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Recent attention has been focused on the use of thermal energy to treat discogenic pain (in- tradiscal electrothermal therapy purchase 150mg ranitidine with mastercard, or IDET) purchase 300mg ranitidine free shipping. Whether the mechanism of action is deafferentative 150mg ranitidine with visa, biomechanical buy cheap ranitidine 150 mg on line, or both remains to be eluci- dated,65,66 although clinical data suggesting a delayed therapeutic effect after the procedure would suggest the latter. One randomized prospective, double-blinded study has been reported to date (at the 2002 annual meeting of the International Spinal Injection Society): Pauza et al. In this particular study, all investigators were surgeons, and all patients who were treated with IDET were considered to be potential surgical candidates. When this group is compared with those who underwent IDET only (N 43), similar rates of improvement in terms of functional scores and pain relief were noted. However, when patients were asked specif- ically whether they felt that the procedure was worthwhile and would consider it again, 61% of the IDET-only group responded positively versus only 27% of the surgical group. Controversy remains, however, regarding the mechanism of action of intradiscal thermal treatment. The in vitro limitations of this study are apparent, inasmuch as such a study de- sign fails to take into account the ongoing processes of healing. Light microscopy demonstrated significant coalescence of col- lagen, with no evidence of endplate damage. Temperature mapping in this study did suggest that an intradiscal thermocouple raised the tem- perature significantly across the entire posterior annulus, thereby in- ducing the observed changes. From a surgical perspective, the efficacy of intradiscal therapy remains to be proven, although its prospects are encouraging. Clearly, the ran- domized prospective study methodology such as that of Pauza et al. Vertebroplasty and Kyphoplasty Osteoporotic vertebral compression fractures are the leading cause of disability and morbidity in the elderly. Traditionally, these fractures have been treated nonsurgi- cally, except in cases of fractures associated with neurological com- promise. Obviously, surgical reconstruction in the patient with osteo- porosis is challenging. From a surgical point of view, orthopedic fracture care emphasizes the restoration of anatomy, correction of de- formity, and subsequent preservation of function. These goals have not been met in the conservative care of patients with vertebral compres- sion fractures. The ideal treatment should address both the fracture- related pain and the mechanical compromise related to kyphosis. Suggested indications included stabilization of painful osteoporotic fractures, painful fractures due to myeloma, and painful hemangiomata. Reports on clinical outcome for vertebroplasty have been encouraging, with most patients experiencing partial or complete pain relief within 72 hours. Certainly, in a patient with multiple levels and significant debility, this may be the procedure of choice. However, a potential theoretical limitation of vertebroplasty is its inability to address the aspect of persistent deformity, which is accompanied by a theoretical increased risk of adjacent segment degeneration, or possible fracture, as well as chronic pain related not to the fracture per se but, rather, to the postural concerns raised by deformity. Kyphoplasty claims to reduce a fracture via an inflatable bone tamp placed percutaneously into the vertebral body. Kyphoplasty has not been investigated in the treatment of nonosteoporotic spinal metastatic disease. Initial re- ports of pain relief with kyphoplasty are comparable to those for ver- tebroplasty. In the initial series of these investigators, there were four major complications in 340 patients. Kyphosis reduction may also be seen with vertebroplasty simply as a result of pain relief, so the effect with kyphoplasty may be less significant as an indicator of a procedural advantage. References 63 The obvious theoretical advantage of kyphoplasty—namely, an at- tempt to restore normal anatomy—requires further follow-up and in- vestigation. Certainly, if fracture reduction can be demonstrated to result in a decreased risk of adjacent segment failure, either by a pain- ful degenerative change or subsequent fracture, then the advantages of kyphoplasty would be apparent.

