Mark C. Adams, MD

• Professor, Urology and Pediatrics, Monroe Carell Jr.
• Children? Hospital at Vanderbilt, Pediatric Urology,
• Vanderbilt University, Nashville, Tennessee

Patients are trained to refrain from performing rituals (compulsions) despite having increased anxiety stemming from obsessional thoughts neuropathic arthritis definition buy voltaren with american express, images or impulses (response prevention) arthritis in dogs natural medicine buy generic voltaren canada. For example arthritis in back medicine cheap voltaren 100mg with mastercard, a patient whose obsessions involve fear of contamination is asked to touch various surfaces (exposure) but refrain from washing hands (response prevention) rheumatoid arthritis new zealand discount voltaren 100mg on-line. Over time arthritis is dogs order voltaren online now, this helps to break the vicious cycle of compulsive acts in response to obsessions arthritis in outer knee purchase cheap voltaren online. Tokens are accumulated and exchanged at the end of a specified time period for gifts such as snacks psoriatic arthritis in my back voltaren 100 mg mastercard, toys arthritis in the back muscles buy generic voltaren on-line, watching television, or playing video games. When maladaptive behaviors occur then there is a penalty with a certain number of tokens is taken away. What makes a behavior desired or maladaptive and the rewards/penalty associated with them are clearly communicated in advance to the patients. This is followed by the patient imitating the behavior to also get rewarded for this enactment. Shaping is brought about by positive reinforcement of successive approximations of desired behavior. Examples include activity scheduling, graded task assignment, relaxation exercises, assertiveness training, thought record, coping cards, and biofeedback. Theoretical background: Information processing utilizes cognitive representations also termed as core beliefs or schemas. These schemas and the resulting automatic thoughts influence emotions and behavior and help deal with a great number of stimuli that we are constantly being exposed to (10). Multiple factors at the biological, developmental, social levels contribute to the formation of schemas. Psychiatric disorders are characterized by dysfunctional schemae and maladaptive thoughts (cognitive distortions) that lead to abnormal affect and maladaptive behavioral patterns that reinforce core beliefs. Commonly seen cognitive distortions include over-generalizing, selective abstraction, minimization/ magnification, catastrophizing, and dichotomous thinking. Patients with residual symptoms or recurrent illness may find "booster" sessions helpful to maintain response (14). The first few sessions are aimed at getting comprehensive history and identifying current problems. Based on the problems, an attempt is made to elicit, test, and modify maladaptive schemae and cognitive distortions. Formal joint agenda setting, homework, and feedback are important tools to reinforce learning, maintain focus, and move in the right direction. Socratic questioning, emotional state during sessions (15), imagery, and role play are useful in uncovering and dealing with cognitive distortions. Generation of alternatives, examining evidence, decatastrophizing, reattribution, thought recording, and cognitive rehearsal are some of the techniques used to modify schemae/cognitive distortions (16). Automatic thought Note down the most important thoughts/images which troubled you during that time. Emotion Which feelings or emotions (sadness, anxiety, anger etc) Did you feel in that situationfi Result Asses how much do you believe now in your automatic thoughts (0-100%) and in the intensity of your emotions (0-100%) Adapted from. Over the years, Klerman and Weissman became leading exponents of and researchers in the field. Techniques utilized by these authors focus on the goals of 1) changing communication, and 2) solving interpersonal problems to help improve interpersonal relationships to improve emotional well-being. Initial Phase: this is focused on a confirmation of the diagnosis of depression and education about depressive symptoms. This is followed by understanding significant interpersonal relationships and, thereafter, identifying target problem areas. The interpersonal formulation is based on one of four key interpersonal problem areas: grief, interpersonal deficits, interpersonal role disputes, or role transitions. Furthermore, the therapist highlights how changes in patient interpersonal relationships relate to changes in symptomatology. Termination Phase: Here the therapist discusses termination and encourages patients to understand and describe specific changes in their psychiatric symptoms, especially as they relate to improvements in the identified problem area. The therapist also assists the patient in consolidating gains, and helping him identify early warning signs of symptom recurrence. It aims at enhancing and expanding patient motivation as well as their capability to reduce dysfunctional behavior. Theoretical background: Emotional vulnerability is dependent on biological factors such as temperament and impulse dyscontrol. In the presence of an invalidating environment (such as parental/caretaker neglect or abuse), emotional dysregulation may emerge which constitutes the core problem (19). In response to stress, these patients engage in maladaptive behaviors such as suicidal, self-injurious, or avoidance to escape from distressing emotions (20). Initially while problem solving, behavioral analysis is used to identify the sequence of internal events (emotional state), external events (stimulus), and consequences associated with problem behavior. Several strategies such as cognitive modification, behavioral skills training, solution analysis, didactic approach, and insight development are used to break the maladaptive cycle. Priority is given to replace risky behaviors such as suicidal or self injurious behaviors with healthy alternatives. Patients individually meet for one hour every week with their primary therapist and review their treatment goals. Group skills training uses a didactic approach and empowers patients with skills such as: fi Mindfulness to increase awareness and be in the present moment fi Emotional regulation to understand and accept emotions and thereby, reduce emotional vulnerability. Family therapy views the functionality of the system as a whole to decipher individual behavior patterns amid complex interactions within the family system. It assumes people are best understood as operating in systems and treatment must include all relevant parts of the system. While many clinicians view families as an important aspect of understanding individual illness and treatment; others view family disequilibrium as the core issue, with individual illness a result of or solution to such disharmony (23). General systems theory applies to biological processes of considerable complexity since any living system must have boundaries in order to regulate its exchange with systems outside of itself. Over the years, general systems theory has been applied to the assessment of family systems and subsystems that also must have clear boundaries to stay functional. Further work by Minuchin helped define a continuum of families ranging from enmeshed (with permeable and diffuse boundaries) to disengaged (inappropriate rigid boundaries). Families with clear boundaries lie in the middle of this continuum and are considered the most functional. A significant related concept is that of "Family homeostasis," by which as a system, the family unit attempts to maintain a relatively stable state; when subjected to an incongruent force, it tries to restore back to a state of pre-existing equilibrium (24). While conducting a comprehensive initial evaluation, a convenient tool used for family assessment is the three-generational genogram. Initially developed by Bowen, this genogram maps family relationships and provides a structure with which difficulties are explored by the therapist. During the initial phase of treatment, the therapist tries to better understand family strengths, preferred styles of thinking, contributory cultural issues, and the life cycle phase for the family. Furthermore, the therapist establishes and strengthens therapeutic relationships, defines goals of therapy, and switches focus from the individual to the family. The middle stage, where majority of therapy "work" happens, is an attempt to bring about change. These goals could involve persistently inflexible patterns of family functioning, definition of family boundaries, or presentation of alternative modes of interacting for the family. The termination phase involves a review with the family of goals that were or were not achieved. The original problems and alternatives suggested are revisited and often the sequences leading to the pathology are reconstructed. The therapist also acknowledges problems may arise in the future and suggests how the family might then use skills they learned to help solve any such future conflicts (25). Boundary making is utilized to change the psychological distance between family members. Unbalancing techniques are used to change the hierarchical relationship of members of a family system or subsystem. Paradoxical techniques are occasionally used to make the family unit understand why a symptom is being maintained in their system (24, 25). Therapy can help couples perceive and appreciate differences in ongoing individual challenges and the struggles rotted in the relationship. The life history of each person in couples therapy is important as is the history of the relationship itself. Different values, assumptions, and expectations may not be intentional, much less, personal. Mundane concerns over children, careers, and life transitions often stir up misunderstandings, stress, and unnecessary stress between couples. Thus, couples in therapy may gain perspective, learn new skills, discuss struggles and resentments without rancor. In practical terms, both partners are usually seen together by two co-therapists at weekly to monthly intervals for an average of 6-10 sessions of 1-1fi hours. Clinical Applications: To resolve conflicts, couples must confide in a therapist to safely explore sources of and possible solutions to problems or failings in the relationship. One or both in a couple may harbor concerns that inhibit their acceptance of therapy. Unstated fears often persist that a psychotherapist will be judgmental or partisan. Similar fears that the therapy will drive the couple apart rather than draw them closer commonly occur. However, not only is seeking out help is a healthy sign of maturity and hope rather than insecurity, it can be the basis upon which a couple may renew trust, esteem, and conviviality (24). Supportive psychotherapy often spans a long term with brief contacts, although it can take a limited form of more extended sessions within a brief period (26). The synthetic nature of supportive psychotherapy can be conceptualized across four major areas (26): fi Establishment and maintenance positive therapeutic alliances fi Formulation of patient problems, i. Clinical Applications: Supportive psychotherapy is actually a continuum from merely supportive efforts such as a case manager may use, toward more expressive psychotherapy appropriate to the level of patient psychopathology and resilience. Supportive psychotherapy is especially pertinent for patients vulnerable to psychotic regression in the course of nondirective psychodynamic psychotherapy, or who have limited capacity to forge and sustain close relationships, or who are less skilled at verbalizing distress. Regardless of the clientele, essential aspects of supportive therapy include close attention to and elicitation of expressed emotions as "ventilation" as well as possible insight. It also includes overt explanation and education by the therapist to assist patient understanding of themes, struggles, and conflicts in their lives in order to facilitate confidence that such difficulties can be overcome. Similarly, supportive psychotherapy can entail open expressions by the therapist that are intended to boost confidence or restore morale. Supportive psychotherapy also often includes counseling advice or direct recommendations about specific problems. Group psychotherapy can address inadequacies acquired in earlier group experiences from childhood through adolescence and beyond. In group therapy, patients join together with others to share problems or concerns, to better understand themselves and others, and to learn from and with others. It helps patients enhance interpersonal relationships and otherwise learn about themselves. It mobilizes feelings of isolation, depression or anxiety that the group and/or leader can help interpret so patients may make significant change and feel better about the quality of their lives (27). Group psychotherapy entails a small number of people (generally no more than eight or ten) who meet together regularly (most often weekly) under the guidance of one (or sometimes two) therapists (28). Clinical Applications: Supportive, behavioral, cognitive, and psychodynamic approaches arise in the course of group therapy. Most commonly, dynamic group therapy fosters a wide variety of transference relationships than is likely in individual therapy. Group therapy has given rise to a great many permutations that include more didactic or focused therapeutic themes. For example, anxiety management or social skills groups combine cognitive and behavioral techniques to treat specific problems common to all group members. Self-help groups such as Alcoholics Anonymous frequently rely on techniques of group dynamic that also build a supportive and instructive milieu. Moreover, principles of group therapy and group dynamics underlie broader applications in other settings such as business consultation, schools management, and community organizations. Still, the suitability of particular patients for particular therapeutic techniques can be broadly outlined. Some basic principles of selection are: fi Patients who are vulnerable to psychotic breakdown are unsuited to non-directive approaches fi Patients who have little capacity of making and sustaining relationships fi Patients who are less verbally able are also relatively unsuited to non-directive approaches. Heinz Kohut emphasized that here, parents or other adults "mirror the grandiose self" of the child (28). This grandiosity derives from how children are (or should be) surrounded by praise and love with every minor achievement warmly applauded. However, as is all too clear in any psychiatric clinic, not every child had sufficient such tonic boosting to inure solid self-image. Indeed, many exit childhood sensing that they are unwanted, fundamentally bad, or failures or less favored than a sibling, and so on. A second critical learning period for self-esteem is adolescence when parental influences wane or even become negative, while peer group influences become vital and avidly sought as peer group acceptance fosters high self-esteem. Such rejection by peers can further compound low self-esteem acquired early childhood or even efface high self-esteem previously engendered by parents. It is true that important life events may have effects both positive, such as success in college or career, or negative as in being rejected by a desirable college or failing in a career. But in the clinic many successful, happily married people still have problems ensuing from bad experiences in early childhood or adolescence. Ferdo Knobloch recognized the value of "corrective experience," elaborating ideas of Alexander and French (29) who saw how therapy can offer a re-run of bad experience. Knobloch (30) noted how individual psychotherapy can refurbish defects in the original parent/child relationship when, over a long course of care with a reassuringly supportive therapist, the patient can overlay bad early learning with newly positive experiences. Such therapy emphasizes the importance of childhood experiences as the therapist adopts aspects of the role of parent via patient transference. Here the good therapist is able to elevate the patient into something of an equal, in the way that a good parent eventually assists a child to separate and individuate as a health, self-actualized adult. However, if low self-esteem arose in negative adolescent experiences, individual therapy cannot effect a re-run. What is instead needed is a re-run with a group that represents the adolescent peer group. This re-run can most effectively be achieved with group therapy, as other treatment group members understudy the role of adolescent peers. In practical terms, the sequelae of negative childhood events are perhaps best addressed by individual therapy whereas those due to adversities in adolescence are likely to benefit from group therapy. It is less widely appreciated but quite important to appreciate that such research also directly links psychotherapy to evolution, particularly the emotive and rational capacities and reactivities of highly social species such as Homo sapiens. Most patients are able to give a clear account of how they felt about themselves in childhood and adolescence, and these reports should be taken into account in deciding between individual and group therapy as well as in guiding the course of any dynamic therapy toward the resolution of and recovery from problems in living. Long-term changes in defense styles with psychodynamic psychotherapy for depressive, anxiety and personality disorders. The efficacy of short-term psychodynamic psychotherapy in specific psychiatric Disorders: A meta-analysis. Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: a meta-analysis. Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial. Two-year randomized control trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Critical learning periods for self-esteem: Mechanisms of psychotherapy and implications for the choice between individual and group treatment. Textbook of Psychiatry/The Agitated/Violent Patient Nelson Mandela discusses violence by saying "This suffering is a legacy that reproduces itself, as new generations learn from the violence of generations past, as victims learn from victimizers, and as the social conditions that nurture violence are allowed to continue. Few people have not been touched by violence of one form or another, whether it be directly toward the individual or towards persons who are somehow connected to the individual.

In doing so rheumatoid arthritis fatigue buy voltaren overnight, policy makers need to take broad social interests into account arthritis in back and shoulders order genuine voltaren on line, including employee and consumer interests and concerns for the environment arthritis fingers bent generic voltaren 50mg with mastercard. These strategies recognize that certain obstacles make it harder for women than for men to start and grow enterprises neck brace for arthritis in neck cheap voltaren 100 mg. Tourism and agribusiness are prioritized because of their potential for employment creation incipient arthritis definition buy generic voltaren. On the one hand arthritis back discount voltaren 100 mg without a prescription, reforms by their own nature are supposed to be general and any specifc provision could be perceived as a politically unpalatable affrmative action what does rheumatoid arthritis in fingers look like effective voltaren 50mg. On the other hand arthritis in dogs knees buy cheap voltaren 50 mg line, it is normally the case that the playing feld is not leveled for everybody, and certain entrepreneurs or frms, current or potential, experience obstacles that are specifc to their group and, if not addressed, not only raise issues of fairness and equity, but can also hinder the growth potential of the whole economy. Furthermore, traditionally disadvantaged groups may be less able to take advantage of a level playing feld. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 3 the disadvantageous position of women in entrepreneurship has been widely documented. Also, in all regions of the world, including in developed economies, female-owned enterprises are substantially and signifcantly smaller than those owned by men (Bardasi, Sabarwal, and Terrell 2011; Minniti 2010). This is partly because women are more likely than men to operate in industries where frms are smaller and less effcient, but also because women face disproportionate obstacles in accessing fnance, accessing markets, obtaining licenses and permits (because of limited mobility, time constraints, and sometimes discrimination and higher exposure to bribes and sexual harassment), accessing courts and dispute-resolution systems, accessing networks, and accessing assets and property. The type of interventions that can reduce those obstacles, however, may not explicitly target a subgroup and because of their own nature, may be disproportionately benefcial to women, youth, or a specifc industry. For example, as female entrepreneurs are disproportionately penalized by lengthy and cumbersome registration procedures (Simavi, Manuel, and Blackden 2010), reforms meant to simplify business registration are disproportionately benefcial to women, even when women are not explicitly targeted by the reform. Similarly, reforms introducing one-stop shops, setting up alternative dispute-resolution systems, or reducing administrative barriers can be especially advantageous to current and potential women entrepreneurs. Access to fnance and start-up fnancing, simplifcation of the administrative and regulatory framework, and business assistance and support have been identifed as key crucial factors to address in policies and programs to support youth entrepreneurship (Schoof 2006). These activities promote economic growth and improved livelihoods, which in turn help cement peace dividends and lasting recovery (Bagwitz and others 2008, p. Most studies are quick to point out that the private sector never completely disappears in war, even if it becomes disrupted and distorted by confict, functioning typically on an informal level. Piffaretti (2010) puts a clearer emphasis on regulatory reform before institution building. A second group that supports this approach argues that institutional reforms should precede regulatory reforms. Collier and Hoeffer emphasize that institutional governance and social policies should come ahead of sectoral and macrolevel policies (Collier and Hoeffer 2000; 2002, p. Donors and governments cannot just set up a 9 regulatory environment and assume that foreign and local enterprise will sprout. Reform of the justice and security sector must also be a priority above and beyond business regulations to enforce the regulations and contract rights in the frst place. Finally, a third group stresses that early simplifcation of regulations restores investor confdence and attracts businesses and entrepreneurs. However, other reforms are equally important, if not more signifcant to investors, such as rule of law, infrastructure development (electricity and roads), fnance, and confronting corruption (World Bank 2010; Mills and Fan 2006). The only issue is that both the World Development Report and Mills and Fan remain unclear on the details of sequencing these institution-building steps in terms of investment climate regulatory reforms (see World Bank 2010, pp. A leading Donor Committee for Enterprise Development report cites a difference of opinion among practitioners over whether interventions should target particular industries or entire systems and value chains (MacSweeney 2008, pp. Each donor or nongovernmental organization tends to emphasize its favored approaches. These studies argue, directly and indirectly, that regulatory and interventionist approaches should not be viewed as mutually exclusive, but as complementary in encouraging growth in fragile environments. The World Development Report 2011 (World Bank 2010) leans in this direction by highlighting both investment climate reforms and direct interventions as important for fragile 6 Investment Climate Reforms states. In particular, the report gives attention to the positive role that direct interventions can make in stimulating the private sector through new market and value chain programming in case study examples of Kosovo dairy and Rwanda coffee ventures (2010, pp. It recognizes that creating the right business climate is often not enough to attract investment in violent situations. This is just as too much focus on reforming political and security institutions runs the risk of ignoring key economic dynamics behind confict (Collier and Hoeffer 2002). The guidebook from the German Organization for Technical Cooperation (Bagwitz and others 2008) does the best job of steering practitioners toward a mix of investment climate and direct interventions, depending on particular confict drivers and development goals (see also Curtis and others 2010). Outside the World Bank Group, most practitioner and scholarly literature supports an integrative approach. The interventionist approach is the most fractured and divergent, with each donor emphasizing different interventions and with practically no concern for sequencing direct interventions. Industrial sectors may have laws An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 7 and regulations specifc to an industry or feld of economic activities, such as licensing and registration requirements or tax treatment. Initially focusing on agribusiness and tourism, this practice sought to deepen engagement in strategic industries and improve the business environment and growth prospects for light manufacturing. Interviews with members of the practice suggest that it took some time to fnd a focus and that its ultimate scope extends beyond the legal and regulatory focus of the broader investment climate practice. Instead, it also includes activities relating to