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As seen previously allergy treatment in toddlers cheap 5 mg desloratadine with mastercard, many implementation problems are present in both successful and unsuccessful projects. Does this result hold even when inadequate borrower performance happens with, say, good supervisionfi This helped identify which, if any, positive aspects of investment climate projects design reduce or eliminate the negative impact of implementation problems on achieving the development objectives. The results show that a good risk assessment can help reduce the negative outcome associated with poor borrower performance and the event of a crisis. Furthermore, the negative impact of a crisis can be reduced with a simpler design and good supervision. Similarly, the chances of achieving the development outcome are higher if a poor M&E is associated with a simpler design, if a complex design is associated with a good risk assessment, and if a poor risk assessment is paired with a simpler design. First, there are aspects under the control of the World Bank Group that can reduce or eliminate the 126 Investment Climate Reforms Figure 5. More specifcally, inadequate borrower performance can be alleviated by having a simpler project design, and a crisis can be dealt with better if the project does not have a complex design, has a good supervision, and has a good risk assessment. Finally, there is one implementation problem for which no other aspect of the design can alleviate its negative impact: inadequate technical design. In the context of a single tranche operation, only initial An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 5 127 measures in this area could be envisioned, leaving open the question of how these reforms would be sustained on completion of the operation. For example, the project did not pursue business simplifcation in the city of Aden as planned because of other activities by the parallel Bank project. Thus, selectivity and fexibility in project design is essential in contexts characterized by political instability and weak capacity. Yet the difference in the design and implementation strategy between Sudan and South Sudan led to vastly different results. In light of the weak institutional capacity, less emphasis on areas of reform and more attention to implementation assistance might have been a better strategy. The results for regulations show a signifcant impact only for the number of procedures and time to complete registration. In contrast, no outcome indicator for trade shows any signifcant improvement just two years after approval. This implies that trade reforms take more time (than the average two years) to produce measurable results. For example, the project supported the re-established business registry and helped enact the Investment Promotion Act, among other regulatory reforms. Project activities not only included support to drafting the laws but also involved intensive hands-on support through every step of the enactment and implementation process. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 5 129 Post-confict Liberia also faced capacity defcits. However, the country stands out as an example where several positive factors contributed to largely successful investment climate reforms. Although the 2011 elections and local capacity limitations were an implementation constraint, technical support by the World Bank Group helped overcome some of these weaknesses. According to an external evaluation, the relevance of investment climate reforms in Liberia is evident from the participatory approach and the demand-driven nature of many initiatives undertaken, with detailed requests for assistance directly formulated by the benefciaries and backed by preliminary analyses and discussions (Economisti Associati 2011). One key lesson of this program is that even in a post-confict country with limited implementation capacity, a reform program can be successful if there is genuine and strong government commitment. It also adopted other means, such as building solid partnerships and relationships with relevant line ministries, and leveraging and utilizing relationships with senior and mid-level bureaucrats. Both government and stakeholder engagement, therefore, are keys to ensure the success of interventions. Facilitating government ownership of reforms involves a careful assessment of the political feasibility of the proposed interventions, as well as identifcation of measures to reduce diminishing client interest in reforms. The fragile political economy has a fundamental bearing on the success of investment climate interventions. In Nepal, investment climate reforms immediately followed the end of the confict in 2006. An investment climate minidiagnostic noted that analyzing and recommending priority reform areas in the investment climate are a key to embarking on a postconfict reform program. With increasing stability, a good investment climate becomes essential in realizing latent investment. Successive elections, the abolishment of the monarchy, and constitutional changes led to perpetual political uncertainty. In the Republic of Yemen, civil unrest disrupted the progress of several Bank Group projects. To counter political uncertainties, the project was designed as a single tranche operation with the option to offer a programmatic series to the new administration. Given the systemic risk of political uncertainty, Bank engagement An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 5 131 through analytical work rather than lending might have been more appropriate, or prior actions that could be accomplished quickly but were of an irreversible nature might have been preferable. World Bank projects are more likely to be fagged for having too many components and less likely to be fagged for implementation delays. A review of project evaluations suggests that three factors are associated with success or failure: counterpart commitment, local capacity and human resource quality, and project complexity. For the frst two factors, greater commitment and better capacity (or explicit attention to capacity building) appear to aid effectiveness. World Bank Group Collaboration and Results Collaboration and how it occurs are not recorded formally in the World Bank Group. This explains why the extent of collaboration reported by the two institutions is substantially different. Unfortunately, presenting evidence of such links in practice is diffcult because the effectiveness discussion in project An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 5 133 Figure 5. It must be recognized, however, that these fndings are based on a small number of observations. He provided extensive comments on the draft National Arbitration Center of Cambodia subdecree, led one consultation session with the private sector and government, and met frequently with high-level offcials in the government to advise them on the major issues related to the establishment of the Center. All parties had different modus operandi, but there was a clear division of tasks, accompanied by continuous communication between task team leaders, especially before endorsing with the client any action and requirement; this guaranteed full cooperation of all the agencies and successful delivery of the project. Although this was not main factor behind the failure of the project, it certainly detracted from performance. This joint approach allowed the Bank Group to face the client with just one interface and add depth and breadth to the scope of reforms that were already ongoing when this project was launched. The project helped build the frst-ever comprehensive inventory of business licenses in Madagascar.

