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Perceived social support has been investigated in several studies gastritis medication effective 400mg sevelamer, and results have been inconsistent gastritis diet questionnaire purchase 400 mg sevelamer with visa. Ord-Lawson and Fitch (1997) investigated the relation between perceived social support gastritis diet discount 800mg sevelamer otc, as measured by the Medical Outcomes Study social support survey and the Importance of Social Support Questionnaire (developed by the authors) gastritis doctor cheap sevelamer 400mg online, and mood of 30 men diagnosed with testicular cancer within the past two months. Results indicated that there was no signi"cant relationship between social support and mood. Komproe, Rijken, Winnubst, Ros, and Hart (1997) found that perceived available support, as rated by women who recently underwent surgery for breast cancer (84% early stage cancer), was associated with lower levels of depressive symptoms. Budin (1998) studied unmarried early stage breast cancer patients using a cross-sectional design, and found that, after accounting for symptom distress and treatment. Two prospective studies have found postsurgical perceived support from family members to be related to less distress at later time points, among women with breast cancer (Hoskins et al. However, neither study adjusted for initial levels of psychological distress, which would have clari"ed whether or not perceived support predicted changes in distress. Alferi, Carver, Antoni, Weiss, and Duran (2000) examined cancer-speci"c distress (intrusive thoughts and avoidance symptoms) and psychological distress among 51 Hispanic women being treated for early stage breast cancer. Women were evaluated presurgery, postsurgery, and at 3-, 6-, and 12-month follow-ups. Emotional support from friends and instrumental support from the spouse at presurgery predicted lower distress postsurgery. This study evaluated the impact of distress on subsequent support from spouse, friends, and family. Distress at several time points predicted erosion of instrumental support from women in the family. Similar "ndings were reported by Bolger, Foster, Vinokur, and Ng (1996) in a sample of breast cancer patients followed up to 10 months postdiagnosis. Several studies have evaluated the associations between received or enacted support and psychological adaptation among cancer patients. De Ruiter, de Haes, and Tempelaar (1993) examined the relationship between the number of positive social interactions and psychological distress among a group of cancer patients who were either in treatment or completed treatment. In this cross-sectional study, positive support was associated with distress only among patients who had completed treatment. A second cross-sectional study by Manne and colleagues (Manne, Taylor, Dougherty, & Kemeny, 1997) investigated the potential moderating role of functional impairment and gender on the relationship between spouse support and psychological distress. Spouse support was associated with lower levels of distress and higher levels of well-being for female patients, but was not associated with distress or well-being among male patients. Spouse support was associated with lower psychological distress among patients with low levels of functional impairment, whereas spouse support was not signi"cantly associated with distress among patients with high levels of functional impairment. These results suggest that the reason that the association between support and distress has not consistently been found is because support·s impact may depend on contextual or demographic variables such as gender and physical disability. One of the few studies focusing on patients with late 66 Coping and Social Support stage disease was recently conducted by Butler, Koopman, Classen, and Spiegel (1999), who studied a relatively large group of metastatic breast cancer patients. This crosssectional study suggested that avoidance was associated with smaller emotional support networks. Unfortunately, the methodology would not allow for evaluation of causality; it is possible that patient avoidant symptoms lead them to avoid others and thus lead to a smaller group of people providing emotional support. In addition, the stigma associated with this disease places patients at high risk for social isolation. Similar "ndings were reported in longitudinal studies (Hays, Turner, & Coates, 1992; Nott, Vedhara, & Power, 1995). Less satisfaction with social support at baseline was predictive of a decline in quality of life. Studies have also investigated the possibility that different types of support are associated with distress. Studies examining potential buffering effects of social support, using both cross-sectional (Pakenham, Dadds, & Terry, 1994) and longitudinal (Siegel et al. Osteoarthritis is a similar chronic disease that is painful, but typically less disabling and progressive in nature. Both diseases have numerous physical consequences, including pain and severe physical disability that can result in signi"cant social and psychological impact. Studies using measures of both perceived available support and support received. Although the majority of studies have employed cross-sectional designs, several studies using longitudinal designs have also reported associations between social support and psychological distress.

