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Specific tactics for this strategy may include incentives and mandates that encourage or require patients virus 24 order trimethoprim 960 mg with amex, families infection red line generic 480 mg trimethoprim free shipping, clinicians virus zoo purchase trimethoprim 480 mg without a prescription, health care leaders infection preventionist best buy trimethoprim, health care organizations, and health care systems to change their behaviors in ways that promote and support patient and family engagement. Ideally, incentives should be aligned with performance measures on metrics such as patient-reported experience and outcomes, inclusion of patients and families in team-based care, and the extent of progress toward achieving patient-centered goals. Themes of patient and family engagement are central throughout the Patient Protection and Affordable Care Act. Several provisions directly address patient engagement and patient-centeredness, including support for primary care medical homes, medication management, community health assessments, and incentives for chronic disease prevention under Medicaid. Several additional provisions, while not solely focused on patient engagement, utilize its main principles and concepts. Provisions focused on quality reporting and quality measurement development, for example, require patient-centered assessments and similar tools. This strategy highlights the importance of engaging patients and families "as informed, empowered partners in their care, " and aims to incorporate patient and caregiver preferences, improve the experience of care, and promote selfmanagement. Medicaid reform in North Carolina will provide more opportunities to incentivize patient engagement amongst providers. The State Health Plan provides health insurance coverage for approximately 630, 000 North Carolina state employees and dependents, including teachers, state university faculty and staff, and lawmakers. The State Health Plan also plans to focus on initiatives to improve health literacy among patients and has begun moving toward valuebased insurance design, in which patients can choose from plans that offer financial incentives for actions taken to improve their health. Private payers have also implemented policies to enhance patient and family engagement. Group purchaser incentives include discounts on renewal of employee plans if employees participate in the recommended preventive care. One example of incentives is the national Blue Distinction Center program, which identifies centers of excellence for nonemergent surgeries, based on generally recognized quality indicators such as postoperative complications and readmission rates. Another example is requiring a smaller copay for patients going to a designated patient-centered medical home to receive primary care. Self-funded plans have implemented a number of other creative ways to offer incentives to members who choose higher quality facilities and providers. Aetna has increased its focus on vulnerable populations, engaged healthy populations, and facilitated prevention by providing incentives for patients who complete health risk assessments and participate in health promotion and wellness programs. Employers offering health care coverage can support patient and family engagement by providing information about health care plans and options available to employees in easy to understand language. Employers can also provide additional education about the various plans and information on how employees can access the health care system. Employers can explore options for caregiver coverage for patient support and other services that save costs and resources for health care organizations and systems each year. Health care payers can also support patient and family engagement through clear, easy to understand information on their insurance options. Further, advisory committee members should be incorporated into the planning and governance structures of health care payers to ensure that concerns of patient and family representatives are heard and addressed. For example, payers can develop reimbursement policies that factor in patient satisfaction or the use of evidence-based practices that promote patient and family engagement. Tactics which promote patient and family engagement may include the use of motivational interviewing, peer support strategies, shared decision-making tools, and health literacy strategies. Embracing these strategies as part of reimbursement formulas will help prepare the health care team for the culture change of more engaged patients and families, as discussed in Chapter 3. Payers can also consider providing reimbursement for peer Employers and health care payers play significant roles in supporting patient and family engagement. For example, in the fields of mental health, developmental disabilities, and substance abuse services, peer support services are certified and credentialed through a training process that facilitates reimbursement. There are other state efforts to consider credentialing services for billing and reimbursement. The Task Force examined the role employers and payers can play in promoting legislation and regulatory requirements, as well as corporate policies that support patients, families, and caregivers. The Task Force focused its recommendations on ways these partners can enhance patient and family engagement. Engaging Employees in their Health and Well-Being In addition to providing health care services for communities, health care organizations are employers. In many communities across North Carolina, health care organizations are among the largest employers. In 2008, the health care industry in North Carolina employed almost 500, 000 people.