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They often denigrate their physicians in a defensive effort to maintain a sense of mastery allergy list buy desloratadine 5 mg. Treatment of these individuals is difficult because they rarely desire to change and seldom seek help. G roup t h er apy is h elpfu l on ly if t h e t h erapist can make t h e inevit able confront at ion by group members somehow palat able t o t h e pat ient. Psych ot h er apy wit h t h ese in d ividu als is ch allen gin g, an d t h e pat ient oft en t er min at es treatment when confrontation is attempted. H owever, in bipolar pat ient s t here are also mood changes and functional impairments that are not seen in narcissistic personality disordered patients. Those with histrionic personality disorder have a need for attention, but it does not specifically need to be of the admiring kind, wh ich is t h e case wit h narcissist ic personalit y disordered pat ient s. H e apologizes t o t h e pat ient, st at ing t h at h e h ad an emergency involving anot her pat ient. Patients with narcissistic personality disorder do not handle aging well because beauty, strength, and youth are often highly valued. Any blow to their fr agile (bu t cover t) self-est eem can r aise t h eir feelin gs of envy an d an ger, an d subsequently lead to depression. All the other life occurrences represent changes which may be stressful to people, but do not affect those with personality disorders any differently than the general population (other than the fact that patients with personality disorders in general do not handle any kind of st ressors well). Patients with narcissistic personality disorder rarely seek treatment and tend to have little insight into their grandiosity. When these individuals do present for treatment it is usually due to underlying anger or depression resulting from being belittled or not receiving the admiration to which they feel ent it led. T h e p at ien t d efen d s again st h is feelin gs of h u r t an d an ger t owar d t h e t h er apist by using devaluat ion. D evaluat ion along wit h idealizat ion and denial are considered primit ive (lower-funct ioning) defense mechanisms used by patients with personality disorders such as narcissistic and borderline. They are very seldom capable of true empathy with others and often manipulate them fo r p e rso n a l g a in. Ta c t i s i m p o r t a n t a s w e l l, a s t h e s e i n d i v i d u a l s h a n d l e c r i t i c i s m p o o r l y. This is the third time the patient has been referred to a psychiatrist under such circumstances. Th e p a t ie n t st a t e s t h a t p e o p le d o n o t like h im a n d wo u ld like t o se e h im fa il. He cit e s a s a n e xa m p le o n e in st a n ce in which one of his colleagues was late in sending him some material he needed, re su ltin g in th e p atie nt b e in g u n ab le to comp le the h is assign m e nt in a t im e ly fash io n. On a m e n t a l st at u s e xa m in at io n, t h e p a t ie n t a p p e a rs so m e wh a t a n g ry a n d su spicious. H e appears suspicious of his colleagues and of t he int erviewing psych iat r ist. H e r ead s h id d en mean in gs int o ben ign r emar ks or act ion s (su ch as t h e pager going off). The results of his mental status examination are normal except for his paranoia, which does not reach delusional proportions. Maintain a respectful alliance in working with a patient with paranoid personalit y disorder. Co n s i d e r a t i o n s the presentation in the case vignette is probably one of the most common for these patients, who do not normally seek out mental health treatment. Although pervasive paranoia and suspiciousness characterize this patient, the absence of any true paranoid delusions or hallucinations make a true psychotic disorder unlikely. The psychiatrist should take a low-key approach and not try to overcompensate by making friends with the patient. H e or she should provide clear, straightforward answers t o all quest ions and explain everyt hing t hat he or she is doing or recommending. H allucinat ions can occur in all five senses (gust atory, olfactory, auditory, visual, and tactile). These patients are often preoccupied wit h quest ion ing t h e loyalt y or t r u st wor t h in ess of fr ien ds, even wh en t h is is unjustified. They believe that the motives of others are malevolent, and they are quick to react to defend their characters. As in all personality disorders, these symptoms cannot occur exclusively during t he course of anot her psychiat ric illness such as sch izophrenia, or occur due to anot her medical condit ion or t he use of a subst ance. T hey can be different iat ed from those with a delusional disorder by the absence of fixed delusions, as the paranoia of patients with a personality disorder never reaches delusional proportions. In t e r vie w Tip s Patients with paranoid personality disorder can become even more suspicious wh en a physician t ries t o become t oo friendly or close because t h ey wonder about the motives behind this behavior. Jon es, I d id n ot ar r an ge t o h ave m y p ager go off in t h e m id d le of ou r m eet ing. Someone from t h e out side simply needed t o speak wit h me, and t h erefore my secret ary paged me. In the case of both schizophrenia and bipolar disorder wit h psychot ic features, however, t here must be evidence of persistent psychotic symptoms (delusions or hallucinations). People with paranoid ideation may often be consoled or reassured by a trusted friend, and they do not often act on these suspicious. By contrast, people with paranoid delusions have fixed (ie, they are not able to be reassured) and false beliefs that others mean them harm. This patient would benefit from small dosage, short-term antipsychotic therapy to manage his delusional thinking. W ith a paranoid delusion, which is, by definit ion, a psychot ic sympt om, ant ipsychot ic drugs are t he t herapy of ch oice. Becau se t h e pat ient is n ot exh ibit in g d an ger ou s beh avior t o h im self or others, hospitalization is not required. Reassurance, by definition of a delusion (fixed, false belief), will be unhelpful. Ant ianxiet y medicat ion is unhelpfu l an d in effect ive wit h a p sych ot ic d isor d er, as is p sych ot h er apy. Project ion is a defense mechanism by which individuals deal wit h conflict by falsely attributing to another their own unacceptable feelings, impulses, or thoughts. Blaming others for their own sentiments and actions directs the focu s away from t h e person doin g t h e accu sing. For example, a pat ient wh o is angry wit h his therapist suddenly st art s accusing the t herapist of being angry wit h him.

