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Revista de la Real acadèmia de medicina de les Illes Balears. Volumen 31, número 3, 2016

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VOLUM 31 NÚM. 3 SETEMBRE - DESEMBRE 2016 Medicina Balear PUBLICACIÓ DE LA REIAL ACADÈMIA DE MEDICINA DE LES ILLES BALEARS Biogeomedicine: The earth as the new patient for biomedical sciences under the “one health” concept facing climate change Valores de tensión arterial en población laboral del área mediterránea española. Relación con sectores laborales y otras variables socio demográficas Influence of portal vein/superior mesenteric vein resection on morbility, mortality and survival of patients with pancreatic ductal adenocarcinoma in the Balearic Islands ¿Tiene impacto social una Unidad de Dolor? Varón de 86 años pluripatológico con fiebre de origen desconocido www.medicinabalear.org

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Medicina Balear www.medicinabalear.org Medicina Balear, òrgan de la Reial Acadèmia de Medicina de les Illes Balears, va aparèixer el 1986 amb l’objectiu de donar curs a les inquietuds científiques i fomentar l’esperit d’investigació dels professionals de la sanitat balear i amb la pretensió suplementària de projectar en la societat temes d’interès sanitari. Medicina Balear publica en català, castellà o anglès treballs originals, articles de revisió, cartes al director i altres escrits d’interès relacionats amb les ciències de la salut i presta particular atenció als treballs que tinguin per àmbit les Illes Balears i altres territoris de la conca mediterrània occidental. La revista sotmet els originals a la revisió anònima per al menys dos experts externs (peer review). El material científic publicat a Medicina Balear resta protegit per drets d’autor. Medicina Balear no és responsable de la informació i opinions dels autors. Aquesta obra -llevat que s’indiqui el contrari en el text, en les fotografies o en altres il·lustracions- és subjecta a la llicència de Reconeixement-NoComercial-SenseObraDerivada 3.0 Espanya de Creative Commons; http://creativecommons.org/licenses/by-nc-nd/3.0/es/. Així, doncs, s’autoritza al públic en general a reproduir, distribuir i comunicar l’obra sempre que se’n reconegui l’autoria i l’entitat que la publica i no se’n faci un ús comercial ni cap obra derivada. Medicina Balear es troba incorporada a la Biblioteca Digital de les Illes Balears, de la Universitat de les Illes Balears, i està inclosa en les bases de dades següents: Latindex (catàleg), Dialnet, Índice Médico Español, DOAJ, Imbiomed E D I TA Reial Acadèmia de Medicina de les Illes Balears www.ramib.org Campaner, 4, baixos. 07003 Palma de Mallorca Tel. 971 72 12 30 Email: info@ramib.org Pàgina web: http://www.ramib.org  Dipòsit Legal: PM 486 - 95 eISSN: 2255 - 0569 Disseny i maquetació Intelagencia Publicitat - www.intelagencia.es - intelagencia@intelagencia.es

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Medicina Balear Publicació quadrimestral de ciències de la salut de la Reial Acadèmia de Medicina de les Illes Balears Director A. Arturo López González, RAMIB, Reial Acadèmia de Medicina de les Illes Balears (RAMIB) CONSELL EDITORIAL Subdirector Joan March Noguera, RAMIB Editor científic Marta Couce Matovelle, Case Western Reserve University Assessors editorials José A. Guijarro Pastor, AEMET · Jaume Rosselló Mir, UIB Redactor en cap J. L. Olea Vallejo, RAMIB Vocals Antoni Aguiló Pons, Universitat de les Illes Balears · Bartolomé Bur- guera González, Cleveland Clinic (Ohio) · Amador Calafat Far, Socidrogalcohol · Carlos Campillo Artero, Universitat Pompeu Fabra · Valentín Esteban Buedo, Conselleria de Sanitat, Generalitat Valenciana · Carmen González Bosch, Universitat de València · Miguel A. Limon Pons, Institut Menorquí d’Estudis · Virgili Páez Cervi, Bibliosalut · Lucio Pallarés Ferreres, Hospital Son Espases, Ibsalut · Ignacio Ricci Cabello, University of Oxford · Guillermo Sáez Tormo, Universitat de València · Ma Teófila Vicente Herrero, IUNICS CONSELL CIÉNTIFIC Mª José Anadón Baselga (Universidad Complutense de Madrid), Miquel Capó Martí (Universidad Complutense de Madrid), Antonio Coca Payeras (Universitat de Barcelona), James