Nicotinell

Mark van der Laan PhD

• Professor, Biostatistics and Statistics

https://publichealth.berkeley.edu/people/mark-van-der-laan/

Important gains in reducing is an important strategy for increasing the use of post the morbidity and mortality from unsafe abortions abortion contraception and helping women prevent have been made quit smoking 5 as buy nicotinell 35 mg overnight delivery, especially in Latin America and the subsequent unintended pregnancies (Tripney quit smoking 6 months pregnant discount nicotinell on line, Kwan quit smoking purchase cheapest nicotinell, Caribbean quit smoking recovery chart cheap 35 mg nicotinell, with the use of this strategy. Early iden appropriately tailoring the approach is critical (Banerjee tification and response can play an important role in Interventions to Improve Reproductive Health 107 secondary prevention by mitigating the consequences of recognize the signs and respond appropriately and safely. Women exposed to violence require comprehensive, Early identification and response can also contribute gender-sensitive health care services that address the to primary prevention by identifying and supporting physical and mental health consequences of their experi the children of women who suffer domestic violence. Women may also require cri Evidence suggests that early intervention is likely to sis intervention services to prevent further harm. Women also identify of the problem, raise awareness, and establish links in health care providers as the professionals they would the multisectoral response that is needed to address this most trust with the disclosure of abuse (Feder and serious health risk for women. A new focus on intimate partner violence and for sexual violence against adolescent sexual health has spurred interest in better women. They also review the evidence for service deliv ways to reach adolescents with effective messages and ery and training on these issues for health care providers services. New approaches to reducing gender-based and make evidence-based recommendations to improve violence have been tested and the lessons learned have the response of the health sector to violence against been distilled in clinical and policy guidelines. Data from multiple and Health Providers Experiences with Medical Abortion surveys and years. Priorities (third edition): Volume 7, Intentional Injury and ?Revisiting Community-Based Distribution Programs: Are Environmental Health, edited by C. Population Growth Perspectives on Sexual and Reproductive Health 37 (3): and Economic Development: Policy Questions. Cuidate?A Sexual Risk Reduction Program in Mexican Interventions to Improve Reproductive Health 113 Youth. Safe Abortion: Technical and Policy Guidance for and Uganda: Impact on Sexual and Reproductive Health Health Systems. However, ruptured during the third stage of labor before the placenta is uterus, a possible consequence of obstructed labor, delivered. In comparison with oxytocin, oral or sublingual to increase or decrease severe maternal morbidity or misoprostol was associated with an increased risk of mortality (Hofmeyr and others 2013). Additional research is needed allow easier assessment of the uterus and its contractil to further determine the relative effectiveness and the ity. The injectable uterotonic drugs of uterine massage before, after, or both before and oxytocin and ergometrine are both extremely effective after delivery of the placenta (Hofmeyr, Abdel-Aleem, in causing uterine contraction. However, if injectable uterotonics are not available atony?failure of the uterus to contract sufficiently?is or have been ineffective, misoprostol can be adminis recommended for all women. However, late cord clamping increased (Sengstaken-Blakemore or Foley?s), balloon catheters early hemoglobin concentrations and iron stores in (Bakri and Rusch), and condoms. Generalized seizures (eclampsia) occur in erally used when other treatments have failed. The evidence supporting these procedures is limited because Preventing Preeclampsia they are emergency, life-saving procedures. The B-Lynch the only interventions that have shown clear benefit technique has some advantages in that it is relatively in reducing preeclampsia risk in selected populations simple to perform, preserves fertility, and has good suc are low-dose aspirin (Duley and others 2007) and cess rates (89 percent to 100 percent) (Price and Lynch dietary supplementation with calcium (Hofmeyr and 2005). In addition, various forms of occlusive gels in 4,121 pregnant women, low-dose aspirin in women and foams are in development. The mainstays of treatment are versus expectant management depends on the severity antihypertensive drugs for blood pressure control and of disease and is influenced by the setting. Antihypertensive ther expectant management for women with severe preec apy in preeclampsia aims to reduce the risk of severe lampsia between 24 and 34 weeks gestation (Churchill hypertension and stroke, with a steady reduction in and others 2013); however, the expectant approach is blood pressure to safe levels, avoiding sudden drops that probably associated with less neonatal morbidity. Interest has increased in the development toin for the treatment of eclampsia (Duley, Henderson