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An extensive survey of rehabilitation doctors in sub-Saharan Africa identified only six gastritis diet 7 up purchase discount prevacid online, all in South Africa viral gastritis diet buy cheap prevacid 15mg on-line, for more than 780 million people gastritis or ibs buy prevacid 30 mg on-line, while Europe has more than 10 000 and the United States more than 7000 (142). Data from official Chapter 4 Rehabilitation statistical sources showing the large disparities in supply of physiotherapists are shown in. The lack of women in rehabilitation professions, and the cultural attitudes towards gender, affect rehabilitation services in some contexts. The low number of women technicians in India, for example, may partly explain why women with disabilities were less likely than men to receive assistive devices (112). Female patients in Afghanistan can be treated only by female therapists, and men only by men. Professionals are not obliged, however, to be members or to respond to the survey questionnaires. Seychelles Tunisia Canada Australia Bahrain 109 Finland World report on disability prevent female physiotherapists from participating in professional development and training workshops and limit their ability to make home visits (160). Expanding education and training Many developing countries do not have educational programmes for rehabilitation professionals. According to the 2005 global survey of 114 countries, 37 had not taken action to train rehabilitation personnel and 56 had not updated medical knowledge of health-care providers on disability (110). Differences across countries in the type of training and the competency standards required influence the quality of services (92, 136, 161). In Afghanistan one study found that physical therapists with two years of training had difficulty with clinical reasoning and that clinical competencies varied, especially for managing complex disabilities and identifying their own training needs (168). Given the global lack of rehabilitation professionals, mixed or graded levels of training may be required to increase the provision of essential rehabilitation services. Where graded training is used, consideration should be given to career development and continuing education opportunities between levels. The complexity of working in resource-poor contexts suggests the importance of either university or strong technical diploma education (136). The feasibility of establishing and sustaining tertiary training needs is determined by several factors including political stability, availability of trained educators, availability of financial support, educational standards within the country, and the cost and time for training. Low- and middle-income countries such as China, India, Lebanon, Myanmar, Thailand, Viet Nam, and Zimbabwe have responded to the lack of professional resources by establishing mid-level training programmes (92, 170). Mid-level therapists are also relevant in developed countries: a collaborative project in north-eastern England compensated for difficulties in recruiting qualified professionals by training rehabilitation assistants to work alongside rehabilitation therapists (152). Mid-level workers, therapists and technicians can be trained as multipurpose rehabilitation workers with basic training in a range of disciplines (occupational therapy, physical therapy, speech therapy, for example), or as profession-specific assistants that provide rehabilitation services under supervision (152, 170). A positive side-effect of mid-level training is that trained professionals are limited in their ability to emigrate to developed countries Chapter 4 Rehabilitation Box 4. Education in prosthetics and orthotics through the University Don Bosco In 1996 the University Don Bosco in San Salvador, El Salvador, started the first formal training programme for prosthetics and orthotics in Central America, with support from the German Technical Cooperation organization. The University Don Bosco, now the leading institution for prosthetics and orthotics education in Latin America, has graduated about 230 prosthetists and orthotists from 20 countries. Several approaches were instrumental in the success of this training initiative: Strong partnership. An established education institution with strong pedagogical expertise, University Don Bosco was identified to assume overall responsibility for the training. The German Technical Cooperation agency, experienced in developing prosthetics and orthotics training programmes in Asia and Africa, provided the technical and financial support. A six-month orientation phase enabled the different partners to agree on details of project implementation, including objectives, activities, indicators, responsibilities, and resources. From the first intake of 25 students, two outstanding graduates were selected for postgraduate studies in Germany. Following their return in 2000, responsibilities were gradually transferred from the advisors to the graduates. The distance-learning programme, available in Spanish, Portuguese, English, and French, is now also offered in Angola and Bosnia and Herzegovina. Prosthetic and orthotic technicians and engineers were integrated into the general health system in El Salvador, and support was provided to other countries to establish similar programmes. Identifying and developing appropriate technologies ensured sustainable provision. Mid-level training is also less expensive, and although insufficient by itself, it may be an option for extending services in the absence of full professional training (136). They can work across traditional health and social services boundaries to provide basic rehabilitation in the community while referring patients to more specialized services as needed (152, 175). Providing opportunities for people with disabilities to train as rehabilitation personnel would broaden the pool of qualified people and could benefit patients through improved empathy, understanding, and communication (176). Training existing health-care personnel in rehabilitation the duration of specialist training for doctors in Physical and Rehabilitation Medicine varies 111 World report on disability across the world: three years in China (Chinese Standards), at least four years in Europe (37), and five years in the United States (177). Some countries have used shorter courses to meet the urgent need for rehabilitation doctors: in China, for example, a one-year certificate course in applied rehabilitation, run between 1990 and 1997, was developed at Tongji Medical University, Wuhan, graduating 315 doctors now working across 30 provinces (Nan, personal communication 2010). In the absence of rehabilitation specialists, health staff with appropriate training can help meet service shortages or supplement services. For example, nurses and health-care assistants can follow up on therapy services (179). Training programmes for health-care professionals should be user-driven, need-based, and relevant to the roles of the professionals (180). Tertiary and mid-level education can be made more relevant to the needs of people in rural communities by including content on community needs, using appropriate technologies, and using progressive education methods including active learning and problem-based orientation (167, 175, 183, 184). Studies have also shown that interdisciplinary team training develops collaboration, reduces staff burnout, improves rehabilitation implementation, and increases client participation and satisfaction (188). This approach has enabled students to remain in their home country, and is more cost-effective than fulltime study in Australia (182). Where training capacity does not exist in one country, regional training centres may provide a transitional solution (see Box 4. Mobility India trains rehabilitation therapy assistants, and provides specific training in prosthetics and orthotics, to students from 112 Recruiting and retaining rehabilitation personnel Mechanisms to ensure employment for rehabilitation graduates are vital to the future of graduates and the sustainability of training. The code stresses the need for awareness of local health care needs in low-income countries, and for promotion of worker exchanges and training between countries. Several countries have training programmes that target potential rehabilitation and health students from the local community, especially in rural or remote areas (190). The rationale is that locally recruited and trained personnel may be better equipped and prepared for living in the local community (183).
