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By: P. Dawson, M.A.S., M.D.

Vice Chair, State University of New York Downstate Medical Center College of Medicine

Settlements whose economic bases are related to such sectors as agriculture symptoms 2015 flu buy 35mg residronate mastercard, forestry symptoms diabetes type 2 purchase residronate on line amex, tourism treatment example order residronate 35mg without a prescription, water availability, or other climate-related activities could be affected either positively or negatively by climate change, depending partly on the adaptability of those sectors. Related to a range of possible climate change effects ͠higher costs for space cooling in warmer areas, higher costs of water availability in drier areas, more or less exposure to storm impacts in some areas, and sea level rise ͠regions of the United States and their associated settlements are likely to see gradual changes over the long term in their relative attractiveness for a variety of human activities. One example, although its likelihood is highly uncertain, would be a gradual migration of the "Sun Belt" northward, as retirees and businesses attracted by environmental amenities find that regions less exposed to very high temperatures and seasonal major storms are more attractive as places to locate. Changes in regional comparative advantage related to shifts in energy resource use. If climate mitigation policies result in shifts from coal and other fossil resources toward non-fossil energy sources, or if climate changes affect the prospects of renewable energy sources (especially hydropower), regional economies related to the production and/or use of energy from these sources could be affected, along with regional economies more closely linked with alternatives. Resource requirements for urban areas involve larger areas than their own bounded territories alone. Ecologists have sought to estimate the land area required to supply the consumption of resources and compensate for emissions and other wastes from urban areas. By possibly affecting settlements, along with their resource capacities for their inputs and destinations of their outputs, climate change could affect the nature, size, and geographic distribution of these footprints. Human settlements are foci for many economic, social, and governmental processes, and historical experience has shown that catastrophes in cities can have significant economic, financial, and political effects much more broadly. The case which has received the most attention to date is insurance and finance (Wilbanks, et al. Warmer temperatures in periods of the year that are normally cold are not necessarily undesirable. They expand opportunities for warmer-weather recreational opportunities over larger parts of the year, and they expand growing seasons for crops, parks, and gardens. One of the most positive aspects of climate change can be that its capacity to stimulate a broader discussion of what sustainability means for settlements (Wilbanks, 2003; Ruth, 2006). Even if climate change itself may not be the most serious threat to sustainability, considering climate change impacts in a multi-change, multi-stage context can encourage and facilitate processes that lead to progress in dealing with other sources of stress as well. Improved competitiveness compared with settlements subject to more serious adverse impacts. While some settlements may turn out to be "losers" due to climate change impacts, others may be "winners," as changes in temperature or precipitation result in added economic opportunities (see the following section), at least if climate change is not severe. Ideally, these regional projections are at a relatively detailed scale, and ideally they consider seasonal as well as annual changes and changes in extremes as well as in averages; but these conditions cannot always be met. The most comprehensive assessments of possible climate change impacts on settlements in the United States have been two studies of major metropolitan areas: 1. New York: this assessment concluded that impacts of climate change on this metropolitan area are likely to be primarily negative over the long term, with potentially significant costs increasing as the magnitude of climate change increases, although there are substantial uncertainties. Boston: this assessment concluded that long-term impacts of climate change are likely to depend at least as much on behavioral and policy changes over this period as on temperature and other climate changes (Kirshen et al. Internationally, studies have included several major metropolitan areas, such as London (London Climate Change Partnership, 2004) and Mexico City (Molina et al. A relevant historical study of effects of an urban heat wave in the United States is reported by Klinenberg (2003). Adaptation can rely mainly on anticipatory actions to avoid damages and costs, such as "hardening" coastal structures to sea-level rise; or adaptation can rely mainly on response potentials, such as emergency preparedness; or it can include a mix of the two approaches. Research to date suggests that anticipatory adaptation may be more cost-effective than reactive adaptation (Kirshen et al. As just one example, the New York climate impact assessment (Rosenzweig and Solecki, 2001a) projects significant increases in heat-related deaths based on historical relationships between heat stress and mortality, unchanged by adaptation. Climate change is different as an issue because it is relatively long-term in its implications, future impacts are uncertain, and public awareness is growing from a relatively low level to a higher level of concern. Because climate change is different in these ways, it is seldom attractive to consider allocating massive amounts of funding or management attention to current climate change actions. What generally makes more sense is to consider ways that actions which reduce vulnerabilities to climate change impacts (or increase prospects for realizing benefits from climate change impacts) are also desirable for other reasons as well: often referred to as "co-benefits. Cities and towns have used both "hard" approaches such as developing infrastructure and "soft" approaches such as regulations to address impacts of climate variability. Examples include water supply and waste water systems, drainage networks, buildings, transportation systems, land use and zoning controls, water quality standards and emission caps, and tax incentives.