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With each response Alan be- came increasingly animated as he revealed feelings and emotions related to a sense of affiliation and love that affected him deeply generic ranitidine 150mg overnight delivery. Because Alan was usually reluctant to share with his peers generic 300 mg ranitidine free shipping, we discussed this act of self-disclosure not in terms of the subject matter (seeing a vision of the Lord) but in terms of the underlying emotions that each group mem- ber could relate to and explore—the need to be acknowledged discount ranitidine 300mg, treasured cheap ranitidine 300 mg overnight delivery, and accepted unconditionally. Conversely, too much self-disclosure can generate distance among group members that works against intimacy and relational healing. For this reason, an individual who exhibits poor boundaries may never feel part of the larger whole if his or her attempts to improve interpersonal relations are thwarted by alienating behaviors or symptoms. Although the com- pleted drawing may appear innocuous, it typified the larger issues that plagued this teenager (who will be called Sally). The search for friendship and affiliation is never more intense than in the stage of adolescence, and Sally’s exclusion from her larger group of peers was merciless. In one group Sally disclosed an intimate secret and received a support- ive reaction from her peers. Sadly, this single success set in motion a series of indiscriminate self-disclosures that both burdened the group process and further isolated this client. Once this pattern had begun, the management of recovery spiraled downward, and regardless of the directive her render- ings focused on "best friends," with each drawing being presented to select members of the group. As these were ill received (often left behind at the end of the session or thrown away as group members exited), she experi- enced feelings of shame. As Yalom has stated, "the high discloser is then placed in a position of such great vulnerability in the group that he or she often chooses to flee" (1985, p. For this female the stress became un- bearable, and she eventually retreated into the safety and confinement of her mental illness. I contend that, as with all psychotic thought processing, the delusions are never far from the individual’s internal truths. Thus, these disorganized and often nonsensical admissions can offer us a plethora of information when we pay attention to them. The drawing focused on a pregnant woman who is protecting her unborn child from the secondhand smoke of the father. Sally whispered the mother’s written comments ("you are not going to kill my baby") aloud and only paused when a helicopter flew over- head, at which point she said, "Helicopters save. For these reasons, I integrated this symbolic communication into the discussion and feedback. Additionally, it was clear that the group was counterproductive to Sally’s needs, and the ultimate self-disclosure of the drawing was her metaphorical request for protection and safety from the threatening ele- 269 The Practice of Art Therapy ments in her environment. As a result, with Sally’s involvement, she was provided a psychopharmacological review and placed in a group setting that could support her needs, decrease her isolation, and offer an experi- ence of success. When dealing with the difficult-to-treat client, incorporating self- disclosure directives is an invaluable tool in interpersonal learning and in- teraction. A directive that I particularly enjoy centers on issues related to comfort, care, and safety. Thus, if we are to work toward the objectives of belonging, competency, and esteem, the path often begins with security. The right side of the image represents the library where he could read in soli- tude. However, when asked where he was in the drawing (on the left side) he replied, "I’m walking around the cabin. This male had no safe place; even in idyllic surroundings his feelings of isolation, alienation, and insecurity were profoundly devastating. In another example of a self-disclosure directive based on safety and se- curity, Figure 6. In the discussion phase he wove a story in which his safe room was filled with four football fields of cars, which were all organized by type. Recalling the time spent on fortifying his doorway, I asked about the horizontal strip. It was at this point that he described an elaborate security system that re- quired a password both when one entered and when one left.

Satisfaction discount 150mg ranitidine with visa, couple type buy discount ranitidine 300mg on-line, divorce potential discount 150 mg ranitidine fast delivery, attachment patterns generic ranitidine 300 mg visa, and romantic and sexual satisfaction of married couples who participated in marriage en- richment program. Building intimate relationships: Bridging treatment, eduction and enrichment through the Pairs program. Not just friends: Protect your relationship from infidelity and heal the trauma of betrayal. Nichols ARITAL COMMITMENT AND the treatment of couples who are in their first marriage are the focus of this chapter. In American society, Mthis refers mainly to couples who are in their twenties, or in some instances, in their early thirties, who have not been married previously. Couples in later stages of marriage and gay or lesbian couples are the sub- ject matter of subsequent chapters. What do we need to know to work therapeutically with couples in their early years of committed relationships? We need to understand, in the broadest terms, the nature of marriage, cohabitation, and commitment in such relationships. Following that is a brief review of family development and the concepts of individual and marital life cycles—with some reference to family life cycles and the central tasks of those cycles as they pertain to first marriage—and the commitment process; and integrative marital therapy, involving object relations, system theory, and cognitive behavioral con- structs. Clinical illustrations of how interventions are made with couples and individuals requesting marital therapy are then presented. Because not all couples have difficulties with all parts of early marital adjustment, il- lustrations are taken from a variety of cases. Next, reference is made to some issues typically found in therapy with mainstream White American couples and couples from other ethnic, racial, and religious backgrounds. The majority of extant research literature deals with differences between White Americans and African American or Hispanic couples. Napier has succinctly stated, "Mar- riage involves learning to be both separate and together, learning to allo- cate power, learning to play and to work together, and [for some] perhaps the greatest challenge of all, learning to rear another generation" (2000, p. Lewin expressed it decades ago as follows: Manifold needs are generally expected to be satisfied in and through mar- riage... Which of these needs are dominant, which are fully satisfied, and which are not at all satisfied, depend upon the personality of the marriage partners, and upon the setting in which the particular marriage group lives. A distinction made by Kan- tor and Lehr (1975) is helpful in understanding some of the essential differ- ences between the dependency relationship we are involved in with our parents during our formative years and the intimacy in a healthy, adult rela- tionship with a spouse. They distinguish between intimacy and nurturance, defining intimacy as a condition of mutual emotional and often intense closeness among peers. Nurturance, instead of being a two-directional emo- tional exchange, "implies a primarily unidirectional flow of affect" (Kantor & Lehr, 1975, p. As with other parts of marriage, workable, appropriate intimacy is not easily attainted. Persons may have different "social distances": Willingness to marry is considered a symptom of desire for the least social distance. Indeed, marriage means the willingness to share activities and situations that otherwise are kept strictly private. Married life includes permanent physical proximity brought to a climax in the sex relationship. Marriage is the lone voluntary family relationship (Napier, 1988; Nichols, 1988, 1996, 2000). As such, it is the most fragile of family 30 LIFE CYCLE STAGES relationships (Napier, 1988). This fragility is found not only in the attain- ment and maintenance of intimacy but also in the maintenance of the struc- ture of the marriage. Most people marry in the United States, but for recent marriages, nearly half eventually may end in divorce, according to projec- tions by Kreider and Fields (2001). Bramlett and Mosher (2001) report that one-fifth of first marriages end within five years. The first year or so long has been identified by demographers as the most difficult time of adjustment in marriage. Divorce may come a few years later in the marriages in which there is early breakup, but the actual breakup tends to reflect conflict that began in the earliest stages and that did not secure adequate resolution.

