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Two studies found that men who had been athletically active in college had significantly increased risks of later developing prostate cancer (Polednak 1976; Paffenbarger cholesterol risk ratio discount 20mg atorlip-20 mastercard, Hyde cholesterol levels life insurance buy 20mg atorlip-20 amex, Wing 1987) cholesterol lowering fast foods generic atorlip-20 20 mg visa. One study found no overall association between physical activity and prostate cancer risk but found a higher risk (although not statistically significant) of more aggressive prostate cancer (West et al cholesterol control order 20mg atorlip-20 overnight delivery. The two studies of the association of cardiorespiratory fitness with prostate cancer incidence were also inconsistent. Severson and colleagues (1989) found no association between resting pulse rate and subsequent risk of prostate cancer. Oliveria and colleagues (1996) found a strong inverse dose-response relationship between fitness assessed by time on a treadmill and subsequent risk of prostate cancer. Thus the body of research conducted to date shows no consistent relationship between prostate cancer and physical activity. Biologic Plausibility Because the data presented in this section demonstrate a clear association only between physical activity and colon cancer, the biologic plausibility of this relationship is the focus of this section. The alteration of local prostaglandin synthesis may serve as a mechanism through which physical activity may confer protection against colon cancer (Shephard et al. Strenuous physical activity increases prostaglandin F2 alpha, which strongly increases intestinal motility, and may suppress prostaglandin E2, which reduces intestinal motility and, released in greater quantities by colon tumor cells than normal cells, accelerates the rate of colon cell proliferation (Thor et al. It has been hypothesized that physical activity decreases gastrointestinal transit time, which in turn decreases the length of contact between the colon mucosa and potential carcinogens, cocarcinogens, or promoters contained in the fecal stream (Shephard 1993; Lee 1994). This hypothesis could partly explain why physical activity has been associated with reduced cancer risk in the colon but not in the rectum. Physical activity may shorten transit time within segments of the colon without affecting transit time in the rectum. Further, the rectum is only intermittently filled with fecal material before evacuation. Despite these hypothetical mechanisms, studies on the effects of physical activity on gastrointestinal transit time in humans have yielded inconsistent results (Shephard 1993; Lee 1994). Testicular Cancer Two studies investigated physical activity and risk of developing testicular cancer; again, results are inconsistent. A case-control study in England found that men who spent at least 15 hours per week in recreational physical activity had approximately half the risk of sedentary men, and a significant trend was reported over six categories of total time spent exercising (United Kingdom Testicular Cancer Study Group 1994). It showed no association between leisure-time physical activity and risk of testicular cancer, but heavy manual occupational activity was associated with an approximately twofold increase in risk, although this result was not statistically significant. Thus no meaningful conclusions about a relationship between physical activity and testicular cancer can be drawn. Conclusions the relative consistency of findings in epidemiologic studies indicates that physical activity is associated with a reduced risk of colon cancer, and biologically plausible mechanisms underlying this association have been described. The data consistently show no association between physical activity and rectal cancer. Data regarding a relationship between physical activity and breast, endometrial, ovarian, prostate, and testicular cancers are too limited or too inconsistent to support any firm conclusions. The suggestion that physical activity in adolescence and early adulthood may protect against later development of breast cancer clearly deserves further study. Other Site-Specific Cancers Few epidemiologic studies have examined the association of physical activity with other site-specific cancers (Lee 1994). The totality of evidence provides little basis for a suggestion of a relationship. This figure, however, underestimates the actual death toll: in 1993, more than twice this number of deaths occurred among persons for whom diabetes was listed as a secondary diagnosis on the death certificate. Diabetes accounts for at least 10 percent of all acute hospital days and in 1992 accounted for an estimated $92 billion in direct and indirect medical costs (Rubin et al. Diabetes is a heterogeneous group of metabolic disorders that have in common elevated blood glucose and associated metabolic derangements.