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Factors influencing health status and contact with health services allergy medicine that is safe during pregnancy order desloratadine american express, Encounter for prophylactic organ removal. Malignancy in two or more noncontiguous sites A patient may have more than one malignant tumor in the same organ. These tumors may represent different primaries or metastatic disease, depending on the site. Should the documentation be unclear, the provider should be queried as to the status of each tumor so that the correct codes can be assigned. It should not be used in place of assigning codes for the primary site and all known secondary sites. This code should only be used when no determination can be made as to the primary site of a malignancy. Sequencing of neoplasm codes 1) Encounter for treatment of primary malignancy If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63. See guideline regarding the coding of a current malignancy versus personal history to determine if the code for the neoplasm should also be assigned. If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84. Current malignancy versus personal history of malignancy When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed. When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Factors influencing health status and contact with health services, History (of) n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in remission versus personal history the categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission. Factors influencing health status and contact with health services, History (of) o. Malignant neoplasm associated with transplanted organ A malignant neoplasm of a transplanted organ should be coded as a transplant complication. Chapter 3: Disease of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) Reserved for future guideline expansion 4. Diabetes mellitus the diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system. As many codes within a particular category as are necessary to describe all of the complications of the disease may be used. For this reason type 1 diabetes mellitus is also referred to as juvenile diabetes. An additional code should be assigned from category Z79 to identify the long-term (current) use of insulin or oral hypoglycemic drugs. If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. Gestational (pregnancy induced) diabetes 5) Complications due to insulin pump malfunction (a) Underdose of insulin due to insulin pump failure An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory T85. Additional codes for the type of diabetes mellitus and any associated complications due to the underdosing should also be assigned. As indicated by the Excludes 1 note under category G89, a code from category G89 should not be assigned with code F45. Mild substance use disorders in early or sustained remission are classified to the appropriate codes for substance abuse in remission, and moderate or severe substance use disorders in early or sustained remission are classified to the appropriate codes for substance dependence in remission. These codes are to be used only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider. Dominant/nondominant side Codes from category G81, Hemiplegia and hemiparesis, and subcategories G83. Pain Category G89 1) General coding information Codes in category G89, Pain, not elsewhere classified, may be used in conjunction with codes from other categories and chapters to provide more detail about acute or chronic pain and neoplasm-related pain, unless otherwise indicated below. If the pain is not specified as acute or chronic, postthoracotomy, postprocedural, or neoplasm-related, do not assign codes from category G89. A code from category G89 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/ management and not management of the underlying condition. When an admission or encounter is for a procedure aimed at treating the underlying condition. The underlying cause of the pain should be reported as an additional diagnosis, if known. When an admission or encounter is for a procedure aimed at treating the underlying condition and a neurostimulator is inserted for pain control during the same admission/encounter, a code for the underlying condition should be assigned as the principal diagnosis and the appropriate pain code should be assigned as a secondary diagnosis. For example, if the code describes the site of the pain, but does not fully describe whether the pain is acute or chronic, then both codes should be assigned. The default for post-thoracotomy and other postoperative pain not specified as acute or chronic is the code for the acute form. Routine or expected postoperative pain immediately after surgery should not be coded. If appropriate, use additional code(s) from category G89 to identify acute or chronic pain (G89. This code may be assigned as the principal or first-listed code when the stated reason for the admission/encounter is documented as pain control/pain management. When the reason for the admission/encounter is management of the neoplasm and the pain associated with the neoplasm is also documented, code G89. Glaucoma 1) Assigning Glaucoma Codes Assign as many codes from category H40, Glaucoma, as needed to identify the type of glaucoma, the affected eye, and the glaucoma stage. When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and the classification does not provide a code for bilateral glaucoma. When a patient has bilateral glaucoma and each eye is documented as having a different type, and the classification does not distinguish laterality. When a patient has bilateral glaucoma and each eye is documented as having the same type, but different stage, and the classification does not distinguish laterality. Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95) Reserved for future guideline expansion 9.

