Local governments can use their power to regulate land development to prohibit noise-sensitive land use development adjacent to a highway medicine naproxen best 2.5 mg nitroglycerin, or to require that developers plan medicine online generic nitroglycerin 2.5mg on line, design symptoms stomach flu nitroglycerin 2.5mg sale, and construct development in ways that minimize noise impacts medicine quotes doctor buy discount nitroglycerin 2.5 mg line. This listing continues to be extremely useful in the management of the highway traffic noise program medications to treat anxiety discount nitroglycerin 2.5 mg without a prescription, in our technical assistance efforts for State highway agencies symptoms 89 nissan pickup pcv valve bad buy generic nitroglycerin 2.5 mg on line, and in responding to inquiries from congressional sources, Federal, State, and local agencies, and the general public. An updated listing of noise barriers will be distributed nationally for use in the highway traffic noise program. It is anticipated that this information will be requested in 2014 (for noise barriers constructed in 2011, 2012 and 2013) and then again in 2017 (for noise barriers constructed in 2014, 2015 and 2016). Chapter 301 on the basis that this noncompliance is inconsequential to motor vehicle safety. Startrans makes the argument that the subject noncompliance is not performance related and is inconsequential to vehicle safety. These vehicles are already registered and currently represent no concern with licensing. To perform a remedy on this many vehicles invites the possibility of certification decals being reinstalled on the wrong vehicles. In summation, Startrans believes that the described noncompliance of its vehicles is inconsequential to motor vehicle safety, and that its petition, to exempt from providing recall notification of noncompliance as required by 49 U. Therefore, this decision only applies to approximately 107,250 vehicles that Startrans no longer controlled at the time that it determined that a noncompliance existed in the subject vehicles. However, the granting of this petition does not relieve vehicle distributors and dealers of the prohibitions on the sale, offer for sale, or introduction or delivery for introduction into interstate commerce of the noncompliant vehicles under their control after Startrans notified them that the subject noncompliance existed. All of the vehicles are model year 2012 and were manufactured within the period from April 6, 2011 through August 20, 2011. Publicly available data confirms that parents and caregivers generally do not place small children in the front passenger seat. There was not a single discrepancy in the over 10,000 tests involving the Cruze, Equinox, Terrain and Saab 94X vehicles, representing over 92 percent of the subject vehicle population. The air bag classification system will continue to characterize the front seat occupants and enable or disable the air bag, as designed. For the error to occur at all, the vehicle must be restarted in a very particular manner within less than half of one minute of having been turned off. The conditions needed to produce the telltale error are estimated to occur approximately once every 18 months. The noncompliant condition has absolutely no effect on the proper operation of the occupant classification system. As a result, all occupants will continue to receive the benefit of the air bag when they otherwise would, regardless of whether or not the telltale is operating properly during a particular ignition cycle. The noncompliance condition will not occur unless the engine is shut off and restarted within about 24 seconds. Even if the air bag was enabled when the telltale indicated it was disabled, that would be extremely unlikely to increase the risk to motor vehicle safety. As explained in more detail below, this is extremely unlikely to occur in the present case. With respect to the remaining vehicles, the air bag system was enabled or disabled, as desired, over 99. When this occurs, the telltale is the only part of the system affected and the occupant classification system will continue to operate as designed and will enable or disable the air bag as intended. Specifically, the tires in question were inadvertently marked with a maximum load of 1350 kg. While the noncompliant tires are mislabeled; the tires do in fact have the correct marking for the maximum load in pounds on the intended outboard sidewall, and the maximum load marking in both pounds and kg is correct on the intended inboard sidewall. The subject mismarking is inconsequential as it relates to motor vehicle safety and is unlikely to have an adverse impact on motor vehicle safety since the actual performance of the subject tires will not be affected by the mismarking. The markings must be placed between the maximum section width and the bead on at least one sidewall, unless the maximum section width of the tire is located in an area that is not more than one-fourth of the distance from the bead to the shoulder of the tire. If the maximum section width falls within that area, those markings must appear between the bead and a point one-half the distance from the bead to the shoulder of the tire, on at least one sidewall. In the case of this noncompliance, the subject tires are primarily sold in the domestic replacement market, where the load in pounds would be the predominant consumer unit of measurement. A few of the focus group participants had knowledge of tire labeling beyond the tire brand name, tire size, and tire pressure. Bridgestone has provided sufficient documentation that the sidewall mismarkings do comply with all other safety performance requirements of the standard, except the sidewall mismarking. Therefore, this decision only applies to approximately 467 tires that Bridgestone no longer controlled at the time that it determined that a noncompliance existed in the subject tires. However, the granting of this petition does not relieve tire distributors and dealers of the prohibitions on the sale, offer for sale, or introduction or delivery for introduction into interstate commerce of the noncompliant tires under their control after Bridgestone notified them that the subject noncompliance existed. The Treasury will do this through agreements with mortgage servicers to modify loans on their systems. Affected Public: State, Local, and Tribal Governments; Private Sector: Businesses or other for-profits, Not-forprofit institutions. Kevin McIntyre, Acting Director, Financial Accounting and Services Division, Financial Management Service. Federal bond-approving officers should annotate their reference copies of the Treasury Department Circular 570 (``Circular'), 2012 Revision, to reflect this change. Federal bondapproving officials should annotate their reference copies of the Treasury Department Circular 570 (``Circular'), 2012 Revision, to reflect this change. Federal bond-approving officials should annotate their reference copies of the Treasury Department Circular 570 (Circular), 2012 Revision, to reflect this change. With respect to any bonds currently in force with these companies, bondapproving officers may let such bonds run to expiration and need not secure new bonds. Notice is hereby given that the Certificates of Authority issued by the Treasury to the above-named companies under 31 U. Federal bond-approving officials should annotate their reference copies of the Treasury Department Circular 570 (``Circular'), 2012 Revision, to reflect this change. However, no new bonds should be accepted from these companies, and bonds that are continuous in nature should not be renewed. Current Actions: Five line items are added to capture state income tax information for the convenience of the taxpayer. The addition of these lines, offset by a decrease in the estimated responses (to 79,134,5000) will result in an estimated annual burden increase of 6,330,760 hours. Books or records relating to a collection of information must be retained as long as their contents may become material in the administration of any internal revenue law. Generally, tax returns and tax return information are confidential, as required by 26 U. The Basis for Our Action Based upon our review of the nature, scope, and timing of the oil and gas exploration activities and mitigation measures, and in consideration of the best available scientific information, it is our determination that the activities will have a negligible impact on walruses and on polar bears and will not have an unmitigable adverse impact on the availability of marine mammals for taking for subsistence uses by Alaska Natives. Making this rule effective immediately upon publication will ensure that Industry implements mitigation measures and monitoring programs in