Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Differences between coun tries are evident discount aromasin 25mg otc, sometimes usefully expressed in rela tion to cheap aromasin 25mg without a prescription national prosperity discount aromasin, but often extending to other parameters. Development and implementation of an ad equately resourced national cancer control plan is now recognized as a fundamental element within the broad scope of population health and clinical services activ ity. International collaboration provides an opportunity to minimize unnecessary evaluation and to optimize im plementation for the beneft of national, or sometimes local, populations. In parallel with the implementation of cancer control measures, infrastructure for continued, locally relevant, implementation research may be adopt ed and managed, thereby laying the foundation for even more effective cancer control measures consequent to such investigations. Adewole Cancer remains a leading noncom Second, creating awareness about strategy that has yet to be entrenched municable disease in Africa, and it cancer as a complex group of diseas in Africa. Priorities should be the es is also emerging as a great burden es that often have identifable triggers tablishment of cancer registries as when compared with infections that should be pursued in a systematic well as centres of excellence, and the are ravaging the continent. This will involve population training of a critical mass of experts ad of ignorance, poverty, and poor wide health promotion strategies fo to offer multidisciplinary team care health-seeking behaviour makes cused on diet and exercise, lifestyle for cancer patients in Africa, through Africa vulnerable to the cancer bur modifcations, sexuality/family life collaboration with cancer centres den in both male and female, and education programmes, campaigns offering cutting-edge services, pro young and adult populations . Of against cultural norms/practices, and fessional organizations, and pharma the 7. In addition, legislative dations, multinational companies, to about 21 000 cancer deaths per support that promotes healthy living and individuals that are ready to in day, and Africa shares the highest within the household and in commu vest in cancer control in Africa. These initiatives Cancer control in Africa is fea creasing cancer burden is attribut are expected to foster a strong pri sible, but the focus should be on a able to the transitional demographic mary prevention strategy in a con control plan that is realistic, sustain profle of several countries in Africa, tinent where about 33% of cancers able, equitable, and part of a strong with increasing proportions of older are infection-related . Lancet countries had operational cancer should actively participate in cur Oncol, 14:e142–e151. Resistance, barriers to imple Deaths due to cancer are projected Summary mentation, and susceptibil to increase to 13 million in 2030. Determination, commitment, distribution and survival refect vary through interventions to reduce resolve, and collaboration are ing levels of socioeconomic develop incidence, mortality, and mor mandatory requirements to real ment [2,4,5]. Mortality-to-incidence bidity and enhance the quality ize the future gains of population ratios for cancer vary from less of life of those at risk of, or ex based interventions to control than 0. This variation refects less a lack of based on current and accurate knowledge of what should be done determination of burden, real to control cancer than the level of istic targets for improvement, A national cancer control plan is a commitment to implementing ef and continuous surveillance public health programme designed fective cancer control interventions to document performance and to reduce the number of new cancer population-wide. In 2012, annual economic cost of disability low-income countries as strate there were an estimated 14. Population data are the founda tion for understanding the burden and pattern of cancer. These data can also be used to synthesize and prioritize planned interventions, establish system capacity require those with the least ability and capa prevention, early detection, diagno ments for care, evaluate population bility to respond. This based cancer control activities, and To address this growing burden defnition emphasizes the scientifc justify continued investment of re of cancer, population-based cancer and medical content of a plan, which sources according to performance control must be recognized as far is the focus of much of the discourse and outcomes of plans. The cancer burden is driven plan, however, is dependent not by a complex interaction of changing only on its content – what needs to Fig. Guiding principles for den, needs, capacity, impact, and across the disease control spectrum, developing a national cancer control required investment. Comprehensiveness: the plan present the population burden of countries exist in South and Central should address all members of cancer and can do so by time, key America and India. Scope: the plan should address cases), cancer site/type, impact of