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By: Joseph St. Geme, MD

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During their long-term freshwater rearing mood disorder tests purchase wellbutrin sr master card, juveniles may move to anxiety xanax not working buy wellbutrin sr 150mg with amex higher flow areas and disperse into areas inaccessible to mood disorder ubc purchase wellbutrin sr 150mg with amex adults depression gerd symptoms buy wellbutrin sr canada. Intact riparian vegetation, in-stream large woody debris and natural floodplain structure are important for juvenile productivity and survival. Summer low-flow conditions may reduce rearing habitat in area and quality (elevated temperature). Optimal freshwater temperature range is 54 to 57o F and temperatures over 77o F may be lethal. Sub-adults rear in Pacific Ocean continental shelf areas predominately off of Washington and Oregon, and to lesser extent off British Columbia and California. Current insufficient External 5 Fish and wildlife habitat loss or degradation Overharvesting of biological resources Fish passage facilities need to be added or improved in multiple localities. Following emergence in March and April, juveniles migrate to Ozette Lake, where nearly all rear for about a year and then emigrate to the sea the following March through June. Ocean distribution and behavior of sub-adults are not well-known, but young fish may use nearshore ocean areas and move offshore as they growth. Ocean rearing may last from 1 to 3 years, but majority rear for about 2 years before returning to spawn. Historical abundance was very large, based on peak harvest values, and minimum viable spawning abundance goal for recovery is 35,500. Abundance estimates have been highly variable and uncertain, but methodologies have improved and average annual abundance of returning adults for a recent ten-year period was over 2,500. Spawning substrates vary from cobble/large gravel to coarse sand and silt, and groundwater upwelling sites appear to be favored spawning sites. Ocean rearing areas are not well-known, but nearshore and offshore North Pacific waters are likely used. Winter-run steelhead in mature condition may begin entering natal rivers in early December; spawning occurs typically from early March to early June, with peak in late April/early May. Juveniles that migrate seaward do so predominately from April to June, with peak in May; some mature in freshwater without going to sea, more commonly in males than females. Ocean migration paths are not well-documented but sub-adults may rear in central North Pacific Ocean or Gulf of Alaska; rearing typically occurs for 1 to 3 years, with 2 years the most common. In Washington, there are 14 historical winter-run and five historical summer-run populations. Dams in several rivers have significantly reduced or eliminated historical distribution. Recent analyses indicated that in Washington, only the Wind River summer-run population was considered viable, and most others were at very high or high risk levels. Habitat Adults use wide variety of freshwater habitats, spawning or holding in river mainstems and large and small tributaries. They migrate relatively far upstream in natal rivers compared to other salmonids and access is aided by flow conditions during migration timing. Newly emerged juveniles use shallow gravel bed areas in riffles, among boulders, or near stream banks. During long-term rearing, juveniles may move throughout watershed, using differing habitats in response to seasonal flow and temperature conditions. Historical population structure of Pacific Salmonids in the Willamette River and Lower Columbia River basins. Current insufficient External 4 Energy development and distribution Restore or maintain adequate passage and optimum flows for fish. Current insufficient External 5 Fish and wildlife habitat loss or degradation Fish passage facilities need to be added or improved in multiple localities. Dams impede passage and reduce or modify access to large areas of historic range, and other habitat degradation limits distribution and productivity. Summer-run steelhead in immature condition begin entering freshwater in late spring, and travel to and enter natal tributaries through summer and fall; they mature in freshwater and spawn in following calendar year usually from early March to early June. Juveniles that migrate seaward do so predominately from March to June; some mature in freshwater without going to sea, more commonly in males than females. Ocean migration paths are not well-documented but sub-adults may rear in North Pacific Ocean or Gulf of Alaska, typically for 1 to 3 years, with 2 the most common. In Washington, extant populations occur in Yakima, Touchet, Walla Walla, and Klickitat rivers and Rock Creek; a remnant White Salmon River population may recover due to dam removal. Distribution also is reduced by other man-made passage barriers and habitat alterations from agriculture and other development. Abundance has increased in some areas (Yakima Basin and Walla Walla River) but is low in others. Columbia River mainstem is migration corridor and is greatly modified by dams and reservoirs. Current insufficient External 4 Fish and wildlife habitat loss or degradation Fish passage facilities need to be added or improved in multiple localities. Winter-run adults in mature condition may begin entering