the geographic region that reduce the risk of lethal and nonlethal effects to polar bears and Pacific walruses by Industry activities. Fish and Wildlife Service (Service or we), are finalizing regulations that authorize the nonlethal, incidental, unintentional take of small numbers of Pacific walruses (Odobenus rosmarus divergens) and polar bears (Ursus maritimus) during oil and gas Industry (Industry) exploration activities in the Chukchi Sea and adjacent western coast of Alaska. The total expected takings of Pacific walruses (walruses) and polar bears during Industry exploration activities will impact small numbers of animals, will have a negligible impact on these species, and will not have an unmitigable adverse impact on the availability of these species for subsistence use by Alaska Natives. These final regulations include: Permissible methods of nonlethal taking; measures to ensure that Industry activities will have the least practicable adverse impact on the species and their habitat, and on the availability of these species for subsistence uses; and requirements for monitoring and reporting of any incidental takings that may occur, to the Service. Comments and materials received in response to this action are available for public inspection during normal working hours of 8 a. Instead, in our small numbers determination, we evaluate whether the number of marine mammals likely to be taken is small relative to the size of the overall population. Industry conducts activities, such as oil and gas exploration, in marine mammal habitat that could result in the incidental taking of marine mammals. The 2012 request was for regulations to allow the incidental, nonlethal take of small numbers of walruses and polar bears in association with oil and gas activities in the Chukchi Sea and adjacent coastline for the period from June 11, 2013, to June 11, 2018. The information provided by the petitioners indicates that projected oil and gas activities over this timeframe will be limited to exploration activities. Offshore activities, such as exploration drilling, seismic surveys, and shallow hazards surveys, are expected to occur only during the openwater season (JulyNovember). The petitioners have also specifically requested that these regulations be issued for nonlethal take. The petitioners have indicated that, through the implementation of appropriate 35365 mitigation measures, they are confident that no lethal take will occur. Prior to issuing these regulations in response to this request, we evaluated the level of industrial activities, their associated potential impacts to walruses and polar bears, and their effects on the availability of these species for subsistence use. The activities and geographic region specified in the request, and considered in these regulations, are described in the ensuing sections titled ``Description of Geographic Region' and ``Description of Activities. These regulations do not authorize, or ``permit,' the actual activities associated with oil and gas exploration. The State of Alaska is responsible for permitting activities on State lands and in State waters. The Chukchi Sea region encompasses an area of approximately 240,000 square kilometers (km) (approximately 92,644 square miles). Within that time, oil and gas exploration activities could occur during any month of the year, depending on the type of activity. Offshore activities, such as exploration drilling, seismic surveys, and shallow hazards surveys, are expected to occur Description of Activities only during the open-water season these final regulations cover (JulyNovember). Onshore activities exploratory drilling, seismic surveys, may occur during winter. This time period includes the Specific locations, within the entire open-water seasons of 2013 designated geographic region, where oil through 2017, when activities such as and gas exploration will occur will be exploration drilling, seismic surveys, determined based upon a variety of geotechnical surveys, and shallow factors, including the outcome of future hazards surveys are likely to occur, but Federal and State oil and gas lease sales terminates before the start of the 2018 and information gathered through open-water season. The information provided by scale of oil and gas activities projected the petitioners indicates that offshore to occur in the Chukchi Sea region over exploration activities will be carried out the specified time period (2013 to 2018). Further onshore include Industry exploration operations activities will be limited and are not of oil and gas reserves, as well as expected to occur in the vicinity of environmental monitoring associated known polar bear denning areas or with those activities, on the western coastal walrus haulouts. The specific dates and the Service identified and deemed durations of the individual operations similar to the type requested in the and their geographic locations are petition. For example, surveys; (3) shallow hazards surveys; (4) we chose to analyze the potential other geophysical surveys, such as ice impacts of two annual seismic gouge, strudel scour, and bathymetry operations on polar bears and Pacific surveys; (5) geotechnical surveys; (6) walruses, rather than the requested one onshore and offshore environmental seismic operation, to allow incidental studies; and (7) associated support take coverage in the event that more An after-action report on exploration activities and marine mammal monitoring activities will have to be submitted to the Service within 90 days after completion of the activity. Details of monitoring and reporting requirements are further described in ``Potential Effects of Oil and Gas Industry Activities on Pacific Walruses and Polar Bears. Description of Geographic Region these regulations allow Industry operators to incidentally take small numbers of walruses and polar bears within the area, hereafter referred to as the Chukchi Sea region (Figure 1; see Final Regulation Promulgation section). Of these, offshore drilling and seismic surveys are expected to have the greatest potential effects on Pacific walruses, polar bears, and Alaska Native subsistence activities. Offshore Exploration Drilling Offshore exploration drilling will be conducted from either a floating drilling unit, such as a drillship or conical drilling unit, or a jack-up drilling platform. The operating season for exploration drilling with these types of drilling units is expected to be limited to the open-water season, from July 1 through November 30, when the presence of ice is at a minimum. Petitioners indicate that bottom-founded platforms will not be used during exploration activities due to water depths greater than 30 meters (m) (100 feet [ft]) and possible pack ice incursions. Drilling operations are expected to range between 30 and 90 days at individual well sites, depending on the depth to the target formation, and difficulties during drilling. The drilling units and any support vessels typically enter the Chukchi Sea at the beginning of the season and exit the sea at the end of the season. Drillships are generally self-propelled, whereas jack-up rigs must be towed to the drill site. These drilling units are largely self-contained with accommodations for the crew, including quarters, galleys, and sanitation facilities. Drilling operations will include multiple support vessels in addition to the drillship or platform, including ice management vessels, survey vessels, and on and offshore support facilities. For example, each drillship is likely to be supported by one to two ice management vessels, a barge and tug, one to two helicopter flights per day, and one to two supply ships per week. Ice management is expected to be required for only a small portion of the drilling season, if at all, given the lack of sea ice observed over most current lease holdings in the Chukchi Sea region in recent years. Most ice management will consist of actively pushing the ice off its trajectory with the bow of the ice management vessel, but some icebreaking could be required. One or more ice management vessels generally support drillships to ensure ice does not encroach on operations. The purpose of such surveys is to ground truth existing seismic data with geological information from the wellbore. A small airgun array is deployed at a location near or adjacent to the drilling unit, and receivers are placed (temporarily anchored) in the wellbore. Exploration drilling programs may entail both onshore support facilities for air support where aircraft serving crew changes, search and rescue, and/or re-supply functions where support facilities will be housed and marine support where vessels may access the shoreline. For offshore support purposes, a barge and tug typically accompany the vessels to provide a standby safety vessel, oil spill response capabilities, and refueling support. Most supplies (including fuel) necessary to complete drilling activities are stored on the drillship and support vessels. Helicopter servicing of drillships can occur as frequently as one to two times per day. Based upon information provided by the petitioners, we estimate that up to three operators will drill a total of three to eight wells per year in the Chukchi Sea region during the 5-year timeframe of these final regulations (June 2013 to June 2018). Offshore 2D and 3D Seismic Surveys Seismic survey equipment includes sound energy sources (airguns) and receivers (hydrophones/geophones). The airguns store compressed air that upon release forms a bubble that expands and contracts in a predictable pattern, emitting sound waves. The sound energy from the source penetrates the seafloor and is reflected back to the surface where it is recorded and analyzed to produce graphic images of the subsurface features.