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The belief that white sugar in the diet somehow "feeds" cancer is very common antibiotic resistant gonorrhea buy discount trimethoprim online, but the truth is more complicated antibiotics you cannot take with methadone order trimethoprim 480 mg mastercard. All cells virus how about now discount trimethoprim 480 mg fast delivery, including cancer cells antibiotics for dogs baytril purchase 480 mg trimethoprim with visa, in the body use sugar (glucose) from the bloodstream for fuel. Blood glucose comes from foods containing carbohydrates, including healthful fruits, vegetables, whole grains, and low-fat dairy products. When there is not enough carbohydrate in the diet, some glucose is even produced by the body from protein-containing foods through a special process. It is excess body fat that has been convincingly linked to greater risk of several types of cancer. Highly refined foods and foods with added sugars, such as sugary drinks and sweets, are also low in fiber and low in nutrients. These foods may also increase insulin resistance, and this has been linked to an increased risk of developing diabetes, heart disease, and overweight and obesity. These comprehensive reviews of cancer research worldwide calculated that approximately 117, 000 cancer cases in the United States each year are linked to excess body fat. There are many reasons why people may prefer to eat foods grown organically with fewer pesticide residues. However, studies clearly affirm that consuming a diet rich in fruits and vegetables, whether grown conventionally or organically, is an important part of a diet that lowers overall cancer risk. Fat that accumulates in the abdominal area-lending the body an "apple shape"-is often visceral fat. People with too much visceral fat have been shown to be at greater risk for developing obesity-related diseases and cancer. Another type of fat tissue, subcutaneous fat, is located directly beneath the skin. While these methods are not perfect, they can help people assess whether their weight and waist size fall within the healthy range. Staying within the healthy range throughout life is important for lowering cancer risk. Use a measuring tape and follow these easy steps: Place a tape measure around the waist above the tip of the hipbone. The word "phytochemical" means a naturally occurring plant (phyto, in Greek) chemical. Phytochemicals provide a plant with color, aroma, and flavor as well as protection from infection and predators. The colors, fragrances, and taste of the plant hint at the phytochemicals it contains. In the human diet, some phytochemicals work together to protect the body from cancer and other diseases. Preventing this type of damage might help protect us from cancer and other diseases. The best way to provide the body with phytochemicals is to eat a balanced diet that includes whole grains, legumes, nuts, seeds, and a variety of colorful fruits and vegetables. Avoid foods and drinks that promote weight gain: Consume energy-dense foods sparingly (high calories for amount and few nutrients). Bake until the flesh is tender when pierced, roughly 45 to 90 minutes (depending on size). While the squash is cooling, in a large, heavy pan heat the canola oil over medium-high heat. Add the onion and leek and sautй for about 4 minutes, until the onion is translucent. Per serving: 103 calories, 3 g total fat (<1 g saturated fat), 18 g carbohydrate, 3 g protein, 3 g dietary fiber, 330 mg sodium. Holiday Quinoa Salad with Pomegranate and Fresh Herbs ѕ cup quinoa 1ѕ cups water ѕ tsp. Cook over medium-high heat, stirring constantly with wooden spatula until grains stick to bottom of pot and then start to move freely and smell toasty, about 5 minutes. When grains of quinoa start to pop, move pot off heat and pour in 1ѕ cups water, standing back as it will splatter.