rivers in late November; spawning may occur from February to June with peak spawning in April or May. Summer-run adults return to rivers from May to October and mature in freshwater, with spawning occurring in following calendar year from January to May. Other exclusively summer-run populations occur upstream of falls or cascades that exclude fish returning in winter due to flows. Juveniles that migrate seaward do so predominately in April and May; some mature in freshwater without going to sea, more commonly in males than females. Ocean migration paths are not welldocumented but sub-adults may rear in central North Pacific Ocean or Gulf of Alaska, typically for 1 to 3 years, with 2 years the most common. Dams in several rivers significantly reduced or eliminated historical distribution, and other man-made barriers. Summer-run populations are generally small due to limited habitat and abundance trends are not well-monitored. Habitat Adult steelhead use wide variety of freshwater habitats, spawning in river mainstems and large and small tributaries. They migrate relatively far upstream compared to other salmonids and access is aided by flow conditions during their return timing. Redds (nests) are constructed in riffles and downstream margins of pools in streambeds where gravel sizes are optimal. Instream woody debris, boulders and stream bank structure provide important cover. As juveniles grow they move to higher water velocity areas and maintain individual territories for feeding. Instream cover is important for overwintering juveniles, and intact riparian vegetation is essential for contributing woody debris, supporting invertebrate prey, and shading. Central North Pacific Ocean and Gulf of Alaska are likely marine rearing habitats. Identifying historical populations of steelhead within the Puget Sound distinct population segment. Current sufficient Both 3 Fish and wildlife habitat loss or degradation Dam and barrier removal. Current insufficient External 4 Energy development and distribution Fish and wildlife habitat loss or degradation Restore or maintain optimum flows for fish. Current insufficient External 5 Fish passage facilities need to be added or improved in some localities. Dams impede passage, reduce access to large areas of historic range, and limit productivity.

Bone scan is a sensitive test for bone metastasis mood disorder onset 150 mg wellbutrin sr overnight delivery, making ectopic hormone production more likely in this case mood disorder 26990 purchase wellbutrin sr 150 mg visa. There are high concentrations in human breast milk mood disorders dsm 5 ppt purchase wellbutrin sr 150 mg on-line, although the physiologic significance is unknown mood disorder free test discount wellbutrin sr 150mg mastercard. It also may secrete antidiuretic hormone, causing syndrome of inappropriate antidiuretic hormone. Adenocarcinomas cause hypercalcemia by metastasizing to bone, which would cause an abnormal bone scan. Bronchoalveolar carcinomas do not usually cause ectopic hormone production or metastasize to bone. Signs of hypothyroidism include dry coarse skin, puffy hands/face/feet (myxedema), diffuse alopecia, bradycardia, peripheral edema, delayed tendon reflex relaxation, carpal tunnel syndrome, and serous cavity effusions. The symptoms of hyperthyroidism include hyperactivity, irritability, dysphoria, heat intolerance, sweating, palpitations, fatigue and weakness, weight loss with increased appetite, diarrhea, loss of libido, polyuria, and oligomenorrhea. Signs include tachycardia, atrial fibrillation (particularly in the elderly), tremor, goiter, warm moist skin, proximal myopathy, lid lag, and gynecomastia. It stimulates hydroxylation of 25-hydroxyvitamin D, resulting in the more active form. Malnutrition from fasting or starvation may result in depletion of phosphate, causing hypophosphatemia during refeeding. Sepsis may cause destruction of cells and metabolic acidosis, resulting in a net shift of phosphate from the extracellular space into cells. It is important to rule out disorders of the uterus or outflow tract before initiating an exhaustive workup for hormonal causes. On examination, one may find obstruction of the transverse vaginal septum or an imperforate hymen, which should be treated surgically. An elevated prolactin in such a patient should direct your evaluation toward a neuroanatomic abnormality or hypogonadotropic hypogonadism. In patients admitted to the hospital with symptomatic hypercalcemia, malignancy is the most common cause. Hypercalcemia from thiazide diuretics and familial hypocalciuric hypercalcemia result from disordered regulation of calcium in the kidney. The Z-score compares individuals with those in an age-, race-, and gendermatched population. Infertility is attributable to female causes in 58% of cases and male causes in 25% of cases, and 17% remain unexplained after evaluation. Initial evaluation of the infertile couple includes counseling regarding the appropriate timing of intercourse and discussion of modifiable risk factors for infertility, including drug and alcohol use, cigarette smoking, caffeine, and obesity. In the female partner, it is important to confirm ovulation and assess tubal patency. Polycystic ovarian syndrome can be found in 30% of women who have anovulatory cycle and is associated with androgen excess. If polycystic ovarian syndrome is suspected, the female