Drane (Edinboro University), Leopoldo Forner Navarro (Universitat de València), Alexandre García-Mas, (Universitat de les Illes Balears), Antoni Gelabert Mas (Universitat Autònoma de Barcelona), Joan Grimalt Obrador (Consell Superior d’Investigacions Científiques, CSIC), Federico Hawkins Carranza (Universitat Complutense de Madrid), Joan Carles March Cerdà (Escuela Andaluza de Salud Pública, EASP), Gabriel Martí Amengual (Universitat de Barcelona), Jasone Monasterio Aspiri (Universitat Autònoma de Barcelona) Rosa Pulgar Encinas (Universidad de Granada), Ciril Rozman (Universitat de Barcelona). Amb la col·laboració de www.medicinabalear.org

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PLAN DE FORMACIÓN EN REANIMACIÓN CARDIOPULMONAR BÁSICA Y DESFIBRILACIÓN SEMIAUTOMÁTICA diciembre 2015, marzo y octubre 2016 Col·legi Oficial de Metges de les Illes Balears Passeig Mallorca 42 - Palma AVALADO POR: Direcció General d’Acreditació, Docència i Recerca en Salut COLABORAN:

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VOLUM 31 NÚM. 3 SETEMBRE - DESEMBRE 2016 Medicina Balear PUBLICACIÓ DE LA REIAL ACADÈMIA DE MEDICINA DE LES ILLES BALEARS www.medicinabalear.org SUMARI EDITORIAL Protecció, prevenció i promoció de la salut María José Ramos Monserrat ORIGINALS Biogeomedicina: La tierra como el nuevo paciente para las ciencias biomédicas bajo el concepto “una salud” ante el cambio climático Roa-Castellanos, R.A., Anadón Baselga, M.J., & Capó Martí, M.A. Valores de tensión arterial en población laboral del área mediterránea española. Relación con sectores laborales y otras variables socio demográficas María Gil Llinás, Pilar Estades Janer, Pilar Laínez Ibáñez, Eduardo Tejedo Benedicto, Mª Nieves Monroy Fuenmayor, Antonio Siquier Cantallops Influencia de la resección de vena porta/vena mesentérica superior en la morbilidad, mortalidad y supervivencia de los pacientes con adenocarcinoma ductal de páncreas en las Islas Baleares Rafael Morales Soriano, José Carlos Rodríguez Pino, Carmen De Juan, Carmen Garrido, Isabel Amengual Antich, Mónica Guillot Morales, José M. Morón Canis, Xavier Molina Romero, Xavier González Argente, Silvia Tejada Gavela ¿Tiene impacto social una Unidad de Dolor? Raquel Peláez, Pablo Gandía, José L. Aguilar, Pilar Sanchis 8-9 11-17 18-24 25-38 39-44 ESTUDI DE CASOS Varón de 86 años pluripatológico con fiebre de origen desconocido Catalina Moyà Salom, Anabel Ballester Ballester, María Isabel Fullana Barceló, Cristina Gómez Bellvert, Manuel del Río Vizoso 45-49 eISSN 2255-0569

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VOLUME 31 NUMBER 3 SEPTEMBER - DECEMBER 2016 Medicina Balear SCIENTIFIC JOURNAL OF THE ROYAL ACADEMY OF MEDICINE OF THE BALEARIC ISLANDS www.medicinabalear.org CONTENTS EDITORIAL Protection, prevention and health promotion María José Ramos Monserrat ORIGINAL ARTICLES Biogeomedicine: The earth as the new patient for biomedical sciences under the “one health” concept facing climate change Roa-Castellanos, R.A., Anadón Baselga, M.J., & Capó Martí, M.A. Blood pressure values in a working population of Spanish Mediterranean. Relation to employment sectors and other sociodemographic variables María Gil Llinás, Pilar Estades Janer, Pilar Laínez Ibáñez, Eduardo Tejedo Benedicto, Mª Nieves Monroy Fuenmayor, Antonio Siquier Cantallops Influence of portal vein/superior mesenteric vein resection on morbility, mortality and survival of patients with pancreatic ductal adenocarcinoma in the Balearic Islands Rafael Morales Soriano, José Carlos Rodríguez Pino, Carmen De Juan, Carmen Garrido, Isabel Amengual Antich, Mónica Guillot Morales, José M. Morón Canis, Xavier Molina Romero, Xavier González Argente, Silvia Tejada Gavela Has any social impact a Chronic Unit Pain? Raquel Peláez, Pablo Gandía, José L. Aguilar, Pilar Sanchis CASE ESTUDIES 86 years old multipathological male with fever of unknown origin Catalina Moyà Salom, Anabel Ballester Ballester, María Isabel Fullana Barceló, Cristina Gómez Bellvert, Manuel del Río Vizoso 8-9 11-17 18-24 25-38 39-44 45-49 Medicina Balear 2013; 26 (2); 5-6 eISSN 2255-0569