strengthening value chains, investment promotion (especially foreign direct investment promotion), strengthening sectoral institutions and standards, promoting specialized fnancing mechanisms (such as warehouse receipts), and a variety of other activities. Chapter 2 reviews the relevance of the World Bank Group from three different perspectives: strategy, interventions, and diagnostic tools. Chapter 4 reviews the methods used by the Bank Group to assess the social benefts of regulatory reform. Chapter 5 provides insights into factors affecting the performance of investment climate interventions, collaboration across the Bank Group institutions, and country perspectives. Within this context World Bank Group efforts aim to promote reforms to improve the conditions for frms to enter, operate, and exit both in domestic and international markets as well as in key sectors. Consequently, all projects that aim to reform the regulatory environments for businesses, irrespective of the sector and source of fnancing, will be part of the scope of this evaluation. In the 1990s, the Bank Group realized that macroeconomic reforms alone would not guarantee long-term growth. To support investment climate reform work, the Bank Group uses a number of indicators and benchmarking tools to help shed light on the characteristics and quality of the investment climate in a country, identify areas for reform, and monitor progress. In recent years new tools have been developed for specifc areas of the regulatory environment. The diagnostic tools include surveys (for example, Enterprise Surveys and Tax Compliance Cost Surveys), indicators and indices (for example, Doing Business; Women, Business, and the Law; Investing Across Borders; and Logistics Performance Index), and assessments (for example, Investment Climate Assessments, marginal effective tax rate, and standard cost model). The approach followed includes literature reviews, target-setting methodologies, analysis of value for money (such as standard cost model), and sustainability of reforms. In addition, the department has initiated an impact evaluation program both at a global level (Joint Bank Group-Donor Program on Impact, Sustainability and Value for Money of Investment Climate Reform) and a regional level (for example, Investment Climate Africa Impact Initiative). Some impact evaluations cover limited social dimensions such as informality (in Benin/Malawi) and patient safety (in Kenya). In supporting investment climate reforms, the Bank Group has adopted two distinct business models. There is also the World Bank business model, which is implemented through not only advisory services, but also through investment and policy-based lending. When not funded through the loans, advisory services are generally funded through trust funds or reimbursable advisory services. Regardless of the differences between the business models, the two institutions work in the same space and with the same clients. Evaluation Design and Methodology the conceptual framework for this evaluation is represented in Figure 1. This framework is a combination of theoretical literature and World Bank Group strategic priorities and objectives. As a matter of fact, regulatory reforms impact a wide set of stakeholders in society, not just businesses. Consequently, both at the design stage of reforms (ex ante) and when estimating its impact (ex post), it is important to estimate the increase or reduction in cost and benefts of these reforms. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 13 F ig ure 1. It includes analysis at two levels: (i) interventions (such as regulations for entry, bankruptcy law, and so forth) and (ii) client countries, as reforms produce results at the country level and are not implemented in isolation; rather, they are the consequence of a sustained and prolonged engagement with the client country. Finally, this list is taken as a good practice standard of the set of regulatory areas a 18 typical country with the best regulatory environment would have (Table 1. This evidence shows that only about half of the regulatory areas are covered by these diagnostic tools. This implies that these two diagnostic tools are only partially helpful in identifying regulatory areas of intervention. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 17 Table 1. NotE: Accounting and auditing standards are handled by the International Monetary Fund or the World Bank through the Reports on the Observance of Standards and Codes go. Doing Business stopped indexing its indicators on employment regulations but continues to report them. However, in terms of share, one in three development policy operations includes investment climate components, but only one in ten lending operations includes investment climate components. The World Bank Group activities in investment climate can be grouped in three main categories: those aimed at improving the business environment for entry, operation, and exit. Within each of these groups, the Bank Group implements a number of different interventions (Table 1. These interventions 24 aim to simplify and streamline regulatory procedures, remove sector-specifc administrative constraints, revise the legal framework and institutions, establish effective dialogue systems between private and public sectors, and harmonize procedures and systems (Table 1. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 21 Table 1. Regulations is a broad category as it appears in project documents and includes licensing, permits, and administrative barriers. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 23 Table 1. This includes administrative reform programs, establishment of electronic registries of all valid licenses, design of screening mechanisms for new licenses to ensure necessity and quality, implementation of one-stop shops for licensing needs, and drafting and submission of new laws and amendments. Licenses addressed include those for business operations, construction, and environmental permits. Registration Registration includes procedures that are offcially required, or commonly done in practice, for an entrepreneur to start up and formally operate an industrial or commercial business, as well as the time and cost to complete these procedures and the paid-in minimum capital requirement. Competition the interventions aim to remove sector-specifc constraints that affect market Policy competition, enact the law on competition, and work with the competition council and other line ministries on reducing the concentration in key sectors. Interventions in this area support regulatory and competition assessments of businesses in the services sector and the creation of relevant toolkits and manuals. Contract this intervention seeks to revise and harmonize commercial laws and codes, civil Enforcement procedure laws, and laws regarding the functioning of the judiciary and court systems. Transfer judicial services from central courts and judges to municipal courts and clerks, establishment of new courts, automation of judicial procedures, and capacity building and training for lawyers, judges, and clerks are activities that help to improve enforcement mechanisms for businesses. Doing this intervention aims to prepare subnational and national indicators related to Business nine of the Doing Business areas. This includes training with local partners on the Indicators Doing Business methodology, report preparation and disseminaition, and technical assistance to implement reform proposals and recommendations. Investment Under this intervention, laws and strategies to promote increased investment, both Policy and from foreign and domestic investors, and in key sectors and locations, are adopted. Promotion Investment promotion trainings and workshops are conducted, investor aftercare programs developed and implemented, and investment oversight committees and agencies formed. This is done through new or amended labor laws, addressing wage-setting mechanisms and hiring quotas, and revising residency permits for foreign skilled workers. Property this intervention addresses access to land, registering property, and protecting Rights intellectual property rights. Review of legislation, digitization of property records and development of cadaster systems, and one-stop shops for property registration are among the activities used to promote property rights. Cadastres or surveys, together with land registries, are tools used around the world to map, prove, and secure property and use rights. PublicPublic-Private Dialogue interventions support programs that improve the quality Private and sustainability of policy reforms by providing fexible and robust mechanisms Dialogue that address shortfalls in representation, communication, and coordination between relevant stakeholders. This is done through market demand analysis and feasibility studies, best practices frameworks, and identifcation of land, investors, and developers for the zone. Business this intervention aims at streamlining burdensome tax payment and administration Taxation procedures for businesses by implementing small business tax regimes, electronic fling, and taxpayer education and services. Other activities and tax laws work to harmonize the tax system and reduce certain taxes, while at the same time eliminating exemptions. Trade Trade logistics comprises three core areas of reforms: (a) simplifying and harmonizing Logistics trade procedures and documentation, integrating risk management systems into border inspections and clearance, and implementing electronic processing, automation, and single window systems; (b) industry-specifc reforms focus on agribusiness supply chains and on improving national logistics and distribution services; (c) regional integration reforms seek to improve trade logistics systems and services and border clearance at the regional level and foster mutual recognition of international standards, accreditation, and certifcation. Bankruptcy these interventions aim at identifying weaknesses in existing bankruptcy law and the main procedural and administrative bottlenecks in the bankruptcy process in order to implement good practices to improve both the effciency and the outcome of insolvency proceedings. Activities include improvements in existing regulations on company reorganization, through amendments to national bankruptcy acts and laws. Debt this intervention aims to improve insolvency laws, based on global best practices, Resolution/ with regard to provisions relating to assets of the debtor, avoidance of transactions Insolvency proceedings, reorganization, creditor rights, and secured lending. It improves institutional capacity for speedy resolution of disputes and technical assistance to improve court capacity. It is important to note, however, that although both institutions operate in the same space, the scope of their investment climate interventions is generally different, with some overlap. The Bank focuses more on higher-level reforms, such as revising and harmonizing laws and codes, reforming institutions, developing strategies, and coordinating government agencies and ministries. Excluding sector reforms, which account for some 20 percent of all interventions, both institutions focus the great majority of interventions (80 percent) on frm operation, with 15 percent on entry and the remaining 5 percent on exit. Across interventions, regulations, trade, and investment promotion account for almost half of all interventions. The World Bank conducts almost exclusively (over 80 percent of all) interventions in trade and property rights, as well as the majority of interventions on investment promotion. The distribution of interventions over time shows a remarkably similar trend for the two institutions. In terms of value, however, the two institutions provide a signifcantly different amount of support. The Middle East and north Africa and South Asia Regions have the fewest interventions (4 percent Figure 1. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 27 Figure 1. Similarly, both institutions 28 Investment Climate Reforms pay particular attention to lowerand lower-middle-income countries, where 8 of 10 interventions are implemented. All interventions have active projects, with regulation, investment policy, trade, and tax being 25 the most common and competition and labor the least. However, when in the World Bank these are part of lending operations, the average length is substantially higher. World Bank development policy operations with investment climate components are completed on average in less than two years; projects that include mostly investment climate components are implemented on average over six years. In terms of income the distribution of interventions shows that almost half of interventions are in low-income countries, whereas entry and exit almost equally distributed between the three income groups. In a few countries, for example, Cambodia, interventions focus on specifc areas such as trade promotion.