partner should have levels of testosterone and dehydroepiandrosterone assessed. Determination of patency of the uterine outflow tract and fallopian tubes is also recommended through performance of a hysterosalpingogram. Endometrial biopsy was once a frequent component of the evaluation of infertility to exclude 59. Numerous studies have indicated important benefits in both primary and secondary prevention of cardiovascular disease. Statins are generally well tolerated, with an excellent safety profile over the years. Dyspepsia, headache, fatigue, and myalgias may occur and are generally well tolerated. The risk of myopathy is increased in the presence of renal insufficiency and with concomitant use of certain medications, including some antibiotics, antifungal agents, some immunosuppressive 518 Review and Self-Assessment drugs, and fibric acid derivatives. Barrier methods (condoms, cervical cap, diaphragm) have an actual efficacy between 82 and 88%. Oral contraceptives and intrauterine devices perform similarly, with 97% efficacy in preventing pregnancy in clinical practice. The peak incidence is between 30 and 50 years of age, and women are affected more frequently than are men. During the initial phase of follicular destruction, there is a release of thyroglobulin and thyroid hormones. Patient A is consistent with the thyrotoxic phase of subacute thyroiditis except for the increased radioiodine uptake scan. Notably, a decreased incidence of neuropathy, retinopathy, microalbuminuria, and nephropathy was shown in individuals with tight glycemic control. Given their prevalence, the cost of screening, and the generally benign course of most nodules, the choice and order of screening tests have been very contentious. A small percentage of incidentally discovered nodules will represent thyroid cancer, however. Four percent of nodules undergoing biopsy will be malignant, 10% are suspicious for malignancy, and 86% are indeterminate or benign. Clinically, this is manifested as hypoglycemia unawareness and defective glucose counterregulation, with lack of glucagon and epinephrine secretion as glucose levels fall. An estimated prevalence of 3% in persons over age 40 years is a generally accepted figure. Most frequently, the disease is Review and Self-Assessment asymptomatic and is diagnosed only when the typical sclerotic bones are incidentally detected on x-ray examinations done for other reasons or when increased alkaline phosphatase activity is recognized during routine laboratory measurements. The etiology is unknown, but increased bone resorption followed by intensive bone repair is thought to be the mechanism that causes increased bone density and increased serum alkaline phosphatase activity as a marker of osteoblast activity. Because increased mineralization of bone takes place (although in an abnormal pattern), hypercalcemia is not present unless a severely affected patient becomes immobilized. Hypercalcemia, in fact, would be an expected finding in a patient with primary hyperparathyroidism, bone metastases, or plasmacytoma, with plasmacytoma typically producing no increase in alkaline phosphatase activity. Osteomalacia resulting from vitamin D deficiency is associated with bone pain and hypophosphatemia; normal or decreased serum calcium concentration produces secondary hyperparathyroidism, further aggravating the defective bone mineralization. Purple skin striae and hirsutism occur 65% of the time in these patients, and amenorrhea about 60% of the time. About one-third of macroadenomas (>1 cm) will become invasive or exert mass effect; surgery should be considered for incidental macroadenomas. Hearing loss is very frequent, usually due to bony compression of the eighth cranial nerve. The most commonly affected areas include the pelvis, the skull, and the vertebral bodies. Physical findings of bony deformity such as frontal bossing of the skull or bowing of an extremity, an elevated alkaline phosphatase level, or characteristic findings on plain radiographs, such as cortical thickening and lytic and sclerotic changes, suffice. All of the hormones have inhibitors that act in a negative feedback loop to regulate their production and release. A genetic deficiency of either protein impairs lipolysis and results in an elevation in plasma chylomicrons. The triglyceride-rich proteins persist for days in the circulation, causing fasting levels higher than 1000 mg/dL. Clinically, these patients may have repeated episodes of pancreatitis secondary to hypertriglyceridemia. Eruptive xanthomas may appear on the back, the buttocks, and the extensor surfaces of the arms and legs. Its action on osteoclasts, however, is indirect and likely is mediated through its actions on the osteoblasts. Ultimately, this leads to an increase in serum calcium, an effect that can be seen within hours of drug administration. Activated vitamin D then helps to increase calcium levels by increasing intestinal absorption of both calcium and phosphate. It results from a relative or absolute deficiency of insulin combined with a counterregulatory hormone excess. In particular, a decrease in the ratio of insulin to glucagons promotes gluconeogenesis, glycogenolysis, and the formation of ketone bodies in the liver. Ketosis results from an increase in the release of free fatty acids from adipocytes, with a resultant shift toward ketone body synthesis in the liver.