enhanced over time to incorporate cancer control from the perspec interventions as affecting stage dis more detailed data on diagnosis tives of human development, risk tribution, 5-year survival, disability, and treatment. Along with projec factor control, and health and dis the presence or absence of health tion and modelling methodologies, ease management. Evidence base: the plan should graphical, political, economic, eth es, programme evaluation, and in be based on evidence or best nic, and heritage status [2,7,9]. In the vestments, thereby allowing health practices and should incorporate United Kingdom and the European systems to maintain optimal cancer indicators and metrics of perfor Union, comparative presentation of control outcomes. Estimates of the propor into account measures to defne recognition of the global variation tion of the population covered by standards and ensure consis in incidence, mortality, and 5-year cancer registries range from more tent application, such as access, survival, and reasons for this varia than 80% in North America, Europe, timeliness, quality of care, and tion – which include access to care, and Australia to approximately 30% safety. Regional registries also tors infuencing compliance improving cancer burden, mitigating vary in their comprehensiveness, with therapy: the plan should variation, and addressing disparities. Integration and continuity: countries are challenged by having recording standards. Irrespective of the plan should strive for conti neither registries nor a systematic their coverage and quality, registries nuity across states of health and ability to collect data. Thus, even in munity, and tertiary or specialist cal facilities, low cancer awareness, regions without functioning regis poor follow-up, poorly maintained environments. Potential solutions with input and support from the to rationalize activities, investments, include establishing the culture of public, patients, providers, poli and performance of cancer control evidence, supported by data, be cy-makers, and payers. Ultimately, ef this plan is relatively straightforward tion of being self-suffcient and forts to establish reliable population as it is based on best practices, the sustainable. What interventions for cancer are most important: risk factor control, early detection, diagnosis, treatment, and care? How interventions will be implemented, and how the process of implementation will be monitored and evaluated. How will human, technology, facilities, and organizational resources be aligned to the implementation? When activities will be undertaken according to priority, what is the capability and the resource avail ability (the operational plan). How the national cancer control plan and its implementation will be fnanced (the business plan).
Social and Physical Disability Pathology Severe impairment of most or all social activities due to purchase generic aromasin line No reported case with pathological examination buy discount aromasin line. Summary of Essential Features and Diagnostic Cri Pathology teria Loss of many large fibers in affected sensory nerve order 25mg aromasin visa. Onset of lancinating pain in external meatus several days Chronic inflammatory changes in trigeminal ganglion to a week or so after herpetic eruption on concha. Differential Diagnosis Summary of Essential Features and Diagnostic Cri Differentiate from otic variety of glossopharyngeal neu teria ralgia, which does not have herpetic prodromata. X2 table cutaneous pain in distribution of the ophthalmic division of the trigeminal associated with cutaneous scarring and history of herpetic eruption in an elderly patient. Neuralgia of the Nervus Differential Diagnosis Intermedius (11-7) the syndrome is usually characteristic. X2b Definition Sudden, unilateral, severe, brief, stabbing, recurrent pain in the distribution of the nervus intermedius. Severe lancinating pains felt deeply in external auditory Main Features canal subsequent to an attack of acute herpes zoster. Pain Quality: sharp agonizing electric shock-like stabs of pain System felt in the ear canal, middle ear, or posterior pharynx, the sensory fibers of the facial nerve. Page 63 Periodicity is characteristic, with episodes occurring for Site weeks or months, and then months or years without any Tonsillar fossa and adjacent area of fauces. Intensity: extremely severe; probably one of the external auditory canal (otic variety) or to neck (cervical most intense of all acute pains. Precipitation System Pain paroxysms can be triggered by non-noxious stimu Peripheral and central mechanisms involving glosso lation from the posterior pharynx or ear canal. Sharp, stabbing bouts of severe pain, often Relief triggered by mechanical contact with faucial area on one From carbamazepine and baclofen. Or from surgical side, also by swallowing and by ingestion of cold or acid procedures: microsurgical decompression of the nervus fluids. Pain Quality: sharp, stabbing bursts of high-intensity intermedius or section of the nerve. Time Pattern: episodic bouts occurring spontaneously several times daily or triggered by Usual Course any of above