of a blood pressure monitor suitable for settings without Smart, and Chou 2010). In this study, However, limited evidence suggests that induction at normal levels of placental growth factor accurately more than 36 weeks of gestation reduces poor maternal predicted which women did not need delivery for preec outcomes in mild preeclampsia (Koopmans and others lampsia within two weeks. For earlier gestations, the decision for delivery available as a rapid bedside diagnostic tool, shows 120 Reproductive, Maternal, Newborn, and Child Health promise as an adjunct to clinical assessment of women on reducing maternal deaths and stillbirths. However, with preeclampsia, particularly for its apparent ability to there was insufficient evidence for robust conclusions distinguish women who require intensive surveillance to be drawn (van Lonkhuijzen, Stekelenburg, and van and delivery from those who can be managed expec Roosmalen 2012). Obstructed labor accounts for an estimated breech presentations at or beyond 36 weeks, but more 4 percent of maternal deaths (Lozano and others 2012), research is needed. Symphysiotomy is an operation the global burden of maternal deaths (Khan and others in which the fibers of the pubic symphysis are par 2006). A Cochrane review are widely acceptable practices for preventing hospital evaluated evidence for maneuvers to relieve shoul transmissible infections. However, the use the Odon device has been developed to assist vaginal of antibiotics among women with a third or fourth delivery. The Lancet Every Newborn Series term, and this practice should be avoided in its absence presents Lives Saved Tool modeling with estimates of lives (Wojcieszek, Stock, and Flenady 2014). Important interventions initiated in the antenatal or Vaginal application of antiseptics for cesarean delivery. The risk of such as family planning, for which there is good evidence postoperative endometritis was reduced by 61 percent, of a positive impact on perinatal health (Stenberg and but no clear difference was detected in postoperative others 2013). Subgroup analysis suggests that beneficial effects might be greater for women with ruptured membranes. Findings from the Kesho-Bora trial, in which early cant benefits compared with controls. Pregnant women with untreated syphilis ciated with a reduction in perinatal mortality (Alwan, have a 21 percent increased risk of stillbirths (Gomez Tuffnell, and West 2009). Limited evidence from two pregnant women considered to be at high risk of com before-and-after studies of community-based skilled plications secondary to placental insufficiency leads to a birth attendance shows a 23 percent significant reduc significant reduction in the risk of perinatal mortality, tion in the risk of stillbirth (Yakoob and others 2011). Although the partograph is widely used and accepted to detect abnormal labor, strong evidence to recommend its general use is lacking (Lavender, Hart, and Smyth Intrapartum Interventions 2013). This basic the use of electronic fetal heart rate monitoring during emergency care includes the following: labor reduces perinatal mortality. Continuous cardi the infant with shoulder dystocia, and skilled vaginal otocography halved the risk of neonatal seizures without delivery of the breech infant) significant reductions in cerebral palsy, infant mortality. Availability of parenteral antibiotics, parenteral oxy or other standard measures of neonatal well-being and tocin, and parenteral anticonvulsants for preeclamp was associated with an increased risk of assisted and sia or eclampsia operative delivery. This trial has important implications for shown to be very effective in preventing poor neona the setting, implementation, and scale up of this inter tal outcomes in well-resourced settings. Interventions to Reduce Maternal and Newborn Morbidity and Mortality 127 Antibiotics. However, evidence is insufficient to K administration in newborns for the prevention of determine the existence of neuroprotective benefits vitamin K deficiency bleeding and early phototherapy for infants of women with high-risk pregnancies at for jaundice. Infants who are exclusively breastfed for gests that substantially more infrastructure may be six months experience less gastrointestinal morbidity necessary, in addition to provider training and com (Kramer and Kakuma 2012), less respiratory morbidity, munity mobilization, to have a meaningful effect on and less infection-related neonatal mortality than par neonatal outcomes. Cooling reduced neonatal mortality Interventions in the Pipeline by 25 percent and the authors conclude that induced Household air pollution is recognized as a risk factor hypothermia should be performed in term and late pre for several health outcomes, including stillbirth, preterm term infants with moderate or severe hypoxic ischemic birth, and low birthweight, but rigorous evidence for encephalopathy if identified before age six hours (Jacobs the impact of reducing household air pollution on these and others 2013). However, most of these studies were birth outcomes is lacking (Bruce and others 2013). Routine anticonvulsant prophylaxis with barbiturates A habitual supine sleeping position has been asso for the neuroprotection of term infants with