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Over the past two decades scientists have made great strides toward understanding the biological roots of gratitude anxiety ulcer buy genuine venlor on line, the various benefits that accompany gratitude anxiety causes buy 75mg venlor overnight delivery, and the ways that people can cultivate feelings of gratitude in their day-to-day lives. Most people have an instinctive understanding of what gratitude is, but it can be surprisingly difficult to define. Indeed, gratitude can mean different things to different people in different contexts. However, researchers have developed some frameworks for conceptualizing gratitude so that it can be studied scientifically. For example, Robert Emmons and Michael McCullough define gratitude as a two-step process: 1) "recognizing that one has obtained a positive outcome" and 2) "recognizing that there is an external source for this positive outcome. Most of the studies in this paper focus on trait (or "dispositional" gratitude) and/or gratitude as an emotion. Animals as diverse as fish, birds, and vampire bats engage in "reciprocal altruism" activities- behaviors that one animal performs to help another member of their species, even at a cost to themselves, presumably because they recognize at some instinctual level that the other individual may repay the favor at a later date. Many scientists see this desire to repay generosity as an expression of gratitude. In fact, some scientists suggest that gratitude may have evolved as a mechanism to drive this reciprocal altruism, thereby turning strangers into friends and allies who are more likely to help one another. Support for the idea that gratitude may have arisen as an evolutionary adaptation comes in part from research on primates. Studies have found that chimpanzees are more likely to share food with a chimpanzee that had groomed them earlier in the day and are more likely to help another chimpanzee with a task if that chimpanzee had helped them in the past. Studies from neuroscience have identified brain areas that are likely involved in experiencing and expressing gratitude, providing further evidence for the idea that gratitude is an intrinsic component of the human experience. Additionally, a few studies have identified specific genes that may underlie our ability to experience gratitude. This work suggests that even fairly young children have some concept of gratitude that develops as they mature. Executive Summary Individual Factors Linked To Gratitude Even if humans as a species have a general propensity for gratitude, what determines whether an individual feels grateful or not? Several studies have explored whether certain personality factors-such as extraversion, agreeableness, conscientiousness, neuroticism, or openness to experience-are associated with dispositional gratitude; their results have differed. Other studies have found evidence suggesting that gratitude may be conceptualized as its own personality factor. There are a number of cognitive factors that can influence how much gratitude a person feels in a certain situation. Several studies have found that girls and women report feeling more grateful than boys and men, possibly because boys and men- at least in the United States-may be more likely to associate gratitude with weakness or indebtedness. Multiple studies report associations between elements of religiosity/spirituality and dispositional gratitude, suggesting that there may be a link between religion and gratitude. One study found that people assigned to pray for their partner, or pray in general, for four weeks reported higher gratitude at the end of the study than people who were assigned to think about their daily activities or to think positive thoughts about their partner. However, another study found that priming people to think about religious concepts did not increase their gratitude or generosity. For example, one study found that men in the United States reported experiencing gratitude less frequently than those in Germany, and another study found that American, Brazilian, Chinese, and Russian children differed in the ages and extent to which they expressed different forms of gratitude. For example, a study of fourth and fifth grade students and their biological parents found a small but statistically significant relationship between the self-reported gratitude of the children and their mothers, but not between the children and their fathers. Another study explored why more grateful parents might have more grateful children, finding that more dispositionally grateful parents were more likely to place their children in situations that might evoke feelings of gratitude, such as volunteering for people in need. Executive Summary Individual Benefits Of Gratitude Research suggests that gratitude may be associated with many benefits for individuals, including better physical and psychological health, increased happiness and life satisfaction, decreased materialism, and more. Many more studies have examined possible connections between gratitude and various elements of psychological well-being. In general, more grateful people are happier, more satisfied with their lives, less materialistic, and less likely to suffer from burnout. Gratitude may also benefit people with various medical and psychological challenges. For example, one study found that more grateful cardiac patients reported better sleep, less fatigue, and lower levels of cellular inflammation, and another found that heart failure patients who kept a gratitude journal for eight weeks were more grateful and had reduced signs of inflammation afterwards. Several studies have found that more grateful people experience less depression and are more resilient following traumatic events.