mentioned stimuli. Intensity: very severe, Recurrent bouts over months to years, interspersed with interferes with eating. Associated Symptoms Cardiac arrhythmia and syncope may occur during par Social and Physical Disability oxysms in some cases. Signs and Laboratory Findings Pathology the important and only sign is the presence of a trigger Most patients have impingement on the nervus interme point, usually on fauces or tonsil; sometimes it may be dius at its root entry zone. Essential Features Usual Course Unilateral, sudden, transient, intense paroxysms of elec Fluctuating; bouts of pain interspersed by prolonged tric shock-like pain in the ear or posterior pharynx. Differential Diagnosis Must be differentiated from tic douloureux involving the Social and Physical Disability Vth nerve, glossopharyngeal neuralgia, and geniculate Only as related to pain episodes. May be confused with Definition trigeminal neuralgia limited to mandibular division. Sudden severe brief stabbing recurrent pains in the dis tribution of the glossopharyngeal nerve. X8b Page 64 Neuralgia of the Superior Differential Diagnosis Glossopharyngeal neuralgia, carotidynia, local lesions. X8e Paroxysms of unilateral lancinating pain radiating from the side of the thyroid cartilage or pyriform sinus to the angle of the jaw and occasionally to the ear. Occipital Neuralgia (11-10) Site Definition Unilateral, possibly more on the left in the neck from Pain, usually deep and aching, in the distribution of the side of the thyroid cartilage or pyriform sinus to the second cervical dorsal root. May be a variant of glossopharyngeal System neuralgia, which has also been called vago-glosso Nervous system. Combined ratio of vagoglosso pharyngeal neuralgia to trigeminal neuralgia is about Main Features 1:80. Pain Quality: usually Prevalence: quite common; no epidemiological data; severe, lancinating pain often precipitated by talking, most often follows acceleration-deceleration injuries. Sex swallowing, coughing, yawning, or stimulation of Ratio: women more frequently affected, but statistical the nerve at its point of entrance into the larynx. Pain Quality: deep, aching, pressure pain in suboccipital area, Associated Symptoms sometimes stabbing also. Relief Relief from analgesic nerve block, alcohol nerve block, Signs and Laboratory Findings or nerve section. Diminished sensation to pinprick in area of C2 and ten derness of great occipital nerve may be found. A large styloid process or calcified stylohyoid ligament may Social and Physical Disability be contributory (cf. Essential Features Pathology Sudden attacks of unilateral lancinating pain in the Unknown. Perhaps related to increased muscle area of the thyroid cartilage radiating to the angle of activity in cervical muscles. Page 65 Summary of Essential Features and Diagnostic System Involved Criteria Peripheral nervous and autonomic nervous systems. Intermittent episodes of deep, aching, and sometimes stabbing pain in suboccipital area on one side. Differential Diagnosis Continuous moderate to severe ache in the ocular and Cluster headaches, posterior fossa and high cervical periocular area or behind the eye, no triggering.
The model and resulting distributions take into account the known nonchemical-specific variability in human physiology as well as total variability and uncertainty in dichloromethane-specific metabolic capability order aromasin online. Selection of the first percentile allows generation of a numerically stable estimate for the lower end of the distribution generic 25mg aromasin otc. The mean value of the human equivalent oral dose in Table 5-3 was about twofold higher than the corresponding first percentile values cheap aromasin express, and the mean value of human equivalent inhalation concentration in Table 5-7 was approximately threefold higher than the first percentile value. The mean:first percentile ratios for these distributions are attributed to the dependence of the dose metric on hepatic blood flow rate (metabolism being flow-limited). This blood flow is expected to be highly and tightly correlated with liver volume, resulting in very similar delivery of dichloromethane per volume liver across the population. The population-structured distributions for physiological parameters and broadened distributions for metabolic parameters used here provide a good degree of confidence that the population variability has not been underestimated. There are some differences between men and women at 70 years of age, but neither of these would be greatly misrepresented by the general population estimate. This difference most likely results from the higher specific respiration rate in children versus adults, which allows them to eliminate more of orally ingested dichloromethane by exhalation, leading to lower internal metabolized doses. As noted above, for oral exposures, this leads to faster elimination by respiration in children, while for inhalation exposures it leads to higher uptake for a given air concentration. Moreover, oral exposures are simulated as occurring in a series of bolus exposures (drinking episodes) during the day, and the