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The commensal midsouth pain treatment center reviews cheap generic rizact uk, or domestic knee pain treatment running discount rizact online, rodents are Old health significance of these rodent groups are distinct pain treatment for arthritis on the hip purchase line rizact, World rodents which were imported to pain treatment with methadone order 5mg rizact overnight delivery North America cape fear pain treatment center purchase rizact 5mg online. These commensal rodents are not indigenous to pain medication for dogs metacam best order rizact North America but accompanied humans as stowaways on their ships of emigration and trade. The roof rat, Rattus rattus, originated from the southeast Asian mainland, spread along the ancient caravan routes from India across the Middle East, to East Africa and the eastern Mediterranean. Roof rats were probably introduced to the New World during the 15th or 16th Century, first reaching South America in the mid 1500s. The Norway rat, Rattus norvegicus, was introduced later, migrating westward from Central Asia, first appearing in the beginning of the 18th Century. The first record of its introduction into the United States (possibly from Europe) was in the late 1700s. The house mouse, Mus musculus, also spread westward from central Asia, through the Middle East, to the Mediterranean shores and Europe. These mice were probably introduced into Latin America aboard ships from Spain and Portugal and subsequently spread into the southern United States and California. Commensal rodents have a keen sense of hearSensory abilities ing and can detect vibrations in the ultrasonic range. Commensal rodents are nocturnal (active at They are extremely sensitive to sudden or loud noise. Though their eyes are specialized for vision in low light, acuity is generally poor. Most rodents are Physical capabilities color blind, perceiving light in shades of gray. As mentioned earlier, the incisors of rodents grow throughout their lifetime requiring constant gnawTouch. The vibrissae (whiskers) and the long guard ing to keep them at manageable length. Rodents can hairs on their bodies are extremely sensitive to tactile gnaw through any material that is softer than their stimuli. The vibrissae and guard hairs serve as guides enamel, including wood, aluminum, sheetrock, poor (thigmotaxis) along vertical walls and nearby objects, quality concrete, asphalt, hard rubber hoses, electrical providing compensation for rodents poor vision. Commensal rodents have an acute sense of ware cloth, these materials can be used as rodent exsmell. Rats and mice have prominent footpads and tomed to human activity and thus lingering human well developed claws. They have four toes on their front odors do not usually dissuade them from traps and baits. The sense of taste is well developed in comhaired, to balance their bodies when climbing. They prefer fresh food to old or spoiled mensal rodents are excellent climbers and have little food. Some species seem especially sensitive to exor no difficulty climbing rough surfaces of vertical tremely minute quantities of bitter or other unpleasant wooden beams or walls, and can traverse utility and substances included in toxic baits. Norway rats can lethal applications can lead to bait-refusal or bait-shyascend vertical pipes up to 7 cm in diameter. Front foot Commensal rodents are relatively tolerant of changes to the environment given their association with human habitation. Rats accustomed to living in areas where human activity or changes to the environment are frequent may be easier to control than populations where Hind foot interaction with humans is less common. House mice are by nature curious and less neophobic than rats, tending to investigate objects that are recently introduced in their environment. Adult house mice can jump vertically up to ing late fall or early winter, commensal rodents tend to 35 cm (1 ft). In late spring or early summer they return to the outdoors, or might remain Swimming. All three species of commensal rodents are indoors if food and suitable harborage are available. Rats can swim continuously from one to almost three days if necessary, and can remain subReproduction merged for almost 30 seconds. Most speto enter homes by swimming through the water seal in cies reach sexual maturity in 3-5 months. Their burrows consist of several connectmore than a single year; however, in captivity some ing tunnels and have more than one exit. When living outdoors, Commensal rodents can cause significant economic loss house mice will construct shallow burrows in the open to agriculture, especially through consumption and or cultivated fields, or live under piles of rubbish. Fecal contamination of foodstuffs for humans or other Behavior animals can lead to disposal and subsequent loss of Periods of activity. Rodents can also nocturnal and usually have two peaks of night-time disrupt agricultural activities indirectly through destrucfeeding activity. Weaker and less-dominant individution of property such as hoses, storage containers, and als may be forced to be active during daytime. Rodents can cause economic damage to human cant daytime activity observed among primarily nocresidences by gnawing insulation on electric wires turnal species may indicate increased population denwhich can lead to fires; up to 5-20% of fires of unsity. The home range of most rodents is genthe United States may exceed $1 billion annually. Roof rats can readily travel for several blocks along utility wires and overhead vegetation. Roof rats usually occur in smaller family groups and are not as gregarious as the Norway rats. Roof rats are the predominant rodent species in suburban areas and waterside habitats (riprap of shorelines) of the southern coastal and inland valleys of California. Roof rats are also found at Roof rat (Rattus rattus) elevations up to 1070 m (3500 ft) in the Sierra Nevada (black rat, fruit rat, ship rat) foothills of California. Significance: Roof rats can cause considerable damDescription: the roof rat is a moderate-sized rodent, age to buildings, equipment, vegetation, and other slightly smaller than the Norway rat. They frequently destroy length (tip of nose to tail-end) is approximately 35-45 agricultural crops, particularly tree fruits. Tail is longer than the head and body, infectious disease agents are associated with roof rats, measuring 18-26 cm (7-10 in), sparsely haired, and uniincluding Salmonella, Streptobacillus (rat bite fever), formly colored. Roof rats in California Ornithonyssus bacoti, the tropical rat mite, which may vary in color from black with a gray belly to brownishinfest humans if its rodent host is removed. The nose fer of infected fleas from wild to commensal rodents of the roof rats is pointed; the eyes are large. Ears are during an epizootic remains a theoretical risk wherprominent, hairless, usually more than 2 cm (fi in) long ever these species coexist. Food: Although omnivorous, roof rats prefer vegetables, fruits, nuts, and cereal grains. Habitat: Roof rats are semi-arboreal species, preferring to live in fruit and nut orchards, in the crowns of palm trees, in shrubs and vines, and dense growths of Algerian ivy. They prefer to nest above ground, often Norway rat (Rattus norvegicus) in attics, within walls, and in enclosed spaces of cabi(brown rat, sewer rat, wharf rat, house rat, barn rat) nets and shelving. Older residential neighborhoods with overgrown vegetation and newer residential suburban Description: the Norway rat is the largest of the comdevelopments amidst former orchards are likely habimensal rodents. The total length is