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14 graziani.darrel



Increasing Public Awareness of Potential Groundwater
Contamination from Pharmaceuticals and Personal Care
Products at Homes with Private Wells and Onsite
Sewage Treatment Systems
2010 - 2011
Environmental Public Health Leadership Institute Fellow(s):
Darrel J. Graziani, P.E., R.S., B.S. Chemical Engineering
Environmental Administrator Palm Beach County Health Department 800 Clematis Street, 4th Floor West Palm Beach, FL33401 561-837-5900 Darrel_Graziani@doh.state.fl.us John W. McLeod, R.S., MPH
Director – Environmental Health Services Cuyahoga County Board of Health Acknowledgements:
Palm Beach County Health Department
Alina Alonso, MD, Director
John X O'Malley, P.G., R.S., MPH, Director, Division of Environmental Public Health
Scott A. Harrison, R.S., BS, Environmental Manager, Operations Section
Ishmael Gonzalez, MS, Environmental Specialist, Operations Section
Richard Marella, U. S. Geological Survey
2010–2011 Fellow Project National Environmental Public Health Leadership Institute EXECUTIVE SUMMARY:
The Palm Beach County Health Department (Department) has responsibility for ensuring safe drinking water for nearly 1.3 million residents every day. Within the County, nearly 87 percent of the population receives drinking water from a groundwater source. Of this population, 89 percent receive drinking water from a public water system and the remaining 11 percent ( 120,000 people) from private wells. Many of these private wells are located on properties served by onsite sewage treatment systems. Current regulations are aimed at protecting groundwater and drinking water supplies through construction and design standards for both private wells and onsite sewage treatment systems. These regulations require a single bacteriological sample and satisfactory results for approval and use of a private well. After that, the homeowner is responsible for the proper operation and maintenance of the well and drinking water treatment system, if any. The current regulations were implemented before the issue of pharmaceuticals and personal care products (PPCPs) was recognized. With research identifying PPCPs in the effluent and biosolids from wastewater treatment plants, soils irrigated with reclaimed water, groundwater supplies, streams, and lakes, the U.S. Environmental Protection Agency (EPA) has categorized PPCPs as "emerging contaminants of concern" with a potential to impact drinking water sources. To address the potential impact of PPCPs on private wells, the Department has initiated a sampling project at homes with onsite sewage treatment systems by teaming with the U.S. Geological Survey to sample 30 wells for some 160 PPCPs. The results will be used to identify existing levels within the County, evaluate the effectiveness of the Department's regulatory requirements, and further educate the public on the PPCPs issue by sharing the information obtained with the various stakeholders including the Board of County Commissioners, EPA, Florida Departments' of Health and Environmental Protection, and the residents of Palm Beach County. The Palm Beach County Health Department (Department) has responsibility for ensuring safe drinking water for nearly 1.3 million residents every day. The Department accomplishes this task through its permitting, compliance and enforcement activities associated with the drinking water and permitting programs of the Florida Department of Environmental Protection, the Florida Department of Health, the South Florida Water Management District, and Palm Beach County. For Palm Beach County, the U.S. Geological Survey (USGS) has estimated that nearly 87 percent of the population receives their drinking water from a groundwater source1. The USGS further reports that of this 87 percent, 89 percent receive their drinking water from a public water system and the remaining 11 percent from private wells. The USGS2 estimates that more then 120,000 Palm Beach County residents withdraw nearly 11.47 million gallons of water per day for domestic use from about 47,500 private wells. In addition, the USGS reported that Palm 2010–2011 Fellow Project National Environmental Public Health Leadership Institute Beach County has more than 61,000 onsite sewage treatment systems that discharge nearly 9 million gallons per day to on-site drainfields3. The Department is aware that many of these onsite sewage treatment systems provide service to properties with private wells. To protect the groundwater and drinking water supply, private wells and onsite sewage treatment systems are subject to construction and design standards. Prior to final approval and use, the current regulations require the collection of a single bacteriological sample and satisfactory results. After the well is approved, the homeowner is responsible for the proper operation and maintenance of the well and drinking water treatment system, if any. Unlike public water supplies, private systems are not subject to any routine monitoring or the primary or secondary drinking water standards. Concern over pharmaceuticals and personal care products (PPCPs) in drinking water supplies continues to grow as research activities, supported by improved analytical methods, generate new data. Research has already identified PPCPs in the effluent and biosolids from wastewater treatment plants, soils irrigated with reclaimed water, groundwater supplies, streams, and lakes. PPCPs have been categorized by the U.S. Environmental Protection Agency (EPA) as "emerging contaminants of concern" with a potential to impact drinking water sources which increases the need for further research. As part of its efforts to increase public awareness to the vulnerability of the groundwater supplies and further educate private well owners, the Department has initiated a project to sample 30 private wells at homes with onsite sewage treatment systems for more than 160 PPCPs compounds (PPCPs). Tables 1 and 2 list the targeted PPCPs. The Department has teamed with the U.S. Geological Survey to complete the sampling and analysis. The results of the sampling will be used to identify existing levels within the County, evaluate the effectiveness of the Department's regulatory requirements, and further educate the public on the PPCPs issue. Information obtained from the project will be shared with the various stakeholders including the Board of County Commissioners, EPA, Florida Departments' of Health and Environmental Protection, and the residents of Palm Beach County. Problem Statement:
Why should we be concerned about pharmaceuticals and personal care products in private
wells at homes with on-site sewage treatment and disposal systems?

