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Danijela Jelovac, M.D.

  • Assistant Professor of Oncology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/5503711/danijela-jelovac

Newly formed spermatids are round cells with central hiv infection rates msm purchase medex mastercard, spherical nuclei acute hiv infection symptoms mayo cheap 1mg medex mastercard, prominent Golgi complexes over the counter antiviral buy medex cheap, numerous mitochondria hiv infection natural history purchase medex canada, and a pair of centrioles hiv infection rates manitoba order medex with mastercard. At the onset of spermiogenesis hiv infection brain buy medex without a prescription, many small granules appear in the Golgi membranes and eventually coalesce to form a single structure called the acrosome. The developing acrosome is bounded by a membrane, the acrosomal vesicle, which also is derived from the Golgi complex and is closely associated with the outer layer of the nuclear envelope. The acrosomal vesicle expands and then collapses over the anterior half of the nucleus to form the head cap. The acrosome, which contains hydrolytic enzymes, remains within the acrosomal membrane. As these events occur, the two centrioles migrate to a position near the nucleus on the side opposite of the forming acrosome. Nine peripheral doublets plus a central pair of microtubules develop from the distal centriole and begin to form the axoneme of the tail. The proximal centriole becomes closely associated with a caudal region of the nucleus called the implantation fossa. As the axoneme continues to develop, nine longitudinal coarse fibers extend around it and blend with nine short, segmented columns that form the connecting piece, which unites the nucleus (head) with the tail of the spermatozoon. The annulus, a ringlike structure, forms near the centrioles and migrates down the developing flagellum. Randomly distributed mitochondria migrate to the flagellum and become aligned in a tight helix between the centrioles and the annulus. This spirally arranged mitochondrial sheath characterizes the middle piece of the tail of a mature spermatozoon. Simultaneously, marked changes occur in the nucleus: it becomes condensed, elongated, and slightly flattened. The bulk of the cytoplasm now is associated with the middle piece of the evolving spermatid, and as differentiation nears completion, the excess cytoplasm is shed as the residual body, leaving only a thin layer of cytoplasm to cover the spermatozoon. The residual cytoplasm is phagocytized by Sertoli cells as the spermatozoa are released into the lumen of the seminiferous tubule. Although morphologically the spermatozoa appear mature, they are nonmotile and largely incapable of fertilization at this time. In most species, spermatids at specific stages of differentiation always are associated with spermatocytes and spermatogonia, which also are at specific stages of development. A series of such associations occurs along the length of the same seminiferous tubule, and the distance between two identical germ cell associations is called a "wave" of seminiferous epithelium. Human germinal epithelium exhibits a mosaic of such areas, and six different cell associations have been described. Such associations represent a fundamental pattern of cycling of the germinal epithelium during sperm production. The time taken for spermatogonia to become spermatozoa is relatively constant and species-specific: in humans it is about 64 days. If germ cells fail to develop at their normal rate, they degenerate and are phagocytosed by adjacent Sertoli cells. The structural details of the different segments are best seen with the electron microscope. It contains the connecting piece that joins the nine outer dense fibers of the tail to the implantation fossa of the nucleus. The region of the connecting piece that joins the implantation fossa is expanded slightly to form the capitulum. The middle piece extends from the neck to the annulus and consists of the axoneme, the nine coarse fibers, and the helical sheath of mitochondria. The principal piece is the longest part of the tail and consists of the axoneme and the nine coarse fibers a (2 + 9 + 9 arrangement) enclosed by a sheath of circumferential fibers. The circumferential fibers join two longitudinal thickenings (columns) of this sheath located on opposite sides. The end piece is the shortest segment of the tail and consists only of the axoneme surrounded by the plasmalemma. The chromatin of the nucleus is very condensed and reduced in volume, providing the functionally mature sperm with greater mobility. The condensed form of chromatin also protects the genome while the spermatozoon is in route to fertilize the ovum. The acrosomal cap covers the anterior two-thirds of the nucleus and contains enzymes that are important for penetration of the ovum at fertilization. The last step in the physiologic maturation of spermatozoa takes place in the female reproductive tract and is called capacitation. This final activation occurs in the oviduct and is characterized by the removal of a glycoprotein coat and seminal proteins from the plasmalemma overlying the acrosome, by changes in the acrosomal cap, and by changes in the respiratory metabolism of the spermatozoa. Excretory Ducts the excretory ducts consist of a complex system of tubules that link each testis to the urethra, through which the exocrine secretion, semen, is conducted to the exterior during ejaculation. The duct system consists of the tubuli recti (straight tubules), rete testis, ductus efferentes, ductus epididymis, ductus deferens, ejaculatory ducts, and prostatic, membranous, and penile urethra. This simple columnar epithelium lies on a thin basal lamina and is surrounded by loose connective tissue. The lumina of the tubuli recti are continuous with a network of anastomosing channels in the mediastinum, the rete testis. The efferent ductules follow a convoluted course and, with their supporting tissue, make up the initial segment of the head of the epididymis. The luminal border of the efferent ductules shows a characteristic irregular contour due to the presence of alternating groups of tall and short columnar cells. Each contains the organelles normally associated with epithelia as well as supranuclear granules that are lysosomal in nature. The nonciliated cells show numerous microvilli on their apical surfaces and are thought to absorb much of the testicular fluid that is present in this part of the ductal system. Cilia on the other cell type beat toward the epididymis and help move the nonmotile sperm and testicular fluid in that direction. The epithelium lies on a basal lamina and is bounded by a layer of circularly arranged smooth muscle that thickens toward the duct of the epididymis. Cilia are not found beyond the ductuli efferentes, and the movement of sperm through the remainder of the duct system depends on the contractions of the muscular wall and fluid flow. This highly coiled duct and its associated vascular connective tissue form the rest of the head, body, and tail of the epididymis. The epithelial lining is pseudostratified columnar and consists of principal and basal cells. Long, branched microvilli, inappropriately called stereocilia, extend from the apical surfaces of the principal cells. Like microvilli found elsewhere, they contain an axial bundle of actin microfilaments. The actin microfilaments extend from the stereocilia into the terminal web region of the principal cells. A very large Golgi complex takes up a supranuclear position in the cell, and the basal region is filled by an abundance of endoplasmic reticulum. The channels of the rete testis are surrounded by a dense bed of vascular connective tissue. One of the functions of the principal cell is absorption; together, the proximal portion of the ductus epididymidis and the ductuli efferentes absorb over 90% of the fluid produced by the seminiferous epithelium. Ubiquitin, a highly conserved protein molecule, is secreted by principal cells of the epididymal epithelium. It forms covalently linked polyubiquitin chains on structures within the epididymal fluid, such as defective sperm and debris, during epididymal transit. These identified targets are recognized for endocytosis and removed from the epididymal fluid by the principal cells of the epididymal epithelium. The epithelium lining of the mid and distal regions of the ductus epididymis also secrete glycoproteins, sialic acid and other factors that are believed to play a role in sperm maturation. Basal cells are small, round cells that lie on the basal lamina, interposed between the principal cells. Scattered intraepithelial lymphocytes often are present in the epithelium of the ductus epididymidis. The epididymal epithelium lies on a basal lamina and