blackberry thickets, grain mills, poultry ranches, aniapproximately 32-46 cm (13-18 fi in). The muzzle is blunt, the eyes are small, and the ears are small, rarely over 2 cm (fi in) long, close-set, and covered with fine hairs. Food: Norway rats are omnivorous, but prefer meat, poultry, fish and other sea food, garbage, and cereal grains. Habitat: Norway rats are primarily a burrowing speDescription: the house mouse is small and resembles cies. The body of the house mouse is slendations of buildings, in soil banks, rock piles, along der averaging 15-20 g (0. The tail is uniformly the absence of sanitary landfills, they also occupy gray in color and equal to, or slightly longer than the poorly managed rubbish and garbage dumps. Fur is also be encountered in sewers, in wharf areas, and in gray to brown with the underside slightly lighter, varythe riprap of shores. The muzzle is pointed, eyes are frequent cellars, stores, warehouses, slaughterhouses, prominent, and ears are large, about 1. Norway rats are gregarious and have feeders, with a daily food requirement of about 0. House mice can survive in a dry habitat the Norway rat is the natural host of the oriental rat without available water, as they are capable of hydroflea, Xenopsylla cheopis, the classic vector of plague. Habitat: House mice will occupy any convenient space between walls, inside cabinets, in or under furniture, warehouses, and storage areas. When conditions are favorable, house mice can live outdoors quite independently of humans, in weeds, grasslands and in piles of rubbish. Their home range is very limited, usually 310 m (10-30 ft), as they prefer to have their nesting sites close to a food source. They are also often infected with Salmonella and carry mites capable of transmitting rickettsialpox. They are rarely seen during daytime cal contamination of foodstuffs, commensal rodents unless populations are large. Their presence is usually serve as a reservoir or vector for numerous microbiodetermined by indirect evidence of activity. From these logic pathogens that are potentially infectious to husigns, one can ascertain species of rodent, the populamans. A partial list of these diseases and their most tion density, and whether the infestation is current or frequently associated rodent host is provided in Table old. Rodent-borne diseases are transmitted directly by contamination of human food with their feces or urine, Droppings. Fresh droppings are usually shiny, soft, and contact with infected body fluids and/or rodent blood, moist. Rodents will generally use the same, familthrough bites exacted inadvertently or during attempts iar pathways from their harborage to obtain food and to protect themselves. In older, larger metropolitan arwater, navigating by continual body contact with a vereas, rat bite estimates range from 5 to 10 per 100,000 tical wall, fence, or other surface. Indoors, these runpersons, though this is likely an underestimate as rat ways are evident as grease marks along walls, steps, bites are not routinely reported. Outdoors, other persons who are incapable of protecting themthe runways can be seen as narrow beaten pathways selves may be more susceptible to rat bites. Selected infectious disease associated with California rodents Disease Etiologic (causative) Reservoir Vector/s-Mode of Transmission Agent Plague Bacteria Fleas Urban Commensal rodents Xenopsylla cheopis Yersinia pestis Sylvatic Ground squirrels, chipmunks, woodrats Oropsylla montana, Hoplopsyllus anomalus, and several other species of wild rodent fleas Lyme Disease Bacteria Peromyscus spp. Ixodes pacificus Relapsing Fever Bacteria Chipmunks Soft tick Borrelia hermsii Ornithodoros hermsi Leptospirosis Bacteria Commensal rodents, Urine contamination Leptospira spp. Dermacentor andersoni Hantavirus Pulmonary Virus Peromyscus maniculatus Inhalation of aerosolized excreta Syndrome Sin Nombre virus Babesiosis Protozoan Presumably wild rodents Bites by infected Ixodes ticks, blood Babesia sp. Urine stains may or may not be readily ground or floor level, whereas rub marks caused by observed in normal light. A portable ultraviolet light roof rats are more common overhead among beams in usually helps fluoresce suspected urine stains. These may be found of cross beams as the roof rats travel along rafters, or lodged around entry points, in their feces, and in conwhere the rafters connect to the walls (Figure 6-4). Characteristic musty odors Unless a heavy infestation is present, house mice do may be present when heavy infestations occur, espenot commonly leave rub marks. Planning an integrated rodent control program Because of the complexity of biological and behavioral factors involved, control of commensal rodents, whether community-wide or on a local scale, should be carefully planned. A comprehensive control strategy should include all of the following actions: Identify the rodent species and estimate the size and extent of infestation. Figure 6-4 Assess the motivation, knowledge, attitude, and acceptance of affected persons towards the conSound. However, when infestations are heavy, rodents may be seen Estimate costs and relative benefits of control during daytime. Burrow systems are Conduct environmental sanitation/modification, usually located near a source of food and water. The structural modification (exclusion), and prevenpresence of fresh food fragments and freshly dug earth tive maintenance. Freshly gnawed Population reduction marks will show distinct tooth marks, but as they get A population is the estimated number of pest rodents older, the gnawed areas become darker with grease and within the area of concern, be that a city block, regional smoother with repeated body contact. Laying smooth tracking patches of flour or talc components of an effective rodent suppression program along runways may bring to light rodent activity. The can include trapping, poison-baiting, use of tracking five-toed hind feet may leave more distinct tracks than powders, ectoparasite control, or a combination of the four-toed front feet. If rodents are observed traversing for controlling small number of rodents within homes, water pipes, two traps should be fastened to the pipe, schools, food processing/handling plants, hospitals, and with the trigger ends of each trap facing in the opposite other environments in which sanitation and limited directions. The commonly Wear gloves to remove captured rodents and dispose available snap trap is the most effective and widely of the carcasses in a secured plastic bag. Bait selection for snap traps can be a complex matter and the most effective bait can vary between different populations of the same rodent species. Although rodents are omnivorous, they have specific food preferences: Norway rats prefer meats and meat products, bacon, and fresh, smoked, or dried fish; roof rats prefer nuts, fruits, and vegetables, but will also feed on meat or meat products; house mice prefer grains and cereal products. Peanut butter, especialy the chunky variety, is often accepted by all three species. Figure 6-6 Unless a disease surveillance or special scientific study is being conducted, the use of live-animal traps is not generally recommended as a control method because of the potential for transmission of diseases and ectoparasites while handling live rodents. Individuals interested in conducting live trapping of rodents should consult with an experienced professional before embarking on such a project. Check the operation of the traps before placement to ensure that they are working properly. Place the traps in areas rodents frequent, including runways, at entry points, and in close proximity to nesting areas.

