HESC 220, ALL notes
HESC 220, ALL notes HESC 220
Cal State Fullerton
Popular in Concepts Health Science
Popular in Nursing and Health Sciences
Yeraldin S. Barrera
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CH 1: What is public health? • People of developed countries are healthier today than they were a century ago. o This is mainly due to improved living conditions brought about by public health. § Sanitation § Better nutrition and food service/preparation § Occupational safety • In the 1980’s public health was taken for granted. • However, new health concerns were appearing: o AIDS epidemic o Environmental pollution growing o Aging population demanding increased health services o Social problems (teen pregnancy, violence, substance abuse) • In 1988 the Institute of Medicine published The Future of Public Health. • This refocused attention on the importance of public health and has revitalized the field. • The report gives a four-‐part definition describing public health’s o Mission o Substance o Organizational Framework o Core Functions • Mission – “the fulfillment of society’s interest in assuring the conditions in which people can be healthy.” • Substance – “organized community efforts aimed at prevention of disease and promotion of health.” • Organizational Framework – encompasses “both activities undertaken within the formal structure of the gov’t and the associated efforts of private and voluntary organizations and individuals.” • Core Functions – defined as 1) assessment, 2) policy development, 3) assurance • Assessment – ex: Taking vitals (preliminary assessment) • Development – ex: Treatment Plan • Assurance – ex: Follow-‐up appt, assure that it is resolved Medical Practice Model • To better understand public health and its functions we can compare it to medical practice • Medicine is concerned with a patient as public health is concerned with the community • A doctor will assess the patient, diagnose the problem, seek for the cause of the problem and then strategize how best to treat the patient. • In public health, we follow a similar model, but work instead with the community, the public. • Public Health’s focus is more preventative, where as medical is based on the aftermath, treatment, etc. (retroactive) • Assessment – ex: Monitor health status – death rates due to car accidents • Development – ex: Develop policies for seat belt laws, educate the public • Assurance – ex: Enforce laws, evaluate effectiveness • Public health has the responsibility of assuring people that the services needed for the protection of the public’s health are available and accessible to everyone. Public health’s focus on prevention makes it more abstract than medicine, and its achievements are therefore more difficult to recognize Public Health is unseen when working ex: no flu outbreaks Sciences of Public Health • The six disciplines of public health: o Epidemiology o Statistics o Biomedical Sciences o Environmental Health Sciences o Social & Behavioral Sciences o Health Policy & Management or Health Administration Epidemiology • The basic science of public health, the study of epidemics. • It focuses on human populations, usually starting with an outbreak of disease in a community. • Epidemiologists look for common exposures or other shared characteristics in the people who are sick, seeking the causative factor. Statistics • Because public health deals with the health of populations statistics are relied upon heavily. • Governments collect data of births, deaths, certain communicable diseases, age of death, cause of death, etc…these numbers can be diagnostic tools. • To understand what the numbers mean it is important to understand certain statistical concepts and calculations. Other Sciences • Biomedical Sciences • Environmental Health Science • Social and Behavioral Sciences o Health Policy & Management or Health Administration Prevention and Intervention • Public Health’s approach to health problem’s in a community (a five-‐step process): o Define the health problem. o Identify the risk factors associated with the problem. o Develop and test community-‐level interventions to control the cause of the problem. o Implement interventions to improve the health of the population o Monitor those interventions to assess their effectiveness. Three levels of Prevention: o Primary – seeks to avoid the occurrence of an illness or injury by preventing exposure to the risk factor. o Secondary – seeks to minimize the severity of illness or damage due to injury. o Tertiary – seeks to minimize disability by providing medical care or rehabilitative services. • Chain of Causation: o Agent o Host o Environment • Prevention is accomplished by breaking the chain at any step. CH 2 Why is Public Health Controversial? Public health: • Can be viewed as a broad social movement • Beauchamp (a health philosopher), wrote “public health should be a way of doing justice. A way of asserting the value and priority of all human life.” • Social Justice vs. Market Justice • Social Justice – “suggests the minimal levels of income, housing, employment, education and health care should all be basic fundamental rights.” • Market Justice – “emphasizes individual responsibility, minimal obligation to the common good” • The broad view of PH creates controversy in our