perina ciated with an increase in stillbirth (Owusu and others tal asphyxia is not recommended (Evans, Levene, and 2013). Institution of Increasing the coverage of interventions demon continuous positive airway pressure may bring down strated to be effective and cost-effective is essential, the requirement and cost of surfactant therapy (Rojas but reliable data remain limited (Mangham-Jefferies Reyes, Morley, and Soll 2012). In those instances, an Fottrell and others 2013), and safe motherhood initia alternative data source is noted. Do Women with Pre-Eclampsia, and Their Babies, Scaling-up of skilled care for pregnancy and child Benefit from Magnesium Sulphate? A Systematic Review of ?Interventionist versus Expectant Care for Severe Pre Ecologic Studies. Evidence regarding fever Disease Surveillance and Response Vaccines and incidence is variable, with country-specific reports from Biologicals 1997). This new strategy is being common themes across the available research: implemented in the public sector in most Sub-Saharan African countries (Bastiaens and others 2011). High proportion of fever etiologies due to viral is undoubtedly shifting; understanding the etiology of pathogens when appropriate viral diagnostic tests are nonmalarial fevers in each context is the logical next step available; studies without viral diagnostics reveal a to improve pediatric clinical outcomes of other treatable high proportion of undiagnosed febrile illnesses serious febrile illnesses, such as pneumonia, sepsis, bacte-. Given rampant and expanding antimicrobial drug resis tance globally, care must be taken to use antibiotics only Although the available evidence suggests that most when indicated and to develop careful guidelines when viral and some specific bacterial diseases, such as rick resources are limited. Present guidelines are based on ettsiosis and leptospirosis, are likely to be underdiag clinical features that are unfortunately poorly predictive nosed, data are either not available or are limited from of the diseases causing fever.

Radicular pain may occur alone quit smoking support groups discount nicotinell american express, in the absence of Clinical Features: the pain is lancinating in spinal pain quit smoking exhausted buy nicotinell master card, whereupon it should be classified as limb quality and travels along a narrow band quit smoking keep coughing generic nicotinell 52.5mg on line. Chronic inflammation of the nerve root complex and numbness and weakness quit smoking oils proven 52.5mg nicotinell, confirmed objectively by its meningeal investments. The former relates to objective Radiculopathy may occur in isolation or in association neurological signs due to conduction block. The Paresthesias in a dermatomal distribution can be two conditions may nonetheless coexist and may be caused by ischemia of a spinal nerve or its roots, and caused by the same lesion; or radiculopathy may follow may be regarded as a feature of incipient conduction radicular pain in the course of a disease process. However, radiculopathy and radicular pain are both Pathology: Any lesion that causes conduction block distinct from referred pain. There is no physiological or in axons of a spinal nerve or its roots either directly by clinical evidence that referred pain can be caused by the mechanical compression of the axons or indirectly by same processes that underlie radiculopathy. X1kC, Where spinal and radicular pain occur, the suffixes S while concomitant radicular pain in the arm would be and R are used, respectively. Thoracic Spinal or Radicular Pain Syndromes X-1 Thoracic Spinal or Radicular Pain Attributable to a Fracture S/C codes R only/in addition X-1. XlnR X-2 Thoracic Spinal or Radicular Pain Attributable to an Infection S/C codes R only/in addition X-2. X2bR X-3 Thoracic Spinal or Radicular Pain Attributable to a Neoplasm S/C codes R only/in addition X-3. X4dR * the asterisk is inserted in spinal and radicular codes where no letter is required in the sixth place. X51R X-5 Thoracic Spinal or Radicular Pain Attributable to Arthritis S/C codes R only/in addition X-5. X8*R X-6 Thoracic Spinal or Radicular Pain Associated with a Congenital S/C codes R only/in Vertebral Anomaly addition X-6(S)(R) Thoracic Spinal Pain Associated with a Congenital 323. X4 X-8 Thoracic Spinal Pain of Unknown or Uncertain Origin S/C codes R only/in addition X-8. X8iR Origin 23 X-9 Thoracic Discogenic Pain S codes only R only/in addition X-9(S) Thoracic Discogenic Pain Trauma 333. X7cS X-10 Thoracic Zygapophysial Joint Pain S/C codes R only/in addition X-10(S) Thoracic Zygapophysial Joint Pain Trauma 333. X7tS/C X-11 Costo-Transverse Joint Pain S codes only R only/in addition X-11(S) Costo-Transverse Joint Pain Trauma 333. X7eS X-12 Thoracic Muscle Sprain S codes only R only/in addition X-12(S) Thoracic Muscle Sprain Trauma 333. X7fS X-13 Thoracic Trigger Point Syndrome S codes only R only/in addition X-13(S) Thoracic Trigger Point Syndrome Trauma 332. X7hS X-14 Thoracic Muscle Spasm S codes only R only/in addition X-14(S) Thoracic Muscle Spasm Trauma 332. X8fS X-15 Thoracic Segmental Dysfunction S/C codes R only/in addition X-15(S)(R) Thoracic Segmental Dysfunction Trauma 333. X7dR X-16 Radicular Pain Attributable to a Prolapsed