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Seizure is a paroxysmal allergy symptoms bee sting cheap desloratadine online american express, uncontrolled, abnormal discharge of electrical activity in the brain. A prodromal phase is a phase which follows some seizures and may last minutes or hours. Which of the following dangerous activities should be avoided or undertaken only with special safe guards in seizure disordersfi Which of the following is not a typical characteristic of catatonic schizophreniafi Which one of the following is often not in the differential diagnosis of schizophreniafi One type of schizophrenia which is characterized by giggling and the habit of looking into the mirror is: A. Significance of common mental illnesses About 500 million people are believed to suffer from neurotic, stress-related and somatoform disorders worldwide. Another 200 million suffer from mood disorders, such as chronic and manic depression. Community based studies done in Stirling County, Canada in 1950s showed estimates of the lifetime prevalence of mental disorder to be 57%, and significant mental impairment 24%, with 20% needing psychiatric attention. In low-income countries where morbidity and mortality due to malnutrition and preventable infectious diseases are very common, mental disorders which are 12 not regarded as life-threatening problems are seen to be insignificant and unworthy of attention. Religion and culture have great influence on the perception of the causation and the remedies of mental illnesses in Ethiopia. The majority of Ethiopians believe that all diseases, particularly mental illnesses are afflictions caused by supernatural evil factors. Research done by Giel and co-workers between 1966 to 1969 from 4 general outpatient clinics in Ethiopia indicate that 6. After the development of new screening methods, a prevalence of 12% was found for mental disorders in a small sample in Addis Ababa. Most people in the country use traditional methods for treating mental illness and those who look for a modern treatment method do so after trying several local means (1). Despite the fact that epidemiological findings consistently indicate that serious mental disorders in low income countries are as common as in the developed world, the opposite belief seems to govern the attitude and decisions of many health planners in low-income countries. The idea that mental illnesses are less common in lowincome countries than in developed countries has been disputed. The results of more recent studies suggest that some mental disorders like depression and anxiety are even more prevalent in low income countries than in the developed world. Although it is clearly understood that mental illness can lead to poverty, disability, malnutrition and infection, it requires far-sightedness to appreciate the link between mortality and serious mental problems (1). This in turn has contributed to undermining the prevalence of mental illnesses (3). Learning objectives By the time the reader completes studying this module, he/she should be able to: fi Identify mental illness as one of the most important public health problems. B is a 25-year-old male merchant from Bate who was brought to the health center chained by his family members claiming that he is mad. He was relatively healthy until six months ago when he started to show abnormal behavior of restlessness, sleeplessness, irritability, and aggressiveness. At times, he laughs out loud for no apparent reason, then becomes suddenly depressed. The problem has progressed to a point where currently he insults everyone around him and even fought with some of his colleagues at work. His family 14 members kept him at home chained and confined to a small room so that no one can see him. He was not eating well since the onset of the illness and currently he totally refused to eat. The patient states that he is receiving messages from God and accuses his wife of poisoning his food. The capacity in an individual to form harmonious relations with others and to participate in, or contribute/constructively to changes in his social and physical environment (2). Epidemiology Generally, there is lack of comprehensive data concerning the epidemiological aspects of mental illness. Different epidemiological studies have shown that females have higher rates of mental illness than males. Mental illnesses are more common in those with large family size and in those who are single rather than married. They are seen more in cities than rural areas and the prevalence increase with the size of the city (2). The 1994 annual report of the Ministry of Health of Ethiopia showed that out of the patients seen at health institutions in one-year period, only 1. Mental illnesses or behavioral problems in children are given even less attention than those of adults in Ethiopia. In 1968, it was reported that only 11 of 18, 978 children who attended clinics showed some form of mental disturbance. Etiologic factors of mental illness There is no known single causative agent for mental illnesses. Children from mentally ill parents are more likely to develop mental illnesses than children of healthy parents. Organic factors like cerebrovascular diseases, nervous system diseases, endocrine diseases and chronic illnesses such as epilepsy are associated with mental illnesses. Social and environmental crises like poverty, tension, emotional stress, occupational and financial difficulties, unhappy marriage, broken homes, abuse and neglect, population mobility, frustration, changes in life due to environmental factors like earthquakes, flood and epidemics are associated with mental illness. Environmental factors other than the psychosocial ones capable of producing abnormal human behavior include toxic substances such as carbon disulfide and monoxide, mercury, manganese, tin, lead compounds, etc. Psychological factors like early childhood experiences of abuse and other psychological trauma during childhood play an important role in the development of mental illness in adult life. Behavioral factors like indulging in drugs, alcohol and substances like khat are associated with mental illness. Other factors associated with mental illness include nutritional deficiency; infections before and after delivery and birth trauma; road, occupational and other accidents; and radiation accidents. The nervous system is most sensitive to radiation during the period of neural development. Clinical features of common mental illnesses Mental illnesses have diverse signs and symptoms, which are grouped or clustered together to become a specific diagnosis. These groups of symptoms and signs should be persistent and intense to indicate mental illness. Disorders of perception the most distinctive phenomena in mental illnesses are disorders of perception. A person sees spiders and snakes on the ceiling of his or her room where there are none. A person believes that an external force controls him or her, a spaceman sends him message by radio. Disorders of emotion this involves a sustained abnormal feeling tone experienced by patient. Such patients may have low mood, anger, anxiety or excessive happiness without any reason. Disorders of motor activity these are abnormalities of social behavior, facial expressions and posturing. Disorders of memory this is the inability to retain and recall information (distortion of recall). A person may find it difficult to remember what he or she had for breakfast after few hours. Disorders of consciousness this is the impaired awareness of the self and the environment. Disorders of attention and concentration this is the inability to focus on the matter at hand and failure to maintain that focus.