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The mosaic pattern of woven bone is structurally inferior and can bow and fracture more readily depression definition uk purchase 150mg wellbutrin sr mastercard. In other families mood disorder due to general medical condition purchase genuine wellbutrin sr, susceptibility loci have been mapped to depression diagnosis test online order 150 mg wellbutrin sr free shipping loci on chromosomes 18q23 mood disorder webmd order wellbutrin sr 150 mg without prescription, 6p21. The skeletal sites most commonly involved are the pelvis, vertebral bodies, skull, femur, and tibia. Numerous active sites of skeletal involvement are more common in familial cases with an early presentation. It results from increased bony vascularity, expanding lytic lesions, fractures, bowing, or other deformities of the extremities. Bowing of the femur or tibia causes gait abnormalities and abnormal mechanical stresses with secondary osteoarthritis of the hip or knee joints. Long bone bowing also causes extremity pain by stretching the muscles attached to the bone softened by the pagetic process. Back pain results from enlarged pagetic vertebrae, vertebral compression fractures, spinal stenosis, degenerative changes of the joints, and altered body mechanics with kyphosis and forward tilt of the upper back. Rarely, spinal cord compression may result from bone enlargement or from the vascular steal syndrome. Skull involvement may cause headaches, symmetric or asymmetric enlargement of the parietal or frontal bones (frontal bossing), and increased head size. Cranial expansion may narrow cranial foramina and cause neurologic complications including hearing loss from cochlear nerve damage from temporal bone involvement, cranial nerve palsies, and softening of the base of the skull (platybasia) and the risk of brainstem compression. Pagetic involvement of the facial bones may cause facial deformity, loss of teeth and other dental conditions, and, rarely, airway compression. The incidence of sarcoma appears to be decreasing, possibly because of earlier, more effective treatment with potent antiresorptive agents. The majority of tumors are osteosarcomas, which usually present with new pain in a longstanding pagetic lesion. Osteoclast-rich benign giant cell tumors may arise in areas adjacent to pagetic bone and respond to glucocorticoid therapy. The extensive arteriovenous shunting and marked increases in blood flow through the vascular pagetic bone lead to a high-output state and cardiac enlargement. However, high-output heart failure is relatively rare and usually develops in patients with concomitant cardiac pathology. Diagnosis the diagnosis may be suggested on clinical examination by the presence of an enlarged skull with frontal bossing, bowing of an extremity, or short stature with simian posturing. An extremity with an area of warmth and tenderness to palpation may suggest an underlying pagetic lesion. Other findings include bony deformity of the pelvis, skull, spine, and extremities; arthritic involvement of the joints adjacent to lesions; and leg length discrepancy resulting from deformities of the long bones. Vertebral cortical thickening of the superior and inferior end plates creates a "picture frame" vertebra. Radiographs of long bones reveal bowing deformity and typical pagetic changes of cortical thickening and expansion and areas of lucency and sclerosis (Fig. Radionuclide 99mTc bone scans are less specific but are more sensitive than standard radiographs for identifying sites of active skeletal lesions. The marked increase in bone turnover can be monitored using biochemical markers of bone formation and resorption. The degree of bone marker elevation reflects the extent and severity of the disease. Lower values suggest less extensive involvement or a quiescent phase of the disease. Urinary and serum deoxypyridinoline, N-telopeptide, and C-telopeptide levels are products of type I collagen degradation and are more specific for bone resorption than hydroxyproline. These newer bone resorption markers have distinct advantages over measurement of 24-h or secondmorning void hydroxyproline/creatinine ratio, which requires control of dietary gelatin intake and precise urine collection and analysis. However, the discovery of hypercalcemia, even in the presence of immobilization, should prompt a search for another cause of hypercalcemia. In contrast, hypocalcemia or mild secondary hyperparathyroidism may develop in Paget patients with very active bone formation and insufficient dietary calcium intake. Hypocalcemia can occur during bisphosphonate therapy when bone resorption is rapidly suppressed and active bone formation continues. Note the coarsening of the trabecular pattern with marked cortical thickening and narrowing of the joint space consistent with osteoarthritis secondary to pagetic deformity of the right femur. The development of effective and potent pharmacologic agents (Table 29-1) has changed the treatment philosophy from treating only symptomatic patients to treating asymptomatic patients who are at risk for complications. For each tablet, etidronate strength is 400 mg; tiludronate is 200 mg; alendronate is 40 mg; and risedronate is 30 mg. However, the restoration of normal bone architecture following suppression of pagetic activity suggests that treatment may prevent further deformities and complications. As a result of decreasing bone turnover, pagetic structural patterns, including areas of poorly mineralized woven bone, are replaced by more normal cancellous or lamellar bone. The improvement in skeletal structure can be demonstrated on standard radiographs and 99mTc bone scans, which