found was a Monday effect. There was also a subsequent article published on alcohol and the U-shape effect (McElduff and Dobson, 1997). It showed essentially a small amount of alcohol is a good thing and became part of a big body of evidence. She said, `We had 10 years of research, we knew how to do these things and we knew what the main questions were. Although there was very limited dissemination via conferences, there was dissemination through meetings and with collaborators at the national level and extensive dissemination at a local Hunter region level with the clinicians, patients, community and community groups. Professor Dobson provided the following example of dissemination at the local level: `Cessnock is probably the best example. And then you get people like the school teachers, who were really keen on changing conditions, the local doctors. It was explained at interviews that the people, particularly in the coalfields areas, created opportunities for the research and health-promotion team from the university, who, in turn, made sure that they always took those opportunities. The research and health-promotion teams undertook extensive prevention and sociological work, particularly with schools `about how you could change the diet, given the diet was a thing determined by the extended family, you almost had to influence the grandmothers to do anything. There was also dissemination through the media and particularly through the local media. This included focussing on how people can be proactive and what they can do for themselves to gain control of their blood pressure and cholesterol, etc, rather than just relying on medical treatment. Although there were some examples of difficult experiences with the media, Dobson found that it was valuable in generating more interest in the research and the associated health promotion. The more direct impacts were with the clinicians working with the research and the healthpromotion team and their work with the Hunter community and the local patient and advocacy groups. As noted earlier, the fact that some of the articles by clinicians using their own patient data are cited as project outputs demonstrates that there were some downstream influences on clinical practice stemming from the project. Professor Dobson believed that the case study grant did have impact through the healthpromotion activity on the way that patients became more aware of and responsible for management of their own care. This occurred particularly through patient groups and patient advocacy groups, who she believed were very good at disseminating and translating the results into patient education and changes in behaviour. As a result the research team and students would put a lot of work and time into these groups and their activities and events. Less clear was the impact of the research and the associated health promotion on influencing public attitude towards medical research. Interviews for this case study suggested that the close work with patients and the community did have an impact on the research team and their approach to future work and links to health promotion. Reductions in cigarette smoking, diastolic blood pressure and total cholesterol and increased use of aspirin fully explained the 3. In contrast, increased use of aspirin, beta blockers, fibrinolytic therapy and angiotensin-converting enzyme inhibitors explains less than half of the 8. Table 5-2 shows, in point form and by impact category, some of the impacts, described more fully above, that have emerged from this grant. Dobson, `Is the Increase in Coronary Heart Disease on Mondays: an Artefact of Registration Broadhurst, `Declining Rates of Coronary Heart Disease in New Zealand and Australia. Grant Application, Application Form for Grant-in-aid Research - Senior Research Fellowship, Follow-up study of heart attack patients, 1991, grant reference G91S3283. Grant-in-Aid Assessment Forms, Grant Reference G91S3283, 1991, held in the National Heart Foundation of Australia archives. Grant-in-Aid Assessor Report, Grant Reference G91S3283, 1991, held in the National Heart Foundation of Australia archives.

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