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Yet circumstances that create persistent feelings of not being safe and of being unable to erythematous gastritis definition buy cheap prevacid online control situations cause children to gastritis eggs cheap prevacid online visa anticipate further events even as they deal with the effects of one trauma (Pynoos gastritis symptoms list cheap prevacid, Steinberg, & Goenjian, 1996; Kiser et al. Key Research Findings Studies of children living in poor inner-city neighborhoods document extremely high rates of exposure to trauma (70-100%) (Dempsey, Overstreet, & Moely, 2000; Fitzpatrick & Boldizar, 1993; Macy, Barry, & Noam, 2003). In addition to normal childhood stresses, children in these circumstances are often exposed to violent crime in their neighborhood or school; gang and drug activity; house fires; victimization, incarceration, or death of a family member; family violence; and maltreatment (Black & Krishnakumar, 1998; Buckner, Bassuk, Weinreb, & Brooks, 1999; Coulton, Korbin, & Su, 1999; Dempsey, 2002; Dubow, Edwards, & Ippolito, 1997). This rate of exposure raises public health concerns (Cooley-Quille, Turner, & Beidel, 1995; Margolin & Gordis, 2000). Because feeling safe and secure is a prerequisite for healthy emotional development and general welfare (Hirsch et al. Their reactions to trauma include increased monitoring of their environment for dangers, anxiety when separated from trusted adults, irritability and aggression, or increased need for affection, support, and reassurance. In the short term, such reactions may signal appropriate upset and serve as strategies for successful adaptation. Complex trauma is a varied and multifaceted phenomenon, frequently embedded in a matrix of other psychosocial problems. The symptom presentation of children exposed to prolonged, repeated trauma is best described by affective and physiological dysregulations; attachment disorders and disturbed relatedness; changes in consciousness and self-perception; cognitive distortions regarding trauma and perpetrator; and changes in systems of personal meaning (Cook, Blaustein, Spinazzola, & van der Kolk, 2003). In relation to the symptoms affecting attention, concentration, and memory, these children often experience disruptions in academic learning and skill development. Their hypervigilance, heightened sense of alert, and posttraumatic play may set them apart from peers, restrict the normalcy of their social interactions, and place them at risk for delays in social competence. Childhood victims of chronic trauma risk development of a lack of basic trust in the ability of others to protect them, a view of the world as threatening, a lack of selfconfidence, and a dysregulated nervous system (Macy, Barry, & Noam, 2003; Perry & Pollard, 1998; Pfefferbaum, 1997; Pynoos et al. Finally, lowered future expectations are often formed as children with chronic trauma histories experience ongoing functional impairments, including substance abuse, delinquency, suicidality, acts of self-destruction, chronic anger, unstable relationships, and dissociation (Davies & Flannery, 1998; Pynoos, Steinberg, & Piacentini, 1999). There is a small but growing literature on the potential for positive outcomes following exposure to trauma. Some adolescents demonstrate both outward and intrapersonal growth through their struggle to deal with the bad things that happen to them (Levine, Laufer, Hamama-Raz, Stein, & Solomon, 2008). Risk and Protective Factors Epidemiological and social science research is beginning to document the extent and cost of youth traumatization. Both risk and protective factors for development of trauma-related disorders exist at multiple levels-individuals, families, schools, neighborhoods, and society. Risk factors are the conditions in these settings that predispose children and adolescents to trauma-related disorders. The context of urban poverty along with multiple individual, family, school, and community risk factors not only increases the likelihood of trauma exposure, but also heightens vulnerability to traumatic distress after exposure (Whittlesey et al. For children and adolescents, individual vulnerability (female gender, genetic predisposition), characteristics of the trauma (loss, proximity, etc. Through supportive relationships with family and friends, these children learn and use coping and problem-solving skills that encourage positive adaptation. Some best-practice guidelines include the need to gather information from multiple sources, especially from both child and caregiver. It is also important to measure symptoms in all three clusters (reexperiencing, avoidance, and hyperarousal) plus indicators of complex trauma such as futurelessness, shame, guilt, and changes in self-esteem and systems of meaning. See Appendix A for a list of frequently used measures for assessing traumatic exposure and responses in children and adolescents. There is inadequate evidence of effectiveness for other psychosocial treatments and for psychopharmacology. Empirical evidence and clinical support are lacking for current models of treatment for children who have experienced chronic trauma. In general, the treatment manualization, control design, training of clinicians, fidelity checks, and follow-up in these studies were exemplary. Education about reactions to trauma; relaxation training; cognitive therapy, real life exposure, stress or trauma exposure; social problemsolving. Conclusion and Comment Pilot data and case studies suggest that it is a promising practice. Children and adolescents growing up in urban poverty face increased risks for exposure to trauma. Ongoing stressors may include violent crime, family violence, death of a family member, maltreatment, and many others. Such harsh environments and poor living conditions often result in high levels of distress and posttraumatic stress symptoms. Although children and adolescents are at risk for numerous negative outcomes, there is also the potential for resilience and growth following traumatic experiences. Researchers have worked to identify those factors which can either put youth at a higher risk for future difficulties or help shield them from negative outcomes. Despite progress in better understanding the effects of trauma on children and adolescents, more work remains in developing empirically-supported, developmentally appropriate assessment tools and interventions, especially for children exposed to multiple or chronic trauma. For youth displaying other symptoms related to on-going risk and chronic stressors, several promising treatment approaches are emerging. Research with children and adolescents living in urban poverty has shown that youth are resilient, and with help, can learn to survive and emerge stronger from even the most challenging environments. However, the possibility of resilience does not reduce the public health need to improve challenging environments and the services available to individuals living in poverty. Children in low-income, urban settings: Interventions to promote mental health and well-being. Homelessness and its relation to the mental health and behavior of low-income, school-age children. Closing the quality chasm in child abuse treatment: identifying and disseminating best practices. Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Measuring treatment outcomes with the trauma symptom checklist in sexually abused children with multiple trauma histories. Treating sexually abused children: One year follow-up of a randomized controlled trial. A treatment study of sexually abused preschoolers: Outcome during one year follow-up. Complex trauma in children and adolescents: White paper from the National Child Traumatic Stress Network Complex Trauma Task Force. Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering post-traumatic stress symptoms. Negative coping as mediator in the relation between violence and outcomes: Inner-city African American youth. Interrelatedness of marital relations and parent-child relations: A meta-analytic review. The prevalence and consequences of exposure to violence among African-American youth.