is surrounded by a thin lamina propria and a thin layer of circularly arranged smooth muscle cells. Near the ductus deferens, the muscle layer thickens and becomes three-layered (inner longitudinal, middle circular, outer longitudinal); it is continuous with that of the ductus deferens. The regional differences reflect differences in the mobility of the ductus epididymidis. Proximally, the duct shows spontaneous peristaltic contractions that slowly move spermatozoa through the epididymis; distally, the peristaltic contractions are reduced, and this region serves to store sperm. Those entering the proximal part of the duct mostly are incapable of fertilization and swim in a weak, random fashion. Spermatozoa from the distal portion are capable of fertilizing ova and show strong, unidirectional motility. How the ductus epididymidis contributes to the maturation of spermatozoa is unknown. It is characterized by a wall consisting of a mucosa, a thick muscularis, and an adventitia. The mucosa is thrown into longitudinal folds that project into the lumen and is lined by a pseudostratified columnar epithelium resting on a thin basal lamina. The muscularis is the dominant feature of the ductus deferens and consists of three layers of smooth muscle cells arranged longitudinally in the inner and outer layers and circularly in the middle layer. The muscularis is surrounded by the loose connective tissue of the adventitia, which blends with neighboring structures and anchors the ductus deferens in place. Powerful contractions of the muscular wall propel sperm from the distal ductus epididymidis and rapidly transport them through the ductus deferens during ejaculation. The lumen expands and the mucosa is folded, creating a labyrinth of pocket-like recesses. The muscular coat of the ampulla is thinner and the layers are less distinct than in other parts of the ductus deferens. Nearly all the smooth muscle in the muscularis of the ductus deferens is phasic smooth muscle characterized by distinct action potentials and rapid contraction. Nearly every smooth muscle cell is innervated (multiunit innervation) by the autonomic nervous system. This accounts for the rapid, forceful, pulse-like contractions of the ductus deferens during ejaculation. It is about 1 cm long and is lined by a pseudostratified or stratified columnar epithelium. The mucosa forms outpockets that are similar to , but not as well developed as, those in the ampulla. The remainder of the wall of the ejaculatory duct consists only of fibrous connective tissue. The prostatic urethra is lined by a thin transitional epithelium and bears a dome-shaped elevation, the colliculus seminalis, on its posterior wall. The two ejaculatory ducts, one draining each testis, empty into the prostatic urethra on either side of the prostatic utricle. The numerous glands of the surrounding prostate also empty into this part of the urethra. Accessory Sex Glands Male accessory sex glands include the seminal vesicles, prostate, and bulbourethral glands. The secretion from each of these glands is added to the testicular fluid and forms a substantial part of the semen. The duct of each joins with the distal end of the ductus deferens to form an ejaculatory duct. The mucosa of the seminal vesicles is thrown into numerous complex primary folds that give rise to secondary and tertiary folds. These project into the lumen and subdivide the seminal vesicle into many small, irregular compartments that give the lumen a honeycombed appearance. All the compartments communicate with a central lumen, although in histologic sections the impression is one of individual chambers. The mucosal folds are lined mainly by pseudostratified columnar epithelium consisting of rounded basal cells interposed between cuboidal or columnar cells. The mucosal cells contain numerous granules, some lipid droplets, and lipochrome pigment, which first appear at sexual maturity and increases with age. The cytoplasm contains abundant granular endoplasmic reticulum, a prominent supranuclear Golgi complex, and conspicuous, dense secretory granules in the apical cytoplasm. The epithelium rests on a thin lamina propria of loose connective tissue with many elastic fibers. A muscular coat is present and consists of an inner layer of circularly arranged smooth muscle cells and an outer layer in which the smooth muscle cells have a longitudinal orientation. External to the muscle coat is a layer of loose connective tissue (adventitia) rich in elastic fibers. Secretions from the seminal vesicles form a substantial part (65-70%) of the total ejaculate. It is a yellowish, viscid secretion that contains fructose, prostaglandins, factors that increase sperm motility, factors that suppress the immune response in the female reproductive tract against semen, and factors that clot and then liquify semen in the vagina. Fructose is a source of energy for sperm whereas prostaglandins are thought to stimulate smooth muscle contractions within the walls of the tubular structures of the female reproductive tract to aid in moving sperm to the site of fertilization.

In women taking insulin antiviral yahoo discount medex 5mg fast delivery, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules hiv infection steps buy 5mg medex with amex. Contraception Postpartum care should include psychosocial assessment and support for self-care acute hiv infection timeline discount 1mg medex fast delivery. Interpregnancy or postpartum weight gain is associated with increased A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned hiv infection symptomatic stage discount medex 1 mg amex. Planning pregnancy is critical in women with preexisting diabetes due to the need for preconception glycemic control and preventive health services antiviral zanamivir order genuine medex line. Women with diabetes have the same contraception options and recommendations as those without diabetes antiviral blog medex 1mg mastercard. Lower blood pressure levels may S118 Management of Diabetes in Pregnancy Diabetes Care Volume 40, Supplement 1, January 2017 be associated with impaired fetal growth. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin. Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume, which may reduce uteroplacental perfusion (53). On the basis of available evidence, statins should also be avoided in pregnancy (54). Optimal glycemic control, preeclampsia, and gestational hypertension in women with type 1 diabetes in the diabetes and pre-eclampsia intervention trial. Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships. Periconceptional A1C and risk of serious adverse pregnancy outcome in 933 women with type 1 diabetes. The National Institute of Child Health and Human DevelopmentdDiabetes in Early Pregnancy Study. Glycaemic control during early pregnancy and fetal malformations in women with type 1 diabetes mellitus. Glycemic targets in the second and third trimester of pregnancy for women with type 1 diabetes. Refera ence intervals for hemoglobin A1c in pregnant women: data from an Italian multicenter study. Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis. Metformin versus placebo from first trimester to delivery in polycystic ovary syndrome: a randomized, controlled multicenter study. Prospective parallel randomized, double-blind, double-dummy controlled clinical trial comparing clomiphene citrate and metformin as the first-line treatment for ovulation induction in care. Does breastfeeding influence the risk of developing diabetes mellitus in children Healthful dietary patterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes mellitus. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program Outcomes Study 10-year follow-up. B Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold $180 mg/dL (10. C Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. E Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake. A Sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. E the treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value is,70 mg/dL (3. C There should be a structured discharge plan tailored to the individual patient with diabetes. Therefore, inpatient goals should include the prevention of both hyperglycemia and hypoglycemia. Hospitals should promote the shortest, safe hospital stay and provide an effective transition out of the hospital that prevents acute complications and readmission. For in-depth review of inpatient hospital practice, consult recent reviews that focus on hospital care for diabetes (3,4). Because inpatient insulin use (5) and discharge orders (6) can be more effective if based on an A1C level on admission (7), perform an A1C test on all patients with diabetes or hyperglycemia admitted to the hospital if the care. A Cochrane review of randomized controlled trials using computerized advice to improve glucose control in the hospital found significant improvement in the percentage of time patients spent in the target glucose range, lower mean blood glucose levels, and no increase in hypoglycemia (9). Thus, where feasible, there should be structured order sets that provide computerized advice for glucose control. Previously, hypoglycemia in hospitalized patients has been defined as blood glucose,70 mg/dL (3. A blood glucose level of #70 mg/dL is considered an alert value and may be used as a threshold for further titration of insulin regimens. Safety standards should be established for blood glucose monitoring that prohibit the sharing of fingerstick lancing devices, lancets, and needles (17). Point-of-Care Meters Appropriately trained specialists or specialty teams may reduce length of stay, improve glycemic control, and improve outcomes, but studies are few. Details of team formation are available from the Society of Hospital Medicine and the Joint Commission standards for programs. Quality Assurance Standards Even the best orders may not be carried out in a way that improves quality, nor are they automatically updated when new evidence arises. To this end, the Joint Commission has an accreditation program for the hospital care of diabetes (12), and the Society of Hospital Medicine has a workbook for program development (13). This evidence established new standards: insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold $180 mg/dL (10. Conversely, higher glucose ranges may be acceptable in terminally ill patients, in patients with severe comorbidities, and in inpatient care settings where frequent glucose monitoring or close nursing supervision is not feasible. Significant discrepancies between capillary, venous, and arterial plasma samples have been observed in patients with low or high hemoglobin concentrations and with hypoperfusion. However, in certain circumstances, it may be appropriate to continue home regimens including oral antihyperglycemic medications (21). Prolonged sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged (2,11). Therefore, premixed insulin regimens are not routinely recommended for in hospital use. Type 1 Diabetes In the critical care setting, continuous intravenous insulin infusion has been shown to be the best method for achieving glycemic targets. Typically basal insulin dosing schemes are based on body weight, with some evidence that patients with renal insufficiency should be treated with lower doses (25). Transitioning Intravenous to Subcutaneous Insulin of hypoglycemia compared with a basalbolus regimen (30). A review of antihyperglycemic medications concluded that glucagon-like peptide 1 receptor agonists show promise in the inpatient setting (32); however, proof of safety and efficacy await the results of randomized controlled trials (33). Moreover, the gastrointestinal symptoms associated with the glucagon-like peptide 1 receptor agonists may be problematic in the inpatinet setting. Regimens using insulin analogs and human insulin result in similar glycemic control in the hospital setting (22). If oral intake is poor, a safer procedure is to administer the rapid-acting insulin immediately after the patient eats or to count the carbohydrates and cover the amount ingested (22). A randomized controlled trial has shown that basal-bolus treatment improved When discontinuing intravenous insulin, a transition protocol is associated with less morbidity and lower costs of care (26) and is therefore recommended. For patients continuing regimens with concentrated insulin in the inpatient setting, it is important to ensure the correct dosing by utilizing an individual pen and cartrige for each patient, meticulous pharmacist supervision of the dose administered, or other means (28,29). Noninsulin Therapies the safety and efficacy of noninsulin antihyperglycemic therapies in the hospital setting is an area of active research. A recent randomized pilot trial in general medicine and surgery patients reported that a dipeptidyl peptidase 4 inhibitor alone or in combination with basal insulin was well tolerated and resulted in similar glucose control and frequency Patients with or without diabetes may experience hypoglycemia in the hospital setting. While hypoglycemia is associated with increased mortality, hypoglycemia may be a marker of underlying disease rather than the cause of increased mortality. Despite the preventable nature of many inpatient episodes of hypoglycemia, institutions are more likely to have nursing protocols for hypoglycemia treatment than for its prevention when both are needed. A hypoglycemia prevention and management protocol should be adopted and implemented by each hospital or hospital system. There should be a standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol to immediately address blood glucose levels of #70 mg/dL [3. Predictors of Hypoglycemia In one study, 84% of patients with an episode of severe hypoglycemia (,40 mg/dL [2. Despite recognition of hypoglycemia, 75% of patients did not have their dose of basal insulin changed before the next insulin administration (37). Studies of "bundled" preventative therapies including proactive surveillance of glycemic outliers and an interdisciplinary data-driven approach to glycemic management showed that hypoglycemic episodes in the hospital could be prevented. Compared with baseline, two such studies found that hypoglycemic events fell by 56% to 80% (38,39). The Joint Commission recommends that all hypoglycemic episodes be evaluated for a root cause and the episodes be aggregated and reviewed to address systemic issues. Consistent carbohydrate meal plans are preferred by many hospitals as they facilitate matching the prandial insulin dose to the amount of carbohydrate consumed (40). Regarding enteral nutritional therapy, diabetes-specific formulas appear to be superior to standard formulas in controlling postprandial glucose, A1C and the insulin response (41). When the nutritional issues in the hospital are complex, a registered dietitian, knowledgeable and skilled in medical nutrition therapy, can serve as an individual inpatient team member. Orders should also indicate that the meal delivery and nutritional insulin coverage should be coordinated, as their variability often creates the possibility of hyperglycemic and hypoglycemic events. Candidates include patients who successfully conduct self-management of diabetes at home, have the cognitive and physical skills needed to successfully self-administer insulin, and perform selfmonitoring of blood glucose. If self-management is to be used, a protocol should include a requirement that the patient, nursing staff, and physician agree that patient selfmanagement is appropriate. For patients receiving enteral or parenteral feedings who require insulin, insulin should be divided into basal, nutritional, and correctional components. For patients receiving continuous peripheral or central parenteral nutrition, regular insulin may be added to the solution, particularly if. A starting dose of 1 unit of human regular insulin for every 10 g dextrose has been recommended (44), to be adjusted daily in the solution. For full enteral/parenteral feeding guidance, the reader is encouraged to consult review articles (2,45) and see Table 14. Glucocorticoid Therapy Glucocorticoid type and duration of action must be considered in determining insulin treatment regimens. Once-aday, short-acting glucocorticoids such as prednisone peak in about 4 to 8 h S124 Diabetes Care in the Hospital Diabetes Care Volume 40, Supplement 1, January 2017 Table 14. For long-acting glucocorticoids such as dexamethasone or multidose or continuous glucocorticoid use, long-acting insulin may be used (21,45). For higher doses of glucocorticoids, increasing doses of prandial and supplemental insulin may be needed in addition to basal insulin (47). Perioperative Care In noncardiac general surgery patients, basal insulin plus premeal regular or short-acting insulin (basal-bolus) coverage has been associated with improved glycemic control and lower rates of perioperative complications compared with the traditional sliding scale regimen (regular or short-acting insulin coverage only with no basal dosing) (23,50). Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State Many standards for perioperative care lack a robust evidence base. Perform a preoperative risk assessment for patients at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure. For further information, regarding treatment, refer to recent in-depth reviews (3,56). Discharge planning should begin at admission and be updated as patient needs change. Inpatients may be discharged to varied settings including home (with or without visiting nurse services), assisted living, rehabilitation, or skilled nursing facilities.