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Although tobacco is the leading cause of morbidity and premature mortality in the United States gastritis diet ginger buy sevelamer 800mg cheap, allied health professionals generally do not receive adequate tobacco cessation training gastritis foods to eat list buy sevelamer 800 mg without a prescription. The vast majority of medical Evidence for Genetic Influence on Tobacco Use in Humans 157 schools gastritis from ibuprofen discount sevelamer 800 mg without a prescription, for example gastritis nunca mas 800mg sevelamer with amex, do not provide comprehensive tobacco cessation training to medical students (Ferry, Grissino, & Runfola, 1999). Receiving specialized training, however, has been shown to lead to increased delivery of smoking cessation counseling among health care professionals (Lancaster, Silagy, & Fowler, 2000; Sinclair et al. According to the ·Clinical Practice Guideline for Treating Tobacco Use and Dependence,Z which summarizes the results of more than 6,000 published articles, "ve key components of tobacco cessation counseling are: (a) ask patients whether they use tobacco, (b) advise tobacco users to quit, (c) assess patients· interest in quitting, (d) assist patients with quitting, and (e) arrange follow-up care (Fiore et al. Although physicians are aware of the health consequences of using tobacco (Wechsler, Levine, Idelson, Schor, & Coakley, 1996), smoking status is assessed in only about one-half to two-thirds of patient clinic visits, and cessation assistance is provided in only about one-"fth of smokers· visits (Goldstein et al. In a meta-analysis of 13 studies comparing group programs to self-help programs (Stead & Lancaster, 2000), group program participants were signi"cantly more likely to have quit for six or more months (odds ratio 2. Group therapy exhibited similar ef"cacy as similar-intensity individual counseling. A principal drawback of group programs is their limited reach, because participation rates tend to be low (Stead & Lancaster, 2000). Smokers must be motivated not only to attempt to stop, but also to commit the time and effort required to attend group meetings. Although data indicate that quit rates are enhanced with more intensive group programs or counseling, smokers tend to prefer less intense, briefer forms of self-help counseling (Fiore, Smith, Jorenby, & Baker, 1994; Hughes, 1993). Mandatory counseling, such as that required by many health insurers if a patient is to receive cessation medications at no cost or at a reduced price (co-pay), may act as a barrier to patients· quitting (Fiore et al. Thus, from a health policy standpoint, it will be important to weigh the costs/bene"ts of offering a brief, less intense, and less effective treatment to more potential quitters versus the costs/bene"ts of offering a more intense, more effective treatment to fewer potential quitters. Future Directions the market for smoking cessation aids is relatively small but growing. It is clear that improved methods of promoting cessation are needed; this might include new medications (Centers for Disease Control and Prevention, 2000), new indications for existing medications, combination therapy, new or improved behavioral approaches, and/or increased knowledge for effective methods of matching medications and behavioral approaches to individual patients. In addition, research is needed to examine the safety and ef"cacy of different medications for use in special populations, such as adolescents, pregnant women, patients with depression, and smokeless tobacco users (Fiore et al. While risk factors for relapse following treatment with pharmacological and nonpharmacological cessation approaches have been identi"ed, relatively little work has been done to identify which smokers should receive which treatments. One reason for this is that the typical analytic approach used to identify risk factors. For example, it is incorrect to assume that because all women, who have been shown to be at higher risk for relapse than men by conventional statistical methods, require the same treatment approach. In fact, it can be shown with appropriate analytic tools, that some women do very well in response to treatment. Previous research has identi"ed subgroups of smokers with wide variation in responsiveness to both pharmacological (Swan, Jack, Niaura, Borrelli, & Spring, 1999; Swan, Jack, & Ward, 1997) and nonpharmacological (Swan, Ward, Carmelli, & Jack, 1993) treatments. One of the keys to the future of matching treatments to individual smokers will be consistent attention to and analysis of individual differences in treatment responsiveness. While no one has yet demonstrated the presence of speci"c gene-environment interactions on tobacco use in humans, because of insuf"cient study sample sizes, interactions have been demonstrated in biometric models of twin similarity for alcohol use (Koopmans, Heath, Neale, & Boomsma, 1997). It has been speculated that if such interactions exist, they could emerge as potentially powerful determinants of susceptibility and maintenance of tobacco dependence (Kendler, 1999; Swan, 1999). Definition of Phenotypes In most behavior genetic and genetic epidemiologic studies, ·smokingZ has been assessed as a static phenotype. In the "eld of psychiatric genetics, an area fraught with numerous examples of nonreplication (Kendler, 1999), some investigators believe that more detailed measures of phenotypes, relying on actual measurements of behavior, physiological responses, or biological characteristics such as brain structure from imaging studies, will provide more replicable associations with genetic markers than have more general summary measures (Gelernter, 1997; Kendler, 1999). In the "eld of tobacco use, numerous possibilities exist in which the relationships of phenotypes to genetic factors may actually be larger should the full range of phenotypes be explored. We have developed a classi"cation of possible phenotypes (referred to as endophenotypes by Kendler, 1999) to organize phenotype selection for genetic investigations of tobacco use (see Table 7. The majority of genetic studies, to date, have involved only this level of phenotypic description. Longitudinal assessments that emphasize the process of, or progression toward the development of regular smoking or tobacco dependence. As an illustration, two individuals both might be classi"ed as ever-smokers, having smoked 100 or more cigarettes in their life, yet their smoking topography may differ dramatically,for example, one person might have taken years to develop into a daily smoker, whereas the other might have converged rapidly on daily smoking (and thus have a much steeper ·slopeZ or ·trajectoryZ for the development of daily smoking). Pooled analyzes of the results from these studies lead to the conclusion that 56% of smoking initiation is attributable to genetic factors (44% to environmental sources), while 67% of variance in indirect measures of tobacco dependence can be attributed to genetic factors (33% to environmental sources; Sullivan & Kendler, 1999).