For private wells constructed in Palm Beach County, the quality of the groundwater is simply assumed to be good and the drinking water provided to be safe based on observations, historical information and limited testing. Basically it is a belief that the lack of any know or observed hazard in an area should ensure that the groundwater is free of contamination and safe for use. Although most private wells are not subject to extensive testing, the State of Florida has several programs in place to protect its groundwater supplies and a goal to identify contamination prior to impacting either private or public drinking water wells. The State's main programs focus on environmental impacts of commercial and industrial activities. These programs include cleaning up hazardous waste sites and the regulation of hazardous wastes, domestic wastewater treatment and industrial wastewater treatment. 2010–2011 Fellow Project National Environmental Public Health Leadership Institute For the homeowner with a private well, the State has limited resources to sample well water for the hundreds of possible contaminants. Most sampling currently performed is in response to an environmental release in a known area. In some limited cases, sampling is performed to respond to an unknown health threat that may or may not be associated with the groundwater supply as was the case with the recent Cancer Cluster investigation within Palm Beach County. In addition to these programs, the USGS conducts routine groundwater sampling throughout the Country to assess the overall quality of our groundwater. In their overview of the groundwater data collected between 1991 through 2004 from domestic wells, the USGS reported4: • More then one in five (23 percent) of the sampled wells contained one or more contaminants at a concentration greater than a human-health benchmark. • Contaminants most often found at concentrations greater than human-health benchmarks were inorganic chemicals, with all nut nitrate derived primarily from natural sources. • Nitrate is the only contaminant derived primarily from man-made sources that was found at concentrations greater than a human-health benchmark in more then 1 percent of the wells. • Man-made organic compounds were detected in more than half (60 percent) of the sampled wells, but concentrations were seldom greater than human-health benchmarks (less than 1 percent of wells). • Microbial contaminants were detected in as many as one-third of the approximately 400 • About half (48 percent) of the sampled wells contained at least one contaminant at a level or concentration outside the range of values recommended by the EPA for the aesthetic quality of water. • Contaminants usually co-occurred with other contaminants as mixtures.
The Department's responsibility to ensure safe drinking water goes beyond merely enforcing
existing regulations and requirements. The sampling for PPCPs represents research that will be
used to inform and educate private well owners on the potential vulnerability of their drinking
water supply. The over cost of the sampling is nearly $300,000 or $10,000 per well for 160
contaminants.
Behavior-Over-Time Graph

Figure 1 is an expected Behavior-Over-Time graph associated with the goals of the project. The
graph illustrates three basic concerns of the Department: 1) Regulatory Programs; 2) Public
Awareness and Concern; and 3) Public Water Costs. The Department's expectations include the
following:
2010–2011 Fellow Project National Environmental Public Health Leadership Institute • Regulatory Programs – The existing programs will remain in place with no additional cost burdens on the public (Flat Line) which provides an affordable option to public water in areas without existing infrastructure. When the public requires program enhancements then the cost burden to the public will increase for use of a private well (Step Increase). • Public Awareness and Concern - The level of public awareness (Relatively Flat Line) of the existing regulatory programs is below the level which the Department believes allows for an informed decision on the use of a private well. When awareness increases or becomes concern, as expressed during the cancer cluster investigation, the public begins to understand the program limitations (Upward Slope). When awareness and concern meet the existing regulatory programs a decision point is identified. In this case, the graph represents a decision to enhance the regulations. • Public Water Costs – The cost of public water, regardless of the number of people connected, is expected to continue to rise (Upward Slope).