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Patients are usually unwilling in an observed setting generic ranitidine 300mg amex, the rating process can be com- to submit to prolonged interviews purchase ranitidine 150 mg fast delivery, and practitioners are pleted quickly 300mg ranitidine with amex. The chief disadvantage of capacity assess- fulfill all these requirements order 150 mg ranitidine mastercard, these principles should be ment is the reliance on patients’ subjective estimates considered when deciding whether it is worth assessing a of their abilities. Because some patients function substantially below their capacity, this approach may underestimate their functional ability. Dimensions of Geriatric Assessment Performance-based measures are direct observations of particular actions. Advantages include an increase in Cognitive Function objectivity as patients’ biases and those of their proxies are minimized. Disadvantages include the need to train Assessment of the cognition of elderly patients generally the observer and the costs for specialized equipment to focuses on detection of dementia and delirium. Although create the task being observed: an audiometer to create these two conditions can be distinguished by time course, a tone, stairs to climb, etc. In fact, the presence of dementia is a risk factor for Patient factors may also affect the performance of the the development of delirium in elderly hospitalized instrument in clinical settings; these include educational patients. Finally, each test has a limited range in which it is sen- The prevalence of dementia, an acquired, progressive sitive, commonly referred to as ceiling and floor effects. Therefore, the yield of screening for cognitive impair- ment because virtually everyone scores at the top. Because the initial Conversely, a floor effect is when everyone scores at the phases of impairment can be quite subtle, it can be dif- bottom of the scales. For example, in a population of ficult for a clinician to make the incidental discovery healthy community-dwelling older persons, the ceiling of cognitive impairment. Structured examination tech- effect would apply if one measured basic activities of niques may be helpful in detecting early dementia. Such daily living (BADL, discussed below); almost all the detection has become increasingly important because a patients are able to complete all the relevant tasks. Sim- number of pharmacologic and behavioral interventions ilarly, in a nursing home population, almost all patients have been shown to slow the progression of symptoms will be dependent in all items of the instrumental activi- and delay nursing home placement for patients with ties of daily living scale (IADL; discussed below); thus, moderate Alzheimer’s disease. Practitioners must be aware of the range of bers and caregivers to plan for the future. It principles of screening derive from preventive services is easy to apply and interpret. Screening has been defined as using "a test or be given by office staff after minimal training. It requires that the least five requirements for screening: (1) a screening test patient answer many of the same orientation questions as must have acceptable sensitivity and specificity; (2) the the MMSE but also asks for the name of the current and test must detect a condition in a presymptomatic stage; past president, the patient’s mother’s maiden name, and (3) there must be a proven treatment for this condition; his or her birthday, address, and phone number. As the (4) there must be additional benefit derived from receiv- questionnaire is shorter, it takes less time to administer. Reuben Other useful and rapidly administered tests are the attention, such as digit span or stating the months of the Clock Drawing task and the Time and Change test. Both year backward, may also help detect delirium at an early are performance-based tests. Because of the temporal variability that is the hall- tive function and visuospatial skills by having the patient mark of delirium, a patient may seem entirely lucid at the draw a clock face and place the hands at 10 min after 11 time of evaluation. There are standardized scoring methods17 for the out reports from collateral informants, family or nurses. It is associated with sig- shown to be accurate in both inpatient and outpatient nificant morbidity and mortality. A score under 15 is considered abnormal,22 concise approach, a single question screen,"Do you often although there are concerns about its sensitivity even at feel sad or depressed? In one trial, 17% of demented patients affirmatively, it should be followed by the 30-question demonstrated a perfect score. The single question may be as accurate to any lists of relevant words before the test begins and in identifying depression as the long version of the GDS,37 are expected to create their list de novo.

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