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The limbic system is a group of connected and related brain regions that mediate emotions and flight or fight attitudes antibiotic resistance legionella pneumophila buy discount trimethoprim 960mg on-line. The limbic or "emotional brain" is more primitive by evolutionary standards virus killing children order trimethoprim once a day, and is not necessarily under control by the higher intellectual cortex bacteria virtual lab buy genuine trimethoprim on-line. This system receives sensory and higher cortical inputs antimicrobial ointment purchase trimethoprim 960mg, calls upon memories and determines the threat level imposed by a stimulus. The amygdala for instance is a limbic structure in the base of the brain that is important in anger and rage. In cats, electrical stimulation of the amygdala causes hissing, back arching and the hair to stand on end, typical of anger and defense postures in cats. In animals that have damage to the amygdala a placid state results in which anger cannot be induced. Inputs to the amygdala are thought to originate from the hippocampus, the cingulate cortex and other parts of the limbic system. The locus ceruleus is the source of most of the stimulant neurotransmitter norepinephrine in the nervous system. Cells here project to other brain areas, releasing norepinephrine to activate other systems and increase arousal and alertness. Release of norepinephrine increases heart rate, blood pressure and primes the muscles and nervous system for fight or flight. If the stress reaction is excessive or the perceived threat too frequent, tachycardia (racing heart), hypertension, muscle tension, bowel spasms, and dyspepsia can result. Cortisol promotes fluid and salt retention and impairs inflammation, functions helpful in the short term during flight or fight situations or injury. A variety of human studies indicate stress promotes decreased gastric emptying and accelerated colonic transit in normal volunteers. A pioneering study by Almy measured colonic contractions during flexible sigmoidoscopy. The volunteers were told that a cancer was found, leading to abrupt increases in colonic contractions, which resolved after the hoax was explained. Other stressors such as ball-sorting, driving in city traffic and mentally challenging listening tasks similarly increase colonic contractions and reduce gastric motility. Recent data also indicates that intestinal sensitivity increases with stress compared to relaxation. In gastroesophageal reflux for example, psychological stressors can increase heartburn symptoms. The majority of dyspepsia is functional, that is not associated with ulcers, gallstones, reflux esophagitis or cancer. In both of these common disorders, motility and sensory changes are present which mimic the stress state. Both disorders demonstrate hypersensitivity of the gut (either stomach or intestine). In functional dyspepsia the stomach generally has mildly reduced emptying and reduced accommodation of meals. These alterations are likely to cause symptoms such as diarrhea and intestinal cramps due to increased contractions of the gut and increased sensitivity of the gut during stress. Conversely, symptoms are persistent in subjects with ongoing "threatening" psychosocial stressors. Sedatives such as the benzodiazepine Librium can reduce the effect of stress on the gut. Summary There is much yet to learn about the effects of stress on the gastrointestinal tract. The exact neural and hormonal pathways that mediate excess gut sensitivity and altered contractility during stress are not defined. Specific neurotransmitters are likely to underlie the gastrointestinal stress reaction, and may be amenable to pharmacologic blockade. New tools such as brain imaging to study brain responses to stressors and drugs, and molecular biology to study function of neurotransmitters and their receptors are likely to lead to better understanding of the stress response and its role in disease states.

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Major sources of refined grains in the diets of Americans are yeast breads (26% of total refined grain intake); pizza (11%); grain-based desserts (10%); and tortillas antibiotics for dogs eye cheap 480mg trimethoprim amex, burritos lg anti bacteria cheap trimethoprim 960 mg without prescription, and tacos (8%) (Figure 3-7) virus joints infection buy trimethoprim with a visa. Alcohol In the United States global antibiotic resistance journal order 480mg trimethoprim with amex, approximately 50 percent of adults are current regular drinkers and 14 percent are current infrequent drinkers. Folic acid is added to enriched refined grains to a level that doubles the amount lost during the refining process. One ounce-equivalent of grain is 1 one-ounce slice bread; 1 ounce uncooked pasta or rice; Ѕ cup cooked rice, pasta, or cereal; 1 tortilla (6" diameter); 1 pancake (5" diameter); 1 ounce ready-to-eat cereal (about 1 cup cereal flakes). The consumption of alcohol can have beneficial or harmful effects, depending on the amount consumed, age, and other characteristics of the person consuming the alcohol. Strong evidence from observational studies has shown that moderate alcohol consumption is associated with a lower risk of cardiovascular disease. Moderate alcohol consumption also is associated with reduced risk of all-cause mortality among middle-aged and older adults and may help to keep cognitive function intact with age. However, it is not recommended