As depicted in the graph, sometime in the future the Department would enact enhanced
regulations for construction and approval of a private well that would require additional
safeguards and monitoring to ensure safe water. The graph identifies two existing gaps that the
Department is addressing as part of the project. The first gap represents the difference between
the existing regulations and the public's awareness of the limitations of the existing regulations.
The second gap represents the cost differential between the construction and operation of a
standard domestic well versus the cost to connect to public water. It is important to note that the
Department's regulatory program has no impact on the cost for public water and that Gap 2 is
only reduced through a higher cost burden on the private well owner.
Causal Loop Diagram and Applicable Archetypes
Figure 2 is a simplified Casual Loop Diagram that focuses on the activities after sampling is
completed and excludes the initial phases of the project which included the sampling scope,
contractor selection/negotiation, and funding. Through the application of Systems Thinking, the
Department looked at other possible outcomes of the project. This included the following:
• Intended Action – Conduct sampling that increases available data to the public which in turn increases public awareness to PPCPs and groundwater vulnerability issues. The overall result is increased public support for the program which allows further research in the area of emerging chemicals of concern. • Unintended Action – Sampling data results in heightened public concerns which forces o Additional PPCP sampling which funding may not be available; or 2010–2011 Fellow Project National Environmental Public Health Leadership Institute o Demand for public water which creates additional issues including:  Cost and availability issues provided the utilities have the capability to provide the services including: • As demand increases costs and availability issues should decrease which in turn would decrease the number of private wells while increasing the demand for public water. • Costs and Availability issues are significant increasing the number of private wells and support for the program which allows an affordable but safe alternative. 10 Essential Environmental Health Services:
The Department expects that the project would touch almost all of the ten essential environmental health services shown in Figure 3. Through its self evaluation (Figure 4) the Department identified three services within the drinking water program that were below acceptable levels. These services included: • Essential Service #1: Monitor Environmental and Health Status to Identify and Solve Community Environmental Health Problems • Essential Service #5: Develop Policies and Plans That Support Individual and Community Environmental Health Efforts • Essential Service #10: Research for New Insights And Innovative Solutions To Environmental Health Problems And Issues The self-evaluation noted that research efforts (Essential Service #10) were all but non-existent (Score 38) within the drinking water program and that little activities had been undertaken in more then 10 years. This project will reduce the performance gap and provide needed research in the area of potential contamination of PPCPs in the groundwater supply in Palm Beach County. Through the project, the Department will improve its research capabilities. The self-evaluation noted that monitoring efforts (Essential Service #1) were directed entirely to the regulatory requirements of the existing regulations (Score 46). This project will enhance performance while providing needed monitoring outside the regulatory requirements and will further public health in Palm Beach County. Through the project, the Department will enhance its monitoring capabilities. The self-evaluation noted that developing policies and plans to support environmental health efforts (Essential Service #5) was restricted to activities within the Federal and State regulatory programs (Score 44). This project will reduce the performance gap by providing new policies for private well clearance outside the existing regulatory requirements and further public health in Palm Beach County. 2010–2011 Fellow Project National Environmental Public Health Leadership Institute National Goals Supported
The project is directly supported by all six goals of the "National Strategy to Revitalize Public Health Services."5 Specifically: • Builds on the Department's capacity to respond to environmental public health threats including emerging issues through the use of new and improved technology. • Research into areas outside the Department's normal regulatory activities of the drinking • Fosters leadership within the Department's ranks by introducing staff to research capabilities, community partners, agency partners, and available funding sources. • Improves the Department's communication efforts with the public, the elected officials, and our counterparts at the various federal, state and local governmental agencies. • Further develops the workforce through increased knowledge of the capabilities of the Department, of the Department's relationship with the local elected officials, and procedures to develop and manage a project. • Furthers the existing strategic partnerships between the Department, the USGS, the EPA, the CDC, Palm Beach County, the Florida Department of Health and the Florida Department of Environmental Protection. In addition to the National Strategy, the project is also supported by the "Recommendations for Non-Technical Competencies at the Local Level" of the American Public Health Association. The competencies that staff will need to demonstrate through the project include the ability to complete the assessment and manage the project through the approval process. Staff will also be required to communicate the results to the public and the stakeholders in manner that does not result in unnecessary fears of drinking water supplies.