Because these processes have been shown to result in effective adaptation symptoms 10 days before period 35 mg residronate sale, they may be of particular interest to marketers and consumer researchers symptoms multiple myeloma buy 35mg residronate otc. A final area of opportunity in the situational research domain pertains to the nexus between role medications not to crush order residronate amex, identity, and coping behaviors. The coping literature demonstrating situational differences as a function of life roles suggests that this may be an important moderating factor in determining coping responses. Key differences in appraisal and coping emerge as consumers shift across roles as "parents," "spouses," or "employees. The salience of a specific social identity may implicate various aspects of appraisal, such as the degree to which consumers feel in control of a situation as well as the degree of efficacy they perceive over the stress situation. Research has shown that when a salient identity is threatened, coping options are similarly influenced by the nature of the identity (Matheson & Cole, 2004). Research is needed to examine how these identity effects alter consumer behavior, such as the degree to engage in problem and emotion-focused coping behaviors. These identity-based appraisal differences should be investigated in terms of the transactional coping model. In this section, seven strategies for producing new coping related insights are articulated. The list, presented in random order, outlines broad prescriptions for building theory related to several promising avenues: 1. The consumer coping literature has focused predominantly on the immediate and short-term psychological consequences of stress. Little is known about how appraisal and coping differences impact other important areas of consumer behavior. One possibility is that individual consumer differences in coping styles extend beyond the transactional framework. Such research would further cement the import of coping research to consumer theory. Because the consumer literature has emphasized context-dependent models of coping, relatively less is known about how stable coping styles impact long-term consumer well-being. These long-term effects may reveal dispositional differences in how consumers interact with firms, adjust to market-related stressors as well as their degree of loyalty to specific firms. Although there is significant benefit in examining coping within circumscribed contextual boundaries, as important is the ability to see how coping styles operate across contexts. The impact of positive emotions within the transactional framework has been largely ignored by both consumer coping researchers and by coping researchers in psychology. Positive emotions are often experienced coincident with negative emotions (Folkman & Moskowitz, 2004), and these phenomena merit further scholarly attention. It is possible that the presence of positive emotions moderates many of the observed relationships within the transactional framework. The coping literature has experienced significant debate regarding the structure of coping. This polemic bears similarity to ontological debates waged by emotions and personality researchers in recent years. This discourse has shed light on the possibility that several competing structural views of coping are possible. In consumer behavior, research to date has not moved beyond the problem-focused/emotion-focused typology. However, consumer researchers should be aware that several alternative structural theories exist and future consumer research should test these alternative views. It is perhaps somewhat surprising given the enormous potential of consumer researchers to affect change among marketers and policy makers that coping research to date has not had more to say regarding critical coping-related issues, such as consumer health. Additionally, the problem of soaring levels of consumer credit debt is considered to be at a near crisis point, and millions of consumers are struggling with record levels of debt. As of yet, consumer research has been agnostic as to how consumers and marketers can address these critical societal problems and assist consumers in coping with these issues.