He demonstrates a positive association of physician population values with all cancer and ischemic heart disease and an inverse association with all other causes cancer treatment 60 minutes purchase nitroglycerin 2.5mg on-line. The primary issue is that so-called ecologic data are used medicine effects cheap nitroglycerin 2.5mg with amex, that is medicine 1900s spruce cough balsam fir discount 2.5 mg nitroglycerin visa, data on populations rather than data on individuals treatment junctional rhythm safe nitroglycerin 6.5 mg. Gofman is the assumption that the number of physicians per 100 medicine queen mary discount nitroglycerin 6.5mg,000 population is a surrogate for the dose of medical radiation received by the population 4 medications at target trusted nitroglycerin 6.5 mg. Summary the interpretation that medical radiation has been a major contributor to death from cancer and ischemic heart disease in the United States during the period 19401990 is not shared by the committee. There are insufficient data on dose and disease in individuals to lead to this conclusion. Effects of Radionuclides That Cross the Placenta In Chapter 8 the committee considers post-Chernobyl data on the excess papillary thyroid cancers arising in radioiodine-exposed children, some of whom received their exposure in utero. With respect to carbon-14 and tritium, brief comments are made in response to issue 3. The committee recommends that this issue be addressed as part of a larger review of maternal exposures in humans that may affect the fetus. Effects of Radiation on Female Fetuses In Chapters 6 and 7, the committee considers the effects of in utero radiation, including medical radiation and radiation from the atomic bombs. In the recent paper by Delongchamp and colleagues (1997), nine cancer deaths among females exposed in utero to the atomic bombs were noted in comparison to only one among males. Minimal information exists in the medical literature with respect to sex-specific effects, and none reports a gender-specific association between radiation and cancer. Because of the current practice of minimizing radiation exposure to pregnant women, the committee considers it unlikely that this issue will be able to be addressed by future epidemiologic studies. The tritium effects observed do not differ qualitatively from those resulting from external irradiation with X-rays or -rays. The evidence available indicates that the relative biological effectiveness of -irradiation from tritium is generally greater (by two- to threefold) than that of -irradiation and similar to or slightly greater (one- to twofold) than X-irradiation. The same general principles also apply to in vivo effects from organically bound carbon-14. It is important to point out that the committee was not constituted to review the biokinetic aspects of doses from internal radionuclides such as tritium, carbon-14, strontrium90, radiocesium, and radioiodine. Effects of Organically Bound Radionuclides Cellular and animal data are available for the development of judgments on the tumorigenic, genetic, and developmental effects of tritiated water and organically bound tri- 4. Data Integrity and Quality this issue is addressed in Chapter 8 on occupational radiation studies. The committee acknowledges that there is imprecision in exposure estimates of all epidemiologic studies, especially in retrospective studies of occupational groups. In general, however, studies of workers exposed to radiation tend to have better exposure data than studies of workers exposed to chemicals because of the concurrent estimation of exposure through the use of radiation badges. The committee notes that imprecision in the estimation of radiation exposure will tend toward an underestimation of any true association between radiation and health effects. To the extent that models based on these data are utilized to set standards of population exposure, the standards will tend to be lower than those that would be based on completely accurate data. Effects on Various Populations the atomic bomb data are based on two populations in Japan at one point of time. The relation of radiation exposure to age at exposure and gender has been extensively studied and is summarized in Chapter 6. Data on occupational and medical exposure to radiation are available for a number of populations throughout the world for many decades. However, few details are presented in these studies on age at exposure and sex, except of course for sex-specific studies. The committee recommends that future studies of populations exposed to ionizing radiation include not only information on factors that may interact with radiation exposure, but also information on possible risks present in persons with varying demographic characteristics. In other words, hormesis now connotes a value judgment whereby a low dose of a noxious substance is considered beneficial to an organism. A recent publication reviews data for and against the concept of hormesis (Upton 2000), while noting that further research needs to be done at low-dose and low-dose-rate exposures to resolve the issue. Another recent review argues against the validity of a linear no-threshold model in the low-dose region (Cohen 2002). The committee also reviewed a compilation of materials submitted by Radiation, Science, and Health Inc. Much of the historical material on radiation hormesis relates to plants, fungi, algae, protozoans, insects, and nonmammalian vertebrates (Calabrese and Baldwin 2000). For the purposes of this report on human health effects, the committee focused on recent information from mammalian cell and animal biology and from human epidemiology. It has been postulated that such stimulation 332 might result in a net health benefit after exposure, and these observations are sometimes offered as mechanisms for hormesis. Oxidative damage is much more complex than they appreciate and involves predominantly proteins and mitochondrial targets associated with transcription, protein trafficking, and vacuolar functions (Thorpe and others 2004). They also hypothesize that low-dose radiation induces a specific repair mechanism that then acts to reduce both spontaneous and radiation-induced damage to below spontaneous levels, thus causing a hormetic effect. A recent study (Barquinero and others 1995), which reported that chronic average occupational exposure of about 2. It is unclear whether such competing events would result in a net gain, net loss, or no change in health status. In general, to observe hormetic effects the spontaneous levels of these effects have to be rather high. The committee notes in the Biology section that a very low radiation dose was reported to cause a reduction in transformation in vitro below a relatively high spontaneous transformation frequency. However, problems and possible artifacts of the assay system employed are also discussed. When radioresistance is observed after doses that cause some cell lethality- for example, after chronic doses that continually eliminate cells from the population-the radioresistance that emerges may be caused either (1) by some inductive phenomenon or (2) by selecting for cells that are intrinsically radioresistant. Either process 1 or process 2 could occur as the radiosensitive cells are selectively killed and thus eliminated from the population as the chronic irradiation is delivered. In the end, an adaptive or hormetic response in the population may appear to have occurred, but this would be at the expense of eliminating the sensitive or weak components in the population. In chronic low-dose experiments with dogs (75 mGy/d for the duration of life), vital hematopoietic progenitors showed increased radioresistance along with renewed proliferative capacity (Seed and Kaspar 