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There is a sizable group of Americans who are economically middle class who have health conditions, and they may be bearing the brunt of the changes, including the cost of care, in the system. What is being missed and not adequately explained to the average citizen is how health reform is significantly changing the American healthcare delivery system and how we as a nation-and even as individuals-approach and contemplate health. In a nutshell, under health reform, we are 1) attempting to increase access to healthcare by establishing financial security. Higher-cost services such as inpatient care, readmissions to the hospital, and excess use of the emergency department as a substitute for primary care are scrutinized so as to target appropriate care (better care). In a way, the dual concepts guiding health reform are insurance access and the allocation and management of financial risk (increasing insurance coverage and spreading more financial risk to the provider class). Thus, the Three Aims of better health, better care, and lower or controlled costs are addressed through this focus. This is a simplification of health reform; however, the essence of reform is embodied in that framework. The structural redesign of the American health delivery system brings into the framework of discussions essential elements that have been covered throughout this Biennial Report: financial conditions and constraints, health professional workforce demand and supply, organizational arrangements and systems, health quality metrics and analytics, quality of care and patient safety improvement, and health information technology, such as electronic medical records. Health reform is pervasive, systemic, and complex, encapsulating needs and wants that have meaning for the private and public sectors, and individual and collective levels, and involve the tangible and conceptual. The issue for rural citizens and providers is, do they fit in this new value-based system How can health facilities with limited utilization, workforce shortages, and financial constraints navigate this new delivery system One national rural health and health reform expert commented that "the greatest threat to the sustainability of rural healthcare systems are market forces that will force doctors and patients to choose high-value providers and partners-and rural will be left behind. Essentially, what we are attempting to do is gradually adjust our payment structure from one that relies on and reinforces paying for more services on a fee-for-service basis. So, what are some of the significant changes in pursuit of better care, better health, and lowered costs Burwell announced in January 2015 some ambitious goals to shift Medicare payments into a value-based framework. The secretary announced in March 2016 that the goals for that year were already met, well ahead of the end of the year. One is the Hospital Readmissions Reduction Program, where hospitals that have excess readmissions are penalized. Hospitals are given an incentive on a pay-for-performance method wherein a portion of reimbursement is influenced by how well the hospital performs on a set of measures compared with other hospitals or how much they improve their performance on each measure compared with their baseline performance period. All three of these initiatives are indicative of the drive to correlate quality with payment and to emphasize value or outcomes. In other words, payment follows the patient as one payment allocation is made to be shared by all the providers for an episode of care. This contrasts to the traditional approach, where each provider receives a separate payment directly from the payer. The theory is that a bundled payment may be more efficient and is awarded based on value or outcome as opposed to each provider receiving a payment for specific services. Some healthcare experts have cautioned that one of the unintended implications is that the bundled payment structure may change relationships with post-acute-care providers. Unless the patient specifically says they want to go back to their home provider, the post-acute care does not have to take place in the originating community. Experts feel this will lead to changes in some facility-to-facility relationships. The American Academy of Pediatrics pioneered the idea in 1967 to create a new medical approach that strove to include patients and families in the treatment process by emphasizing primary healthcare that was accessible, family-centered, coordinated, comprehensive, continuous, compassionate, and culturally effective. It emphasizes the role of primary care, and sometimes is called the primary care medical home model. In the early 2000s, family medicine also adopted the language of patient centeredness in a report titled, the Future of Family Medicine: A Collaborative Project of the Family Medicine Community, which called for everyone to have a personal medical home. Mental or behavioral health and other specialty services can be woven into the application of the model. It can also incorporate per-member, per-month medical home payments and allows for risk adjustment. The Geisinger Health Plan program (associated with the Geisinger Medical Center, a large rural-based system in Pennsylvania) was found to have reduced hospital admissions by 18% and readmissions by 36% per year. The Group Health Cooperative of Puget Sound was found to have reduced emergency department visits by 29%. The Milbank Memorial Fund and the Patient-Centered Primary Care Collaborative issued a report on the model in 2014. The study showed that there have been some improvements in cost, utilization, population health, prevention, and patient satisfaction, but there is still a gap in evidence with regard to physician satisfaction. A study published in the Journal of the American Medical Association was less promising. It can be physicians only, hospitals only, physicians and hospitals, or other health providers. The Shared Savings and the Pioneer models were announced in 2011, and while they each concentrate on improving care and quality for Medicare beneficiaries along with reducing healthcare costs, they do differ in their construction. The Pioneer Model accepts risk for at least 15,000 beneficiaries (with 5,000 in rural areas). The Next Generation model requires even more risk allocation to the providers, above what is found in the Pioneer Model (up to 100% of the risk). This also means that the Next Generation model provides for more opportunity to share in cost savings (bonuses for better care coordination and care management). The networks entering this model tend to be experienced, having been either part of a Pioneer or a Shared Savings model. Next Generation also employs prospective rather than retrospective benchmarks and will test beneficiary incentives. The fundamental difference between the Shared Savings, Pioneer, and Next Generation models rests with risk. The Pioneer Model has a higher level of financial risk assigned to the providers than the Shared Savings Model, and the Next Generation Model can assume even more risk than the Pioneer Model. It is a combination of experience (including positive financial incident and operating within a network of providers working in the same direction) and risk tolerance that facilitates where a provider or network of providers may be on this risk continuum. As is implied, the one-sided model operates in a manner where the providers are eligible for payment bonuses for meeting quality measures and reducing spending; however, they do not experience penalties if those benchmarks are not achieved. In a two-sided model, providers experience greater risk and can not only benefit from bonuses but can also be subject to penalties. This is likely because of a natural tendency for organizations to be cautious and conservative when approaching a new effort, especially one where a decision can have significant implications for the financial viability of the organization. Generally, there are no incentives or penalties given to patients for following or not following healthful behaviors. This is a small start; it is an inducement to participate in a network focusing on quality and improved outcomes. This is likely positive for the patient, but it lessens the ability of the health system to maintain a core base. Partnership for Patients is a quality-of-care and patient-safety initiative that has had the goal of saving 60,000 lives by averting millions of hospital-acquired conditions over three years through the reduction of complications and readmissions, and by improving care transition from one care setting to another. The most recent data indicated that 50,000 fewer patients died in hospitals and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions. A second effort is the Comprehensive Primary Care Initiative, which is a multi-payer partnership between Medicare, Medicaid, and primary care physicians in four states (Arkansas, Colorado, New Jersey, and Oregon). Under the project, primary care providers receive non-visit-based care management fees from the payers by focusing on care management for patients in most need. Preliminary studies from the first year of implementation showed that the project generated more Medicare savings than costs associated with the provider management fees. While similar to the Comprehensive Primary Care Initiative (multi-payers), this model is managed by the eight states involved, not Medicare. There are other initiatives addressing healthy infants, better coordination of chronic disease management, and state innovation models. It should also be pointed out that this transformation built on quality and outcomes linked to payment is not easy. Not only will there be winners and losers along the path to reform but also there will be approaches or models that will be modified or even rejected. It will take time and dedication, mixed with a high tolerance for failure, to find approaches and methods that work. As a North Dakota health expert stated, "Our missions are changing in rural hospitals to be leaders for better population health and prevention, no longer