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Multidisciplinary pain programs have strong clinical efficacy and empirical data supporting their cost-efficiency anxiety management buy venlor 75 mg lowest price. Otherwise anxiety questionnaire order 75 mg venlor otc, the taper can precipitate doctor-shopping, illicit drug use, or other behaviors that pose a risk to patient safety. Although there are no fool-proof methods for preventing behavioral issues during an opioid taper, strategies implemented at the beginning of the opioid therapy are most likely to prevent later behavioral problems if an opioid taper becomes necessary. Patients who exhibit aberrant behaviors during the taper may have (Opioid Use Disorder). Surprisingly, opioid tapers rarely cause significant and long term increases in pain. If these occur, they tend to be during and immediately following completion of the opioid taper. In addition to antidepressant medications, anti-inflammatories and anticonvulsants can be used to address increased pain in patients who have no contraindications. Office-based buprenorphine treatment is an effective evidence-based option which should be considered for patients with both chronic pain and opioid use disorder. Recognition and Treatment of Opioid Use Disorder Opioid therapy can lead to the development of opioid use disorder. Although the true incidence is unknown, this risk ranges from 3-fold for acute low dose opioids to 122-fold for chronic high dose opioids. Examples include taking opioids in larger amounts than intended, spending a great deal of time trying to obtain opioids, strong craving for opioids, recurrent opioid use in situations where it is physically hazardous, social impairment such as withdrawal from family and friends, and conflict with medical providers over opioid use. These patients may experience an improvement in their quality of life if a transition can be made to medication-assisted treatment for opioid use disorder. However, it is important to recognize the stigma attached to the word "addiction," and it is generally best to avoid use of that term. As efforts to address the prescription opioid overdose epidemic have decreased the supply of prescription opioids, some patients have transitioned to heroin as a cheaper alternative. The numbers of people starting to use heroin have been steadily rising since 2007 with a corresponding increase in heroin overdose. Patients diagnosed with opioid use disorder should receive a combination of medication-assisted treatment and behavioral therapies. Expert physician mentors are available to assist with questions or concerns about opioid tapering and assessment and treatment of substance use disorders. Consider prescribing naloxone as a preventive rescue medication for patients with opioid use disorder, especially if heroin use is suspected. Medication-assisted treatment with either sublingual buprenorphine products or methadone is common in patients who have co-occurring chronic pain and opioid use disorder. Providers without a waiver should consider getting one or refer the patient to a provider with a waiver to prescribe buprenorphine. This treatment may be the only practical option for patients in rural areas where methadone and other treatment programs are difficult to access. Patients who require methadone maintenance must be referred to a federally licensed opioid treatment program. Evidence There is very little evidence that outpatient non-medication treatment for opioid use disorder is effective. Once a moderate to severe opioid use disorder has been diagnosed, there is strong evidence for efficacy of methadone or buprenorphine maintenance combined with behavioral therapies compared to nonmedication treatment. This section serves as an overview to orient primary care providers to special needs of these populations in regards to opioid use and does not include all modalities for pain management. Opioid use in pregnancy is increasing at an alarming rate, an estimated 3 to 4-fold increase between 2000 and 2009. Many pregnancies are unplanned, and women of reproductive age may be using opioids prior to a clinically recognized pregnancy. These factors make management of opioid use during pregnancy particularly challenging for healthcare providers.

Percentages are not adjusted for age of other sociodemographic population differences anxiety symptoms preschooler order 75 mg venlor overnight delivery. From the licensing of health care professionals such as nurses and pharmacists anxiety quizzes venlor 75 mg visa, to the regulation and monitoring of pre-hospital ambulance services and licensure of hospital and long-term care facilities, the bureau works to assure that safe and appropriate care is provided to Massachusetts residents. The Bureau licenses nearly 1,700 facilities, including 120 hospitals (acute and non-acute), nearly 450 nursing homes, and nearly 300 clinics. It also monitors more than 200 home health agencies and works to ensure that safe care is provided in all of these locations. In addition to facility licensure, the bureau licenses more than 200,000 health care professionals throughout the state. More than 300 ambulance services with more than 1,700 vehicles are also licensed by the bureau. The Bureau also licenses over 1,500 pharmacies and wholesale druggists and issues Massachusetts Controlled Substances Registrations to over 44,500 health care professionals, facilities, and community programs. The following sections highlight activities that the Bureau performs to assure the safety and quality of the health care that the residents of Massachusetts receive. Monitoring Adverse Events and Infections in Hospitals the Division of Health Care Quality monitors many aspects of hospital care, including events and infections that should not occur. The preliminary report of the first four months of data was released in April 2009. These collaborative efforts include the dissemination of evidence-based preventive best practices, identification of specific process and outcome measures for monitoring, promoting transparency and accountability through public reporting, increasing community education and awareness, and professional education. Investigating incidents and complaints is a key way in which the Bureau protects the health and safety of patients. In addition to the incident and complaint investigation, the Bureau conducted more than 1,400 certification and licensure inspections and follow-ups in the last fiscal year. The Department has worked collaboratively with a wide variety of stakeholders to reduce falls. Utilization of Nursing Homes the Bureau periodically assesses nursing home utilization rates in order to project future need for nursing home beds in the state. These assessments, along with national statistics, show that utilization of nursing