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See also Expert testimony; Litigation; indiidual disciplines accreditation and gastritis newborn discount prevacid 30 mg visa, 194 appellate review standard gastritis symptoms in hindi discount prevacid 30 mg with amex, 10 gastritis beans discount 15 mg prevacid overnight delivery, 11, 85, 92, 97, 102 autopsy, 9 Daubert decision, 8, 9-10, 11-12, 90-93, 95-98, 99 n. See also Forensic odontology admissibility of evidence, 107-108, 175 analytical approaches, 64, 174-175 distortion of skin, 174, 176 errors and bias, 47, 174-175, 176 guidelines, 173-174, 175 reporting of results, 175-176 research needs, 175, 176 this document is a research report submitted to the U. See Medical examiners and coroners; Medicolegal death investigation system Coverdell. See also Homeland security; National Bioforensic Analysis and Countermeasures Center; U. See also Admissibility of forensic evidence; Interpretation of forensic evidence; Reporting of results access to, 11, 98 E Ear prints, 145, 149, 150 Education and training accreditation of, 75, 197, 225, 228-229, 237 advanced courses, 227 apprenticeship model, 15, 26-27, 140, 187, 217, 224, 232, 233, 238 associate degree, 148, 220-221, 225 challenges and improvement opportunities, 14, 224-229 continuing education, 197, 218, 231, 233-234, 236, 259-260 this document is a research report submitted to the U. See Automated Fingerprint Identification System; Friction ridge analysis Fire debris. See also indiidual components case backlogs, 61-62 challenges, 4-5 components, 55-77 disparities in, 5-6, 55 federal activities, 64-70 fragmentation, 14-33, 6, 77, 78 governance, 16-20, 78-83; see also Oversight of forensic practice nonlaboratory units, 63-64 professional associations, 16, 74-77 recommendations, 19-20, 78, 81-82 research funding, 71-75 Forensic science disciplines. See also Pressures on forensic science system capacity and quality, 37 homeland security and, 5, 32-33, 52, 279-286 Forensic Specialties Accreditation Board, 74-75, 209-210 Friction ridge analysis. See Friction ridge Law Enforcement Assistance Administration, 223, 231, 251, 252 Lie detector tests, 64, 68, 88 Lip prints, 145, 149, 150 Litigation. See also Admissibility of forensic evidence; Expert testimony; Landmark decisions appellate review standard, 85, 92, 97, 102 bias in judges and juries, 123 civil cases, 11, 89, 97-98, 107, 250 criminal cases, 9, 11, 12, 36, 45, 53, 87, 88, 95-96, 97, 98, 106-110, 237, 250, 254 education of judicial community for, 27, 178, 234-238 juror comprehension of and expectations about evidence, 48-49, 86, 88, 218, 236-237 limitations of adversary process, 10, 12, 53, 85, 86, 91, 103, 110 scientific expertise of judges and lawyers, 85, 87-88, 110 Laboratories. Secret Service, 66, 68 validation of methods, 21, 22, 114, 115, 189, 197-198, 202, 206 workloads, 36, 58, 60, 61, 65-66, 68 Landmark decisions Daubert. See also Medicolegal death investigation system best practices, 252 caseload, 49, 244 historical origins, 241-242 jurisdiction, 49, 50, 244, 260 missions, 56, 243, 244-245 this document is a research report submitted to the U. See Forensic odontology Office of the Director of National Intelligence, 70, 282 Oversight of forensic practice. See Forensic Pathology; Medical examiners and coroners Pattern/impression evidence. See also Footwear and tire impressions; Fiber evidence; Friction ridge analysis; Handwriting analysis; Toolmark and firearm identification automated pattern recognition, 139, 140, 158-159 certification, 76-77 individualization principle, 43-44, 136 professional associations, 76-77 proficiency testing, 47 Q Quality assurance and quality control. See Footwear and tire impressions Standard Ammunition File, 67 Standardization of educational materials, 189 reporting of results, 22, 189-190 Standards and guidelines. See also Ballistic evidence, 44 accreditation in, 68 admissibility of evidence, 97, 107-108 analyses, 37, 38, 42, 145, 152 certification programs, 210 class characteristics, 152 databases and reference libraries, 67, 151, 152, 153 error rates, 154 generation of marks, 150-151 guidelines, 153, 155, 202, 204 individual characteristics, 150, 152 laboratories for, 60, 65, 68 personnel and equipment shortages, 59 research needs, 154 sample data and collection, 151-152 this document is a research report submitted to the U. December2016 this resource was prepared by the author(s) using Federal funds provided by the U. In additiontoaddressingissuesof age andgender,interventionprogramsshouldlooktotake advantageofthecomparativelylongradicalizationdurationsthatexistacrossthe ideologicalspectrum,whichoftenlastseveralmonthsoryears,andtheyshouldtargetthe face-to-faceandvirtualsocialnetworksthatmobilizeloneandgroup-basedextremiststo act. Department of Justice 7 ProjectOverview Despitemorethanadecadeofintenseinterestintheissueofradicalization,thereremains weakempiricalgroundingfor ourcurrentunderstandingofthestructures andprocesses bywhichsomeindividualscometoadoptextremistideologiesandengageinideologically motivatedviolence(Borum2011;Horgan2008;NeumannandKleinmann2013). Department of Justice 9 articles,journalisticaccountsincludingbooksanddocumentaries,courtrecords,police reports,witnesstranscribedinterviews,psychologicalevaluations/reports,and informationcreditedtotheindividualbeingresearched(verifiedpersonalwebsites, autobiographies,socialmediaaccounts). Department of Justice 11 Third,alsostartinginJune2013,researcherscodedtherelevantbackground,contextual, andideologicalinformationonarandomsampleofindividualswhowereselectedfor inclusioninthedataset. Department of Justice 12 theavailabilityofcriticalinformationrelatedtotheirbackgroundsandactivitiesinpublic sources;theirparticipationasamemberofagroupormovementrepresentingthefarleft, farright,orradicalIslamistideologicalmilieus;andtheirstatusasmost-likelyorleastlikelycases(Eckstein1975;GeorgeandBennett 2005)forextanttheoriesofradicalization. Settheorymethodsareanespeciallyusefulwayof this resource was prepared by the author(s) using Federal funds provided by the U. Department of Justice 13 analyzingradicalizationbecausetheyweredesignedtodealwithcausalcomplexity,such asmultiplepathwaysandnon-linearcausation,andtheyrelyontheuseofdatawherethe mainoutcomeofinterestdoesnotvaryacrossthecases(i. Department of Justice 14 ProjectFindings Thefindingsofthisprojecthelptoanswerthefourresearchquestionsthataredescribed above. Department of Justice 15 PartI:IdeologicalComparisons Problemstatement ExtentresearchhasfailedtorigorouslycompareIslamist,farright,farleft,andother extremistmovementsdespiteprimafacieindicationsthatthereareimportantdifferences intheradicalizationcausesandprocessesforindividualswhoactacrossthesemilieus (Borum2011). Ideology Noevidence Evidenceof ValidN %missing ofabuseas abuseas minor minor Allcases 97. Weacknowledge thatmosttheoriesfromcriminologyareintendedtoexplainvariationinnon-crimeand crime,asopposedtonon-violentcrimeandviolentcrime,andthatattemptstoapplythese perspectivestonewoutcomeareaswillrequiresomeadjustmentstothewaysinwhichthe this resource was prepared by the author(s) using Federal funds provided by the U. Peoplewillbe this resource was prepared by the author(s) using Federal funds provided by the U. Department of Justice 30 influencedaccordingtothefrequency,intensity,duration,andpriorityoftheir relationshipswithothers,whointurnhelpcreateandmolddefinitionsofbehaviors(Akers 2009). Followingthelogicofoutbiddingtheory, extremistswillbemorelikelytoengageinviolencewhentheyaremembersofgroupsor this resource was prepared by the author(s) using Federal funds provided by the U. Department of Justice 33 Similarly,thepeereffectsresearchperspectivearguesthatthepresenceofclose-knitpeer groupscanleadtoagreaterriskofengaginginextremebehaviorsthattheindividualmay otherwisenotconsider. Department of Justice 35 ControlVariables Weidentifiedfifteenvariablesfromtheresearchliteratureonviolentcrimeforinclusionin themodelsthatcontrolfortheeffectsofvariousfactorsthatarenotcoveredbythe theoriesdescribedabove. Department of Justice 36 MissingDataTechniques Missingdataisachallengethatallresearchersconfront,butitisparticularlyimportantfor researchsuchasthisbasedonopensourcedatacollection. Thesevariablesinclude: this resource was prepared by the author(s) using Federal funds provided by the U. Department of Justice 37 Controlvariable Previous criminalactivity Description Evidencethattheindividualengagedincriminal activitypriortotheirradicalization Structureofvariable O=Noevidenceofpreviouscriminalactivity 0. EmpiricalResultsandDiscussion Theresultsofthestep-wisemodelingtechniquearereportedinTable19,withthecolumns representingthefollowingmodels: ModelA:basecriminological(controls) Model1:basecriminological+socialcontrol Model2:basecriminological+socialcontrol+socialbond Model3:basecriminological+socialcontrol+socialbond+sociallearning Model4:basecriminological+socialcontrol+socialbond+sociallearning+peereffects Model5:basecriminological+socialcontrol+socialbond+sociallearning+peereffects+ outbidding34 33AccordingtotheUnitedStatesDepartmentofHealthandHumanServices,fewerthan12outofevery1000children,or 1. However,duetotherelativelysmall numberofcasesintheFarLeftandIslamistgroupsandissuesofmissing data, we were not able to produce statistically this resource was prepared by the author(s) using Federal funds provided by the U. Not surprisingly,individualswhoadheredtoideologiesthatpromotenon-violentformsof politicalresistancewere found to be significantly less violentthanthose onthefarrightor thosewhoadhere to Salafi jihadistideologies. Theseorganizationstypicallypromotenon-violentformsofpoliticalresistance, which stands incontrastto traditionalfar leftgroups,such as the Weather Underground, whocommonlyperpetratedactsofpoliticalviolence. Department of Justice 40 Independentvariable Married Stableemploymenthistory Pastmilitaryexp. Activemilitary Abusedaschild Radicalfamily Cliquemembership Groupcompetition Controls Previouscriminalactivity Mentalillness Education Gender Age Age(squared) Islamistideology Farrightideology Farleftideology Exposure1950s Exposure1960s Exposure1970s Exposure1980s Exposure1990s Exposure2010s Table20-Regressionmodels:comparisonofmissingdatastrategies Note:n=1,473exceptinfixedvaluesubstitutionmodel,wheren=1,395duetolist-wisedeletionofcaseswithunknownvalueforAgeandAgesquared, Standarderrorsnotedinparentheses,*p. Ourapproachin thissectionis differentthanthestandardstatisticaltechniquesthatwereused above, wherecausationwastreated as linear and whichsoughttoestablishthe net-effectsof variousindicators(i.