just a hospital for acute care but now a real health center for the entire community. Since the Third Biennial Report, there has been a significant level of activity that involves not only how we deliver and pay for healthcare but also how we think about health, including a greater recognition of social determinants of health, population health, and our individual and societal role and responsibility. One statewide health expert recently said, "We are used to there being new rules for the game. In healthcare, we learn those new rules-could be a regulatory change, could be a new program, could be a new reimbursement stream-and we learn how to apply those new rules, to play by them. Others have remarked that what is being implemented today will evolve over time and be very different in five or 10 years. There is a great deal of adjustment, and while it is not necessarily pervasive in North Dakota, there is enough on the surface that a general sense of a directional change can be noted. Caravan Health was developed in 2013 by a group of rural hospital administrators and rural physicians to develop and implement a redesigned rural model for better care and health, and one that could be economically viable within the context of a reduced-cost structure. There are more than 6,000 providers serving more than 500,000 rural Medicare beneficiaries. It is a Medicare Shared Savings one-sided model (no risk but if savings are gained, the rural facilities can share in those savings with Medicare). We [hospitals] are the pariah of society because when things go bad [for people], the hospital does well [makes money], so this feels good. Care coordination, integrated with an annual wellness visit and patient data analytics, drives improved patient management. Health experts and analysts have stressed the importance of the annual wellness visit. It is much more than a physical exam since it is a planning process for the patient. During these encounters, the provider can assess and code or recode the patient and the conditions. Patients who are not seen on an annual basis can result in the facility losing revenue. As much as 75% of chronic diseases are not coded or miscoded every year, resulting in significant revenue loss. A consultant has commented that "high-cost patients [are] an opportunity to control costs," which now leads to a better bottom line. A third service provided from Caravan Health is a 24-hour nurse advice hotline, which assists in addressing health needs of patients with comorbidities and high users of the health system. Workflow redesign is a fourth service and is essentially the umbrella concept for specific services like care coordination, using quality and utilization metrics, and annual wellness visits. This entails learning how as a health facility organization to better manage care for the patient and the facility. Granted "volume to value" implies that frequent patient contact adds cost to the system. In order to have better patient outcomes, there is a need for appropriate care services that are seen as investments in health status, are less costly to the system, and produce better outcomes and cost savings. The consultant summed it up in this manner: "We are seeing a lot more follow-up care. So more clinic contact is good, with more contact leading to [a] better opportunity to monitor and manage the patients. Physician compensation needs to tie into wellness and incentivize the physician to do more wellness. This is a good example of how the restructuring can work to the benefit of the providers. One of the hurdles for North Dakota providers is that the economic efficiency attributed to North Dakota healthcare can be problematic. It has been stated that it is harder to show savings in North Dakota because the efficiency is already high enough; it is more difficult to identify ways to save resources. Most of the cost savings experienced in Year One were associated with readmissions and emergency department changes. Emergency department visits are tracked, for example, and if a patient has three or more visits in a six-month period, that activates a higher level of care coordination, such as health coaching and patient encouragement. That is part of a growing awareness on the part of providers as to how social determinants intervene and influence population health. It was stated, "Why would we not intervene and help before a patient has a crisis It is a more humane way of healthcare, being proactive with them before and after a hospitalization. This saves money and [addresses] growing or worsening health problems for the patient. We need case management to be active and engaged in the clinic, community, senior centers, basically everywhere. It was stated that the "view of the health business is changing as there is movement from a volume payment to outcome payment. You need to grow outside your market not through hospital inpatient services but other services like outreaching occupational therapy, physical therapy, and more.

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Shinault- Small is familiar with the people and speech patterns of the study area hiv infection in kerala order medex 5 mg overnight delivery. She also analyzed sign- in sheets and prepared a demographic summary of those in attendance by gender describe the hiv infection cycle buy generic medex 5 mg online, community hiv infection rates wiki order medex toronto, organizational affiliation hiv infection rate mozambique 1mg medex sale, and race ("race" refers to categories commonly understood by the general public and as used in the U hiv infection rate nepal buy 5mg medex visa. The contract was let through a cooperative agreement with the Historic Charleston Foundation antiviral bacteria order medex paypal. Meeting transcripts and the transcript analysis document will be archived at the Avery Research Center for African American History and Culture in Charleston, South Carolina. Transcript Analysis Meaningful content analysis required an empirical derivation of topics and concepts from a sample of the transcripts. Five College of Charleston students from the Low Country area were selected to assist in this process. This transcription coding team, directed by Shinault- Small, included four female students and one male student, all of whom were African American and came from diverse socioeconomic backgrounds. Working independently, the students produced a collective master list of key words and concepts in the transcripts. Once this master list of keywords was completed, the final coding list of topics and concepts was derived by post- hoc analysis of consensus among the panelists. Using this completed list, the panel coded all of the transcripts for key concepts. Dias used the raw coding data produced by the panel, to conduct the statistical content analysis of the transcripts. The content analysis, by its nature, represents frequency of topics and makes no attempt to represent the intensity of sentiments expressed by speakers. Of 124 keywords and concepts mentioned in the transcripts, the top ten in frequency of mention, by race of speaker, follow in the tables above. Other frequently mentioned topics, especially from African American speakers, included traditional arts/sweetgrass baskets, oral history, land retention, community empowerment, economic growth, and cemetery/graveyard accessibility and preservation. There were no statistically significant differences in key word rankings by meeting location, race, organizational affiliation, or gender. Nonetheless, there were some interesting if not statistically significant tendencies. For example, Individual/ Family History ranked number one for both white and black speakers. While Educational Activities ranked second with black speakers, it ranked only sixth with white speakers. Conversely, Rice/Indigo/Gullah Culture/ History ranked second with white speakers but only seventh with black speakers. Gullah Language, which ranked tenth with black speakers, did not appear in the top ten for white speakers (Dias 2001). It is noteworthy that family history was one of the most frequently mentioned concerns in the first series of community meetings in 2000. Increasingly, researchers have focused attention on the family and kinship structures of Gullah/Geechee people and the impact of current economic and demographic change. In addition to the bare statistical results, a detailed examination of meeting transcripts provided important general insights and guidance for subsequent community outreach and ethnographic understanding of Gullah/Geechee communities. Likewise, the specifics of the content analysis became an important factor in the development of alternatives that were responsive to the views expressed by meeting participants. After the transcript analysis was completed, a summary of the results was widely disseminated via newsletter. No attempt was made to assess any possible influence this distribution of data might have had on subsequent feedback from Gullah/Geechee people. National Park Service 5 Small Meetings in Key Counties As previously stated, project personnel recognized the inadequacy of the usual public meeting procedure for reflecting the concerns of Gullah and Geechee people and communities, whose ways of life past and present are the object of this study. Applied anthropological experience has demonstrated the shortcomings of the standard public meeting format for reaching "culturally different" populations. These shortcomings include unfamiliarity with public speaking, smallcommunity group pressure to refrain from external airing of differences of opinion, and physical disabilities and familial responsibilities that can impair accessibility to large public forums. Recognizing these drawbacks to open communication, the project team sought to create opportunities for a broader spectrum of Gullah/Geechee people to participate in the process and to express their views and concerns in more comfortable settings. The counties chosen for this part of the research were Glynn and McIntosh counties in Georgia and Beaufort, Charleston, and Georgetown counties in South Carolina. Porcher, a Low Country native and former