higher body fat content occurring in the elderly (see Appendix B) means that such a dose that might saturate metabolism and, therefore, have a higher fraction exhaled in a leaner individual will tend to be more sequestered in fat and slowly released, resulting in a higher fraction metabolized (less saturation of metabolism) in a more obese individual. The difference among adults of different ages for dosimetry from oral ingestion (bolus exposure) will be greater than the difference for inhalation exposures. More careful examination of Figure 5-12 shows that the distribution for 70-year-old women, for whom the fat fraction is estimated to be greatest, has a lower peak and higher upper tail than for the general population. Thus, the physiological differences have some impact that is qualitatively consistent with what is seen from oral exposure, given the mechanistic considerations described here, but the impact of those differences is less for inhalation exposure. Choice of Study/Data—with Rationale and Justification No human data are available for the quantification of potential neoplastic effects from oral exposures to dichloromethane. In the only chronic (2-year) oral exposure cancer bioassay, significant increases in the incidence of liver adenomas and carcinomas were observed in male B6C3F1 mice exposed by drinking water, with incidence rates of 19, 26, 30, 31, and 28% in groups with estimated mean intakes of 0, 61, 124, 177, and 234 mg/kg-day, respectively (trend p-value = 0. Incidences of liver tumors in female mice were not presented in the summary reports, but it was reported that exposed female mice did not show increased incidences of proliferative hepatocellular lesions (Serota et al. Evidence of a trend for increased risk of liver tumors (described as neoplastic nodule or hepatocellular carcinoma) was seen in female F344 rats but not males exposed via drinking water (p < 0. However, the potential malignant characterization of the nodules was not described, and no trend was seen in the data limited to hepatocellular carcinomas. The derivation of the cancer oral slope factor is based on the male mouse data (Serota et al. The study authors concluded that there was no dose-related trend, that there were no significant differences comparing the individual dose groups with the combined control group, and that the observed incidences were “within the normal fluctuation of this type of tumor incidence. Although the occurrence of one elevated rate in an exposed group may reflect normal fluctuations in the incidence of these tumors (described for this laboratory as 5–40%, with a mean of 17. Modeling intake, metabolism, and elimination of dichloromethane in mice and humans is feasible. The resulting distribution of human internal doses was multiplied by a human internal dose tumor risk factor (in units of reciprocal internal dose) to generate a distribution of oral slope factors or inhalation unit risks associated with a chronic unit oral or inhalation exposure, respectively. Dose-Response Data Data for liver tumors in male B6C3F1 mice following exposure to dichloromethane in drinking water were used to develop oral cancer slope factors (Serota et al. Significant increases in incidence of liver adenomas and carcinomas were observed in male but not female B6C3F1 mice exposed for 2 years (Table 5-11). No significant decreases in survival were observed in the treated groups of either sex compared with controls. The at-risk study populations (represented by the denominators in the incidence data) were determined by excluding all animals dying prior to 52 weeks. Mice dying prior to 52 weeks, as estimated from the survival data shown in Figure 1 of Hazleton Laboratories (1983), were excluded from the denominators. Internal doses were estimated from simulations of actual daily doses reported by the study authors. Dose Conversion and Extrapolation Methods: Cancer Oral Slope Factor Dose conversion. For the mouse, physiological parameters and partition coefficients were adjusted to match those reported in Andersen et al. A first-order oral -1 absorption rate constant (ka) of 5 hours was taken from Reitz et al. Figure 5-14 shows the comparison between 214 internal and external doses in the liver in mice and humans. The whole-body metabolism metric was also examined; however, this metric would be more relevant under a scenario of slowly cleared metabolites that undergo general circulation. Error bars th th indicate the range of 5 –95 percentile for the subpopulations sampled at select concentrations. Different 2 polynomial models were compared based on adequacy of model fit as assessed by overall χ goodness of fit (p-value > 0. Due to the lack of a monotonic increase in tumor response at the high dose, the model did not adequately fit the data. The modeling of the 215 remaining four dose groups exhibited an adequate fit to the data. The mouse liver tumor risk factor (extra risk per unit internal dose) was calculated by dividing 0.