that anyone begin drinking or drink more frequently on the basis of potential health benefits because moderate alcohol intake also is associated with increased risk of breast cancer, violence, drowning, and injuries from falls and motor vehicle crashes. However, breastfeeding women should be very cautious about drinking alcohol, if they choose to drink at all. Excessive drinking increases the risk of cirrhosis of the liver, hypertension, stroke, type 2 diabetes, cancer of the upper gastrointestinal tract and colon, injury, and violence. Excessive drinking over time is associated with increased body weight and can impair short- and long-term cognitive function. For the growing percentage of the population with elevated blood pressure, reducing alcohol intake can effectively lower blood pressure, although this is most effective when paired with changes in diet and physical activity patterns. Excessive alcohol consumption is responsible for an average of 79, 000 deaths in the United States each year. Binge drinking also is associated with a wide range of other health and social problems, including sexually transmitted diseases, unintended pregnancy, and violent crime. There are many circumstances in which people should not drink alcohol: Individuals who cannot restrict their drinking to moderate levels. Besides being illegal, alcohol consumption increases the risk of drowning, car accidents, and traumatic injury, which are common causes of death in children and adolescents. Drinking during pregnancy, especially in the first few months of pregnancy, may result in negative behavioral or neurological consequences in the offspring. Moderate alcohol consumption is defined as up to 1 drink per day for women and up to 2 drinks per day for men. Heavy or high-risk drinking is the consumption of more than 3 drinks on any day or more than 7 per week for women and more than 4 drinks on any day or more than 14 per week for men. Binge drinking is the consumption within 2 hours of 4 or more drinks for women and 5 or more drinks for men. Americans should follow the recommendations provided in this chapter to help achieve a dietary pattern that will meet their nutrient needs, control calorie intake, and help reduce the risk of certain chronic diseases. This goal can be achieved by consuming fewer foods high in sodium, solid fats, added sugars, and refined grains. It is not recommended that anyone begin drinking alcohol or drink more frequently on the basis of potential health benefits. The dietary patterns outlined in Chapter 5 can help Americans reduce their consumption of these foods, thereby meeting their nutrient needs within appropriate calorie levels. Appendix 4 discusses how food labels can help consumers evaluate and compare the nutritional content and/or ingredients of products, and assist them in purchasing foods that contain relatively lower amounts of certain undesirable nutrients and ingredients, such as sodium, saturated and trans fats, and added sugars. However, many Americans do not eat the array of foods that will provide all needed nutrients while staying within calorie needs. In the United States, intakes of vegetables, fruits, whole grains, milk and milk products, 57 and oils are lower than recommended. As a result, dietary intakes of several nutrients-potassium, dietary fiber, calcium, and vitamin D-are low enough to be of public health concern for both adults and children. Several other nutrients also are of concern for specific population groups, such as folic acid for women who are capable of becoming pregnant. This chapter describes food choices that should be emphasized to help Americans close nutrient gaps and move toward healthful eating patterns. Guidance on food choices for a healthy eating pattern generally groups foods based on commonalities in nutrients provided and how the foods are viewed and used by consumers. The following recommendations provide advice about making choices from all food groups while balancing calorie needs.

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Shortages of other health care professionals who provide cancer care-radiation and imaging technologists antibiotic resistance efflux pump buy trimethoprim 960mg with amex, laboratorypersonnel virus on computer discount trimethoprim 960 mg without prescription, pharmacists medicine for uti bactrim cheap trimethoprim 480 mg visa, socialworkers antibiotic probiotic timing buy trimethoprim american express, andotherpublichealthworkers- alsowillaffectcancercarequalityacrossthe entire care continuum. The population of oncology socialworkers, whichmaynumbernomorethan about1, 000nationwide, 432 help patients cope withcancer-relateddepressionandmyriadother psychosocialissues;theyalsofrequentlyserve as patient navigators and are active in cancer screening and assessment activities. The shrinking cadre of oncology social workers, coinciding with the growing social work needs of increasing numbersofoldercancerpatients, hasthepotential totranslateintoasignificanttollinhuman, personal, and economic costs. Other includes American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and multiple race. Women, minorities, and persons with disabilities in science and engineering: 2011. Asian applicants werefoundtobe4percentlesslikelytoreceive funding compared with their white counterparts. Moreover, thestudyfoundthatblack/African AmericanandAsianapplicantsresubmitted applicationsmoretimesbeforebeingawardedR01 grants compared with white applicants. Mentors