Program Goal: To increase public awareness about potential contamination of private drinking
water wells from pharmaceuticals and personal care products at homes with on-site sewage
treatment and disposal systems.
Health Problem: In Palm Beach County nearly 120,000 residents obtain their drinking water
from private wells with a large number of these wells located on properties served by an on-site
sewage treatment and disposal system. These private wells are not subject to routine monitoring
leaving many residents potentially exposed to bacteriological and chemical contamination.
2010–2011 Fellow Project National Environmental Public Health Leadership Institute Outcome Objective: By September 30, 2012, a report on the sampling of 30 private wells for
more than 160 contaminants will be presented to the Palm Beach County Board of County
Commissioners and made available to the public through the Department's Web Page.
Determinant: The number of calls received by the Water Programs Section requesting
information on private well testing.
Impact Objective: By September 30, 2012, the report will be released to the public following the
presentation to the Board of County Commissioners. Target is to reach 10 percent of the
impacted population through direct mail or web site hits for copies of the report and associated
fact sheets about pharmaceuticals and personal care products.

Contributing Factors:
1) Lack of public awareness of the potential impacts from
pharmaceuticals and personal care products being released into the groundwater from on-site
sewage treatment and disposal systems. 2) High costs of maintaining, monitoring and testing
private wells for homeowners. 3) Access to a public water supply in remote areas of the County.
4) High cost of public water supply in the less populated areas of the County.

Process Objectives:

1. By March 1, 2011, secure funding and a contract with the USGS for the sampling of 30 private wells on properties served by an on-site sewage treatment and disposal system.
Event: Implement a contract with the USGS for the sampling
Activities: 1)Create and agenda item for approval by the BOCC; 2) Obtain BOCC
approval for the funding; and 3)Legal/Tallahassee review of the USGS Contract
2. By September 30, 2011, complete the field activities associated with the USGS sampling of the 30 private wells.
Event: Field Sampling
Activities: 1) Assist USGS in identifying 50 private wells for sampling; 2) Secure
property access to sample the wells (USGS); and 3)Conduct well sampling.
3. By March 31, 2012, obtain sampling results and a draft report from the USGS. Event: Review Draft Report
Activities: 1) Review the draft report and sample results; 2) Comment of the draft report
Share the sample results with the home owners; and 3)Share the sample results with the
County Administrator
4. By September 30, 2012, present the results of the project to the Board of County Commissioners.
Event: Board of County Commissioner's Public Meeting
Activities: 1)Finalize the Report with the USGS; 2) Develop Fact Sheets about the
Report; and 3)Establish a BOCC Agenda Item to present the report
2010–2011 Fellow Project National Environmental Public Health Leadership Institute The project began with the Department's Environmental Public Health Director's vision of a research project into the PPCPs issue at homes with private wells and onsite sewage treatment systems. Some local utilities had already begun testing the public water supplies and the effluent from the wastewater treatment plants and associated biosolids for PPCPs. However, little efforts were underway for private wells which provide drinking water to nearly 120,000 people in Palm Beach County. The project began with staff investigating laboratories for PPCPs capabilities. The investigations quickly lead to a partnership with the USGS which had an interest in not only providing the laboratory services but participating as a stakeholder and sharing costs. The Department recognized the benefits of working with the USGS which included reduced costs, an experienced sampling team, a national recognized laboratory support system, and technical support in preparing the final report and providing information on the meaning of the sample results. The Department's plan is to fund the project through a local pollution recovery fund that has significant restrictions on the type of project which can be funded. The PPCPs project meets the criteria for funding and the buy-in through the Health Department Director and the Palm Beach County administration has been achieved. Final approval from the Board of County Commissioners and execution of the contract documents between the Department and the USGS must be completed before field activities can begin. Once the field activities are completed the USGS will report the results back to the Department. The Department will then present the information to the stakeholders and provide a briefing on the results. NEXT STEPS:
The Department is in the process of funding approval with an agenda item developed and pending submittal for the February 2011 Commission meeting. If the Commission votes not to approve the funding, the project will end without any further actions towards sampling. If funding is approved, a contract with the USGS will be negotiated and upon execution field activities would begin. Field activities include identification of 50 prospect wells and agreements to sample from at least 30 private well owners signed. Next the sampling activities will be performed and samples shipped to the USGS laboratories. Upon completion of the analysis, the USGS will review the data internally and generate a formal report. EXPECTED OUTCOMES:
The Department expects that the funding will be approved and 30 wells will be identified and sampled by the USGS. The results of the sampling will show limited amounts of some of the targeted PPCPs in the well water. The amounts, given the current construction and design standards are expected to be at levels which show no harmful effects to humans. The Department and USGS are prepared to respond to the individual well owners should the data show unexpected values of any of the targeted PPCPs. 2010–2011 Fellow Project National Environmental Public Health Leadership Institute LEADERSHIP DEVELOPMENT OPPORTUNITIES:
Darrel J. Graziani, P.E., R.S.