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But regulation enabling market activity also produces outcomes that can reduce social value allergy medicine heart palpitations purchase generic desloratadine line, including pollution, congestion, inequitable treatment of employees and consumers, unequal distribution of wealth, and unequal access to goods and services. Therefore, although regulatory reform often generates public goods, not all members of a population are guaranteed to beneft equally, and some may not beneft. Reform impacts stakeholder groups unevenly; some groups may suffer serious disadvantages as a consequence of reform. Reform enables, motivates, and constrains stakeholder groups to adapt to a changed regulatory landscape in different ways, with variable consequences. Both increases and reductions in social value are possible consequences of regulatory reform, impacting stakeholders in various ways. Assessment of the impact of regulatory reform should attempt to capture these diverse tendencies. Analytical Framework: Assessing the Social Value of Regulatory Reform the concept of social value resonates with the longstanding notion of economic welfare (Pigou 1920) and with contemporary ideas of human development, capabilities, quality of life, well-being, happiness/life satisfaction, and sustainability (Sen 1979; Bleys 2012). Economic growth is not An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 4 99 an end in itself but rather a means to the end of improved human welfare; broadly understood, it is a point increasingly recognized by governments and supranational organizations. How societies defne social value is likely to be infuenced by a wide range of factors, including the policies of national, subnational, and supranational governments; the wealth of the population and its distribution; availability of public services and access to infrastructure; the role and infuence of civil society organizations (political parties, business associations, trade unions, and pressure groups); and demographic factors such as age, ethnicity, language, religion, and location. For example, some might perceive regulatory reform intended to provide a minimum income standard through a national minimum wage as enhancing social value by raising employment incomes and reducing poverty. In contrast, others might believe a national minimum wage reduces social value because of anticipated adverse impacts on economic effciency, business proftability, and employment. So in proposing a set of empirical indicators of social value, it is important to recognize the contested character of the concept and the indicators that attempt to operationalize it. Regulatory reform is a dynamic force shaping the activities of business and nonbusiness stakeholders, enabling and motivating action as well as constraining it (Anyadike-Danes and others 2008; Kitching, Hart, and Wilson 2013; Kitching, Kasperova, and Collis 2013). Consequently, the appropriate analytical framework comprises a theory of change connecting regulatory reform, the actions of businesses, and the wide variety of stakeholders with whom they interact (consumers, suppliers, employees, investors, and others) to the wide range of social value effects (Figure 4. By infuencing business and stakeholder activities, regulatory reform generates (or fails to generate) diverse forms of social value. Some studies highlight, for instance, the potential for regulation to contribute to improved environmental protection (for example, Leiter, Parolini, and Winner 2011; Testa, Iraldo, and Frey 2011; Wilson, Williams, and Kemp 2012), whereas others question it (Kneller and Manderson 2012) or suggest that stricter enforcement might make things worse (Cheng and Lai 2012). National governments and supranational bodies such as the European Commission have adopted impact assessment procedures to estimate likely costs and benefts as an aid to regulatory decision making, including consideration of whether to regulate at all (for example, Radaelli and de Francesco 2010; Staronfiova 2010; Dunlop and others 2012). Social return on investment methodologies vary, but all take into account the range of stakeholders involved in the impact value chain, specify relevant indicators and quantitative or fnancial measures for the indicators, and outline the types of data required. Where regulatory reforms are complex and far reaching, capturing social value outcomes might be diffcult, because identifying relevant stakeholders, mapping impact chains that link reforms to indicators, fnding appropriate data sources, and quantifying (and monetizing) social value may be very challenging, particularly where outcomes differ for stakeholder groups or occur over long time periods. The model distinguishes direct fnancial, compliance, and long-term structural costs. Compliance costs are further subdivided into substantive and administrative compliance costs: the former refer to those needed to comply with a regulatory requirement, the latter to those needed to document or disclose compliance. But it is arguably even narrower as a measure of social value, because it ignores any benefts of regulation. All 819 projects in the investment climate portfolio were reviewed by keyword search and subsequent closer examination. Second, formal assessments do not always refer to all regulatory reforms implemented as part of an intervention. If formal impact assessments undertaken: Do assessments incorporate estimates of social valuefi If estimates of social value incorporated: Are they presented in quantitative or discursive formfi For example, stakeholder assessment of regulatory reform proposals, recording number and diversity of stakeholders (business versus nonbusiness [consumers, employees]; small frms versus large frms); other If yes: Is regulatory quality measured (for example, volume of regulation, reduced complexity, rate of change, reduced administrative burden/compliance costs, clearer guidance on inspection and enforcement mechanisms, other)fi Impact Indicators Is regulatory reform argued/demonstrated to generate changes in any of the following indicatorsfi An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 4 103 Table 4. Note: Percentages do not sum to 100 due to rounding; percentages of single-point or range estimates refer to all 55 evaluations reporting quantitative estimates of social value (either alone or in combination with qualitative/discursive formats). Single-point estimates might provide useful indications of likely social value in terms of particular indicators, but they risk conveying a spurious precision and lack sensitivity to the changing circumstances that support higheror lower-value outcomes. This suggests a narrow rather than a multistranded conception of social value and leaves a large gap in the understanding of how regulatory reform might contribute to social value. Other indicators of economic value were also reported: employment, prices, productivity, infrastructure, business creation, exports, and access to education and training. Although it is diffcult to know precisely what is meant by each of these terms in the context of brief descriptions in projects documents, their inclusion does suggest that the World Bank Group emphasizes the economic effects of regulatory reform and assumes that changes in the economy will necessarily bring about desirable changes in social value. Economic changes might be associated with improvements in one or more aspects of social value, but they do not guarantee them and might also lead to reductions in social value where regulatory reform leads to a redistribution of benefts among different social groups. Other benefciaries identifed included taxpayers, consumers, investors, and employees. Again, the logic appears to be that where businesses beneft from reform, it is assumed that this necessarily feeds into increases in social value, implicitly defned in terms of benefts for nonbusiness stakeholders. This suggests that important distributional issues are neglected in World Bank Group projects; these are essential to understanding social value outcomes and the extent to which shared prosperity is achieved. Again, this could be an unintended consequence of the underlying assumption that regulatory reform is assumed to generate changes in economic behavior that, in turn, necessarily produce social benefts. Conversely, there is no automatic relationship between the two; economic and social changes are connected in complex ways. Bank Group projects provide very limited evidence of the links between regulatory reform and economic and social impacts. Furthermore, businesses are not the only stakeholders affected by regulatory reform, and reducing costs and increasing investment are not the only objectives of such reforms. Other stakeholder groups and regulatory reform effects should be incorporated within evaluations. Regulatory reform need not necessarily beneft all members of the population equally. Indeed, some groups may be worse off after reform because some stakeholders are enabled to act in ways that, intentionally or inadvertently, disadvantage or exclude such groups. Last, evaluations are not conducted according to a common template, so there would be gains from standardizing the questions asked and data obtained. This would at least enable cross-project compar isons that might stimulate new thinking about how to implement initiatives as well as how to evaluate them. This profle of intended benefciaries is refected in the very business-centered analyses presented, presupposing that where business benefts, then social value is necessarily generated. Procedural outcome indicators refer to changes in regulatory processes and institutions. Impact indicators are the most important for a proper assessment of the social value outcomes of regulatory reform (Table 4. First, and fundamentally, none of the projects explicitly defned social value in relation to regulatory reform initiatives, although some used close synonyms, such as social development outcomes (in Thailand). These Enhanced access to the energy infrastructure are potentially very wideImprovement in population health ranging and might include any of the benefts listed in Table 4.