country, as Americans place a heavy value on individualism and a market-‐oriented society. • Many Americans oppose being told what to do (e.g. wear a seatbelt). • Moralists oppose discussing health issues that address personal unhealthy behaviors (adolescent sexuality, unsafe sex practices) The Debate • Economic – just about every PH measure will have a negative economic impact on some group (lost jobs, increased taxes, lost income, increased price of product) • Specific Examples ??? • The cost of PH measures are usually easier to calculate than the benefits (ex. LA smog). It is very difficult to put a dollar value on life and health. • Individual Liberty – The U.S. Constitution lists “promote the general welfare” as one of the gov’ts primary purposes. • The controversy comes as we have to decide to what extent the gov’t can and should restrict individual freedom for the purposes of improving the public’s health. • Most controversial are restrictions on people’s freedom to harm themselves. • Moral and Religious Opposition – Public Health often arouses controversy on moral grounds, most often when it confronts sexual and reproductive issues. • Sex education, provision of contraception, teaching safer sex practices, abortion • While regulating for the common good, basing legislation on morality has proven ineffective, self-‐defeating and a threat to liberty, in part because we differ in what we view as moral. CH 3 Powers and Responsibilities of Government Government and Public Health § Government’s role in public health is determined by law. § Government’s activities must be authorized by legislation at the federal, state or local levels. § Public Health law can be further defined by decisions of the courts at the various levels of government. § The federal role in public health is based on the Constitution’s statement “to promote the general welfare” § Examples: § Dept of Health and Human Services -‐ FDA, CDC, NIH, Medicaid/Medicare § Other federal departments/agencies -‐ Dept of Labor, OSHA; EPA; Dept of Agriculture; Dept. of Education, etc… § Helmets for motorcyclists § Since the 1980’s there has been a strong push by Congress to cut government regulation and move powers back to the States. § The Constitution does not mention health. § Because the Tenth Amendment states “the powers not delegated to the United States by the Constitution…are reserved to the States respectively,” public health has been a responsibility primarily of the states. § Most state constitutions provide for the protection of public health. § Responsibility for some public health activities may be delegated by the state to local governments. How the Law Works § Police Powers – government's broad power to act to protect the public’s welfare/health. § Police powers evoked for 3 reasons: § To prevent one from harming another § To protect the common good § In some cases to protect a person from harming himself/herself § At any level of gov’t a legislature perceiving a need, passes a statute. § The statute may be challenged in court, and the decision of the court may be appealed to higher courts. § On issues of constitutionality, a state court may overturn a local law or court decision, and a federal court may overturn a state law or court decision. § 1905, Smallpox Vaccine example Nongovernmental Role in Public Health § Govt. may play the primary role in public health, however nongovernmental organizations play important roles, especially in education, lobbying and research. § Amer. Heart Assoc; Amer. Cancer Assoc, Amer. Diabetes Assoc § Professional membership organizations, APHA, AMA § Associations: Amer. Assoc of Schools or Public Health § Foundations: Robert Wood Johnson, Kaiser Family Foundation § Consumer Groups CH 4-‐6 Epidemiology Epidemiology • Epidemiology – the study of the distribution and determinants of disease frequency (disease=health outcome). • Epidemiological methods are used: o to investigate causes of disease. o to identify trends in disease occurrence that may influence the need for medical and public health services. o to evaluate the effectiveness of medical and public health interventions. • Epidemic vs. Endemic • Epidemiologists count cases of disease. • Once they detect signs of an epidemic, they ask who, when and where questions. • Who is getting the disease? • When and where is the disease occurring? • From this information they can hypothesize why it is occurring. • Their ultimate goal is to use this knowledge to control and prevent the spread of disease. • John Snow, known as the father of modern epidemiology • First example of the use of epidemiology to study and control disease. • Cholera epidemic in London in 1848, Snow hypothesized that cholera was spread by polluted drinking water. • In 1853, severe cholera outbreak, Snow tested his hypothesis in a kind of natural experiment. • Epidemiologic surveillance – a system governments use requiring certain “notifiable” disease be reported as soon as they are diagnosed. • Epidemiologic surveillance – a system governments use requiring certain “notifiable” disease be reported as soon as they are diagnosed. • They are usually infectious diseases whose spread can be prevented if the appropriate actions are taken. • Timely reporting allows public health officials to detect an emerging epidemic at