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Nor do they favor multi-decade investments that can keep capital tied up for years gastritis lettuce buy 400mg sevelamer with amex. Instruments such as green bonds and YieldCos use familiar financial instruments to enhance capital flows to sustainable infrastructure gastritis symptoms home remedies buy generic sevelamer 400 mg line. The year 2014 saw the first issuance of a green bond by an emerging economy at the municipal level gastritis diet 101 cheap 400 mg sevelamer free shipping, by the city of Johannesburg gastritis diet sample menu cheap sevelamer 800mg on line. YieldCos are publicly traded companies created by a parent company that bundle operating infrastructure assets to generate predictable cash flows that are then paid out in dividends to shareholders. Green bonds have had a favorable reception from investors who see them as a good way to achieve market-competitive returns while incorporating climate change as part of their institutional missions. This could further incentivize investment by long-term institutional investors and support the development of sustainable infrastructure as an asset class. Green bonds and YieldCos also reduce risks associated with infrastructure investments. For instance, the credit risk associated with green bonds is typically lower than that of similar project bonds because that 96 risk is assumed by the issuing entity and not by the cash flows from the individual project. Given these lower risks, green-bond yields tend to be on the lower end of the spectrum as well. YieldCos, on the other hand, reduce risk by pooling projects, thus helping institutions to diversify their investments. This model seeks to capture the additional value created by infrastructure though impact fees, special assessment districts, or tax increment financing. In essence, this allows infrastructure to be financed based on its ability to raise the value of the surrounding land once it is built. Similar models could be designed for sustainable infrastructure; if adaptation infrastructure were to make a community safer from flooding and increase property values, for instance, this value could be used to finance the upfront investment. While adopting and scaling up the range of financial instruments could be helpful, doing so does not significantly alter the risk-adjusted returns for sustainable infrastructure-the primary metric upon which portfolio managers are judged. Investors will stay away until these returns are shown to be as good as other options. Another challenge is to develop financial instruments that respond to the growing need for small-scale infrastructure. This need has been rising due to the current trend of decentralization of infrastructure services such as water services and electricity (Perera et al. This is especially the case in emerging and developing countries where small-scale infrastructure is a critical element of economic development (Perera et al. As a result, the composition of the investments, financing flows, and infrastructure owners are likely to be substantially different between traditional and sustainable infrastructure, even though the total volumes of financing may not differ much (Bielenberg et al 2016). This will require working with a more diverse set of infrastructure owners that are not established creditworthy entities such as large corporations or central governments, but are smaller (and sometimes less credit-worthy) entities such as households, mid-sized industrial companies, and emerging economy cities. In addition to the challenge of financing less credit worth entities are the higher transaction costs arising from the need for project preparation, due diligence and structuring many smaller projects (Perera 2015). For example, power is traditionally provided by a centralized grid financed by the government and operated by a utility. Renewable energy development, on the other hand, is often off-grid and financed by individual households or communities. In poor rural areas in countries such as Kenya and Tanzania, a significant share of new rural electrification is being financed by people making only a few dollars a day. This could include bundling multiple projects in order to achieve scale and drive down the overall costs (Perera 2015). Innovation will also be needed to finance a more diverse set of investors in sustainable infrastructure compared to traditional infrastructure, including many smaller and often less creditworthy investors, such as in solar energy. In rural Kenya and Tanzania, for example, a significant share of new rural electrification is being financed by low-income households. New models will be needed that contain transaction costs and offer adequate risk-adjusted returns for investing in small distributed assets, including possibly bundling multiple projects to achieve scale (Perera et al. Regulations on investment limits, capital adequacy, and reserve requirements, the valuation of assets and liabilities and limits on foreign investment can discourage investors from making longer-term and cross-border investments in sustainable infrastructure.

