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Associate Professor, Stanford University School of Medicine
It is about the processes by which bargains between state and society are made (including policies and institutions) and how they are subsequently implemented and monitored (by organizations) spasms kidney area discount 500 mg methocarbamol otc. State capacity spasms toddler discount 500mg methocarbamol visa, or the ability of the state to implement policy through its agencies muscle relaxant quality 500 mg methocarbamol, is an important aspect of governance spasms or twitches purchase methocarbamol 500 mg free shipping. Weak institutions and low-capacity public sector agencies in resourcedependent developing countries mean that the ability of the state to make policy decisions to mitigate the resource curse will be equally weak. Understanding how natural resource extraction interacts with institutions and governance to cumulate into broader political economy trajectories is crucial for elaborating potential developmental assistance. Furthermore, development partners may, in collaboration with reformist clients, adopt an even more transformative stance regarding institutions; again, success will hinge on a firm grasp of the political economy of natural resource dependence. Transforming Rents into Riches Natural resources yield "rents," or extraordinary profits from their production, which are crucial to the political economy of resource-led development. Chapter 2 reviews the scholarship on the "rentier state" and how resource rents interact with institutions and political economy dynamics, then develops a core political economy framework for this volume that rests on understanding how rents flow through the system. Provided here is a brief overview of the analytical logic that animates this work. Many different domestic and international stakeholders are involved in natural resource policy making and extraction, and the relationships among these actors are constantly shifting across the value chain. Political economy scholarship often relies on regime typologies to distinguish why certain types of country settings yield certain outcomes. In order to help country counterparts and development practitioners diagnose the political economy trajectory a resource-dependent country is embarked upon, this volume advances a simple typology that is structured around two crucial dimensions: · · the credibility of intertemporal commitment-or the degree to which policy stability and bargains over time can be enforced and deviations from such agreements are subject to sanction; and the overall political inclusiveness of the prevailing state-society compact-or the extent to which diverse social, economic, and political viewpoints are incorporated into decision-making, and a sense of either collectivist or clientelist welfare is privileged over purely elite interests. Although these dimensions are interdependent to some extent, positioning them against each other yields a typology of four distinct country settings (table 1. Characterizations of each setting, as well as unbundled components underlying each dimension, can be found in chapter 2. Development interventions to mitigate the resource curse are aimed at assisting reform in countries such that their policy making and institutional framework across the natural resource value chain approximate those found in countries squarely within the ideal bottom-right quadrant of programmatic pluralism. In other words, natural resource rents are most reliably transformed into sustainable development riches when a government can make credible intertemporal commitments to both extractive companies and its own citizens, and when the political regime is inclusive such that the government faces incentives to use resource rents to provide public goods that enhance the collective welfare. This typology may be used to characterize a country at a specific time, but countries also evolve dynamically, sometimes transforming from one political economy setting to another. In order to be successful, development initiatives must find mechanisms to resonate with, and eventually transform, the underlying political and institutional dynamics of resource-dependence. Typology of Natural ResourceDependent Settings Credibility of intertemporal commitment Political inclusiveness Less inclusive/ less collectively oriented Less credible/ weaker enforcement Patrimonial rule Individualized political authority built on a hierarchy of cronyism; emphasis on private (elite) goods; exploitation of public resources for private gain Clientelist pluralism Political competition based on extensive use of clientelism; provision of particularist goods; low horizontal accountability More credible/ stronger enforcement Hegemonic government Institutionalized one-party regime; either predatory or benevolent; emphasis on private (elite) goods with some particularist and public goods Programmatic pluralism Electoral competition based on programs geared toward collective welfare enhancement; provision of public goods; horizontal and vertical democratic accountability More inclusive/ more collectively oriented Source: Adapted from Barma and Viсuela (2010). Introduction: Beyond the Resource Curse 13 using this typology indicates the shape of the feasible political space within which good-fit interventions must be elaborated if they are to be tractable and sustainable. The unbundled components underlying the two dimensions of intertemporal credibility and political inclusiveness (see chapter 2) offer traction in terms of developing principles for intervention. As development practitioners and country counterparts move toward articulating good-fit interventions that are compatible with underlying incentives, the typology suggests three paths for designing these initiatives: · · · Interventions primarily aimed at extending time horizons, thereby enhancing intertemporal credibility; for example, emphasizing a simple, rule-based process for granting resource concessions that minimizes investor uncertainty and enhances predictability. Reforms that emphasize mobilizing stakeholders to cooperate on natural resource management, thereby broadening political inclusiveness; for example, easing information asymmetries by using model contract and fiscal regimes or at least disclosing contract terms in order to empower third-party audit and oversight. Interventions that enclave institutions and capacity in natural resource management so that some, albeit limited, functionality is possible even when the wider political economy dynamics are perverse. Intelligently designed interventions along these lines can both strengthen salutary dynamics by tapping into incentives that push in the right direction and work with counterparts on transformative interventions that could alter the underlying political economy dynamics for the better. The thematic chapters of this volume-chapter 3 on sector organization, chapter 4 on taxation, and chapter 5 on public investment- describe the political economy incentives and dynamics at each respective point of the value chain, comparing them against the four political economy settings sketched in the typology and showing how they contribute to typical natural resource management outcomes in low-income, resource-dependent countries. Each chapter then outlines specific potential good-fit interventions that make sense within those political opportunities and constraints, describing how different 14 Rents to Riches? Distinctive Characteristics of the Extractive Industries Practitioners in resource-dependent countries face many of the challenges of poor policy making, limited capacity, and weak institutions that are characteristic of developing countries in general. As discussed further in chapter 2, these distinctive qualities together make resource rents central to the political economy of resource-dependent countries and make the extractive industries particularly susceptible to short time horizons and the pursuit of private enrichment over public welfare.