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Efforts to gastritis questionnaire order 15 mg prevacid with amex abruptly eliminate all substances of abuse will not be successful with all patients gastritis jelovnik buy prevacid 30mg on line. The use of aversive contingencies gastritis diet dr oz buy cheap prevacid 30 mg on line, such as methadone dose reduction or even withdrawal, for continued abuse of cocaine (or sedatives or alcohol) for patients in methadone maintenance treatment is controversial. Some psychiatrists believe that requiring methadone withdrawal for persistent substance abuse causes many patients to cease or greatly limit use, whereas failure to enforce such limits implicitly gives patients license to continue use. Others believe that methadone withdrawal is never justified for patients abusing alcohol or other substances because of the proven efficacy of methadone in reducing intravenous heroin use, improving social and occupational functioning, and providing the opportunity to continue to motivate patients to reduce other substance use. Psychiatric factors the reduction of opioid use in patients with a preexisting co-occurring psychiatric disorder may precipitate the reemergence of previously controlled psychiatric symptoms. In prescribing medications for co-occurring non-substance-related psychiatric disorders, psychiatrists should be alert to the dangers of medications with a high abuse potential and to possible drug-drug interactions between opioids and other psychoactive substances. In general, benzodiazepines with a rapid onset, such as diazepam and alprazolam, should also be avoided because of their abuse potential (1418). However, benzodiazepines with a slow onset and substantially lower abuse potential. With all other psychotropic medications, decisions about prescriptions should consider that patients may not take medications as prescribed; random blood or urine monitoring can sometimes help in determining adherence. Comorbid general medical disorders the injection of opioids may result in the sclerosing of veins, cellulitis, abscesses, or, more rarely, tetanus infection. Tuberculosis is a particularly serious problem among individuals who inject drugs, especially those dependent on heroin. Infection with the tubercle bacillus occurs in approximately 10% of these individuals. Guidelines regarding prophylactic treatment for patients with a positive skin test have been published (1421). Possible effects of opioid use and the related lifestyle on the course of the pregnancy include preeclampsia (toxemia), miscarriage, premature rupture of membranes, and infections. Possible short- and long-term effects on the infant include low birth weight, prematurity, stillbirth, neonatal abstinence syndrome, and sudden infant death syndrome (1327, 1422, 1423). Approximately 50% of the infants born to women with opioid dependence are physiologically dependent on opioids and may experience a moderate to severe withdrawal syndrome requiring pharmacological intervention. The goals of treatment for the pregnant opioid-using patient include ensuring physiological stabilization and avoidance of opioid withdrawal; preventing further substance abuse; improving maternal nutrition; encouraging participation in prenatal care and rehabilitation; reducing the risk of obstetrical complications, including low birth weight and neonatal withdrawal, which can be lethal if untreated; and arranging for appropriate postnatal care when necessary. In a randomized comparison of enhanced and standard methadone maintenance for pregnant opioid-dependent women, Carroll et al. Contingency management approaches may also be implemented to enhance adherence (1299, 1428, 1429). Withdrawal from methadone is not recommended, except in cases where methadone treatment is logistically not possible. In cases where medical withdrawal is necessary, there are no data to suggest that withdrawal is worse during any one trimester. Although the long history of methadone use in pregnant women makes this medication the preferred pharmacotherapeutic agent, a growing body of evidence suggests that buprenorphine may also be used. Although the study was limited by its small sample size, buprenorphine and methadone showed comparable outcomes in terms of neonatal abstinence syndrome. Data from unconTreatment of Patients With Substance Use Disorders 123 Copyright 2010, American Psychiatric Association. Data on other treatments for opioid withdrawal or dependence during pregnancy are sparse. In particular, data on the safety of clonidine in pregnant patients are not available. However, a narcotic antagonist should never be given to a pregnant substance-using patient because of the risk of spontaneous abortion, premature labor, or stillbirth. This section of the guideline focuses on the first group, substance use disorders. Usually this continuous use will result in tolerance, withdrawal, and a pattern of compulsive use. However, they have shown a maladaptive pattern of substance use that is associated with significant recurring adverse consequences. Nicotine abuse is not included because clinically significant psychosocial problems from tobacco use are rare unless dependence is also present (1432); nicotine intoxication is also not included because it is very rare. Associated features of substance use disorders a) Cross-sectional features Patients presenting for treatment of a substance use disorder frequently manifest signs and symptoms of substance-induced intoxication or withdrawal. The clinical picture varies with the substance used, the dosage, the duration of action, the time elapsed since the last dose, the presence or absence of tolerance, and co-occurring psychiatric or general medical conditions. The expectations of the patient, his or her style of responding to states of intoxication or physical discomfort, and the setting in which intoxication or withdrawal is taking place also play a role. Patients experiencing substance-induced intoxication generally manifest changes in mood, cognition, and/or behavior. Mood-related changes may range from euphoria to depression, with considerable lability in response to or independent of external events. Cognitive changes may include shortened attention span, impaired concentration, and disturbances of thinking. Behavioral changes may include wakefulness or somnolence and lethargy or hyperactivity. Impairment in social and occupational functioning is also common in intoxicated individuals. Other cross-sectional diagnostic features commonly found in patients with a substance use disorder include those related to any co-occurring psychiatric or general medical disorders that may be present. Examples of general medical problems that may be directly related to substance use include cardiac toxicity resulting from acute cocaine intoxication, respiratory depression and coma in severe opioid overdose, and hepatic cirrhosis after prolonged heavy drinking (559). Partial or complete withdrawal from abused substances may be followed by variable periods of self-imposed or involuntary. Treatment of Patients With Substance Use Disorders 125 Copyright 2010, American Psychiatric Association. In some patients, dependence on a single substance may lead to use of and ultimately dependence on another substance. Although many individuals who abuse alcohol or illicit substances maintain their ability to function in interpersonal relationships and in the work setting, substance-dependent patients presenting for treatment often have profound psychological, social, general medical, legal, and financial problems. These may include disrupted interpersonal (particularly family) relationships, absenteeism, job loss, criminal behavior, poor academic or work performance, failure to develop adaptive coping skills, and a general constriction of normal life activities. Peer relationships often focus extensively on obtaining and using illicit substances or alcohol. The risk of accidents, violence, and suicide is significantly greater for these individuals than for the general population (1449, 1450). Nicotine dependence About 33% of adults who smoke make a serious attempt to stop smoking each year (729).
