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  • Assistant Professor in Medicine
  • Member of the Duke Cancer Institute
  • Member of Duke Molecular Physiology Institute


In several dozen states medications vitamins order requip 0.25mg fast delivery, additional laws prevent youth access by designating enforcement authorities medications you cant drink alcohol with discount requip 2 mg free shipping, enforcing license suspension or revocation for sales to treatment urinary tract infection order 0.5mg requip mastercard minors the treatment 2014 discount 0.5 mg requip amex, banning vending machines in areas accessible to minors, or restricting advertising. However, one study found that even when 82% of merchants complied with laws banning sales to minors, teenagers reported only a small decrease in their ability to purchase tobacco and no decline in its use. Data show that in 1994, of 122 million full-time workers in the United States, nearly 100 million worked indoors. Approximately 13% of the national decline in cigarette consumption in the United States between 1988 and 1994 was attributed to smoke-free workplaces. The Canadian tobacco tax experience in the 1980s and early 1990s demonstrated the potential health impact. As a result, per capita cigarette consumption (adjusted for estimates of tobacco smuggling) dropped by 38% (1982 to 1992). Other forms of tobacco such as snuff, chewing tobacco, and pipe tobacco also are taxed. Both the tax increase and the funded tobacco control program contributed to this decline. However, the post-1993 rate of decline, while still significantly more rapid in California than in the rest of the United States (where the decline in consumption halted), slowed to less than one-third of the rate seen in 1989 through 1993. Recently, data showed the prevalence of current smoking among adults in Massachusetts was 19. Minnesota (1986) and Michigan (1994) also have initiated limited tax-funded media campaigns. A counter-advertising public health approach aims to reduce tobacco use by deglamorizing and denormalizing use of the product. To be effective, such mass media antismoking campaigns should provide consistent messages from multiple sources, repeatedly and over a long period, and should work in concert with other interventions and policies, with the goal of changing societal norms. Also, institutionalizing counter-advertising campaigns has posed a public health challenge, as funding for such campaigns can be subjected to legislative diversion. Such advertisements can be controversial yet memorable and, ultimately, effective. Wave 1 (1954 through 1973) featured a number of individual lawsuits against an industry that maintained that tobacco products had never been proven to cause disease. The industry claimed that smokers chose to smoke, hence assuming risk for themselves. In essence, the 1965 Federal Cigarette Labeling and Advertising Act, which requires warning labels on all cigarette packaging and labeling, ironically served as a shield from liability. Although the original jury verdict of $400,000 favored the plaintiff, it was reversed on appeal and the case finally was dropped after years of litigation. Wave 3 (1994 to the present) capitalizes on the release of internal industry documents and subsequent industry concessions that tobacco is addictive and causes cancer and that tobacco companies had consciously marketed their products to children. From this ensued an increasing number of individual lawsuits and class action suits. The money realized from this suit will establish a foundation for the study of diseases associated with tobacco. In the first phase of this massive class action suit, the industry was found liable for punitive damages, with the award potentially in the hundreds of billions of dollars. Then the industry signed a Master Settlement Agreement with 46 state attorneys general in November 1998, agreeing to pay $206 billion over 25 years in exchange for no future state litigation. As the twentieth century ends, states are embroiled in historic discussions of how best to spend the settlement money. The Master Settlement Agreement expressly states that parties "have agreed to settle their respective lawsuits and potential claims pursuant to terms which will achieve for the Settling States and their citizens significant funding for the advancement of public health, the implementation of important tobacco-related public health measures, including the enforcement of mandates and restrictions related to such measures, as well as funding for a national foundation dedicated to significantly reducing the use of tobacco products by youth. The Federal Food, Drug and Cosmetic Act defines a drug as "an article (except for food) intended to affect the structure and function of the body.