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Issues Relevant to Treatment of Mental Disorders Although women are more likely to suffer from depressive gastritis diet 800mg sevelamer free shipping, anxiety gastritis diet cheap sevelamer 800mg line, and eating disorders gastritis symptoms treatment mayo clinic cheap sevelamer 800mg without prescription, most do not seek treatment diet gastritis adalah generic sevelamer 800mg online. Women seek treatment for mental disorders more often than men (Zerbe, 1999), but only one-third to one-fourth of women with depression actually seek professional help or treatment (Kessler, 2000). Women are also unlikely to pursue treatment for a substance abuse disorder (Mondanaro, 1989). When women do seek help, it is usually from their primary care physicians rather than from a mental health specialist (Glied, 1997; Narrow, Regier, Rae, Manderscheid, & Locke, 1993). Primary care physicians typically provide pharmacological treatment for affective disorders. Therefore, for the interdisciplinary intervention needed to treat such mental disorders, it is important for clinical health psychologists to have a presence in primary care settings, either as a referral source for adjunctive psychotherapy or as part of a multidisciplinary treatment team in the primary care setting itself. Treatment outcomes are likely to be enhanced when the various treatment team members. Moreover, interdisciplinary treatment that incorporates a biopsychosocial approach can facilitate adherence to antidepressant medication protocols, improve satisfaction with care, and help offset medical costs (Katon, 1995). Although women commonly receive psychotropic medications, research has not investigated the interaction between such medications and a woman·s menstrual cycle even though menstrual cycle, pregnancy, and the postpartum period can in"uence the course of mood and anxiety disorders (Leibenluft, 1999). As a result, the American Medical Association (1991) notes that research on the use of antidepressants originally was conducted on men and cautions that antidepressants may work differently for women than men, citing the fact that effectiveness of some antidepressants can vary over the course of a woman·s menstrual cycle. It has also been noted that women experience more adverse side effects when taking antidepressants. Speci"cally, women are less likely to tolerate the side effects of weight gain or drowsiness and often stop treatment when these side effects occur (Kessler, 2000). Medical research should continue to investigate the interaction of psychotropic medications with the menstrual cycle, pregnancy, and lactation, as well as identify side effects speci"c to women so that such treatment barriers can be addressed. According to Smith Barney Research (1997), Health Care 523 ·Women make three-fourths of the health care decisions in American households and spend almost two of every three health care dollars. These statistics suggest that women continue to make a large proportion of health care decisions for their family as they have historically, especially regarding their children and elderly relatives (Of"ce of Women·s Health, 2000). Women typically visit their doctors on a regular basis and use preventive services twice as much as men, but, unfortunately, women spend more money out-of-pocket for needed medical care (Commonwealth Fund, 1994). Women usually have some type of insurance coverage; however, they are more likely to be covered by public insurance, speci"cally Medicaid (Clancy, 2000). Furthermore, women are substantially more likely than men to have minimal or no coverage because they represent the majority of part-time and service employees (Commonwealth Fund, 1994). As expected, women without health insurance go without needed medical care, especially vital preventive services including mammograms and Pap smears (Commonwealth Fund, 1994). Insurance also in"uences use of various health care services and treatment options. The lack of health care coverage also may help explain why many diseases go undetected in women. Relationships with Health Care Providers Women frequently receive services from more than one physician because reproductive services are traditionally isolated from other health services (Clancy, 2000). As a result, many women have dif"culty navigating the health care system to receive appropriate medical care. Studies indicate that the use of preventive care services is related to the age and sex of the physician, with younger physicians and female physicians more likely to provide preventive services (Clancy, 2000). More speci"cally, female physicians are more likely to provide Pap smears and recommend mammography to their patients than male physicians (Franks & Clancy, 1993; Lurie et al. In a study conducted by Lurie, Margolis, McGovern, Mink, and Slater (1997), physicians and patients were surveyed to see why higher rates of breast and cervical cancer screening occur among female physicians. The results indicated that higher rates of screening occur because women prefer female physicians and that female physicians are more concerned about prevention issues. Female physicians spent more time per visit with patients than male physicians and were more concerned about prevention issues. Furthermore, female physicians reported feeling more comfortable performing breast exams and Pap smears, as well as taking a sexual history from women. Studies have also revealed that male and female physicians communicate differently with patients. Roter, Lipkin, and Korsgaard (1991) analyzed 537 audiotapes of medical visits to evaluate gender differences in communication between physicians and patients.