Smoking is the single greatest risk factor and most important cause of chronic obstructive pulmonary disease arthritis exclusion diet purchase 100mg voltaren otc. A phobic disorder is characterized by the presence of irrational or exaggerated fears of objects or situations arthritis in feet supplements order voltaren 50 mg with amex. The situation or object of the fear is not inherently dangerous or an appropriate source of anxiety arthritis pain lying down order online voltaren. Palpitations arthritis symptoms feet burning order voltaren with american express, Accelerated Q: When and how often does the plaintiff experience palpitations or accelerated Heart Rate heart ratefi The plaintiff may have unpleasant and distressing sensations in the throat arthritis medication etodolac buy discount voltaren 50 mg line, epigastrium pain in fingers not arthritis generic 100mg voltaren with visa, or abdomen rheumatoid arthritis blisters buy cheap voltaren line. Tachycardia rheumatoid arthritis prevalence new zealand discount 50 mg voltaren amex, watery salivation, and a sudden drenching sweat occur with nausea and vomiting. The plaintiff may experience a fluttering, skipping, or pounding heart (atrial fibrillation) after surgery. A phobic disorder is characterized by the presence of irrational or exaggerated fears Heart Rate of objects or situations. The situation or object of the fear is not inherently (continued) dangerous or an appropriate source of anxiety. The adjustment disorder with anxiety is characterized by symptoms of nervousness, worry, jitteriness, and motor tension. In addition, psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. Hyperthyroidism, or thyrotoxicosis, results from overproduction of thyroid hormone Heart Rate by the thyroid gland. The signs and (continued) symptoms of hyperthyroidism include both physical and psychiatric complaints. These signs, often resembling influenza symptoms, may be precipitated by the abrupt ending of one or two weeks of Accelerated continuous opioid use. During Heart Rate the final stages of withdrawal, the plaintiff may experience overconcern for bodily (continued) discomfort, poor self-image, and a decreased ability to tolerate stress. Psychological factors are judged to be associated with the symptom or deficit and the symptoms are not intentionally feigned or produced. The often has exaggerated and vague complaints focusing on either organs or types of symptoms such as pseudoneurologic or conversion symptoms, gastrointestinal, female reproductive, psychosexual, pain, and cardiopulmonary symptoms. Symptoms of amphetamine or similarly acting sympathomimetic drug consumption Heart Rate may include fighting, grandiosity, elation, hypervigilance, psychomotor agitation, (continued) impaired judgment, and impaired social or occupational functioning. Physical symptoms may include flushing, difficulty breathing, tachycardia, pupil dilation, elevated blood pressure, sweating or chills, nausea, and vomiting. It often produces personality changes, tiredness, confusion, dizziness, tremor, anxiety, tachycardia, and sweating during acute attacks. Toxic effects may include gross tremor, increased deep tendon reflexes, persistent headaches, vomiting, mental confusion progressing to stupor, seizures, or cardiac arrhythmias. Fatigue may be caused when body tissues do not receive sufficient nutrients and Heart Rate oxygen. A diseased heart is often unable to pump adequately for the lungs to (continued) oxygenate the blood. Palpitations or an accelerated heart rate are also symptoms of heart diseases such as: (reference 2, pp. Sweating, Cold Clammy Hands Q: When and how often does the plaintiff sweat or have cold clammy handsfi Q: Does the plaintiff have a history of sweating or cold clammy hands before the injury in questionfi The plaintiff often has exaggerated and vague complaints focusing on either organs or types of symptoms such as pseudoneurologic or conversion symptoms, gastrointestinal, female reproductive, psychosexual, pain, and cardiopulmonary symptoms. The plaintiff may have symptoms of panic, sweating, tachycardia, shakiness, and difficulty breathing. Other behavioral symptoms may include euphoria, psychomotor agitation, impaired judgment, and impaired social or occupational(functioning. While dependence on opioids is less common than on Clammy Hands alcohol or tobacco, it has been estimated that fifteen percent of males and nine (continued) percent of females have used an opioid (nonmedical) during their lifetime. These signs, often resembling influenza symptoms, may be precipitated by the abrupt ending of one or two weeks of continuous opioid use. Withdrawal symptoms develop when the plaintiff reduces or stops the prolonged moderate or heavy use of these substances. Cluster headaches are characterized by severe unilateral pain in the eye or temple. A classic migraine (vascular) headache may be accompanied by visual disturbances, sensory motor or speech disturbances, sweating, nausea or vomiting, and emotional changes. The enlargement of both abdominal lymph nodes may mechanically interfere with the motor activity of the gut and thus cause constipation, fever, backache, bloating, and belching. Physical symptoms may include dilated pupils, tachycardia, sweating, palpitations, blurred vision, tremors, and incoordination. Panic attacks are associated with endocrinological disorders including hyperthyroidism, as well as hypothyroidism. Dry Mouth Q: Does the plaintiff have a history of a dry mouth before the injury in questionfi Riboflavin is one of the B complex vitamins essential for the normal carbohydrate metabolism of yeast cells and animal tissues. Q: Does the plaintiff have any other medical conditions that may cause a dry mouth, such as atrophic glossitisfi Dizziness or Lightheadedness Q: When and how often does the plaintiff experience dizziness or lightheadednessfi Q: Does the plaintiff have a history of dizziness or lightheadedness before the injury in questionfi There are a number of hereditary, familial, or developmental labyrinthine degenerative diseases of the ear in which vertigo (sensation or illusion of motion) occurs. Other symptoms may include fullness in the neck, shortness of breath, nervousness, dizziness, and apprehension. The plaintiff may have symptoms of panic, dizziness or lightheadedness, sweating, tachycardia, shakiness, and difficulty breathing. Symptoms may include lightheadedness, faintness, ringing in the ears, weakness, blurring of vision, and tingling around the mouth or in the extremities. Associated symptoms include nystagmus (tremulous movement of the eyeballs), deafness, and other signs of middle-ear disease. Adverse drug reactions of confusion, lightheadedness, and depression can occur when the plaintiff has renal (kidney) insufficiency, an organic brain syndrome, or when the anti-ulcer drugs are taken in combination with other drugs that slow metabolism. Behavioral changes may include belligerence, assaultiveness, apathy, impaired judgment, and impaired social or occupational functioning. Nausea, Diarrhea, or Q: When and how often does the plaintiff have nausea, diarrhea, or abdominal Abdominal distressfi Distress Q: Does the plaintiff have a history of nausea, diarrhea, or abdominal distress before the injury in questionfi Q: Does the plaintiff have a history of any medical conditions that may cause nausea, diarrhea, or abdominal distressfi An adjustment disorder is a transient over-reaction to stress that usually occurs Abdominal within 90days and remits within six months. The adjustment disorder with anxiety is Distress characterized by symptoms of nervousness, worry, jitteriness, and motor tension. Symptoms are often more severe in the spring and fall and may be associated with mild anorexia, fatigue, nervousness, irritability, alternating periods of constipation and diarrhea, or burning sensations in the epigastriuin (upper and middle abdomen). Symptoms of a neuroendocrine disorder include sudden headaches, excessive Abdominal sweating, and palpitations. Often there are associated tremors, weakness, nausea, Distress and epigastric discomfort. The plaintiff may also complain of chest pain, shortness (continued) of breath, lightheadedness, blurred vision, and flushing. The enlargement of both abdominal lymph nodes may mechanically interfere with the motor activity of the gut and thus cause constipation, pain, fever, backache, bloating and belching. These signs, often resembling influenza symptoms, may be precipitated by the abrupt ending of one or two weeks of Diarrhea, or continuous opioid use. During Abdominal the final stages of withdrawal, the plaintiff may experience overconcern for bodily Distress discomfort, poor self-image, and a decreased ability to tolerate stress. Withdrawal symptoms develop after the reduction or cessation of the prolonged moderate or heavy use of these