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Evidence for the effectiveness of interventions and programmes is extremely beneficial to: guide policy-makers in developing appropriate services allow rehabilitation workers to gastritis vinegar order cheap prevacid line employ appropriate interventions support people with disabilities in decision-making gastritis diet 6 pack order prevacid toronto. Long-term longitudinal studies are needed to gastritis recipes buy prevacid once a day ascertain if expenditure for health and health-related services decreases if rehabilitation services are provided. Research is also needed on the effect rehabilitation has on families and communities, for example, the benefits accrued when caregivers return to paid work, when support services or ongoing long-term care costs are reduced, and when persons with disabilities and their families feel less isolated. A broad approach is required as benefits of rehabilitation often accrue to a different government budget line from that funding rehabilitation (207). Relevant strategies for addressing barriers in research include the following: Involve end-users in planning and research, including people with disabilities and rehabilitation workers, to increase the probability that the research will be useful (269, 274). More research such as that by the Cochrane Collaboration (Rehabilitation and Related Therapies) (208) is needed when feasible. Systematically disseminate results so that: policy across government reflects research findings, clinical practice can be evidencebased, and people with disabilities and their families can influence the use of research (269). Providing international learning and research opportunities will often involve linking universities in developing countries with those in high-income and middleincome countries (68). Countries in a particular region, such as South-East Asia, can also collaborate on research projects (275). In middle-income and high-income countries with established rehabilitation services, the focus should be on improving efficiency and effectiveness, by expanding the coverage and improving the relevance, quality, and affordability of services. In lower-income countries the focus should be on introducing and gradually expanding rehabilitation services, prioritizing cost-effective approaches. International cooperation can help share good and promising practices and provide technical assistance to countries that are introducing and expanding rehabilitation services. Human resources Increase the numbers and capacity of human resources for rehabilitation. Relevant strategies include: Where specialist rehabilitation personnel are in short supply, develop standards in training for different types and levels of rehabilitation personnel that can enable career development and continuing education across levels. Establish strategies to build training capacity in accord with national rehabilitation plans. Identify incentives and mechanisms for retaining personnel especially in rural and remote areas. Train non-specialist health professionals (doctors, nurses, primary care workers) on disability and rehabilitation relevant to their roles and responsibilities. Policies and regulatory mechanisms Assess existing policies, systems, services, and regulatory mechanisms, identifying gaps and priorities to improve provision. Develop or revise national rehabilitation plans, in accord with situation analysis, to maximize functioning within the population in a financially sustainable manner. Financing Develop funding mechanisms to increase coverage and access to affordable rehabilitation Service delivery Where there are none, or only limited, services introduce minimum services within existing 122 Chapter 4 Rehabilitation health and social service provision. Relevant strategies include: Developing basic rehabilitation services within the existing health infrastructure. Strengthening rehabilitation service provision through community-based rehabilitation. Prioritizing early identification and intervention strategies using community workers and health personnel. Relevant strategies include: Developing models of service provision that encourage multidisciplinary and client-centred approaches. In all settings, three principles are relevant: Include service-users in decision-making. Technology Increase access to assistive technology that is appropriate, sustainable, affordable, and accessible. Relevant strategies include: Establishing service provision for assistive devices. To further enhance capacity, accessibility and coordination of rehabilitation measures the use of information and communication technologies - telerehabilitation - can be explored. Research and evidencebased practice Increase research and data on needs, type and quality of services provided, and unmet need (disaggregated by sex, age, and associated health condition). Improve access to evidence-based guidelines on cost-effective rehabilitation measures. Disaggregate expenditure data on rehabilitation services from other health care services. Stockholm, Socialstyrelsen, the National Board of Health and Welfare, 2006. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Australasian Psychiatry: bulletin of Royal Australian and New Zealand College of Psychiatrists, 2007,15:310-314. Integrating patient empowerment as an essential characteristic of the discipline of general practice/family medicine. Organizing human functioning and rehabilitation research into distinct scientific fields. Rationale and principles of early rehabilitation care after an acute injury or illness. Targeted early rehabilitation at home after total hip and knee joint replacement: Does it work? Multimodal early rehabilitation and predictors of outcome in survivors of severe traumatic brain injury. Evaluation of activity and effectiveness of occupational therapy in stroke patients at the early stage of rehabilitation. Early versus delayed inpatient spinal cord injury rehabilitation: an Italian study. Costs and quality of life for prehabilitation and early rehabilitation after surgery of the lumbar spine. Rates of early intervention services in very preterm children with developmental disabilities at age 2 years. Cluster randomized trial of a parent-based intervention to support early development of children in a lowincome country. General movements: a window for early identification of children at high risk for developmental disorders. Washington, National Dissemination Center for Children with Disabilities, 2009 Physical rehabilitation outcome measures: a guide to enhanced clinical decision-making, 2nd editon. Assessing the benefits of using assistive technologies and other supports for thinking, remembering and learning.
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As with other complex change chronic gastritis food to avoid order prevacid with american express, it requires vision chronic gastritis x ray buy discount prevacid 15 mg, skills gastritis hypertrophic purchase prevacid 15mg on line, incentives, resources, and an action plan (90). Since the mid-1970s Italy has had legislation in place to support inclusive education for all children with disabilities resulting in high inclusion rates and positive educational outcomes (33, 91, 92). New Zealand shows how government ministries can promote an understanding of the right to education of disabled students by: publicizing support available for disabled children reminding school boards of their legal responsibilities reviewing information provided to parents reviewing complaints procedures (93). A survey of low-income and middle-income countries found that if political will is lacking, legislation will have only a limited impact (31). Other factors leading to a low impact include insufficient funding for education, and a lack of experience in educating people with disabilities or special educational needs. Clear national policies on the education of children with disabilities are essential for the development of more equitable education systems. By 1991 it had established a Special Education Unit and launched a national programme of inclusive education (95). The national programme for inclusive education was launched in 10 pilot schools, one in each district of the country. Training in inclusive teaching was developed for teachers in these schools, and for student teachers, with the help of specialists and people with disabilities themselves. A recent study on inclusive education in Lesotho found variability in the way that teachers addressed the needs of their children (96). There was a positive effect on the attitudes of teachers, and without a formal policy it is unlikely that improvements would have occurred. Creating or amending a national plan of action and establishing infrastructure and capacity to implement the plan are key to including children with disabilities in education (79). The Centre for Special Education worked with an international nongovernmental organization to set up two pilot projects, one rural and one urban. Local steering committees for each project were active in raising awareness in the community and conducting house-to-house searches for children who were missing from official school lists. The pilot projects identified 1078 children with a wide range of impairments who were excluded. Training was provided to administrators, teachers, and parents on: the benefits of inclusive education special education services individualized educational programmes carrying out accommodation and environmental modifications assessment family services. In addition, technical assistance was given in such areas as mobility training for blind students and training for parents on exercises to improve mobility for children with cerebral palsy. With international donor support a similar programme was conducted in three other provinces. Within three years attendance rates in regular classes of children with disabilities increased from 30% to 86%, and eventually 4000 new students were enrolled in neighbourhood schools. Teachers and parents had also raised their expectations of children with disabilities. Despite the progress, only around 2% of preschool and primary schools in Viet Nam are inclusive, and 95% of children with disabilities still do not have access to school (90). But the success of the pilot projects has helped change attitudes and policies on disability and has led to greater efforts on inclusion. The Ministry of Education and Training has committed itself to increase the percentage of children with disabilities being educated in regular classes. Funding There are basically three ways to finance special needs education, whether in specialized institutions or mainstream schools: through the national budget, such as setting up a Special National Fund (as in Brazil), financing a Special Education Network of Schools (as in Pakistan), or as a fixed proportion of the overall education 218 budget (0. Other countries, including Switzerland and the United States, use a combination of funding methods that include national financing that Chapter 7 Education can be used flexibly for special needs education at the local level. Whichever funding model is used, it should: be easy to understand be flexible and predictable provide sufficient funds be cost-based and allow for cost control connect special education to general education be neutral in identification and placement (98, 99). One system for comparing data on resources between countries categorizes students according to whether their needs arise from medical conditions, behavioural, or emotional conditions, or socioeconomic or cultural disadvantages (31). The resources dedicated to children with medical diagnoses remain the most constant across ages. Those allocated to children with socioeconomic or cultural disadvantages are more heavily concentrated among younger age groups, and drop off sharply by secondary school (100). The decline in resources for these categories may reflect higher drop-out rates for these groups, especially in the later stages of secondary school, implying that the system is not meeting their educational needs. It is clear that the Central and South American countries are providing resources for students with disabilities in the pre-primary and primary years. But there is a rapid fall-off of provision in the early secondary school period and no provision at all in the later secondary period. The project resulted in a centralized, national approach to the development of policy and practice in inclusive education. There are now 539 schools across 141 districts providing inclusive education and specialized support for more than 3000 children with disabilities (102). While the costs of special schools and inclusive schools are difficult to determine it is generally agreed that inclusive settings are more cost-effective (33). Inclusion has the best chance of success when school funding is decentralized, budgets are delegated to the local level, and funds are based on total enrolment and other indicators. School interventions Recognizing and addressing individual differences into ability groups is often an obstacle to inclusion whereas mixed-ability, mixed-age classrooms can be a way forward (17, 69). In 2005 the European Agency for Development in Special Needs Education studied forms of assessment that support inclusion in mainstream settings (105). The following principles were proposed: Assessment procedures should promote learning for all students. The needs of students with disabilities should be considered within all general assessment policies as well as within policies on disability-specific assessment. The assessment procedures should aim to promote diversity by identifying and valuing the progress and achievements of each student. Instead, assessments should focus on learning and teaching practices that lead to more inclusion in a mainstream setting.
