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Associate Professor, University of Utah School of Medicine

Overcoming Building an appropriate system of financial intermediation that is accessible Barriers to poor people and yet sustainable for the lending institution can be a challenge muscle relaxant hamstring buy on line ponstel. Overcoming the vulnerability imposed by continual reliance on subsidies (finance as charity) by establishing a market-based system (finance as business) that can operate on its own is not easy spasms 1983 imdb discount 250mg ponstel free shipping. In most cases muscle relaxant hiccups buy cheap ponstel on-line, it is not something that can be fully achieved within the time frame of one or sometimes even a series of Bank lending operations spasms and spasticity cheap 250 mg ponstel amex. In some borTowingcountries where barr-iersare created by remoteness, poor infrastructure, a stagnant or primarily subsistence economy, illiteracy, or social factors such as caste and gender. Need What is needed to build and support sustainable financial systems with the for Intermediation poor is a combinationiof financial and social intennediation. Mechanisms must be created to bridge the gaps created by poverty, illiteracy, gender, and remoteness. Local institutiolnsmust be built ancl nurtured, and skills and confidence of new low-income clients developed. I Group-Based Approaches One of the most promising routes to sustainable financial intermecliation is the use of local self-help groups. Although many local variations exist, the approach essentially involves identification and organization of local voluntary associationis or self-help groups amonlg disadvantaged populations. These groups are then liniked1 with for-miial financial institutions or assisted in developing their own parallel. Grameen was established as a financial institution in 1983 to provide financial services to low-income niral households that had no access to formal sector programs. Grameen supports the formation of self-selecting-"solidarity" groups of five people. Members receive small working capital loans backed only by the joint liability of other members. This means that even though the loans are given individually, default by any member blocks access to further credit for others in the group until they either prevail on the defaulter to pay or cover the debt themselves out of joint savings or a pooled contribution. Members are also requi-ed to contribute to group savings and emergency funds on a regular basis. Many borrowers use the loans for petty trade, traditional agricultural processing. Reflecting its responsiveness to the vulnerability of its members to seasonal and other shocks, Grameen also lends for "consum1ption" purposes. The villagers rejected the solidarity group approach (based on Grameen Bank) and chose to create a village credit ftund in which the whole village is collectively responsible ftor repaymiient individual loans. Each community elects a three-person village of credit commillttee, which is responsible for selecting boriowers and ensuring that loans are repaid. Decisionmaking rests entirely at the local level and the village credit comnmittee holds open meetings to evaluate community member loani applications. Expansioni has been rapid with fifty-nine such commliittees established, more than 2. Advantages of Group-Based Services Group-based approaches have several advantages to the finanicial intermediary: group liability is an effective collateral substitute. Group-based finailcial systems can in many situationis effectively shift some of the costs and risks h1 from the lending institution to the group. The savings mobilizecd by groups are often re-lent to their memitber-sfor emergenicies. Advantages For women, one of the most important aspects of a group is that it provides a for Women legitimate "social space" beyond the home and fosters a sense of solidarity that allows them to deal more freely with unfamiliar formal institutions and processes. One reason may be that in many societies women have few other financial opportunities and value them highly. Group membership may also have a personal and social value beyond its economic utility. Characteristics Characteristics of strong groups include self-selection of members, literacy of at least a few gr-oup members, and membership of only one genlder. Elements of groups that, contrary to general belief, do not appear to affect group performance include group size, leadership rotation, and the kincd frequency of group meetings. They may be costly to set up: con-uption or control by powerful groups is a possibility: and minority groups or the most disadvantaged are often excluded. Nevertheless, the resiliency and popua -ff5 larity of many locally based, financial service organizations indicates that locally managed groups can improve their financial management practices and move toward sustainability through selft-helpefforts.