show decreased isotope accumulation in pagetic sites. The potencies of various bisphosphonates are expressed relative to that of etidronate, the first clinically useful agent in this class. Etidronate use is now limited as the doses required to suppress bone resorption may impair mineralization. Thus, etidronate is administered in 6-month treatment cycles followed by a 6-month drug-free period. Failure to adhere to the cyclic regimen can produce osteomalacia manifested by bone pain and fractures. Etidronate should not be used in patients with advanced lytic lesions in weight-bearing bones. The major advantage of etidronate is that it is relatively well tolerated and only occasionally causes transient diarrhea or bone pain. The second-generation oral bisphosphonates tiludronate, alendronate, and risedronate are more potent than etidronate in controlling bone turnover and thus induce a longer remission at a lower dose. Oral bisphosphonates are poorly absorbed and have the potential to produce esophageal ulceration, reflux, and, rarely, perforation. Consequently, the effects of pamidronate are best evaluated 3 months after the initial dose. Pamidronate and zoledronate are generally well tolerated; however, a small number of patients experience a flulike syndrome that may begin 24 h after the first infusion. The dose may be reduced to 50 U/d three times weekly after an initial favorable response to 100 U daily; however, the lower dose may require long-term use to sustain efficacy. Secondary resistance after prolonged use may be due to either the formation of anticalcitonin antibodies or downregulation of osteoclastic cell-surface calcitonin receptors. The lower potency and injectable mode of delivery make this agent a less attractive treatment option that should be reserved for patients who either do not tolerate or do not respond to bisphosphonates. Etiology and Genetics Naturally occurring and gene knockout animal models with phenotypes similar to those of the human disorders have been used to explore the genetic basis of osteopetrosis. The primary defect in osteopetrosis is the loss of osteoclastic bone resorption and preservation of normal osteoblastic bone formation. Clinical Presentation the incidence of autosomal recessive severe (malignant) osteopetrosis ranges from 1 in 200,000 to 1 in 500,000 live births. As bone and cartilage fail to undergo modeling, paralysis of one or more cranial nerves may occur due to narrowing of the cranial foramina. Failure of skeletal modeling also results in inadequate marrow space, leading to extramedullary hematopoiesis with hypersplenism and pancytopenia. Hypocalcemia due to lack of osteoclastic bone resorption may occur in infants and young children. Adult (benign) osteopetrosis is an autosomal dominant disease that is usually diagnosed by the discovery of typical skeletal changes in young adults who undergo radiologic evaluation of a fracture.

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Develop strategies to mood disorder vs bipolar 150mg wellbutrin sr free shipping minimize negative reactions by considering the following: Emphasize factors that inspire trust bipolar depression symptoms test free 150 mg wellbutrin sr otc, such as expressing empathy depression therapist order 150 mg wellbutrin sr with amex, showing competence in the area of expertise needed to anxiety coping skills purchase wellbutrin sr 150 mg fast delivery respond to the incident, encouraging stakeholder feedback, honesty and sincerity in your communication and actions, and committing to the long term by maintaining a visible presence even after the news cameras have left. However, that trust may quickly erode if information is inaccurate, inconsistent, or overly optimistic. If the estimate of risk turns out to be "more serious than we thought," your trustworthiness is greatly damaged. Under the pressure of scrutiny and the desire to "fix" problems, one may be tempted to guarantee outcomes. Make every effort to get back to people to ensure that the promises you make are being kept. Remember, your stakeholder may also be a stakeholder of another responding organization. Power struggles or visible confusion among your organization and other organizations will reduce credibility of all of the players and further frustrate your stakeholders. Methods to communicate to stakeholders include: Designated Web page for partners Telephone call from management or management representative Specific backgrounders and periodic updates. Identify stakeholders whose reactions will have the greatest impact if the crisis escalates. These reactions will vary based on the disruption and how the perception affects them. Identify: Stakeholders who can have the greatest impact Common concerns and reactions to address Strategies to minimize negative reactions Actions and communication to inform and develop trust Consistent themes and messages to convey with empathy Preemptive communication strategies Concern for less important stakeholders Loyalty of your advocates, discouraging your adversaries, and keeping your ambivalents neutral. Estimate the management time and resources based on what had to be done and who is responsible for each action item. One of the best methods of building partnerships is to start building relationships informally through community and social networks. Strong, collegial relationships can be very helpful when emergency coordination is required. Each potential partner should play a specific role during a crisis, and this role should be determined and agreed upon before a crisis situation occurs (or at the very least, in the first few hours of a crisis event). It is helpful to assess what each partner brings