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For projections pain medication for dogs with tumors cheap 10mg rizact fast delivery, Figure 22 provides two snapshots of the low-growth scenario (A2A1) for 2020 and 2050 pain treatment center of franklin tennessee purchase rizact no prescription. In both future years pain treatment center southaven ms cheap rizact 5mg amex, many countries are projected to pain treatment arthritis purchase rizact 10mg without prescription experience a decrease in environmental capacity pain medication for pancreatitis in dogs order rizact 5 mg without prescription, in some cases partially compensated for by increases in other areas backbone pain treatment yoga order 5 mg rizact mastercard. Key Contributors to Adaptive Capacity by Country As stated above, there are several key indicators/parameters for any given country that can provide insight into its adaptive capacity, such as literacy rates, basic services, energy supply, and changes in production. In Latin America and the Caribbean, population has steadily increased since the 1900s and is expected to continue the trend through 2030. Availability of adequate human resources is a necessary condition to enhance adaptive capacity. It is also important that these resources have the appropriate level of education and access to basic services in order to have the ability to support economic growth. An illiterate person is defined as an individual unable to read and write a short simple statement on his or her everyday life. Nicaragua and Haiti, however, in 2005 still had greater than one third of the population older than 15 years of age classified as illiterate. This significantly affects economic growth, economic diversification, and adaptive capacity. Table 8 shows past and projected population for the selected countries, and Table 9 illustrates the level of illiteracy in the region. Throughout the 1970s, 1980s, and 1990s the countries in Central America and the Caribbean experienced long periods of social unrest, capital flight, economic contraction, and large intraregional and extra-regional migration. Nicaragua and El Salvador, in particular, saw many of their best flee to Costa Rica beginning in the 1970s, and by 2000 over 8 percent of Costa Rica consisted of immigrants from those two countries. During the same period, Mexico also received many migrants from Guatemala and Nicaragua. At the end of the 1990s, Guatemala and the other countries in the region signed peace agreements and experienced the repatriation of many of their citizens from Mexico. By 2000, Mexico had a significantly smaller portion of immigrants from these countries than it had in 1990. There is also the added element of intra-regional seasonal migration exercised by those following the agricultural sector for employment. On a yearly basis, there are migrations from northern Panama to southern Costa Rica and from northern Guatemala to southern Mexico. Migration from Central America and the Caribbean to the United States also increased during the same period. The largest growth in the number of immigrants from Latin America to the United States occurred from 1990 to 2000 when a 97 percent increase occurred. The proportion of the original total population that migrated to the United States during this period represented a wide range of the total population in the country of origin in the year 2000. The proportion ranged from 13 percent in the case of El Salvador, 9 percent for Mexico, 8 percent for Dominican Republic, 7. The migration from Central America and the Caribbean, intra-regional and extra regional, has resulted in a systematic and regular transfer of funds from the United States and other countries to the families and relatives that remained in the countries of origin. They are the fourthand fifth-largest remittance-receiving countries in Latin America and the Caribbean. The low levels of the latter three reflect the fact that they have relatively few emigrants in the United States. While much attention is given to remittances from developed countries, particularly the United States, there are substantial intra-regional remittance flows too. A 2003 study of Costa Rica and Nicaragua revealed that about one-third of remittances received in Nicaragua are sent from Costa Rica. Since Mexico is the second largest destination of Guatemalan workers after the United States, it can easily be concluded that some of the remittances going to Guatemala are coming from Mexico. Another key indicator of the level of adaptive capacity is the infrastructure for basic services. In most of the countries selected for this assessment the majority of the population is concentrated in urban areas, and the largest urban areas are found in the coastal areas of the countries. Basic infrastructure/services such as water, electricity, and sewage are important elements in the ability to reduce and recover from the impact of such extreme events as hurricanes, floods, and droughts. Table 3 depicts the level of basic infrastructure in some of the selected countries. Another key contributor to adaptive capacity is the extent of forests in this region. Deforestation is a significant environmental issue for every country selected for this report. These areas are projected to be used for pasture and expanding livestock production. During this timeframe Cuba was the only country that experienced increases in forest area. Except for the Dominican Republic, which maintained the size of its forest area, all the other countries have steadily reduced their forests, from 6 percent in Costa Rica and Mexico to 37 percent in Honduras. Several countries in Central America and the Caribbean as well as Mexico have made an effort to increase the amount of protected areas. Table 11 shows how the selected countries have changed protected areas from 1990 to 2007. Mexico is the largest contributor, having doubled the amount of land under protection and increasing the amount of marine areas many-fold during the same period. Mexico 76 640 131 775 148 505 180 210 187 004 4 408 35 255 40 660 40 660 45 021 Republica Dominicana. Conclusions the systematic evaluation of the impact of climate change in the Caribbean and Central American is only beginning. Most of the countries, however, are beginning to quantify greenhouse gas inventories and run simulation models to estimate the potential impact associated with projected global average increase in temperatures, rise in sea level, and changes in rainfall. Even if these studies are not yet available, leaders in the region now accept that, while the region does not contribute to global greenhouse gases in a significant way, it is highly vulnerable to the effects generated by severe climate variability. This has been observed over the past 20 years, and leaders understand that it is critical for them to develop sustainable development policies and to enhance their capabilities to respond and adapt to severe weather events. Energy resources, production, and use vary widely across the countries under review. All the countries under review will experience population growth, economic growth, and industrialization, they will increase their need and demand for energy. All the countries rely on imported fossil fuels, with the exception of Mexico, which is a net exporter of energy resources. Although they are very small contributors to global emissions, most countries will benefit from increasing use of renewable energy. Most have begun efforts to evaluate and implement small projects, such as wind energy in Nicaragua and Costa Rica and an intensive effort in the Dominican Republic to evaluate hydro electricity. As populations continue to grow in the same areas, increasing water extraction and rising sea levels are expected to have severe impact on the quantity and quality of water available. Many of the aquifers of these countries are open to ocean waters and are already experiencing increases in salinity. Rising sea levels will accelerate the deterioration of aquifers and available water resources. An increase in intra-regional and extra-regional migration during the 1980s and 1990s resulted from social unrest and economic contraction. The large number of immigrants coming to the United States in the past 2025 years will