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eISSN 2255-0569 EDITORIAL Protecció, prevenció i promoció de la salut Protection, prevention and health promotion María José Ramos Monserrat Directora General de Salut Pública i Participació Conselleria de Salut Govern de les Illes Balears Salut Pública treballa des de tres eixos: la protecció, la prevenció i la promoció de la salut. D’acord amb la Organització Mundial de la Salut, la prevenció abasta les mesures destinades no tant sols a prevenir l’aparició de la malaltia, tals com la reducció dels factors de risc, sinó també a detenir el seu avanç i atenuar les seves conseqüències una vegada establerta. La promoció de la salut, en canvi, és el procés polític i social que permet a les persones incrementar el control sobre els determinants de la salut i en conseqüència millorar-la. L’Organització Mundial de la Salut no va incloure cap definició de protecció de la salut en el seu Glosario de promoción de la salud. Podríem definir la protecció com el conjunt d’accions dirigides a preservar la salut de les persones de tots aquells riscs que estan presents en el medi ambient o en els aliments. La protecció, la prevenció i la promoció de la salut tenen àrees d’intersecció. Els programes d’educació per a la salut a les escoles, per exemple, estan a cavall entre la prevenció o la promoció de la salut. Les campanyes per promoure el rentat de mans entre els manipuladors d’aliments tenen un component de protecció de la salut, però també de prevenció. Programes com Sabor del mediterrani, impulsats per la Direcció General de Salut Pública i Participació, que acredita als restaurants que promouen la dieta mediterrània, són una mostra de programes que combinen la protecció i la promoció. En qualsevol cas, des de fa més de vint anys es sumen evidències que aquells programes que combinen els tres elements: protecció, prevenció i promoció de la salut, són els que obtenen més beneficis en la salut. Així, l’abordatge dels accidents de trànsit a Espanya, que inclou: normativa i millora d’infraestructures i vehicles (protecció), campanyes en els mitjans de comunicació (prevenció) i mesures com el carnet per punts (promoció), han situat a Espanya com el cinquè país del món amb millor seguretat vial. 8 Medicina Balear 2016; 31(3): 8-9

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D’aquesta manera estem lluitant contra el tabaquisme, amb un reforç de les inspeccions per vetlar pel compliment de la llei pel que fa als espais sense fum i a la venda de tabac (protecció), recuperant la formació de professionals sanitaris en abordatge de tabaquisme (prevenció) i a través de programes d’hospitals, centres educatius i empreses saludables, que vetlen no només per protegir els pacients, alumnat i treballadors i treballadores del tabac, sinó que volen moure’ls cap a una vida més saludable. Pensem que aquest ha de ser també el camí per fer front a altres problemes de Salut Pública, com són el sobrepès i l’obesitat, tenint en compte que no totes les solucions han de sorgir del sector salut, com en el cas de la seguretat vial, impulsada per la Dirección General de Tráfico del Ministerio del Interior. Protecció, prevenció i promoció de la salut Bibliografía: Glosario de promoción de la salud. World Health Organization 1998. Disponible en: http://www.msssi.gob.es/profesionales/saludPublica/prevPromocion/docs/glosario.pdf OBJECTIU ZERO ACCIDENTS Medicina Balear 2016; 31(3): 8-9 CONTRIBUEIX A LA REDUCCIÓ D’ACCIDENTS Suma fins a ZERO A la construcció, qualsevol accident, per lleu que sigui, és de vital importància perquè afecta la salut i el futur laboral d’una persona. Integrar a l’empresa sistemes d’avaluació de + formació + vigilància riscos + mesures preventives de la salut és indispensable per evitar accidents. Perquè la prevenció és una part més de la feina i de la gestió empresarial. La salut és un dret; reduir la sinistralitat, una obligació. Estratègia de Seguretat i Salut Laboral Illes Balears 2016 - 2020 9