Our daughter is now able to live independently cholesterol lowering diet plan menu order atorlip-20 once a day, owns her own home cholesterol levels venison purchase cheapest atorlip-20 and atorlip-20, has a good job cholesterol medication names uk atorlip-20 20mg lowest price, and is a taxpaying contributor to our state cholesterol lab values chart atorlip-20 20mg fast delivery. Without quality treatment, her positive outcome would not have happened, and our family would have incurred much greater health care costs over time, with the very real possibility of repeated crises and hospitalizations. It is inconceivable to expect success by replacing the flawed Tenncare program with one that would provide less oversight and incentivize the state to pursue further cuts resulting in increased revenue for the state. We are concerned that the block grant would adversely affect the medical care that our adult daughter is receiving. With regular care from her psychiatrist and effective medications, she has been able to hold the same job for 25 years. Reject it, Beverly 15 Jonathan Reeve From: Sent: To: Subject: Kay Kress <ekaykress@gmail. It is a very bad idea as it will ultimately compromise health care for the indigent and poor. We should have never turned down money for the Medicaid expansion and this will make matters worse. Peter Donofrio Kathleen Donofrio 1708 Linden Avenue Nashville, Tn 37212 18 Jonathan Reeve From: Sent: To: Subject: rorlowske@everyactioncustom. Cancer treatments: this is very personal to me because I have had colon cancer and was treated at Vanderbilt Univ Oncology dept, with an excellent staff. Your responsibility/our responsibility is to take care of our people, especially the most vulnerable. Denise Ondrejcak Sent from my iPhone 22 Jonathan Reeve From: Sent: To: Subject: jeanne40@everyactioncustom. This proposal will do nothing to correct or improve the horrific healthcare record that has been the history of TennCare. With little or no oversight, why should anyone turn over billions of dollars over to a state that expelled 200,000 children from the TennCare rolls and is already at or near the bottom of every healthcare measure This will do nothing to alleviate the healthcare crisis in rural areas where 13 hospitals have already closed and another 20 are in danger of closing due to the lack of health insurance of our citizens and the economic distress of so many of our counties. And why would any company move into those communities when there are no hospitals to service their employees Why would any more retirees move to our beautiful state when they cannot reach a hospital within a reasonable amount of time The Republican refusal to expand Medicaid is a direct cause of our rural hospital crisis. Why would you allow our healthcare infrastructure, which is key to attracting economic development and new residents, to decay to the point where we have life threatening healthcare deserts We have turned away billions of dollars that would have gone to improve healthcare in our state and keep hospitals open and jobs in our communities. We have counties where the only healthcare available is the back of an ambulance which can take up to an hour to arrive and another hour to get to a hospital. There is no wonder that the only people who want this proposed block grant scheme are Bill Lee and the boneheaded "leadership" in the state legislature who refused Medicaid expansion based on pure racism. Step up to the job of taking care of our citizens and our healthcare infrastructure. Refusal to expand Medicaid is simply adding to the economic distress of our rural communities. I am a retired hospital pharmacist with more than 34 years in health care, and I have been active in the Chattanooga community in assisting the underserved. As you know, the Tennessee population is one of the sickest in the country, with estimates that approximately 675,000 have no health insurance. There is considerable evidence that residents of states that have expanded Medicaid have improved health care. I would like state efforts to be focused on improving the health care of Tennessee residents, and I believe Amendment 42 would have detrimental effects on our most vulnerable population. However, any savings would have to come at the expense of decreasing enrollees, cutting services, or cutting reimbursement to providers. The amendment states that there are operational efficiencies that can be improved. Using 2016, 2017 and 2018 average member months will underestimate the eligible individuals.

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Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care: a review of treatment options and their applicability in the civilian trauma setting crestor cholesterol medication side effects cheap atorlip-20 online visa. A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma cholesterol i shrimp purchase 20 mg atorlip-20 visa. A systematic review of the use of tourniquets and topical haemostatic agents in conflicts in Afghantistan and Iraq cholesterol levels in cheese purchase atorlip-20 overnight. Advanced hemostatic dressings are not superior to gauze for care under fire scenarios cholesterol vegetable oil buy generic atorlip-20 20 mg online. Revision Date September 8, 2017 205 Facial/Dental Trauma Aliases None noted Patient Care Goals 1. Preservation of dentition Patient Presentation Inclusion Criteria Isolated facial injury, including trauma to the eyes, nose, ears, midface, mandible, dentition Exclusion Criteria 1. Stable dentition (poorly anchored teeth require vigilance for possible aspiration) 3. Mental status assessment for possible traumatic brain injury [see Head Injury guideline] 6. Specific re-examination geared toward airway and ability to ventilate adequately Treatment and Interventions 1. Alternatively, an alert and cooperative patient can hold tooth in mouth using own saliva as storage medium 5. Expect patient cannot spit/swallow effectively and have suction readily available b. Preferentially transport sitting up with emesis basin/suction available (in the absence of a suspected spinal injury, see Spinal Care guideline) 7. Epistaxis - squeeze nose (or have patient do so) for 10-15 minutes continuously 8. Transport with tissue wrapped in dry sterile gauze in a plastic bag placed on ice c. Severe ear and nose lacerations can be addressed with a protective moist sterile dressing Patient Safety Considerations 1. Maintenance of a patent airway is the highest priority; therefore, conduct cervical spine assessment for field clearance (per Spinal Care guideline) to enable transport sitting up for difficulty with bleeding, swallowing, or handling secretions Notes/Educational Pearls Key Considerations 1. After nasal fractures, epistaxis may be posterior and may not respond to direct pressure over