Thoracic Disk S/C codes R only/in addition X-16(R) Radicular Pain Attributable to a Prolapsed Thoracic Disk Trauma 303. The asterisk is inserted in spinal and radicular codes where no letter is required in the sixth place 24 E. Local Syndromes of the Upper Limbs and Relatively Generalized Syndromes of the Upper and Lower Limbs 1. Where spinal and radicular pain occur, the suffixes S and R are used, respectively. If a radicular pain occurs in an area with a different location it should be coded additionally. For example, pain due to a prolapsed disk causing both local spinal and local radicular pain in the neck would be coded 133. X8fS * the asterisk is inserted in spinal and radicular codes where no letter is required in the sixth place. Sacral Spinal or Radicular Pain Syndromes * Note: S codes include R codes unless specified as ?S only. X0*R * the asterisk is inserted in spinal and radicular codes where no letter is required in the sixth place. X9fS (See also 1-16) * the asterisk is inserted in spinal and radicular codes where no letter is required in the sixth place. Pain Definition especially occurs with small fiber damage (sensory fi Constant or intermittent burning, aching, or lancinating bers). Nerve biopsy may reveal the above, plus features limb pains due to generalized or focal diseases of pe of the specific disease process. Summary of Essential Features and Diagnostic Criteria Site Chronic distal burning or deep aching pain with signs of Usually distal (especially the feet) with burning pain, but sensory loss with or without muscle weakness, atrophy, often more proximal and deep with aching. X3a Arms: inflammatory or immune reactions Prevalence: common in neuropathies of diabetes, amy 203. X8a Legs: unknown or other of a single affected nerve (b) deep aching, especially X03. Distal burning and deep aching pains are often long Pain is not referred to the absent body part but is per lasting, and the disease processes are relatively unre ceived in the stump itself, usually in region of transected sponsive to therapy. Main Features Social and Physical Disabilities Sharp, often jabbing pain in stump, usually aggravated Decreased mobility. Pain often Page 40 elicited by tapping over neuroma in transected nerve or from person to person. Believed to be more com mon if loss of limb occurs later in life, in limbs than in Associated Symptoms breast amputation, in the breast before the menopause Refusal to utilize prosthesis. Phantom limb pain is almost always associated with Usual Course distorted image of lost part. Develops several weeks to months after amputation; persists indefinitely if untreated. Associated Symptoms Aggravated by stress, systemic disease, poor stump Relief health. Relief No therapeutic regimen has more than a 30% long-term Social and Physical Disabilities Severe pain can preclude normal daily activities; failure efficacy. Sympathectomy or sur gical procedures upon spinal cord and brain, including Pathology stimulation, are sometimes helpful. Social and Physical Disabilities Essential Features May preclude gainful employment or normal daily ac Pain in stump. Related to deafferentation of neurons and their sponta neous and evoked hyperexcitability. This title is being introduced to cover the painful syn dromes which formerly were described under the head Main Features ings of ?Reflex Sympathetic Dystrophy and Follows amputation, may commence at time of amputa ?Causalgia. Varies greatly in severity term ?reflex sympathetic dystrophy because not all the Page 41 cases seem to have sympathetically maintained pain, and System not all were dystrophic. The conditions usually follow Peripheral nervous system; possibly the central nervous injury which appears regionally and have a distal pre system. The pain is frequently described as burning and continuous and exacerbated by movement, In the previous edition of this classification, causalgia continuous stimulation, or stress. It is taken to be pain tions in hair growth, and loss of joint mobility may de that is maintained by sympathetic efferent innervation or velop. Affective symptoms or disorders occur sec for the pain but simply follows the common clinical ob ondary to the pain and disability. Guarding of the af servation that in certain cases sympatholytic interven fected part is usually observed. Measurements of skin blood flow may show an increase Complex Regional Pain Syn or a reduction. Testing of sudomotor function, both at rest and evoked, indicates side-to-side asymmetry. The drome, Type I (Reflex Sympathetic bone uptake phase of a three-phase bone scan may re Dystrophy) (1-4) veal a characteristic pattern of subcutaneous blood pool changes. It is associated at Relief some point with evidence of edema, changes in skin In cases with sympathetically maintained pain, sym blood flow, abnormal sudomotor activity in the region of patholytic interventions may provide temporary or the pain, or allodynia or hyperalgesia. Site Complications Usually the distal aspect of an affected extremity or with Phlebitis, inappropriate drug use, and suicide. Abnormalities in skin blood Inability to perform activities of daily living and occupa flow may develop including changes in skin temperature tional and recreational activities.