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ORIGINAL eISSN 2255-0569 Biogeomedicine: The earth as the new patient for biomedical sciences under the “one health” concept facing climate change Biogeomedicina: La tierra como el nuevo paciente para las ciencias biomédicas bajo el concepto “una salud” ante el cambio climático Roa-Castellanos, R.A., Anadón Baselga, M.J., Capó Martí, M.A. Department of Toxicology and Health Law. Faculty of Medicine. Complutense University of Madrid. Correspondencia Ricardo Roa-Castellanos Facultad de Medicina. Universidad Complutense de Madrid Departamento de Toxicología y Legislación Sanitaria. Av. Complutense. s/n 28040. Madrid E-mail: rroa01@ucm.es Recibido: 11 – VII – 2016 Aceptado: 2 – IX – 2016 doi: 10.3306/MEDICINABALEAR.31.03.11 Abstract Introduction: Climate change (CC) is an underrated issue for health sciences. But, CC -the worst current ecotoxicological phenomenon- is the main threat to Public Health and the majority of living populations taking into account similar earlier events in Earth’s history. So far the leadership for controlling CC has been primarily focused on politics (geopolitical agreements) and Geoengineering. However, this complex problem calls for deeper analysis of health and life sciences. Objectives and methods: The involvement and action of the foregoing sciences mediated by transdisciplinary integration is a deontological duty. Moreover, attention is needed when observing the present refractory amplification of CC. Thus, Documentary Systemic Review combined with Cross-cutting transdisciplinary interpretation is the chosen methodology. Identification of integrative triad models for epistemological explanation and exemplification is also used. Results: Faced with the present disassembled state of disciplines in CC that are trying to regroup facing new complex studies, a new paradigm between life and health sciences is proposed. Based on ecotoxicology and epidemiology’s triads and other recent combined fields in life, health and Earth’s sciences, Biogeomedicine results as such a transdisciplinary perspective. Conclusions: Transdisciplinary and qualitative investigation on the subject bring back the very essence of the Ars medica. Widening the approach to the problem leads to the identification of a missing field for studying CC’s therapeutic neutralization. Biogeomedicine can be built relying on the “One Health” concept from mixed biomedical perspectives, basic and applied sciences and geosciences. Inferring qualitative approach strategies, either from medical humanities (micro and macrocosms analogies) or Von Bertalanffy’s theoretical biology would lead to a better, more complete understanding of the problem and how to control it. Keywords: Climate Change, Ecotoxicology, Biogeomedicine, Medical Geology, Transdisciplinary research Resumen Introducción: El Cambio Climático (CC) ha sido un problema infravalorado para las ciencias de la salud. Pese a ello, el CC -también el peor de los problemas ecotoxicológicos actuales- es la mayor amenaza para la Salud Pública y la mayoría de las poblaciones vivas teniendo en cuenta antecedentes similares en la historia terrestre. Hasta ahora el liderazgo para tratar el CC ha recaído en los campos de la política (a través de firma de acuerdos geopolíticos) y la Geoingeniería. Sin embargo, este complejo problema clama por mayor análisis desde las ciencias de la salud y la vida. Objetivos y métodos: El involucramiento y acción de estas ciencias, mediadas bajo integración transdisciplinaria, es una obligación al observar la refractaria amplificación que se ha notado recientemente del fenómeno. Revisión documental sistémica combinada con interpretación transversal transdisciplinar es el método seleccionado. Identificación de triadas modelares es utilizada para ejemplificar y explicar el análisis epistemológico. Resultados: Se observa que en las últimas décadas varios campos científicos se están reagrupando otra vez de cara a estudios complejos. Basados en el ejemplo integrativo de las triadas de la epidemiología y la ecotoxicología en la lectura de la realidad, aparece la Biogeomedicina como la perspectiva transdisciplinar buscada. Conclusiones: La investigación transdisciplinaria y cualitativa regresa la esencia del Ars medica. Ampliar la aproximación disciplinaria del problema lleva a descubrir el campo faltante para estudiar la neutralización del CC desde una óptica terapéutica. La Biogeomedicina puede construirse al fundamentarse en el concepto “Una Salud” desde perspectivas biomédicas, ciencias básicas y aplicadas, y geociencias. Inferir estrategias cualitativas de aproximación bien desde las humanidades médicas (Micro y macrocosmos análogos) o de la biología teórica de Von Bertalanffy, basada en la integración de sistemas, puede arrojar un mejor y más completo entendimiento del problema y su control. Palabras clave: Cambio climático, Biogeomedicina, Ecotoxicología, Medical geology, Investigación Transdisciplinaria Medicina Balear 2016; 31(3): 11-17 11