Fluctuations in hormones during perimenopause and lower levels in menopause are involved in inflammation of the gums muscle relaxant gel india methocarbamol 500 mg without a prescription, sensitivity of the teeth muscle relaxant 2mg cheap 500mg methocarbamol with amex, tooth loss muscle relaxer x buy generic methocarbamol 500 mg on line, and a burning sensation in the mouth and tongue muscle relaxer 93 discount methocarbamol uk. Burning sensations in the mouth can be a symptom of diabetes or anemia, and gum inflammation may be related to an increased risk of cardiovascular disease. A palpitation can feel like a rapid heart rate, missed heartbeats, or irregular heartbeats. Not all heart palpitations are related to a decrease in estrogen levels but may be a symptom of anxiety, panic disorder, fears, or depression. Fortunately, women in their 40s and early 50s, during the most common time of the menopause transition, are not likely to have a serious cardiac problem. Another symptom commonly reported during menopause is joint pain and/or body aches. This is not currently well understood, but it is likely there is a connection between hormones, immune function, and inflammation in the joints. Osteoarthritis, specifically, is a common joint disease that increases with age and affects women more than men. While the symptoms of hot flashes, mood swings, insomnia, sexual dysfunction, and the rest are annoying at best, and can significantly impact quality of life, the most significant changes associated with menopause are osteoporosis and cardiovascular disease. For a comprehensive discussion on osteoporosis, refer to Chapter 14, and for heart disease, refer to Chapter 9. Prevalence, risk factors, evaluation, and alternative and conventional approaches and treatments are covered in these chapters. Menopause Evaluation the onset of perimenopause is an important time for a comprehensive health and lifestyle evaluation. A thorough medical history, complete physical exam, and selected tests depending on your age, your symptoms, and other medical problems should be done by a licensed healthcare practitioner. Tests to determine ovarian function are not routinely done because the diagnosis of perimenopause or menopause is largely able to be made based on the medical history. Practitioners can use hormone testing on an individual basis, mostly to differentiate menopause from thyroid problems, abnormal causes of a lack of menses such as elevated prolactin levels, or premature ovarian failure (premature meno- pause). There is a recent popular notion that saliva or serum testing can be done to determine estrogen, progesterone, and testosterone levels or individual estrogen levels including estriol, estrone, and estradiol. For the perimenopausal woman, it is difficult to gather conclusions on test results when the hormones are in such a fluctuating state. There are so many peaks and valleys and so much erratic hormone activity that testing offers little value in most situations. However, I would point out that there is no mathematical grid comparing values of estrogen or progesterone or of testosterone levels in the blood and how that would equate with a certain dose of the comparable hormone. The form of hormones and the delivery method-oral, transdermal, sublingual, or injection-also behave differently from woman to woman. Even if testing is done, the decision basically comes down to good clinical judgment and the willingness of the woman and her practitioner to try various approaches. Risk assessment for heart disease is discussed in Chapter 9 and for osteoporosis, Chapter 14. Diabetes risk assessment is a combination of history and physical exam, glucose screening, and lipid panel testing. Seek the advice of practitioners who can inform you about the spectrum of options. Other important situations also warrant testing and are discussed in the appropriate chapters in this book. To name a few, abnormal uterine bleeding may need thyroid blood tests, pelvic ultrasound, or endometrial biopsy. The goal is to do this with methods that do not increase the risk of lifethreatening diseases such as breast cancer, blood clots, and strokes. In order to accomplish these fundamental goals, the menopausal woman and her practitioner must embrace an individualized approach. An alternative and comprehensive approach is distinct in that the evaluation of each woman lends a great deal of attention not only to individual symptoms, but also to her individual risks for future diseases. A licensed naturopathic physician is currently the only primary health-care provider trained in all these options, although he or she may have to refer for some selected expertise in osteoporosis, heart disease, gynecology, or endocrinology.