1992). Although one might interpret these observations as an adaptive effect at the cellular level, the exposed animal population experienced a high incidence of myeloid leukemia and related myeloproliferative disorders. The authors concluded that "the acquisition of radioresistance and associated repair functions under the strong selective and mutagenic pressure of chronic radiation is tied temporally and causally to leukemogenic transformation by the radiation exposure" (Seed and Kaspar 1992). The general thesis presented is that stress responses activated by low doses of radiation, particularly those that would increase immunological responses, are more beneficial than any deleterious effects that might result from the low doses of ionizing radiation. Although evidence for stimulatory effects from low doses has been presented, little if any evidence is offered concerning the ultimate deleterious effects that may occur. In the section of this report on observed dose-response relationships at low doses, bystander effects and hyper radiation sensitivity for low-dose deleterious effects in mammalian cells have been observed for doses in the 10100 mGy range. End points for these deleterious effects include mutations, chromosomal aberrations, oncogenic transformation, genomic instability, and cell lethality. These deleterious effects have been observed for cells irradiated in vivo as well as in vitro. Adaptive Response the radiation-adaptive response in mammalian cells was demonstrated initially in human lymphocyte experiments (Olivieri and others 1984) and has been associated in recent years with the older concept of radiation hormesis. A more extensive treatment of adaptive effects is discussed in another section of this report. Radiation adaptation, as it was initially observed in human lymphocytes, is a transient phenomenon that occurs in some (but not all) individuals when a conditioning radiation dose lowers the biological effect of a subsequent (usually higher) radiation exposure. In lymphocyte experiments, this reduction occurs under defined temporal conditions and at specific radiation dose levels and dose rates (Shadley and others 1987; Shadley and Wiencke 1989). However, priming doses less than 5 mGy or greater than ~200 mGy generally result in very little if any adaptation, and adaptation has not been reported for challenge doses of less than about 1000 mGy. Furthermore, the induction and magnitude of the adaptive response in human lymphocytes is highly variable (Bose and Olivieri 1989; Hain and others 1992; Vijayalaxmi and others 1995), with a great deal of heterogeneity demonstrated between different individuals (Upton 2000). Also, the adaptive response could not be induced when the lymphocytes were given the priming dose during G0. Statistical analyses of the distribution of deaths in these studies indicate control animals usually show a greater variance around the mean survival time than groups exposed to low doses of radiation. In addition, the longer-living irradiated animals generally have a reduced rate of intercurrent mortality from nonspecific and infectious diseases during their early adult life, followed by a greater mortality rate later in life. Since these investigations were conducted under conditions in which infectious diseases made a significant contribution to overall mortality, the interpretation of these studies with respect to radiationinduced cancer or other chronic diseases in human populations must be viewed with caution. For example, the cited data of Lorenz (1950) show a small difference in life span in mice exposed to 0. A French study (Caratero and others 1998) shows life lengthening in irradiated mice compared to controls; unfortunately, the control life spans were significantly shorter by 100150 d than any in other published data for this mouse strain (Sacher 1955; Congdon 1987). In a study by Covelli and colleagues (1989), a decrease in incidence of malignant lymphoma at low doses of radiation (46 and 52% age-adjusted incidence at X-ray exposures of 500 and 1000 mGy versus 57% incidence in control animals) shows a reduction in tumor incidence relative to the control frequency. After peaking at 60% lymphoma incidence (3000 mGy), the frequencies decline, "possibly due to cell inactivation becoming predominant at higher doses over the initial transforming events. In the Ishii study, the authors speculate that possible mechanisms may include augmentation of the immune system or initiation of an "adaptive response. Human populations, which have a wider spectrum of "spontaneous" tumors occurring at a lower incidence, may not be expected to respond to radiation in the same way as mouse strains with high lymphoma incidence. A positive association is one in which the rate of disease is higher among a group exposed to some substance or condition than among those not exposed, and a negative (or inverse) association is one in which the rate of disease is lower among the exposed group. If an association is judged to be causal, a positive association may be termed a causal effect and a negative association could be termed a protective effect. One type of epidemiologic study that has been used to evaluate the association between exposure to radiation and disease is the "ecologic" study in which data on populations, rather than data on individuals, are compared. Another example of an ecologic study is the evaluation of geographic areas with high background levels of radiation compared to areas with "normal" background levels. The fact that cancer rates in these high-background-radiation geographic regions are not elevated is sometimes cited as evidence against a linear no-threshold model (Jaworowowski 1995). It is also true that certain populations residing in highbackground areas, such as occur at high altitudes, have lower levels of health problems than those residing at lower altitudes. This observation has been interpreted by some as evidence for a hormetic effect of radiation. A protocol of 50 mGy three times a week gave a smaller (not statistically significant) decrease to 67. The mean survival time was significantly prolonged from 283 d for the control animals to 309 d with the three-exposure-per-week protocol and to 316 d with the twice-a-week protocol. This is not interpreted to mean that work per se reduces the risk of mortality, but rather that healthy persons start to work more often than unhealthy persons (Monson 1990). A third type of epidemiologic study that has been used to evaluate the association between exposure to radiation and disease is the case-control study. Persons with a specific disease are compared to a control group of persons without the disease with respect to their past exposure to radiation. This type of study is unusual in radiation epidemiology, in that most general populations have relatively low exposure to radiation. Thus, if some exposure does not cause cancer and if a number of case-control studies are conducted, there will be a normal distribution observed in the odds ratios that describe the association between exposure and disease. In interpreting these studies, it is inappropriate to select only those that are consistent with an excess or deficit of disease. Rather, the entire distribution must be examined to assess the likely relationship between exposure and disease. The studies discussed here illustrate the variability that is inherent in all epidemiologic studies and the need to evaluate the entire body of relevant literature in order to assess possible associations between radiation and disease, be they positive or negative. In its evaluation of the literature and in its discussions, the committee has found no consistent evidence in the epidemiologic literature that low doses of ionizing radiation lower the risk of disease or death. Some studies show isolated positive associations between radiation exposure and disease, and some show isolated negative associations. However, the weight of the evidence does not lead to the interpretation that low doses of radiation exert what in biological terms is called hormesis. Summary the committee concludes that the assumption that any stimulatory hormetic effects from low doses of ionizing radiation will have a significant health benefit to humans that exceeds potential detrimental effects from the radiation exposure is unwarranted at this time. Another important consideration is the expected magnitude of the increase in health effect induced by excess background radiation. If one assumes a linear no-threshold response, a calculation can be made for expected cancers induced by excess radiation in a high-background-radiation area. In this study, a population receiving 34 mGy per year was compared to an adjacent control population receiving 1 mGy per