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One important reason is that most grazing is in arid or semi-arid zones where water is scarce chronic gastritis months prevacid 30mg mastercard, limiting the expansion or intensification of livestock production gastritis prevention order prevacid overnight delivery. Production from mixed systems is still expanding rapidly gastritis mind map generic 15 mg prevacid visa, and water is not a limiting factor in most situations. Here, productivity gains are expected from an increased level of integration between livestock and crop production, with animals consuming considerable amounts of crop residues. In contrast, more intensively managed mixed systems and industrial livestock systems are characterized by a high level of external inputs, i. The demand for these products, and thereby demand for the corresponding raw materials. In addition, cereal and oil crops occupy arable land, where water generally has a considerable opportunity cost. In such areas the livestock sector may be directly responsible for severe environmental degradation through water depletion, depending on the source of the irrigation water. Although, in rainfed areas, even the increasing appropriation of arable land by the sector may, more indirectly, lead to depletion of available water because it reduces the water available for other uses, particularly food crops. In view of the increase of "costly" water use by the livestock sector, it is important to assess its current significance. These four crops account for roughly three-quarters of the total feed used in the intensive production of monogastrics. As a result, maize production in the developing countries is projected to grow at 2. Such contrasts are particularly marked in China where wheat and rice production is expected to grow only marginally over the projection period of aforementioned report, while maize production is expected to nearly double. The share due to intensification will go up to 90 percent and higher in the land-scarce regions of the West Asia/North Africa and South Asia. It is estimated that in the developing countries at present, irrigated agriculture, with about a fifth of all arable land, accounts for 40 percent of all crop production and almost 60 percent of cereal production. The area equipped for irrigation in developing countries is projected to expand by 40 million hectares (20 percent) over the projection period. This suggests that despite a certain number of unverified assumptions, the resulting aggregate quantities may provide fairly accurate estimates. When we include evapotranspiration of water received from precipitation in irrigated areas, this share rises to some 10 percent of total water evapotranspired in irrigated areas. Similar absolute amounts in the more water short West Asia and North Africa region represent some 15 percent of total water evapotranspired in irrigated areas. By far the highest share of water evapotranspired through irrigation is found in Western Europe (over 25 percent), followed by eastern Europe (some 20 percent). In southwestern France for example irrigated maize (for feed) has repeatedly been held responsible for severe drops in the flow of major rivers, as well as damage to coastal aquaculture during such summer droughts, and unproductive pastures for the ruminant sector (Le Monde, 31-07-05). It is clear that feed production consumes large amounts of critically important water resources and competes with other usages and users. Part of it may be re-usable in the same basin, while another may be polluted6 or evapotranspired and, thereby, depleted. Water polluted by livestock production, feed production and product processing detracts from the water supply and adds to depletion. Point-source pollution is an observable, specific and confined discharge of pollutants into a water body. Applied to livestock production systems, point- 6 Water pollution is an alteration of the water quality by waste to a degree that affects its potential use and results in modified physico-chemical and microbiological properties (Melvin, 1995). Non-point source pollution is characterized by a diffuse discharge of pollutants, generally over large areas such as pastures. Livestock excreta contain a considerable amount of nutrients (nitrogen, phosphorous, potassium), drug residues, heavy metals and pathogens. If these get into the water or accumulate in the soil, they 136 can pose serious threats to the environment (Gerber and Menzi, 2005). Different mechanisms can be involved in the contamination of freshwater resources by manure and wastewater. Water contamination can be direct through the loss via runoff from farm buildings, losses from failure of storage facilities, deposition of faecal material into freshwater sources and deep percolation and transport through soil layers via drainage waters at farm level. It can also be indirect through non-point source pollution from surface runoff and overland flow from grazing areas and croplands. As mineral N is susceptible to volatilization, this percentage is often lower in manure applied on the land. Note: Owing to the variation in intake and nutrient content of the feeds, these values represent examples, not averages, for highly and less productive situations. Some of the nutrients ingested are sequestered in the animal, but most of it return to the environment and may represent a threat to water quality. In intensive production areas, these figures result in high nutrient surpluses that can overwhelm the absorption capacities of local ecosystems and degrade surface and groundwater quality (Hooda et al. According to our assessment, at the global level, livestock excreta in 2004 were estimated to contain 135 million tonnes of N and 58 million tonnes of P. In 2004, cattle were the largest contributors for the excretion of nutrients with 58 percent of N; pigs accounted for 12 percent and poultry for 7 percent. The major contributors of nutrients are the mixed production systems that represent 70. They can protect micro-organisms from the effect of salinity and temperature, and may pose a public health hazard. Eutrophication is a natural process in the ageing of lakes and some estuaries, but livestock and other agriculture-related activities can greatly accelerate eutrophication by increasing the rate at which nutrients and organic substances enter aquatic ecosystems from their surrounding watersheds (Carney et al. If the plant growth resulting from eutrophication is moderate, it may provide a food base for the aquatic community. If it is excessive, algal blooms and microbial activity may overuse dissolved oxygen resources, which can damage the proper functioning of ecosystems. These impacts occur both in freshwater and marine ecosytems, where algal blooms are reported to cause widespread problems by releasing toxins and causing anoxia ("dead zones"), with severe negative impacts on aquaculture and fisheries (Environmental Protection Agency, 2005; Belsky, Matze and Uselman, 1999; Ongley, 1996; Carpenter et al. In proper functioning ecosystems the ability of wetlands and streams to retain P is then crucial for downstream water quality. But an increasing number of studies have identified N as the key limiting nutrient.