substances. Distress Headaches will occur in about one-third of moderate to high caffeine consumers (continued) when their daily intake is stopped. The plaintiff is preoccupied with bodily functions such as heartbeat, sweating, gastrointestinal functioning, peristalsis, minor physical abnormalities, or a specific organ such as the heart. The often gradual onset of acute pyelonephritis causes early symptoms of urinary frequency, dysuria, and fever. Toxic effects may include gross tremor, increased deep tendon reflexes, persistent headaches, vomiting, mental confusion progressing to stupor, Diarrhea, or seizures, or cardiac arrhythmias. The plaintiff with masked depression hides a dysphoric mood with gastrointestinal problems, chronic pain, insomnia, weight loss, and other physical complaints. Symptoms may include tremor exaggerated with movement, difficulty speaking and swallowing, incoordination, personality changes, explosive anger, abdominal pain, diarrhea, nausea and vomiting, and dementia. Vertigo, pounding headaches, fainting, dimness of vision, tinnitus (a ringing in one Abdominal or both ears), irritability, anorexia, restlessness, inability to concentrate, lethargy, Distress fatigue, drowsiness, and Gastrointestinal complaints are common symptoms of (continued) anemia. Trouble Swallowing, Q: When and how often does the plaintiff have trouble swallowing or a lump in the Lump in throatfi Throat Q: Does the plaintiff have a history of having trouble swallowing or lump in the throat before the injury in questionfi Q: Does the plaintiff have a history of any medical conditions that may cause trouble swallowing or a lump in the throatfi The plaintiff may have unpleasant and distressing sensations in the throat, Lump in epigastrium, or abdomen. Tachycardia, watery salivation, and a sudden drenching Throat sweat occur with nausea and vomiting. Allergic rhinitis is seasonal or perennial inflammatory disease of the nasal membranes. Defective copper excretion Lump in causes an accumulation of copper in the liver, brain and other tissues. Symptoms Throat may include tremor exaggerated with movement, difficulty speaking and (continued) swallowing, incoordination, personality changes, explosive anger, abdominal pain, diarrhea, nausea and vomiting, and dementia. S/he may complain of smothering or being unable to breath, feel lightheaded, dizzy, or numb in the extremities and around the mouth. Exaggerated Startle Q: When and how often does the exaggerated startle response occurfi Response Q: Does the plaintiff have a history of an exaggerated startle response before the injury in questionfi Q: Does the plaintiff have a history of any medical or psychological conditions that may cause an exaggerated startle responsefi Symptoms are often more severe in the spring and fall and may be associated with mild anorexia, fatigue, nervousness, irritability, alternating periods of constipation and diarrhea, or burning sensations in the epigastrium (upper and middle abdomen). Response Symptoms of amphetamine or similarly acting sympathomimetic drug consumption (continued) may include fighting, grandiosity, elation, hypervigilance, psychomotor agitation, impaired judgment, and impaired social or occupational functioning. An anxiety reaction may cause psychomotor agitation, insomnia or hypersomnia, high blood pressure, tachycardia, and paranoia. Common symptoms include depression or anxiety (with symptoms of a major depressive episode), self-reproach or guilt, fearfulness, tension, and physical restlessness. Psychological effects of the disorder may cause severely impaired judgement leading to dangerous decisions and accidents. Depressed women may experience an overconcern for Startle the baby, guilt, or feelings of inadequacy. Symptoms can include prominent, generalized anxiety symptoms, Panic attacks, or obsessions or compulsions. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. Specify if: With Generalized Anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation With Panic Attacks: if Panic Attacks predominate in the clinical presentation With Obsessive-Compulsive Symptoms: if obsessions or compulsions predominate in the clinical presentation Coding note: Include the name of the general medical condition on Axis I. Questions Symptoms can range from generalized anxiety symptoms (worry, restlessness, etc) to panic attacks (discrete periods of intense fear or discomfort) to obsessions or compulsions. There must be evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. The diagnosis of an anxiety disorder due to a general medical condition cannot be made if the symptoms can be accounted for by another mental disorder. The disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. This link must be made with some relative certainty, in order for the diagnosis to be accurate. Q: Is there any evidence of recent or prolonged substance use (including medications with psychoactive effects)fi The use of many illicit substances such as amphetamines, marijuana, cocaine, ecstasy, alcohol, and prescription medications may lead to symptoms of anxiety. Questions the diagnosis of substance-induced anxiety disorder may be more appropriate. There must be a prominent general medical condition for the diagnosis of anxiety disorder due to a general medical condition. In primary anxiety disorders, there is typically no specific and direct causative physiological mechanism associated with the onset of the anxiety symptoms. A variety of general medical conditions may cause anxiety symptoms, including endocrine conditions (thyroid disease, pheochromocytoma, etc), cardiovascular conditions (congestive heart failure, arrhythmia, etc), respiratory conditions (pneumonia, hyperventilation, etc), metabolic conditions (porphyria), and neurological conditions (neoplasms, encephalitis, etc). Q: Does the plaintiff have a history of any medical conditions that may cause anxiety or panic attacksfi The plaintiff with Specific Phobia experiences a marked and persistent fear of a clearly discernible object or situation. Plaintiffs claiming a specific phobia often have an early history of childhood fears, including school phobia. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as Obsessive-Compulsive Disorder. Familial conditions are more common in bioFamilial logical relatives, and may have pre-existed the cause of action. In the case of Pattern Specific Phobia, fears of blood and injury have a particularly strong familial pattern. The plaintiff suffers from an immediate anxiety response in the form of a situationally bound or situationally predisposed panic attack. The plaintiff may try to avoid the situation or if not possible, he/she may endure it with intense anxiety or distress as described above. In many cases, the anxiety and avoidance behaviors would have pre-existed the cause of action. Questions If the witness indicates the possibility of other life stressors or other conditions, see (continued) the section on life stressors for further questions. It often produces personality changes, confusion, dizziness, tremor, anxiety, tachycardia, and sweating during acute attacks. A panic disorder is characterized by discrete periods of panic or intense anxiety. Between attacks, the plaintiff is anxious, worried, and fears having another attack. Panic symptoms include dizziness, shortness of breath, heart palpitations, smothering or choking sensations, feelings of unreality, tingling in hands or feet, hot and cold flashes, sweating, faintness, trembling or shaking, and the fear of dying or going crazy. The plaintiff typically avoids crowds, being outside alone, General standing in line, crossing a bridge, or riding in a vehicle. Agoraphobia is the fear and avoidance of places and situations in which the plaintiff would be unable to escape or get help if s/he had embarrassing symptoms. Symptoms of a limited agoraphobic attack may include dizziness or falling, depersonalization or derealization, loss of bladder or bowel control, vomiting, and cardiac distress. The avoidant plaintiff is characterized by social inhibition or discomfort, fear of negative evaluation, and timidity, along with a great desire for companionship and guarantees of uncritical acceptance. These plaintiffs rarely seek help because of a tendency to be moralistic, grandiose, and extrapunitive. The plaintiff with social phobia or social anxiety disorder, fears situations in which s/he may be scrutinized by others or in which s/he may do something humiliating or embarrassing. The plaintiff avoids or endures with intense anxiety situations such as public speaking, eating or writing in front of others, using public toilets, or answering questions in social situations. Questions the schizoid plaintiff is introverted, withdrawn, and prefers to be alone. S/he (continued) tends to be indifferent to social relationships and has few close friends outside the family.