facilitate this movement. In addition, the observed and projected incidence of diseases and pathogens varies across the countries under review. The Government of the Dominican Republic has not observed and has not projected a correlation between climate change variability and increases in health effects of its population. It is not clear if it is a difference in the quality of information or the limitations of the models used in the initial assessments of each country. Although most countries in the Central America and Caribbean region have started to evaluate the impact of climate change in their economic, social, and natural resources, there is limited understanding of the viable options to address the problems. Many limitations that exist today on climate change preclude making projections good enough to take action. They include limitations in models used, quality of data, and quantity of relevant data. Equally problematic is the limitation of funding to undertake detailed modeling for each country in such a way that the result is information that also ranks, evaluates and recommends financial options. Reviewers must still capture the full impact on socio-economic systems and the ability of those systems to recover and adapt to and reduce the effects of severe weather events. The first assessments submitted by these countries have laid the foundation for improving models used and for improving the quality and quantity of data. The initial studies have also illustrated the gaps that exist between the current level of knowledge and what is needed for the development of policies that will improve the adaptive and response capacities of the countries under review. Over the rest of South America (central and northern Andes, eastern Brazil, Patagonia) the biases tend to be predominantly negative. The largest biases occur during the boreal winter and spring seasons, when precipitation is meager. Unfortunately, this choice of regions for averaging is particularly misleading for South America since it does not clearly bring out critical regional biases such as those related to rainfall underestimation in the Amazon and La Plata Basins. Simulation of the regional climate is seriously affected by model deficiencies at low latitudes. The simulations have a systematic bias towards underestimated rainfall over the Amazon Basin. The simulated subtropical climate is typically also adversely affected by a dry bias over most of south-eastern South America and in the South Atlantic Convergence Zone, especially during the rainy season. In contrast, rainfall along the Andes and in northeast Brazil is excessive in the ensemble mean. However, in general, the largest errors are found where the annual cycle is weakest, such as over tropical South America (see. This model ensemble captures some large-scale features of the South American monsoon system reasonably well, including the seasonal migration of monsoon rainfall and the rainfall associated with the South America Convergence Zone. However, the South Atlantic subtropical high and the Amazonia low are too strong, whereas low-level flow tends to be too strong during austral summer and too weak during austral winter. The model ensemble captures the Pacific-South American pattern quite well, but its amplitude is generally underestimated. Seth and Rojas (2003) performed seasonal integrations driven by reanalyses, with emphasis on tropical South America. The model was able to simulate the different rainfall anomalies and large-scale circulations but, as a result of weak low-level moisture transport from the Atlantic, rainfall over the western Amazon was underestimated. Annex B: Information Deficiencies that Preclude a Full Evaluation of the Impact of Climate Change on Central America, the Caribbean, and the Regions Adaptive Capacity Regional leaders have not addressed the problem of the projected impact of climate change with possible policy changes or infrastructure investments because of a lack of systematic analysis that quantifies and qualifies the potential impact to the region. This lack of rigorous analysis restricts the development of relevant and economically viable options. There are significant gaps in the ability to fully understand all the dimensions of climate change at the economic, social, and/or environmental level in the region in a systematic way. There are gaps and deficiencies in data, systematic methodologies/analysis, and tools to monitor, share, and track information and events at the local, national, and regional levels. Several entities at the national and regional levels are working to develop better analytical methods and information-sharing as well as better data and availability. To increase the likelihood that this evaluation represents a reasonable assessment of projected climate change and its impact in Central America and the Caribbean as well as the regions adaptive capacity, the following gaps would need to be addressed: In physical science research, regional analyses will continue to be limited by the inability to model regional climates satisfactorily, including complexities arising from the interaction of global, regional, and local processes. One gap of particular interest is the lack of medium-term (20-30 years) projections that could be relied upon for planning purposes. Similarly, scientific projections of water supply and agricultural productivity are limited by inadequate understanding of various climate and physical factors affecting both areas. Similar types of issues exist for the biological and ecological systems that are affected. Again, research agendas on vulnerability, adaptation, and decision-making abound. The first carbon cycle models did not include carbon exchanges involving the terrestrial domain. In another example, ecosystems research models are only beginning to account for changes in pests. As anthropogenic climate change is the result of human decisions, the lack of knowledge about motivation, intent, and behavior is a serious shortcoming. Overall, research about the impact of climate change on the Central America and Caribbean region has been undertaken piecemeal: discipline by discipline, sector by sector, with political implications separately considered from physical effects. Outside the National Communications, small-scale case studies have been done, but little systematic analysis. This lack of rigorous analysis can be remedied by integrated research into the energy, economic, environmental, and political conditions and possibilities. Holloway, Tropical drying trends in global warming models and observations, Proceedings of the National Academy of Sciences 103 (April 18, 2006): 16. Campbell, Biological response to climate change on a tropical mountain, Nature 398(1999): 611 615. Nebojsa Nakicenovic and Rob Swart (Cambridge: Cambridge University Press, 2000). Hewitson, Regional Climate Projections: Supplementary Material, in Climate Change 2007: the Physical Science Basis, eds. Diaz, Climate change scenario for Costa Rican montane forests, Geophysical Research Letters 35 (2008).