year. One can estimate the expected excess percentage of cancers resulting from the 23 mGy difference in exposure per year using a linear nonthreshold model and the lifetime risk estimates developed in this report. A calculation by this committee indicated that the expected percentage of cancers induced by the excess background radiation would be 12% above the cancers occurring from all other causes in a lifetime. Even if all confounding factors were accounted for, it is questionable whether one could detect an excess cancer rate of 12%. Excess cancers may indeed be induced by elevated radiation exposure in high-background areas, but the excess may not be detectable given the high lifetime occurrence of cancer from all causes. Ordinarily, epidemiologists do not consider ecologic data such as this as being sufficient for causal interpretations. Since the data are based on populations, no information is available on the exposure and disease status of individuals. Such data cannot be controlled adequately for confounding factors or for selection bias. Although ecologic data may be consistent with an inverse association between radiation and cancer, they may not be used to make causal inferences. A second type of epidemiologic study that has been used to evaluate the association between exposure to radiation and disease is the retrospective cohort study. Persons who have had past exposure to radiation are followed forward in time, and the rate of disease is compared between exposed and nonexposed subjects or between exposed subjects and the general population.
The unit is led by an Assistant Inspector in Charge located at Dulles symptoms 5dp5dt fet buy 2.5mg nitroglycerin with visa, Virginia and is comprised of Inspector Program Managers medicine 5325 discount nitroglycerin 6.5 mg on line, Forensic Computer Analysts and Ad Hoc analysts domiciled in each of the eighteen Inspection Service Field Divisions treatment plant discount nitroglycerin 2.5mg free shipping. Digital evidence analysts are tasked with examining computer evidence and any digital media for information or data pertinent to Postal Inspection Service investigations xanax medications for anxiety purchase nitroglycerin 6.5mg free shipping. Examples of cases that may incorporate this type of evidence are: child pornography/exploitation medicine hat lodge discount nitroglycerin 6.5 mg with visa, homicide symptoms 9 days after embryo transfer generic nitroglycerin 2.5mg with amex, rape, suicide, mail theft, fraud, identity theft, or other related crimes against the Postal Service. In addition to processing cases, the Digital Evidence Unit is available for technical advice and assistance in seizing and preserving evidence at the crime scene. There are currently 240 trained Computer Forensics Agents in 105 field offices worldwide. There are currently 13 operational and interconnected storage locations nationwide: C3, Newark, Tampa, Detroit, Chicago, Houston, Denver, Los Angeles, Seattle, San Diego, Boston, Miami and San Juan. With the popularity of smartphones, iPhones and wireless internet communication, that number has grown and the amount of data contained within a mobile device has also grown. The Pathfinder program has effectively supported numerous field investigations that have required the ability to search vast amounts of digital data for evidentiary content. It is used to organize and then search through seized evidence data, primarily on cases with large amounts of data. While this is a 36% increase in the number of pieces of media processed, it is a 1029% increase in the amount of data processed over the same time period. It also includes an expanded commitment to public awareness and community outreach. Ever-changing technologies and tactics by offenders demand nimble and innovative training for law enforcement. The Threat Assessment revealed a growing problem that will require more investment in investigators, prosecutors, technology, tools, and research to search out and find offenders. The market that demands younger victims, violent images, and on-demand sexual assaults must be diminished. The Threat Assessment revealed troubling links between those who traffic in child pornography and those who participate in the production of the images or molest children offline. Well-trained investigators are critical to finding and arresting those who profit, in money or otherwise, from the pain of our children. The sexual abuse and exploitation of children rob the victims of their childhood, irrevocably interfering with their emotional and psychological development. Working toward reducing this blight on society will include a coordinated effort to achieve the broad Strategy goals, specific goals to address the current threats identified, the programmatic goals of the Department, and the goals of each of the components. This Strategy recognizes that investigation and prosecution will not alone defeat the threat our children face. A multi-disciplinary approach to the problem is required because of the complexity of the threats involved. Solving this problem must include not only investigators and prosecutors, but social service providers, educators, medical professionals, academics, non-governmental organizations, and members of industry, as well as parents and families. Second, the Department will build on the success of the Project Safe Childhood initiative. Third, the Department will increase its commitment to a leadership role in finding a global solution to the transnational problem of the sexual exploitation of children. Fourth, the Department will work toward improving the quality, effectiveness, and timeliness of computer forensic investigations and analysis. Fifth, the Department will increase its commitment to effective and sophisticated training for prosecutors and investigators. Sixth, the Department will continue to partner with Industry to develop objectives to reduce the exchange of child pornography. Seventh, the Department will explore opportunities to increase the education and awareness of federal, state, local and tribal judges of the difficult issues involved in child sexual exploitation. In support of the goals above, the Department has set priorities for accomplishing the goals of this National Strategy. Goals to Address Dangers Identified by the Threat Assessment To address the specific dangers identified by the Threat Assessment, the Department will emphasize certain areas of priority, including: (1) child pornography and online enticement of children for sexual purposes; (2) commercial sexual exploitation of children (domestic prostitution), (3) child sex tourism; and (4) child exploitation in Indian Country. Child Pornography and Online Exploitation the Threat Assessment revealed that the expansion of the Internet has lead to an explosion in the market for child pornography, leading, in turn, to increased access, creation, and distribution of these abusive images. As noted above, Project Safe Childhood was designed to develop district-specific strategies between U. Priorities Utilizing enhanced investigative and technological resources, the Department will focus its efforts on the most dangerous, most prolific offenders. Sophisticated training for investigators 138 and prosecutors, as well as enhancing forensic and technology available to both, will increase the impact the Department can make on this problem. Through partnerships with Industry, the Department will explore strategies to reduce the ability of offenders to use the Internet to traffick in these vile images. The Department will assess its current methods of collecting data on the scope of the problem, and determine whether further, or different, data collection would contribute more fully to eradicating this problem. The Department will explore close partnerships with the State Attorneys General and District Attorneys to share best practices, standards, information and strategies to attack this threat. These partnerships should include education, outreach, sex offender monitoring and deterrence. The Department is also fully committed to its role in the global battle against the sexual exploitation of children, and will foster international cooperation in sharing information, technology, victim identification, forensics, and best practices. We will also participate in transnational enforcement operations and training opportunities. As previously noted, research into various aspects of child sexual exploitation, from offender behavior to victim impact, is critically important so that the Department can adjust to the ever-changing practices of those who prey on our children. The Department will focus substantial research funding into these important areas, and will ensure that this research is informed by all the key