community health outreach specialist with more than thirty years experience in the area. Ironically, this study returned her to the Sea Islands of Beaufort County, South Carolina, the site of her first field research study during the late 1960s. The differences she observed in the cultural landscape of the islands were striking. They were Alyssa Stewart Lee, graduate student in City and Regional Planning at Georgia Institute of Technology, and two who were studying cultural anthropology, Jonna Hausser Weaver from State University of West Georgia and Kareema Hunter from Georgia State University. Pleasant basketmakers, Vera Manigault and Jeanette Lee, accompanied researchers on some of the trips. The lead fieldworker and one of the interns were white; the other two interns were of African American descent. During the fieldwork phase of the project, community leaders in the key counties accompanied the principal researcher to a large number of culturally significant sites related to Gullah/Geechee culture. Several speakers at public meetings in 2000 expressed their concerns about the number of outside researchers who have come into Gullah communities to study or write about their culture. Over the years numerous researchers have, in fact, visited these communities and used the acquired information for their own purposes with little or no feedback to the communities involved. Many researchers have never reported their findings in non- academic forums, asked for editorial assistance, or sent copies of their work to those who helped them. As a result, Gullah/Geechee people say they have felt exploited and believe that they should share in any financial gain made from telling their story. Commodification by the tourist industry of baskets, basketmakers, and other elements of the culture may in fact take dollars from the people themselves. Hargrove 1997, 2002) Special Resource Study field researchers spent a great deal of time building rapport with community leaders. Frequently, the lead researcher became involved in local preservation efforts and fundraising activities. Through singing, laughing, worshipping, praying, sharing meals, and talking into the "wee hours" with Gullah/Geechee people in the key counties, close relationships were developed. Other field researchers have spent long periods of time in Gullah/Geechee communities and also formed close relationships. This has been accomplished through newsletters, follow- up meetings, personal contact, sharing of photographs, and social interaction. Likewise, an earlier draft of this report was distributed to key individuals in Gullah/Geechee communities as well as to respected external specialists for review and commentary. These methods included transect walks (and drives) with local residents, mapping of key social and cultural sites (whether marked by a building or other manmade structure or not), formal interviews with community members, participation in naturally occurring functional equivalents of "focus groups". Using the standard ethnographic method of participant observation, the lead researcher and her Gullah/Geechee acquaintances began to share stories of their childhoods. Although the lead researcher interacted with a broad spectrum of Gullah/Geechee people in terms of age, gender, and occupation, there were certain categories of people, such as teenagers and small children, who were underrepresented in her contacts. One of the most extreme incidents of positive feedback occurred in a small community meeting at a church near Mt. When Guy and Candie Carawan (1989) lived on the island during the 1960s, they frequently heard comments such as, "Why would we want to dig up the past and talk about slavery, segregation, and all that stuff. Past history appeared to be less important to those people who are struggling for survival in the present. Today on Johns Island, poverty is still an issue, but there is growing interest and conscious effort to perpetuate selected elements of Gullah historical heritage. All presentations are made in the Gullah language, and young people who participate must practice carefully with the elders to be sure they have learned correct pronunciation of their lines. Pride in Gullah heritage and language appears to be spreading among the young people on the island. Eventually, groups became willing to take a more detached view and consider the alternatives as a whole. Community Meetings: Round Two A follow- up series of large venue public meetings was held during the fall of 2002. These meetings were held in the same locations as the original meetings in 2000, but were conducted as workshops rather than as open forums. The three action alternatives were presented at separate stations in the meeting room. Team members were available to record comments for those who were uncomfortable with writing. Participants were urged to share literature from the meetings with church and community organizations. They were also invited to contact team members by telephone, letter, and/or e- mail to make further comments or suggestions. All responses to these suggested preliminary alternatives were considered in the development of the final list of alternatives presented later in this document. The workshop format of the 2002 meetings did not allow for a transcript analysis comparable to that of the first round of meetings. However, all of the comments received have been recorded and are presented in Appendix C. Some of the participants seemed to be satisfied with the individual interpersonal approach, while others said that the workshop format did not allow for sufficient public expression of preferences. For additional information on agencies and programs that may provide help, see "Cultural Resource Preservation Tools and Methods" later in this document. Writing the Report After completion of both rounds of community meetings and review of the literature, Cynthia H. Other members of the team provided editorial advice and wrote sections of the report. Once that review was complete, a draft report was distributed to a panel of experts on Gullah/Geechee and African American history, society, and culture. The peer panel was comprised of individuals from academic institutions, museums, and Gullah/Geechee communities themselves. This final version of the report was revised to reflect the suggestions, concerns, and comments received from organizations, agencies, and private individuals. Scholarly Overview Gullah/Geechee people and their culture have been subject to intense academic research by anthropologists, sociologists, ethnographers, folklorists, linguists, and archaeologists for more than 100 years. They may well be the most extensively studied African American population in the United States. From the onset, much of this study has focused on the distinct creole language traditionally spoken by the Gullah people of South Carolina, which is known as Geechee in coastal Georgia. National Park Service 9 Equally important to this linguistic research are studies of Gullah and Geechee folklore and oral traditions. In addition, there is a longstanding body of research on Gullah/Geechee arts, crafts, music, and religious customs. For the past several decades, historians and social scientists have devoted increased attention to research on Gullah/Geechee social traditions and community life. More recently, applied researchers from a number of disciplines have examined the effects of multiple economic and social stresses on Gullah/Geechee communities and the psychological and cultural responses of Gullah/Geechee peoples to those stresses. Paralleling the social and cultural research on Gullah/Geechee people is a small but significant body of biomedical, anthropometric, and genetic study of the Gullah/Geechee population (Pollitzer 1999). One of these studies was a broad historic and demographic overview of coastal South Carolina, Georgia, and Northeast Florida. The University of Georgia research team, which conducted the study, was led by an anthropologist, Benjamin Blount, who had several years of research experience on the African American commercial fishermen of Georgia (Blount 2000). Results of the project served as an initial foundation for tracking population change in the Gullah/Geechee region. The other project was an annotated bibliography prepared by an independent researcher, Roslyn Saunders of Georgetown, South Carolina. Pollitzer, emeritus professor of anthropology at the University of North Carolina, published his authoritative synthesis of Gullah history, culture, and population biology, the Gullah People and Their African Heritage (1999). His work brought together a vast body of research that traced the origins of Gullah/Geechee people to West and Central Africa and detailed their distinctiveness as a population group. He discusses the demographic and economic pressure placed on the culture by rapid coastal economic development and points out that the very survival of the Gullah/Geechee as a people is at risk. He further demonstrates how the Gullah/Geechee people show greater continuity with African and Afro- Caribbean languages and 10 Low Country Gullah Culture Special Resource Study cultures than do most other African American groups in the United States. Pollitzer prepared a condensation of this monumental work on the Gullah people for inclusion in this study. The condensed work is included here as Appendix D by permission of the publisher and may not be further reproduced from this report. Despite his wide- ranging synthesis of published studies, Pollitzer did not claim his work to be an exhaustive search of scholarly literature. There is limited coverage of very recent publications and of unpublished theses and dissertations. This study, contracted through the Historic Charleston Foundation, was conducted by Melissa D. Hargrove, a University of Tennessee doctoral student in cultural anthropology, who has been conducting ethnographic research in various Gullah/Geechee communities since 1997. This document reaffirms the distinctiveness of Gullah language, people, and culture, while providing an introduction to the current cultural stress faced by the Gullah/Geechee people.