Regular physical activity has no apparent effect on statural growth and biological maturation myofascial pain treatment center san francisco discount 5mg rizact with mastercard. Data suggesting later menarche in female athletes are associational and retrospective a better life pain treatment center golden valley az buy 10mg rizact fast delivery, and do not control for other factors that influence the age at menarche advanced diagnostic pain treatment center order 5 mg rizact with amex. It is also associated with greater skeletal mineralization tuomey pain treatment center discount 5 mg rizact fast delivery, bone density heel pain treatment video buy generic rizact 10 mg on line, and bone mass (Bailey and McCulloch pain solutions treatment center buy discount rizact on-line, 1990). However, excessive training associated with, or causing, sustained weight loss and maintenance of excessively low body weights may contribute to bone loss and increased susceptibility to stress fractures (Dhuper et al. Information is scant on the relationship between childrens physical activity and fitness and present and future health status (Malina, 1994; Twisk, 2001). Most evidence is limited to cross-sectional comparisons of active and nonactive children. Active children tend to have lower skinfold thickness than inactive children (Raitakari et al. Exercise training has been shown to slightly reduce the percentage body fat and improve lipoprotein profile in obese children (Gutin et al. The tracking of body fatness, blood pressure, and lipoprotein profile appears to be moderate from adolescence into adulthood (Clarke et al. The energy cost of growth comprises the energy deposited in newly accrued tissues and the energy expended for tissue synthesis. It is recognized that the energy deposited in newly synthesized tissues varies in childhood, particularly around the adolescent growth spurt, but these variations minimally impact total energy requirements. Longitudinal data on the body composition of normally growing adolescents are not available. However, Haschke (1989) estimated the typical body composition of male and female adolescents from literature values of total body water, potassium, and calcium. The energy cost of tissue deposition was approximately 20 kcal/d, increasing to 30 kcal/d at peak growth velocity. Marked variability exists in the energy requirements of adolescents due to varying rates of growth and physical activity levels (Zlotkin, 1996). In adolescents, growth is relatively slow except around the adolescent growth spurt, which varies considerably in timing and magnitude between individuals. Occupational and recreational activities also variably affect energy requirements. The equations below are the same as those used for children ages 3 to 8 years, but the additional amount added to cover energy deposition resulting from growth is somewhat larger (25 kcal/d compared with 20 kcal/d). One way to do this is to evaluate physical efforts by estimating how many miles an individual would have to walk in one day to induce a comparable level of exertion (in terms of kcal expended). Unlike food intake, which is generally underreported, physical activities tend to be overestimated, and activities of one kind may cause a reduction in activities of another. Plots of the residuals showed no evidence of nonlinear patterns of bias (although there was a general increased magnitude of residuals with increasing values of each variable). Basal metabolism increases during pregnancy due to the metabolic contribution of the uterus and fetus and increased work of the heart and lungs. The increase in basal metabolism is one of the major components of the increased energy requirements during pregnancy (Hytten, 1991a). In late pregnancy, approximately one-half the increment in energy expenditure can be attributed to the fetus (Hytten, 1991a). The fetus uses about 8 ml O2/kg body weight/min or 56 kcal/kg body weight/d; for a 3-kg fetus, this would be equivalent to 168 kcal/d (Sparks et al. The basal metabolism of pregnant women has been estimated longitudinally in a number of studies using a Douglas bag, ventilated hood, or whole-body respiration calorimeter (Durnin et al. Marked variation in the basal metabolic response to pregnancy was seen in 12 British women measured before and throughout pregnancy (Goldberg et al. Energy-sparing or energy-profligate responses to pregnancy were dependent on prepregnancy body fatness. Nonpregnant prediction equations based on weight are not accurate during pregnancy since metabolic rate increases disproportionately to the increase in total body weight. In late gestation, the anti-insulinogenic and lipolytic effects of human chorionic somatomammotropin, prolactin, cortisol, and glucagon contribute to glucose intolerance, insulin resistance, decreased hepatic glycogen, and mobilization of adipose tissue (Kalkhoff et al. Although levels of serum prolactin, cortisol, glucagon, and fatty acids were elevated and serum glucose levels were lower in one study, a greater utilization of fatty acids was not observed during late pregnancy (Butte et al. These observations are consistent with persistent glucose production in fasted pregnant women, despite lower fasting plasma glucose concentrations. After fasting, the total rates of glucose production and total gluconeogenesis were increased, even though the fraction of glucose oxidized and the fractional contribution of gluconeogenesis to glucose production remained unchanged (Assel et al. Until late gestation, the gross energy cost of standardized nonweight-bearing activity does not significantly change. In the last month of pregnancy, the energy expended while cycling was increased on the order of 10 percent. The energy cost of standardized weight-bearing activities such as treadmill walking was unchanged until 25 weeks of gestation, after which it increased by 19 percent (Prentice et al. Standardized protocols, however, do not allow for behavioral changes in pace and intensity of physical activity, which may occur and conserve energy during pregnancy. Gestational weight gain includes the products of conception (fetus, placenta, and amniotic fluid) and accretion of maternal tissues (uterus, breasts, blood, extracellular fluid, and adipose). The energy cost of deposition can be calculated from the amount of protein and fat deposited. The total energy deposition between 14 and 37+ weeks of gestation was calculated based on an assumed protein deposition of 925 g of protein, and energy equivalences of 5. Total energy deposition during pregnancy was estimated from the mean fat gain of 3. Lactation Evidence Considered in Determining the Estimated Energy Requirement Basal Metabolism. The increased energy expenditure is consistent with the additional energy cost of milk synthesis. Theoretically, the energy cost of lactation could be met by a reduction in the time spent in physical activity or an increase in the efficiency of performing routine tasks. The energetic cost of nonweight-bearing and weight-bearing activities has been measured in lactating women (Spaaij et al. Adaptations in the level of physical activity are not always seen in lactating women. Reductions in physical activity have been reported in early lactation (4 to 5 weeks postpartum) in the Netherlands (van Raaij et al. Physical activity increased in the lactating Dutch women from 5 to 27 weeks postpartum (van Raaij et al. While a decrease in moderate and discretionary activities appears to occur in most lactating women in the early postpartum period, activity patterns beyond this period are highly variable. These sources of error may be attributed to isotope exchange and sequestration that occurs during the de novo synthesis of milk fat and lactose, and to increased water flux into milk (Butte et al. Milk energy output is computed from milk production and the energy density of human milk. Beyond 6 months postpartum, typical milk production rates are variable and depend on weaning practices. The energy density of human milk has been measured by bomb calorimetry or proximate macronutrient analysis of representative 24-hour pooled milk samples. The changes in weight and therefore energy mobilization from tissues occur in some, but not all, lactating women (Butte and Hopkinson, 1998; Butte et al. In general, during the first 6 months postpartum, well-nourished lactating women experience a mild, gradual weight loss, averaging 0. Changes in adipose tissue volume in 15 Swedish women were measured by magnetic resonance imaging (Sohlstrom and Forsum, 1995). In the first 6 months postpartum, the subcutaneous region accounted for the entire reduction in adipose tissue volume, which decreased from 23. Mobilization of tissue reserves is a general, but not obligatory, feature of lactation. In the 10 lactating British women, the total energy requirements (and net energy requirements, since there was no fat mobilization) were 2,646, 2,702, and 2,667 kcal/d (11. In 23 lactating Swedish women, the total energy requirement at 2 months postpartum was 3,034 kcal/d (12. In nine lactating American women, the total energy requirement was 2,413 kcal/d (10. The women in the above studies were fully breastfeeding their infants, who were less than 6 months of age. In these studies, mean milk energy outputs during full lactation were similar (483 to 538 kcal/d or 2. During the first 6 months of lactation, milk production rates are increased (Butte et al. Customary milk production rates