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Ricardo Roa-Castellanos et al. Introduction On one hand, Climate Change (CC) means not only the biggest threat for Public Health in the XXI century1, but also the main risk of foreseeable mass extinction. Many biological populations, including different taxonomic kingdoms, species and systemic habitats (i.e. terrestrial and marine ecosystems; rural, wild and urban habitats) are vulnerable to drastic changes in weather2, 3, 4. At the same time, it is evident that the globalized society has relied, since 1992, on Geopolitical agreements and Geoengineering to face refractory CC5. Meteorological tendencies, however, continue to worsen. Notwithstanding, the great damage as well as the particular mechanisms and impacts of this complex problem belongs to the realms of Earth, life and health sciences. For instance, if global warming exceeds 3°Celsius (C) over the 21st century, it could eliminate many species on the planet (approximately 60%) due to physical-chemical effects of unbalanced gas dynamics in the atmosphere6: That would mean the loss of planetary homeostasis and diverse populations. When establishing Paleo-bioclimatology comparisons for equivalent past imbalances, the “Big five” Earth’s mass extinctions (involving the loss of 50-90% of species each time) were accompanied by global temperature changes of at least 5°C7. Likewise, those depletions in living populations were preceded by a set of changes to environmental conditions, which resembles today’s current tendencies8: multiple-simultaneous disintegrative events, atypicalhigh-intensity milieu stressors, unusual climate change and highly elevated atmospheric CO2 (Figure 1). From a transdisciplinary viewpoint it means an increasing event of entropyat the Physical chemistry level, which is produced within the troposphere’s Geochemistry byadding complex positive feed-back mechanisms inside the biogeochemical cycles, and therefore, the Earth’s macro-system. On the other hand, transdisciplinary research (TR) combines information from different fields, aimed at finding solutions for complex life-world problems, including scientific perception, objective and subjective data and theoretical analysis. This process of narrowing down keycomponents and widening epistemological perspectives for problems, contrasting scientific information helps us to readjust previous interpretations. In addition, it reframes knowledge theory and results in integrative solutions because it allows the combined use of experimental and social science9, 10. Consequently, Health law and TR are natural allies considering their methodologies. Moreover, the latter develops descriptive, normative and practice-oriented knowledge in order to help solve, mitigate or prevent life-world problems identifying complex structures10. Applying transdisciplinary analogies may match previously unnoticed relationships and compatible categories between different epistemological fields. For example, under the so-called phenomenon of “extinction” –in biological and geological terminology–, devastating episodes of morbidity and mortality rates can be seen from a Public Health perspective. The foregoing reveals CCs importance for contemporary health impact studies focused on the analytical category known as “populations”. The need for these types of connections and systemic analogies for developing a complex health-system of thought towards CC, is urgent to dismantle mechanisms that have worsened lately. Medical deontology, trained professional thought and therapeutic knowledge should be integrated and aimed to stabilize unbalanced organic systems to benefit its different-level components (cells repertoires, tissues, organs, apparatus, individuals, symbiotic groups, ecosystems, etc.). That is compatible especially with the deontological responsibility, learned rational reasoning and inherent skills of health workers. Material and methods SFiipgluereSt1a:tioCnOIc2 eGlCoborael Atmospheric Concentration according Data. Source: National Oceanic and to Mauna Loa and Atmospheric Admi- nistration. 