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Excess fluid intake can lead to polyuria muscle relaxant medication over the counter generic ponstel 250 mg with visa, but primary polydipsia rarely results in changes in plasma osmolality unless urinary diluting capacity is impaired muscle relaxant 2 purchase ponstel online from canada. More sensitive assays can in turn be used to detect microalbuminuria back spasms 37 weeks pregnant cheap ponstel 500mg line, an important screening tool for diabetic nephropathy muscle relaxant side effects order ponstel 500mg fast delivery. A urine albumin to creatinine ratio >30 mg/g defines the presence of microalbuminuria. The ratio of protein to creatinine in a random, "spot" urine can also provide a rough estimate of protein excretion; for example, a protein/creatinine ratio of 3. Protein excretion rates >3 g/d are termed nephrotic range proteinuria in that they may be accompanied by hypoalbuminemia, hypercholesterolemia, and edema (the nephrotic syndrome). Nephrotic syndrome can be associated with a variety of extrarenal complications (Chap. Specific therapy for a variety of causes of nephrotic syndrome is discussed in Chap. Hematuria Gross hematuria refers to the presence of frank blood in the urine and is more characteristic of lower urinary tract disease and/or bleeding diatheses than intrinsic renal disease (Table 52-3). Pyuria may also occur with allergic interstitial nephritis (often with a preponderance of eosinophils), transplant rejection, and noninfectious, nonallergic tubulointerstitial diseases, including atheroembolic renal disease. Pain in the joints must be evaluated in a uniform, thorough, and logical fashion to ensure the best chance of accurate diagnosis and to plan appropriate follow-up testing and therapy. Joint pain and swelling may be manifestations of disorders affecting primarily the musculoskeletal system or may reflect systemic disease. Is the pain located in a joint or in a periarticular structure such as soft tissue or muscle? Nonarticular condition Consider · Trauma/fracture · Fibromyalgia · Polymyalgia rheumatica · Bursitis · Tendinitis No Is it articular? No Yes Acute Chronic Consider · Acute arthritis · Infectious arthritis · Gout · Pseudogout · Reactive arthritis · Initial presentation of chronic arthritis Is inflammation present? No Yes Chronic noninflammatory arthritis Chronic inflammatory arthritis 1­ 3 How many joints involved? Yes Consider other inflammatory or septic arthritides · Gram stain, culture mandatory No Are crystals present? Diseases of upper lumbar spine refer pain to upper lumbar region, groin, or anterior thighs. Diseases of lower lumbar spine refer pain to buttocks, posterior thighs, or rarely the calves or feet. Pain from hip may be confused with spine pain; manual internal/external rotation of leg at hip (knee and hip in flexion) reproduces the hip pain. Neurologic exam-search for focal atrophy, weakness, reflex loss, diminished sensation in a dermatomal distribution. Stenosis results from acquired (75%), congenital, or mixed acquired/congenital factors. Most pts treated surgically experience relief of back and leg pain; 25% develop recurrent stenosis within 7­10 years. Vertebral fractures from trauma result in anterior wedging or compression of vertebral bodies; burst fractures involving vertebral body and posterior spine elements can occur. Most common cause of nontraumatic fracture is osteoporosis; others are osteomalacia, hyperparathyroidism, hyperthyroidism, multiple myeloma, or metastatic carcinoma. Osteoarthritis (Spondylosis) Back pain induced by spine movement and associated with stiffness. Osteophytes or combined disc-osteophytes may cause or contribute to central spinal canal stenosis, lateral recess stenosis, or neural foraminal narrowing. Vertebral Metastases Back pain most common neurologic symptom in pts with systemic cancer and may be presenting complaint; pain typically not relieved by rest. Lumbar spinal epidural abscess presents as back pain and fever; exam may be normal or show radicular findings, spinal cord involvement, or cauda equina syndrome. Osteoporosis Loss of bone substance resulting from hyperparathyroidism, chronic glucocorticoid use, immobilization, other medical disorders, or increasing age (particularly in females).

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When asked to look at the same issue in a differenit wvay spasms hiatal hernia cheap ponstel 500mg with amex, some womnen foulld that they valued one item mor-e than another and as a group began to articulate and understanidthe reasons why spasms chest generic ponstel 250 mg free shipping. These group interactions helped them to understand how constraints on women affect the family and village as a whole muscle relaxant mechanism 500 mg ponstel for sale. Having said this spasms feel like baby kicking cheap 500mg ponstel amex, we noted that organizing women into focusgroups for discussion and decisionmaking had empowering effects on them; in at least one instance, it gave them confidence to take the initiative to improve their circumstances. As was customary at such meetings, the men were seated at the fi-onit the room and the women gathered at the of rear. She then put forth her own suggestion for a collective oven, which she argued would benefit many more of the families in the village. She received support in this from many of the other village women, who then also felt encouraged to speak. These women had gained strength from having done their own analysis and examining the pros and cons of various options. The consensus they had built around these priorities during group discussions and focus groups gave them the power to speak and the knowledge to defend their choices. My guess is that it will be quite a revelation for many to see that village women not only have the ability to identify constraints and invent solutions but that they can be quite good at quantitative analysis as well. The locally (lerived strategies that will be presented to Moroccan policymakers will constitute a fresh source of information. Not only will this input influence sector recommendations, but it will be available to help guide the future work of the participating ministries. This meanisthat allyolne Llider the age of T 9~0-albout ha11 pOpU]ationl-doesniot the kn0ow whiatit mleajis to live in peace. Telephonieservice was erratic, and electricity andiwater were only occasionally available. More thani anythingt else, however, the difficulties and frustrations I faced revolved arounidgetting things cloneat work. I did not realize just how difficult it was in Mozambiqueuntil I actually lived there. Previously, I had comie as a member of a Baiik mlission,well looked after by Mozambique officials. Living and working in Maputo allowed me to understand in a differelt way why the Mozambique portfolio had so many implementation problems. A generation of war simply does not produce the kind of policy and administrative environment needed to implemenit. Although the war was a handy scapegoat on which to blame problems, I also realizecdit was more than just the war that was causing the problems. Clearly, too little communication took place among the various parts of the government, a situation that was not really a consequence of the war. In doing so, we thought it might be possible to develop a network of support for implementing Bank-financed projects. The fact that these people often come from government service weakens that service and demotivates those left behind. No two donors follow the same procedures, thereby immensely complicating administrative actions in government. Then, in January 1991, I returned to Washington to attend the Mozambique Country Team retreat. We also sought to claritfythe roles, functions, and decisionmaking powers of the country team compared with the divisional team. The seminar was facilitated in a way that had some Mozambique Country Team members playing the roles of various government officials while others played normal Bank roles. We would use a workshop format in which all participants-government and Bank-would work together intensively on the problems hindering project implementation. Fortunately, this facilitator had become interested in w hat we were doing and reshuffled his workload to be with us.