Even in the favorable situation in which the baseline risk is relatively well estimated compared to symptoms stiff neck generic requip 2mg mastercard the risk of the exposed group (when nj abro oil treatment order requip 1 mg visa,U is large relative to 9 treatment issues specific to prisons cheap 2 mg requip fast delivery nj symptoms 3 dpo cheap requip 0.5mg amex,E), the ability to reliably detect small increases in risk associated with exposure requires a large number of exposed individuals at risk. For example, using the usual criterion for statistical testing in order to detect with probability. A key objective of this report is the calculation of quantitative estimates of human health risks. In theory, such estimates could be derived by identifying a large group of individuals having common exposure profiles within each stratum and following the groups over a long period of time. As described above, the proportion of individuals in each group who develop cancer in specific time periods provides the desired estimates of risk. At low levels of exposure, cancer risks associated with exposure are small relative to baseline or background risks. The increases in observed cancer rates associated with exposure are small relative to the natural random fluctuations in baseline cancer rates. Thus, very large groups of individuals would have to be followed for very long periods of time to provide sufficiently precise estimates of risk associated with exposure. Consequently, direct estimates of risk are not possible for stratified subpopulations. The alternative is to use mathematical models for risk as functions of dose and stratifying variables such as sex and age. Estimation via Mathematical Models for Risk Model-based estimation provides a feasible alternative to direct estimation. Model-based estimates efficiently exploit the information in the available data and provide a means of deriving estimates for strata and dose profile combinations for which data are sparse. This is accomplished by exploiting assumptions about the functional form of a risk model. Of course, the validity of estimates derived from models depends on the appropriateness of the model; thus model choice is important. If exposure increases risk, then r > 1; if exposure decreases risk, then r < 1, and r = 1 corresponds to the case of no association. For most carcinogens, exposure is not a simple dichotomy (unexposed, exposed) but occurs on a continuum. For all carcinogens it is generally agreed that sufficiently large doses increase the risk of cancer. Thus, for many carcinogens the only open or unresolved issue is the dependence of risk on small or low doses. Low-dose ranges are often the most relevant in terms of numbers of exposed individuals. They are also the most difficult ranges for which to obtain unequivocal evidence of increased risk. These difficulties result from the fact that small increases in risk associated with low levels of exposure are difficult to Copyright National Academy of Sciences. Biologically based and empirically derived mathematical models for risk are discussed in the next two sections. Biologically Based Risk Models Biologically based risk models are designed to describe the fundamental biological processes involved in the transformation of somatic cells into malignant cancer cells. The use of biologically based risk models in epidemiologic analyses can result in a greater understanding of the mechanisms of carcinogenesis. These models can also help to expose the complex interrelationships between different time- and agedependent exposure patterns and cancer risk. Biologically based risk models provide an analytical method that is complementary to the traditional, well-established, empirical approaches. Armitage and Doll (1954) observed that for many human cancers the log-log plot of age-specific incidence rates versus age is nearly linear, up to moderately old ages. These models have been fit to various data sets, leading to the observation that most cancers arise after the occurrence of five to seven stages. Comprehensive reviews of the mathematical theory of carcinogenesis have been given by Armitage and Doll (1961), Whittemore (1978), and Armitage (1985).

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The second is the probability density function medicine 832 requip 0.5 mg generic, which is the derivative of F(t) with respect to medications varicose veins generic 0.25mg requip overnight delivery t treatment synonym buy requip 1mg, that is treatment 5th metatarsal avulsion fracture buy discount requip 2mg on-line, f(t) = (d / dt)F(t), and measures the rate of increase in F(t). The instantaneous incidence rate, also known as the hazard function, is the ratio f (t). This approximation is the theoretical counterpart of the relationship between risks and rates described in the discussion of risk. In the remainder of this chapter, incidence rate means instantaneous incidence rate unless explicitly noted otherwise. Incidence Rates and Excess Risks It is clear that the incidence rate plays an important role in the stochastic modeling of disease occurrence. Consequently, models and methods for studying the dependence of disease occurrence on exposure are generally formulated in terms of incidence rates. In the following it is assumed that individuals have been stratified on the basis of age, sex, calendar time, and possibly other factors related to disease occurrence, and that incidence rates are stratum specific. In the simple case of two exposure categories, exposed and unexposed, let E(t) and U(t) denote the incidence rates of the exposed and unexposed groups, respectively. If disease occurrence is unrelated to exposure, one expects that E(t) = U(t), whereas lack of equality between these two incidence rates indicates an association between disease occurrence and exposure. The difficulties can be seen by considering the estimates of risk from the longitudinal follow-up study described in "Rates, Risks, and Probability Models. In response to the multiplicity of parameters produced by their earlier models, Armitage and Doll proposed a simpler two-stage model designed to avoid parameters not readily estimable from available data. A major limitation of these early two-stage models is their failure to address the multiplication and death of normal cells, which was known to occur in tissues undergoing malignant change (Moolgavkar and Knudson 1981). A revised two-stage model was later proposed by Moolgavkar and colleagues, which allowed for the growth of normal tissue and the clonal expansion of intermediate cells (Moolgavkar and Knudson 1981). Numerous two-stage models have since been described in the literature (Fisher 1985; Moolgavkar 1991; Sielken and others 1994; Luebeck and others 1996; Heidenreich and others 1999, 2002a, 2002b; Moolgavkar and others 1999; Heidenreich and Paretzke 2001; Moolgavkar and Luebeck 2003). Symmetrical division results in two initiated cells, while nonsymmetrical division results in an initiated cell and a differentiated cell. The rate of symmetrical division is designated by (t), and the death differentiation rate by (t). A study of atomic bomb survivors illustrates the usefulness of the two-stage model in radiation epidemiology (Kai and others 1997). Findings from this analysis include the observation of a high excess risk among children that may not be explained by enhanced tissue sensitivity to radiation exposure. The temporal patterns in cancer risk can be explained in part by a radiation-induced increase in the pool of initiated cells, resulting in a direct dose-rate effect (Kai and others 1997). This database contains personal dosimetry records for workers exposed to ionizing radiation since 1951, with current records for more than 500,000 Canadians (Ashmore and others 1998). The basic assumption of this model is that a malignant cell results from the accumulation of mutations, with k mutations required for malignancy. The effect of exposure is that an increment of dose at age a, at rate d(a), results in a multiplicative increase r[1 + d(a)] in the rate of all k mutations. Although this model applies to both recessive and dominant mutations, it does not explicitly allow for selective proliferation of cells having only some of the required mutations. The general mutagen model has been applied successfully to A-bomb survivor data (Pierce and Mendelsohn 1999; Pierce and Preston 2000) and to underground miners exposed to radon (Lubin and others 1995). For example, the study population-specific parameters for A-bomb survivor data models are city c and calendar year y, that is, p = (c, y). The incidence rate is, in general, a function (a, e, d, s, p) of all of these factors. When the excess risk functions are dependent on the study population-that is, when they depend on the factor p-estimates of risk derived from the models are specific to the study population and therefore of limited utility for estimating risks in other populations. Thus, it is desirable to find suitable models in which either the excess risk or the excess relative risk does not depend on population-specific parameters. The formulas and equations in the remainder of this chapter are described only for the relevant case a.