400 375 350 ConcCenOt2ration 325 (ppm) 300 Atmospheric Concentration of Carbon Dioxide (1744-2005) Siple Station Ice Core Mauna Loa 275 250 1700 1750 1800 1850 1900 Year 1950 2000 2050 This work was carried out from exhaustive comparative Documentary Review material. Methodologies of Qualitative-Transdisciplinary Research9 were applied in order to extend and deepen knowledge on Climate Change (CC) for biomedical understanding. To contrast current approaches to and perceptions of CC, relevant background and state of the art from different disciplines were observed from multidisciplinary academic literature. Following the standards of the Handbook of Transdisciplinary Research byusing Cross-cutting interpretation9, 10 was the methodological approach developed to detect the similarities between epistemological, cultural, terrestrial and organic systems. The analysis was oriented to signal milestone articulating elements for the different fields through theoretical triad composition. Policy-relevant suggestions to identify common normative critical 12 Medicina Balear 2016; 31(3): 11-17

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Biogeomedicine: the earth as the new patient for biomedical sciences under the “one health” concept facing climate change points for health, life and Earth sciences’ professional intervention were highlighted. Results First triad: the shared fundamentals for medicine, geology and ecology Remarkably, Hippocrates is strongly clear when initiating the treatise “On air, waters and places” in his Corpus Hippocraticum. There,he develops his Ars medica with a surprisingly detailed deontological instruction based onunderstanding of nature, especially valuable at present when dealing with Climate Change: “Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces (for they are not at all alike, but differ much from themselves in regard to their changes). Then the winds, the hot and the cold, especially such as are common to all countries, and then such as are peculiar to each locality (…) From these things he must proceed to investigate everything else” Hippocrates, accordingly, conceived hygiene as an amplified concept: “an influence of atmosphere, soil, and water on human health”, commenting that “every disease has its own nature and arises from external causes”. The principle upon which the deontological labor of medicine relies is a natural triad (understood conforming to the Merriam-Webster dictionary as “a group of three closely related compounds or elements”). In this case: Air, water and soil (Figure 2). By widening the comprehension of health problems, Hippocrates gave more importance to the expected outcome (prognosis) of the organic disequilibrium rather than its iden- tification (diagnosis)11. However, in this translation from the planetary Phýsis system to the so-called organic MikroPhýsis of the human body’s system12, it is possible to identify the first triad template for Biogeomedical considerations. For each of the 3 elementsconsidered since Hippocratic medicine started, there is an equivalent system, which interact on an individual, ecological and planetary level with each other. The bottom line of this synthetic idea for medicine was: systemic equilibrium preserves health13. Meanwhile, systemic imbalance,either by excess or deficiency, can lead to illness and death. CC shows, for instance, that a gas imbalance produces land and aquatic impact1, 25. Second triad: population becomes a new patient for medicine In Health sciences a second transdisciplinary precedent was Public Health itself.This new paradigm was a mixture of sciences, skills and convictions that were focused on the preservation and improvement of the health of populations through preventive (rather than curative) measures14. Public Health was one of the first examples of modern