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Main Features Acute generic aromasin 25mg otc, subacute buy aromasin 25mg on line, or chronic pain of the elbow during Site grasping and supination of the wrist cheap aromasin 25 mg on line. Acute severe aching pain in the shoulder following trauma, usually a fall on the outstretched arm. Signs Signs Tenderness of the wrist extensor tendon about 5 cm dis A partial tear is distinguished from a complete tear by tal to the epicondyle. Resisted wrist dorsiflexion repro subacromial injection of local anesthetic; partial tears duces pain. The arm may drop to the side if passively abducted to 90° (“drop Usual Course arm sign”) if there is a complete tear. Radiologic Finding Laboratory and Radiologic Findings High riding humeral head on X-ray. Page 126 Pathology Site Strain or partial tear of tendon at tendoperiosteal junc Wrist. Pain at the lateral epicondyle, worse on movement, ag Main Features gravated by overuse. Differential Diagnosis Nerve entrapment, cervical root impingement, carpal Aggravating Factors tunnel syndrome. Xla Signs Occasional tendon swelling; tenderness over the tendon in the anatomical snuff box area. Finkelstein’s sign re produces the pain; the patient’s thumb is folded into a Medial Epicondylitis (Golfer’s Elbow) fist and then the wrist is deviated to the ulnar side. Pathology Aggravating Factors Inflammatory lesion of tendon sheath usually secondary As for tennis elbow. Signs Essential Features Tenderness over the tendon insertion of the medial epi Severe aching and shooting pain in the radial portion of condyle. Differential Diagnosis Laboratory and Radiologic Findings Arthritis of the wrist, scaphoid injury. Definition Differential Diagnosis Chronic aching pain in the fingers with degenerative As for tennis elbow. The pain is chronic and aching in the fingers and Definition aggravated by use and relieved by rest. There may be Severe aching and shooting pain due to stenosing teno mild morning stiffness for less than half an hour and synovitis of abductor pollicis longus or extensor pollicis subjective reduction of grip strength, worse with trauma brevis. Page 127 Signs conduction across the elbow and often by denervation of Bony enlargements of the distal interphalangeal joints those intrinsic muscles of the hand innervated by the are called Heberden’s nodes, and those of the proximal ulnar nerve. Entrapment of the ulnar nerve in a fibro-osseous tunnel formed by a groove (trochlear groove) between the ole System cranon process and medial epicondyle of the humerus. The groove is converted to a tunnel by a myofascial covering, and the etiology of the entrapment is multiple. Time pattern: usually nocturnal, typically System awakening the patient several times and then subsiding Peripheral nervous system (ulnar nerve). Main Features Gradual onset of pain, numbness, and paresthesias in the Associated Symptom distribution of the ulnar nerve, sometimes followed by Aggravated by handwork such as knitting. The ulnar nerve is frequently and/or atrophy of the thenar muscles (abductor pollicis thickened and adherent. On electrodiagnostic testing brevis); nerve conduction studies showing delayed sen there is slowing of conduction in the ulnar nerve across sory and motor conduction across the carpal tunnel are the elbow, accompanied by denervation of those intrin diagnostic. The course may be stable or slowly progressive; if the latter, surgery is necessary, either decompression or Social and Physical Disability transposition of the nerve. Summary of Essential Features and Diagnostic Criteria Pathology A gradual onset of pain, paresthesias, and, at times, mo Compression of median nerve in wrist between the car tor findings in the distribution of the ulnar nerve. The diagnosis is confirmed by slowing of naculum); focal demyelination of nerve fibers, axonal shrinkage and axonal degeneration. Intensity: variable from mild to severe depending upon the temperature and Definition Episodic attacks of aching, burning pain associated with other stimuli. Sometimes vasoconstriction of the arteries of the extremities in re may last days if painful ischemia skin ulcers develop. Progressive Site Predominantly in the hands, unilateral initially, later spasm of the vessels leads to atrophy of the tip, giving bilateral. Advanced cases may de System velop focal areas of necrosis at the fingertip, occasion Cardiovascular system. Anxiety and Main Features other signs of sympathetic overactivity such as increased Prevalence: Raynaud’s phenomena can occur in 5% of sweating in the limbs and piloerection develop. Onset: most common between puberty Temporary relief from sympathetic block, and occa and age 40. Exacerbations during emotional stress and sional prolonged relief from sympathectomy in the early possibly at time of menses. Initially the digits Pathology become ashen white, then they turn blue as the capillar the cause of “cold sensitivity” is unknown. Abnormali ies dilate and fill with slowly flowing deoxygenated ties in sympathetic activity have not been proven. Finally the arterioles relax and the attack comes ever, local application of cold is necessary to elicit the to an end with a flushing of the diseased parts. Pain response of Raynaud’s syndrome, and the threshold for Quality: initially the pain is deep and aching and varies triggering the response is lowered by any factor that from mild to severe, changing to severe burning dyses increases sympathetic outflow or circulating catechola thesias in the phase of reactive hyperemia. X7c Legs involving both upper extremities and absence of specific organic disease. Signs and severity syringomyelia, poliomyelitis, ruptured cervical disk, vary steadily with degree of cold exposure, see below. After a few nio, immersion foot), cold sensitivity syndrome; days, severe burning or stinging pain, particularly after.