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Such studies are needed as part of ongoing research efforts aimed at a systematic understanding of contextual factors leading to changes or stability of cognitive functioning with aging medicine world cheap residronate express. Contextual factors that enable older adults to function particularly well may then lead to promising interventions and improvements in cognitive and behavioral outcomes treatment diverticulitis cheap residronate 35mg. Circadian arousal A number of studies have found that the age differences in processing can be moderated by individual variation in circadian arousal patterns that is correlated with performance on a variety of cognitive tasks medicine mountain scout ranch purchase residronate without prescription. Specifically, performance tends to peak at certain level of circadian arousal when greater cognitive resources are presumably available, and this peak occurs, more or less regularly, at a specific point in the day. Hence, individual variation in circadian arousal patterns can significantly alter cognitive performance across time of day. Normative data collected on over 2,200 college students (aged 18Ͳ3) and 1,200 older adults (aged 60ͷ5) in North America indicate that roughly 40% of younger adults show eveningness tendencies, with less than 10% showing morningness tendencies. By contrast, less than 2% of older adults show eveningness tendencies, and the majority (~79%) are morning-types. As one example of dramatic time of day differences in how younger and older adults live their daily lives, consider age differences in media use and shopping (Yoon, 1997). More than 80% of the older participants in that study indicated that they read newspapers early in the morning, while only 14 % of younger subjects reported doing so during early morning hours. Magazines, on the other hand, were read in the afternoon or evening by more than two-thirds of both younger and older adults. About half of the older people indicated a clear preference for shopping in the morning or early afternoon, whereas younger people tended to prefer the late afternoon or evening. Other studies have found intellectual and physical behavior to vary across age and time of day. The synchrony between circadian arousal periods and performance can have a major impact on a wide array of cognitive tasks, particularly on those with an inhibitory component (for a review, see Yoon, May, Goldstein, & Hasher, in press). At their nonoptimal time of day, however, older adults show a marked decline in cognitive performance. This is in contrast to younger adults who are able to process in detail even at their nonoptimal time of day. Yoon, Lee, and Danziger (2007) further investigated whether this time of day effect also impacts persuasion processes performed under relatively high involvement. They find that the attitudes of older adults are more strongly affected by an easy to process criterion, picture-relatedness, at their nonoptimal time of day (afternoon) and by a more difficult to process criterion, argument strength, at their optimal time of day (morning). In contrast, the attitudes of younger adults are affected primarily by argument strength at both their optimal (afternoon) and nonoptimal (morning) times of day. The results accentuate the need for matching marketing communications to the processing styles and abilities of older adults. Taken together, the evidence suggests that in investigations of aging, it is important to guard against any potential biases by controlling for individual and group differences in circadian arousal patterns. Insofar as we know that older adults tend to reach their mental peak in the morning while younger adults do so in the evening, studies failing to account for such differences in arousal patterns may otherwise produce results that reflect a systematic under- or overestimation of relationships between age and other variables of interest. The set of contextual factors that we have discussed thus far are by no means exhaustive. They are, however, intended to underscore the importance of research aimed at integrating memory in broader cognitive, biological, and social contexts in order to continue to enhance our understanding of older adults. The first involves deliberative decision making with the classic five stages: problem recognition, information search, alternative evaluation, purchase decision, and post-purchase behavior. Such decision making typically reflects systematic attribute-by-attribute processing and is characterized as conscious, analytical, reason-based, and relatively slow. In contrast, the second type of decision making is affective/experiential, and involves intuitive, automatic, associative, and fast decisions. When consumers have limited processing resources, they may pass directly from problem recognition to purchase decision to the post-purchase phase, using affective feeling to direct their choice process. So, for example, in one recent experiment, consumers with limited processing resources were more likely to choose chocolate cake, an option that generates positive affect and negative cognitions about health, than to choose fruit salad, an option that generates negative affect and positive cognitions about health (Shiv & Fedorikhin, 1999). In this type of decision making, ambient mood can also affect how consumers evaluate an object through a "how do I feel about it heuristic. They often end up mistaking their current mood state for their feeling toward a product (Pham, 1998).

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The middle of the older age group (55Ͷ4) was willing to use the senior discount even though they believed that others would not give senior citizen discount users much respect treatment with cold medical term buy generic residronate 35 mg line. Another study examined how older adults dispose of favorite possessions (Price symptoms 9 dpo order line residronate, Arnould treatment tinnitus cheap residronate online visa, & Curasi, 2000). Through in-depth interviews they studied various aspects of disposition decisions including precipitating events, emotions associated with decision, meaning of possessions, and tactics for disposing of possessions. Of these, precipitating events seemed most sensitive to age differences, but it would be informative to have future research that conducts age-based comparisons across different possession or consumption domains. Heuristic/Affective Decision Making Age difference in one type of affect-based decision making-risky choices-has been extensively studied in psychology. The decks with lower immediate rewards have lower long-term punishments and thus yield an overall net gain, but decks with higher immediate reward have higher long-term punishment. Future research is needed linking performance on the gambling task to neurological changes. Improving Consumer Decision Making In general, the existing decision-making literature suggests that elderly consumers differ from younger consumers in important ways at each stage of the decision-making process. At the information search stage, the presence of age differences in the amount of search is not surprising because most of the consumer behavior research is based on extensive prior work in gerontology that suggests less search among older adults. At the alternative evaluation stage, a host of unresolved questions center on the decision rules and heuristics that different aged consumers use when evaluating alternatives. Some processes may differ across age groups because older consumers, with fewer cognitive resources than younger consumers, may perceive higher cognitive costs for certain strategies. Other processes may not differ, when consumers of all ages are able to use familiar and well-practiced heuristics. We now discuss intervention programs such as decision aids, training programs and stimulus redesign. Decision aids A series of experiments used decision aids to reduce age differences in the correct use of the nutritional information contained on product labels (Cole & Gaeth, 1990). As discussed in the section on memory, older adults are known to be more susceptible to interference from the irrelevant components of a stimulus (or other environmental noise) than are younger adults. In the experiments, participants had to select a cereal that met certain criteria, but some participants first circled the relevant information before making a decision. Although both older and younger adults benefited from the simple aid, older consumers made fewer good nutritional choices than younger consumers. In a second experiment, the investigators put relevant information in a separate location on the label. This time, older adults with moderate, but not severe disembedding deficiencies, were helped, but the field independent younger individuals gained little from the aid. Given that the stated aim of nutritional labeling laws is to make nutritional information easy for all consumers to use, this study suggests that such information should be placed in the same spot on all labels. In a different study, Cole and Balasubramanian (1993) tried to aid the use of nutritional information by encouraging older and younger adults to write information down as they acquired it from the computer. Using this decision aid, age differences in search intensity were greatly diminished. Taken together, these studies suggest that decision aids may successfully improve consumer decision making. Circling, organizing, or writing down important information may especially help the elderly consumer focus on relevant information. Training and education Gaeth and Heath (1987) developed an interactive training program to reduce susceptibility to misleading advertising without increasing consumer suspicion of advertising claims. Regarding knowledge, older adults appear to build up a knowledge system that they can deploy to aid in decision making. Some argue that knowledge systems become increasingly selective and domain-specific with age, so that older adults can draw on this knowledge system to make better decisions. More important from a decisionmaking perspective, however, older subjects in the study were better calibrated (knew better what they knew and did not know) than younger subjects.