The studies include cross-sectional and lon survey items addressing sleep duration may have good face va gitudinal epidemiologic designs quit smoking 80524 zip code buy cheap nicotinell 35mg line, randomized controlled trials quit smoking 5 months ago and hot flashes generic nicotinell 17.5 mg with visa, lidity quit smoking 7 weeks ago discount 35 mg nicotinell overnight delivery, most have not been formally validated with psychomet meta-analyses quit smoking acupuncture discount nicotinell 52.5 mg on-line, and a range of other designs. Fourth, sleep duration is not consistently defned man performance category may have the strongest evidence across studies. For example, short sleep may be categorized base, which included experimental laboratory studies, objec as < 5, 5, 6, or < 8 hours, and reference groups may have sleep tive measure of sleep and outcomes, evidence of cumulative durations of 7, 8, 7?8, 7?9, or 6?8 hours. Fifth, measures of effects, and support from population-based cohort studies sleep duration do not capture information about the regularity documenting ?real life outcomes. The threshold was set at the lowest sleep on self-reported health outcomes, such as height and weight, duration the panel agreed was appropriate to support optimal diabetes, and hypertension which may provide an additional health in adults: 7 hours. Meeting our need for sleep poor approximations of real-world effects that typically re duration, timing, regularity, and quality requires volitional be fect accumulated sleep debt over weeks, months, or years. Similarly, the time course of habituation in the laboratory However, a large proportion of inter-individual variability in may not refect habituation effects outside of the laboratory, sleep is likely explained by psychological, behavioral, social, or the degree to which self-directed changes in sleep. Second, few ders, which are frequently undiagnosed and/or untreated, fur studies examined sleep duration in the range of 6 to < 7 hours. This likely refects the aims of experimental studies, which For reasons stated above, the consensus panel focused solely often maximize differences in outcomes by contrasting ex on the dimension of sleep duration, while recognizing the im treme sleep duration groups. The absence of experimental portance of other dimensions such as timing, regularity, and groups in the 6?7 hour sleep range creates uncertainty in quality. The recommendation statement55, which focuses on recommendations for the large portion of the population that the sleep amount that promotes optimal adult health, does not report sleep durations of 6?7 hours. Although our literature search tal studies lack generalizability because they include small excluded studies focusing primarily on one of these other di samples that do not represent the population in terms of age, mensions, we recognize that they may have contributed im sex, race/ethnicity, socioeconomic status, or health history. We also Fourth, while the focus on objective, physiological sleep is a excluded research assessing the physiological impact of total strength of laboratory studies, these objective measures cor sleep deprivation, since it can only be maintained for a few relate weakly with self-reported sleep duration, which is the days at a time and cannot refect habitual sleep, which was the method most relevant to clinical, public health, and policy focus of the panel. Standard methods to model such discrep When gauging the value and utility of the literature in ad ancies must be sought until accurate, scalable, objective mea dressing our question, the panel was keenly focused on the sures of sleep duration are developed for utilization in large nine tenets of causality typically referred to as the Bradford epidemiological studies. Hill criteria,115 which include: (1) strength of association, (2) consistency of fndings, (3) specifcity and (4) temporal se 5. Although empirical data were not In general, there was consensus that 6 hours of sleep or less available to address each of these criteria for each health out was inappropriate to support optimal health in adults. There come, they served as a framework for discussion, voting, and was also consensus that 7?9 hours of sleep were appropriate to recommendations. There was consensus that the the issue of biological plausibility is particularly salient to appropriateness of 9 or more hours of sleep on optimal adult the associations between long sleep, health, and mortality. Consensus panel struggled to identify plausible physiologic mechanisms could not be reached regarding the appropriateness of sleep by which longer sleep might cause poor health or increase durations in the 6?7 hour range, but the median vote indicated mortality. The recommendation statement indicates a thresh this duration was in the inappropriate range. This threshold implies that more sleep is likely sleep duration threshold versus a sleep duration range to pro not damaging to health. Implicit to a range recommendation is the tualization of sleep, inherent to a range recommendation, sug conclusion that sleep duration above a certain amount is detri gests health is compromised by obtaining too little or too much mental to health. Since the panel could not reach consensus tion between long sleep and adverse health outcomes in some that longer sleep was physiologically harmful, and since there categories, Round 3 voting revealed uncertainty regarding the was a consensus that longer sleep is benefcial for some indi appropriateness of > 9 hours of sleep for adult health. As more evidence is collected regard to come to a consensus regarding biologically plausible path ing long sleep, this recommendation may need to be revisited. Another important issue with regard to longer sleep dura tions is the dearth of studies assessing the physiological im Optimal Dose of Sleep Model pact of sleep extension. Evidence in most categories regarding Sleep Saturation Model the association between long sleep and poor health was mixed, 10. Lacking convincing experimen tal evidence showing