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Hughes contracted syphilis when in his 30s gastritis in pregnancy prevacid 30 mg low cost, before antibiotics were available (Brown & Broeske gastritis diet 91352 prevacid 15 mg lowest price, 1996) atrophic gastritis definition order prevacid online from canada. To treat the disease, he underwent painful and risky mercury treatment; unfortunately, the treatment was not a complete success, and by the time he was in his 40s, the disease appears to have progressed. Symptoms can include gradual personality changes and poor judgment, which may take up to 15 years to emerge. In response to the panic, some people develop a phobia of the stimuli related to their panic and anxiety symptoms. Anxiety disorders frequently co-occur with other psychological disorders, such as depression or substance-related disorders. The high comorbidity of depression and anxiety disorders suggests that the two disorders share some of the same features, specifically high levels of negative emotions and distress-which can lead to concentration and sleep problems and irritability. Treatments that target social factors include group therapy focused on panic disorder and couples or family therapy, particularly when a family member is a safe person. Thinking like a clinician All you know about Fiona is that she has had about ten panic attacks. Now suppose that Fiona starts missing Monday classes because of panic attacks on those days. She also stops going to parties on the weekend because she had a couple of panic attacks at parties. Would you change or maintain your answer about whether she has panic disorder-why or why not? By the end of the semester, Fiona no longer goes out of her apartment for fear of getting a panic attack. Summary of Panic Disorder (With and Without Agoraphobia) the hallmark of panic disorder is recurrent panic attacks. People in different cultures may have similar-but not identical-constellations of symptoms, such as ataque de nervios and wind-and-blood pressure. Less commonly, people develop agoraphobia without panic disorder, but they fear triggering symptoms of panic. Neurological factors contribute to panic disorder and agoraphobia, including: (1) A heightened sensitivity to detect breathing changes, which in turn leads to hyperventilation, panic, and a sense of needing to escape. Psychological factors that contribute to panic disorder and agoraphobia include: (1) Conditioning of learned alarms that elicit panic symptoms. Social factors related to panic disorder and agoraphobia include: (1) a greater than average number of social stressors during childhood and adolescence; (2) the presence of a safe person, which can decrease Thinking like a clinician What is the difference between fear and anxiety? If people can have symptoms of anxiety when they have other types of disorders, what determines whether an anxiety disorder is the diagnosis? Summary of Social Phobia (Social Anxiety Disorder) Social phobia is an intense fear of public humiliation or embarrassment, together with an avoidance of social situations likely to cause this fear. Social phobia may be limited to specific types of performance-related situations or may be generalized to most social situations. Neurological factors that give rise to social phobia include an amygdala that is more easily activated in response to social stimuli, too little dopamine in the basal ganglia, too little serotonin, and a genetic predisposition toward a shy temperament, or behavioral inhibition. Psychological factors that give rise to social phobia include cognitive distortions and hypervigilance for social threats-particularly about being (negatively) evaluated. Moreover, people in different cultures may express their social fears somewhat differently. Thinking like a clinician Iqbal is horribly afraid of tarantulas, refusing to enter insect houses at zoos. Do you need any more information before determining whether Iqbal has a specific phobia of tarantulas? How might Iqbal have developed his fear of tarantulas-what factors are likely to have been involved in its emergence and maintenance? What treatments are likely to be effective and what are the advantages and disadvantages of each? When you use her bathroom, you notice that all her toiletries seem very organized. The next day, you notice that her classwork is well-organized-arranged neatly in color-coded folders and notebooks. Thinking like a clinician Nick loved his job-he was a programmer and he worked from home. However, his company was recently bought by a larger firm that wants Nick to start working in the central office a few days a week. What determines whether Nick has a social phobia, or is just shy and nervous about the work changes? Common obsessions include anxiety about contamination, ordering, losing control, doubts, and getting rid of objects. Common compulsions include washing, order, counting, checking, and hoarding or collecting. Neurological factors, such as an overreactive amygdala and genetics, appear to contribute to specific phobias. Psychological factors that give rise to specific phobias include operant conditioning, possibly classical conditioning, and cognitive biases related to the stimulus. Observational learning-a social factor-can influence what particular stimulus a person comes to fear. These two disorders are distinguished in part by the timing and duration of symptoms. An event is considered traumatic if the individual experienced or witnessed an actual or threatened death or serious injury and responded with intense fear, helplessness, or horror. Interpersonal violence is more likely to lead to a stress disorder, as are traumatic events that are severe, of long duration, and of close proximity. After a traumatic event, classical and operant conditioning contribute to the avoidance symptoms. Treatments that target social factors are designed to ensure that the individual is as safe as possible from future trauma, and to increase social support through group therapy or family therapy. Thinking like a clinician Two friends, Farah and Michelle, came back from winter break. Based on what you have read, what do you think would be appropriate treatment for her? Anna and her mother alternated shifts, Anna taking the night shift, staying awake by his bedside. Her symptoms included severe vision problems, headaches, a persistent cough, paralysis (in her neck, right arm, and both legs), lack of sensation in her elbows, and daily periods of a state of consciousness similar to sleep-walking. Anna was diagnosed with hysteria, an emotional condition marked by extreme excitability and bodily symptoms for which there is no medical explanation. Breuer became a colleague of Sigmund Freud and told Freud about Anna and her treatment, later described in Studies in Hysteria (Breuer & Freud, 1895/1955).
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Targeting Neurological and Other Biological Factors: Medications There has been an increasing trend toward the medicalization of sex therapy diet with gastritis purchase prevacid once a day, that is gastritis diet 5 2 purchase prevacid online, a tendency to gastritis what to eat purchase cheap prevacid on-line target neurological and other biological factors (see Table 11. In the 1990s, medical treatments for erectile dysfunction began in earnest with the advent of the drug Viagra and the marketing campaign for it, which brought the topic of erectile dysfunction from a rarely discussed but relatively common problem among older men to a topic of everyday conversation. Viagra (and its competitors, such as Cialis) is not a cure but a treatment for impotence, and it is effective only if the man takes a pill before sexual activity. Critics point out that prescribing this type of medication for a woman will not improve sexual functioning when the problem is with her relationship, not her body (Bancroft, 2002). For example, consider a middle-aged man with erectile dysfunction who is given Viagra and resumes sexual intercourse with his postmenopausal wife. Many researchers and clinicians maintain that in such cases the woman does not have a disorder, although she may have a relationship problem (Basson et al. One of the main goals of treatments that directly target psychological factors related to sexual dysfunctions is to educate patients about sexuality and the human sexual response. Another goal is to help patients develop strategies to counter negative thoughts, beliefs, or attitudes that may interfere with sexual desire, arousal, or orgasm (Carey & Gordon, 1995). For instance, during sexual activity, some people are preoccupied with nonsexual thoughts that prevent them from reaching full arousal or orgasm. These nonsexual thoughts might be work-related worries, thoughts about household tasks that need to be done, or worries that someone will interrupt the sexual encounter. Cognitive treatment may involve teaching a patient how to filter out such thoughts and (re)focus on the sexual interaction. The therapist might encourage the patient to apply standard cognitive methods (see Chapter 4) to sexual encounters, such as problem solving ("You could turn the phone off") or cognitive restructuring ("Are you likely to think of a solution to your work problem while making love? If not, you can let your mind focus on the physical sensations you are experiencing"). Sometimes the sense of being dysfunctional or inadequate generalizes from the sexual realm to the whole self, and the individual with a sexual dysfunction comes to have low selfesteem and self-doubts generally. In such cases, the therapy may use cognitive and behavioral methods (see Chapter 4), to address the thoughts and feelings of being inadequate in multiple spheres of life. Homework for women with female orgasmic disorder (as well as other sexual dysfunctions) may include masturbation in order to learn more about what sensations and fantasies facilitate arousal and orgasm (Meston et al. For many patients, a first step is to begin to (re)discover pleasurable sensations through specific homework exercises. In the beginning of behavioral treatment, homework may include sensate focus exercises, which are designed to increase awareness of pleasurable sensations, but preclude orgasm. One such task might be a sensual bath, either alone or with a partner; the goal is not to come to orgasm but rather to become aware of pleasurable sensations. N P S Typically, the therapist explains a homework assignment during a session, and the patient or couple reports the results during the following session. The goals of behavioral techniques are to help patients develop a more relaxed awareness of their bodies and increase their orgasmic responding and control. In addition, therapists typically use specific behavioral techniques for different sexual dysfunctions. For instance, people with sexual aversion disorder may undergo desensitization as part of their treatment, gradually