Race/ethnicity and socioeconomic status (SES) are social categories that capture differential exposure to conditions of life that have health consequences. Race/ethnicity and SES are linked to each ...other, but race matters for health even after SES is considered. This commentary considers the complex ways in which race combines with SES to affect health. There is a need for greater attention to understanding how risks and resources in the social environment are systematically patterned by race, ethnicity and SES, and how they combine to influence cardiovascular disease and other health outcomes. Future research needs to examine how the levels, timing and accumulation of institutional and interpersonal racism combine with other toxic exposures, over the life-course, to influence the onset and course of illness. There is also an urgent need for research that seeks to build the science base that will identify the multilevel interventions that are likely to enhance the health of all, even while they improve the health of disadvantaged groups more rapidly than the rest of the population so that inequities in health can be reduced and ultimately eliminated. We also need sustained research attention to identifying how to build the political support to reduce the large shortfalls in health.
Advances in molecular biology identifying the many carrier-mediated organic anion transporters and advances in microscopy that have provided a more detailed anatomy of the canalicular conduit make ...updating the concept of osmotically determined canalicular flow possible. For the most part water flow is not transmembrane but via specific pore proteins in both the hepatocyte and the tight junction. These pores independently regulate the rate at which water flows in response to an osmotic gradient and therefore are determinants of canalicular bile acid concentration. Review of the literature indicates that the initial effect on hepatic bile flow of cholestatic agents such as Thorazine and estradiol 17β-glucuronide are on water flow and not bile salt export pump-mediated bile acid transport and thus provides new approaches to the pathogenesis of drug-induced liver injury. Attaining a micellar concentration of bile acids in the canaliculus is essential to the formation of cholesterol-lecithin vesicles, which mostly occur in the periportal region of the canalicular conduit. The other regions, midcentral and pericentral, may transport lesser amounts of bile acid but augment water flow. Broadening the concept of how hepatic bile flow is initiated, provides new insights into the pathogenesis of canalicular cholestasis.
Chromophoric dissolved organic matter (CDOM) is a ubiquitous component of the open ocean dissolved matter pool, and is important owing to its influence on the optical properties of the water column, ...its role in photochemistry and photobiology, and its utility as a tracer of deep ocean biogeochemical processes and circulation. In this review, we discuss the global distribution and dynamics of CDOM in the ocean, concentrating on developments in the past 10 years and restricting our discussion to open ocean and deep ocean (below the main thermocline) environments. CDOM has been demonstrated to exert primary control on ocean color by its absorption of light energy, which matches or exceeds that of phytoplankton pigments in most cases. This has important implications for assessing the ocean biosphere via ocean color-based remote sensing and the evaluation of ocean photochemical and photobiological processes. The general distribution of CDOM in the global ocean is controlled by a balance between production (primarily microbial remineralization of organic matter) and photolysis, with vertical ventilation circulation playing an important role in transporting CDOM to and from intermediate water masses. Significant decadal-scale fluctuations in the abundance of global surface ocean CDOM have been observed using remote sensing, indicating a potentially important role for CDOM in ocean-climate connections through its impact on photochemistry and photobiology.
This paper reflects a vision of how family medicine residency training will be redesigned to prepare graduates to meet the health care needs of their patient populations and regional communities. ...Family physicians are needed to serve as personal physicians and as the patient's usual source of care, as recognized in historic documents that have defined the specialty's enduring role in society as the foundation of the health care system. Modern residency practices will include residents as junior partners and members of multidisciplinary faculty teams. Residency practices will measure and improve care consistent with the triple aim: enhancing the experience of care for patients, improving outcomes of care for populations, and reducing waste and the cost of care in the system.Curricula will include core elements of the roles of family physicians, including the development of therapeutic relationships with patients and families, recognizing patients' needs and expectations, professionalism, the identification and management of acute and chronic illness, maternity care, and the care of hospitalized patients. Also included will be emerging expectations of family physicians, including team roles, expanded care through telehealth and patient portals, identifying and intervening in modifiable social determinants of health, addressing structural racism, closing gaps of inequitable care for their patient populations, managing addiction as a treatable chronic illness, improving performance through clinical data registries, personalized medicine, and leadership. Wellness and assurance of a satisfying career will be a priority focus of preparation for career-long practice. Residents will become competent in the comprehensive scope of practice needed to serve in the role of continuous personal physician on multidisciplinary teams that serve as the usual source of care for populations in regions where the residencies are located.
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