canbeparticularlyvaluablefortraineesfrom underrepresented groups who still are unlikely to encountermanyresearchersintheirfieldswho "looklikethem. Deputy Director, National Institutes of Health, Presentation to Committee; 2008 Jun 11. Research training grants also are targeted at women scientists returning to the workforce after aperiodoffamily-relatedabsenceandtodisabled individuals pursuing cancer research careers. Without adequatepreparationattheseearlystages, students arehighlyunlikelytoeverenterthebiomedical research and medical training pipelines. Moreover, lack of effectivementoringhasbeenidentifiedasan important reason trainees decide not to pursue researchcareers. Amongotherbenefits, mentors provide trainees with the perspective that comes from research experience, assist trainees in making contacts and learning research processes and procedures at their institutions, and help young Recruitment and Retention Preparing and inspiring young people to consider careers in science and medicine are most successful when outreach and core academics startattheK-12gradelevels. Table 9 Key Characteristics of Effective Mentor/Trainee Relationships Mentor Shows that research is interesting and rewarding Provides opportunities for laboratory experiences Provides expertise in research area and techniques Introduces the trainee to the scientific community Helps the trainee understand scientific organizations, their relationships, and various aspects of their function Provides needed resources and information Acts as a sounding board for professional and personal matters Provides encouragement Offers personal attention and guidance Helps trainee contend with academic barriers; provides advice about thesis and authorship issues Provides advice about balance between home and laboratory Provides advice about career options Provides help with self-promotion and professional survival Trainee Learns different options and how to weigh them Identifies appropriate institutions and laboratories Learns to narrow field of study Enhances research knowledge and skills; builds positively on strengths Identifies potential advisors and collaborators Learns scientific organizations and their functions Brings new perspectives and values to the research community Builds personal bonds and good interpersonal/interprofessional relationships Builds self-confidence Counteracts isolation; develops social support and publication competence Learns to evaluate abilities realistically Learns good communication skills Builds professional competence; learns career mobility and forecasting Adapted from: National Cancer Institute Center to Reduce Cancer Health Disparities. Bothsexesincreasingly aredemandingabetterbalanceofworkand personal life and are less willing to work the often grueling schedules that are common among professionalsinthesefields. Some attempts to accommodate familyobligations, suchasextendingthetenure track, are actually looked upon negatively. Confidenceissuesmaymanifestasalowerbeliefin the likelihood of achieving tenure among women scientists compared with male counterparts that in turn may translate into a reduced willingness torepeatedlysubmitandresubmitapplications for independent grant funding. As with the intramural program, loan repayment alsoisavailabletoclinicalresearchersfrom disadvantagedbackgrounds. TheNationalHealth Service Corps offers repayment of medical school loansinexchangeforatwo-yearfull-time(or four-yearhalf-time)commitmenttopracticeina medically underserved area. Some states have loan repayment or loan forgiveness programs for health service providers, including physicians, nurses, nurse practitioners, physician assistants, and social service workers, and a few such programs may exist outside of government. Ensuring quality cancer care through the oncology workforce: sustaining care in the 21st century. Committee on Maximizing the Potential of Women in Academic Science and Engineering, National Academy of Sciences, National Academy of Engineering, Institute of Medicine. Beyond bias and barriers: fulfilling the potential of women in academic science and engineering. Recruitment and Retention Strategies Meeting the cancer research and care workforce demandsofthecomingdecadeswillrequire creativity, foresight, and tenacity on the part of all stakeholders: government, academic institutions, scientificandmedicalsocieties, canceradvocates, andquasi-governmentalandprivatehealth policyorganizations. Numerous strategies are beingconsideredortestedtoincreasethenumber of people who choose oncology research or care as a career. And we think about how many of our dollars are used to support the facilities and administrative infrastructure of the institutions at which these activities occur. Thefollowingsectionsdescribethesesystem weaknesses as well as selected initiatives to improvehealthcarecoordinationbothbroadly andspecificallyforcancerpatients/survivors. In addition, this chapter highlights several recent technological advances with untapped potential to revolutionizehealthcaredelivery. Nearly a third of the elderly Americans studied had received surgical interventions during the last yearoflife;comparedwiththepatientsampleas a whole, those who had undergone surgery were most often younger, male, nonwhite, and had more comorbidities. Barriers to Health Care Delivery System Improvements Although the United States has a wealth of health careresources, healthcareoutcomeslagbehind those of other developed nations.

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