an early stage. o Example – Hepatitis A § County health notices an outbreak of Hepatitis A thus an epidemiological investigation must occur. § Who? They start with the reported cases and interview those with Hep. A § When? They ask on what date did the symptoms first appear? § Where? They ask where they obtained their food and water during the period of likely exposure, and what sources did they have in common. o Other examples: Legionnaires Disease & EMS § Epidemiological surveillance is a major line of defense in protecting the public against disease. § The sooner the system kicks in, the sooner action can be started to stop the epidemic. § That action may be vaccination campaigns, isolation of infected food workers, new regulations on air conditioning systems, recall of contaminated food or drugs, etc. Epidemiology & Chronic Diseases • Until the 20 century, conditions such as heart disease and cancer were thought to be a natural part of aging and no one thought to look for causes or try to prevent them. • Since these diseases of aging typically develop over time and cannot be prevented or cured by a vaccine or a simple pill, preventing the public from developing these conditions is the best way to protect them. To do this we need to understand the cause(s) of the disease and the factors that influence its progress • Examples: prospective cohort studies • Framingham, 1948 – Heart Disease o Within 10 years they were able to identify 3 major risk factors: high blood pressure, high cholesterol, & smoking • Doll & Hill physician study early 1950’s – Lung Cancer o Four years after the start of the study several conclusions were apparent. o Death rate from lung cancer 20 times higher among smokers than non smokers, death rate among ex-‐smokers was lower than smokers, and there was no difference in those that lived in urban or rural areas. Epidemiological Terms • Frequency • Rate • Incidence • Prevalence • Distribution (of disease) • Determinants (of disease) Epidemiological Studies • Answers to the who, when and where questions provide clues as to the causes of disease or source of an outbreak. This type of analysis is called descriptive epidemiology. • The hypothesis generated by descriptive epidemiology are then tested by formal epidemiological studies, designed to confirm or disprove a hypothesis. • Prospective Vs. Retrospective -‐ in both cases investigators are looking for associations between exposure to the suspected causative factor and disease (health outcome). • Intervention Studies • Cohort Studies • Case Control Studies n Intervention Studies • Example: Clinical Trial • Treatment group vs. Control group • Placebo effect • Randomized, doubly-‐blind (most convincing clinical trial) • Why are clinical trials necessary? n Cohort Studies – link exposures to results by observation alone • In a typical cohort study, large numbers of people (all healthy at the time the study begins) are questioned concerning their exposure. • Observed over a period of time as researches watch to see whether those who were exposed are more likely to develop the disease/condition • Framingham Heart Study, Nurses Health Study • Findings -‐ Relative Risk n Case Control Studies – start with people who are already ill and look back to determine their exposure. • Focus on a smaller number of people. • People who have the disease are compared with controls, healthy people chosen to match the cases as much as possible (age, sex, etc.) • Example – Reye’s syndrome Problems and Limits of Epidemiology • While a formal study can strongly support the conclusion that a certain exposure causes a certain disease, there are many potential sources of error in drawing such a conclusion. • Studies of chronic diseases, which often have multiple determinants and develop over long periods of time, are especially prone to error. • Problems with Studying Humans o Sources of Error o Study design o Confounding variables o Bias – selection, reporting, recall o Proving Cause and Effect • Ethics in Epidemiology Ethics in Public Health Basic Ethical Principles • Respect o Honor Personal Autonomy o “Autonomous persons: an individual capable of deliberation about personal goals and of acting under the direction of such deliberation.” o To give weight to a persons’ considered opinions and choices o And to refrain from obstructing their actions. o Protect those with diminished autonomy. Ex: disabled, children, elderly Beneficence • “To do good” • “Do no harm” • Maximize benefits and minimize harms • not no harm, but minimization of risks to the greatest extent possible. Justice • Fairness in selection of subjects… • To receive the potential benefits of research: Access to benefits • To bear the burdens of research: Suffer risks and adverse effects Tools for implementing Ethical Principles • Respect – Informed Consent • Beneficence – Protocol, risk vs. • benefit • Justice – Inclusion/exclusion • criteria CH 30 The Future of Public Health The Future of Public Health • But first a look back… • Average lifespan increased by 30 years since 1900 o 25 of those years are due to Public Health improvements • In 1999, the CDC published a top ten list of great public health achievements th of the 20 century based on the impact they have had and will continue to have on death, illness and disability