beyond 6 months postpartum typically vary and depend on weaning practices (Butte et al. Because adaptations in basal metabolism and physical activity are not evident in wellnourished women, energy requirements of lactating women are met partially by mobilization of tissue stores, but primarily from the diet. In the first 6 months postpartum, well-nourished lactating women experience an average weight loss of 0. The coefficients and standard error derived for only overweight and obese men and women are provided in Appendix Table I-10. For the combined data sets, the standard deviations of the residuals ranged from 182 to 321. Persons who do not wish to lose weight should receive advice and monitoring aimed at weight maintenance and risk reduction. This could be due to a reduction in energy expenditure per kg body weight or to a decrease in physical activity. These values can be used to estimate the anticipated reduction in metabolizable energy intake necessary to achieve a given level of weight loss, if weight loss is achieved solely by a reduction in energy intake and there is no change in energy expenditure for physical activity. For example, a weight loss of 1 to 2 lb/wk (65 to 130 g/d) is equivalent to a body energy loss of 468 to 936 kcal/d, because the energy content of weight loss averages 7. Therefore, to maintain a rate of weight loss of 1 to 2 lb/wk, the reduction in energy intake would need to be 844 (468 + 376) to 1,478 kcal/d (936 + 542) after 10 weeks of weight loss. The impact on energy expenditure of weight loss regimens involving lesser or greater reductions in energy intake need to be assessed before rates of weight reduction can be more precisely predicted. However, it must be appreciated that reduction in resting rates of energy expenditure per kilogram of body weight have a small impact on the prediction of energy deficits imposed by food restriction, and the greatest cause of deviation from projected rates of weight loss lies in the degree of compliance. In addition, children under 2 years of age should not be placed on energy-restricted diets out of concern that brain development may inadvertently be compromised by inadequate dietary intake of fatty acids and micronutrients. Mean of the residuals did not differ from zero, and the standard deviation of the residuals ranged from 74 to 213. The mean of the residuals did not differ from zero and the standard deviation of the residuals ranged from 73 to 208. The specific equation for the overweight and obese boys was statistically different from the equation derived solely from normal-weight boys (P > 0. The specific equation for the overweight and obese girls was statistically different from the equation derived solely from normal-weight girls (P > 0. The equations for the normal-weight boys and girls differed from the combined equation (P = 0. Weight Reduction in Overweight Children Ages 3 Through 18 Years Weight reduction at a rate of 1 lb/m (15 g/d) is equivalent to a body energy loss of 108 kcal/d (assuming the energy content of weight loss averages 7. This lack of data makes it impossible to describe the relationship between change in energy intake and change in body energy for children in whom weight loss is indicated. However, if the negative energy balance is achieved by a reduction in energy intake alone, at least a 108 kcal/d decrease in energy intake. Small reductions in energy intake of the magnitude required to resolve childhood overweight gradually over time are within the potential for ad libitum changes induced by improvements in dietary composition. When energy intake is unable to match energy needs (due to insufficient dietary intake, excessive intestinal losses, or a combination thereof) several mechanisms of adaptation come into play (see earlier section, Adaptation and Accommodation). Reduction in voluntary physical activity is a rapid means of reducing energy needs to match limited energy input. In children, reduction in growth rates is another important mechanism of accommodation to energy deficit. Under conditions of persistent energy deficit, the low growth rate will result in short stature and low weight-for-age, a condition termed stunting. A chronic energy deficit elicits mobilization of energy reserves, progressively depleting its main source: adipose tissue. Thus, an energy deficit of certain duration is associated with changes in body weight and body composition. As body weights decrease, so do energy requirements, although energy turnover may be higher when expressed per kg of body weight due to a predominant loss of fat tissue relative to lean tissue. In healthy, normal-weight individuals who face a sustained energy deficit, several hormonal mechanisms come into play, including a reduction in insulin release by the pancreas, a reduction in the active thyroid hormone T3, and a decrease in adrenergic tone. These steps are aimed at reducing cellular energy demands by reducing the rates of key energy-consuming metabolic processes. However, there is less evidence that similar mechanisms are available to individuals who already have a chronic energy deficit when they are faced with further reductions in energy input (Shetty et al. The effects of chronic undernutrition in children include decreased school performance, delayed bone age, and increased susceptibility to infections. Although estimates of energy needs can be made based on the initial deficit, body weight gain will include not only energy stored as fat tissue, but also some amount in the form of skeletal muscle and even visceral tissues. Thus, as recovery of body weight proceeds, the energy requirement will vary not only as a function of body weight but in response to changes in body composition. The energy needs for catch-up growth for children can be estimated from the energy cost of tissue deposition.

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High As Likely As Not Moderate evidence (several sources achilles tendon pain treatment exercises order rizact paypal, some consistency pain treatment on suboxone purchase 10 mg rizact visa, methods Documenting Uncertainty: fi 1 in 2 vary and/or documentation limited treatment for long term pain from shingles buy genuine rizact on line, Confdence and Likelihood etc back pain treatment nhs generic rizact 10mg amex. Confdence is expressed sources pain management for my dog effective 10mg rizact, extrapolations alternative pain treatment center tacoma best 10 mg rizact, inconsistent fndings, poor documentation qualitatvely and ranges from low confdence (inconclusive and/or methods not tested, etc. Department of Health and Human Services, Lead Coordinator Offce of the Assistant Secretary for Preparedness and Response Allison Crimmins, U. Easterling, National Oceanic and Atmospheric Administration Committee Members Kristie L. Ebi, University of Washington John Balbus, National Institutes of Health Rebecca J. Beard, Centers for Disease Control and Prevention Vanessa Escobar, National Aeronautics and Space Administration Rona Birnbaum, U. Environmental Protection Agency Barry Flanagan, Centers for Disease Control and Prevention Janet L. Environmental Protection Agency Jada Garofalo, Centers for Disease Control and Prevention Jada F. Environmental Protection Agency Cristina Gonzalez-Maddux, formerly Institute for Tribal Environmental Lesley Jantarasami, U. Environmental Protection Agency Professionals George Luber, Centers for Disease Control and Prevention Micah Hahn, Centers for Disease Control and Prevention Shubhayu Saha, Centers for Disease Control and Prevention Elaine Hallisey, Centers for Disease Control and Prevention Paul Schramm, Centers for Disease Control and Prevention Michelle D. Global Change Research Program, Administration National Coordination Offce Mary Hayden, National Center for Atmospheric Research Kimberly Thigpen Tart, National Institutes of Health Stephanie C. Herring, National Oceanic and Atmospheric Juli Trtanj, National Oceanic and Atmospheric Administration Administration Jeremy Hess, University of Washington Radley Horton, Columbia University Chapter Authors Sonja Hutchins, Centers for Disease Control and Prevention Vito Ilacqua, U. Department of Health and Human Services John Jacobs, National Oceanic and Atmospheric Administration Allan