Storage of vitamin D occurs in the body medications affected by grapefruit buy genuine residronate online, so a single large dose may be effective for several weeks 10 medications that cause memory loss best purchase residronate. Uses Dietary deficiency of vitamin D occurs where there is poverty and poor diet medicine 2 order residronate 35mg online, accentuated by lack of sunlight. The small dose of calcium is unnecessary, but a preparation of vitamin D alone is not available. Calciferol tablets provide a pharmacological dose of vitamin D and are used for treatment of hypoparathyroidism and in cases of vitamin D-resistant rickets due to intestinal malabsorption or chronic liver disease. It is used in: נrenal rickets, together with a phosphate-binding agent; נhypoparathyroidism and (paradoxically) secondary hyperparathyroidism; נvitamin D-resistant rickets; נnutritional and malabsorptive rickets can be treated with small doses of -calcidol instead of conventional vitamin D. Vitamin D is available in a number of forms, many of which are derived from each other by sequential metabolism in the skin, liver and kidney, and each of which has specific indications. The most potent and rapid-acting orally available vitamin D preparations are 1,25 dihydroxycholecalciferol, and 1-hydroxycholecalciferol. When patients are hypocalcaemic, calcium can be supplemented orally as calcium carbonate with or without various preparations of vitamin D. If urgent calcium replacement is required, a 10% solution of calcium lactate or gluconate (the former yielding more calcium) may be administered intravenously. Patients who are receiving vitamin D plus calcium should have periodic checks of their serum Ca2 and creatinine concentrations, as the major adverse effect is hypercalcaemia. Regular plasma calcium and creatinine measurements (weekly initially) are essential. Calcium and vitamin D supplements are used in patients at risk of osteoporosis if intake is below 1 g of elemental calcium daily. The P-C-P backbone structure renders such compounds very stable ͠no enzyme is known that degrades them. Management of hypercalcaemia per se buys time for this and can be divided into general and specific measures. Uses Alendronic acid or risedronate (by mouth) are first-choice bisphosphonates for the prevention and treatment of osteoporosis; etidronate is an alternative if these are not tolerated. Etidronate is started at low dosage up to six months when many patients achieve remission; a further course may be given following relapse. High doses should be used only if lower doses fail or if rapid control of disease is needed. Mechanism of action Bisphosphonates modify the crystal growth of calcium hydroxyapatite by chemical adsorption to the crystal surface, reducing bone remodelling and turnover by osteoclasts. Adverse effects Renal impairment is a caution or contraindication for all bisphosphonates. This is minimized by taking alendronic acid or risedronate when sitting upright or standing, on an empty stomach before breakfast, and remaining standing for half an hour before eating. Inhibit bone resorption by osteoclasts; etidronate also inhibits mineralization with chronic use. Oral absorption is poor; short t1/2 in plasma and long t1/2 in bone; renal clearance. Food and/or calcium-containing antacids further reduce gastrointestinal absorption of bisphosphonates. The most common side effects are gastro-intestinal disturbances (Note: with regard to oesophagitis and ulceration with alendronic acid, this drug must be taken with water and the patient must be able to stand for 30 minutes post-ingestion). Calcitonin lowers calcium levels more rapidly than bisphosphonates, and may be used concomitantly in severe cases. They disappear rapidly from the blood, distributing to bone, where their effects are long lived. Within 24 hours, approximately 50% of the absorbed dose is excreted unchanged in the urine, but the remainder is excreted over many weeks. It is given daily by subcutaneous injection for periods up to 18 months, monitoring serum calcium, phosphate, alkaline phosphatase, creatinine and electrolytes. Case history A 52-year-old woman has had epilepsy since childhood, treated with phenytoin 300 mg/day and her fits have been well controlled.

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