exposing themselves to frightening or aversive elements of the sexual situation (Kaplan, 1995). Researchers have examined how well specific psychosocial treatments (that is, treatments that directly target psychological and social factors) help people with particular sexual disorders. For erectile dysfunction, treatments such as psychoeducation and behavioral homework assignments (such as increasing communication skills) can help to increase satisfaction with erectile functioning, sexual frequency, and satisfaction with the relationship (Heiman & Meston, 1997). Premature ejaculation is significantly helped by behavioral techniques (de Carufel & Trudel, 2006), such as the squeeze technique (Kaplan, 1989): Right before ejaculation, the man squeezes the base of the tip (just below the head) of his erect penis for about 4 seconds. Once he has mastered this technique during masturbation, he tries sexual relations with his partner; if necessary for control, he can employ the squeeze technique during sexual relations with his partner (Heiman & Meston, 1997). Women with vaginismus may be helped by systematic desensitization, which involves gradual dilation of the vaginal opening until vaginal spasms no longer occur. Comstock/Punchstock Targeting Social Factors: Couples Therapy the sex therapy techniques discussed in the previous section may be implemented alone (by the individual with a sexual dysfunction) or with a partner. Sex therapy may involve teaching couples specific cognitive and behavioral techniques. However, implementing such techniques with a partner requires motivation and willingness to be open with the partner about sexual matters and to experiment sexually. Moreover, how a couple interacts sexually occurs against the backdrop of their overall relationship. Couples therapy may also address issues of power, control, and lifestyle as they relate to the sexual dysfunction; for example, the therapist may employ techniques from systems therapy (see Chapter 4) to focus on assertiveness within the sexual aspects of the relationship. In turn, changes in these factors lead, through feedback loops, to changes in neurological and other biological factors (which underlie orgasm) as well as social factors (the meaning for both partners of an orgasm and the changes in their interactions). Although all the techniques mentioned may alleviate sexual dysfunctions, the definition of "success" is less clear-cut than for treatments of most psychological disorders. As we noted at the beginning of this chapter, sexuality and sexual dysfunctions typically involve other people besides the patient, and a treatment that the patient views as successful may not be perceived that way by the partner. Yet she might explain that when her husband had difficulty with his erections, he was much more affectionate, sexually attentive to her, and creative in their sexual interactions. Treatments that directly target only one type of factor, such as medication, may seem to resolve the problem for the patient, but instead can-via feedback loops among the three types of factors-have unexpected negative consequences for the couple. Steve Kelley/Cartoonist Group Targeting only a neurological (or other biological) factor in one partner may not improve the overall sexual functioning and satisfaction of the couple. Sexual dysfunctions fall into one of four categories: disorders of desire, arousal, orgasm, and pain. Sexual desire disorders involve three components: cognitive, emotional, and, to a lesser extent, neurological (and other biological). Problems with any of these components can lead to hypoactive sexual desire or sexual aversion disorder. Sexual arousal disorders arise when the normal progression through the excitement phase is disrupted. The two disorders pertaining to arousal are female sexual arousal disorder and male erectile disorder. Sexual orgasmic disorders are characterized by persistent problems with the orgasmic response after experiencing a normal excitement phase and adequate stimulation. These disorders may involve neurological (and other biological), cognitive, and emotional components. Two of these involve an absence or delay of orgasmic response: female orgasmic disorder and male orgasmic disorder. Typically, men with orgasmic disorder are able to climax with masturbation but not with vaginal intercourse.
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Very few studies have looked at the prevalence of disability among the poor gastritis from ibuprofen purchase prevacid without a prescription, or across the distribution of a particular welfare indicator (income gastritis diet food list purchase genuine prevacid online, consumption gastritis with fever generic 15 mg prevacid mastercard, assets), or across education status. A study of 20 countries found that children in the poorest three quintiles of households in most countries are at greater risk of disability than the others (106). Disability across expenditure and asset quintiles in 15 developing countries, using several disability measures suggests higher prevalence in lower quintiles, but the difference is statistically significant in only a few countries (132). Estimates of unmet needs have been included as a subcomponent in some national studies on people with disabilities in low-income and middle-income countries. The estimate of unmet needs is often based on data from a single survey and related to broad service programmes such as health, welfare, aids and equipment, education, and employment. In Africa national studies on living conditions of people with disabilities were conducted between 2001 and 2006 in Malawi, Namibia, Zambia, and Zimbabwe (159). Across the four countries the only sector that met more than 50% of reported needs for people with disabilities was health care. The studies revealed large gaps in service provision for people with disabilities, with unmet needs particularly high for welfare, assistive devices, education, vocational training, and counselling services (see Table 2. In 2006 a national study on disability in Morocco estimated the expressed need for improved access to a range of services (160). People with disabilities in the study expressed a strong need for better access to health care services (55. Some 20% of people with disabilities needed physiotherapy, but only 6% received it. A 2007 national study on rehabilitation needs in China found that about 40% of people with disabilities who needed services and assistance received no help. The unmet need for rehabilitation services was particularly high for aids and equipment, rehabilitation therapy and financial support for poor people (162). These studies relied on a combination of different data sources, especially the national population disability surveys and administrative data collections on disability services (158). An analysis of these demand and supply data combined provided an estimate of unmet needs for services. Furthermore, because the concepts were stable over time it was possible to update the estimates of unmet needs. Met and unmet need for services reported by people with a disability, selected developing countries Service Namibia Needed (%) Health services Welfare services Counselling for parent or family Assistive device services Medical rehabilitation Counselling for disabled person Educational services Vocational training Traditional healer Zimbabwe b Malawi b Zambia b a Received (%) 72. Percentage of total number of people with disabilities who expressed a need for the service. Percentage of total number of people with disabilities who expressed a need for service who received the service. Costs of disability the economic and social costs of disability are significant, but difficult to quantify. They include direct and indirect costs, some borne by people with disabilities and their families and friends and employers, and some by society. Many of these costs arise because of inaccessible environments and could be reduced in a more inclusive setting. Knowing the cost of disability is important not only for making a case for investment, but also for the design of public programmes. Comprehensive estimates of the cost of disability are scarce and fragmented, even in developed countries. Many reasons account for this situation, including: Definitions of disability often vary, across disciplines, different data collection instruments, and different public programmes for disability, making it difficult to compare data from various sources, let alone compile national estimates. For instance, reliable estimates of lost productivity require data on labour market participation and productivity of persons with disabilities across gender, age, and education levels. But even for these programmes, consolidated data at the national level are scarce. Public spending on disability programmes Direct costs of disability Direct costs fall into two categories: additional costs that people with disabilities and their families incur to achieve a reasonable standard of living, and disability benefits, in cash and in kind, paid for by governments and delivered through various public programmes. People with disabilities and their families often incur additional costs to achieve a standard of living equivalent to that of non-disabled people (120, 124, 148, 163). This additional spending may go towards health care services, assistive devices, costlier transportation options, heating, laundry services, special diets, or personal assistance. Researchers have attempted to calculate these costs by asking disabled people to estimate them by pricing the goods and services that disabled people report they need, by comparing actual spending patterns of people with and without disabilities, and by using econometric techniques (120, 124, 164). In Ireland the estimated cost varied from 20% to 37% of average weekly income, depending on the duration and severity of disability (164). In Viet Nam, the estimated extra costs were 9%, and in Bosnia and Herzegovina 14% (148). While all studies conclude that there are extra costs related to disability, there is no technical agreement on how to measure and estimate them (163). Extra costs of living with disability Nearly all countries have some type of public programmes targeted at persons with disabilities, but in poorer countries these are often restricted to those with the most significant difficulties in functioning (165). They include health and rehabilitation services, labour market programmes, vocational education and training, disability social insurance (contributory) benefits, social assistance (non-contributory) disability benefits in cash, provision of assistive devices, subsidized access to transport, subsidized utilities, various support services including personal assistants and sign language interpreters, together with administrative overheads. The cost of all programmes is significant, but no estimates of the total cost are available.