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Diagnostic Features Panic disorder refers to recurrent unexpected panic attacks (Criterion A) allergy testing jersey uk cheap desloratadine uk. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of a list of 13 physical and cognitive symptoms occur. In contrast, expected panic attacks are attacks for which there is an obvious cue or trigger, such as a situation in which panic attacks typically occur. In the United States and Europe, approximately one-half of individuals with panic disorder have expected panic attacks as well as unexpected panic attacks. Thus, the presence of expected panic attacks does not rule out the diagnosis of panic disorder. Persons who have infrequent panic attacks resemble persons with more frequent panic attacks in terms of panic attack symptoms, demographic characteristics, comorbidity with other disorders, family history, and biological data. In terms of severity, individuals with panic disorder may have both full-symptom (four or more symptoms) and limited-symptom (fewer than four symptoms) attacks, and the number and type of panic attack symptoms frequently differ from one panic attack to the next. Examples include avoiding physical exertion, reorganizing daily life to ensure that help is available in the event of a panic attack, restricting usual daily activities, and avoiding agoraphobia-type situations, such as leaving home, using public transportation, or shopping. Associated Features Supporting Diagnosis One type of unexpected panic attack is a nocturnal panic attack. In the United States, this type of panic attack has been estimated to occur at least one time in roughly one-quarter to one-third of individuals with panic disorder, of whom the majority also have daytime panic attacks. In addition, there may be pervasive concerns about abilities to complete daily tasks or withstand daily stressors, excessive use of drugs. Prevalence In the general population, the 12-month prevalence estimate for panic disorder across the United States and several European countries is about 2%-3% in adults and adolescents. In the United States, significantly lower rates of panic disorder are reported among Latinos, African Americans, Caribbean blacks, and Asian Americans, compared with non-Latino whites; American Indians, by contrast, have significantly higher rates. Lower estimates have been reported for Asian, African, and Latin American countries, ranging from 0. The gender differentiation occurs in adolescence and is already observable before age 14 years. Although panic attacks occur in children, the overall prevalence of panic disorder is low before age 14 years (<0. Development and Course the median age at onset for panic disorder in the United States is 20-24 years. A small number of cases begin in childhood, and onset after age 45 years is unusual but can occur. Only a minority of individuals have full remission without subsequent relapse within a few years. Although panic disorder is very rare in childhood, first occurrence of "fearful spells" is often dated retrospectively back to childhood. As in adults, panic disorder in adolescents tends to have a chronic course and is frequently comorbid with other anxiety, depressive, and bipolar disorders. Lower prevalence of panic disorder in older adults appears to be attributable to age-related "dampening" of the autonomic nervous system response. Many older individuals with "panicky feelings" are observed to have a "hybrid" of limited-symptom panic attacks and generalized anxiety. Older individuals may retrospectively endorse explanations for the panic attack^which would preclude the diagnosis of panic disorder), even if an attack might actually have been unexpected in the moment (and thus qualify as the basis for a panic disorder diagnosis). Thus, careful questioning of older adults is required to assess whether panic attacks were expected before entering the situation, so that unexpected panic attacks and the diagnosis of panic disorder are not overlooked. While the low rate of panic disorder in children could relate to difficulties in symptom reporting, this seems unlikely given that children are capable of reporting intense fear or panic in relation to separation and to phobic objects or phobic situations. Therefore, clinicians should be aware that unexpected panic attacks do occur in adolescents, much as they do in adults, and be attuned to this possibility when encountering adolescents presenting with episodes of intense fear or distress. Although separation anxiety in childhood, especially when severe, may precede the later development of panic disorder, it is not a consistent risk factor. Reports of childhood experiences of sexual and physical abuse are more common in panic disorder than in certain other anxiety disorders. Most individuals report identifiable stressors in the months before their first panic attack. There is an increased risk for panic disorder among offspring of parents with anxiety, depressive, and bipolar disorders. Respiratory disturbance, such as asthma, is associated with panic disorder, in terms of past history, comorbidity, and family history. Culture-Related Diagnostic issues the rate of fears about mental and somatic symptoms of anxiety appears to vary across cultures and may influence the rate of panic attacks and panic disorder. Clarification of the details of cultural attributions may aid in distinguishing expected and unexpected panic attacks. For more information regarding cultural syndromes, refer to the "Glossary of Cultural Concepts of Distress" in the Appendix. The specific worries about panic attacks or their consequences are likely to vary from one culture to another (and across different age groups and gender). G ender-Related Diagnostic Issues the clinical features of panic disorder do not appear to differ between males and females. Also, for a proportion of individuals with panic disorder, panic attacks are related to hypersensitive medullary carbon dioxide detectors, resulting in hypocapnia and other respiratory irregularities.