Auclair, U. Barker, University of California, Davis Patrick Kinney, Columbia University Charles B. Department of Health and Human Services, Carolina Substance Abuse and Mental Health Services Administration Kaitlin Benedict, Centers for Disease Control and Prevention Samar Khoury, Association of Schools and Programs of Public Martha Berger, U. Environmental Protection Agency Health Karen Bouye, Centers for Disease Control and Prevention Max Kiefer, Centers for Disease Control and Prevention, National Terry Brennan, Camroden Associates, Inc. Institute for Occupational Safety and Health Joan Brunkard, Centers for Disease Control and Prevention Jessica Kolling, Centers for Disease Control and Prevention Vince Campbell, Centers for Disease Control and Prevention Kenneth E. Kunkel, Cooperative Institute for Climate and Satellite Karletta Chief, the University of Arizona North Carolina, Tracy Collier, National Oceanic and Atmospheric Administration and Annette La Greca, University of Miami University Corporation for Atmospheric Research Erin Lipp, the University of Georgia Kathryn Conlon, Centers for Disease Control and Prevention Irakli Loladze, Bryan College of Health Sciences Allison Crimmins, U. Environmental Protection Agency Jeffrey Luvall, National Aeronautics and Space Administration Stacey DeGrasse, U. Department of Health and Human Services, Arie Manangan, Centers for Disease Control and Prevention Offce of the Assistant Secretary for Preparedness and Response Marian McDonald, Centers for Disease Control and Prevention U. Global Change Research Program xii Impacts of Climate Change on Human Health in the United States Sandra McLellan, University of Wisconsin-Milwaukee Chapter Coordinators David M. Environmental Protection Agency Stephanie Moore, National Oceanic and Atmospheric Administration Jada F. Garofalo, Centers for Disease Control and Prevention and University Corporation for Atmospheric Research Lesley Jantarasami, U. Environmental Protection Agency Rachel Morello-Frosch, University of California, Berkeley Andrea Maguire, U. Environmental Protection Agency Joshua Morganstein, Uniformed Services University of the Health Daniel Malashock, U. Department of Health and Human Services, Sciences Public Health Service Christopher G. Environmental Protection Agency Jennifer Runkle, Cooperative Institute for Climate and Satellites Nicholas H. Ogden, Public Health Agency of Canada North Carolina Hans Paerl, the University of North Carolina at Chapel Hill Marcus C. Global Change Research Program, Carlos Perez Garcia-Pando, Columbia University National Coordination Offce Dale Quattrochi, National Aeronautics and Space Administration John Ravenscroft, U. Schramm, Centers for Disease Control and Prevention Subcommittee on Global Change Research Leadership and Carl J. Department of Commerce Services, Offce of the Assistant Secretary for Preparedness and Response Vice Chairs Mario Sengco, U. Environmental Protection Agency Michael Freilich, National Aeronautics and Space Administration Mark M. Army Corps of Engineers (Adjunct) Joel Schwartz, Harvard University Perry Sheffeld, Icahn School of Medicine at Mount Sinai, New York Principals Alexis St. Department of Health and Human Services Kimberly Thigpen Tart, National Institutes of Health William Breed, U. Department of the Interior Juli Trtanj, National Oceanic and Atmospheric Administration Pierre Comizzoli, Smithsonian Institution Robert Ursano, Uniformed Services University of the Health Wayne Higgins, U. Department of Agriculture Joanna Watson, Centers for Disease Control and Prevention, Jack Kaye, National Aeronautics and Space Administration National Institute for Occupational Safety and Health Dorothy Koch, U. Wolkin, Centers for Disease Control and Prevention Craig Robinson, National Science Foundation Lewis Ziska, U. Department of Housing and Urban John Balbus, National Institutes of Health Development George Luber, Centers for Disease Control and Prevention J. Department of State National Aeronautics and Space Administration Joshua Glasser, Bureau of Oceans and International Environmental Sue Estes, Universities Space Research Association and Scientifc Affairs John Haynes, Science Mission Directorate U. Department of Agriculture Martha Berger, Offce of Childrens Health Protection Isabel Walls, National Institute of Food and Agriculture Rona Birnbaum, Offce of Air and Radiation Bryan Bloomer, Offce of Research and Development U. Department of Commerce Allison Crimmins, Offce of Air and Radiation Michelle Hawkins, National Oceanic and Atmospheric Amanda Curry Brown, Offce of Air and Radiation Administration Janet L. Gamble, Offce of Research and Development Hunter Jones, National Oceanic and Atmospheric Administration Vito Ilacqua, Offce of Research and Development Juli Trtanj, National Oceanic and Atmospheric Administration Michael Kolian, Offce of Air and Radiation Marian Rutigliano, Offce of Research and Development U. Department of Defense Jean-Paul Chretien, Armed Forces Health Surveillance Center White House National Security Council James Persson, U. Department of Health and Human Services Review Editors John Balbus, National Institutes of Health Charles B. Global Change Research Program xv Impacts of Climate Change on Human Health in the United States References: 1. National Academies of Sciences Engineering and Medicine, ties/available-technical-inputs 2015: Review of the Draft Interagency Report on the Impacts of Climate Change on Human Health in the United States. The report responds to the 1990 Congressional mandate to assist the Nation in understanding, assessing, predicting, and responding to human-induced and natural processes of global change. The purpose of this assessment is to provide a comprehensive, evidence-based, and, where possible, quantitative estimation of observed and projected climate change related health impacts in the United States. Environmental Protection Agency National Oceanic and Atmospheric Administration John Balbus Stephanie C. Herring National Institutes of Health National Oceanic and Atmospheric Administration Janet L. Bell Shubhayu Saha Cooperative Institute for Climate and SatellitesNorth Carolina Centers for Disease Control and Prevention Daniel Dodgen Marcus C. Environmental Protection Agency Assistant Secretary for Preparedness and Response Juli Trtanj Rebecca J. Eisen National Oceanic and Atmospheric Administration Centers for Disease Control and Prevention Lewis Ziska Neal Fann U. The Impacts of Climate Change on Human Health in the United States: A Scientifc Assessment. Rising greenhouse gas threats, together with changes in sensitvity and the ability to concentratons result in increases in temperature, changes in adapt to those threats, increases a persons vulnerability to cliprecipitaton, increases in the frequency and intensity of some mate-related health efects. These climate human health interact with underlying health, demographic, change impacts endanger our health by afectng our food and and socioeconomic factors. Through the combined infuence water sources, the air we breathe, the weather we experience, of these factors, climate change exacerbates some existng and our interactons with the built and natural environments. While As the climate contnues to change, the risks to human health all Americans are at risk, some populatons are disproporcontnue to grow. Already in the United and pregnant women, older adults, vulnerable occupatonal States, we have observed climate-related increases in our groups, persons with disabilites, and persons with preexistng exposure to elevated temperatures; more frequent, severe, or or chronic medical conditons. Almost all of these threats are expected to worsen with contnued climate change. Some of these health threats will occur over longer tme periods, or at unprecedented tmes of the year; some people will be exposed to threats not previously experienced in their locatons. Overall, instances of potentally benefcial health impacts of climate change are limited in number and pertain to specifc regions or populatons. For example, the reducton in cold-related deaths is projected to be smaller than the increase in heat-related deaths in most regions. Changes in aquatic habitats and species may affect subsistence fshing among Indigenous