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In the top panel that a heart rate more than 80% of maximum attainable (A) synthroid 75mg overnight delivery, the survival curve (fraction of initial population left during a stress test is dangerous, and that the maximum alive as age increases) of a typical ("normal") population heart rate attainable during a stress test reliably is compared with the survival curve of a genetically decreases by about 1 beat per minute each year during similar population placed into an optimum environment aging. The rate of this decline is reduced by about half ("enhanced environment") or a population modified in highly trained athletes, but even in such athletes, genetically or subject to dietary restriction. Note that an maximum heart rate and maximum oxygen consumption enhanced environment can increase average life span rate nevertheless decline with age. In contrast, genetic variance and dietary restriction can increase not only average life span but maximum life span as well. When these same data are plotted in terms The Gompertz Curve of rate of mortality (the number of individuals that have The essential feature of senescence, at least when applied died over an arbitrarily small unit of time), the mortality to mortality, is that the rate at which death occurs rate of all groups increases exponentially with age and increases with time. If the rate at which death occurred reaches the same high rate toward the end of life; the were constant (e. In most species, nential increase (although then the rate increases even senescence, manifest as an increase in the rate of mortal- faster toward the end of life), whereas genotype and ity with age, can be described by a remarkably simple dietary restriction can actually change the rate at which mathematical function. Because mortality rate increases species that have been studied, including flies, nematodes, exponentially with age, these effects are more easily and rodents, increases exponentially with time, first understood by subjecting the rate data to a logarithmic observed in humans by Benjamin Gompertz after observ- transform. After such a transform, log (mortality rate) ing actuarial statistics and reported in 1825. Normal and enhanced envi- pertz equation can be stated succinctly as Rm(t) =-(1/n) ronment groups have similar slopes. If anything, the dn/dt = R e(at), where Rm(t) is the mortality rate at time enhanced environment group may exhibit a slightly * 0 or age t, n = the number of survivors at time t, R0 is the higher slope because the intercept is lower, whereas mortality rate at time t = 0, interpreted as a vulnerability genotype and dietary restriction can actually decrease the factor depending on the hostility of the environment, slope of this transform. This When the rate of mortality becomes high enough, an equation can be linearized by log transform into arbitrarily small number of individuals will be left alive lnRm(t) = ln(R0) + at. In practice, maximum The intercept of this line is generally dependent on the life span is determined empirically, and in humans is gen- hostility of the environment, whereas the slope is depend- erally assumed to be around 125 years (for women; some- ent on the genetic background of the population, for what lower for men). Normal, standard population dynamics; enhanced environment, dynamic pattern as might be observed by idealized optimization of environ- ment, leading to "rectangularization" of the survival curve; enhanced genotype or dietary restriction, dynamic pattern observed by single gene mutations that extend maximum life span (such as AGE-1) or by dietary restriction regimens that extend maximum life span. Depicted in this way, rate of mortal- ity increases exponentially with age (Gompertz function).

C-MB Communication skills The teaching of communication skills to medical students has improved greatly across the board in recent years discount synthroid 200mcg with visa, largely in response to public demand. Patients want to know more about their condition and to have more involvement in the decisions, for instance about treatment options, which affect their lives. The skills needed to communicate well with patients are often not fully appreciated, and many, including well established doctors think it is something you either have or do not have. While it is true that some doctors do have a natural flair for the right bedside manner and know instinctively when to hold a hand or when a moment of quiet reflection is appropriate, many of the skills can in fact be learnt quite easily. Such skills are not just about explaining procedures and 67 LEARNING MEDICINE breaking bad news but also about how and when to keep quiet and listen, to ask the right questions in the right way, drawing out the patient’s story, which allows you to make an accurate diagnosis and formulate a suitable management plan, as well as earning trust and showing empathy. Much of this teaching is done in small groups and uses actors role playing patients with fellow students watching on television monitors. This type of training is also a compulsory part of postgraduate training in general practice, so the practice early on is time doubly well spent. Let a former student, now a medical senior house officer, describe her experiences of communication skills training. Communication skills You will be spending the rest of your prospective career talking to patients so it’s nice to be able to do it well—indeed it’s one of the major ways in which your medical skills are judged. To this end, the communication skills teaching is designed to give you a few pointers as to how to handle various patient scenarios so that you and the patient go away happy (and less liable to sue! There is a small group of students, a doctor, psychologist, and a TV/video at each session. You are in the room next door with an actor and a video camera to keep you company. Before it starts, all you can think of are your friends watching you on TV next door in this totally artificial situation and how stupid it all seems! They might be trying to tell you about their piles or of "trouble down below, Doctor". There are various scenarios and patients that the actors can play, and they are invariably superb.