the nares with bleeding running down posterior pharynx, potentially compromising airway 3. Avulsed teeth may be successfully re-implanted if done so in a very short period after injury b. Frequency that weight or length-based estimate are documented in kilograms o Trauma-01: Pain assessment of injured patients. Revision Date September 8, 2017 208 Head Injury Aliases None noted Patient Care Goals 1. Administer oxygen as appropriate with a target of achieving 94-98% saturation 209 2. If patient unable to maintain airway, consider oral airway (nasal airway should not be used with significant facial injury or possible basilar skull fracture) c. Assume concomitant cervical spine injury in patients with moderate/severe head injury 3. Geriatric Consideration: Elderly patients with ankylosing spondylitis or severe kyphosis should be padded and immobilized in a position of comfort and may not tolerate a cervical collar Notes/Educational Pearls Key Considerations 1. If endotracheal intubation or invasive airways are used, continuous waveform capnography is required to document proper tube placement and assure proper ventilation rate 4. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain o Trauma-04: Trauma patients transported to trauma center. Prognostic factors in civilian gunshot wounds to the head: a series of 110 surgical patients and brief literature review. Influence of prehospital treatment on the outcome of patients with severe blunt traumatic brain injury: a single-centre study. The relationship between out-of-hospital airway management and outcome among trauma patients with Glasgow Coma Scale scores of 8 or less.

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Revision Date September 8 cholesterol without fasting buy atorlip-20 online pills, 2017 297 Hypothermia/Cold Exposure Aliases Hypothermia cholesterol test monitoring system generic 20 mg atorlip-20 overnight delivery, frost bite cholesterol levels uk vs europe discount atorlip-20 online american express, cold induced injuries Patient Care Goals 1 vap cholesterol test quest 20 mg atorlip-20 with amex. Maintain hemodynamic stability Prevent further heat loss Rewarm the patient in a safe manner Appropriate management of hypothermia induced cardiac arrest Prevent loss of limbs Patient Presentation 1. Patients may suffer from hypothermia due to exposure to a cold environment (increased heat loss) or may suffer from a primary illness or injury that, in combination with cold exposure (heat loss in combination with decreased heat production), leads to hypothermia 2. Patients may suffer systemic effects from cold (hypothermia) or localized effects. Patients with mild hypothermia will have normal mental status, shivering, and may have normal vital signs while patients with moderate to severe hypothermia will manifest mental status changes, eventual loss of shivering and progressive bradycardia, hypotension, and decreased respiratory status 4. Patients with frostbite will develop numbness involving the affected body part along with a "clumsy" feeling along with areas of blanched skin - later findings include a "woody" sensation, decreased or loss of sensation, bruising or blister formation, or a white and waxy appearance to affected tissue Inclusion Criteria Patients suffering systemic or localized cold injuries. Patients with cold exposure but no symptoms referable to hypothermia or frostbite Patient Management Assessment 1. Patient assessment should begin with attention to the primary survey, looking for evidence of circulatory collapse and ensuring effective respirations a. The patient suffering from moderate or severe hypothermia may have severe alterations in vital signs including weak and extremely slow pulses, profound hypotension and decreased respirations b. The rescuer may need to evaluate the hypothermic patient for longer than the normothermic patient (up to 60 seconds) 298 3. Mild: vital signs not depressed normal mental status, shivering is preserved; body maintains ability to control temperature b. Maintain patient and rescuer safety - the patient has fallen victim to cold injury and rescuers have likely had to enter the same environment. Remove the patient from the environment and prevent further heat loss by removing wet clothes and drying skin, insulate from the ground, shelter the patient from wind and wet conditions, and insulate the patient with dry clothing or a hypothermia wrap/ blanket. Cover the patient with a vapor barrier and, if available, move the patient to a warm environment b. Hypothermic patients have decreased oxygen needs and may not require supplemental oxygen i. Provide beverages or foods containing glucose if feasible and patient is awake and able to manage airway independently d. Vigorous shivering can substantially increase heat production - shivering should be fueled by caloric replacement. Bair Hugger) can be an effective field rewarming method if available 299 Monitor frequently - if temperature or level of consciousness decreases, refer to Severe Hypothermia, below g. The recommended fluid for volume replacement in the hypothermic patient is normal saline h. If esophageal temperature monitoring is not available or appropriate, use an epitympanic thermometer designed for field conditions with an isolating ear cap iii. Rectal temperatures may also be used, but only once the patient is in a warm environment - rectal temperatures are not reliable or suitable for taking temperatures in the field and should only be done in a warm environment (such as a heated ambulance) b. Care must be taken not to hyperventilate the patient as hypocarbia may reduce the threshold for ventricular fibrillation in the cold patient ii. Indications and contraindications for advanced airway devices are similar in the hypothermic patient as in the normothermic patient c. Prevent further heat loss by removing the patient from the environment and removing wet clothes and drying skin, insulate from the ground, shelter the patient from wind and wet conditions, and insulate the patient with dry clothing or a hypothermia wrap/ blanket. Cover the patient with a vapor barrier and, if available, move the patient to a warm environment d. Chemical or electrical heat sources should never be applied directly to the skin ii. Attempt to keep the patient in the horizontal position, especially limiting motion of the extremities to avoid increasing return of cold blood to the heart ii. Once in a warm environment, clothing should be cut off (rather than removed by manipulating the extremities) f. Move the patient only when necessary such as to remove the patient from the elements f. If alterations in mental status, consider measuring blood glucose and treat as indicated (treat per Hypoglycemia or Hyperglycemia guidelines) and assess for other causes of alterations of mentation i.