partners involved in child exploitation prevention and interdiction. The Domestic Prostitution of Children the Threat Assessment described that children, often runaways, are recruited and coerced into prostitution by pimps who lure the children with food, clothes, attention, friendship, and love. They then use violence or intimidation to trap these children into a life of prostitution. These cases are uniquely difficult to investigate and prosecute, but progress has been made, as noted previously in this Report. Priorities the Department will explore the expansion of the Innocence Lost Initiative into other cities. We will also work to ensure that adequate victim services for this group of child victims are available to assist these victims break free from their offenders and aid law enforcement in investigating and prosecuting those who have abused them. The Department will also explore strategies to reduce the demand for prostituted children through public awareness campaigns and systematic enforcement. The Department will work closely with the Departments of Education and Health and Human Services to develop comprehensive strategies to combat the glorification of pimps and prostitution often found in popular culture. The Department will also focus resources on coordinated training to include first responders and medical providers, so that these personnel can better recognize the signs that a child might be a victim of forced prostitution. Child Sex Tourism the Threat Assessment revealed that some Americans capitalize on their relative wealth and travel to foreign nations to purchase the sexual assault of children for as little as five dollars. Many countries are considered an easy target for these predators, due to a variety of reasons. Priorities the Department will continue to increase its capacity to investigate Americans who sexually exploit children abroad. We will also pursue opportunities for international cooperation, information sharing, and training across borders to reduce this crime. The Department of State will be a key partner in these efforts, and the Department will pursue a close working relationship to develop strategies and initiatives to combat child sex tourism. The Department will also explore formulating "jump teams" to travel to foreign hot spots for sustained efforts to coordinate with foreign law enforcement, and in developing proactive enforcement operations. In this area, like in the others in this Report, research is critical, and will be fully supported by the Department. Offender behavior is an area ripe for research, and will aid law enforcement in identifying those likely to offend in this way. Indian Country the Threat Assessment noted that there is a lack of data available to measure the threat that sexual exploitation poses to children in Indian Country. There is, however, widespread agreement among child exploitation professionals that the threat is a serious one. Toward that end, the Department will continue its efforts to assess the scope of the problem and build upon resources already being devoted to fighting this threat. A key partnership that must be developed is between the Department and the Department of Education. The two should pursue development of prevention and education measures for schools in Indian Country. The Department will also explore targeted grant funding for education, awareness and the promotion of reporting of child exploitation in Indian Country. The Department will also commit to assisting in the expanded training of first responders, investigators and prosecutors in Indian Country. Further research into the scope of the problem will be necessary, and will be a priority for the Department. Programmatic Goals In addition to the priorities related to key areas examined by the Threat Assessment, the Department will pursue goals and priorities in the areas delineated below. The Department intends to continue to support and increase coordination with Internet Safety training programs. The Threat Assessment noted that children who are sexually assaulted are most often victimized by those closest to them. Continued, and expanded, investment into education, Internet Safety training, community-outreach, and public awareness must be a high priority. As noted above, the Department has a robust set of programs relating to Internet Safety training and community outreach. A coordinated approach including the Department of Education will reach many more thousands of school children. Such coordination is already underway, and Department representatives have met with Department of Education personnel to discuss programs in the future. In the next report to Congress, the Department anticipates reporting on programs the two Departments will have implemented. As described in the Threat Assessment, offenders are using advanced technology to avoid detection, share strategies to abuse children, and to traffic in vile images of children. This include the creation of a national database to perform three critical functions: first, to allow federal, state, local, and international law enforcement to deconflict their cases with each other; second, to allow federal, state, and local law enforcement to engage in undercover operations from a portal facilitated or hosted by the database; and, third, to share information and intelligence, as well as conduct analysis, on dangerous offenders and future threats or trends. Especially as the level of sophistication of offenders, and the newly-emerging threat of organized groups, rises, such a technological tool is simply critical in the fight against the sexual exploitation of our children. Many federal, state, and local agents currently utilize many different systems to conduct undercover operations, 141 deconflict cases, and share information. However, a national system linking all those law enforcement investigators, and approved international partners, will exponentially increase our knowledge of the threats and our ability to track suspects, than ever before. The Department is committed to increasing the number of federal prosecutions of child exploitation crimes. The Department intends to achieve this goal by continuing to pursue the increasing number of investigations that are initiated by federal and state law enforcement officers. The more investigations that are pursued, the more likely it is that the number of successful prosecutions will result. Further, the Department plans to continue educating and training prosecutors to develop expertise in prosecuting child exploitation cases. This Report highlights the numerous agencies and entities engaged in the fight against child exploitation, increased cooperation between federal, state, and local law enforcement and nongovernment organizations will only strengthen the battle. To that end, cooperation between the Department and industry remains a high priority. Industry, like Internet Service Providers and software makers, will be a valuable partner in the fight to protect our children from technologyfacilitated child exploitation. Another critical area of coordination with industry is in the retention of data that might be relevant to child exploitation investigations. The Department has participated in an Online Safety and Technology Working Group led by the Department of Commerce to discuss this issue, among others, with industry and other interested parties, and a report to Congress will be forthcoming from that group. As noted above, Americans who travel to abuse foreign children show the worst of America to the rest of the world. The Department is committing resources to working with our international partners to address this problem. Increased cooperation between allies is a critical underpinning to successfully curtailing what is known as "child sex tourism. In preparing this Report, a comprehensive review of the relevant research relating to child exploitation was conducted, and is reviewed at the end of this Report. As the Threat Assessment noted, there are troubling links between those who exploit children by collecting and trading in their sexually abusive images and those who are hands-on abusers. However, to better prioritize targets and assess individual risk levels, research is need to answer many questions, such as: how high is the risk a child pornography trafficker will be a hands-on offender; does the collection and use of these 142 vile images for sexual gratification increase the desire to sexually act against a child; does the type of image used for sexual gratification, whether violent or of very young children, impact the risk to offend; does the sheer volume of images collected or trafficked affect that risk? The Department, through the Office of Justice Programs will continue to fund this kind of critical research, but non-governmental organizations should also join in this effort. Departmental Component Goals In addition to the goals noted above, the Department will strive to improve in other, concrete, ways. Over the next several months, the Department will work to fill the outstanding vacancies and train the new Assistants in this complex area of specialty. They will continue their efforts to oversee, coordinate, and distribute funding to the numerous groups that contribute to the fight against child exploitation. United States Marshals Service the Marshals Service will stand up a fully operational National Sex Offender Targeting Center to better track and apprehend fugitive sex offenders.