in the U.S. They are NOT listed in order of importance o Routine use of vaccination o Improvements in motor vehicle safety o Safer workplaces o Control of infectious diseases o A decline in deaths from heart disease & stroke o Safer and healthier foods o Healthier mothers and babies o Access to family planning & contraceptive services o Fluoridation of drinking water o Recognition of tobacco use as a health hazard Challenges for the 21 Century • Renewed threats from infectious diseases • Overpopulation • Rising costs of medical care for aging population • The challenge of understanding and altering human behavior – the factor that now contributes most substantially to premature mortality. Strategic Planning for PH • Management-‐by-‐objectives approach • Healthy People (national health objectives) o This planning process encourages states and local communities to use the national objectives as a basis for developing measurable objectives of their own. o Healthy People 2020 goals: § Attain high quality, longer lives free of preventable disease, disability, injury, & premature death § Achieve health equity, eliminate disparities, & improve the health of all groups § Create social & physical environments that promote good health for all § Promote quality of life, healthy development, & healthy behaviors across all life stages • A group of public health associations, funded by the CDC, have been working on ways to help local public health agencies/organizations apply the management-‐by-‐objectives approach. Integration of Public Health and Medical Practice • Because of the high and continuously rising cost of medical care, managed care has become much more prevalent. • Managed care moves the objectives of medicine closer to the mission of public health—keeping people healthy. • Traditional fee-‐for-‐service medicine focuses on people who seek care and financially rewards practitioners who provide service to the patient. • Managed Care Organizations are responsible for all their members, yielding financial rewards when the need for expensive medical service is averted. The Ultimate Challenge to Public Health in the 21 Century • “If Public Health’s mission is to fulfill society’s interest in assuring conditions in which people can be healthy, PH has yet to succeed in fostering a national debate on the relative return on investment to improve population health.” • PH agencies are chronically starved for funding to carry out essential public health services that are clearly cost-‐effective in raising the health status of communities • Health is determined by the social, physical, and economic environments; health behaviors and genetics. Health is affected only marginally by medical interventions. • The challenge for PH will be to educate the public and policy makers about the role of these non-‐medical factors in determining people’s health and to convince people of the importance of the core PH functions in protecting and promoting the health of the entire population. CH 11 Chronic Disease Chronic disease • With public health’s success against infectious disease in the early 1900’s, a change in the major causes of illness and death began in the 1920’s. • Today chronic degenerative diseases, namely heart disease and cancer, are the leading causes of death. • While the risk of these diseases increase with age, they still can strike people in their prime. Cancer is the leading cause of death in Americans aged 45-‐65 and CVD runs a close second. • Prevention of disease usually requires some understanding of the cause, a requirement that is generally much more difficult to fulfill for chronic diseases than infectious ones. • With chronic disease there is no single pathogen and in most cases they have multiple causes. In addition, they tend to develop over long periods of time further complicating the task of pinpointing causes. • However, the gradual onset of many chronic diseases gives us the advantage of early detection thus allowing secondary prevention and intervention early in the disease process that can mitigate its impact. Cardiovascular Disease • Encompasses two of the three leading causes of death in the U.S. -‐-‐ heart disease and stroke. • Causes of CVD have been relatively well established through epidemiological studies, animal experiments and examination of bodies after death from CVD. • The understanding of CVD has been facilitated by its prevalence in the U.S. and due to the important role of blood components and the ease of studying blood. Cancer • Cancer has proven much more difficult to understand than CVD, in part because it has so many manifestations. Breast cancer is very different from lung cancer. • Therefore each cancer must be studied separately. • Very often public health efforts targeting cancer prevention or intervention target each cancer seperately. Other Chronic Diseases • Diabetes: numbers diagnosed in U.S. rapidly rising, however receives far less attention than CVD and cancer as it is usually treatable. • Mental Illness: major cause of disability in the country • Alzheimer’s Disease and Dementia • Arthritis: can be very debilitating and greatly reduce quality of life Chronic Diseases & Public Health • Chronic diseases are the leading causes of death and disability in the United States, with CVD and cancer leading