homes by people ages 85+ has declined significantly. Health Care Quality 67 movement away from nursing homes to new models of care or could also reflect a healthier older population. As of February 2010, eight community hospitals and seven tertiary hospitals are participating in the trial. Massachusetts enacted legislation in 2000 establishing that a Cardiac Care Quality Advisory Group develop standards for collecting cardiac data. Regulations passed in April 2002 required all Massachusetts hospitals providing cardiac surgery and/or angioplasty to collect patient data. Data are reported annually and allows the monitoring of outcomes for cardiac surgery and angioplasty. Patients could also have been diverted away from hospitals where their doctors practiced or where they habitually sought care. In the months since the policy has been enacted, data collected indicate that wait times at emergency departments have not increased, even without diversion as an option. Hospitals have worked to address patient flow issues in order to reduce overcrowding and boarding in the emergency department. Summary the activities discussed are examples of some of the vital work done by the Bureau and the Department to protect the health of patients and communities. The Bureau of Health Care Safety and Quality is committed to protecting, preserving and promoting the health of all residents in the Commonwealth through strategic health planning, and by assuring the delivery of safe, high quality, person-centered health care for all. Locally, the Massachusetts Healthcare Quality and Cost Council went so far as to set the ambitious goals of eliminating hospital-acquired infections in Massachusetts by 2012, and serious patient safety events. Nationally, Consumer Reports has repeatedly advocated public reporting of infection rates by hospital, encouraging subscribers to support state and national legislation. In fact, the March 2010 issue includes information listing hospital-specific infection data from fifteen states. Massachusetts has taken great strides in addressing these priorities and recommended strategies. Annual public reporting of hospitalspecific data for Serious Reportable Events and infection rates creates public accountability, and allows for insightful analysis of the underlying causes, and effective actions to prevent future occurrences.

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When wetlands anxiety ulcer purchase generic venlor pills, forests anxiety symptoms relationships order venlor 75mg on-line, and woodlands are converted (for agriculture, for example, or urban development), local communities may suffer. For privileged others, whose "ecological footprints" dwarf those of the poor and weak (Wackernagel and Rees 1995), there are often substitutes-something else, often somewhere else. Issues of common and conflicting interests and of reducing demands can be expected to surface. In any case, there are vital policy questions about how to achieve well-being for all, and especially for those who experience it least. Balancing Priorities: Present Versus Future the relationship between ecosystem change and human well-being has both current and future dimensions. The overexploitation of ecosystems may temporarily increase material well-being and alleviate poverty, yet it may prove unsustainable. That is, each generation should bequeath to its successor at least as large a productive base as it inherited. Thus the concept of sustainable development incorporates not only intragenerational but also intergenerational equity. In practice, can the present generation be expected to pursue sustainable development policies? After all, parents care about both the current and future well-being of their children. Such individual concerns find a reflection in societal preferences only when prevailing property rights and other institutional structures take them into account. Instead, bad or weakly functioning institutions not only permit adverse consequences for human well-being from past and present actions but also hold no one to account. Often, the damage to ecosystems is the result of elite and powerful groups, both domestic and international, extracting short-term values for quick gains, thereby overriding the often longer-term interest of individuals and local communities (Jepson et al. If property rights to local ecosystems are ill defined or inadequately protected, such actions can have long-term adverse effects on ecosystem services that no one is responsible for. For example, fish farms created by clearing mangroves can benefit economically the company that has created the farms, but the action will inflict future damage on those who would otherwise have depended on the mangroves for provisioning, regulating, supporting, and cultural services (Gilbert and Janssen 1998; Ong 2002). Institutions and Freedoms Earlier sections demonstrated how many of the constituents or determinants of well-being were directly or indirectly provided by ecosystem services. It has also been shown that ecosystem services are not infinite and are subject to scarcity. Although there are potentials for substitutability with other forms of capital, thresholds exist beyond which substitutes are not possible. For example, while many pharmaceuticals can be produced synthetically, the therapeutic potential of extinct, undiscovered species can never be developed. Scarcity and the chance to add value provide powerful incentives for individuals or groups to try to gain privileged access and rights-of-use to many ecosystems and their services. They do this by influencing the political, economic, and social institutions that govern their access, management, and use (Ostrom 1990; Acheson 1993; Alston et al. Institutions-formal and informal-mediate the link between ecosystem services and the constituents and determinants of human well-being. For example, institutions for community forest management in India have successfully facilitated access to forest products for local communities (Chopra and Dasgupta 2002). In most cases, inequitable distribution of or access to ecosystems and their services occurs when formal or informal institutions break down (Binswager 1989; Jaganathan 1989; Duraiappah 1998). This happens either when institutions do not exist or when they are inefficient or ineffective. Commonly, powerful individuals or groups prevent the establishment of institutions. Existing bodies that mediate the distribution of goods and services may also be appropriated for the benefit of powerful minorities. Certain preconditions, or "freedoms," are necessary to ensure that this process Ecosystems and Human Well-being 83 is equitable and fair. These freedoms, by permitting a fair and equitable social process, play a critical role in preventing or mitigating institutional failure.