interacting disciplines based on transdisciplinary approaches: social and political sciences went into dialogue with medicine.The reason? Back then, there was another body that was demanding health care in times of multiple epidemicsin human and animal medicine: the social body. This concept included population for Health analyses. The word epidemiology comes from the Greek words epi-, meaning “on or upon”, demos, meaning “people”, and logos, meaning “the study of”Ídem. Population -as intellectual concern- was the center not only of Public Health, but also is the core forcurrent complex knowledge fields such as Political Economy and Biopolitics15. Figure 2: Elementary common system triad of elements for Earth, health and life sciences TRANSDISCIPLINAR EARTH, HEALTH AND LIFE SCIENCES’ TRIAD AIR METEOROLOGY NEUMOLOGY (GAS DYNAMICS) -AERIAL ECOSYSTEMS- WATER HYDROLOGY - NEPHROLOGY (FLUID AND ELECTROLYTE BALANCE) -AQUATIC ECOSYSTEMS- Medicina Balear 2016; 31(3): 11-17 SOIL EDAPHOLOGY & PEDOLOGY - SOFT & HARD TISSUES (SOLID COMPONENTS OF ORGANIC ARCHITECTURE) -TERRESTRIAL ECOSYSTEMS- 13

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Ricardo Roa-Castellanos et al. Respectively, epidemiology is considered a basic science of Public Health16. Epidemiology, being the study of the distribution and determinants of health-related states in populations, and the application of this study to the control of health problems, identified another triad: The epidemiological triad observed mutual action-reactions, constant co-factors for illnesses, and cause-effect mechanisms through three main interacting disease elements and often, a vehicle of infection (vector) that is commonly a biological population as well (Figure 3). It is noteworthy that the modulatory element for the interconnecting triad –that is also the key element for Climate change–, is the environment. This goes in agreement with the U.S’ Centers for Disease Control and Prevention (CDC), so Hippocratic observations were proved correct. Third triad: environment as subject of biomedical intervention CC is a relatively recent problem. Scientific consensus estimates CC started around the middle of the XVIII century. Less than 250 years determine the period of atmospheric disturbance as stated in different fields of science that has caused ecosystem, atmospheric and thus climatic imbalance threatening Health.Among gases, gas pollutants became a menace. Environmental toxicology had changed to Ecotoxicology under the pressure of solving major related problems (Chernobyl, Agro-chemicals as endocrine disruptors, Fukushima, lixiviates contamination, Climate change, etc.)17. Discussion Causes for CC initiation were the following civilization changes that are culturallystill occurring: 1) the Industrial Revolution, 2) Urbanization (hardening) of natural lands, recruitingat the same time the main part of the human populations in cities, from where nature (another species analogue tocell repertoires) is expelled inducing Biotic homogenization, 3) Abandonment of previous (Naturalistic-Classical) ethics which arereplaced by a utilitarian/ hedonistic/materialistic system of customs, then globalized 17, 18, 19, 20, .22, 24 Ecosystem Imbalance means Health Impact If there is an Eco-ethics sense,ithas gradually been lost since most of theurbanizedhuman populationhas ceasedreal contact with nature. Moving to cities with specialized knowledge, having limited perceptions andartificial habitats hascreated virtual-delusional environments. In contrast, the real (objective) Life-world in transdisciplinary studies9, 18 continues to depend on the same materialistic mechanisms of its necessary physical-biological functioning. When articulating different fields’ readings it is possible to comprehend that the denominated climate change for Earth sciences terminology, is the sameair pollution phenomena in medical terms. Its health impact, therefore, could have been underrated so far, and is only understandable by means of the “One Health” concept. According to this approach, human, animal, plant, and environmental health work as one integrated larger system. As a case in point, pollution hasat least two subtle mechanisms of affecting systemic health following recent French studies: 1) the Direct health impact is severe in line with sanitary authorities. For instance, Air pollution kills 48,000 people a year in France and 34,000 of these deaths are avoidable. Pollution caused by human activity such as transport, industry, heating and agriculture, causes nine (9%) percent of the French annual death toll19. 