the list. • Preventing these diseases, an important PH priority, requires understanding their causes. • Despite the tremendous progress made by biomedical science in the understanding of the bases of chronic disease, a great deal more is left to learn about what can go wrong with the human body and how to prevent it. CH 9 Infectious Diseases Infectious Agents • The major epidemic diseases are caused by bacteria, viruses, or parasites. • The fact that each of the epidemic diseases were caused by a specific microbe was established in the 1880’s and 1890’s. • Robert Koch developed techniques to classify bacteria by their shape and their propensity to be stained by different dyes. • He also created a set of rules to help prove that a specific disease was caused by a specific organism (Koch’s Postulates). Koch’s Postulates • 1. the organism must be present in every case of the disease • 2. the organism must be isolated and grown in the laboratory • 3. when injected with the laboratory-‐grown culture, susceptible test animals must develop the disease • 4. the organism must be isolated from the newly infected animals and the process repeated Bacteria • Bacilli are bacteria that are rod shaped when observed under the microscope. (ex. cholera, plague, typhoid, tetanus, diphtheria). • Cocci are round shaped bacteria (ex. streptococci, staphylococci, pneumococci). • Spirochete are corkscrewed shaped bacteria (ex. syphilis). • While bacteria are living , single-‐celled organisms that can grow and reproduce outside the body if given the appropriate nutrients, viruses are not complete cells. Viruses • Viruses are simply complexes of nucleic acid and protein that lack the machinery to reproduce themselves. • They reproduce themselves by taking control of the cell’s machinery often killing the cell in the process. • Viruses can effect animal and plant cells and can withstand extreme conditions such as treatment with alcohol and drying in a vacuum and then become active again when they are injected into a living cell. • Examples: smallpox, polio, hepatitis, influenza Parasites • Human disease can also be caused by protozoa, or single-‐celled animals that can live as parasites in the human body. Examples: malaria spread by mosquitoes, cryptosporidiosis, which caused the Milwaukee diarrhea, and other parasites such as roundworms, tapeworms, etc Means of Transmission • Infectious diseases are spread by a variety of routes, directly from one person to another or indirectly by way of water, food, or vectors such as insects and animals. • Respiratory infections, both bacterial and viral, such as cold, flu and TB are transmitted through the air on “aerosols” (water droplets produced when an infected person coughs or sneezes). • They can also be transmitted from an infected person to objects. • GI infections are generally spread by the fecal-‐oral route, may result from poor personal hygiene or by contamination of drinking water. • Vector-‐borne diseases generally use a more complex route from one person to another, most often using an insect. • Each disease has its own pattern of development after a person is infected and the time during which the patient is capable of transmitting the infection to others varies from one disease to another. Chain of Infection • The public health approach to controlling infectious diseases is to interrupt the chain of infection. 1. Pathogen – is a virus, bacterium, or parasite that causes the disease in humans. 2. Reservoir – any place where the pathogen lives and multiplies. 3. Method of Transmission – the way the pathogen travels from one host to another, or from a reservoir to a new host. 4. Susceptible host – a new potential host may not be susceptible because the host has immunity to the pathogen. Interrupting the Chain of Infection • Public health measures to control the spread of disease are aimed at interrupting the chain of infection at whichever links are most vulnerable. • Link 1 – pathogen could be killed (ex. antibiotic) • Link 2 – eliminate the reservoir that harbors the pathogen (ex. controlling rat population) • Link 3 – transmission for one host to another could be prevented by quarantining infected individuals, or by warning people to boil their water, hand washing, use of condoms, etc. • Link 4 – the resistance of the host can be increased by immunization Infectious Diseases and Public Health’s Role • Public health measures to prevent the spread of infectious diseases include both routine preventive measures and emergency measures to control an outbreak once it has begun. HESC 220 Preparing to Write a Literature Review Part I Learning Objectives • Understand the essence and purpose of a literature review • Understand and be able to implement the steps involved in writing a literature review • Understand and become equipped with the skills necessary to enhance writing ability • Understand the value of creating and utilizing a topic outline • Understand the importance of proof reading and the value of rewriting What a literature Review is NOT? • It is NOT a research paper... • What is a Literature Review? • A review or summary of the current research literature on a specific topic. • A comprehensive survey of publications in a specific field of study. Contributing Factors of Adolescents Contracting an STD