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This is important when you Hours considered that the 40-hour work week is a myth for most Americans stages of hiv infection cdc buy generic medex 1 mg online. The average work week for many is almost a full day longer (47 hours) throat infection symptoms of hiv buy generic medex online, with 39% working 50 or more hours per week (Saad hiv infection symptoms after 2 years proven 1mg medex, 2014) hiv infection pics order discount medex. Challenges in the Workplace for Middleaged Adults: In recent years middle aged adults have been challenged by economic downturns hiv infection chance buy medex cheap online, starting in 2001 hiv infection treatment guidelines order medex on line, and again in 2008. Fifty-five percent of adults reported some problems in the workplace, such as fewer hours, pay-cuts, having to switch to part-time, etc. While young adults took the biggest hit in terms of levels of unemployment, middle-aged adults also saw their overall financial resources suffer as their retirement nest eggs disappeared and house values shrank, while foreclosures increased (Pew Research Center, 2010b). Not surprisingly this age group reported that the recession hit them worse than did other age groups, especially those age 50-64. Middle aged adults who find themselves unemployed are likely to remain unemployed longer than those in early Figure 8. In the eyes of employers, it may be more cost effective to hire a young adult, despite their limited experience, as they would be starting out at lower levels of the pay scale. In addition, hiring someone who is 25 and has many years of work ahead of them versus someone who is 55 and will likely retire in 10 years may also be part of the decision to hire a younger worker (Lachman, 2004). American workers are also competing with global markets and changes in technology. Those who are able to keep up with all these changes or are willing to uproot and move around the country or even the world have a better chance of finding work. The decision to move may be easier for people who are younger and have fewer obligations to others. Leisure As most developed nations restrict the number of hours an employer can demand that an employee work per week, and require employers to offer paid vacation time, what do middle aged adults do with their time off from work and duties, referred to as leisure Around the world the most common leisure activity in both early and middle adulthood is watching television (Marketing Charts Staff, 2014). The leisure gap 336 between mothers and fathers is slightly smaller, about 3 hours a week, than among those without children under age 18 (Drake, 2013). Those age 35-44 spend less time on leisure activities than any other age group, 15 or older (U. This is not surprising as this age group are more likely to be parents and still working up the ladder of their career, so they may feel they have less time for leisure. As you read earlier, there are no laws in many job sectors guaranteeing paid vacation time in the United States (see Figure 8. Ray, Sanes and Schmitt (2013) report that several other nations also provide additional time off for young and older workers and for shift workers. In the United States, those in higher paying jobs and jobs covered by a union contract are more likely to have paid vacation time and holidays (Ray & Schmitt, 2007). A total of 658 million vacation days, or an average of 2 vacation days per worker was lost in 2015. The reasons most often given for not taking time off was worry that there would be a mountain of work to return to (40%), concern that no one else could do the job (35%), not being able to afford a vacation (33%), feeling it was harder to take time away when you have or are moving up in the company (33%), and not wanting to seem replaceable (22%). Since 2000, more American workers are willing to work for free rather than take the time that is allowed to them. A lack of support from their boss and even their colleagues to take a vacation is often a driving force in deciding to 337 forgo time off. In fact, 80% of the respondents to the survey above said they would take time away if they felt they had support from their boss. Two-thirds reported that they hear nothing, mixed messages, or discouraging remarks about taking their time off. Almost a third (31%) feel they should contact their workplace, even while on vacation. The benefits of taking time away from work: Several studies have noted the benefits of taking time away from work. It reduces job stress burnout (Nimrod, Kleiber, & Berdychevesky, 2012), improves both mental health (Qian, Yarnal, & Almeida, 2013) and physical health (Stern & Konno, 2009), especially if that leisure time also includes moderate physical activity (Lee et al. While people in their early 20s may emphasize how old they are to gain respect or to be viewed as experienced, by the time people reach their 40s they tend to emphasize how young they are. Neugarten (1968) notes that in midlife, people no longer think of their lives in terms of how long they have lived. Levinson (1978) indicated that adults go through stages and have an image of the future that motivates them. This image is called "the dream" and for the men interviewed, it was a dream of how their career paths would progress and where they would be at midlife. According to Levinson the midlife transition (40-45) was a 338 time of reevaluating previous commitments; making dramatic changes if necessary; giving expression to previously ignored talents or aspirations; and feeling more of a sense of urgency about life and its meaning. Levinson believed that a midlife crisis was a normal part of development as the person is more aware of how much time has gone by and how much time is left. The future focus of early adulthood gives way to an emphasis on the present in midlife, and the men interviewed had difficulty reconciling the "dream" they held about the future with the reality they experienced. Consequently, they felt impatient and were no longer willing to postpone the things they had always wanted to do. Although Levinson believed his research demonstrated the existence of a midlife crisis, his study has been criticized for his research methods, including small sample size, similar ages, and concerns about a cohort effect. Vaillant was one of the main researchers in the 75 year-old Harvard Study of Adult Development, and he considered a midlife crisis to be a rare occurrence among the participants (Vaillant, 1977). Additional findings of this longitudinal study will be discussed in the next chapter on late adulthood. Most research suggests that most people in the United States today do not experience a midlife crisis. Results of a 10-year study conducted by the MacArthur Foundation Research Network on Successful Midlife Development, based on telephone interviews with over 3,000 midlife adults, suggest that the years between 40 and 60 are ones marked by a sense of well-being. The crisis tended to occur among the highly educated and was triggered by a major life event rather than out of a fear of aging (Research Network on Successful Midlife Development, 2007). We all know that stress plays a major role in our mental and physical health, but what exactly is stress The term stress is defined as a pattern of physical and psychological responses in an organism after it perceives a threatening event that disturbs its homeostasis and taxes its abilities to cope with the event (Hooker & Pressman, 2016). Stress was originally derived from the field of mechanics where it is used to describe materials under pressure. The word was first used in a psychological manner by researcher Hans Selye, who was examining the effect of an ovarian hormone that he thought caused sickness in a sample of rats. Surprisingly, he noticed that almost any injected 339 Stress hormone produced this same sickness. He smartly realized that it was not the hormone under investigation that was causing these problems, but instead the aversive experience of being handled and injected by researchers led to high physiological arousal, and eventually to health problems like ulcers. He developed a model of the stress response called the General Adaptation Syndrome, which is a three-phase model of stress, which includes a mobilization of physiological