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The possible cutback or elimination of many elements of Medicaid cholesterol unit conversion discount atorlip-20 20mg without prescription, such as physical therapy cholesterol conversion atorlip-20 20 mg otc, hospice cholesterol in small eggs cheap atorlip-20 20mg visa, transplant coverage baba ramdev cholesterol yoga 20mg atorlip-20 otc, and prescription drugs. The waiver proposal is a profit incentive for the state to reduce care for the sickest and most vulnerable, children, women, and the disabled, who can ill afford it. Please do not go forward with this harmful waiver that would politicize the Federal Medicaid program. She needs assistance for the very most basic needs including feeding, breathing, and bathing. I know from personal experience both as a former state lawyer and as an advocate for TennCare/Medicaid program enrollees, that the State of Tennessee and its officials cannot be trusted to do what is right to protect the vulnerable population TennCare is designed to serve, while maintaining program integrity. If anything, Tennessee needs greater federal oversight rather than less oversight and more of what the State euphemistically calls "flexibility. The financially and medically disadvantaged citizens of Tennessee need and deserve the protections in the Medicaid statutes and regulations. I urge you to maintain these protections by rejecting the Tennessee block grant proposal. This state needs to expand Medicaid to provide insurance for over 600,000 uninsured Tennesseans. Years of not expanding Medicaid has been a disgrace to and disregard for fellow Tennesseans who deserve more from their state. Those blocking this expansion should be ashamed and those trying to plug the dike with a bandaid will live to regret this poorly devised plan. A Concerned Citizen 23 Jonathan Reeve From: Sent: To: Subject: Crystal Colter <crystal. Block grants are rife with opportunities for misuse, as the grantees may or may not ever actually deliver medical services they could be startups that fail, and the $ is gone. We have seen this happen in other arenas child welfare, for example, where facilities closed without serving a single child. The only way to guarantee medical services is to cover individuals and let them choose a provider and obtain medical care. Sent from my iPhone 25 Jonathan Reeve From: Sent: To: Subject: David Twiggs <dtwiggs2@icloud. Nor will it adequately cover the costs of Tennessee hospitals and/or nursing homes. As an autistic adult, it is most likely that what is being proposed would virtually eliminate needed services, and it would have a devastating effect, on my health and wellbeing. The proposal does nothing to address the real healthcare crises in our state such as rural hospital closures and the Medicaid coverage gap. The program ensures these individuals have access to coverage for health and financial security, and supports the health care infrastructure we all depend on. This block grant proposal would cause immense harm and jeopardize coverage for these vulnerable Tennesseans. This proposal goes against the objectives of Medicaid because it gives Tennessee new authority to cut services. The state should not be allowed to make changes to the Medicaid program without federal oversight or eliminate federal standards which are in place for the protection of patients. I work with clients who need high levels of care, and the provisions in the proposal about reducing the amount of services someone can receive is highly concerning. Under this proposal, people who need the most services are the ones who will bear the brunt of any reductions. As someone who works with the elderly on a daily basis, assisting them in applying for Tennessee Medicaid, I cannot emphasize enough how badly Tennessee Medicaid is needed to cover our most vulnerable citizens. This would allow more people access to medical treatment and medications, saving cost for more extensive treatment in the future.

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