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Much of the literature on therapy for complex traumatic stress disorders may be helpful as well (see allergy symptoms hives and swelling generic 5mg desloratadine amex, among others, Briere, 1989; Chu, 1988, 1998; Courtois, 1999, 2004; Courtois et al. Depending on individual circumstances, treatment teams may include representatives from a variety of professional disciplines, including psychopharmacologists, case managers, family therapists, expressive therapists, sensorimotor psychotherapists, and medical professionals. However, inpatient treatment may be necessary at times when patients are at risk for harming themselves or others and/or when their posttraumatic or dissociative symptomatology is overwhelming or out of control. Inpatient treatment is often used for crisis stabilization and the building (or restoring) of skills and coping strategies. An inpatient evaluation can screen for the presence of other comorbid conditions that require immediate treatment. Given the current constraints of third-party payers, most hospitalizations are brief and only for the purpose of safety, crisis management, and stabilization. In some cases, the structure and safety of a hospital setting can facilitate therapeutic work that would be destabilizing or even impossible in an outpatient setting. When resources are available to support a more prolonged length of stay, inpatient treatment can include planned and judicious work on traumatic memories and/or work with aggressive and self-destructive alternate identities and their behaviors. Specialized inpatient units dedicated to the treatment of trauma and/or dissociative disorders may be particularly effective in helping patients develop the skills they need to become more safe and stabilized. These programs provide services that are not usually provided in general hospital psychiatric programs: specialized diagnostic assessments, intensive individual psychotherapy, specialized group therapies, expert psychopharmacological interventions, and specialized trauma-focused work on symptom management and skill building. Unfortunately, restraint and seclusion may be traumatizing to all patients, let alone those with preexisting posttraumatic psychopathologies. Accordingly, many hospital systems are now committed to an ideal goal of minimizing or eliminating the use of seclusion and restraint. In this regard, these restrictive measures often can be avoided by careful planning in advance for symptom management and containment strategies to help in times of crisis. Programs that allow an individualized focus for the trauma survivor and that are cognizant of trauma-related issues may be most helpful for this purpose. In general, these specialized programs use multiple daily groups to educate about trauma-related disorders, to teach symptom management skills, and to provide training in relationships and other life skills. Some such therapy groups have resulted in symptom exacerbation and/or dysfunctional relationships among group members. These types of groups can help educate patients about trauma and dissociation, assist in the development of specific skill sets. These task-oriented groups should be time limited, highly structured, and clearly focused. These groups provide ongoing support, 150 International Society for the Study of Trauma and Dissociation focus on improvement of interpersonal functioning, and buttress the goals of individual therapy. Some patients may make good use of 12-step groups such as Alcoholics Anonymous, Narcotics Anonymous, or Al-Anon when addressing substance abuse problems. In addition, there is the potential for poor boundaries among group members, including disturbed, overdependent, and/or exploitive behavior. Pharmacotherapy Psychotropic medication is not a primary treatment for dissociative processes, and specific recommendations for pharmacotherapy for most dissociative symptoms await systematic research. In the only naturalistic study of outpatient dissociative disorder treatment, 80% of patients received adjunctive medication (Brand, Classen, Lanius, et al. It is essential that the functions of the therapist and the medicating psychiatrist be clearly defined. In general, the medicating physician should play an adjunctive role, focusing primarily on medication management and seeing the patient more frequently only when medications are being adjusted or in response to a psychiatric emergency. The regular exchange of significant information between treatment team members is important to provide an ongoing context for interventions and adjustments to the treatment. As in any psychopharmacologic treatment, issues of non-adherence to the medication regimen, including overuse, underuse, and/or surreptitious use of other drugs or alcohol, should always be a consideration. This task may fall to the primary therapist if the psychopharmacologist is not familiar with such inquiries. Thus, prescribers should be especially alert to the potential negative effects of polypharmacy in this patient population. Often this is a more parsimonious and helpful intervention than initiating new trials of medications. The standard response ranges for titration of selective serotonin reuptake inhibitor antidepressants apply to this population. However, these older medications may be helpful in some patients who can use them safely, especially the anti-obsessive tricyclic medication clomipramine (Anafranil). Often the best result is that the patient acknowledges that he or she would be more depressed without antidepressant medication rather than experiencing a significant remission in depressive symptoms. Anxiolytics may be used primarily on a short-term basis to treat anxiety, but the clinician must keep in mind that the commonly used benzodiazepine medications have addictive potential, a risk for those patients vulnerable to substance abuse. This is thought to be because of the severe chronic hyperarousal and putative alterations in benzodiazepine receptor binding in these patients. Other medications with marked sedative-hypnotic effects may be used for sleep problems in this population. Instead, because of problematic side effects such as somnolence neuroleptics may lead to decreased function rather than to the disappearance of voices. Multimodal dissociative hallucinosis with auditory, visual, olfactory, tactile, and gustatory manifestations, often in the context of loss of reality testing (dissociative psychosis), generally does not respond robustly to antipsychotic medication, although this may help with overall hyperarousal, panic, terror, and thought disorganization. This may permit effective psychotherapeutic interventions for the dissociative/posttraumatic processes underlying these symptoms. Medications associated with these side effects include clozaril (Clozapine) and olanzapine (Zyprexa) and, to a lesser extent, quetiapine (Seroquel), risperidone (Risperdal), aripiprazole (Abilify), and ziprasadone (Geodon). The psychiatrist must carefully monitor all patients taking atypical antipsychotics, and, if significant weight gain and/or the metabolic syndrome develop, the patient and psychiatrist should carefully review the risks and benefits of continuing the medication. The latter may manifest with refractory, often bizarre, quasi-delusional or frankly delusional 154 International Society for the Study of Trauma and Dissociation cognitive distortions.