that sleep extension alters human physi ology in unfavorable ways, and acknowledging that even the most carefully conducted epidemiological studies cannot con 1. In other words, it seems plausible that illness associated inactivity likely increased both subjective reports of sleep duration and mortality risk. The panel strongly Sleep Duration (hours) encourages future experimental studies to examine the effects Adapted with permission from Marshall et al. The green line represents an optimal dose of Our consensus recommendation statement presents sleep sleep where the odds of incident disease are lowest. The orange duration as static, as most epidemiological studies assessed line represents a sleep saturation model, where longer sleep is not sleep duration via a single question or measurement and ex necessarily associated with poor health, and may be benefcial in some perimental studies held sleep constant throughout the research circumstances. However, the panel understood this is not the most Journal of Clinical Sleep Medicine, Vol. Based on this process, fve many individuals have a variable sleep lifestyle, curtailing specifc areas for future research consideration are presented. This pattern can result in untoward circadian effects measures of sleep when possible, well-validated self-report or ?social jetlag,?116 where the body experiences circadian dis measures, and ecologically valid study designs. Epidemiologi ruption equivalent to taking a 2?3 hour ?fight westward on cal and longitudinal cohort studies would beneft from using Friday night (with later circadian bedtimes and wake times home polysomnography, actigraphy, or other novel objective than usual) only to ?fy back on Sunday night?waking ear methods to measure sleep duration. Ecological validity also sleep measurement are to measure sleep without disturbing it, touches upon the limitations of highly controlled, laboratory and to achieve this at reasonable cost. These studies are not able should include psychometrically-validated questions and mea to ascertain compensatory physiological effects that are likely sures. Thus, sleep duration in the real world is a health, such as timing, regularity, and quality, could lead to dynamic process; understanding this process requires research a more nuanced understanding of sleep-health relationships. In addition, more laboratory studies are needed that the panel faced many challenges in the process of generat systematically vary sleep opportunity in discrete steps be ing the consensus recommendation. Perhaps the biggest issue tween doses of 6 hours and 8 hours, using objective assess was the heterogeneity of sleep duration measurement. These rospective self-report, the most common method in epidemio studies should examine relevant time periods. However, sleep duration can vary substantially over covery effects within the ranges most often reported by people time,118?120 and there is little information on how individuals ac in the population. Other laboratory studies could systemati count for such variation in their reports. Also, self-report ques cally mimic the more typical lifestyle of cycling through doses tions may have captured time in bed rather than time asleep. Investigate downstream mechanisms linking habitual with chronic illness who spend long periods of time in bed. Investigating mecha is also uncertain, in some studies, whether individuals include nisms requires studies from epidemiologic and experimental nap time in their reports of total sleep time. Self-reported sleep perspectives, as well as research study designs that bridge duration often differs considerably from objective measures of these two approaches. For example, additional studies are sleep duration, and may underestimate or overestimate sleep needed that bring real-world short and long sleepers into the duration compared to these other methods. Intervention studies could also help to clarify whether sitivity (detecting sleep) than specifcity (detecting wake). Such studies could a result it often overestimates sleep duration relative to self help to address whether sleep plays a causal role in health and reports and to a lesser extent polysomnography, particularly in functioning, or whether it serves as a marker of other processes. Better delineate the upstream physiologic, behavioral, so measures brain activity. In addition, the roles numbers of individuals, in participants home environments, of race/ethnicity, socioeconomic factors, neighborhood, and and over multiple nights. Moving forward, the widespread other factors that may contribute to sleep and other adverse availability and acceptance of consumer sleep technologies outcomes require further study. Better understanding the ge may create opportunities for accurate, reliable, scalable ob netic, physiologic, and environmental factors that infuence jective sleep duration assessment in large epidemiological sleep duration can inform intervention strategies. Since we do not yet know whether habitual sleep duration can be modifed in the real 7. Intervention studies can determine whether tions between sleep duration and health, many critical ques increasing habitual sleep duration among insuffcient sleep tions remain open. The recommendations of the panel are ers or extending sleep in normal sleepers results in improved intended to be a frst step toward promoting adequate sleep outcomes, and how such changes can best be achieved. The studies would not only assess the effects of sleep extension panel achieved consensus based on the existing literature, but on human physiology, but also address the inconsistent epi noted many knowledge gaps that need to be addressed in order demiological data showing long sleep is associated with poor 941 Journal of Clinical Sleep Medicine, Vol. Sleep loss and performance in residents and nonphysicians: a help to understand how different health and functioning out meta-analytic examination. Extended work shifts and the risk of motor are more common than diagnosed sleep disorders to get proper vehicle crashes among interns.