Expected survival refers to the proportion of people in the general population alive for a given amount of time and is calculated from life tables of the entire Australian population arthritis gout relief cheap voltaren amex, assumed to be cancer free arthritis pain top of foot purchase voltaren 100 mg free shipping. A simplifed example of how relative survival is interpreted is shown in Figure F1 arthritis in dogs discount 50mg voltaren. Given that 6 in 10 people with cancer are alive 5 years after their diagnosis (observed survival of 0 arthritis diet causes buy 100mg voltaren with amex. This means that individuals with cancer are 67% as likely to be alive for at least 5 years after their diagnosis as are their counterparts in the general population arthritis in outer knee buy discount voltaren on line. Expected survival was calculated fromFigure F1: Simplified example of how relative survival is calculated Figure F1: Simplified example of how relative survival is calculated the life tables of the entire Australian population rheumatoid arthritis infusion discount voltaren 50mg without a prescription, as well as the Australian population stratifed by remoteness area and socioeconomic area arthritis feet treatment uk buy voltaren with mastercard. Expected survival was calculated from the life tables of the entire Australian population arthritis in feet pain buy 100 mg voltaren with mastercard, as well as the Australian populationfrom the life tables of the entire Australian population, as well as the Australian populationfrom the life tables of the entire Australian population, as well as the Australian population from the life tables of the entire Australian population, as well as the Australian population stratified by remoteness area and socioeconomic area. It is the default approach, wherebyapproach, wherebyapproach, wherebymatched people in the general population are considered to be at riskmatched people in the general population are considered to be at riskmatched people in the general population are considered to be at risk approach, wherebyThe period method was used to calculate the survival estimates in this report (Brenner & Gefellermatched people in the general population are considered to be at risk until the corresponding cancer patient diesuntil the corresponding cancer patient diesuntil the corresponding cancer patient diesor isor is censored (Ederercensored (Edereror is censored (Ederer& Heise& Heise 1959). The period1996), in which estimates are based on the survival experience during a given at-risk or follow-upmethod was used to calculate the survival estimates in this report (Brenner & the periodThemethod wasperiod method wasused to calculate the survival estimatesused to calculate the survival estimatesin this reportin this(Brennerreport (Brenner& & the periodperiod. Time at risk is left truncated at the start of the period and right censored at the end so thatmethod was used to calculate the survival estimates in this report (Brenner & Gefeller 1996), in which estimates are based on the survival experience during a given at-Gefeller 1996), in which estimates are based on the survival experience during a given at-Gefeller 1996), in which estimates are based on the survival experience during a given atGefeller 1996), in which estimates are based on the survival experience during a given atrisk or follow-up period. Time at riskanyone who is diagnosed before this period and whose survival experience overlaps with this periodrisk or follow-up period. Time at riskisis left truncated at the start of the period and rightleft truncated at the start of the period and rightis left truncated at the start of the period and right risk or follow-up period. Time at risk is left truncated at the start of the period and right censored at the end so that anyone who is diagnosed beforecensored at the end so that anyone who is diagnosed beforecensored at the end so that anyone who is diagnosed beforethis period and whose survivalthis period and whose survivalthis period and whose survival censored at the end so that anyone who is diagnosed beforewould be included in the analysis. Calculation of conditional relative survivalCalculation of conditional relative survivalCalculation of conditional relative survivalCalculation of conditional relative survival Calculation of conditional relative survival Conditional survival isConditional survival isConditional survival is the probability of survivingConditional survival isthe probability of survivingthe probability of survivingthe probability of survivingjj moremorej days, given that an individual hasdays, given that an individual hasmorej moredays, given that an individual has alreadydays, given that an individual has Conditional survival is the probability of surviving j more days, given that an individual has already survivedalready survivedalready survivedii days. It was calculated using the formula: ((+)+) (+) == (+)= = wherewhere where wherewhere indicates the probability of surviving at leastindicates the probability of surviving at leastindicates the probability of surviving at leastjj more days given survival of atmore days given survival of atj more days given survival of at indicates the probability of surviving at leastindicates the probability of surviving at leastj more days given survival of atj more days given survival of at least i days leastleast ii daysdaysleast i days least i days ++ indicates the probability of surviving at leastindicates the probability of surviving at leastindicates the probability of surviving at leastii++i+jj daysdaysj days + indicates the probability of surviving at least i+j days + indicates the probability of surviving at least i+j days indicates the probability of surviving at leastindicates the probability of surviving at least indicates the probability of surviving at leastindicates the probability of surviving at leastii days. The 95% confidence intervals were constructed assuming that conditional survival estimates the 95% confdence intervals were constructed assuming that conditional survival estimates follow afollow a normal distribution. Prevalence Prevalence Limited-duration prevalence is expressed as N-year prevalence throughout this report. For example: of people alive at the end of that day who had been diagnosed with cancer in the past N years. An individual who was diagnosed with 2 separate cancers will contribute separately to the prevalence of each cancer. However, this individual will Note that prevalence is measured by the number of people diagnosed with cancer, not the number contribute only once to prevalence of all cancers combined. An individual who was diagnosed with 2 separate cancers will contribute separatelyprevalence for individual cancers will not equal the prevalence of all cancers combined. However, this individual will contribute only once to prevalence of Prevalence can be expressed as a proportion of the total population at the index date. For this reason, the sum of prevalence for individual cancers will not equal thereport, the prevalence proportion is expressed per 10,000 population due to the relative size prevalence of all cancers combined. Prevalence can be expressed as a proportion of the total population at the index date. In thisDifferences in limited-duration prevalence are presented according to age in the report. Note that while age for survival and incidence statistics refers to the age at diagnosis, prevalence report, the prevalence proportion is expressed per 10,000 population due to the relative size of the age refers to the age at the point in time from which prevalence was calculated, or numerator and denominator. Therefore, a person diagnosed with cancer in 1982 who turned 50 that year would be counted as age 80 in the prevalence statistics (as at the end of Diferences in limited-duration prevalence are presented according to age in the report. Therefore, a person diagnosed with cancer in 1982 who turned 50 that year would be counted as age 80 in the prevalence statistics (as at the end of 2012). It is a number between 0 and 1 although it can exceed 1 in certain the same comparability and interpretation problems associated with them when trying to make international comparisons. Step 2: Calculate the proportion of records that occur at each stage of diagnosis: Stage I (6,110 fi 13,427) = 0. On occasion, data sources may be subject to processes intended to improve the reliability of statistical information. Appendix G notes the enhancements and impacts upon the data in the Cancer in Australia series. Item 1 Aboriginal and Torres Strait Islander population projections At the time of writing this report, Aboriginal and Torres Strait Islander population projections and estimates were available only where derived from the Aboriginal and Torres Strait Islander population estimate at 30 June 2011. The Aboriginal and Torres Strait Islander population at 30 June 2016 is 19% larger than the 2011 estimate. Rather than publish age-standardised rates based on 2011 population projections which are likely to substantially overstate Indigenous incidence and mortality rates when compared with the anticipated rates using population projections derived from 2016 data, only counts are provided. Age-standardised rates of cancer for Indigenous Australians will be published in the future after Aboriginal and Torres Strait Islander population projections derived from 2016 data are available. Relative survival statistics were not included because the available life tables are based on Aboriginal and Torres Strait Islander population data which, as discussed above, are outdated. The average annual count of Indigenous Australians diagnosed with cancer in the 2017 edition of this publication was 1,189 (between 2008 and 2012). The revised number of Indigenous Australians diagnosed with cancer for the same period and based on more complete Indigenous data is 1,549. This is diferent to previous versions of this report and will result in a greater number of deaths being attributed to colorectal cancer. The Remoteness Structure, which divides each state and territory into several regions on the basis of their relative access to services, has 6 classes of remoteness: Major cities, Inner regional, Outer regional, Remote, Very remote and Migratory. This information is used as a proxy for the socioeconomic disadvantage of people living in those areas and may not be correct for each person in that area. The use of a standard classifcation system enables the storage and retrieval of diagnostic information for clinical and epidemiological purposes that is comparable between diferent service providers, across countries and over time. Administrative databases include the Australian Cancer Database, the National Mortality Database and the National Hospital Morbidity Database. Cancer in Australia 2019 143 colonoscopy: A procedure to examine the bowel using a special scope, usually carried out in a hospital or day clinic. Expected survival estimates are crude estimates calculated from life tables of the general population by age, sex and calendar year. Indigenous: A person of Aboriginal and/or Torres Strait Islander descent who identifes as an Aboriginal and/or Torres Strait Islander. Non-Indigenous: People who have declared that they are not of Aboriginal or Torres Strait Islander descent. A patient who is admitted and separated on the same day is allocated 1 patient day. These estimates allow comparisons to be made between geographical areas of difering population sizes and age structures. Cancer in Australia 2019 145 rare cancer: A cancer with an age-standardised incidence rate of less than 6 per 100,000 persons. Some risk factors are regarded as causes of disease, others are not necessarily so. The authors would like to thank all colleagues who commented on earlier drafts, including members of the Cancer Monitoring Advisory Group who provided expert advice and assistance in producing this document. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2011. Analysis of bowel cancer outcomes for the National Bowel Cancer Screening Program 2018. Non-melanoma skin cancer: general practice consultations, hospitalisation and mortality. Estimating the demand for radiotherapy from the evidence: a review of changes from 2003 to 2012. Palliative Care Outcomes Collaboration, Australian Health Services Research Institute. Randomized controlled clinical efectiveness trial of cognitive behavior therapy compared with treatment as usual for persistent insomnia in patients with cancer. Managing menopausal symptoms in breast cancer survivors: Results of a randomized controlled trial. Efects of cognitive behavior therapy in severely fatigued disease-free cancer patients compared with patients waiting for cognitive behavior therapy: A randomized controlled trial. Efect of telecare management on pain and depression in patients with cancer: A randomized trial. Increasing time trends of thin melanomas in the Netherlands: what are the explanations of recent accelerationsfi Returning to work after treatment for haematological cancer: fndings from Australia. National Breast and Ovarian Cancer Centre and Royal Australasian College of Surgeons national breast cancer audit. Cancer in Australia 2019 153 Prostate Cancer Foundation of Australia and Cancer Council Australia 2016. Food, nutrition, physical activity, and the prevention of cancer: a global perspective. International Statistical Classifcation of Disease and Related Health Problems, 10th Revision. Breast cancer in young women: key facts about breast cancer in women in their 20s and 30s. From 1982 to 2019, thyroid cancer and liver cancer incidence rates increased more than for any other cancer. Recent trends show increasing incidence probably due to better diagnostic techniques. Although biliary cancer can occur anywhere in the biliary tract, 40-60% of them involve the hilum. The peak age for bile duct cancer is in the seventh decade and more males are affected than females. However, a high incidence is noted in patients with congenital biliary cystic disease (15-20%). A diagnosis of such a condition should warrant surgical treatment, so as to prevent the development of biliary malignancy in future. Stringent measures of radiation protection is to be offered to the workers in the nuclear energy sector, since radioisotopes used commercially like Thorium, Radon etc are thought to be associated with the development of cholangiocarcinoma. Diagnostic criteria Abdominal ultrasound examination which reveals dilated intrahepatic biliary radicles with a collapsed gall bladder and extrahepatic bile duct must be suspected to be a case of hilar obstruction unless proven otherwise. Diagnosis is based on radiological criteria and pathological confirmation is not mandatory prior to surgery in resectable lesions. In Resectable hilar cholangiocarcinoma standard curative surgery entails hemihepatectomy with caudate lobectomy and extrahepatic bile duct excision with regional lymphadenectomy. Preoperative Biliary drainage may salvage segments of hepatic parenchyma and reduce risk of postoperative liver failure. Portal vein embolization to increase the remnant liver volume in patients with postresection volumes are less than 25%. Role of adjuvant therapy after resection remains controversial; however chemotherapy or chemo radiation may be tried 4 Unresectable tumors require endoscopic or percutaneous biliary drainage or stenting. Palliative Gemcitabine based chemotherapy may be considered along with supportive care. Liver transplantation is indicated at selected centres, for patients with early stage cholangiocarcinoma and anatomically unresectable lesions, but this approach should not be offered outside the scope of clinical trials. This condition is not however suitable for treatment at a secondary hospital, and must be referred to a tertiary care center. Day Care d) Referral criteria: Biliary obstruction with undilated gall bladder or extrahepatic bile ducts must be regarded as hilar obstruction unless proven otherwise. These patients must be referred for evaluation and management to a tertiary care center. Extended resections with portal vein resection and reconstruction where portal vein in involved. Biliary drainage and supportive care with or without chemoradiotherapy for unresectable and metastatic disease. Day Care d) Referral criteria: Patients considered candidates for liver transplantation may be referred to transplant units. Surgical management of proximal bile duct cancer: extended right lobe resection increases resectability and radicality. Chemotherapy improves survival and quality of life in advanced pancreatic and biliary cancer. Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study. Palliation of nonresectable bile duct cancer: improved survival after photodynamic therapy. Purpose, use, and preparation of clinical practice guidelines for the management of biliary tract and ampullary carcinomas. Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up. Results of surgical resection for patients with hilar bile duct cancer: application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization. Parenchyma-preserving hepatectomy in the surgical treatment of hilar cholangiocarcinoma. Aggressive preoperative management and extended surgery for hilar cholangiocarcinoma: Nagoya experience. In recent years, breast cancer has emerged as the commonest female malignancy in the majority of Asian countries. In India, breast cancer incidence has overtaken cervical cancer incidence in most urban registries. Case definition: For both situations of care (mentioned below*) Histopathologically or cytopathological diagnosis of invasive or non invasive cancer of tissue obtained from breast. Family history of breast and ovarian cancers A lactational period of 6 months or more is associated with decreased risk of breast cancer. Similarly, having the first live birth after age 30 doubles the risk compared to having first live birth at age less than 25 years. Obesity is the other potentially modifiable risk factor that requires 11 multidimensional preventive attention with major health benefits that extend beyond cancer prevention. Societal and public health intervention in these areas has the potential to abrogate much of the increase in breast cancer incidence that has been observed in the West. There is little representation from developing countries, if any, in the expert panels that formulate these guidelines. Clinical practice in developing countries, however, continues to be largely guided by these guidelines since they are based on high quality evidence with expert appraisal. Many of these guidelines are not literally applicable to developing countries because of constraints on resources and/or expertise. Clinical Diagnosis: Pathology guidelines: fi Histopathological diagnosis of breast cancer by a biopsy (prior to neaoadjuvant chemotherapy, if planned) or on the surgical specimen is a must. In the latter situation 12 in operable breast cancer, pre-operative establishment of diagnosis by fine needle aspiration is appropriate and acceptable. Investigations: Radiology guidelines All centres treating breast cancer should have facilities for plain chest radiograph and ultrasound scanning of the abdomen. However, such centres need not necessarily have facilities for breast imaging including mammography, breast sonography and other advanced imaging techniques. The long-term safety and quality of life gains with breast conserving surgery have been proven in high quality studies and this procedure should be offered to patients who are eligible to receive it. Thus eligible and desirous patients should be referred to an appropriate higher centre for breast conservation.

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This organization of the mode shares the same characteristics of individual schemas such as activation threshold and permeability arthritis pain relief cream order voltaren 50mg with amex, which are especially relevant when we consider psychological disorders arthritis medication in australia purchase voltaren 100 mg with visa. Self-Expansive Mode the major sector of personality concerned with the enhancement of personal resources is labeled the self-expansive mode arthritis in old dogs symptoms discount voltaren on line. The self-expansive mode is associated with a desire to increase the value an individual attaches to himself or herself arthritis relief juice 50 mg voltaren. Positive self-expansion is associated with pleasure and increased self-esteem arthritis diet help purchase voltaren no prescription, whereas negative self-expansion is associated with pain and decreased self-esteem arthritis knee lump discount voltaren 50mg mastercard. This self-expansive mode generally facilitates adaptation such as goal attainment; however arthritis in the knee medication voltaren 50mg without a prescription, in response to aversive circumstances arthritis pain meaning discount voltaren 50mg on-line, it is also involved in the conservation of resources. Like other modes, the self-expansive mode constitutes a major organization within the personality, integrated under a specific goal or objective. It is composed of a variety of schemas containing simple or complex beliefs oriented to reactions to events. The infrastructure of a goal in the self-expansive mode is composed of expectancies regarding the subjective value and outcomes of goal attainment. The clusters of beliefs that represent obligations follow an imperative form: You must, or you should. Given the anticipated outcome of this decision, she attaches a high value to this choice. Obligations in the self-expansive mode consist of rules of conduct that serve to reinforce goal attainment by safeguarding momentum when satisfaction diminishes. Dysphoria following a setbackprovidesawarningforindividualstoexaminetheirexpansiveexpectationsandtodetermine the need for a change in strategy. Self-esteem serves as the catalyst for leveraging expectations, such that elevated self-esteem increases expectations. Assume that, in fact, the young woman is granted admission to a prestigious law school. The algorithm related to achievement has been activated, such that her personal self-image and perceived social self-image are enhanced. She becomes less euphoric and begins to focus on the possibility that she may not live up to her expectations and meet the rigors of law school. Consider that in keeping with the experiences of many other students, the young woman does not perform well during her first year. The evaluation (or devaluation) of the self-image is drawn from the conditional beliefs. Whereas success activates the positive outcome belief, the converse is true for a negative outcome. As negative beliefs (schemas) about self become energized, the young woman becomes pessimistic about the likelihood that she will reach her goal. This shift in self-esteem refiects a shift to more negative beliefs, which tend to bias her interpretations of events. Taken to an extreme, her distorted cognitions could represent a reactive depression. The degree of depression may be related to the discrepancy between her original expectations and her current evaluation of her performance. Bipolar and Endogenous Depression A serious challenge to a psychological theory of clinical disorders is the ability to deconstruct endogenous disorders such as bipolar disorder and nonreactive depression. Furthermore, unlike reactive depression, for example, these endogenous conditions do not seem to respond well to attempts by other people to advocate selfSelf-protective mode: a network control in the case of mania or reasoning to counter extreme negative ideation in the case of concerned with the depression. In the case of endogenous depression, the normal response of failure leads to a constriction of investments and self-devaluation. Endogenous depression and bipolar disorder became disassociated from the personality (self-expansive mode) to become displaced autonomous entities impermeable to environmental factors. Self-Protective Mode A second major mode or sector of personality, the self-protective mode, forms the substrate for the anxiety disorders and paranoia. This mode is typically concerned with the early detection of a dangerous situation. The traditional fight-or-fiight