populations. Global Change Research Program 2 Impacts of Climate Change on Human Health in the United States In recent years, scientfc understanding of how climate change increases risks to human health has advanced signifcantly. Even so, the ability to evaluate, monitor, and project health efects varies across climate impacts. For instance, informaton on health outcomes difers in terms of whether complete, long-term datasets exist that allow quantfcaton of observed changes, and whether existng models can project impacts at the tmescales and geographic scales of interest. Diferences also exist in the metrics available for observing or projectng diferent health impacts. For some health impacts, the available metrics only describe changes in risk of exposure, while for others, metrics describe changes in actual health outcomes (such as the number of new cases of a disease or an increase While all Americans are at risk, some populations are in deaths). This assessment strengthens and expands our understanding causal chain between a climate change impact and its assoof climate-related health impacts by providing a more defniciated health outcome. This assessments fndings represent tve descripton of climate-related health burdens in the Unitan improvement in scientfc confdence in the link between ed States. It builds on the 2014 climate change and a broad Natonal Climate Assessment1 range of threats to public health, and reviews and synthesizes key while recognizing populatons of Every American is vulnerable to the health contributons to the published concern and identfying emergimpacts associated with climate change literature. These consideratons rising demand for data that can provide the context for underbe used to characterize how clistanding Americans changing mate change afects health, this report assesses recent analyhealth risks and allow us to identfy, project, and respond ses that quantfy observed and projected health impacts. The overall fndings chapter characterizes the strength of the scientfc evidence underscore the signifcance of the growing risk climate change for a given climatehealth exposure pathway or link in the poses to human health in the United States. For example, areas previously unafchange afects diferent people and diferent communites to fected by toxic algal blooms or waterborne diseases because of diferent degrees. While ofen assessed individually, exposure to cooler water temperatures may face these hazards in the future multple climate change threats can occur simultaneously, resultas increasing water temperatures allow the organisms that cause ing in compounding or cascading health impacts. Even areas that currently experience these health threats may see a shif in the tming of the seasons With climate change, the frequency, severity, duraton, and that pose the greatest risk to human health. This means that areas already ways: frst, by changing the severity or frequency of health experiencing health-threatening weather and climate phenomproblems that are already afected by climate or weather factors; ena, such as severe heat or hurricanes, are likely to experience and second, by creatng unprecedented or unantcipated health worsening impacts, such as higher temperatures and increased problems or health threats in places where they have not previstorm intensity, rainfall rates, and storm surge. Climate Change and Health Conceptual diagram illustrating the exposure pathways by which climate change affects human health. Here, the center boxes list some selected examples of the kinds of changes in climate drivers, exposure, and health outcomes explored in this report. Some of the key factors that infuence vulnerability for individuals are shown in the right box, and include social determinants of health and behavioral choices. Some key factors that infuence vulnerability at larger scales, such as natural and built environments, governance and management, and institutions, are shown in the left box. The examples listed in the frst column are those described in each underlying chapters exposure pathway diagram. Moving from left to right along one health impact row, the three middle columns show how climate drivers affect an individuals or a communitys exposure to a health threat and the resulting change in health outcome. For a more comprehensive look at how climate change affects health, and to see the environmental, institutional, social, and behavioral factors that play an interactive role in determining health outcomes, see the exposure pathway diagrams in chapters 28 in the full report. This is expected to lead to an incascade of illnesses, including heat cramps, heat crease in deaths and illness from heat and a potenexhaustion, heatstroke, and hyperthermia in the tial decrease in deaths from cold, particularly for presence of extreme heat, and hypothermia and a number of communities especially vulnerable to frostbite in the presence of extreme cold. Temperature extremes can also worsen chronic conditions such as cardiovascular disease, Days that are hotter than the average seasonal temrespiratory disease, cerebrovascular disease, and perature in the summer or colder than the average diabetes-related conditions. Prolonged exposure seasonal temperature in the winter cause increased to high temperatures is associated with increased levels of illness and death by compromising the hospital admissions for cardiovascular, kidney, and bodys ability to regulate its temperature or by respiratory disorders. Future Increases in Temperature-Related Deaths Key Finding 1: Based on present-day sensitivity to heat, an increase of thousands to tens of thousands of premature heat-related deaths in the summer [Very Likely, High Confdence] and a decrease of premature cold-related deaths in the winter [Very Likely, Medium Confdence] are projected each year as a result of climate change by the end of the century. Future adaptation will very likely reduce these impacts (see the Changing Tolerance to Extreme Heat Finding). Because small temperature differences occur much more frequently than large temperature differences, not accounting for the effect of these small differences Climate change will increase the frequency and severity of future extreme heat events while also resulting in generally warmer would lead to underestimating the future impact of summers and milder winters, with implications for human health. Cities by Season this fgure shows the projected increase in deaths due to warming in the summer months (hot season, AprilSeptember), the projected decrease in deaths due to warming in the winter months (cold season, OctoberMarch), and the projected net change in deaths compared to a 1990 baseline period for the 209 U. Changes in this tolerance have been associated with increased use of air conditioning, improved social responses, and/or physiological acclimatization, among other factors [Medium Confdence]. Expected future increases in this tolerance will reduce the projected increase in deaths from heat [Very Likely, Very High Confdence]. Some Populations at Greater Risk Key Finding 4: Older adults and children have a higher risk of dying or becoming ill due to extreme heat [Very High Confdence]. People working outdoors, the socially isolated and economically disadvantaged, those with chronic illnesses, as well as some communities of color, are also Outdoor workers spend a great deal of time exposed to temperature extremes, often while performing vigorous especially vulnerable to death or illness [Very High activities. The changing climate has modifed weather patterns, which in turn have infuenced the levels and location of outdoor air pollutants such as ground-level ozone (O3) and fne particulate matter. Finally, these changes to outdoor air quality and aeroallergens also affect indoor air quality as both pollutants and aeroallergens infltrate homes, schools, and other buildings. Poor air quality, whether outdoors or indoors, can negatively affect the human respiratory and cardiovascular systems. Higher pollen concentrations and longer pollen seasons can increase allergic sensitization and asthma episodes and thereby limit productivity Ragweed pollen frequently triggers hay fever at work and school.


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