To assist the Air Force in its continued efforts to combat sexual assault perpetration within its ranks quit smoking 90 days ago will thc show in hair purchase nicotinell no prescription, we conducted a review of the existing empirical literature on adult perpetrators who commit sexual assault against other adults quit smoking brochures buy nicotinell 35 mg with mastercard, with a particular focus on research published in 2000 or later quit smoking key chain purchase discount nicotinell line. Our literature search focused on the current state of scientific knowledge and was not limited to studies focusing on military populations quit smoking virginia discount nicotinell 17.5 mg free shipping. We uncovered a substantial amount of research devoted to understanding sexual assault perpetration, including the common characteristics of perpetrators who commit sexual assault, and behavioral patterns among this group of offenders. This report provides a summary of our findings from the review of this body of literature. Research is conducted in four programs: Force Modernization and Employment; Manpower, Personnel, and Training; Resource Management; and Strategy and Doctrine. One survey estimates that 19 percent of women and 2 percent of men in the United States have been sexually assaulted at some point in their lifetime. Similarly, within the armed forces, 23 percent of women and 4 percent of men service members report having been sexually assaulted during their military service. Air Force in its continued efforts to prevent sexual assault by its service members, we reviewed existing literature on the characteristics and behaviors of adults who commit sexual assault (ranging from coercion to aggression to behaviors meeting the legal definition of rape) against other adults (including that by strangers, acquaintances, and groups of 1 perpetrators). Second, we highlight important findings within the literature that could guide ongoing and future sexual assault prevention and training efforts within the Air Force. Third, we discuss whether any sexual assault perpetrator screening tools exist that the Air Force could incorporate in recruitment screening of airmen. We found that most research focuses on solitary men who perpetrate assault against women (which we refer to as male-female sexual assault). Nevertheless, we also searched specifically for relevant literature on female sexual assault perpetrators, men who commit sexual assault against other men, and individuals who participate in group sexual assault. Characteristics of Male Perpetrators Who Sexually Assault Female Victims the most commonly studied contributors to perpetration of sexual assault can be grouped into those related to experience of child abuse, previous sexual behavior, interpersonal-skill deficits, gender-related attitudes, perceptions of peer behavior, and substance abuse. We discuss each of these below, as well as efforts to assess their effects in confluence. Child Abuse Child abuse includes sexual, physical, and emotional abuse, as well as exposure to violence within the home. While some research indicates a relationship between childhood sexual abuse 1 We considered behaviors ranging from sexual coercion. We also considered the range of possible relationships between perpetrators and victims, including strangers, acquaintances, intimate partners/spouses, and groups of perpetrators who commit sexual assault against strangers or known victims. The link between sexual assault perpetration and childhood physical abuse or exposure to family violence appears to be more established. Sexual Behavior Several surveys have found a correlation between self-reported perpetration of sexual violence and number of sexual partners or early initiation of sex. Studies have also identified a significant link between sexual assault perpetration and impersonal attitudes toward sex, defined as practices and beliefs that sex outside a relationship is acceptable. Finally, both cross-sectional surveys and longitudinal surveys following individuals over time have consistently found a history of sexual assault perpetration to be associated with or predictive of additional sexual assault perpetration. Interpersonal Skills Several studies have examined whether sexual assault perpetrators display deficits in their interpersonal skills. Some research indicates that sexual assault perpetrators may have insecure attachment styles and lower empathy toward sexual assault victims, as well as misinterpret sexual cues, but overall, research is mixed. Several studies have failed to find an effect of social skill deficits on adult sexual assault perpetration. More research is needed to clarify the effects of interpersonal-skills deficits and what else may exacerbate difficulties in interpersonal skills. Perceptions of Peer Attitudes and Behavior Several studies have found that individuals who perceive their peers as approving of sexual assault are more likely to commit sexual assault. A smaller number of studies have also identified a link between sexual assault perpetration and perceptions of peer pressure to engage in sexual activity. Substance Use Previous research estimates that in about half of sexual assaults, the victim, the perpetrator, or both consumed alcohol prior to the assault. Research on the association between alcohol use and x sexual assault seems to indicate that alcohol consumption can play a role in sexual assault perpetration. Some studies indicate that alcohol consumption increases misperceptions of female sexual interest. Research