Authorization of 6 months may be granted to medications starting with p 2mg requip with mastercard members with refractory myasthenia gravis who have tried and failed 2 or more of standard therapies (eg treatment centers requip 1mg generic, corticosteroids symptoms tonsillitis purchase 0.25mg requip, azathioprine medications interactions purchase 1 mg requip mastercard, cyclosporine, mycophenolate mofetil, rituximab). Re-authorization of 6 months may be granted when the following criteria are met: a. Standard first-line treatments (corticosteroids) and second-line treatments (immunosuppressants) have been tried but were unsuccessful or not tolerated, or c. Member is unable to receive standard first-line and second-line therapy because of a contraindication or other clinical reason. Re-authorization of 6 months may be granted when the following criterion is met: a. Significant bleeding symptoms (mucosal bleeding or other moderate/severe bleeding) or ii. Platelet count < 50,000/mcL and significant bleeding symptoms, high risk for bleeding or rapid increase in platelets is required*, and iii. Platelet count < 50,000/mcL and significant bleeding symptoms, high risk for bleeding* or rapid increase in platelets is required*, and c. Initial authorization of 6 months may be granted when all of the following criteria are met: a. Member has a history of recurrent sinopulmonary infections requiring intravenous antibiotics or hospitalization. Member lives in an area where measles is highly prevalent and who have not developed an antibody response after two doses of measles, mumps, and rubella virus vaccine live, or. Member has chronic bronchiectasis that is suboptimally responsive to antimicrobial and pulmonary therapy 2. Initial authorization of 3 months may be granted when the following criteria are met: a. Member experienced progressive, multifocal, asymmetrical weakness without objective sensory loss in 2 or more nerves for at least 1 month b. Member has severe disease with significant weakness (eg inability to stand or walk without aid, respiratory weakness) 2. Anticholinesterases (eg pyridostigmine) and amifampridine (eg 3,4-diaminopyridine phosphate, Firdapse) have been tried but were unsuccessful or not tolerated c. Weakness is severe or there is difficulty with venous access for plasmapheresis 2. Re-authorization of 6 months may be granted when member is responding to therapy. Kawasaki Syndrome Authorization of 1 month may be granted for pediatric members with Kawasaki syndrome. Stiff-person Syndrome Authorization of 6 months may be granted for stiff-person syndrome when the following criteria are met: 1. Member had an inadequate response to first-line treatment (benzodiazepines and/or baclofen) Management of immune checkpoint inhibitor-related nervous system adverse events Authorization of 1 month may be granted for management of immune checkpoint-inhibitor toxicities when all of the following criteria are met: 1. Member experienced one or more of the following nervous system adverse events: pneumonitis, myasthenia gravis, peripheral neuropathy, encephalitis, transverse myelitis, or severe inflammatory arthritis Acquired Red Cell Aplasia Authorization of 6 months may be granted for acquired red cell aplasia. Acute Disseminated Encephalomyelitis Authorization of 6 months may be granted for acute disseminated encephalomyelitis in members who have had an insufficient response to intravenous corticosteroid treatment. Autoimmune Mucocutaneous Blistering Disease Authorization of 6 months may be granted for autoimmune mucocutaneous blistering disease (includes pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, and epidermolysis bullosa aquisita) when the following criteria are met: 1. Member has failed or experienced significant complications (eg diabetes, steroid-induced osteoporosis) from standard treatment (corticosteroids, immunosuppressive agents). Autoimmune Hemolytic Anemia Authorization of 6 months may be granted for warm-type autoimmune hemolytic anemia in members who do not respond or have a contraindication to corticosteroids or splenectomy. Birdshot Retinochoroidopathy Authorization of 6 months may be granted for birdshot (vitiliginous) retinochoroidopathy that is not responsive to immunosuppressives (eg corticosteroids, cyclosporine). Churg-Strauss Syndrome Authorization of 6 months may be granted for severe, active Churg-Strauss syndrome as adjunctive therapy for members who have experienced failure, intolerance, or are contraindicated to other interventions. Enteroviral Meningoencephalitis Authorization of 6 months may be granted for severe cases of enteroviral meningoencephalitis.


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