The CDC EPHLI program has been one of the most unique experiences in my 25 year career and far exceeded my expectations. The CDC's funding was greatly appreciated since it opened up the opportunity to our Department when money for such opportunities is just not available. The EPHLI faculty was extremely professional and helpful through the entire process and deserving of a true "Thank You" for all their efforts. I found that the class selection criteria produced a group of individuals from all areas of Environmental Health with very unique perspectives of what needs to be done and how to get it done. I believe the diversity of this group was fantastic. I found use of mentors, coaches and teams a great approach since it allowed guidance throughout the process with input from all three. It was a great demonstration of networking that leads to collaboration. The fact that the mentors had also completed the program added credibility to their comments and direction. I found the individual development plan process unique in that it gave a chance to look internally and see what one needed to do and plan on how to get it done. At first it seemed outside the scope of my "project" as well as the scope of leadership training but as it turned out, surprisingly so, it was excellent lesson in leadership planning. ABOUT THE EPHLI FELLOW
Darrel Graziani is currently employed by the Palm Beach County Health Department in West Palm Beach, Florida as the Environmental Administrator over the Division of Environmental Public Health's Water Programs. He has a Bachelor of Science Degree in Chemical Engineering from the University of South Florida in Tampa and is a registered professional engineer in Florida, North Carolina and Maryland. He is also a Registered Sanitarian and a Certified Environmental Health Professional in Onsite Sewage Treatment and Disposal. He has more then 25 years of professional work experience as an engineer and project manager with experience in the regulatory, consulting, industrial and governmental sectors. He currently supervises 30 engineers, scientists and administrative personnel with overall responsible for the drinking water program, onsite sewage treatment program, domestic wastewater program, swimming pool program, and the well surveillance program. Prior to his current position, he was employed with the Florida Department of Environmental Protection's Southeast District Office as the District Air Program Administrator.
2010–2011 Fellow Project National Environmental Public Health Leadership Institute Figure 1: Behavior-Over-Time Graph:
2010–2011 Fellow Project National Environmental Public Health Leadership Institute Figure 2: Causal Loop Diagrams and applicable Archetypes:
2010–2011 Fellow Project National Environmental Public Health Leadership Institute Figure 3: Ten Environmental Health Services
2010–2011 Fellow Project National Environmental Public Health Leadership Institute Figure 4: 10 Essential Public Health Services Self-Evaluation Scores
Drinking Water Program
Description
1. Monitor
2. Diagnose and Investigate 3. Inform, Educate and Empower 5. Develop Policies and Plans
10. Research
2010–2011 Fellow Project National Environmental Public Health Leadership Institute Figure 5: Project Logic Model:
Activities
Outputs TIER I
Short & Long Term Outcomes, Impacts
Project Approval
• List of PPCP for 10 Essential
• Develop Cost Estimate Standards
• Identify Funding Source Received a Cost Proposal Engage Partners Educated Partners Improve - Monitoring Secured Funding (PR Improve - Diagnose • Enhanced Staff Activate USGS Contract Trust Fund & USGS) • Activated Field • Improve – Inform, • Enhanced inter- Educate & Empower agency Relations • Env. Manager • Improve – Mobilize • Enhance PBCHD • Env. Spec II Project Activation
• No Change – Develop • Env. Spec II Policies & Plans Designate PBCHD Team Team Assignments • Senior Clerk • No Change – Enforce • Identified 50 Private Improve – Link Assist USGS in Well • Secure Access to 30 Improve – Assure Assist USGS with Field Improve – Evaluate Partners
• Sampled 30 Private Improve - Research • Monitor Project Schedule • Field Activity Start/Stop • Actual Field Public Education
• Increased knowledge Project Reporting
of Septic Tank impacts • Increased Public • Draft Report and Sample on Private Wells Final Well Data • Increased knowledge Risks of Private Engage USGA & PBC of Private Well Risks • Increase knowledge of Wells and Septic • Finalize Report & Sample 150 Fact Sheets Regulation limitations • Improved health 50 Report Copies • Engage Home Owners Increased knowledge Posted Final Report on Develop Fact Sheets on private wells • Present the Report to the • Post the Report and Fact Sheets on PBCHD Web Page 2010–2011 Fellow Project National Environmental Public Health Leadership Institute
Table 1. List of organic wastewater compounds (OWCs) compounds and their method
reporting levels (0.08 µ g/L unless otherwise noted in parentheses in µ g/L) that are
analyzed by the USGS National Water Quality Laboratory in Denver, Colorado.