Safe nitroglycerin 2.5 mg. Common Xanax Withdrawal Symptoms (TRUTH).
The overall conclusion from the three studies that met our four criteria is that there is evidence for association between force and epicondylitis based on strength of association medications rights generic nitroglycerin 6.5 mg without prescription. These results may have been influenced by allowing "cases" who had recurrence in the same elbow to be counted as new cases (12 out of 57 employees with epicondylitis had more than one episode symptoms of generic 2.5 mg nitroglycerin amex, and were counted twice) treatment 911 generic nitroglycerin 6.5mg with mastercard. In examining this study treatment herniated disc order nitroglycerin 6.5 mg with amex, it is important to see if the odds of having epicondylitis would be elevated if these workers with recurrences were only counted once medications epilepsy discount 6.5mg nitroglycerin overnight delivery. We counted symptoms vaginal yeast infection discount nitroglycerin 2.5mg fast delivery, only once, the employees with recurrence, as well as the four employees mentioned with simultaneous occurrence in both elbows and subtracted these from the strenuous job cases. This study provides support for the association of forceful work with epicondylitis. Heavy stress in the elbows was assigned to job titles like blaster, driller, or grinder. The major limitation of this analysis of the work-related cases is that it did not consider age, a likely confounder. Overall, this study provides support for the association between forceful work and epicondylitis, particularly in older workers. As a result of the specific elbow exposure assessment, we believe that with regards to stressful or forceful elbow exertions that the 1987 study is more informative. In 95 women sausage makers, there were four cases with insidious onset, while among 160 women referents there were two cases, one with insidious onset, the other related to an "exceptional task of cutting cheese. Rates of medically diagnosed cases of epicondylitis were not statistically different between the two groups, but the results for epicondylar pain (causing sick leave in the two groups), and the fact that the majority of cases in both groups were due to events involving strenuous, repetitive tasks, give some support to forceful, repetitive work as a cause. The authors also stated that "exposure to repetitiveness and force in automobile assembly line work may be less than in other investigated work situations. Temporal Relationship: Force and Epicondylitis See temporal relationship above in Repetition and Epicondylitis. Focusing on those studies that compared workers exposed to force that was documented to be at a high level, to those exposed to a low level, all studies [Chiang et al. Most of these studies examined workers in repetitive, forceful job tasks and did not separate out the independent effect of repetition through any analytic method. In fact, in that study, four workers with acute non-work-related epicondylitis in the nonstrenuous group were noted in the journal article. Another consideration for inconsistency is due to grouping of studies, which may all fulfill good epidemiologic criteria, may all examine the same risk factor, but may compare groups that do not have similar contrasting levels of exposure. Two factors explain the difficulty in determining the reasons for the apparent inconsistencies among the studies on forceful and repetitive work. First, very few of the exposure assessments were quantitative-this is due to existing limitations in directly measuring exposure in detail in most field studies. As a result, there is likely to be frequent nondifferential misclassification of exposure. Second, most of the studies completed have been cross-sectional, and therefore subject to survivor bias. For those working for 12 4-12 to 60 months, a similar trend was found, but a reverse trend was found in those workers employed for over 60 months. The authors stated that because most of the workers were semi-skilled, they were likely to leave their job if they felt frequent muscle pain because of it. They went further to say that the selection mechanism may explain the lack of significant associations between the disorders and the duration of employment. There was no indication that the authors pursued this hypothesis by trying to identify former workers who may have left. This example highlights two important factors concerning the crosssectional studies examining work-related epicondylitis: there is some evidence that older workers may be at higher risk of epicondylitis [Dimberg 1987; Ritz 1995], and there is also a "survivor" effect, which results in the loss to the study of affected workers. These two factors make the interpretation of duration of disease relationships complex and may affect the estimate of the risk of disease. There were studies that used more accurate exposure assessment or had comparison groups with marked differences in levels of exposure to forceful and repetitive work that were positive, such as the Kurppa et al. There were studies with these characteristics that were negative, such as the Viikari-Juntura et al. In both of these studies, those cases of epicondylitis listed in the comparison groups were due to highly repetitive, forceful activities. The lack of a significant difference in the prevalence of the disorder between the two groups may be because the referent, "low" exposure groups had a higher incidence of non-work-related lateral epicondylitis. Coherence of Evidence the epidemiologic results of finding the majority of cases occurring in highly repetitive, forceful work [Moore and Garg 1994; Chiang et al. In cases of lateral epicondylitis occurring in workplaces as well as in sports, the forearm extensors are repetitively contracted and produce a force that is transmitted via the muscles to their origin on the lateral epicondyle. These repetitive contractions produce chronic overload of the bone-tendon junction, which in turn leads to changes at this junction. The most common hypothesis is that microruptures occur at the attachment of the muscle to bone (usually at the origin of the extensor carpi radialis brevis muscle), which causes inflammation. Further repetition of the offending movements causes angiofibroblastic hyperplasia of the origin. Nirschl [1975] stated that the degree of angiofibroblastic hyperplasia is correlated to the duration and severity of symptoms. On histologic analysis of severe cases of epicondylitis, one can see the characteristic invasion of fibroblasts and vascular tissue, the typical picture of angiofibroblastic hyperplasia. Prior to many of the epidemiologic studies, there were numerous reports in the medical literature of clinical case series that suggest a relationship between epicondylitis and repetitive, forceful work. For example, as early as 1936 Cyriax reported that with regard to patients with lateral epicondylitis, "those patients who remember no special overexertion will be found to be working at screwing, lifting, hammering, ironing, etc. Sinclair [1965] reported 2 case series of patients with tennis elbow (lateral epicondylitis), 44 patients treated between 1959-1961 and 38 patients treated between 1961-1963. In the first group of 267, the 130 (48%) whose onset occurred spontaneously had occupations that included gripping tools with consequent 4-14 forearm extensor muscle contraction and repetitive supination/ pronation of the forearm. In the second group of 26, the 23 (88%) who had spontaneous onset worked in jobs with constant gripping or repetitive movements. Many case studies of professional athletes have documented that forceful, repeated dorsiflexion, pronation, and supination movements with the elbow extended can cause epicondylitis. This literature has also referred to increased occurrence in occupations requiring force, awkward postures, and repetitive use of the elbow and forearm [Lapidus and Guidotti 1970; Mintz and Fraga 1973; Berkeley 1985]. These reports, though mainly case series, have lead to further studies that