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A 48-year-old man presents with a series of severe allergy testing reading results desloratadine 5 mg free shipping, reveals a systolic ejection click. Chest X-ray reveals (D) Progestin (E) Surgical fusion unilateral, periorbital headaches lasting from 30 enlarged pulmonary arteries. Which of the following anti-diabetic medications small bowel biopsy for celiac disease. A 17-year-old male presents with fever, hearing ziness, one-sided uterine pain, and amenorrhea. Which of the following medications is prescribed (B) Gestational trophoblastic disease (D) Otitis externa empathy, having a sense of entitlement, and confor maintenance therapy for panic attacks and panic (C) Ovarian cyst (E) Otitis media sidering herself as being special. Which of the following gastrointestinal disorders (E) Uterine cancer with the aging process. Which of the following treatment options is behavior and personality, which of the following (C) Monoamine oxidase inhibitors bowel on itself, and normally involves the sigmoid indicated for a patient who was diagnosed with is the most likely diagnosisfi A 17-year-old boy who was recently diagnosed syncopal episodes when transferring from a sitting (C) 36 hours weakness, muscle aches, and weight loss. Blood pressure in the sitting (D) 48 hours exam reveals hypotension at 100/60 mm/Hg, testicular swelling and tenderness. Blood pressure in the (E) 72 hours hyperpigmentation, and delayed deep tendon him with orchitis secondary to the mumps virus. Based on routinely elevated with little or no reduction in (A) Anti-inflammatories minute when standing. A 45-year-old male presents with chronic periton(C) Beta-adrenergic antagonists (D) Peripheral neuropathy (D) Diabetes insipidus sillar cellulitis. His symptoms include severe sore (D) Calcium channel blockers (E) Medication (E) Diabetes mellitus throat pain and an airway obstruction that has pre(E) Diuretics cipitated sleep apnea. Which of the following diagnostic techniques persistent, marked asymmetry of the tonsils. What chills, and a swollen, hot and tender rash on the involves the invagination of a proximal segment would be most effective in confirming the diagnosis would be the most appropriate course of treatment left lower extremity. A 26-year-old female with history of diarrhea, steerythromycin atorrhea, weight loss, and weakness has a positive 136 A 38-year-old obese white female presents with (C) Immunodilators abnormal bleeding in the gums. Which of the following areas of an electrocarfeeling of vaginal fullness, lower abdominal aching, (D) Mesalamine a decreased platelet count of 40,000 platelets/mcL. Physical examination reveals mild dropping to treat her thrombocytopenia, which has failed. A 40-year-old white male with a history of diabetes (B) Carcinoid stomach tumor 221. A 70-year-old male presents with erectile dys(C) Leads V1, V2, and V3 presents for his annual physical examination. A 48-year-old male presents with cough, hemopWhich of the following is the class of medication (C) Beta-adrenergic agonists jaw, neck, and back stiffness, difficulty swallowing, tysis, focal wheezing, and recurrent pneumonia. Physical exam reveals hyperreflexia Bronchoscopy reveals a pink/purple, well-vasblood pressurefi A 44-year-old male presents with headache, (B) Alpha-adrenergic antagonists which of the following is the most appropriate is the most appropriate diagnosisfi Physical examination (D) Calcium channel blockers (A) Botulism (B) Non-small cell lung carcinoma reveals tenderness to palpation of the sinuses and (E) Diuretics (B) Diptheria (C) Sarcoma opacification of the sinuses with transillumination. Which of the following treatment options is recomfrom the patient reveals she is a prior cocaine abuser (A) Allergic rhinitis 226. Which of the following medications is the most mended for treatment of carcinoid tumorfi Based on the symptoms, (E) Vasomotor rhinitis (B) Ceftriaxone (D) Radiation therapy history, and examination, which of the following (C) Chloroquine (E) Surgical excision 223. Physical examination reveals skin (B) Chronic atrophic rhinitis loss, weakness, and abdominal distention. Which of the following treatment options would (C) Rhinitis medicamentosa suspect Celiac disease. A 24-year-old female with a history of throm(E) Ovarian cysts (A) Aminosalicylates bocytopenia presents with petechiae on the skin (B) Antacids and mucous membranes. Which of the following medications is the only swelling and thickening of the tendon sheath. Which of the following anti-diabetic medications (B) Methotrexate the most appropriate diagnosisfi A 9-year-old boy presents with sudden onset of (C) Metformin (E) Scaphoid fracture severe testicular pain on the right side. Which of the following radiologic modalities is (D) Miglitol exam reveals a swollen scrotum. Which of the following classes of medications most effective in visualizing white matter lesions (E) Rosilitazone testicular torsion. Which of the following is the has been proven successful for the treatment of in the central nervous system associated with 242. A 55-year-old African-American male presents best diagnostic procedure in order to confirm this fibromyalgiafi A 15-year-old male presents with pain in the left idiopathic arthritis is characterized by spiking necrosis of the hip. Based on the (B) Osteoarthritis (B) High-dose corticosteroids (E) X-ray of the abdomen symptoms and physical examination, which of the (C) Pauciarticular arthritis (C) Human growth hormone 243. A 60-year-old female who is being treated for following is the most appropriate diagnosisfi You performed a lateral soft tissue c-spine that fluctuate throughout the day and are resolved infection. Which of the following diagnostic pro(E) Otitis media X-ray, which reveals the classic thumb sign indiwith rest. Lab work reveals elevated (A) Bacterial culture attacks of pain and swelling in the wrists and knees. A 39-year-old male presents with fever, chills, (B) Cefadroxil (D) Rheumatoid arthritis (E) Myasthenia gravis vomiting, muscle pains, insomnia, and irritability.