to the table, including strengths, weaknesses, and unique abilities. Usually this person is not the head of the organization, but typically will keep the leader of the organization informed. Tips for developing partnerships: Design a plan for building relationships before the crisis. Create a partner contact sheet with every available phone number and e-mail address. Reality Check: Despite every good intention to allow partners a preview of a press statement or release, it may be impossible to do so. With some time-sensitive issues, you may have to consider the increased risk of leaks and choose not to share. If possible, consider telling partners to expect a release on a subject or ensure that they get the release and any supporting documents at the same time as the media. These partners may be familiar, trusted, and influential with your target audience, and may be more likely than media alone to motivate the public to take recommended actions. Consider memoranda of understanding with partners to engage them as information disseminators during a public health emergency. Consider supplying them with background information before or soon after an emergency occurs. Develop fast and reliable channels of communication directly to these community leaders so that they will have the facts when their constituencies begin to ask questions. Brief them on such issues as the national pharmaceutical stockpile or public health emergency laws. Instead, consider engaging a neutral party to speak for the diverse group of stakeholders to help resolve differences. The neutral party can speak to the media on behalf of all involved or facilitate a face-to-face meeting. The neutral party can express both consistent and inconsistent points of view from the entire group in an effort to find consensus. Representatives from all elements of the community must be considered, not just those from a vocal advocacy group. Empower group decisionmaking with the following steps: Identify the options and discuss the pros and cons of each alternative. Listening actively reduces mistakes- like believing you understand what is being asked of you, only to discover later that you are mistaken. Dealing with an angry public When risks are uncertain, because science has not reached an answer or a consensus answer, controversies will arise. Add the need to make decisions under the enormous time pressure of a crisis, and the uncertainty may seem unbearable to both response officials and the public. When science cannot lead to a clear path, decision-makers must make choices about what is and is not acceptable. In non-pressure environments, the public may turn to the courts to settle differences about the amount of acceptable or perceived risk. In a crisis, as in the emergency room, where imperfect decisions must be made in minutes, not months, the fallout can be incredibly harsh, especially after the crisis is resolved and the decisions are reviewed with the omniscient power of hindsight. With the strongly held sense of self-determination among Americans, the struggle of imposing some risk on individuals or suspending some civil liberties to protect communities may be great. Great, unless, even in the crisis situation, response officials make an effort to empower the public. Involving stakeholders and building consensus is the most powerful way to advance compliance with public safety requirements before and during an emergency. Anything less will invite civil unrest and greater mistrust of the institutions or government responding to the crisis. These public forums sooth tempers and help the community to work toward a mutually agreeable solution to the common problem. Communication experts and psychologists agree that anger is a defensive response to pain or the threat of pain. Experts identify three basic circumstances where anger is likely to arise: When people have been hurt When they feel threatened by risks not of their own making When they believe that their fundamental beliefs are being challenged. For example, when people feel weak in the face of others who are more powerful, their anger is increased. If they have been manipulated, trivialized, ignored-or worse still, lied to-anger and a sense of unfairness will build. Of course, more than one anger-causing element can be involved in a single situation. It forces the process to slow down and forces everyone to stop and think before replying. Instead of attempting to persuade an individual or community group to take an action, allow them to persuade themselves through a self-discovery process. The key is to not give the solution, but help your audience to discover its own solution. Using feedback as your tool, you can ask the audience questions that will create awareness about the situation in such a way as to empower them to make a difficult choice. As many therapists will attest, a person who comes up with his own answer and says something in his own voice will take ownership of that idea. For example, were a severe communicable disease outbreak to occur, a challenge for officials in emergency response and public health is the possibility that civil rights may need to be temporarily suspended to control the spread of disease. It makes sense that a population that understands the need to quarantine will be more likely to uphold the curfews or quarantine requirements. Questions to help people persuade themselves Start with broad, open-ended questions. Example: What challenges have (you or your community) faced that required consensus building to solve the problem? Then, ask questions to discover the explicit wants, needs, and desires of your audience.

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