3-methyl-1h-indole (skatol) (0.16)
Acetophenone (0.1) Tonalide (AHTN) (0.5) N,N-diethyltoluamide (DEET) (0.1) Benzophenone (0.12) 3-tert-butyl-4-hydroxyanisole (BHA) (0.6) Galaxolide (HHCB) (0.5) Isoborneol (0.06) 3beta-coprostanol (1) Isoquinoline (0.2) beta-Sitosterol (1.6) beta-Stigmastanol (1.2) Cholesterol (1.4) Benz[a]pyrene (0.12) 4-cumylphenol (0.1) 4-n-octylphenol (0.16) Naphthalene (0.1) 4-tert-octylphenol (1) Diethoxynonylphenol (total) (5) Diethoxyoctylphenol (1) 1-methylnaphthalene (0.1) Monoethoxyoctylphenol (1) 2,6-dimethylnaphthalene (0.12) Para-nonylphenol (total) (1) 2-methylnaphthalene Anthraquinone (manufacturing) (0.16) Isopropylbenzene (cumene) (0.1) Bromoform (disinfection byproduct) Bisphenol a (0.4) Caffeine (stimulant) (0.1) Tri(2-butoxyethyl) phosphate (0.4) Cotinine (nicotine metabolite) (0.4) Triphenyl phosphate (0.1) Methyl salicylate (liniment) (0.1) Triethyl citrate (cosmetics) (0.2) Pentachlorophenol (2) Tetrachloroethylene (PCE) Tri(2-chloroethyl) phosphate (0.1) Tri(dichloroisopropyl) phosphate (0.12) Chlorpyrifos (0.12) Tributyl phosphate (0.2) d-Limonene (0.04) 1,4-dichlorobenzene (deoderizer) 2010–2011 Fellow Project National Environmental Public Health Leadership Institute
Table 2. List of antibiotics, pharmaceutical, pharmaceutical degredate compounds and
hormones
11-Ketotestosterone 17-alpha-Estradiol sulfadimethoxine 17-beta-Estradiol sulfamethoxazole Ethynylestradiol Norethindrone (0.8) 4-Androstene-3,17-dione chlorotetracyline cis-Androsterone (0.8) Cholesterol (200) trans-Diethylstilbestrol Dihydrotestosterone (4) epi-chlorotetracycline Primidone Bisphenol A (200) chlorotetracycline Epitestosterone (4) epi-oxytetracycline epi-tetracycline epi-oxytetracycline epi-tetracycline iso-chlorotetracycline Methocarbamol Progesterone (8) 3-beta-Coprostanol (200) Testosterone (0.8) Chlorpheniramine Celecoxib Piperonyl butoxide erythromycin-H2O 2010–2011 Fellow Project National Environmental Public Health Leadership Institute REFERENCES
1 Marella, R.L., 2009, Water withdrawals, use, and trends in Florida, 2005: U.S. Geological Survey, Scientific Investigations-Report 2009-5125, 49 p. 2 U.S. Geologic Survey, 2010, Cost Proposal – "Pharmaceutical water sampling from domestic (private) household wells in Palm Beach County, Florida" 3 Marella, R.L., 2004, Water withdrawals, use, discharge, and trends in Florida, 2000: U.S. Geological Survey, Scientific Investigations-Report 2004-5151, 136 p. 4 Desimone, L.A., Hamilton, P.A., and Gilliom, R.J., 2009, The quality of our nation's waters – Quality of water from domestic wells in principal aquifers of the United States, 1991-2004-Overview of major findings, U.S. Geological Survey Circular 1332. 5 CDC, A National Strategy to Revitalize Environmental Public Health Services, 2003. 2010–2011 Fellow Project National Environmental Public Health Leadership Institute

Source: http://www.heartlandcenters.slu.edu/ephli/finalprojects2011/14GrazianiDarrel.pdf

Rough draft

MEDICATIONS USED FOR THE MANAGEMENT OF DEMENTIA AND RELATED BEHAVIORIAL COMPLICATIONS* R.Ron Finley, B.S Pharm, R.Ph,CGP, Aimee Loucks, Pharm. D., Gil D. Rabinovici, M.D The following is intended to be a review of medications commonly prescribed for the management of dementia and associated psychiatric behavioral complications. At this time, no medications are approved by the FDA for the treatment of psychiatric behavioral conditions related to a dementia; however, one second generation antipsychotic, risperidone, is approved