model is represented in the responses to the usual threats of everyday life. The self-protective mode specifies the characteristics of a particular dangerous situation and dictates appropriate rules to reduce the threat. Because survival depends on accurately identifying dangerous stimuli, it is better to have false positives than false negatives. Hence there is an overinclusive bias, which produces errors but is beneficial in the long run. The estimate of threat in a potentially dangerous situation is dependent on the evaluation of risk relative to individual resources (Beck et al. Internal resources include personal assets such as coping strategies and available help from other individuals. External resources include other reassuring individuals as well as professional helpers. Framed in term of risk, the intensity of the anxiety reaction is dependent upon the subjective probability and severity of harm. Various safety-seeking strategies are adaptive and operate to protect the individual from physical or psychological harm. This bias leads to safety-seeking behavior, which may maintain the problem and transition into a clinical disorder. Thus, a natural concern about being the center of attention may develop into a fear of being in a public place, public speaking anxiety, or in the extreme, paranoia. One of the more unpleasant clinical disorders, generalized anxiety disorder, tends to persist because the underlying fear is continuously activated. In the case of social anxiety disorder, an individual with a belief that he or she is socially inept may worry about being demeaned in all social interactions and might be concerned about rejection from a partner. As previously discussed, the coping strategies used by people to avoid or reduce anxiety tend to perpetuate the disorder. For example, checking to be sure that the oven or water is turned off, trying to block out obsessions, and fieeing the room because of fear of losing control are effective in the short term; however, in the long term these behaviors tend to reinforce the anxiety disorder. Schemas, which are central to information processing, refiect various beliefs, expectancies, evaluations, and attributions, and serve to order everyday experience. Information processing depends upon two interacting subsystems, the automatic system and the refiective system. Stimulus events are initially processed by protoschemas, which provide an initial evaluation of stimuli through the automatic system. The refiective system, aided by attentional processes, refines or corrects the meaning or the product of the protoschemas. Schemas have a number of characteristics with direct implications for the transformation of adaptive to maladaptive functioning. Adaptively modified schemas deactivate dysfunctional schemas, which leads to a reduction in symptoms. The theory of mode is invoked to account for more complex aspects of individual functioning, such as goal attainment. Modes refiect integrated networks of cognitive, affective, motivational, and behavioral systems that form subsectors of personality. The self-expansive and self-protective modes account for proactive goal setting and the self-protective aspects of personality. Aberrations of the self-expansive mode account for symptoms of mania and endogenous depression, and aberrations of the self-protective mode account for symptoms of anxiety and paranoia. Although a complete review of the cognitive specificity literature is beyond the scope of this article, we provide several examples. Individuals with depression predictably make overgeneralizations about their experiences, such as interpreting a small mistake at work as evidence that they are incompetent in all areas of their life. Dysfunctional beliefs, particularly those related to perfectionism, autonomy, and self-criticism, are also associated with bipolar disorder (Alloy et al. Beliefs associated with anxiety are generally characterized by threat, danger, and/or vulnerability. Beyond the clear evidence for the relationship between dysfunctional beliefs and clinical disorders, an impressive body of research has provided direct empirical support for the core premise of cognitive therapy, which holds that changes in beliefs lead to changes in behaviors and emotions. Support for cognitive mediation in treatment studies has been found for a number of disorders, including major depressive disorder (Quilty et al. The applied model proposes that psychopathology is initiated and maintained when the schema-activated components. The triggering stimuli may refiect a broad spectrum of possible events, ranging from discrete external events, such as being rejected or abandoned, failing an exam, or being fired, to specific Situation Focus Behavior Belief Figure 2 the generic cognitive model emphasizes common putative cognitive and behavioral processes across psychopathology. The common underlying psychopathology is represented by the interplay among environmental events, behavior, focus, and beliefs, and the unique features of mental disorders derive from the belief content. Internal events such as memories, thoughts, ruminations, or somatic sensations such as chest pain or sweating may also function as activating stimuli. The triggering stimuli activate latent schemas, which determine the content of current cognitive processing. Once activated, maladaptive schemas preempt normal information processing and bias the beliefs associated with the stimulus event. Biased information processing produces additional cognitive impairments in interpretation and processing. For example, in the case of an individual with social anxiety disorder,theindividualmay,inresponsetowalkingintoacrowdedcafeteria(externalstimuli),activate the schema. Leaving the cafeteria would be a successful short-term strategy and would be negatively reinforced by the likelihood that the individual would experience immediate relief. Table 1 depicts typical stimulus events and examples of corresponding beliefs and maladaptive behaviors commonly associated with a variety of disorders. Interventions the goal of the applied model is to provide clinicians with a tool of broad clinical utility. The applied model will allow clinicians to develop rapid case conceptualizations for a variety of clinical presentations. Furthermore, clinicians can apply the model to yield specific theory-driven interventions for treatment. Each component of the model represents a point for therapeutic intervention; however, many of the interventions overlap and will likely infiuence the remaining components. An individual seeking treatment may present with complaints related to one component of the model. We propose that addressing one component will lead to symptom reduction; however, the most elegant and durable therapeutic approach is one that addresses each of the components. The interventions related to the belief component derive from the theoretical model describing the role of biased beliefs and goal setting. At the outset, the aim of therapy is to identify and set achievable goals, which serve to further motivate the individual during treatment. Interventions that target biased reasoning processes are designed to evaluate beliefs and assumptions held by individuals. Individuals may present with excessive fear of embarrassment or humiliation, as is the case with social anxiety disorder, or a belief that the only way to avoid being victimized is to maintain an aggressive stance, as is sometimes the case with posttraumatic stress The model serves as a template to conceptualize typical activating stimuli and associated beliefs and behaviors. In either case, cognitive restructuring is used to identify and evaluate erroneous beliefs and interpretations (Beck 1995, Wright et al. The clinician can rely on several strategies, such as psychoeducation, to help individuals learn to identify their underlying beliefs and associated thinking patterns as well distinguish between thoughts, feelings, and behaviors. For individuals who have difficulty identifying their thoughts, imagery can be a helpful tool to recognize thoughts, such as negative expectations associated with a certain situation. Once individuals are able to discriminate between thoughts, feelings, and behaviors, they may be encouraged to focus on facts rather than feelings in order to avoid potential pitfalls of emotional reasoning. Numerous strategies to facilitate cognitive restructuring have been developed to help individuals consider alternative explanations and examine the evidence for their beliefs (Beck 1995, Wright et al. Once an individual has adopted an accurate thought, he or she may be encouraged to write the modified thought on a card. Behavioral tests rely on engaging in explicit learning experiences in order to examine and modify beliefs (Dobson & Hamilton 2004). Exercises are designed to provide individuals with the opportunity to uncouple their negative thoughts about a particular stimulus. Alternatively, individuals can be encouraged to develop and activate positive adaptive thoughts for dealing with daily life events. In many cases, clinicians may find it appropriate to help individuals identify and eliminate the use of safety behaviors. In certain instances, individuals who approach a feared situation will attribute their ability to navigate the situation to the safety behavior (Wells et al. Clinicians can suggest behavioral experiments that explicitly require individuals to refrain from using their safety behavior. Through guided discovery, individuals can learn that the use of a particular safety behavior was unrelated to the nonoccurrence of a feared outcome. Various cognitive interventions target the role of biased attention and memory in clinical disorders (Teasdale et al. To this end, several strategiescanbeused;forexample,carefulreviewofcompletedthoughtrecordsmayindicatebiases in attention and associated cognitive distortions. With this information in hand, the clinician can help the individual modify his or her focus and the attached meaning by increasing the range of stimuli the individual pays attention to or by practicing the act of disengaging from stimuli. Over time these interventions can help the individual modify his or her focus and the meanings attached to certain stimuli. Many individuals present for therapy when they notice that the behaviors they rely upon to cope with emotional distress have begun to impinge on their functioning. For many psychological disorders, the goal is to encourage adaptive behaviors and/or reduce maladaptive behaviors. Behavioral methods are generally used in concert with cognitive restructuring to foster durable treatment change (Wright et al. With a completed activity log, clinicians can use guided discovery to help individuals understand the relationship between thoughts, mood, and behavior. For example, depressed individuals often report being withdrawn and engaged in a very narrowed set of activities. These individuals will likely respond to increased engagement in a greater number of pleasurable and/or meaningful activities. Other behavioral interventions include engaging in imagery, relaxation, distraction, or adopting a competing behavior to counteract behaviors such as excessive skin picking. Graded task assignments may be indicated for individuals struggling to complete complex tasks by helping them break down the task into smaller, more manageable parts (Beck 1995). In addition, individuals often benefit from behavioral rehearsal or role-playing certain interactions in order to increase their sense of preparedness and self-efficacy. Case Study A 19-year-old college junior, Louis, awoke out of a deep sleep by the sound of loud knocking on his apartment door. With a growing sense of dread, Louis got out of bed, opened the door, and was met by two men in suits who were displaying badges. Louis soon learned that his girlfriend had committed suicide by jumping in front of a train. During the intake session, the clinician worked with Louis to gather information about his clinical condition and any significant aspects of his life history in order to shed light on possible predisposing and precipitating events.