examined the links between exposure and epicondylitis. An example of an early occupational study is one by Mintz and Fraga [1973], who found that foundry workers (with an average of 14 years of employment) who used tongs requiring twisting and bending of the elbows/forearms for eight hours per day had decreased elbow flexion and extension and pain on physical examination, as well as severe radiographically documented osteoarthritis localized to the elbows. In the studies that are reviewed in Tables 4-1 through 4-4, the occupations with the highest rates of epicondylitis, such as drillers, packers, meatcutters, and pipefitters, are consistent with the force-repetition model of the causation of epicondylitis. The development of epicondylitis in these workers is consistent with proposed biological mechanisms and is plausible. The movement of affected workers out of high exposure jobs limits the ability of cross-sectional studies to accurately determine associations between work factors and epicondylitis. Our ability to accurately identify working conditions with an elevated risk for epicondylitis may require an exposure assessment of each job to a degree that has been beyond the limits of current epidemiological methods. Overall, the majority of the epidemiologic studies are supportive of the hypothesis of an increase risk of epicondylitis for occupations that involve forceful and repetitive work, frequent extension, flexion, supination, and pronation of the hand and the forearm. The surveillance data are also supportive of this hypothesis [Roto and Kivi 1984; Washington State Department of Labor and Industry 1996]. The highest relative risks for epicondylitis in Finland were with mechanics, butchers, food industry workers, and packers; the highest industries in Washington State for 1987-1995 [Silverstein et al. In Press] were construction workers, meat dealers, and foundry workers-all occupations with repetitive, forceful work involving the arms and hands and requiring pronation and supination. In several studies, only dichotomous divisions were made, so conclusions concerning an exposure-response relationship cannot be drawn. Moore and Garg [1994] found a higher risk in workers with high-strain jobs compared to those with low-strain jobs. While Dimberg [1987] found no difference in epicondylitis between blue- and white-collar workers, he found that workers with elbow pain severe enough to require a physician consult were significantly more often in those jobs identified independently as having high elbow stress. Dimberg also found a statistically significant correlation coefficient for lateral epicondylitis and time spent in the present job. Overall, these studies provide considerable evidence for a difference in level of risk for epicondylitis when there are marked differences in the level of exposure to forceful and repetitive tasks. Ritz [1995] reported a positive dose-response relationship between duration of exposure to gas and waterworks jobs regarded as moderately and highly stressful to the elbow and epicondylitis. Roto and Kivi [1984] reported that all workers with epicondylitis in their meat-packing facility worked for more than 15 years in the strenuous job category and had been exposed an average of 5 years longer than non-diseased workers. These studies, with less clear contrasts in exposure, provide support for the exposureresponse relationship between epicondylitis and forceful, repetitive work. Studies Reporting on the Association of Posture and Epicondylitis the six studies in Table 4-3 addressed posture variables. Strength of Association-Posture and Epicondylitis Studies Meeting the Four Evaluation Criteria the Moore and Garg [1994] study (also discussed above) recorded wrist posture using a classification similar to Armstrong et al. In this study, posture was not found to be significantly associated with "hazardous" jobs. This may be due to the heavier weighting given the force rating system than the posture or repetition scale. For example, if a job required extreme posture, the authors increased the force rating instead of the posture rating. If a combination of extreme posture and high-speed movement was required, then the force rating was raised by two levels, but not the posture rating. Data that would allow analysis of the incidence of epicondylitis and the exposure to extreme posture were not presented. Although there was a non-significant association between assembly line work and the presence of either epicondylitis or pronator teres syndrome in shop assistants (11 cases versus 3), there were 5 cases of medial epicondylitis and 2 cases of pronator teres syndrome in the assembly workers and none in the shop assistants. The greater prevalence of medial epicondylitis in assembly workers was attributed to the difficult grasping movements involved in the assembly line work. The authors stated that the overall prevalence may have been "connected with the constant overstrain of flexors in work. The difference in exposure classification scheme may explain why there was no relationship between prevalence of epicondylitis and increasing work strain. However, this study had an overall low participation rate (55%), which limits the interpretation of its result. The other study that may be interpreted as related to a posture variable is the one by Hoekstra et al. This study evaluated video display terminal users at two work sites differing only in whether adjustable office equipment was present. This improper chair adjustment was thought to increase shoulder and elbow flexion, as well as 4-17 wrist deviation, thus producing more symptoms. These conclusions should be considered to be hypothesis generating and not definitive. Temporal Relationship There are no prospective studies that address posture and epicondylitis. Consistency in Association There are too few occupational epidemiologic studies that address posture and epicondylitis to meaningfully discuss consistency of association. Coherence of Evidence Please refer to the "Repetition Section and Coherence of Evidence" for a discussion of the sports literature, and the combination of factors, including extreme postures that have been documented concerning epicondylitis. Exposure-Response Relationship There is little evidence on which to base a discussion exposure response relationship in the epidemiologic studies. Several studies [Ritz 1995; Andersen and Gaardboe 1993a; Dimberg 1987] directly address the issue of work-related versus nonwork-related exposures by assessing both. Two of the most important potential confounders or effect modifiers are age and duration of employment. Nevertheless, in both studies the increase in the risk for epicondylitis in the high-exposure group does not seem related primarily to age, independent of intensity and duration of exposure. Many of the studies controlled for several possible confounders in their analyses. In general, for epicondylitis, psychosocial factors or gender do not appear to be important confounders in occupational studies. These forceful movements included, but were not limited to , repeated dorsiflexion, flexion, pronation, and supination, sometimes with the arm extended. Clinical case series of occupationally-related epicondylitis and studies of epicondylitis among athletes had suggested that repeated forceful dorsiflexion, flexion, pronation, and supination, especially with the arm extended, increased the risk of epicondylitis. In general, the epidemiologic studies have not quantitatively measured the fraction of forceful hand motions most likely to contribute to epicondylitis; rather, they have used as a surrogate qualitative estimation the presence or absence of these types of hand movements [Viikari-Juntura et al. Although we 4-18 recognize this limitation of the epidemiologic studies, there is value in assessing where we are in regards to the epidemiologic evidence of causal inference. There is epidemiologic evidence for the relationship between forceful work and epicondylitis. Those studies that base their exposure assessment on quantitative or semiquantitative data have shown a solid relationship. We conclude that there is insufficient evidence for the association of repetitive work and epicondylitis. For extreme posture in the workplace, the epidemiologic evidence thus far is also insufficient, and we turn to the sports medicine literature to assist us in evaluating the risk of the single factors of repetition and posture. The strongest evidence by far when examining the relationship between work factors and epicondylitis is the combination of factors, especially at higher levels of exposure. This is consistent with the evidence that is found in the biomechanical and sports literature.
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