Writing a Topic Outline Brainstorm: List all the ideas that you want to include in your paper. Organize: Group related ideas together. Organize Contributing Factors of Adolescents Contracting an STD Writing a Topic Outline Brainstorm: List all the ideas that you want to include in your paper. Organize: Group related ideas together. Order: Arrange material in subsections from general to specific Label: Create main and sub headings. Order and Label I. Sexually Transmitted Disease Prevalence a. Adolescent population b. STD Transmission II. Demographics a. Gender b. Race/Ethnicity c. Socioeconomic Status (SES) III. Lifestyle Factors a. Peer pressure b. Self-‐esteem c. Parent/Adolescent relationship IV. STD Awareness a. Education b. Lack of Knowledge c. Prevention Steps in writing a lit review 1. Choose a topic • Choosing a Topic • Something of interest to you… • Something you read about in a popular magazine… • You can start with a broad topic, but you must narrow it as you continue your research. • Focus on a(n): specific gender, ethnic group, region, age group, treatment/intervention/prevention method, etc. 2. Begin your research • Know what scholarly research is and how best to find it (Library presentation) • Scholarly vs. Non-‐Scholarly (Popular) 3. Secure full copies of all relevant articles (abstracts alone are NOT enough) 4. Read your articles and take notes of key points/findings as you go 5. Writing a Topic Outline • An outline organizes your ideas in a logical format and aids you in the writing process (no matter what the topic or type of paper) • Determine the purpose of your paper. • Determine the audience you are writing for. • Develop the thesis of your paper (the main purpose of your paper). 6. Brainstorm: • List all the ideas that you want to include in your paper. 7. Write your paper (remember inverted triangle) 8. Proof read (by yourself and someone else) • THE IMPORTANCE OF PROOF READING!! • Proof Reading and Editing • Ask two friends or family members to read your paper and make written comments on errors as well as issues they found hard to understand or follow. • Compare their points and consider rewriting passages they both found unclear. • Read your paper aloud paying special attention to the areas your friends indicated were unclear – make appropriate revisions. • Always go back to your topic outline and make sure your paper follows the same path. Preparing to Write a Literature Review Part II LITERATURE REVIEW WRITING TIPS Writing Style for a Lit. Review • Expository (fact) vs. Narrative (story) • No first person (I), no personal opinion • What is a thesis statement??? • When reviewing the literature, don’t say “this study found this and this study found that” you must organize the findings… • Be careful of Syntax (what the heck is syntax?) • Ex. A large mass of literature has accumulated on the cell walls of Staphylococci. • Utilize the campus writing center Sentence Structure • “The objective of this study was to find out whether or not the amount of time that school children had a physical activity class effected what their BMI (body mass index) would be.” o Unclear, choppy and difficult to read Reference Page • One to Seven Authors – list all • More than Seven Authors -‐ After the sixth author's name, use an ellipses in place of the author names. Then provide the final author name. There should be no more than seven names. Miller, F. H., Choi, M. J., Angeli, L. L., Harland, A.., A., Stamos, J. A., Thomas, S. T., . . . Rubin, L. H Types of Plagiarism • Using another writer's words without proper citation; • Using another writer’s ideas without proper citation; • Citing a source but reproducing the exact words of a printed sources without quotation marks; • Borrowing all or part of another student’s paper; • Using a paper-‐writing service or having a friend write the paper for you. Proper APA format The research results indicated that teen participants were 2.5 times less likely than the non participants to initiate sexual intercourse during the intervention period (Monahan & Smith, 2002). Or Monahan and Smith (2002) found that teen participants were 2.5 times less likely than the non participants… Or Monahan and Smith (2002) state that “adolescent participants are 2.5 times…” (p. 212). Or She stated, “The placebo effect disappeared when behaviors were studied in this manner” (Miele, 1993, p. 276), but she did not clarify which behaviors were studied. Reference Page Kovach, C. R., Morgan, S., Noonan, P. E., & Brondino, M. (2008). Using principles of diffusion of innovation to improve nursing home care. Journal of Nursing Care Quality, 23(2), 132-‐139. Last Name, Initial(s). (year). Title of article. Title of Periodical, volume number(issue number), page numbers. Title of article – only things capitalized: 1 word of title, 1 word after a colon, and proper nouns Only things Italicized: Title of Periodical and volume number Multiple authors • One to Seven Authors – list all • More than Seven Authors -‐ After the sixth author's name, use an ellipses in place of the author names. Then provide the final author name. There should be no more than seven names. Miller, F. H., Choi, M. J., Angeli, L. L., Harland, A. A., Stamos, J. A., Thomas, S. T., . . . Rubin, L. H
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