resources phase, a coping phase, and an exhaustion phase. Source Psychologists have studied stress in a myriad of ways, and it is not just major life stressor. Even small daily hassles, like getting stuck in traffic or fighting with your friend, can raise your blood pressure, alter your stress hormones, and even suppress your immune system function (DeLongis, Folkman, & Lazarus, 1988; Twisk, Snel, Kemper, & van Machelen, 1999). Stress continues to be one of the most important and well-studied psychological correlates of illness, because excessive stress causes potentially damaging wear and tear on the body and can influence almost any disease process. Dispositions and Stress: Negative dispositions and personality traits have been strongly tied to an array of health risks. One of the earliest negative trait-to-health connections was discovered in the 1950s by two cardiologists. They made the interesting discovery that there were common behavioral and psychological patterns among their heart patients that were not present in other patient samples. Importantly, it was found to be associated with double the risk of heart disease as compared with Type B Behavior (absence of Type A behaviors) (Friedman & Rosenman, 1959). Since the 1950s, researchers have discovered that it is the hostility and competitiveness components of Type A that are especially harmful to heart health 340 (Iribarren et al. Hostile individuals are quick to get upset, and this angry arousal can damage the arteries of the heart. In addition, given their negative personality style, hostile people often lack a heath-protective supportive social network. Social Relationships and Stress: Research has shown that the impact of social isolation on our risk for disease and death is similar in magnitude to the risk associated with smoking regularly (Holt-Lunstad, Smith, & Layton, 2010; House, Landis, & Umberson, 1988). In fact, the importance of social relationships for our health is so significant that some scientists believe our body has developed a physiological system that encourages us to seek out our relationships, especially in times of stress (Taylor et al. Social integration is the concept used to describe the number of social roles that you have (Cohen & Willis, 1985). For example, you might be a daughter, a basketball team member, a Humane Society volunteer, a coworker, and a student. Maintaining these different roles can improve your health via encouragement from those around you to maintain a healthy lifestyle. By helping to improve health behaviors and reduce stress, social relationships can have a powerful, protective impact on health, and in some cases, might even help people with serious illnesses stay alive longer (Spiegel, Kraemer, Bloom, & Gottheil, 1989). According to the National Alliance for Caregiving (2015), 40 million Americans provide unpaid caregiving. The typical caregiver is a 49 year-old female currently caring for a 69 year-old female who needs care because of a long-term physical condition. Looking more closely at the age of the recipient of caregiving, the typical caregiver for those 18-49 years of age is a female (61%) caring mostly for her own child (32%) followed by a spouse or partner (17%). When looking at older recipients (50+) who receive care, the typical caregiver is female (60%) caring for a parent (47%) or spouse (10%). Caregiving for a young or adult child with special needs was associated with poorer global health and more physical symptoms among both fathers and mothers (Seltzer, Floyd, Song, Greenberg, & Hong, 2011). Marital relationships are also a factor in how the caring affects stress and chronic conditions. Fathers who were caregivers identified more chronic health conditions than non-caregiving fathers, regardless of marital quality. In contrast, caregiving mothers reported higher levels of chronic conditions when they reported a high level of marital strain (Kang & Marks, 2014). Age can also make a 341 difference in how one is affected by the stress of caring for a child with special needs. Using data from the Study of Midlife in the Unites States, Ha, Hong, Seltzer and Greenberg (2008) found that older parents were significantly less likely to experience the negative effects of having a disabled child than younger parents. Currently 25% of adult children, mainly baby boomers, provide personal or financial care to a parent (Metlife, 2011). Daughters are more likely to provide basic care and sons are more likely to provide financial assistance. Adult children 50+ who work and provide care to a parent are more likely to have fair or poor health when compared to those who do not provide care. Some adult children choose to leave the work force, however, the cost of leaving the work force early to care for a parent is high. For females, lost wages and social security benefits equals $324,044, while for men it equals $283,716 (Metlife, 2011). Consequently, there is a need for greater workplace flexibility for working caregivers. However, research indicates that there can be positive health effect for caring for a disabled spouse. Beach, Schulz, Yee and Jackson (2000) evaluated health related outcomes in four groups: Spouses with no caregiving needed (Group 1), living with a disabled spouse but not providing care (Group 2), living with a disabled spouse and providing care (Group 3), and helping a disabled spouse while reporting caregiver strain, including elevated levels of emotional and physical stress (Group 4). Not surprisingly, the participants in Group 4 were the least healthy and identified poorer perceived health, an increase in health-risk behaviors, and an increase in anxiety and depression symptoms. However, those in Group 3 who provided care for a spouse, but did not identify caregiver strain, actually identified decreased levels of anxiety and depression compared to Group 2 and were actually similar to those in Group 1. It appears that greater caregiving involvement was related to better mental health as long as the caregiving spouse did not feel strain. The beneficial effects of helping identified by the participants were consistent with previous research (Krause, Herzog, & Baker, 1992; Schulz et al. Female caregivers of a is associated with greater stress spouse with dementia experienced more burden, had poorer mental and physical health, exhibited increased depressive symptomatology, took part in fewer healthpromoting activities, and received fewer hours of help than male caregivers (Gibbons et al. This study was consistent with previous research findings that women experience more caregiving burden than men, despite similar caregiving situations (Torti, Gwyther, Reed, Friedman, & Schulman, 2004; Yeager, Hyer, Hobbs, & Coyne, 2010). Female caregivers are certainly at risk for negative consequences of caregiving, and greater support needs to be available to them. Stress Management: On a scale from 1 to 10, those Americans aged 39-52 rated their stress at 5. The most common sources of stress included the future of our nation, money, work, current political climate, and violence and crime. Given that these sources of our stress are often difficult to change, a number of interventions have been designed to help reduce the aversive responses to duress, especially related to health. For example, relaxation activities and forms of meditation are techniques that allow individuals to reduce their stress via breathing exercises, muscle relaxation, and mental imagery. Physiological arousal from stress can also be reduced via biofeedback, a technique where the individual is shown bodily information that is not normally available to them. This type of intervention has even shown promise in reducing heart and hypertension risk, as well as other serious conditions (Moravec, 2008; Patel, Marmot, & Terry, 1981). For example, exercise is a great stress reduction activity (Salmon, 2001) that has a myriad of health benefits. Problem-focused coping is thought of as actively addressing the event that is causing stress in an effort to solve the issue at hand. A problem-focused strategy might be to spend additional time over the weekend studying to make sure you understand all of the material. Emotion-focused coping, on the other hand, regulates the emotions that come with Source stress.

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