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The consistent treatment of uncertainty is therefore essential for the clarity and utility of assessment reports anxiety symptoms muscle tension order venlor with a mastercard. As part of any assessment process anxiety 247 generic venlor 75 mg line, it is crucial to estimate the uncertainty of findings even if a detailed quantitative appraisal of uncertainty is unavailable. These options include incorporating the value of ecosystems in decisions, channeling diffuse ecosystem benefits to decision-makers with focused local interests, creating markets and property rights, educating and dispersing knowledge, and investing to improve ecosystems and the services they provide. An effective strategy for managing ecosystems will involve a mix of interventions at all points in this conceptual framework. Mechanisms for accomplishing these interventions include laws, regulations, and enforcement schemes; partnerships and collaborations; the sharing of information and knowledge; and public and private action. The choice of options to be considered will be greatly influenced by both the temporal and the physical scale influenced by decisions, the uncertainty of outcomes, cultural context, and the implications for equity and trade- 24 Ecosystems and Human Well-being: A Framework for Assessment offs. Institutions at different levels have different response options available to them, and special care is required to ensure policy coherence. Decision-making processes are value-based and combine political and technical elements to varying degrees. Where technical input can play a role, a range of tools is available to help decision-makers choose among strategies and interventions, including cost-benefit analysis, game theory, and policy exercises. The selection of analytical tools should be determined by the context of the decision, key characteristics of the decision problem, and the criteria considered to be important by the decisionmakers. Information from these analytical frameworks is always combined with the intuition, experience, and interests of the decision-maker in shaping the final decisions. Risk assessment, including ecological risk assessment, is an established discipline and has a significant potential for informing the decision process. Finding thresholds and identifying the potential for irreversible change are important for the decision-making process. Similarly, environmental impact assessments designed to evaluate the impact of particular projects and strategic environmental assessments designed to evaluate the impact of policies both represent important mechanisms for incorporating the findings of an ecosystem assessment into decision-making processes. Experience to date suggests that a number of mechanisms can improve the process of making decisions about ecosystem services. Broadly accepted norms for decision-making process include the following characteristics. Summary 25 take account of thresholds, irreversibility, and cumulative, cross-scale, and marginal effects and of local, regional, and global costs, risk, and benefits? The policy or management changes made to address problems and opportunities related to ecosystems and their services, whether at local scales or national or international scales, need to be adaptive and flexible in order to benefit from past experience, to hedge against risk, and to consider uncertainty. Decision-makers should consider whether a course of action is reversible and should incorporate, whenever possible, procedures to evaluate the outcomes of actions and learn from them. Debate about exactly how to do this continues in discussions of adaptive management, social learning, safe minimum standards, and the precautionary principle. At the same time, many other factors independent of the environment change the human condition, and many natural forces influence ecosystems. A full assessment of the interactions between people and ecosystems requires a multiscale approach, as this better reflects the multiscale nature of decisionmaking, allows the examination of driving forces from outside particular regions, and provides a means of examining the differential impact of ecosystem changes and policy responses on different regions and groups within regions. Effective incorporation of different types of knowledge in an assessment can both improve the findings and help to increase their adoption by stakeholders if they see that their information has contributed to those findings. The usefulness of an assessment can be enhanced by identifying and seeking to address its structural biases. Any assessment empowers some stakeholders at the expense of others by virtue of the selection of issues and of expert knowledge to be incorporated. The ways in which ecosystems are affected by human activities will have consequences for the supply of 26 Introduction and Conceptual Framework 27 ecosystem services-including food, fresh water, fuelwood, and fiber-and for the prevalence of diseases, the frequency and magnitude of floods and droughts, and local as well as global climate. Ecosystems also provide spiritual, recreational, educational, and other nonmaterial benefits to people. Changes in availability of all these ecosystem services can profoundly affect aspects of human well-being-ranging from the rate of economic growth and health and livelihood security to the prevalence and persistence of poverty. At the same time, humans are altering the capability of ecosystems to continue to provide many of these services. Management of this relationship is required to enhance the contribution of ecosystems to human well-being without affecting their long-term capacity to provide services.

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