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Although there are data indicating that fluoxetine can be effective in preventing relapse in these patients (226) muscle relaxant 751 order cheapest ponstel and ponstel, other data suggest that high rates of relapse occur while antidepressants are being taken and possibly higher rates are seen when the medication is withdrawn (240) muscle relaxant magnesium quality 500 mg ponstel. In the absence of more systematic data muscle relaxant pills over the counter buy ponstel toronto, most clinicians recommend continuing antidepressant therapy for a minimum of 9 months and probably for 1 year in most patients with bulimia nervosa spasms lower back pain ponstel 250mg lowest price. Clinicians must attend to the black box warnings concerning antidepressants and conduct appropriate informed consent with patients and families if these medications are to be prescribed (183­189). For patients with bulimia nervosa who require mood stabilizers, the use of lithium carbonate is problematic, because lithium levels may shift markedly with rapid volume changes. Both lithium carbonate and valproic acid frequently lead to undesirable weight gains that may limit their acceptability to bulimia nervosa patients. Selecting a mood stabilizer that avoids these problems may result in better patient adherence and medication effectiveness. Topiramate is not an effective mood stabilizer but may be potentially useful for bulimia nervosa and binge eating disorder (242, 243). However, in contrast to the low rates of adverse effects observed in clinical trials with topiramate, practitioners have reported several patients experiencing adverse effects with the drug, such as word-finding difficulties and paresthesias in a sizable minority of patients, although these may have been related to excessively rapid rates of dosage increases (242, 243). Also of note, patients receiving topiramate for bulimia nervosa lost an average of 1. No data are available regarding the use of these medications for treating bulimia nervosa or binge eating in children or adolescents, but safety and tolerability data have been reported for children and adolescents with other disorders for which lithium (244), valproic acid (245), and topiramate (246) have been prescribed. In these situations, particular attention should be given to a range of potential adverse effects, including abuse. Also perhaps suitable for this "other" category are individuals who experience psychiatric impairment related to the abuse of diet pills and diuretics (264), individuals who are obsessively preoccupied with liposuction (265) to deal with issues of shape and weight, and certain new-onset postgastrectomy eating disorder patients (266). Empirically supported strategies for the treatment of binge eating disorder include nutritional counseling and dietary management; individual or group behavioral, cognitive behavioral, dialectical behavioral, psychodynamic, or interpersonal psychotherapy; and medications. In reviewing the available information on treating binge eating disorder, it is important to consider the focus of treatment. Most programs using nutritional rehabilitation and counseling focus on weight loss as the primary outcome, whereas studies of psychotherapy and medication generally consider reduction of binge eating as the primary outcome measure, with weight loss as a secondary outcome. Clinical consensus suggests that psychodynamic psychotherapy may also be helpful to reduce binge eating in some patients. Some believe that patients with a history of repeated weight loss followed by weight gain ("yo-yo" dieting) or patients with an early onset of binge eating might benefit from following programs that focus on decreasing binge eating rather than losing weight (269, 270). However, at this point, there is little empirical evidence to suggest that obese binge eaters who are primarily seeking weight loss should receive different treatment than obese individuals who do not binge eat. There is less consensus regarding the long-term effects of treatment; however, some studies suggest that most patients continue to show behavioral and psychological improvement at 1-year follow-up (271, 272). Because severe dieting may disinhibit eating and lead to compensatory overeating and binge eating (278), and because chronic calorie restriction can also increase symptoms of depression, anxiety, and irritability (279), alternative therapies have been developed that use a "nondiet" approach and focus on self-acceptance, improved body image, better nutrition and health, and increased physical movement (280­282). Addiction-based 12-step approaches, self-help organizations, and treatment programs based on the Alcoholics Anonymous model have been tried, but no systematic outcome studies of these programs are available. In sum, there appear to be several good psychotherapeutic options for treating binge eating disorder when a reduction in binge eating is the primary goal. Weight loss, particularly in the long term, is a much more elusive goal, not only for obese patients with binge eating disorder but for obese patients in general. However, several studies suggest that at least for some patients at certain stages of recovery, behavioral weight control may be a useful treatment component. Also, because studies have found that binge eating may begin before obesity or dieting (283), specific approaches are needed for nonobese patients struggling with binge eating symptoms. The optimal sequencing of treatments-that is, whether the treatment of binge eating should precede or occur concurrently with weight control treatment-has yet to be definitively determined. The appetite-suppressant medication sibutramine also appears to be effective in suppressing binge eating, at least in the short term, and is additionally associated with significant weight loss (284). Heart rate and blood pressure need to be monitored closely in patients taking sibutramine, and the medication should be discontinued if there are significant elevations in these parameters, although these side effects seem to be uncommon (285).

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