on the association between drug use and sexual assault perpetration is sparse, and more is needed to fully understand the influence of drug use on sexual assault perpetration. It considers developmental, attitudinal, and environmental factors and describes two different pathways to sexual aggression: the hostile-masculinity pathway and the impersonal-sex pathway. The Confluence Model of Sexual Aggression Parental Child violence abuse Sexual Delinquency promiscuity Sexual aggression Attitudes Hostile supporting masculinity violence In the hostile-masculinity pathway, the development of negative attitudes and opinions about8 women leads to sexual aggression. In the sexual-promiscuity pathway, early and increased sexual experiences lead to sexual aggression. While each pathway may independently predict sexual aggression, the Confluence Model also asserts that the pathways can interact to predict sexual aggression. According to the model, individuals who have both high levels of hostile masculinity and high levels of approval for impersonal sex should be most likely to display sexual aggression. The Confluence Model has been tested several times with different populations and has been found to explain about 30 percent of the frequency and severity of sexual aggression xi (Hall et al. Additional research has suggested correlates and precursors to sexual aggression (which includes both legal and illegal behavior), but none is an accurate way to predict who will perpetrate sexual assault at any particular time. Researchers are continuing to work to better explain the etiology of sexual assault perpetration. Behaviors of Male Perpetrators Who Sexually Assault Female Victims: the Cycle of Sexual Offending A recent review of the behavior of sexual assault perpetrators contends they engage in a cycle of offending that consists of three stages: (1) planning on a conscious or unconscious level prior to the offense, (2) committing the offense, and (3) forming thoughts after the offense allowing the individual to commit sexual assault again in the future. Although some perpetrators of sexual assault make a series of deliberate decisions about how, when, and where to hunt, target, and subdue a victim, most make a series of seemingly irrelevant decisions that eventually lead to the commission of a sexual assault. For example, a perpetrator may feel lonely or angry and begin drinking to cope with these negative feelings, then go to a bar or club where there are a number of highly intoxicated women, presenting the opportunity to commit sexual assault. Other research has found that perpetrators behavior during the assault can be very different depending on whether they are strangers or acquaintances of the victim. Following the assault, sexual assault perpetrators commonly display cognitive distortions, or thought processes, that provide justification or excuses for their behavior. Female Sexual Assault Perpetrators, Male-on-Male Sexual Assault Perpetrators, and Multiple-Perpetrator Sexual Assault Research on female sexual assault perpetrators is still emerging, with many fewer studies than on male perpetrators who assault female victims. Most existing research has focused on the characteristics and behaviors of female offenders who commit assaults against children or adolescents. There is little consensus on the characteristics or behaviors of female sexual assault perpetrators. Similarly, until recently there has been little recognition of sexual assault perpetrated by adult men against other adult men. Relatively few studies have examined the issue, and much of the early research on male-male sexual assault simply described the incidents, rather than comparing perpetrators of such acts with a control group. Studies have generally identified two different types of perpetrators based on their motivations for committing the sexual assault. These are homosexual men who assault other homosexual men primarily for intimacy or sexual gratification, and heterosexual men who assault other men as an expression of social dominance xii or control. Overall, however, we know very little about the characteristics of these perpetrators, on whom more research is needed. Finally, multiple-perpetrator sexual assault is that committed by more than one individual. Research does indicate that multiple perpetrator sexual assault offenders tend to be strangers or casual acquaintances of the victim rather than intimate partners. Theory and research generally suggest that a leader, or one offender, directs the actions of another or others during these assaults. Research also suggests that young men in hypermasculine, limited-oversight contexts who have mental health issues or who are under the influence of substances may be more likely to engage in multiple-perpetrator sexual assault. Conclusions and Implications for Prevention Efforts While there is much more to learn about sexual assault perpetrators, several overarching themes emerge from this body of research that are relevant to the Air Force as it structures sexual assault prevention efforts. Sexual Assault Perpetrators Are a Very Heterogeneous Group Implication: To ensure that airmen as well as Air Force leaders are aware of the full range of possible perpetrator types, sexual assault prevention training should ensure that scenarios illustrate the heterogeneity of sexual assault perpetrators and include descriptions of the various known motivations, types, and offending patterns among perpetrators.

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