At the 32-week evaluation point muscle relaxant yoga purchase methocarbamol 500mg on line, 10% of placebo-treated patients remained in treatment (most of the rest having been withdrawn because of urine evidence of persisting illicit opioid use) compared with 76% of maintenance patients muscle relaxant brands generic methocarbamol 500 mg on line. The second placebo-controlled study of methadone treatment was conducted in the late 1980s in Baltimore muscle relaxant breastfeeding best methocarbamol 500mg, Maryland spasms rib cage area generic 500 mg methocarbamol amex, and enrolled 247 opioid-dependent outpatient participants (1350, 1351). The study began by randomly assigning subjects to one of three fixed doses of oral methadone (0, 20, or 50 mg/day). Participants were required to attend the clinic daily for supervised dose ingestion and were discharged for missing 3 consecutive days of treatment. At the end of the 20-week study, significant differences were found among the three groups for treatment retention (primarily between the 50- and 0-mg groups), with the 20-mg group generally doing better than the 0-mg group. In addition, there were significantly lower rates of opioid-positive urine test results for the 50-mg group compared with the other two groups. A variety of secondary outcome measures, such as self-reported illicit opioid use, also showed dose-related effects. In addition to the demonstrated dose-related efficacy of methadone, these study results also indicated that the 20-mg dose of methadone might keep some patients in treatment but was not Treatment of Patients With Substance Use Disorders 165 Copyright 2010, American Psychiatric Association. Study limitations included the use of fixed doses of methadone and the absence of a dose condition 50 mg/day. Further controlled clinical trials of methadone have tested higher versus lower doses of methadone. The induction procedure for the 288 methadone-treated subjects was relatively slow; subjects were started on 30 mg of methadone per day and received 10mg dose increases once per week until the target dose was achieved. Induction, therefore, lasted 5 weeks longer for patients in the 100-mg versus the 50-mg methadone group. Urine samples were collected and tested once per week, and the results were summarized using a set of rules that weighted results based on when the sample was collected and how missing values were handled. Outcomes for the methadone-treated subjects showed higher opioid urine scores (poorer outcomes) for the 50-mg versus the 100-mg group. Another outpatient study compared a moderate dose (4050 mg/day; N=97) with a higher dose (80100 mg/day; N=95) of methadone for the treatment of opioid dependence (1352). This 40-week double-blind, randomized trial used a flexible dosing procedure in which participants could receive dose increases based on evidence of continued illicit opioid use. Primary outcome measures were treatment retention, the results of twice-weekly urinalyses, and self-reported illicit opioid use. The results showed no significant difference in treatment retention for the two groups but found a significantly lower rate of opioid-positive urine samples for the higher-dose condition. Both groups had marked declines in self-reported illicit opioid use, with significantly less use by the high-dose versus the moderate-dose group. Although significant effects were found on some outcomes in this study, both doses produced clinically meaningful decreases in illicit opioid use. The lack of difference between the study groups for treatment retention suggests that there may be a plateau in the dose-related efficacy of methadone in maintaining patients in treatment but not in decreasing illicit opioid use for the doses tested. However, the schedule of twice-weekly urinalyses used in this study may have failed to capture all illicit opioid use occurring in the study population. Other controlled trials of methadone treatment and methadone dosing have also been conducted (1250, 1251, 16671670). In general, these studies have shown that methadone has dose-related efficacy, although it is important to note that not all randomized double-blind methadone studies have shown such an effect. However, it is also important to note that no double-blind, randomized, controlled clinical trials have tested daily doses of methadone 100 mg/day. There have been single-blind and open studies of higher doses of methadone that were conducted primarily in the early years of methadone treatment (16711673), and reports from clinical practice in both the United States and other countries indicate higher doses of methadone are used by some clinicians (13421346). Currently, there is no research database that provides information about the relative efficacy and safety of higher doses. Use of methadone as a withdrawal (detoxification) agent the number of studies examining methadone for treating opioid withdrawal is more limited than the number examining methadone in maintenance treatment of opioid dependence. Outcomes from methadone withdrawal are generally poor (16741676), especially when compared with the success associated with methadone maintenance treatment. These studies have examined the various parameters under which methadone tapering can occur in an effort to determine optimal withdrawal schedules. An early double-blind, randomized, outpatient study of methadone withdrawal by Senay et al. The 127 study participants were in methadone maintenance treatment, with an average dose of 31 mg/day.