However cheap aromasin uk, if for any reason you feel uncomfortable and do not want to purchase aromasin 25 mg with visa continue in the discussion purchase aromasin 25mg on line, you are free to withdraw at any time. This will not affect in any way your the services you receive in the future from Orange County or this agency. Since we will be talking about health, what does being healthy mean to you, personally? Another way to think about health is looking at the health of a community, not just individuals. Today we will be talking about people’s health here in Orange County where you live or work. What do you think are the most healthy things about your physical community/Orange County? Now, thinking about less healthy things, which things concern you the most about the health of your physical community/Orange County? Are there groups of people within your community whose healthcare needs seem to be overlooked, or not met? If you were in charge, what specific things would you do to improve the health status of community members? Are there things you would do to improve people’s access to care, health information, quality of care, subsidies/cost, types of services available? We want to make sure that the health programs in this community will help you and your community. With that in mind, is there anything that we have not asked or that you would like to add? Name Email Address Mailing Address Street Address: City: State: Zip Code 3 2011 Orange County Community Health Assessment Appendix J. Estoy trabajando con el Departamento de Salud del Condado de Orange y Healthy Carolinians del Condado de Orange un grupo de miembros de la agencia y de la comunidad que están interesados en aprender sobre la salud de los residentes del Condado Orange. Hoy nos gustaría saber qué piensan acerca de la salud física, mental y ambiental de su comunidad. La información que ustedes compartan, junto con información obtenida de una encuesta comunitaria, otros diálogos y las estadísticas existentes, nos ayudará a planear futuros programas que satisfagan mejor las necesidades de los residentes del Condado de Orange. Los invitamos a participar porque ustedes son líderes de la comunidad Latina Inmigrante, que puede hablar de su experiencia personal y de sus experiencias como líderes. Compartiremos lo que aprendamos con miembros de comunidad y de la agencia durante foros abiertos en el otoño. En el invierno escribiremos un informe acerca de la salud de nuestro condado, para enviarlo al estado. Si desea ser invitado a un foro comunitario, por favor escriba su dirección en la hoja de asistencia. Estoy aquí para ayudar a facilitar la discusión y escuchar lo que tienen que decir. Si no hay objeciones, vamos a grabar esta discusión para asegurarnos de no perder ningún comentario. Después de esta discusión, vamos a escuchar la grabación y escribir todas las respuestas, luego vamos a borrar o destruir la grabación. Como se trata de una discusión de grupo, no tiene que esperar que yo se lo indique para hablar. Les pido que cuando se retiren, recuerden respetar la privacidad de los demás y no compartir ninguna de la información fuera de esta discusión. Ustedes están aquí, porque voluntariamente aceptaron participar en esta discusión en grupo. Sin embargo, si por alguna razón se siente incómodo y no desea continuar en la discusión, usted es libre de retirarse en cualquier momento. Esto no afectará de ningún modo los servicios que reciba en el futuro del Condado de Orange, o de esta agencia. Uno a la vez, por favor, preséntese y díganos cuánto tiempo ha vivido en el condado de Orange, Carolina del Norte. Como vamos a hablar acerca de la salud, para usted, personalmente ¿qué significa, ser saludable? Otra manera de pensar acerca de la salud es mirando la salud de la comunidad, no solo a los individuos. Hoy vamos a hablar de la salud de las personas aquí en el Condado de Orange, donde usted vive o trabaja. Para usted, ¿cuáles son las cosas más saludables acerca de su comunidad física/el Condado de Orange? Ahora, pensando en cosas menos saludables, ¿Cuáles cosas le preocupan más acerca de la salud de su comunidad física/del Condado de Orange? Pensando en las personas en su comunidad, ¿cuáles son sus principales preocupaciones acerca de la salud? Díganos sobre su propia experiencia para conseguir la ayuda que necesita en el Condado de Orange. Adultos de avanzada edad, hombres, mujeres, personas que viven en áreas rurales, etc. Si estuviera a cargo, ¿Qué cosas específicas haría para mejorar el estado de salud de los miembros de la comunidad?