in the United Kingdom for treating aggressive/assaultive behavior due to Alzheimer's disease. Hopefully, this will serve as a guide to caregivers and healthcare providers in the safe and appropriate use of medications for these indications. Dementia is a syndrome, or a collection of symptoms, characterized by a progressive loss of cognitive abilities that interferes with an individual's ability to function at work or in their usual personal activities. Dementia can affect memory, thinking, language, visual perception, judgment, and behavior. In early stages, an individual may be able to fully compensate for cognitive problems and continue to function independently. A condition known as "mild cognitive impairment" (MCI) may, in some individuals, result ultimately in a diagnosis of AD. In the final stages, dementia prevents an individual from taking care of themselves or providing for their basic needs. Dementia can be caused by a variety of brain diseases and medical illnesses. An accurate diagnosis of the underlying cause of dementia is the first step in selecting optimal drug therapy. The major causes of dementia are Alzheimer's disease (AD), vascular dementia, mixed dementia (vascular and Alzheimer's combined), frontotemporal dementia (FTD) and Lewy-body dementia (LBD). There are other recognized types of dementia, such as those due to human immunodeficiency virus (HIV), Parkinson's disease, Huntington's disease, major organ dysfunction (e.g. heart, lung, liver or kidney failure) and substance abuse, but these are beyond the scope of this article. The following suggestions and comments will focus primarily on AD, which is the leading cause of dementia in the United States and Europe. A few general principles regarding medications are important to consider before initiating therapy in individuals diagnosed with a dementia

Koru february 2014

Mi KORU ME Support Group HAMILTON February 2014 Issue 30 "And now we welcome the New Year, Full of things that have never been." Rainer Maria Rilke New Year's greetings everyone, 2014 is well underway now with a start up of the year's activities. For some, a new year is no more than a change of a calendar. For others, the New Year symbolizes the beginning of a better tomorrow, and a new chapter in their lives. For many people a new year will inspire them to make resolutions, but despite good intentions, they are frequently broken! Often resolutions are centred on achieving better results or accomplishing more. Many people with ME/CFS and FM tend to be perfectionists and their self-esteem is tied in with their sense of achievement. Their typical goals for New Year are often unrealistic. Richard Eyre, in his book, ‘Don't Just Do Something, Sit There', argues that the traditional thinking about self improvement is out-dated or inaccurate. He feels we need new paradigms to ‘reflect our world as it really is, and our lifestyles as they really ought to be.' This is especially true for people with chronic illness. He thinks perhaps we need to rethink these annual goals and look to the New Year with a spirit of ‘anti-resolutions'. This means ‘releasing ourselves from the obligation of things we are not able to do and consider alternatives more supportive of healing and well-being'. He calls it ‘The art of letting go'. For example the goal ‘I will manage my time better so I can do more' can become ‘I will pace myself to allow for rest and recovery'. There is a healing value in ‘letting go'. Definitely food for thought!