In fact muscle relaxant 500 mg purchase genuine methocarbamol, a recent study showed that there is a definite relationship between the amount of cigarette smoke exposure and menstrual cramps spasms side of head purchase methocarbamol 500 mg mastercard. The pain usually begins several hours before or just after the onset of menstruation and is often the most severe the first or second day of menstruation muscle relaxant non-prescription order generic methocarbamol canada. It tends to be spasmodic and is strongest in the lower part of the abdomen above the pubic hairline spasms in chest purchase methocarbamol online pills, although it can often radiate to the back and along the inner aspects of the thighs. More than 50 percent of women with menstrual cramps also have additional symptoms including nausea and vomiting, fatigue, diarrhea, lower backache, and headache. The symptoms may last from a few hours to one day but seldom last longer than two to three days. If dysmenorrhea starts two years or more after menarche, then other causes and secondary dysmenorrhea should be considered. Endometriosis is difficult to distinguish from primary dysmenorrhea because they produce similar symptoms. Pain that starts several days before the menses is less likely to be primary dysmenorrhea. In cycles without ovulation, there is no increase in progesterone production in the second half of the cycle and then decline right before the onset of menses, as in a normal cycle, and there is subsequently no increase in the prostaglandin concentration in the lining of the uterus. These mechanisms form the basis for many of the therapies used, both natural and conventional. Because it is a functional problem and not a disease state that is causing the pain, we can truly focus on a holistic approach by looking for aggravating factors in the diet, lifestyle, environment, and emotional realm. Dietary principles emphasizing good nutritional habits-eliminating junk foods, saturated fats, and trans fats; increasing omega-3 oils from fish, hemp oil, and flax oil; and increasing whole grains, fruits, and vegetables-provide a range of nutrients needed to prevent and treat menstrual cramps. Stress reduction can help relieve tension in the lower back and pelvic area that can worsen cramps. Improvements in posture improve the positioning of the spine and promote proper circulation and nerve stimulation to the pelvic organs. Providing acute pain relief is one of the greatest challenges for natural medicine, whether it is pelvic pain, headaches, or musculoskeletal pain. Mild and moderate levels of pelvic pain are more treatable with natural therapies than is severe pain, although some women with severe pain will experience relief from the therapies that follow. Even when acute pain relief is not accomplished with alternative therapies, a treatment plan for the interim days of the month is important in order to reduce the severity of the recurring including breast tenderness, headaches, and irritability. Primary dysmenorrhea is diagnosed when other causes of pelvic pain have been excluded. The cause of primary dysmenorrhea may be one of several factors, including behavioral and psychological factors; lack of blood flow, and therefore oxygen, to the uterus (ischemia); and increased production and release of uterine prostaglandins. Increased prostaglandins, specifically PgF2-alpha and PgE2, cause uterine contractions that lead to ischemia and pain. The levels of both PgF2-alpha and PgE2 are low during the first half of the menstrual cycle and the early part of the second half, then rise sharply and reach their highest levels shortly before and during the onset of menses. Studies have found that women with dysmenorrhea produce 8 to 13 times more PgF than do women without dysmenorrhea. Having a natural therapeutic treatment plan for the chronic problem and using over-the-counter or prescription conventional medicines for acute pain relief can turn out to be the most effective plan. Many alternative practitioners have experience with natural therapies not included in this book such as acupuncture, homeopathy, and hands-on techniques that may offer effective help for many women with menstrual cramps. I often encourage women to try an herbal or nutritional product for a couple of hours during acute pain. If no relief is accomplished within that amount of time, then switch to a pharmaceutical method of pain control. As each successive month of treating the chronic problem goes by, a measure of the success of that treatment will be a decreased need to use the pain relief medication. It is important not to overlook the role of stressors in our personal lives that can be at least part of the cause of our pain and can also affect our ability to deal with pain. A recent study of over 380 otherwise healthy women demonstrated that women who experienced high stress were twice as likely to experience dysmenorrhea in the following cycle, especially among those women with a prior history of painful menses. Research has shown that behavior therapy has been highly effective in reducing the symptoms of spasmodic dysmenorrhea.
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