2) Also the Indirect mechanisms are notorious and can be exemplified with the health related costs of air Figure 3: Epidemiological Health Triad from its Conventional to its New CDC model. Source: Based on CDC’s Principles of Epidemiology in Public Health Practice, An Introduction to Applied Epidemiology and Biostatistics, Third Edition Epidemiological Health Triad (New CDC Model with impact on CC Evaluation) Agent Vector Agent Vector Host Host 14 Environment Environment Medicina Balear 2016; 31(3): 11-17

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Biogeomedicine: the earth as the new patient for biomedical sciences under the “one health” concept facing climate change pollution (medical treatments, premature death, absenteeism, etc.). Itsannual cost, for 2015, ranged “between 68€ and 96€ billion”. It means less budget for basic health funding, access to therapy and medication, financial support for health research, etc. Moreover, for increasing catastrophic phenomenon such as CC, the risk of institutional collapse and social conflicts (hunger, water scarcity, displacements, conflictsand wars) raise in parallel up to become a governmental problem with these types of system crises. Simultaneous ecosystem affectation, evident through the non-health related costs (decline in agricultural yield [and ecosystem services], degradation of buildings, preventative expenditure, national productivity, etc.) was calculated around 4.3€ billion/year just for France. Taking into account the magnitude of the CC pollution case related to health problems in France: the transport sector aloneproduces 59% of the country’s nitrogen oxide (this means just 1 out of the 6 main greenhouse gases for CC) and up to 19% of its fine particle emissions20. Previously mentioned cultural customs, however, keep changing the ecosystems worldwide. Because of the efficiently built machinery, the surface of the Earth’s macro-system has been transformed very rapidly. The mass deaths of other species-populations imply indu- ced deterioration in the functioning of their local ecosys- tems have (e.g. been mcuatssdorewlena. sPeololuftamnetsthinacnreeaasnindgClyOd2e).teFrioorreastets- normal gas proportions and their dynamics in the atmos- phere. Smoke from productive labour, transportation, and industrial processes keep accumulating and have not efficiently been buffered. Residues and industrial by- products of new livelihoods and food-types have crea- ted continuous sources for diseases, etc19, 20, 21, 22. From a macro-systemic view, multi-functional injuries in organic systems are exceeding the harmful/indifferentactivities of the potential healing repertories: human populations. An ecoethical change is still pending and has to be oriented by biological –not ideological– rules. Curiously, since the second half of the XXth century humanity has witnessed how several fields and disciplines have started to re-join to answer phenomena of a destabilized world. Most of the developments in that sense, such as Ecotoxicology –for which the newreceptor of diagnostic efforts is the altered environment–, have happened symptomatically in the most recent decades. Ecotoxicology breaks down strict disciplinary boundaries since the 70’s23 (Figure 4). Figure 4: Construction of Ecotoxicology as paradigmatic example of transdisciplinary fields associated with co-relative compound disciplines (Graphic made by authors) Toxicology Substances Chemistry Species Environmental Toxicology Medicina Balear 2016; 31(3): 11-17 Ecology Systems ECOTOXICOLOGY Systemic Science Based on understanding the dynamic interactions of its 3 axis (3 S) As a transdisciplinary result is more than the sum of its parts It is neither mere Ecology, nor Chemistry, nor Toxicology (Truhaut, 1975; Van Leeuwen, 1995) 15

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